COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 1 Feb 2024

Chapter 18 - Health Service Executive Funding and Financial Reporting

Mr. Robert Watt (Secretary General of the Department of Health) called and examined.

An Cathaoirleach

I welcome all those in attendance and remind them to ensure their mobile phones are switched off or on silent mode.

Before we start, I wish to explain some limitations to parliamentary privilege and the practice of the Houses as regards reference witnesses may make to other persons in their evidence. The evidence of witnesses physically present or who give evidence from within the parliamentary precincts is protected, pursuant to both the Constitution and statute, by absolute privilege. This means that witnesses 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 their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative they comply with any such direction.

Witnesses are reminded of the long-standing parliamentary practice 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 or her 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, they will be directed to discontinue their remarks. It is imperative they comply with any such direction.

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

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

This morning we are engaging with officials from the Department of Health and representatives of the HSE to examine the following matters: the appropriation accounts for 2022, specifically Vote 38 - health; and from the Report on the Accounts of the Public Services 2022 - chapter 18, Health Service Executive funding and financial reporting. The committee has flagged the following specific items as being of interest: the establishment of the new regional health areas, RHAs; budget controls, governance and outcomes; agency costs; service level agreements, SLAs, with section 38 and 39 organisations; and estates management and capital works.

This morning we are joined by the following officials from the Department of Health: Mr. Robert Watt, Secretary General, Ms Louise McGirr, assistant secretary; Mr. Derek Tierney, assistant secretary; Mr. Kevin Colman, principal officer; Mr. Patrick McGlynn, principal officer; and Ms Sarah Treleaven, principal officer. We are also joined by the following officials from the Health Service Executive: Mr. Bernard Gloster, chief executive officer; Mr. Stephen Mulvany, chief financial officer; Dr. Colm Henry, chief clinical officer; Mr. David Walsh, national director of community operations; and Mr. Brian O’Connell, acting national director of estates. We are also joined by Mr. Evan Coady, principal officer from the Department of Public Expenditure, National Development Plan Delivery and Reform. They are all very welcome.

I call the Comptroller and Auditor General to make his opening statement.

Mr. Seamus McCarthy

The appropriation account for Vote 38 records gross expenditure of €23.7 billion in 2022, up €1.9 billion from the spend in 2021. The vast majority of the expenditure, amounting to just over €23.3 billion, spread across 14 of the Vote subheads, was paid to the HSE. A further €125 million was allocated to the National Treatment Purchase Fund, NTPF. Receipts into the Vote in 2022 totalled €458 million. At year end, net expenditure under the Vote was €42 million less than provided for, and this was liable for surrender to the Exchequer. I issued a clear audit opinion in relation to the appropriation account.

Members will have noted during previous meetings that appropriation accounts are usually presented in terms of output-focused expenditure programmes. The appropriation account for Vote 38 has not been organised in that way. Instead, it remains in the original appropriation account format, with expenditure subheads for administrative resource inputs, and various grant funding lines for bodies under the aegis of the Department of Health. Appendices to the Revised Estimate for the Vote provide ancillary information on an output programme basis, such as primary care, mental health, disability services and acute services. While this spending analysis is presented with certain performance metrics, the link between those metrics and the voted expenditure subheads is difficult to follow.

Chapter 18 of my report on the accounts of the public services examines how grant funding from Vote 38 to the HSE is accounted for in the HSE's annual financial statements and in the appropriation account of the Vote. Voted grant funding accounts for the majority of the HSE’s annual receipts.

The Minister for Health is required by law to issue formal notices of determination to the HSE setting out its annual funding allocation. In effect, this is the budget it is expected to manage within for the year. Separate determinations are issued for capital and non-capital amounts. The HSE is required to respond to these budget determinations by outlining an annual national service plan and capital plan.

Different approval processes apply for the determination of the annual capital and non-capital funding amounts. Under the Health Act 2004, as amended, the approval of the Minister for Public Expenditure, National Development Plan Delivery and Reform must be obtained for the capital funding determination, which for 2022 amounted to €1.2 billion. However, the Minister for public expenditure's approval is not required for the much larger non-capital funding determination, which in 2022 amounted to €22.5 billion.

The actual cash issued from Vote 38 to the HSE in 2022 was €439 million less than the amount determined by the Minister. This was significantly up from the €25 million gap between the funding and budget figures that occurred in 2021. In prior years, such differences between the figures generally did not occur.

As a result of the funding gaps in 2021 and 2022, the HSE’s 2022 financial statements recognise a funding debtor of €464 million for the cumulative amounts not drawn down. It should also be noted that, at the end of 2022, the HSE had an accumulated deficit of €1.24 billion, which will require to be funded in the future.

However, the Health appropriation account statement of financial position does not recognise liabilities to the HSE in that regard. It is not permitted to do so under Vote financial reporting rules set by the Minister for public expenditure.

A report by the Parliamentary Budget Office in 2018 noted that the HSE’s funding allocation is not separately set out in the Revised Estimate for the Vote, and that the realignment of the programmes in the Vote has been recommended for reform since 2008. Progress in this area has been impeded by the HSE’s legacy financial reporting system. When we were finalising the report, the Department indicated that it is planning a restructuring of the Health Vote along output programme lines for the 2025 Estimate.

An Cathaoirleach

I thank the Comptroller and Auditor General. I wish Mr. Watt a good morning. As set out in the letter of invitation, Mr. Watt has five minutes for his opening statement.

Mr. Robert Watt

I wish a good morning to the Chair and members and thank the Chair very much. I am happy to be here before the committee this morning to consider the Appropriation Accounts for 2022. I am joined by colleagues who the Chair has already listed: Louise, Derek, Kevin, Patrick and Sarah. I am also joined by the CEO of the HSE and colleagues from the HSE. I will endeavour to address the specific issues the committee members have raised in their letters to the Department, with a particular focus on the priorities of the Department and the HSE to maximise the provision of safe and efficient health services for our citizens.

In the face of growing healthcare demand each year, there is a need to deliver services both safely and efficiently. Investment in healthcare has not always resulted in improved activity or performance, representing the so-called "productivity puzzle". While we have succeeded in increasing activity in our hospitals, and with increasingly better outcomes for our citizens, this has come at an increasingly high cost to the taxpayer and the Exchequer.

To give some numbers, investment in the acute care system has increased by more than 80% over the last seven years, from €4.4 billion in 2016 to €8.1 billion in 2023, with acute care expenditure now making up over a third of overall spending. The hospital workforce, the numbers of employees, has grown by 36% over the same period. This indicates, allowing for inflation, a real increase of circa 50% - a very significant increase - in the resources of the acute system. The number of patients treated has not kept up with this large increase in resources and a major challenge for us is obviously to increase the levels of activity commensurate with the resources that are allocated by the Exchequer.

As members will be aware, the Minister for Health announced the establishment of a productivity and savings task force, jointly chaired by me and the CEO of the HSE. There are many aspects of this work, but key areas of focus are: the use of new technology to provide services with data and insight to support better performance; adding to the new ways of working that are an increasing feature of our health system, including streamlining operational processes and clinical pathways - there is a very significant reform of clinical pathways led by Dr. Colm Henry - and these are intended to drive productivity across the health sector; and delivering savings across a range of areas including medicines, procurement and standard utilisation of goods and services. Ultimately, the aims of the task force are to maximise value for money and improve patient outcome. That is what we have been tasked by the Government to undertake as part of our efforts this year in terms of improving the services within the allocation made by Government and the Oireachtas.

One of the areas the task force identified as having potential for savings is the use and cost of agency staff. Alongside our workforce, which has increased by over 26,000 since 2020, the spend on agency staff has continued to increase year on year in the same period. The CEO of the HSE has already announced several cost control measures over recent months, including a targeted reduction on expenditure on the use of agency staff within the health service of over 10% and further reductions are being targeted in 2024.

There are levers to safely reduce agency costs and many of these are now under way across the HSE. Actions to reduce agency costs will continue and are intended to deliver a higher level of savings throughout 2024.

A key lever for reducing reliance on nursing agency is through the implementation of the framework for safe nurse staffing and skill mix. This framework is an evidence-based way to determine or seek to determine workforce requirements to meet sustainable high-quality safe care delivery and is being implemented across all acute hospital sites. To date, there have been 1,200 whole-time equivalents recruited and plans for 2024 include agency conversion to continue to progress the roll-out of safe staffing.

Strong controls around sign-off and procurement of agency staff also help to ensure value for money and appropriate use of agency. The HSE has worked with services last year to strengthen these controls and will continue to do so this year.

Finally, I will mention a very important change introduced in the introduction of the public-only consultant contract in March of last year. This enables a work plan with extended and flexible working attendances over longer hours and weekends. We might discuss, with the CEO, the impact this has had over the last six or seven weeks as we have tried to deal with the winter surge in the ED departments and how we tried to use flexible and extended working arrangements to try to contain the very large increase in demand. I am happy to say that over 1,700 consultants, 41% of the total number of consultants, are now employed on this contract. This represents a great opportunity for the health system to significantly increase the contact hours of senior decision-makers in our hospital system. It is probably one of the biggest potential changes that we have seen in recent years.

Alongside a focus on making the health budget go further, the HSE and the Department will have a focus on tighter budgetary control and accountability in conjunction with our colleagues from the Department of Public Expenditure, NDP Delivery and Reform. There is currently extensive oversight and reporting to relevant stakeholders on the HSE financial performance through the year.

Once the annual allocation is made to the HSE, it is, via the national service plan, distributed to services across the HSE for provision of health care. The plan, which is submitted by the board and agreed by the Minister, sets out how the HSE plans to use its resources and the services it will deliver in that year.

The HSE monitors spend and performance across all services, and I am sure the CEO of the HSE will be happy to talk in more detail about those particular processes. The Department provides a further layer of governance and monitors and reports to stakeholders regularly on the spend of the HSE and on all health agencies. High-level governance between the Department and the HSE is exercised through monthly performance meetings between me and Mr. Gloster, as well as quarterly meetings held between the Minister and the chair of the HSE board.

Additional scrutiny is provided through the health budget oversight group, which is chaired by the Department of Public Expenditure, NDP Delivery and Reform, attended by Department of Health and HSE officials. This group meets monthly to discuss financial performance and any other issues that relate to the management and monitoring of spending throughout the year as issues arise.

The financial performance of the HSE is also reported to Government on a regular basis through the Cabinet subcommittee on health and quarterly memorandums to Government. Like other large-spend Departments, the Department submits a quarterly memorandum to Government on how spending is progressing relative to profile.

Notwithstanding the extensive monitoring and oversight processes there remain challenges in managing overruns and balancing the needs of patients and the costs of delivering health services.

I will touch now on some issues the Chair specially asked us to discuss this morning. A key area of investment that can help to improve both patient experience and productivity in the sector is the provision of safe, high-quality infrastructure. It is fair to say that, historically, this is an area where we have not invested enough in modern facilities and infrastructure, and this is evident when one travels around and visits facilities around the country. The overarching objective for the HSE in the annual capital plan is to prioritise contractually committed projects that address known compliance and patient safety risks associated with healthcare infrastructure, equipment and fleet replacement and then continuing initiatives to support patient access to services taking account of available funding.

The committee also referenced the regional health areas. Members will be aware that from the first quarter of this year, the HSE will be reorganised into six regions. Each region will be led by a regional executive officer, all of whom have been appointed and the announcements made, who will be responsible for the delivery of timely, integrated care for their residents. Key milestones in the period ahead include the appointment of the regional executive officers, which has been announced, the roll-out of a new integrated service delivery model, which is the key objective of the new regions, on the front line and standing down hospital groups and CHOs by the end of this year. This is a significant programme of reform and change, led by our colleagues in the HSE. The overall governance arrangements will continue to be progressed through 2024, together with the new regional officers and their teams. These new arrangements should support both clear financial control and accountability and integrated regional care close to patients. The establishment of the regions in the context of changing the structure of the Vote, to add to what the Comptroller and Auditor General mentioned earlier, mean the new regional structures will provide an opportunity to look at how funding is allocated, both on the basis of a functional area and on a geographical area. This is something we are working on in collaboration with the Comptroller and Auditor General during the year.

Lastly, I assure members there is a shared focus between the Department and the HSE on the fact that we need stronger budgetary controls. We need to deliver more efficiencies and savings in the short run while continuing to improve delivery of services to the public. As the Chair knows, demand for these services is increasing significantly year on year. We must utilise new ways of working, better patient pathways and new digital innovations and see more care delivered in the community as part of the enhanced community care programme. As I have said before, we cannot continue to meet the ever-growing demands on our health system and treat satisfactorily the numbers of people turning up, whether for outpatient consultations, to our accident and emergency departments or for elective surgery. Whatever source of care people may be looking for, we cannot continue to meet this demand, and the prospective demand, based on the legacy structures we have. The process of reform, which I think has been significant, needs to accelerate and be embedded if we are going to have a health service we can all be proud of.

An Cathaoirleach

Thank you, Mr. Watt.

Mr. Robert Watt

Thank you, Chair.

An Cathaoirleach

I call Deputy John Brady as our first speaker.

Deputy John Brady

I welcome the rather large delegation in with us this morning. It is certainly one of the largest delegations I have seen for a considerable time. I daresay the recruitment embargo is not impacting negatively on senior management in the Department or the HSE. I will start with a couple of questions posed to Mr. Watt about the secret dossiers compiled by the Department on children with autism. I refer to the ruling last year by the Data Protection Commissioner, DPC, on what was an unlawful practice of serious, "excessive and disproportionate" gathering of sensitive personal information about people, and who then were forced into taking legal action against the State. I wish to ask about the €22,500 fine levied on the Department. Has that fine been paid now?

Mr. Robert Watt

I imagine it has, yes.

Deputy John Brady

Mr. Watt imagines it was paid. Does he think that fine was severe or that the Department got off lightly?

Mr. Robert Watt

I thought it was fair. There was a lot of discussion about it. It is what it is.

Deputy John Brady

Would Mr. Watt have been briefed by some of his officials that the Department got off lightly and the fine fell far below the maximum that could have been levelled? Would he have been briefed on this aspect by any of his officials?

Mr. Robert Watt

Yes, I was briefed on the outcome of the DPC's investigations and on the recommendations and what the fine was.

Deputy John Brady

Okay. Certainly, I think there were internal submissions saying the Department was facing fines of up to €1 million. Regarding the fine of €22,500 for the compilation of very sensitive information and breaching data protection rules, Mr. Watt's own officials in the Department would say it got off lightly for that unlawful practice. Would he agree?

Mr. Robert Watt

The DPC made the ruling, we accepted it and we paid the fine.

Deputy John Brady

Okay. Regarding any of the issues identified by the Data Protection Commissioner in terms of holding that data, have these practices fully ceased now?

Mr. Robert Watt

Various recommendations were made around how historical legacy data are kept, how people gain access to them and the proportionality in respect of the need for those data to be kept. We have changed the rules and issued new guidance to people, in terms of colleagues across the Department, about what data-----

Deputy John Brady

The Department is fully compliant with the ruling from the Data Protection Commissioner.

Mr. Robert Watt

I think in respect of the particular recommendations that were made, yes, we are compliant.

Deputy John Brady

Does Mr. Watt think that or is he sure?

Mr. Robert Watt

Well, I hope we are, Deputy, yes.

Deputy John Brady

Mr. Watt hopes the Department is. That is not very convincing.

Mr. Robert Watt

It is not possible to be 100% sure about any compliance. However, this related to cases going back many many decades-----

Deputy John Brady

In fairness, Mr. Watt, I am well aware of what the ruling was and what it was for. I am asking you, as the Secretary General, if you can give us assurances that the rulings laid down by the Data Protection Commissioner are now fully enforced and that the Department is fully in line with the ruling from the Data Protection Commissioner.

Mr. Robert Watt

I think that is fair to say. We are at this stage. We understood the recommendations.

Deputy John Brady

In terms of the families and children directly impacted by having their data unlawfully compiled in these dossiers, has the Department or the Secretary General issued an apology to those families?

Mr. Robert Watt

This matter has gone on over the last several years. We have met-----

Deputy John Brady

I am aware. Has Mr. Watt apologised to the families and the children in relation to the unlawful collection of their data?

Mr. Robert Watt

We met some time ago. I think this issue arose in 2000 or 2001, I cannot remember exactly-----

Deputy John Brady

I am very conscious of that. I am asking him a very specific and direct question. Has he apologised to the families for the unlawful collection of the dossiers?

Mr. Robert Watt

I do not recall exactly the details, but I think we did. We certainly met-----

Deputy John Brady

Mr. Watt thinks the Department did. The Department of Health has been found by the Data Protection Commissioner to have been breaching data laws and he is not sure as to whether there has been an apology. Will he take the opportunity here now to apologise to those families who were directly impacted?

Mr. Robert Watt

This is an issue that arose years ago.

Deputy John Brady

I am very conscious of that, but the ruling-----

Mr. Robert Watt

I have not been-----

Deputy John Brady

I am sorry, Mr. Watt, the ruling was only made last year by the Data Protection Commissioner. A fine of €22,500 was issued and Mr. Watt's own officials say the Department got off lightly. I am asking him now if he will issue an apology to those families.

Mr. Robert Watt

I am not close to exactly what engagement took place with the families. Many such engagements did take place with the families and the legal officials. I am fairly certain an apology was already issued in relation to how data were collected and other related-----

Deputy John Brady

Will Mr. Watt reiterate an apology?

An Cathaoirleach

I am sorry. I ask Deputy Brady to allow the witness to finish answering the question.

Mr. Robert Watt

No, I will come back with the exact details of what was communicated to the families because I am not exactly sure of this and I do not want to mislead.

Deputy John Brady

Will Mr. Watts take the opportunity here again? If he is not 100% certain an apology has been issued, will he issue one here again today?

Mr. Robert Watt

Chair, I do not know what more the Deputy wants me to say.

An Cathaoirleach

I think-----

Deputy John Brady

Okay. Mr. Watt is refusing to take the opportunity here today.

An Cathaoirleach

What Mr. Watt has indicated is that he is not certain of what happened there and he might be able to come back before the end of the meeting with some clarification.

Mr. Robert Watt

We will come back when we have had an opportunity to speak to colleagues regarding exactly what the position was.

Deputy John Brady

Okay, but I think this is a missed opportunity here this morning. Regarding the whistleblower who exposed this practice regarding these dossiers, Shane Corr, would Mr. Watt agree that he did the State a massive service in exposing this rotten practice within the Department?

Mr. Robert Watt

I am not commenting on any matters concerning Shane Corr.

There are issues in that regard and I am not in a position to comment publicly.

Deputy John Brady

I believe he did the State a great service. It is reported that the Standards in Public Office Commission, SIPO, has launched a preliminary inquiry into complaints made by Mr. Corr. Is Mr. Watt aware of those reports?

Mr. Robert Watt

I am aware of the reports, yes.

Deputy John Brady

Are those reports accurate?

Mr. Robert Watt

I am not commenting on those matters.

An Cathaoirleach

Due process will have to be followed in that regard. I understand why the Deputy is raising the matter.

Deputy John Brady

That is fair enough. Has SIPO been in touch with Mr. Watt?

Mr. Robert Watt

I am not commenting on these matters. It is not fair to ask me about them. As I understand it, investigations are meant to take place privately due to the rights of those involved.

Deputy John Brady

Will Mr. Watt participate fully in any inquiry that may be initiated? Will he give a commitment to full co-operate if an inquiry is initiated?

Mr. Robert Watt

Of course I will but I am not discussing this matter. It was not indicated to us in advance that this matter was going to be discussed. It is not a matter relating to the appropriations for 2022 or to any of the other matters I was asked to be prepared to talk about.

Deputy John Brady

Okay. On budget 2024 and what Mr. Gloster has called a major underfunding of the HSE, does he have concerns about the level of funding to the HSE for 2024?

Mr. Bernard Gloster

In appearing at committees in these Houses in the autumn and in public, I was very clear that the cost base we were running would present us with a serious challenge for 2024 in light of the level of funding we had. Looking at the detail for the last half of 2024, we have a particular difficulty at the moment because there is industrial action as a result of the employment cap I introduced on the very senior management grades the Deputy referred to at the start. Based on the best information available to me, we will certainly be very challenged this year. We have submitted a plan to the Minister and he is considering it. Within that plan, I have made very clear the conditions that will determine the level of the challenge. As I have said on the record previously, my job in the meantime is to do the best I can with what I have. The one caveat I have as regards assurance from Government is that, whatever else I do, cutting services will not be an option.

Deputy John Brady

With regard to maintaining the existing level of services, what did Mr. Gloster and the HSE request from the Department in budget 2024 to maintain existing service levels?

Mr. Bernard Gloster

The request fluctuated between variations of ELS. The recorded position based on the best evidence available to us at budget time was that the problem would cost somewhere in the region of €1 billion or €1.5 billion, based on the cost base. However, there have been substantial reductions in the cost base and efficiencies have been put forward for 2024, which we hope will mitigate the issue. I have set out all of the conditions to do with inflation, demand and the success of our efficient management of the resource. My responsibility as a senior public servant is obviously to aim for the lowest level of deficit and best level of service possible. It is a work in progress but 2024 will be a very challenging year. I say this against the backdrop of further and new investment.

Deputy John Brady

There is obviously a great disparity between what was anticipated to be the minimum required to maintain services and what was actually given in the budget, which was an additional €708 million. There is a great disparity there. What is the rough figure?

Mr. Bernard Gloster

It is not just €708 million. That relates to the core funding but there is also an extra €100 million for additional developments and up to €1 billion in once-off funding. That €1 billion will significantly reduce the impact of the deficit for 2024 in certain areas. As I have said, because I do not have income and expenditure accounts for the last five months of the year, it is very difficult to comment. I will say that it is likely that we will require supplementary funding. My job is to put forward all of the conditions that are likely to reduce the effects of the deficit to the greatest degree possible. I suspect that we will have a very accurate position at the end of the first quarter.

Deputy John Brady

Mr. Gloster has been very open and vocal on the shortfall as regards the money that is needed. It was reported that he wrote to the Minister for Health to express concerns about the underfunding.

Mr. Bernard Gloster

That is correct.

Deputy John Brady

Did he get a reply from the Minister?

Mr. Bernard Gloster

I believe the Deputy is referring to the email to the Minister and Secretary General I wrote the day before the budget. It would not be an overstatement to say that I talk to the Minister practically every day. The replies are constant. Before Christmas, the Minister reported that, in addition to the new development money he got in October's budget, which will allow us to recruit an additional 2,200 staff, he subsequently got a further €95 million in allocations. He is working through that with us to prioritise further spending. The responses are constant, to be fair. The Minister has not been behind the door in supporting us in trying to resolve this challenge.

Deputy John Brady

Supporting verbally is completely different from actually supporting by providing the funding needed to maintain the minimum services required for 2024.

Mr. Bernard Gloster

Again, to be fair to everybody, it is not just verbal support. The cast-iron position is obviously in the letter of determination and the service impact of that is in the service plan. The service plan is with the Minister. I believe we will close out the service plan in the next couple of days. Of course, I do not want to speak for the Minister. It is a matter for him and for the Oireachtas but I believe we will close it out in the next couple of days. We are on course for a good service.

Deputy John Brady

Does Mr. Gloster believe the HSE came out poorly from the budget? Does he believe it was done wrong as regards its requirements to provide the needed level of care?

Mr. Bernard Gloster

I appreciate that the Deputy has a job to do but whether the HSE was done wrong is a value judgment that is not for me to make. I have to work on the facts. What I have said on the public record is that the cost base we were carrying at the end of the year did not match the funding we were allocated for the year ahead and that we had to take steps to reduce that gap. We are working with the Minister and the Department to do that. We got less than we asked for. That is the case in simple terms. I believe everybody knows that.

Deputy John Brady

I have limited time. I will ask about the recruitment embargo and the impact it is having and will have. More than 7,000 critical and essential posts have essentially been scrapped as a result of the embargo. Has the HSE ascertained how many essential posts this will have a direct impact on?

Mr. Bernard Gloster

I am conscious of the Deputy's time and I am happy to come back to this issue. It is hard to know how successful the recruitment embargo was because we still finished the year with net growth of 8,300 on the start of last year. We were only meant to finish with 6,100 so I am not sure if my embargoes are very successful. A number of posts are derogated. Critical posts continue to be filled. I am very clear on that. Additional supports were given coming into the winter pressure period. The posts the Deputy has described as "scrapped", although I would say they have been paused or delayed, are posts planned over a multi-annual cycle to improve clinical programmes and services. That overhang is probably now materialising. People anticipated somewhere between 4,000 and 5,000 posts.

Deputy John Brady

A final question-----

Mr. Bernard Gloster

In fairness, it is important-----

Deputy John Brady

Just a final question on-----

Mr. Bernard Gloster

It is important to put on the record that consideration is now being given to funding a further number of those posts this year from the additional €95 million the Minister secured before Christmas.

Deputy John Brady

On the Government's underfunding of the HSE and the impact that is having by way of the recruitment embargo, does Mr. Gloster agree that the message going out to young graduates who have gone through four years or more of college is that they are not wanted here and that they should go to Dubai, Canada or Australia?

Mr. Bernard Gloster

In fairness, every graduate nurse who wanted a job in Ireland after the recruitment pause got one. They have all been contracted and deployed. Every allied health professional available to work in disability services is being given a job. They are being offered jobs at an expedited rate. An additional recruitment campaign for allied health professionals has taken place. I have relaxed the moratorium now, progressing towards things like midwifery and other essential posts. As a result, I would not agree that is the message we give.

An Cathaoirleach

I thank Mr. Gloster.

Mr. Bernard Gloster

The message we give is that we have employed people at a very successful rate, we are retaining at a better rate and we have employed more than we ever planned to employ.

An Cathaoirleach

I thank Mr. Gloster. Deputy Verona Murphy is next.

Deputy Verona Murphy

Good morning everybody. I have two quick questions on capital infrastructure and the progression relating to the addition of a 97-bed unit to Wexford General Hospital. Can anyone give me an update on those?

Mr. Robert Watt

Mr. Tierney might be able to give an update.

Deputy Verona Murphy

As well as the MRI scanner. Construction is due to begin in quarter 1 of 2024.

Mr. Derek Tierney

We have taken a number of questions from the Deputy over the course of the year. We have committed funding to progress design for the 96-bed ward block. The Minister was in the Chamber here yesterday-----

Deputy Verona Murphy

I am sorry, but I am under the impression it has gone to planning.

Mr. Derek Tierney

Yes. We are in detailed design and we are progressing planning. My colleague Mr. O'Connell will give the Deputy a date on that, but we are committed to funding. We have to allocate funding right across the estate, but that is on our plan for 2024.

Deputy Verona Murphy

Will the MRI scanner go ahead in quarter 1 of 2024?

Mr. Derek Tierney

It is the same, yes.

Deputy Verona Murphy

Any particular date.

Mr. Derek Tierney

No, I am not going to commit to a date here.

Deputy Verona Murphy

But on quarter 1, Mr. Tierney is happy it is on track.

Mr. Derek Tierney

It is on track as far as I am aware. Maybe Mr. O'Connell can given an update on that.

Mr. Brian O'Connell

It is a priority. It is going through the public spending code compliance at the moment. It is in for planning permission as of just before Christmas and we are continuing with the design in parallel.

Deputy Verona Murphy

That is the 97-bed unit.

Mr. Brian O'Connell

Yes. I do not have the detail on the MRI scanner to hand, but my understanding is it is being progressed.

Deputy Verona Murphy

I thank the officials. No doubt they will get another parliamentary question from me just before. That is great.

The crisis relating to mental health continues to escalate. While I hear that everybody is striving to reduce waiting lists and make matters better, I am very concerned at the levels of and escalation in anxiety, especially among children and young teens. Children are refusing to attend school or are not able to do so because of their anxiety. There is also the matter of life-threatening eating disorders. Anorexia is clearly on the rise. I had an incident during the summer where a teenager was kept in one of our general hospitals for more than 30 days before I intervened and had her removed to the Linn Dara facility. Such was the extreme nature of her condition by the time she was referred, she is still there. What surprised me greatly was Linn Dara had up to 12 beds vacant but no staff. All these issues are adding to parents' anxiety and families being affected and there are multiple situations developing from what can only be regarded as the lack of early intervention. I posed a series of parliamentary questions before Christmas. We know about the embargo or the work-to-rule, so I really want to know what precise measures are the HSE and the Department taking to address the crisis funding-wise between what should be regarded as parental support between Tusla and the HSE.

Mr. Bernard Gloster

It remains a significant challenge. It is not for the want of money, I assure the Deputy, and there is no question of it being the result of a recruitment embargo. The level of recruitment in mental health services and then in particular parts of the country is significant. The demand on the CAMHS teams is growing exponentially because of, as the Deputy said, the types of anxiety children are experiencing. On admitting a child to a place like Linn Dara or the CAMHS unit in Galway, the mental health legislation is very specific in terms of someone having a diagnosed mental health condition or mental illness, as distinct from any of the other things that can cross into that space.

Deputy Verona Murphy

Does Mr. Gloster agree that anorexia is a mental health condition?

Mr. Bernard Gloster

I am not disputing the need for intervention in eating-----

Deputy Verona Murphy

Surely it could not take 30 days for what was already diagnosed for a transfer from a general hospital to Linn Dara where the girl in question would have received the treatment. Mr. Gloster is talking about cost savings, but what did 30 days in a general hospital cost?

Mr. Bernard Gloster

An awful lot of money, but I would not-----

Deputy Verona Murphy

How much is "an awful lot of money", Mr. Gloster?

Mr. Bernard Gloster

It could be €1,000 per day, but I-----

Deputy Verona Murphy

It would be at least-----

Mr. Bernard Gloster

Yes.

Deputy Verona Murphy

-----so €100,000 for a child to come to a near-death experience, because she lost 7 kg when she was in the general hospital. Her organs were ready to fail. The girl's mother had to stay with her all day while her husband lay with a terminal cancer diagnosis. He has since passed away and his young child is still in that facility. She was on day release for his funeral. The damage we are causing, the lack of parental support at an early intervention stage is becoming a crisis. It is in crisis. It is becoming unworkable. The same CAMHS unit in Wexford is not taking referrals, which means its waiting list numbers do not appear. It is just refusing to take referrals. It is using the crossover between autism and mental health, whereas patients have both mental health issues and autism. We have a situation in Wexford where our CAMHS psychologist says "No, we do not accept the referral". Doctors are tearing their hair out, but the unfortunate individual patient or client or the child or teenager is just left in limbo. They have nowhere to go and the parents and families have no support. It is becoming mind-boggling. I asked the questions before Christmas because the HSE has got very significant funding in excess of €1 billion and nobody could tell me what was being allocated to parental supports by Tusla or the HSE at that time. I am asking now what portion of funding is being allocated to institute prevention as well as trying to provide a cure.

Mr. Bernard Gloster

Not to misunderstand the Deputy's question, but does she mean across all the mental health area, rather than just eating disorders?

Deputy Verona Murphy

Of course. I mean throughout the CAMHS system. Where a parent cannot get their child into the system, are they entitled to supports? The Parenting Network is one group, and there are many others, such as Parents Plus, that provide necessary supports, but they are unaffordable in many cases.

Mr. Bernard Gloster

On support for children who require integrated services from the HSE, CAMHS, primary care facilities, Tusla or disability facilities - very often all of them - members would have seen the child care law reporting project last week. The latter shows how challenging it is to make all those services work together. In the latter half of last year, the HSE established a specific child and youth mental health programme. We now have a dedicated national clinical lead specifically for children as opposed to just mental health, which was predominantly adults. We have separated adults and children. We have a dedicated full-time resource driving that programme. The resourcing of the CAMHS teams has increased, is increasing and that is continuing. There is a recruitment challenge in that.

Deputy Verona Murphy

I am talking about services that are in existence like the Parenting Network, Parents Plus and many others around the country. Where the HSE is falling down in providing the CAMHS network, from where do we get support for parents who cannot access or are awaiting access? They need support. As a parent, I would find it extremely difficult to deal with any child, including my own, who had a mental health issue. They need supports too and the system is letting them down. The question is where is the budget for that support. I know that a child is not being brought back to Wexford. The parents are being advised not to bring her back to the CAMHS in Wexford because she is going to regress. They are considering having to move to Dublin to ensure their child recovers. That surely does not sound-----

Mr. Bernard Gloster

I will have to look into that, but I do not necessarily agree that that is the best advice to give parents. On supporting-----

Deputy Verona Murphy

That was after engaging with the team in Wexford in an online discussion. The conclusion was that she would be better off staying where she was for treatment.

Mr. Bernard Gloster

I do not doubt that. I will provide an example of supporting parents of children on waiting lists. Many of the same children are in disability services, with them crossing over and back. Due to the waiting lists for our children’s disability network teams and so on, we advertised in the second half of last year for all organisations that could support parents and children like the ones the Deputy mentioned-----

Deputy Verona Murphy

I know the HSE did. I have been contacted by many people who submitted tenders but have heard nothing.

Mr. Bernard Gloster

The final-----

Deputy Verona Murphy

I ask Mr. Gloster to submit to the committee what structures and funding are in place.

Mr. Bernard Gloster

Okay, but to be fair, the point I am trying to make to the Deputy is that a substantial allocation of funding will be made available to those organisations. All of the tenders were screened last week. Due to our country’s history, I unfortunately cannot write a cheque to an organisation without the appropriateness of that being scrutinised. I absolutely-----

Deputy Verona Murphy

I will finish on this-----

Mr. Bernard Gloster

Sorry, but just let me finish.

Deputy Verona Murphy

-----and I ask Mr. Gloster to submit the information. We can write cheques when it all goes wrong and we pay through the nose when the system fails and parents sue or children die. I am trying to institute prevention.

Mr. Bernard Gloster

We share that aspiration.

Deputy Verona Murphy

I thank Mr. Gloster. I look forward to seeing what he submits to us.

Deputy Alan Dillon

My first question is for Mr. Watt. I thank the witnesses for joining us. While I welcome the establishment of the productivity and savings task force, what cost savings does Mr. Watt envisage can be realistically expected? How will they be achieved on the back of the current situation the HSE faces?

Mr. Robert Watt

At this stage, we do not have a specific figure in mind, given the uncertainty in and difficulty of this type of exercise. Initially, the focus will be on the acute side. There are three main spending areas there, the first of which is staff. Mr. Gloster touched upon the developments in that regard. Obviously, people are employed, there is overtime and there are agency staff. We are examining the various elements of that to see whether we can make changes that could take cash out while sustaining and improving services. The second area in the acute hospital system is the medicines budget. I believe it amounts to €700 million or €800 million. There are issues around usage and pricing as well as overlapping issues with the budget of the PCRS. Third, a variety of non-pay and non-medicine budgets are required to fund hospitals – power and heat, food, surgical services, consumables, etc. We are working through each of the areas and trying to establish the extent to which we can examine opportunities to save, be it better pricing, better stock management or better utilisation of consumables. It is right across the board.

As Mr. Gloster stated, this year’s budget is challenging. We have to provide services as best we can at the lowest possible cost. Whatever financial deficit might occur needs to be kept as low as possible. That is the mandate we have been given by the Government and that is what we are trying to do.

Deputy Alan Dillon

Has the Department of Health addressed the concerns around the growing overruns and the approach previously taken towards embedding those overruns in the base of future budgets? Has the Department moved away from that approach now that the task force has been established?

Mr. Robert Watt

The overruns in 2023 were recurring spend unless two things happened – prices fell or demand fell – and neither of those is likely to happen this year. We are seeing inflation slowing down, but that is not the same as prices falling. The demands on the system are astronomical. To provide one figure, the number of outpatient consultation referrals went from 600,000 in 2013 to 1.3 million last year. The number increased by more than 330,000, or almost a quarter, between 2019 and 2023. That is partly due to a post-Covid effect, with people who would normally have sought consultations deferring those during Covid but whose conditions or problems have since worsened, leading them to seeking assistance. We just do not know. We hope that growth will return to a steady 3% or 4%.

In the absence of action, last year’s overruns are recurring and are embedded in the system. The challenge for all of us around this table and our colleagues in the HSE and the Department of Health is to determine what actions we can take to try to make those savings and keep the deficit as low as possible.

Deputy Alan Dillon

Do the officials in the Department of public expenditure and reform agree with Mr. Watt’s summary of where the costs are coming from?

Mr. Robert Watt

Absolutely. I am sure they do, do they not?

Deputy Alan Dillon

Has Mr. Watt had any engagement with them?

Mr. Robert Watt

Everyone here is nodding. They do, absolutely.

Deputy Alan Dillon

I will ask the Department of Public Expenditure, NDP Delivery and Reform officials who are with us today to comment on the proactive steps the Department of Health is taking towards expenditure management.

Mr. Evan Coady

As Mr. Gloster and Mr. Watt have outlined, the savings and productivity task force is an ambitious programme. There is still a great deal of discussion to be had between us and the Department of Health about the pressures that arose in 2023 and the level at which they are permanent or temporary. Mr. Gloster and Mr. Watt also referenced the non-core funding of up to €1 billion, which is essentially provided by the Government to address the post-Covid surge in demand. With that non-core funding as well as significant core funding, the health sector now has €22.8 billion to manage services in 2024. We will engage through the processes that are in place – the health budget oversight group, or HBOG – to oversee demands throughout the year and what effects savings and productivity measures are having on the trajectory of spending in 2024.

Deputy Alan Dillon

Is Mr. Coady’s Department satisfied with the HSE’s willingness to implement cost-cutting measures?

Mr. Evan Coady

The HSE has a good track record. For example, Covid expenditure has reduced from just over €3 billion to €800 million.

Deputy Alan Dillon

Those were exceptional circumstances.

Mr. Evan Coady

For sure, Covid was an exceptional circumstance. There was a target of a 10% reduction in agency costs in 2023. The discussions on the reduction in agency and overtime expenditure are ongoing and the target for 2024 looks to be significant. The HSE’s ability to stand up a recruitment pause, slow down and achieve the recruitment numbers for which it is funded also represents an effort. All of this points to a strong foundation going into 2024. Everyone acknowledges that the position will be challenging, but there seem to be some strong plans in place to deliver savings in 2024.

Deputy Alan Dillon

I thank Mr. Coady.

The Department of Health’s efforts to seek payments from over 800 people in respect of the mandatory hotel quarantine process resulted in a write-off of almost €1 million. Has the Department sought approval from the Department of public expenditure and reform for that write-off?

Mr. Robert Watt

I think we did. I think it was understood that the cost of trying to retrieve the money would have been greater than the likely recoverable rate. That is a decision that bodies have to make at times. Be they public bodies or private ones, they have to make commercial decisions about debts. Unfortunately, the debts in question were bad ones that we needed to write off. It was a controversial system, as it was not a service that people were buying willingly off the State. They were being forcibly quarantined. The circumstances were different than would normally have been the case, but I believe the right decision has been taken.

Deputy Alan Dillon

What is the primary focus of the capital programme in terms of investment?

Mr. Robert Watt

I will ask Mr. Tierney to address that. The programme has many aspects, for example, finishing off large projects, building primary care centres, community beds, digitalisation, refurbishment, etc. Maybe Mr. Tierney will-----

Deputy Alan Dillon

Can we focus specifically on additional bed capacity in hospitals?

Mr. Derek Tierney

In any given year, and in recent years in particular, approximately 60% of our annual allocation is prioritised for contractual commitments, those being where projects are under way.

Then we get into the next tranche which is around regulatory compliant location safety, then infrastructure risk and fleet and equipment upgrade, followed by climate action, which gives us approximately 20 to 25% on an annual basis to progress new initiatives. Bed capacity is our focus both in acute and community hospitals. It has to be, but it is not the only focus.

Deputy Alan Dillon

Regarding acute hospitals, how many new beds came on stream in 2022, 2023?

Mr. Derek Tierney

I would say over the past three years, we have opened about 1,126 beds. We are investing in 2024 to open 147 more beds on top of that and we have between 255 and 257 in a pipeline, whether either in construction, at tender or at detailed design stage for planning permission.

Deputy Alan Dillon

What is the target for 2024?

Mr. Derek Tierney

The target is to open 147 beds in 2024. We also invest in refurbishing existing beds or upgrading old nightingale wards. Our plan is to upgrade another 55 existing beds to replenish them to bring them to infection control and modern building standard.

Deputy Alan Dillon

Regarding the hospitals the Department looks to prioritise, how is that selection process undertaken?

Mr. Derek Tierney

When you look at what the available allocation is when netted out of our priorities, we look at demand pressure, age of stock, and buildability. The HSE has a prioritisation protocol which looks at seven or eight criteria around patient safety needs, demand pressures and so on. Therefore, there is a categorisation or criteria process within the HSE's allocation.

Deputy Alan Dillon

One final question relates to the cost of building inflation. I had a specific case in my own constituency around Ballyhaunis primary care centre where we have a contractor offsite for the past two years. What is the process or protocol in place? Certainly, the people in Ballyhaunis and the surrounding areas of east Mayo have been left in limbo land, not knowing where this project is going, nor have we had any sign of the direction of travel.

Mr. Derek Tierney

It is fair to say the past two to three years have been very challenging from a cost of financing perspective. We deliver primary care centres through three main means, whether this is through a PPP where we bundle a number, contract the market and pay that back over a number of years through unitary payments; using a traditional delivery where the HSE does a design and build, or design which is then put out to the market; or then more prominently in recent years, by pursuing what is called an operation lease model where the private sector takes the risk share on planning permission, design, and cost of financing. We are seeing an impact on delivery in that tranche of projects at the moment. On one hand, it is quite simple. We have engaged a developer to deliver. It has taken a position to put a project on pause because it is looking at viability. We are in the process of re-engaging with a number of developers but as, I think, the Secretary General said, we are seeing inflation softening so that may help unlock where we currently are. However, I cannot give the Deputy certainty on that other than to say we are actively engaged on those properties to try to push them ahead.

Deputy Paul McAuliffe

I thank all the witnesses for their attendance. Like everyone else, I have a question or two about my own constituency which I will tuck in at the end but I will start at the beginning of the conversation. I have a graph before me of the votable spend for Vote 38 for 2019 through to 2022. It does not have specific labels on each bar but the trajectory of increase in health funding is very obvious. Does anybody here have the total spend for 2019 for the record? Do we know that figure?

Mr. Robert Watt

It was approximately €17 billion.

Deputy Paul McAuliffe

The total Vote for 2024 as provided in the budget for this year, is what figure?

Mr. Robert Watt

It is €22.8 billion.

Deputy Paul McAuliffe

Essentially, there are people in this room who voted for Vote 38 and there are people who did not. It is very difficult for those who voted for the budget and see a €6 billion increase in the health funding to listen to other people in the room talking about cutbacks. Yet, the narrative of cutbacks is out there. There are people out there talking about health cuts. People believe that the current Government, the HSE, the Department of Health, have cut spending on health when in fact there has been more than €6 billion of an increase over the course of the Government's term. I have not worked that out but is that a 35% increase over the lifetime of a very short Government? No doubt Covid was an element of that and we are weaning our way down off what was probably a surge of spending for that but it is still a very significant increase. I have to ask the witnesses the question. They are responsible for spending the money. How did we get to a point where people are talking about cutbacks? What happened?

Mr. Bernard Gloster

From a service perspective, unfortunately when anybody sees any type of constraint on or control of how we use what we have, they might chose to represent that as a cut. The simple reality is, if you take a €6 billion increase and take out pricing factors and everything else out of that, that is at least a 50% increase in investment. Due to demand and many other things, but also due to lack of modernisation, our performance has not matched that demand and if you still end up with a waiting list people call it a cut. It is not a cut. I have been in this job for ten months. I have not spoken about the narrative of cuts. We have spoken about how we use what we have better, demonstrate to the people of Ireland how we are using the money they are giving us, and how we deliver the best service possible. Those three variables do not always line up, as the Deputy knows, in public narrative.

Deputy Paul McAuliffe

Let me talk then about the issue of the recruitment embargo because there has been a lot of discussion about that and reference to there being no recruitment, people not being appointed and so on. I am not even using the term "recruitment embargo" but my understanding is that there were funded posts and unfunded posts.

Mr. Bernard Gloster

That is right.

Deputy Paul McAuliffe

I understood that all of the funded, approved posts were filled, can be filled and are allowed to be filled. Is that correct?

Mr. Bernard Gloster

It is slightly more nuanced than that but the Deputy is not far off. People always talk about losing people, attrition or turnover. In net terms, the workforce in the health service has grown more in the past three and a half years than could be traced back to the foundation of the HSE in 2005. That is the first thing. Second, we planned - or at least intended to - recruit roughly 6,100 net new people last year and we finished the year at about 8,300. There are still people who came on in January who were contracted in the winter last year so I imagine, not to give my colleagues a shock, that we could round it as 8,500. That is 2,400 more than we targeted to do. That is a good thing but it is also a bad thing because there comes a point at which that is just not affordable and sustainable. Even within that, critical clinical grades were derogated, and rightly so. In fairness, the Department has never said to me not to do something that would hurt somebody. Again, we are walking a very fine line. All of that recruitment, every grade code in the HSE, is up very significant percentages from 2019 to now. We are talking 25% to 35% growth.

Deputy Paul McAuliffe

So we have more staff-----

Mr. Bernard Gloster

Yes.

Deputy Paul McAuliffe

-----and we have recruited more than even was expected last year.

Mr. Bernard Gloster

Completely, yes.

Deputy Paul McAuliffe

Let me turn then to the idea of unfunded posts. Can Mr. Gloster talk to me about what they are and what that term means? I have heard the Minister use the phrase that it would be like a principal hiring teachers for a ratio for which he does not have approval. Will Mr. Gloster explain that?

Mr. Bernard Gloster

Essentially, an unfunded post is when we say to hospital X or community care area Y that they have a control of 25 jobs. This is the number of posts with which they have to work. However, be it because they are responding to need or because of poor control, they finish up at 28. Three of those jobs are unfunded. This does not dismiss the fact that there might have been a need, a pressure or a good reason. It is not that people recruited willy-nilly. However, those are unfunded posts.

Deputy Paul McAuliffe

And they are the ones that are specifically being targeted as part of the overall?

Mr. Bernard Gloster

We now have to target the overall pause to try to bring the system back to a controllable level. Management administration is a very good example and is the highest percentage growth grade code since 2019. In 2023, before I came into this job, it was agreed that there was an additional 1,450 jobs to go into that category. By the end of 2023, it was 2,200.

That is practically fully paused. There is a very small bit that is not, but it is practically fully paused. It is fully paused because we are carrying about 800 unfunded posts. The result of that is the industrial action we are now dealing with.

Deputy Paul McAuliffe

By the same token, Deputy Murphy and I and others will criticise the HSE for not recruiting more in certain categories. How much of the unfunded post was in some ways about forward-planning the recruitment problem?

Mr. Bernard Gloster

It is a very mature thing in a modern-day healthcare system, when you are planning something like a major change programme in stroke or heart health, that you plan ahead and plan over a succession of four years to recruit for a number of jobs. However, you have to wait every year for the Vote to see if you are able to fund that and, if so, how much of it you can fund. A lot of that has been funded. More is expected, but a cut, to me, is when you have something you are supposed to have and it is taken away.

Deputy Paul McAuliffe

That brings me to my last question on this point. Is it not time we moved to multi-annual funding for health? I am Vice Chair of the housing committee. I have seen how when we have done multi-annual funding for housing for capital it has transformed the way we are able to deliver housing. It has given confidence to the sector. We now have 100,000 houses being constructed, which is a huge amount of public housing. Is it not time we did the same for health? Looking at that figure, an extra €6 billion, if the HSE had confidence in that over time, it would have been able to plan differently. This debate every year about the budget going up and down does not reflect the reality of the total amount of funding.

Mr. Robert Watt

We do have multi-annual funding in respect of capital, which gives certainty on capital projects. It takes a number of years to deliver, so an annual basis would not work. I think there is a very strong argument for multi-annual budgeting for health. It is something we have discussed in the Department on occasion. We have discussed it with the Department of public expenditure and reform. I think it would make sense. Maybe, at the beginning of a new Dáil, when there are four or five years of perspective, you could set out a budget for two, three years then review it halfway through that Dáil. That is a difficult issue for the Minister for public expenditure and reform, the Minister for Finance and the Government to commit to, but we have demand growing by 2% to 3% a year and we have inflation in normal times, so-----

Deputy Paul McAuliffe

I take it as a positive response, but that is a matter for us as well.

There is one issue with the embargo in that the co-ordinator for the drugs task force in our area, a gentlemen named John Bennett, a fantastic man, passed away, and there have been suggestions that that post cannot be filled because of the recruitment embargo, even though it has been filled for 20 years. I ask the witnesses to look at that and maybe come back to me offline.

The second issue is the Finglas counselling service, a fantastic service. The Minister of State with responsibility for mental health was out with them. I believe there are negotiations going on to provide additional new support in the area and, again, for a small amount of money I ask the witnesses to do what they can.

The last point - I might come back to it in the second round - is the Finglas primary care centre. In 2020, we were sitting here talking about a land swap and finalisation of a project and we still have no Finglas primary care centre.

Mr. Bernard Gloster

I will let the other guys talk to the primary care centre as to where that is at. Sometimes, when you introduce a control, because our systems are very immature in some ways, you will get an unintended consequence. There would be no question but that I would consider the co-ordinator of a drugs task force to be an essential job, even if it is categorised as management-admin, which it probably should not be, so we will look after that. I had the pleasure a couple of months ago of going out to north Dublin to GP Care for All, which is essentially like a not-for-profit employment group that employs GPs-----

Deputy Paul McAuliffe

An AHB in health.

Mr. Bernard Gloster

Yes. It is really good, and they needed a one-year enabling grant to allow them expand into Finglas and we gave them that because it is the right thing to do because people need to be able to access their GP. That is why we are managing hospitals the way we are. While the Deputy is waiting for the primary care centre, we have gone ahead with the GP-----

Deputy Paul McAuliffe

Yes, and we do appreciate Mr. Gloster's intervention on that.

Chair, could I get a quick update on the primary care centre?

An Cathaoirleach

As regards the budget figures the Secretary General went through there, there was €439 million in 2022 and the accumulated debt at the end of 2022 was €1.24 billion. What was the accumulated debt in respect of the HSE at the end of 2023? I would like just a quick answer to that.

Mr. Robert Watt

Mr. Mulvany might have the number to hand.

Deputy Paul McAuliffe

Sorry, Chair. Could I just get the reply on the primary care centre?

An Cathaoirleach

I thought you were going to leave it to a second round. Do you want to leave it to a second round? Mr. O'Connell has a quick reply now.

Mr. Brian O'Connell

It is a complex transaction. It is a win-win-win to our mind. We have failed to get planning permission on a previous proposal. We have taken our time to make sure that we will put forward a very good proposal that stands up for us and the community and the neighbouring schools. We are going towards planning permission in quarter 2 of this year-----

Deputy Paul McAuliffe

Brilliant.

Mr. Brian O'Connell

-----and that will really put a strong footing on it. All the transactional elements are almost put in play and it is a very strong collaboration between us, Dublin City Council, which has been very supportive, and the City of Dublin Education and Training Board.

An Cathaoirleach

Mr. Mulvany, I asked about the accumulated debt from the HSE at the end of 2023.

Mr. Stephen Mulvany

In 2021, it was €1.253 billion, and in 2022, €1.243 billion. As regards 2023, we do not have the AFS yet. The AFS-----

An Cathaoirleach

What is it expected to be? You are the chief financial officer. You have the figure in your head.

Mr. Stephen Mulvany

I do not, actually, because we have not had financial data for the past four months.

An Cathaoirleach

Do you think it will be increased?

Mr. Stephen Mulvany

Yes, absolutely.

An Cathaoirleach

By what? A quarter of a billion?

Mr. Stephen Mulvany

North of half a billion.

An Cathaoirleach

So it could be €1.75 billion.

Mr. Stephen Mulvany

Yes, but, again, we have to wait until the AFS is done and the audit is complete.

An Cathaoirleach

Just so as we are clear, the expected carrying debt of the HSE at the end of 2023 is €1.75 billion.

Mr. Stephen Mulvany

In the overall balance sheet and reserves, yes.

An Cathaoirleach

Thank you. I call Deputy Munster.

Deputy Imelda Munster

I want to come back to the recruitment embargo. Mr. Gloster made reference to 4,000 to 5,000 posts. What areas or professions or grades would be affected with the 4,000 to 5,000 posts not being filled?

Mr. Bernard Gloster

They would go right across every grade code, from medical, nursing, management and administration to allied health professionals. They were posts that were over a couple of years indicated as being needed for programmes that were agreed in principle, but each year you would arrive you would determine how much of them you could afford to bring into play. As I have just said, the Minister has secured some additional funding since the budget and he is now looking with us as to the best priorities of those. They would be anticipated posts but they would-----

Deputy Imelda Munster

Would they be funded or unfunded?

Mr. Bernard Gloster

They would be unfunded until they come online in the year they come and then there is an agreement to fund them in that year.

Deputy Imelda Munster

Would they cover the likes of, say, speech and language therapists, occupational therapists, psychologists or psychiatrists?

Mr. Bernard Gloster

They are tied more to programmes than to services. We call them the overhang. If I come back from those, at the moment, in all our disability services, there is no pause on speech and language, OT, physio or the other allied health professionals who assist there. In our primary care services there is an element of pause in them in terms of replacement. The main impact of the pause is probably on the management administration side. That is probably the most significant-----

Deputy Imelda Munster

This is just what is happening on the ground, and that is why I am asking Mr. Gloster the question. There is a 12-year-old Down's syndrome girl and her parents had approached the services for speech and language therapy and were told there was one part-time speech and language therapist for the area - this was in Louth - and there were 700 people waiting. Can Mr. Gloster explain to me what he just said there? There is no pause, and then he said that in primary services there is an element of pause. What does that mean in layman's terms?

Mr. Bernard Gloster

I am talking about two different services. In children's disability teams there is no pause. The half of a speech therapist in that area has nothing to do with recruitment policy; it has to do with the ability to attract speech and language therapists to work in the disability service.

Deputy Imelda Munster

What does Mr. Gloster think is the block? People entered into that profession, obviously had a grá for it and wanted to do it, so why now do they not want to work within the HSE disability service? Why does Mr. Gloster think that is-----

Mr. Bernard Gloster

I think there are a lot of reasons. I might ask Mr. Walsh, who is very familiar with this, to comment on it.

Part of it is because we have more jobs than graduates.

Deputy Imelda Munster

What does that mean?

Mr. Bernard Gloster

We want to hire from the countries that supply-----

Deputy Imelda Munster

Yes. I am curious as to what it is. If one goes to any other European country, and I have family and friends living right across Europe, those services take a preventative approach. They are really progressive and well-run health services. One never hears of shortages such as we have here. Is this the nightmare that is the HSE and all that goes with it? Is it what stops graduates wanting to work within the service? What have the witnesses found to be the thing that means people just do not want to work with the HSE?

Mr. David Walsh

It is complicated, and we need to do a lot of work to make those posts attractive-----

Deputy Imelda Munster

Such as?

Mr. David Walsh

We need a properly resourced plan, which we now have on the disability side, that will work with the professionals within the teams and the various organisations, because a lot of it is done-----

Deputy Imelda Munster

Excuse my ignorance, but what is a properly resourced plan?

Mr. David Walsh

We are currently working specifically on children's network disability teams, CDNTs, and we are working to implement the roadmap, which will try to address many of the issues the Deputy is describing-----

Deputy Imelda Munster

Mr. Walsh is saying that they are not there yet. The HSE has a roadmap.

Mr. David Walsh

The biggest difficulty we have is making those posts attractive which is exactly what the Deputy-----

Deputy Imelda Munster

Will Mr. Walsh give us an inclination of what the roadmap would include to make those posts attractive? How will the HSE encourage graduates who clearly want to work in the field - or they would not have studied the field in first instance - into what they would see as the last place they would want to work?

Mr. David Walsh

We need to make sure that disability is not the last place they want to work-----

Deputy Imelda Munster

The HSE, as the service provider, is the last place, not the disability area. They have trained and qualified in the field. They clearly want to work within that field, but the HSE is a no-no for them. Can Mr. Walsh give me a concrete answer to my question? Something more concrete than a roadmap.

Mr. David Walsh

As the CEO said, we are prioritising disability posts. We have signed off on several hundred vacancies within the CDNTs over the past couple of months. We have a specific targeted approach to recruitment. There probably are not as many opportunities, in the context of other aspects of services, for those professionals, whether they are occupational therapists or-----

Deputy Imelda Munster

Mr. Walsh has not told me how the HSE is making the posts more attractive yet and there are three minutes left on the clock.

Mr. David Walsh

We need to engage with the staff within the system and build the capacity incrementally within those teams.

Deputy Imelda Munster

That is only being done now. For many years, parents have been brought to tears in respect of disability services and the lack of access to them. These are early intervention services; they are seen as critical and crucial. Now we have a roadmap that is literally just talk.

Mr. Bernard Gloster

To be fair, and to pick up on the point that Mr. Walsh is making, it is not the case that the HSE is unattractive. We are the biggest employer of all of those therapists. Every single health and social care system in the world develops services on the basis of multidisciplinary teams. Consider a speech therapist graduating out of Trinity College next autumn. He or she will have a choice of multiple specialties to walk into. It happens to be the case that many graduates find the other specialties more attractive. Many find the disability service environment to be exceptionally pressured. When we talk about improvements we are referring to continuing medical education, better supervision and better possibilities for ways and models of working. The CDNT is the chosen model for now. When Mr. Walsh talks about making that more attractive, he is specifically referring to getting people who want to work with children with disabilities into those teams. We have a recruitment campaign-----

Deputy Imelda Munster

Mr. Gloster referred to the disability service being exceptionally pressured. This is the actual reason. I have made inquiries about this in other European countries. There is not the shortfall in recruitment there. People are there who are needed in those services. The fact that, as Mr. Gloster said, the service is exceptionally pressured is key. It has been so run down people would ask why they should work in an exceptionally pressured health system that just does not work. I refer to the example of one part-time speech and language therapist for 700 children. This is replicated across all of the early intervention services right across the board. That is an absolute failure.

Mr. Bernard Gloster

That is exceptionally concerning. The Friday before last, we closed a competition targeted at CDNTs. We received 435 applications. We will process all of those quickly. Those who are qualified and who wish to take a post will be offered one.

Deputy Imelda Munster

How long does it take to process applications? I have heard that it takes forever in the HSE between the time somebody applies for a job and when they are offered the post. Earlier, there was reference to posts that were approved last year coming on stream. From the time a person applies for a job, how long is it before they are offered that job and start working?

Mr. Bernard Gloster

It can vary from 12, 16, 20 to 24 weeks.

Deputy Imelda Munster

Jesus. Six months.

Mr. Bernard Gloster

Particularly with cases of those allied health professionals who trained abroad. They have to register with CORU and their course has to be validated by CORU. All of those registration processes-----

Deputy Imelda Munster

That would be for one sector but what of the majority of people that are not in that category?

Mr. Bernard Gloster

For the majority of people we are targeting this year we would have a turnaround time of 12 to 16 weeks.

Deputy Imelda Munster

That is exceptionally long too. If a person goes for a job in any other sector they ask how much notice must the interviewee give. If the person says it is two weeks they say "Oh brilliant, start then in a fortnight".

Mr. Bernard Gloster

In fairness, I would say the opposite. If someone is recruited into the Irish health service within 12 weeks, by international standards, that is a gold standard because they all have jobs already and they all have to be processed, vetted, reference checked and cleared, and they all in the majority must give notice to the jobs they were in. A turnaround time of 12 weeks is considered the gold standard. This is not about walking into a shop, handing in the CV and asking for a job.

Deputy Imelda Munster

No, but other professions have managed to go through the vetting process and that. It is public knowledge - and I am not saying this to be insulting - that the recruitment process for applying for a job in the HSE takes forever.

Mr. Bernard Gloster

I would point to the discussion we had about the numbers we recruited last year which shows that this is starting to turn around and has improved substantially. I will certainly take every opportunity to improve it for them. It must be said, however, that we are in a full employment market. I would consider 12 weeks exceptionally good.

An Cathaoirleach

Can I clarify that those posts are funded? Reference was made to several hundred posts signed off for the CDNTs? What was the figure?

Mr. David Walsh

There were some 700 vacancies in the CDNTs. It is our intention to recruit into every single one of them.

An Cathaoirleach

Mr. Gloster said they were being recruited. How many are there?

Mr. Bernard Gloster

The campaign closed last Friday week and there were some 450 applicants.

An Cathaoirleach

Were these for various therapies?

Mr. Bernard Gloster

Right across the therapies, yes.

An Cathaoirleach

Are those posts funded now?

Mr. Bernard Gloster

Yes.

An Cathaoirleach

And there will not be an issue there?

Mr. Bernard Gloster

No.

An Cathaoirleach

I just wanted to clarify that. I want to suspend the meeting for ten minutes. We will return just after 11:00 a.m.

Sitting suspended at 10.59 a.m. and resumed at 11.11 a.m.

An Cathaoirleach

The next speaker is Deputy Catherine Murphy.

Deputy Catherine Murphy

One of the issues that has been addressed is the gap between the budget and what will be needed. We talked about agency staff, overtime and procurement as some of the areas that are being looked at. I listened to the language. Language always tells you something. For example, the phrases "it is an ambitious programme" and "it is challenging" jump out at me. A supplementary budget is what that adds up to for me. Does the HSE have oversight of the integrated financial management system, IFMS, which money was provided for in recent years? It should have been provided many years ago. Where is that system at this stage and when will it be fully delivered?

Mr. Bernard Gloster

I will let Mr. Mulvany answer that because he is leading the IFMS project.

Mr. Stephen Mulvany

We have oversight. The system went live on 1 July in the east, which accounts for approximately 40% of the HSE's statutory spend, excluding the voluntary organisations. While we have a lot of problems, it is now working well overall. While we lost some time on that, and there was the Fórsa dispute. With assistance from the Government, we expect to be able to claw back most of that. We intended to have 100% of the HSE statutory system on it by May 2025. We expect that it will be more like September 2025. We will catch up by changing how we will roll it out and with some additional investment.

Deputy Catherine Murphy

Has it been of benefit on the east coast by showing where savings might be made?

Mr. Stephen Mulvany

Like a lot of transformation programmes - and it is a major transformation programme - there were problems initially. Performance can dip, and we have gone through a lot of that. Now, the services are seeing, certainly regarding some of the basics, such as making payments to suppliers, that we are now able to make payments to many suppliers more quickly. Gradually, as we turn on the reporting capacity, we will have much better visibility of our non-pay spend, including to suppliers at what we call material code level, for better planning. Over time, as we roll out the rest of it, we will be able to see why our costs are moving on the non-pay side, such as whether it is because we are buying and using more consumables or whether it is the price of those consumables. When we link up with the HR system - that is under way - the ultimate aim is to get to the stage where we can plan budgets at an individual position code level and know specifically why we are using more hours.

Deputy Catherine Murphy

Will it be fully available when the new regional system is in place?

Mr. Stephen Mulvany

The new regional system will start on 1 March this year. It should get through its first transition phase by the end of the year, so the system will not be available for that. However, interim reporting has already been built for the six regional executive officers, REOs. We expect to be able to provide them with the financial reports they need, at least at the level we currently provide to the managers, from the time they start.

Deputy Catherine Murphy

There was a supplementary budget of €40 million at the end of last year for the national children's hospital. Where will that €40 million take the project in 2024?

Mr. Derek Tierney

The National Paediatric Hospital Development Board, NPHDB, is engaging with the contractor. The contractor's current programme aims for substantial completion in October. That is what the contractor is being held to and it is the target we are monitoring against.

Deputy Catherine Murphy

Will the €40 million be sufficient to take the project there?

Mr. Derek Tierney

Gosh, no.

Deputy Catherine Murphy

There is a reconciliation.

Mr. Derek Tierney

The sanctioned capital budget was €1.433 billion and the €40 million increased that to get us into the new year. We expect to go to the Government to ask for an increase shortly.

Deputy Catherine Murphy

Has the reconciliation to go to the Government been done at this stage?

Mr. Derek Tierney

Yes, but I will not declare it today.

Deputy Catherine Murphy

Where will the €40 million take the project?

Mr. Derek Tierney

It will account for inflation already incurred on the project. It was to ensure the NPHDB could meet its financial obligations under public financial procedures. It was to allow it to meet liabilities that had arisen.

Deputy Catherine Murphy

We have heard before that the project would run out of money or would require a supplementary budget.

Mr. Derek Tierney

The board was coming up against the original sanctioned budget and the Government needed to increase the sanctioned amount.

Deputy Catherine Murphy

By what date will decisions have to be made before the project runs into difficulty with being unable to pay bills?

Mr. Derek Tierney

Within the next month or two.

Deputy Catherine Murphy

There is no slippage on October.

Mr. Derek Tierney

That is the contractor's programme. It is what the contractor has offered and the date it is being monitored against.

Deputy Catherine Murphy

Would the project have halted in the absence of that €40 million?

Mr. Derek Tierney

No, the point of looking for the sanction for the increase was so that we did not come to a stall.

Deputy Catherine Murphy

On the CDNTs, from what I can see - I can only judge by the cases I have come across, some of which have been the most extreme and harrowing of cases - the services might as well not exist. People do not even get a call back and people who have the most extreme cases are being told to come back in a year's time. Is it a postcode lottery with a particular issue in one CHO area or is it an issue across the board? Is it a funding or staffing issue? What is the impediment to delivering these critical services?

Mr. Bernard Gloster

It is not a funding issue. On the availability of staff, which I discussed with Deputy Munster, we are up against all the other services that are looking to recruit those professionals, which makes it a competitive environment and the work is especially challenging. Some CDNTs are working well because they are staffed and functioning. There are professional differences about whether it is the best model, but it is the chosen model and we expect people to work with it. I certainly do not think we should be in position in any area that people are not having their calls returned. I would not stand over that. Regardless of waiting lists and pressures on people, I have certain basic expectations of the significant number of staff who are in those services, including that they at least keep parents informed. We are trying to supplement the support for parents, as I mentioned earlier to Deputy Verona Murphy. Next week, I hope we will publish a list of organisations CDNTs can use to support parents with different types of play intervention, such as play therapy, music therapy, equine therapy and so on, and family support. All that does not replace what should be in the CDNT, but it is difficult.

Deputy Catherine Murphy

I am not precious about phone calls being returned if the service is being delivered, but I can tell Mr. Gloster about the most extreme cases I have come across. I will talk to him about them later. They are the most extreme cases. He would be horrified by some of these cases and there is not even any engagement with the families. I will take them up with him separately.

Mr. Bernard Gloster

I am certainly happy to say what I have said publicly previously since I came to this job. We are doing a huge amount to make that better.

I am certainly very committed to that and I know the Minister, Deputy O'Gorman, and the Minister of State, Deputy Rabbitte, are as well. I have no difficulty saying on public record that we have come up short for children with disabilities and that is something that would be to my regret as a health service professional and a former social care worker. We have come up short. We are very much improving, but it is going to take a long time to get there.

Deputy Catherine Murphy

I might move on to the local drug and alcohol task force funding. In 2023, €3.5 million was allocated. What kinds of controls are on that in terms of it being spent on what it was announced for? Is it plugging gaps? Will there be a need for multi-annual funding or is it a one-off? I know how much has been allocated to each of the CHO areas but this is about the control on that money actually being spent on what it has been provided for.

Mr. Bernard Gloster

I do not have specific detail on that to hand. If we go back to the previous iterations of the regional drug task forces, I would have a clear expectation, first, that we would not vire that money for anything else and I would expect local chief officers in CHO areas to utilise the money for the task for which it is meant. If they have a difficulty either in recruiting or in utilising the money in a particular way, they should still use it within the overall drugs remit, whether that is on harm reduction such as methadone or on counselling, interventions and so on. I think the control of protecting the money for drugs is what the Deputy is talking about, and I would certainly be happy that this is not a major problem.

Deputy Catherine Murphy

We have been told roughly how much is to be allocated each week. Has it been allocated?

Mr. Bernard Gloster

I might come back to the Deputy on that and give her a specific assurance but I can certainly say that if she has been told how much has been allocated to the various drugs task force services, I can assure her it has been allocated.

Deputy Catherine Murphy

I am hearing from people on the ground, however, that the expectation is very different from the reality, and that is why I have concerns about the control.

Mr. Bernard Gloster

I will certainly look into that.

Deputy Catherine Murphy

Okay. I might come back to Mr. Gloster on that.

Deputy Marc Ó Cathasaigh

I thank the witnesses. I have a number of issues but I want to pick up on something other Deputies raised, relating to the CDNTs and CAMHS. As a member of the autism committee, I know there is a huge issue whereby, when someone arrives with an autism diagnosis, they are referred out of CAMHS and into the CDNT. CDNTs are a black hole at the moment. I have to concur with Deputy Murphy. My experience of trying to make contact with certain CDNTs to try to talk about individual constituents has not been a good one.

When someone speaks for a long time, sometimes some of the things they say will not stack up, and I made a note of something Mr. Gloster said. He stated children cross over and back between services, but that is not my experience at all. Children do not cross over and back between services. I want the CDNTs to work. I want that multidisciplinary approach to work, for children in particular. I could point Mr. Gloster to a school in the centre of Waterford city that has children from three city CDNTs. When I look at the work we are trying to do to get our RHAs to map more closely with our CHOs, I see the fragmentation that is happening with the CDNTs whereby one school will refer children to three different teams and the teachers are tearing their hair out trying to get services. I do not mean to be overly parochial, but my home parish, Butlerstown, is about 5 miles from the city centre and parents have been told their child is now being referred to Dungarvan because they are regarded as living in part of the county. We have to intervene with Ministers to avoid children being put into that position.

Unfortunately, when Mr. Walsh was answering the question earlier, it sounded terribly like civil servant speak. He referred to a "roadmap plan”. These are relatively new structures, and I am hearing about a lot of people who work with the CDNTs leaving. They are leaving to go to private practice and, contrary to some narratives, they are not going to private practice because they want to cash in. They are leaving because they are incredibly frustrated, and they are frustrated because they are not getting to see children. They are engaging in huge amounts of administration, they are not getting to see children and the whole structure is not working for them. As I said, I really want this to work for children. I echo some of the points made by Deputy Murphy about eating disorders and provision for eating disorders within the south east. It is very difficult to get access to services. We do not really want children to be in acute beds, if we are honest. That is not a good place for them or a good solution.

Where are we with this? The phrase "roadmap plan" just makes it sound more distant than ever that we will have some sort of seamless way of referring children to services that are so critically needed.

Mr. Bernard Gloster

First, to clarify, what I meant about "over and back" was not that children go over and back but that the issues cut across both services and, indeed, more widely. When children have many complex needs, there are often arguments between services as to which service is the most appropriate for the child. I have a very clear expectation that all the services of the State should work together to support the child and the family. Children rarely live in one particular item of need. That is a huge problem for us, and-----

Deputy Marc Ó Cathasaigh

I am sorry to interrupt, but this is especially true of autism. When there is an autism diagnosis-----

Mr. Bernard Gloster

Completely.

Deputy Marc Ó Cathasaigh

-----you think to yourself, "My God". We know there is a strong link between mental health and autism, yet they get locked out of the mental health services and it is awful on parents.

Mr. Bernard Gloster

Yes. In respect of the case of the school in Waterford that the Deputy cited, I am the first to admit, and I will put my hands up in saying, that the south east is particularly challenged with the model, more so than other parts of the country are. I am very anxious to get behind that and I have met people there myself. I am anxious to try to improve it. I have met people who left teams, in a very safe way, to allow them to tell me exactly why they left. I really am trying to get under the bonnet of this but the solutions are not simple. We struggle to a huge degree to provide responses to children with autism and to families as a result.

I accept the point about the terminology and language we use. To be fair, the roadmap is the roadmap - it is officially called that - because it sets out the milestones by which we are accountable, the first of which was that new, accelerated recruitment campaign two weeks ago, which I talked about earlier. I am not proud of where we are in our response, but I am in no doubt that we are making improvements.

Deputy Marc Ó Cathasaigh

I think we would all like that to come to pass. I will stay on the south east, given Mr. Gloster mentioned it. The reconfiguration of the new RHAs is welcome. The more quickly we can get them to coherently shadow the CHOs in order that we will get that linkage of services, the better. Under the reconfiguration, however, Limerick hospital anchors the mid-west, which has the smallest population by far among the regions, Galway hospital anchors the north west, Cork hospital anchors the south west but in the south east, we have to refer all the way to St. Vincent's hospital in Dublin. I know the decision was made in 2019 but we have a model for a hospital in Waterford. We have a population of 600,000 who live within an hour of that hospital, which is in excess of the population that relates to the mid-west. Who made the decision in 2019, and why was it made, not to build the south-eastern regional health area around Waterford and adequately resource UHW to be able to answer the health needs of the region?

Mr. Bernard Gloster

I do not think it is a case of it being built around St. Vincent's. The hospital groups have been split in the new geographical areas, and St. Vincent's is one part of that, but all the other services in the south east remain. There has been investment in Waterford hospital and there is no intention of not investing it in the future in deference to St. Vincent's or anywhere else. That is not the purpose of the regional construct at all.

Deputy Marc Ó Cathasaigh

Historically, we have suffered through the link with Cork, and there is concern in the region, which is well founded, that we are going to suffer-----

Deputy Marc Ó Cathasaigh: Historically, we have suffered with the liunk with Cork, and there ius concenr in the region

Mr. Bernard Gloster

But you will be separate from Cork now.

Deputy Marc Ó Cathasaigh

We are going to be separate from Cork now.

Mr. Bernard Gloster

Yes. I have already spoken to the new executive regional officer, Martina Queally. I expedited her appointment in the south east last Monday. She herself will not even have one base to either prejudice one part of the region or the other, as it were. I think you will see a lot of very good engagement and progress there. I am very confident it is a region that can work and it needs to work.

Deputy Marc Ó Cathasaigh

It absolutely does for the people of the region. There are 600,000 people, as I said, within an hour of that hospital.

I will stay on that particular area before I go to more generalised questions. The 8 a.m. to 8 p.m. cardiac service across seven days of the week, as we know, is an extremely important topic in Waterford. I had reason to be glad of the 8 a.m. to 8 p.m. service over Christmas rather than the 6 p.m. cut-off that was there previously. Deputy McAuliffe spoke a lot about funded and unfunded posts. Is the recruitment we need to move to an 8 a.m. to 8 p.m., seven day a week service, funded? Will that happen?

Mr. Bernard Gloster

I am not sure if the chief clinical officer knows exactly the plan on the percutaneous coronary intervention, PCI, service there. It is not a question of unfunded posts, I do not think. I am not exactly sure on the detail of that now.

Dr. Colm Henry

There is no question that those posts are embargoed at all. They are important clinical posts to provide the 8 a.m to 8 p.m. service.

Deputy Marc Ó Cathasaigh

Are they in place?

Mr. David Walsh

I am not sure. I will have to come back on that.

Deputy Marc Ó Cathasaigh

When in Waterford, you hear about recruitment embargoes. I think Deputy McAuliffe did a very good job of myth busting that a little bit. When people in the south east hear about recruitment embargoes in the context of a service we fought so hard for, people worry. Are we content that we are moving to that 8 a.m. to 8 p.m., seven day service?

Mr. David Walsh

I will come back with the report but that is our plan.

Mr. Bernard Gloster

The predominant requirement for 8 a.m. to 8 p.m. is both cardiac nursing and consultant cardiologists. The embargo does not impact on those.

Deputy Marc Ó Cathasaigh

That is very good. It is the clarity that I need.

I want to raise a couple of issues across two heads. In B.1, there are two items jumping out at me where we did not hit the spend we would like. Women's health research and mother and baby homes research. Under E.1 developmental, consultative, supervisory, regulatory and advisory bodies, there was an underspend or postponement to supports for Thalidomide survivors, women’s health taskforce initiatives and Nursing and Midwifery Board of Ireland developmental projects. You can see the common theme in them.

Mr. Bernard Gloster

Dr. Henry or Mr. Mulvany can speak about some of the specific issues on women's areas. In general, in 2022, hitting all the spending targets in certain programmes was slowed and delayed because we were still on the outdrift of Covid and the reprioritisation of services.

Deputy Marc Ó Cathasaigh

You can see, though, in the specific ones that I picked that there is a trend there. It is all around women's health.

Mr. Bernard Gloster

Yes but maybe I can assist the Deputy. The research on the mother and baby homes is something I am very familiar with from my previous life as CEO of Tusla. I think events overtook that in terms of the response to the Mother and Baby Home Commission reports.

On women's health, is there a specific reason on the research side for underspend, Dr. Henry?

Dr. Colm Henry

No, not for progressing with establishing the six maternity networks or sustainable consultant funding. There has been considerable investment in midwife appointments and expansion of gynaecology ambulatory clinics. There has been substantial investment and expansion of both obstetric and gynaecology services in recent years to make them more sustainable and safer.

Deputy Colm Burke

I thank the guests for their presentations here this morning and for dealing with the queries raised. It is important that I would raise something at the very start. There was reference this morning to the health service that does not work. It is important to highlight that the health service is working and that there are more than 3.5 million outpatient appointments per annum between all our hospitals. It is important that we do not portray a total negative response about the health service. Also, life expectancy in Ireland is now one of the highest across Europe. We need to acknowledge that, too. Yes, there are glitches and I am one of the first to highlight issues where there are problems.

First, I turn to cost savings in the HSE. One area where there are not cost savings in real terms is the roll-out of IT and the whole area of the computerisation of medical records and patient data. For instance, if you are in Cork attending three different hospitals there is a paper file in each hospital. With maternity hospitals, it is completely computerised in something like five maternity units but there are 19 maternity units in total. If we have developed it in five, why can we not progress it with the others? There are huge cost savings. This ties in with the other issue of junior doctors leaving. I was speaking to one of our junior doctors recently. One of the big issues that they are so frustrated with in the system here in Ireland is that they spend over 50% of their time trying to follow up issues like scans or reviews whereas if this was all put up on computer they would be able to access it immediately. This is a huge waste of valuable time. Starting with the maternity hospitals, why have we not rolled it out in all 19 units?

Mr. Derek Tierney

We have been concentrating on rolling out an electronic health record, EHR, for maternity services. Our hope is that by the end of 2024, 70% of all births will be registered and captured within that electronic health record system for maternities. Beyond 2024, we look to push that further. We have a very significant ambition in terms of IT deployment right across the health service.

Deputy Colm Burke

The question I am asking is why is it so long. Take social welfare, for example. In 2022, it issued 302,000 PPS numbers to people from 202 different countries but we cannot do this in health. We have our medical cards computerised and all of that done but we have not computerised our medical records or patient records so that you we not have this crazy waste of time that is going on at the moment.

Mr. Derek Tierney

It is well understood and well known that rolling out EHR is very complex. It is very complex technically based on our existing infrastructure and these are large systems. Funding allocation is another contributor in terms of how fast we can go and ultimately the capacity of the system to absorb change is another key factor. We are pushing hard on the maternity roll-out and, as I said, our hope is that by the end of this year, 70% of all live births will be captured and we will progress beyond that. That is competing in a very wide demand for other IT solutions right across the service, whether they are other clinical systems, back-office systems, community systems which we actually have to turn a focus to because our digital maturity in our community landscape is very, very immature and we need to progress on that.

Deputy Colm Burke

But that ties in with the other issue about the use of pharmacies, for instance. We have a whole lot of people having to attend GPs because you cannot open up the whole distribution of medication. If it is a non-prescriptive drug, you could go into ten different pharmacies and get the same drug on the one day whereas if all of that is computerised you could give a lot more work out to pharmacies and people would not have to go to GPs for prescriptions.

Mr. Derek Tierney

That challenge is well understood. Our local pharmacies are equipped with IT infrastructure and they are now connected through healthlink. One of the greatest innovations during Covid was GPs being able to send electronic prescriptions directly to the pharmacy so there was no paper travelling. It was all done electronically. We will build on that through rolling out an e-prescription solution.

The Deputy's earlier point is well made. We have 48 hospitals across the State. They are all on the same network but they are not all on the same system. Our challenge over the next two years, and we have already commenced procurement, is to build what we call a shared-care record that will sit at the heart of all our hospital systems. If you are a clinician in Mayo and treating a patient from Dublin, the shared-care record will at least allow you to see hospital-level information that follows with the patient. That is the first step in the journey. There are ambitions to go beyond that to a full national electronic health records system like the Scandinavian countries or Denmark but that takes significant time and investment and capacity.

Deputy Colm Burke

But there is a huge saving-----

Mr. Derek Tierney

There is of course.

Deputy Colm Burke

If you go back ten years, Denmark worked out it was saving about €1.8 billion per annum. It goes back to the junior doctor. All his colleagues are going to Australia. He is staying in Ireland. He is an intern. The reason he is staying is that he wants to learn more but he also wants to try to improve the system where others-----

Mr. Derek Tierney

I agree, if the Deputy looks at Denmark, it has had 20 years of very high levels of investment so they are coming from a strong foundation. That is the point where we are at now. We are starting to accelerate our investment and you can see some of that innovation in response to Covid-19 and we need to just carry on with that momentum. I might hand over to Dr. Henry, who will have a particular focus on the clinical side.

Dr. Colm Henry

Deputy Burke is completely right in that it has transformed healthcare in those hospitals where it has been implemented, which are Cork, Kerry, the Rotunda and the National Maternity Hospital ,Dublin. Apart from the quality and safety of care, the experience of doctors and nurses working there leads to a much more positive experience. We are trying to expand the line, as Mr. Tierney has said. The next phase is early 2025 for both Limerick and the Coombe and the aim ultimately is to have an integrated system for neonatal and for maternity patients across all 19 units.

Deputy Colm Burke

I will move on to one or two other issues now. One again relates to a nurse who was working here in Ireland and is now working in London and I have raised this before. This is on the lack of co-ordination as to who is on call or available in hospitals. She would go in to work and 20 nurses should be there. One day she would go in there would be eight senior nurses and 12 junior nurses. The next day she would go in there would be two senior nurses and 18 junior nurses. As a result, the whole system is slowing up. In London, she is now finding that no matter what day of the week she goes in, Saturday, Sunday, Monday or Tuesday, there is the same ratio. It is the same every day, seven days a week and is, therefore, a far more efficient system. When are we going to change that in our Irish hospitals where someone is not setting out such a system now? When one has a small number of senior nurses, there is a whole slow-up in the system, especially in accident and emergency. How can we deal with that issue?

Mr. Bernard Gloster

We can consistently challenge for better rostering. With the amount of investment, specifically in nursing in recent years which the Deputy has mentioned, the net growth in their numbers and safe staffing levels being substantially progressed, I would have thought it would be much easier for the profession to achieve the balance the Deputy is talking about. In some cases they do.

Deputy Colm Burke

It is not in all cases.

Mr. Bernard Gloster

It is not in all cases and I accept that.

Deputy Colm Burke

I have raised this previously and I have received a number of comments from nurses who are so frustrated going into work, trying to manage a facility and not being able to do it because from all of the nurses, there is no other senior nurse available to deal with the issues that junior nurses may want to raise.

Mr. Bernard Gloster

All I can say is that it would appear to be a mixed experience because, certainly, I have gone on to many wards at many times of the day and night and at weekends and have met very senior nurses who are highly skilled practitioners, and nurse managers, but I take the Deputy's point. There has been more of a focus on getting to safe staffing levels than probably the balance within that of X senior versus Y junior. It is part of the change process of modernising the health service in rostering.

Deputy Colm Burke

Likewise, it is about having the mechanisms in place and ensuring that we do not have junior doctors who are ending up without having access to people up along the line to make decisions as well. Have we checks and balances in place on that?

Mr. Bernard Gloster

I think we do. There will be variations within that and perhaps Dr. Henry can comment on that. Given the number of consultants, the number of senior doctors in training and the number of junior doctors, there is a far better chance of ensuring that there is a guaranteed level of access to escalated decision-making. Perhaps Dr. Henry might wish to comment on that.

Dr. Colm Henry

The systems and governance arrangements go through to the responsible end individual for any patient's care, namely, the consultant, and it goes through in that way. It is very structured according to the point in time of a person's training profile. As the CEO has alluded to, we have a too high dependency on non-training doctors among the junior doctor task force but, nevertheless, they remain within the same clinical governance structure. By a process of expanding the consultant numbers, and displacing non-training posts with training posts, we are planning to address that. Clearly, that has been the result in recent years but, certainly, in the hospital system, there is a clear escalation process from interns and a clear licence corresponding to each point in time with somebody along their training cycle.

Deputy Colm Burke

I will raise one other issue on infrastructure and its role and have raised this in respect of the elective hospitals. Where are we now with the two elective hospitals for Galway and Cork? Have we still not appointed a design team in both cases and what is the expected timeframe when we will be applying for planning? I was told previously that we will apply and will have planning by October 2023. My understanding is that the design teams have still not been appointed.

Mr. Derek Tierney

I will make a comment on that for the Deputy. The Deputy is right. Our focus is that we are in what we call the draft final business case phase of the project, which is about clarifying costs and bringing those to the Government in due course. At this particular moment, we have finalised the competition tender for health planner and co-ordinator. That is now in a standstill period and we hope to make that appointment and within the next 14 days, as we are obliged to do under public procurement guidelines.

We have also completed what we call a preliminary qualification or suitability assessment phase for the detailed design capability. That has been successful in that we have had a good response from the market and we have choices as to who we would appoint in the future. The next phase will be to develop a design brief and issue that to the successful bidder and, hopefully, have them on board, I would say, in early April.

Deputy Colm Burke

We must look at the rate we are going at this stage as we have a very significant growth in population of some 40% in 20 years. We do not have an increase in growth in capacity. For instance, we talk about all of the new consultants we have appointed. The complaints I am hearing constantly from them is the lack of access to theatre space. When are we going to have this project-----

Mr. Derek Tierney

Can I respond to that, please? There are two other initiatives under way. One is to ensure that we utilise all available theatre space and, second, we are advancing a plan for a surgical hub for both Cork and Galway. They are an intermediate response to tackle waiting lists and elective care.

Deputy Colm Burke

Does that mean that the project of the elective hospital has been put on the long finger?

Mr. Derek Tierney

Absolutely not. We are running on two fronts at the moment. The elective hospitals are big pieces of infrastructure, by their nature, and are not deliverable overnight or within a matter of months.

Deputy Colm Burke

This can be put out to the market for design, build and finance, which was done, for instance, when I was in Cork City Council. We wanted an extension to the city hall. I remember getting in the tender documents and there were about 12 boxes of documents, per tender. It worked successfully. We had the project done in two years. As a result, now, the cost of doing it is far less than if we had gone through the whole process.

Mr. Derek Tierney

I can say, with respect to the Deputy, that hospitals are a different animal. They are very complex and the standards to which we have to design and build far exceeds any general civil building standards.

Deputy Colm Burke

The private sector have done it. The Bon Secours Hospital Cork has done it and has built a huge extension in three years, with design, build and finance.

Mr. Derek Tierney

I have given the Deputy an update to the question as to where we are with our detailed design, our health planning co-ordinator and where we are likely to get to with that detailed design and planning permission. I assure the Deputy that we are moving as fast and as hard as we can in the context of public procurement. We are not waiting. We are developing a surgical hub response in both areas as well, as an intermediate step.

An Cathaoirleach

I thank the witnesses and the Deputy.

Deputy Colm Burke

I thank our witnesses.

An Cathaoirleach

I wish to ask Mr. Mulvany about the budget deficit. In 2022 it was €1.24 billion and at the end of 2023, it was €1.75 billion and could have perhaps exceeded that.

Mr. Stephen Mulvany

We will have to wait until we get the actual last four months' worth of data which we do not currently have.

An Cathaoirleach

That figure, however, will have exceeded it. As chief financial officer, could he see that figure being exceeded?

Mr. Stephen Mulvany

Why does the Cathaoirleach want me to speculate?

An Cathaoirleach

What?

Mr. Stephen Mulvany

I have given the Cathaoirleach an answer and I have said it would be north of €500 million, so I have answered his question.

An Cathaoirleach

It will be north of €500 million.

Mr. Stephen Mulvany

We await the actual data-----

An Cathaoirleach

I know-----

Mr. Stephen Mulvany

Excuse me, Chair, and then the audit of that figure by the Comptroller and Auditor General. There is no new news in what I have given to the committee.

An Cathaoirleach

The reason I am asking is that if it exceeds that figure, I would have to take it that that could mean that it could be in excess of €1.75 billion.

Mr. Stephen Mulvany

We are adding together two different things.

An Cathaoirleach

I know that Mr. Mulvany does not have the accurate figure-----

Mr. Stephen Mulvany

My apologies, but the Cathaoirleach is adding together two different things. The historic part of that deficit, particularly the part pre-the HSE's Vote being disestablished in 2014 or 2015, is different to the more recent piece. The legislation requires that it is last year's outturn-----

An Cathaoirleach

I know that.

Mr. Stephen Mulvany

-----which we carry forward as a first charge on this year, or the first service for approval, if we get it. It is the €500 million figure, not that figure plus the €1.2 billion figure, which is the issue to be addressed in 2024.

An Cathaoirleach

I wish to ask the Secretary General of the Department, Mr. Watt, about this matter. On carrying this figure forward, it seems to be increasing year on year. From the administrative and budgeting point of view, which is the job of the Department, is it the case that that figure will just keep getting rolled over?

Is it the intention that a future government might deal with it? I do not expect you to speak for the Government or the Minister, by the way, but with the current Government, the can may be kicked down the road on this.

Mr. Robert Watt

There are deficits. As the chief financial officer has mentioned, significant deficits of some €800 million were inherited by the health boards. They have got worse because the level of cash allocated has been less than the level of determination of the actual expenditure incurred. We either service those debts, which we would have to continue to do, or start reducing the balances. The latter would involve cash injections into the system for a given year greater than the actual expenditure incurred. That is what it would require over a period-----

An Cathaoirleach

Could it happen that this figure would be added to again this year? I know it is early days yet. As Mr. Gloster said, the HSE is operating in a very challenging environment with a very challenging budget, trying to maintain services. Is it likely that this will be substantially added to?

Mr. Robert Watt

I hope not. If it turns out that the demands of the system are greater than what is budgeted for, the debate will be about providing a Supplementary Estimate and a further cash injection. I think that will be the debate rather than the HSE assuming a level of spending and incurring spending which is not funded in cash terms.

An Cathaoirleach

A new sum of €100 million has been allocated, as I understand it. If the demand exceeds that by a large amount, based on the figures we have seen today, we could be in a situation where we €0.4 billion or €0.5 billion could be added to that on top of what is there already by the end of the year.

Mr. Robert Watt

Is the Chair referring to additional expenditure? As I said, the expenditure increased last year more than we budgeted for primarily for three reasons. Various policy decisions were taken during the year by the Government. There were also issues in relation to inflation and demand. Obviously, the inflation environment is very different.

An Cathaoirleach

I understand that. Population growth and inflation-----

Mr. Robert Watt

We have seen no easing in the demand in emergency department presentations or anything else over the last six or seven weeks.

An Cathaoirleach

I will come to that in a minute.

Mr. Robert Watt

As we said, there is a risk this year in terms of budget.

An Cathaoirleach

I want to move on to the issue of agency staffing and overtime. In your opening statement you said that the workforce has increased by 26,000 since 2020 but yet the number of agency staff continues to increase year on year. Why is this happening? You said it is a puzzle that we have to unravel.

Mr. Robert Watt

It is down to higher demand for services. Even with an increase in staffing, particularly in the acute hospital system, there is demand for more overtime and for more agency staff. It comes back to the issues that we have been debating in the last half hour, including Deputy Burke's comments on digitalisation. I think more effective digitalisation could have an enormous impact on productivity. I think rosters-----

An Cathaoirleach

Nobody will deny that 26,000 is a substantial increase in staff.

Mr. Robert Watt

Yes, it is a massive increase.

An Cathaoirleach

The point is that if there are 26,000 more staff and the demand for, and cost of, agency workers is increasing, this should not be a puzzle. There has to be a rational explanation for this. Can Mr. Gloster tell me what is happening in the HSE to cause this situation? I understand that there are greater demands in that we have an increasing and ageing population. However, that does not explain away the mismatch. Why is that?

Mr. Bernard Gloster

There are a couple of factors. When staff numbers go up, we would expect agency dependency to go down, unless the demand for services is outstripping the number that the staffing is going up by. Quite simply, when we take the variables of things like new staff, numbers, absenteeism, agency workers and overtime, it does not add up properly. That would suggest to me a mix of demand and pressure in certain services and the wrong positioning of resources in some other services. Some do not have what they need, while others might have more than they need.

The control environment is another factor. I talked about this throughout the autumn. There are three factors to managing the deficit position in the health service. About a quarter to a third is in the inflationary factor, which looks like it is heading slightly downwards. We will see what it does. The next is in the growth in demand. Attendances in emergency departments for the month of January are up by 16% compared to the month of January last year, so there is very significant demand. The third part, which is the one I am responsible for, is the control environment. Our control environment has been poor. That is why the recruitment pause was introduced for certain grades and we have seen the reaction to that. Culturally, our health service has not been used to those types of controls and cross-checks.

An Cathaoirleach

I accept that.

We received a piece of correspondence a few months ago from the HSE - I do not have it to hand so I will go from memory - that gave a picture of staffing in CHO 8. What stood out for me was that there were 30 to 35 more management-administration staff than what was required, whereas right across what I would term the front-line services, there are shortfalls. The CDNTs, which were discussed earlier, are a case in point. The HSE does a population chart for that every year. The last one of those I saw was for Laois-Offaly, and showed that the CDNTs were at between 50% and 60% strength. In the case of one therapy area, the CDNT was down to well below 50%. I know it is a challenge - you have outlined that - but the letter said there were excessive numbers in management-administration. Unfortunately, I do not have the letter to hand. Why is this the case? Why are we carrying this kind of imbalance? I understand that there has to be management-administration, but there is a public perception, somewhat confirmed by the letter, that parts of the HSE are overmanaged. However, when people try to access services they can be thin on the ground. You are only ten months in the job; I understand that. As I said at the time you took the position, it is a big ship to try to steer around and keep on the right course. Why do we have these mismatches and why do we not have the staff where we need them?

Mr. Bernard Gloster

There is a lot there to respond to. At the very start of the equation, to be fair to people who are categorised as management-administration, a large number of them are front-line workers. The clerical officer that one meets in the emergency department when one books in and the secretary on the CDNT are front-line workers. There is a serious number of front-line workers. All the digital staff Mr. Tierney talked about are classed as management-administration staff. They are not management-administration; they are experts in digital technology.

An Cathaoirleach

According to that letter, there is an excessive number of them.

Mr. Bernard Gloster

There is an excessive number of them. I am queueing up behind the Cathaoirleach to tell the world that. The numbers increased by 34% from 2019 due to a couple of factors. The first is the absence of a control check and balance which I talked about. To be fair, on the CDNT issue, I have not allowed the pressure on the management-administration grade to affect recruitment on the CDNT side. If that was communicated or articulated as a justification, it certainly should not have been.

I think it is important to speak about the control environment. The numbers in management-administration increased by over 800 more than we planned for or budgeted. I am not saying we do not need them. I am not saying that they are not all working hard. However, I am saying that we have to look at the environment and at what happened the minute we introduced the control on that. I now cannot see my accounts for five months and I cannot answer parliamentary questions. The reaction in our culture is counterintuitive to any type of serious control. That is the part we are changing in 2024.

An Cathaoirleach

Like us, people in the HSE are accountable to the public. You have a seven-year term, as I understand it. Is it your intention to try to address that mismatch?

Mr. Bernard Gloster

Yes, completely.

An Cathaoirleach

Okay, because that is what we need to hear.

Mr. Bernard Gloster

It should not be a case of management-administration versus occupational health, occupational therapy or anything else. We should identify what a service needs to function to deliver the services to the people. That is what should calibrate the deployment of the resource.

An Cathaoirleach

The correspondence I have mentioned was dated 31 October and provided follow-up information on foot of a PAC meeting.

The letter was not very explanatory, but those were the figures in it. Does Mr. Gloster feel the embargo on recruitment is adding to agency costs? Is it having the opposite effect to what is intended? The aim of the embargo is to reduce costs and control spending, but is there a case that it is having the opposite effect?

Mr. Bernard Gloster

I would be first to admit that the slowdown in recruitment in an individual line in an individual hospital can cause the unintended consequence of needing extra agency staff, particularly in the winter. We went for both a pause in recruitment and a 10% reduction in agency costs. When we see the figures, we will see how much of that happened, and whether 10% happened. Would one cause the other? Yes, it could, if the controls were not there, but that should not be the case.

An Cathaoirleach

I put the question to Mr. Watt. The Minister and the Government decide policy, but is the Minister aware that this could have unintended consequences?

Mr. Robert Watt

The Minister is aware of the challenge and of what needs to be done-----

An Cathaoirleach

Is he aware of the unintended consequences-----

Mr. Robert Watt

I think we are all-----

An Cathaoirleach

-----one of which is that the embargo could drive up agency costs?

Mr. Robert Watt

In the context of a weak control environment, yes. As the CEO has said, we need to have a stronger control environment now and into the future.

An Cathaoirleach

Okay. We will move to the second round of questions.

Deputy John Brady

I will start with the national children's hospital. In October of last year the chief officer of the National Paediatric Hospital Development Board, David Gunning, was before the committee. He stated fairly categorically that the hospital would finally be completed after so many missed dates by 29 October 2024. He said there would be a six-month fit-out, and he would expect the first patients to be in situ by May 2025. Does that timeline still stand?

Mr. Derek Tierney

I think he would have said at the time that the contractor's programme was showing a completion date of 29 October and the board was doing everything it could to make that happen. In fairness, that is down to contractor performance. There is at least a six-month commissioning programme. One follows the other. That is still the case. The contractor has not shifted from that programme. Within that engagement it is saying it is still committed to delivering to that programme. That is what we are tracking and marking against.

Deputy John Brady

The Minister said yesterday that it is really hard to say whether those dates will be adhered to and whether they are feasible. Is it really hard?

Mr. Derek Tierney

I think the Minister was making a point about whether past performance is a predictor of future performance. I think he was looking at the contractor's performance to date. There is risk with every programme, contract and project we deliver. The contractors' programmes are qualified, but that is what the contractor has put on the table. In the absence of that, it is our best information.

Deputy John Brady

Would Mr. Tierney be confident? There have been serious concerns in terms of the contractor being at full capacity, or anywhere near half-capacity. Are we confident at this point that the commitments that have been given by the contractor are being met?

Mr. Derek Tierney

There was an intense round of engagement last summer, probably at the end of June and in early July. A number of things have happened since. Royal BAM's executive on this project now attends the site once a month to make sure BAM International has a presence on site and understands our concerns, the Government's concerns and the concerns of all stakeholders. The contractor has upped its resource level, and in particular its subcontractor level. The resources increased from July 2023 to the end of last year. We saw a break over the Christmas and new year period as you do with any holiday season. I know from speaking to the board yesterday that those resource levels are back up to the pre-Christmas levels.

Deputy John Brady

Are they at 100% operational capacity?

Mr. Derek Tierney

It is hard to say if that is 100%.

Deputy John Brady

It is hard to say. That is the same language as the Minister used yesterday. It is not very reassuring.

Mr. Derek Tierney

I am sure they have increased resources in response to that engagement last year.

Deputy John Brady

How optimistic is Mr. Tierney that we will have full completion by 29 October?

Mr. Derek Tierney

I just go on the facts. The programme that is in front of me says 29 October.

Deputy John Brady

It is really hard to say.

I will move on to another area, which is mental health services. There is a serious crisis in mental health going back a number of years. We have seen that play out quite graphically in Linn Dara in Cherry Orchard, where a number of beds are still closed. The goes back over a number of years. As we know, the appointment of a national director for mental health services was a commitment in the programme for Government. Where are we with the appointment of a national director?

Mr. Bernard Gloster

We have increased the national capacity for leadership in mental health from one or two to four. There is an assistant national director and a clinical lead for adult, and an assistant national director and a clinical lead for children. There seems to be a notion or a view that the grade difference between assistant national director and national director would save the mental health service. I have worked in the health services and mental health services for a long time, and I do not subscribe to that view. The national lead-----

Deputy John Brady

Would Mr. Gloster not agree that there are governance and accountability issues going back many years? The most striking example was probably the scandal in the services in Kerry. Does he not think that comes down to governance and accountability being the primary concern?

Mr. Bernard Gloster

In part it comes down to clinical governance, it comes down to management governance, it comes down to practice and it comes down to local history in areas. I am saying that the resolution of that is not necessarily in the difference between a national director and something else. The issue is whether there is national leadership and consistency in the mental health service. There is now a far great chance of that with this separation and with the dedicated resources for both children and adults. I am clear that is the right thing to do.

Deputy John Brady

On the appointment of a national director, I know Mr. Gloster is dancing around on the issue-----

Mr. Bernard Gloster

I am not dancing around.

Deputy John Brady

The Minister of State, Deputy Butler, has called for the appointment of a national director.

Mr. Bernard Gloster

I have discussed that with the Minister of State. I have explained to her, and she accepts my rationale, that what she wants to achieve is a dedicated and full-time focus on improving mental health. I am confident that is what we are doing.

Deputy John Brady

I mentioned the closure of inpatient beds in Linn Dara in Cherry Orchard. That is a huge setback in the provision of CAMHS. When will that unit be reopened? What is the cause of the serious shortage of beds in the system? I think there are 54 beds overall in the service, which is a fraction of what is required. There is a major crisis there. When will that unit be reopened?

Mr. David Walsh

There are currently 13 of the 24 open. There has been a longstanding challenge there in recruiting staff. It is a unit that is heavily dependent on agency staff. I do not have a timeline for when the other 11 beds will open. The local management tries to operate within what it can recruit. It had a major recruitment programme last year, and it hopes to repeat it again this year. However, it is struggling to maintain staffing at the level required. Currently, 51 of the 72 CAMHS beds nationally are open. Merlin Park University Hospital is the other facility with beds closed at the moment. The others are close to capacity, but there is a struggle with Linn Dara and a struggle in that piece of Dublin with recruiting mental health professionals.

Deputy John Brady

I refer back to a previous conversation with my colleague, when Mr. Walsh stated there is a roadmap to address some of the issues. Is there a similar roadmap to fill a critical service that is really at crisis point? At this stage I am not very optimistic, from his response, that we will see those beds open any time soon.

Mr. David Walsh

The roadmap refers to the CDNTs. There is a very comprehensive plan around child and youth mental health as well that is being led by the assistant national director and clinical lead. Also, as part of the other discussion we must consider how we use the beds within the new children's hospital. All of that is within that framework to see how we manage demand and capacity, particularly in the east, with having St. Vincent's in Fairview, Linn Dara and the beds in the new children's hospital as well. That is a critical component.

Deputy Catherine Murphy

On the national children's hospital, we had a response from Mr. Watt to questions we posed on 15 January in which he dealt with some of the issues involved. He provided a table relating to the drawdown prior to construction. We all know there have been problems with construction delays over the years and that there is now a higher level of inflation than previously. That was partly a consequence of the contractor not having sufficient people on site. Even last year, according to its minutes, that was a criticism of the NPHDB. The contract goes two ways. I keep on asking a question about the obligation on the other side, which has breached its contract by not completing on time and, as a consequence, costing the State money. What effort will be made to make sure that this aspect is addressed in the final cost?

In his reply, Mr. Watt referred to the capital funding being prioritised and that there is a priority list in descending order. First, it would be very useful to have that priority list because the overrun will obviously impact on other projects and it would be important for us to see them. Could Mr. Watt provide that? Will there be a contractual liability on the contractor's side for non-completion within the timeframe?

Mr. Derek Tierney

The first question was about inflation. I do not think we can pin that on the contractor. That is geopolitical and macroeconomic. It is an externality.

Deputy Catherine Murphy

I am making the point from the point of view of time.

Mr. Derek Tierney

Yes. The provisions in the contract do allow inflation recovery. That is the contract we signed, so if inflation goes above 4% the contractor has an entitlement-----

Deputy Catherine Murphy

The point I am making is that if the project was completed on time we would be less exposed to that part of the contractual obligation.

Mr. Derek Tierney

Yes, in theory. As far back as 2018 and 2019, however, PwC's independent report gave a very good overview of the contract, the early stages of planning, project design, etc. That is well recognised since 2018 and 2019, and our inflationary environment kicked in in 2021 and 2022.

The question of liability is the nub of the issue. The contractor was obliged to deliver by November 2022, which has obviously passed. This is the subject of the engagement between the board and the contractor in terms of liability, faults, and claims. We are trying to work our way through that. The board has got to engage with the contractor and get this job finished as soon as possible. That is the ambition. That has to be the objective. The other approach could be to turn this into a very adversarial and litigious engagement but that would take longer.

Deputy Catherine Murphy

Is this a one-way street in terms of the liability?

Mr. Derek Tierney

No, it is not. Both the employer and the contractor have rights under the contract and that will be determined in due course.

Deputy Catherine Murphy

What about the priority list? I remain unhappy with this because any contract is a two-way thing. This sends a terrible message to anyone engaging with the State in a contract - that they can push it as far as they can. The contractor could have had people on other sites rather than on this site so as to progress them in time because he was dealing with the private sector as opposed to the public sector. I remain convinced that there is a liability on the contractor's side and I want to see it resolved.

Mr. Derek Tierney

There are liability obligations under the contract and the board will seek to apply those, but this has to play out.

Deputy Catherine Murphy

Could Mr. Watt provide the priority list of the capital projects? Some of them will be delayed at the very least as a consequence of the cost overrun. Could he provide us with the information on how that will impact on the list of priority projects?

Mr. Derek Tierney

I might just answer that briefly. As I said at the outset, we get an annual allocation within a multi-annual ceiling indication. The allocation is agreed on an annual basis. I have already advised that 60% of that allocation deals with precommitments. They are our first order drawdown. Where we have contractual commitments or projects under way-----

Deputy Catherine Murphy

But if there is a certain amount of money and then there are overruns – it is clear there will be a huge overrun in relation to this hospital – that has impacts on other projects. I am looking for the priority list to be provided and if we can see the likely impact on it.

Mr. Robert Watt

We will come back with a list of key priorities. There is a large number of priorities. Of the larger projects, there are the four elective hospitals and the national maternity hospital and then we have the Minister's commitments on the expansion in the number of beds. There are larger projects. We will have a list.

An Cathaoirleach

What about other projects such as primary care centres?

Mr. Robert Watt

There are many small projects. As members know we are building-----

An Cathaoirleach

No, what I am asking is if they will be on the list.

Mr. Robert Watt

We can set out the full list of projects that we have above a certain threshold, perhaps €3 million or €5 million. We will figure it out.

Deputy Catherine Murphy

Could I also just make it clear that the question I would like a response to in regard to the local drugs and alcohol task forces is whether the funding provides them with an annual budget. How did the HSE determine how much each CHO area received? Dublin's north and the south inner city, which are part of CHO 7 and CHO 9, respectively, are fairly similar to other big CHO areas yet we are all aware that there is a bigger issue in regard to drugs there. Could the witnesses provide the methodology and the terms and conditions?

Is there a problem also with the payment of pensions? Is there a time lag for the payment of pensions for the HSE?

Mr. Bernard Gloster

There is.

Deputy Catherine Murphy

I am hearing about nurses who have retired for nine months without being paid their pension. What is the time lag and how will it be addressed?

Mr. Bernard Gloster

I have met the pensions regulator since I came to this job. That is a very serious problem, and one that the Pensions Authority has given us a certain amount of time to show form on improving. It is affected by a lot of things. Apart from systems, which I will not blame, the reality is that the health service is still a multiple of former employers and employer numbers so there are different local areas. The number of people retiring is far greater than it was previously. The processing of those payments is nothing to do with money; it is simply to do with the sheer level of work involved. Despite the management administration breach that we have, I did have to sign off the other day on the employment of additional staff specifically for pensions to improve that timeline.

Deputy Catherine Murphy

What numbers are we talking about? Could Mr. Gloster give us a note on it?

Mr. Bernard Gloster

Yes, I can of course. I think I have approved about 15 additional posts to try to mitigate the problem.

Deputy Catherine Murphy

No, I mean the number of people that are waiting.

Mr. Bernard Gloster

Yes, there are people waiting. We do try to help by giving people part-payment of pensions or lump sums but it is not satisfactory. The delay is running to a couple of months, whereas in the Civil Service it is a much shorter timeline. It is not great.

Deputy Catherine Murphy

People are retiring without their pensions.

Mr. Bernard Gloster

Yes.

Deputy James O'Connor

The first question I want to ask relates to the HSE's policies on HSE-led development of primary care centres.

Will Mr. O'Connell please outline the criteria that differentiates between a decision on pursuing an HSE-led project versus that of going through a private developer-led model, and how that decision is made within the organisation and in conjunction with the Department?

Mr. Brian O'Connell

An exercise was done in 2012 to identify 350-odd locations across the country that required either supplementary or additionality to primary care centres. A number of them were addressed by existing facilities. Then we prioritised, down through a number of different parameters, how big the need was spatially so whether they had any facility at all or how substandard so they got a score rating under existing facilities, how pressing was the replacement need and demographics came into it as well. There is a number of other ones that came in. They are prioritised from 1 to 350 on that list and we have been working our way down through that list.

The operational lease mechanism is slightly opportunistic so where we have advertised-----

Deputy James O'Connor

I apologise for pausing Mr. O'Connell but my question is not being answered. When the HSE makes a decision to put a primary centre into a community, and I will give an example in a second, there is the HSE-led project by itself and then there is option of going down the private route. Where in that process does the HSE decide what is private and what is public?

Mr. Brian O'Connell

We have a prioritisation enter that matrix.

Deputy James O'Connor

Please give me an example from the past two years where that might have happened.

Mr. Brian O'Connell

Finglas primary care centre came up earlier and it is No. 2 on the list, as far as I remember. It has gone down the route of pursuing, initially, through the operational lease mechanism. It would have been included in the first advert. It did not get any viable returns so as it was such a high priority it was brought through the Exchequer-funded capital plan route.

The operational lease model has, in its entirety, been very successful. There have been 104 delivered to date through the operational lease nationally. It has been a very good mechanism to deliver in the round. Due to demographics and availability of sites, there will be certain areas where we will not be able to deliver via the operational lease model. We have either added them to the bundle of PPPs, which was pursued with 14 PPPs bundled together off that similar prioritisation list starting from the top down, or, in the rest, we have done a number of them through Exchequer funding as well.

Deputy James O'Connor

My bugbear with this relates to Youghal in east Cork. I do not mean to be parochial but it is a good example. There was a plan at St. Raphael's, which is a former psychiatric facility, and a section of it is still used for that purpose. The facility was heavily modernised. A state-of-the-art plan was rolled out for St. Raphael's to modernise it and make it into a start-of-the-art community healthcare facility by putting in the primary care there, and doing analysis on a community nursing unit being built on site. At some stage during 2022, and perhaps during 2021, that plan was abandoned and, as Mr. O'Connell has said, it was decided to pursue the operational lease model. I cannot wrap my head around why the HSE went so far down the route, spent so much money on the analysis and the site, and effectively went public through its answers to parliamentary questions, the national development plan and the HSE's capital plans for development there to be done to such an extent. A community nursing unit with more than 50 beds was being considered and then there was a decision to switch. I cannot understand why the HSE went so far down the route and then changed course opting for the operational lease model. Why was that done in that instance?

Mr. Brian O'Connell

Again, I do not have the full details.

Deputy James O'Connor

I did ask previously. I am not taking this out on Mr. O'Connell. I did ask that question of Mr. Gloster in this forum. He never came back to me the last time that he appeared before the Committee of Public Accounts on this matter, which is a bit disappointing.

Mr. Bernard Gloster

Yes

Deputy James O'Connor

Please take my question away and come back to me again because I want an answer. It is outrageous.

Mr. Brian O'Connell

I would imagine that it is down to speed of delivery and trying to deliver it as quickly as possible but we will come back to the Deputy on it.

Deputy James O'Connor

I thank Mr. O'Connell very much.

An Cathaoirleach

I want to revert to the Children's hospital and discuss cost overruns. What is the timeline for the projected opening of the hospital? Will someone please confirm the date for the committee? I think Mr. Tierney was answering.

Mr. Robert Watt

At the last programme board meeting, it was expected that the hospital would be completed by the end of October this year and open by the middle of next year.

An Cathaoirleach

So the opening date is the middle of 2025.

Mr. Robert Watt

That is the programme board's assessment of last year.

An Cathaoirleach

When the total drawdown is sanctioned for the hospital, which is likely to be €1.4 billion, will the HSE commit to notifying the committee at that stage of what the drawdown is?

There have been delays on this project. The claims run into thousands at this stage. There have been legal challenges. Suffice it to say, the relationship between the board and the contractor has not been an easy one. There has been a number of difficulties. That has emerged in discussions that we have had with the board and with the Department of Health, etc. Obviously the Department has a lot of information and experience now in terms of this large project, the contractor and all of that. Will Mr. Watt make a submission to the Government, which will be an overview or look back on this project, the difficulties that have arisen, costs, delays and challenges? I understand that there will be claims because, for example, a window must be moved and sometimes tweaks will have to be made in construction along the way. I think we will have to agree that the sheer number of claims regarding this project is excessive. Does Mr. Watt intend to make a submission to Government on this?

Mr. Derek Tierney

Can I comment for a moment?

An Cathaoirleach

Sorry, I want to hear from Mr. Watt first.

Mr. Robert Watt

There are lessons from this project that we have taken into account in the context of, for example, the national maternity hospital, which has been built now on the site at Elm Park. For all future major projects, we need to learn from it.

Without prejudging that review, which is a good idea, there are many, many issues involved in this contract going back to the original site specification, location of the site, the scale of the build, the actual size and design of the build, the extent to which decisions were made in the absence of detailed designs and so on. I spoke to this committee previously just on this matter a few years ago and to three other committees. The Chairman is right about the need for a formal review. There are many lessons, including the form of contract, which is a matter for DPER, and on the balance of rights between the contractor and the State. There are many, many issues that absolutely we need to reflect upon.

An Cathaoirleach

On the site and the location of it, have they presented particular challenges in logistics and costs? Are there lessons to be learned there?

Mr. Robert Watt

Yes.

An Cathaoirleach

At the time this project was signed off, Mr. Watt was the Secretary General in the Department of Public Expenditure and Reform. Is that correct?

Mr. Robert Watt

I was, indeed, yes.

An Cathaoirleach

At that time, had Mr. Watt concerns about the site and nature of the contract? I ask because there have been criticism and scrutiny, insofar as we can examine, of the type of contract that was used in this case. On the contract, the design and the hospital location, it is my view that those three issues have caused problems, delays and costs. In hindsight, does Mr. Watt agree that those three issues have fed into major problems?

Mr. Robert Watt

Those issues are contributing factors to both the delays and the cost runs associated with the project, yes, including the location of the site and the very fact that the enabling works alone cost us €200 million because the Drimnagh sewer had to be moved; the fact that we entered into a two-stage contract process; that we agreed ultimately this maximum price in the absence of a detailed design that did have all the quantities of work set out; and the actual design of the building itself.

Deputies have been there. It is a phenomenal building. It will be fantastic when it is open, but it is a very expensive design in its nature. There are not many straight walls. They are all curved, and they are expensive, as I understand it. There are many other features too which are pretty impressive, but we will benefit from them. All those issues need to be taken on board.

An Cathaoirleach

We all want to see it open and it is fair to say that its optics are fantastic. I have described it before as “an architect’s wow project”. Yet, that does not always match functionality and practicalities.

Mr. Robert Watt

I do not think the design elements, which are spectacular, will in any way offset its functionality as a children's hospital. It will provide a fantastic service into the future. There are elements of it that are wonderful in terms of functionality. The question for the State is on the trade-off between cost, delivery and something that is iconic. It is an iconic building, but that is an issue for the State. One could build something cheaper but it would not be as iconic. Of course, that is a wider challenge about-----

An Cathaoirleach

It could be easier to maintain, though.

Mr. Robert Watt

Certainly, it could be easier to maintain. The footprint is enormous and that will obviously add to the cost. Other aspects of it, such as its digitalisation, the configuration of its rooms, the relationship between different parts of it and, of course, its energy rating, will save massively. There is also the fact that we now have three very old sites that do not work for the clinicians and the staff. They are moving to the new site, which will be fantastic.

An Cathaoirleach

We all agree that they have to be put onto one site.

The window cleaners will be busy.

Mr. Robert Watt

There are a lot of windows. It is an impressive building. It is three times bigger than the last hospital we built.

An Cathaoirleach

Okay. We hope to see it opening in the middle of 2025.

I want to briefly ask about the capital priorities. Can we get feedback specifically on the primary care centre for Portlaoise? Our population has exceeded Kilkenny city at this point, and we do not have a primary care centre. I know some work is being done. Is it on the priority list? Are the pounds, shillings and pence there to match that? Can the representatives come back with that information?

I will raise the matter of the new health areas, which cannot come quickly enough. My only concern is with where the accountability will be. The HSE and health services are massive, but when trying to break it down into six areas, there is the sense that people may argue over where the boundaries are drawn. We had some of that this morning, and understandably so.

The general idea with the hospitals is that the acute and non-acute would align. There are two systems running in two different directions and CHO 8 is a case in point. The hospital area did not match the other services, which was ludicrous in the first place. That move, therefore, cannot come quickly enough.

In the case of Laois, for example, there is a situation in Graiguecullen, which looks like a suburb of Carlow but is part of County Laois. The population is approximately 4,000 people. The people in Graiguecullen will not be serviced in general. A special arrangement has been made in the area of mental health for a couple of clients who are going to Carlow on a temporary basis since the mental health services were pulled from the small health centre in Graiguecullen. My request to Mr. Gloster is for the health centre in Graiguecullen to be upgraded. He and I both know that when the health areas are set up, they will become an independent republic for health purposes. To some extent, they will. In the real world, they will have a budget. The population of the areas is set out in the documents that are before us today. I have no argument with that. Yet, I am asking about a situation like Graiguecullen. I refer to the urban area and there is a big catchment area around it with a radius of approximately 10 miles. That area urgently needs for the health centre to be upgraded. Does that figure in the plan? If it does not, has the HSE set aside funding to upgrade what is there, as well as to try to draw some services back into it? That is my question. I do not expect Mr. Gloster to have an answer on the hoof for it but he might come back with one.

Mr. Bernard Gloster

I will certainly try to answer that. I apologise to Deputy O’Connor if he did not get an answer. I had understood that it had been followed up on, so I apologise for that. The least a Deputy should expect if he or she is promised an answer is that he or she will get one, regardless of what that answer is. I will therefore take that on the chin. I will make sure that happens. My apologies, if it did not.

Graiguecullen, like Abbeyleix and many other parts of the Cathaoirleach’s area of the world, as well as Cork, Kerry, Wexford and everywhere I have been, all require attention. Sensible choices will be made. We have to make sensible choices in the short term around the use of the buildings we have and how best to use them.

On the issue of regional health areas and accountability, I hope that they will be as independent when they have problems as they will be when they have successes. Yet, despite the narrative of management administration, it is the most significant delayering of the system. They will manage all hospitals, community services and public health services and they will report directly to me. That is a very substantial move forward to a pragmatic sort of approach. They will have to determine what the priority is for them within their area.

An Cathaoirleach

Can I say this, though? This is 28 miles, that is, 45 km or 46 km from Portlaoise. People were being told at one stage to go to Athlone for eye and ear appointments. That is more than 100 km away.

Mr. Bernard Gloster

I understand.

An Cathaoirleach

There is a feeling that Covid is being used to pull a lot of services. I am not arguing for services at every crossroads. Yet, I am saying that there is a substantial wing of the new health area. At this point, even, within the most south-eastern part of CHO 8-----

Mr. Bernard Gloster

I will certainly-----

An Cathaoirleach

I am asking Mr. Gloster to look at Graiguecullen. A range of services was provided there, including mental health services. They were valued and operating. I ask him to look at that.

Mr. Bernard Gloster

I will.

An Cathaoirleach

I can tell Mr. Gloster that the little centre there does need some work. It is shabby. It needs to be upgraded.

Mr. Bernard Gloster

I hear you.

An Cathaoirleach

It does need a bit of work to be done. It possibly even needs an extension.

Mr. Bernard Gloster

After Abbeyleix, is it?

An Cathaoirleach

Well, you made a big promise. You did not make a promise about Abbeyleix to me. You went down there.

Deputy Cormac Devlin

I think, Chair, you have mentioned every part of your constituency at this stage.

An Cathaoirleach

I believe there was an audience there and they all heard it. You kept your commitment to go to Abbeyleix, and all I would ask you to do-----

Mr. Bernard Gloster

I will. I hear what you are saying.

An Cathaoirleach

I want to accept that. I know you cannot pull rabbits out of the hat, but you understand-----

Mr. Bernard Gloster

You would be amazed.

An Cathaoirleach

Does Deputy Dillon want to come back in with a brief question?

Deputy Alan Dillon

I wish to raise the current Fórsa union embargo that is in place around their administrative and management grade staff, their continued industrial action and the fact that they are not engaging in the political forum. When will this be resolved or come to a conclusion?

Mr. Bernard Gloster

The Secretary General might also want to comment but I refer to our shared wish. We will be back in the WRC next Tuesday. I am very hopeful in the context of a public sector agreement, which has now been arrived at, that we will come to a resolution. That is my hope. We are certainly up for that. I do not want to pre-empt what will happen beyond that. The Secretary General might want to comment.

Mr. Robert Watt

We do not comment in public, as the Deputy will know, on industrial disputes. We hope that the matter will be resolved next week.

Deputy Alan Dillon

How concerned is Mr. Watt that the unions can hold the political forum to a halt in this regard? Has it impacted his duties within the Department of Health?

Mr. Robert Watt

Yes, it has had an impact. I do not wish to-----

Deputy Alan Dillon

In what way?

Mr. Robert Watt

In multiple ways, but I do not really wish to discuss a matter that we will ultimately have to resolve. It is very impactful. Obviously, we are not in a position to answer parliamentary questions. We are not in a position to gather information on the foot of requests from Members of this House, which we find unsatisfactory. We do not have up-to-date expenditure data, and Mr. Mulvany touched on that earlier. That is very unsatisfactory. We do not have the basic management information tools we need to do our job. It is very disruptive, but I do not really want to get into the ins and outs.

Deputy Alan Dillon

But what will happen if this continues and there is no resolution next Wednesday?

Mr. Robert Watt

We are very hopeful that the dispute will be resolved.

Deputy Alan Dillon

This has been going on since October. The drip-feed of information has been really concerning. We live in a democratic country. Access to information holding those to account is a primary function of our parliamentary activities. For employees of the HSE not to respond to basic-level queries through the parliamentary question forum is certainly really troubling to our function and to the function of this Oireachtas. Mr. Gloster is not instilling great confidence in his management of this situation because this has been allowed to go on and on for the past three months without-----

An Cathaoirleach

I am going to ask the two Accounting Officers to respond briefly on that. It is an issue that is causing problems for every one of us and it has gone on. None of us would disagree with the Deputy there. We will hear from Mr. Watt first and then Mr. Gloster.

Mr. Robert Watt

I absolutely agree with the Deputy. It is not satisfactory and we are not happy about this dispute. We are not happy about the impacts and the specific impact the Deputy has referenced. The context for the resolution of the dispute was obviously the public sector pay agreement because it got wrapped up into the wider discussions around the agreement the Minister, Deputy Donohoe, and his officials have negotiated with all the unions. I understand that balloting is going on. We are in the WRC on Tuesday. We very much hope that at the conclusion of those discussions, the dispute will end. We are very hopeful of that.

Mr. Bernard Gloster

There is a lot of debate we could engage in on it. I will take on the chin what the Deputy said about my management of it. I am very confident that I have approached this very reasonably. There is a danger that we could demonise a group of the workforce when we are at a very sensitive stage of discussion. What I want to do is to resolve it. I believe there is every chance we can resolve it next week. I have written to the Ceann Comhairle about it. I am very clear and I have asked senior managers to use as much flexibility as possible to respond to what questions we can. I absolutely agree with the Deputy that access to information is a critical part of what is done here. I am certainly anxious to deal with it but there is a danger that I will demonise a group of the workforce ahead of negotiations and that would not be helpful.

An Cathaoirleach

The negotiations are at a sensitive stage. Let us not derail them here.

Mr. Bernard Gloster

That is it.

An Cathaoirleach

I think there is an urgency to get it resolved.

Mr. Bernard Gloster

Completely.

An Cathaoirleach

I thank the witnesses and the staff at the Department of Health, the HSE and the Department of Public Expenditure, National Development Plan Delivery and Reform for their work in preparing for today's meeting and for the information provided. I also thank the Office of the Comptroller and Auditor General and the staff for attending and assisting the committee in preparing for today's meeting. A number of matters require follow-up, including, in particular, the priority capital list, and a number of other pieces of follow-up information.

Is it agreed that the clerk to the committee will seek any follow-up information and carry out any agreed actions from today's meeting? Agreed. Is it also agreed that we note and publish the opening statements and briefings provided for today's meeting? Agreed. I wish the Department and the HSE well in their work. Hopefully, some of the not-so-straight lines of communication will be addressed and we can move ahead with the setting up of new health areas and Sláintecare. The meeting is suspended until 1.30 p.m., when we will resume in public session to address business of the committee and correspondence.

The witnesses withdrew.

Sitting suspended at 12.44 p.m. and resumed at 1.32 p.m.