Skip to main content
Normal View

Joint Committee on Health debate -
Thursday, 29 Sep 2016

Update on Health Issues: Minister for Health

The purpose of today's meeting is for the Minister for Health, Deputy Simon Harris, to update the committee on developments in regard to the drug pricing agreement, the emergency department task force and the winter initiative waiting lists. We also request that the Minister engage with us in regard to the mid-year review of the Department Estimates for 2016 and to consider proposals for expenditure in 2017 - Vote 38.

Members are aware of the ongoing efforts by the Oireachtas to improve the engagement of Departments and public bodies with committees in terms of how Vote expenditure is dealt with. The purpose of that part of today's meeting with the Minister is to discuss improvements that may be desirable in the performance information included in that Estimate, a major review of the position as regards outputs and expenditure for the 2016 Estimate for the Department of Education and Skills and a brief on the emerging position on permitting the committee to participate in the 2017 Estimates discussions in advance of the allocation being finalised.

On behalf of the committee, I welcome the Minister for Health, Deputy Simon Harris, who is accompanied by Fergal Goodman, Tracey Conroy, Greg Dempsey and Fiona Prendergast, senior officials from his Department. I draw their attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to that effect where possible. They should not criticise or make charges against any person or persons or entities by name or in such a way as to make him or her identifiable. I also wish to advise them that any submission or opening statements which they have submitted to the committee may be published on the committee website after the meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person outside the Houses or any official either by name or in such a way as to make him or her identifiable.

Before engaging with the Minister, I wish to declare the following interests for the record. I hold a contract with the HSE to deliver general medical services to medical card patients. I am a registered general practitioner with the Medical Council and I am an ordinary member of my representative organisations, namely, the Irish College of General Practitioners, the Irish Medical Organisation and the National Association of General Practitioners.

I invite the Minister to make his opening statement.

I thank the Chairman. I am very pleased to have this opportunity to address the joint committee and I look forward to developing a constructive and interactive relationship with it on a range of issues of mutual concern to all of us and to the citizens of the State. The committee has asked me to update it on a number of important initiatives undertaken by my Department and the Health Service Executive in 2016 and, more generally, to provide an update on the mid-year review of my Department’s Estimate for 2016, Vote 38, and a look ahead to 2017.

As requested, the briefing provided to Deputies and Senators concentrates on the issues in which the committee has expressed particular interest, namely, the recent drugs pricing agreement, the work of the emergency department task force, the planned winter initiative and proposals for a waiting list initiative in 2017. As the committee is aware, in recent years, the Health Vote has typically required an annual supplementary budget to cover deficits. In July of this year, in an effort to properly fund our health service and to break this cycle of Supplementary Estimates, the Government provided an additional €500 million funding to health in 2016. This level of funding also provides me, as Minister for Health, with the opportunity to address some immediate issues facing patients, such as investment in a winter initiative to manage overcrowding in emergency departments, in addition to meeting commitments in a programme for partnership Government. It also places the health service on a sustainable financial footing by stabilising the finances for 2016 and allowing the HSE to set realistic and achievable targets for service areas.

In June, when I announced additional funding of €500 million for the health sector, I emphasised the need for the HSE to deliver services within the funding provided by Government. To ensure delivery of this requirement, I indicated that the revised allocation would be underpinned by an improved performance and accountability framework within the HSE. This enhanced and strengthened framework ensures that designated health service managers are explicitly and personally accountable for managing the performance of services within their allocated budget. The framework sets out clearly the consequences of underperformance. Accountable officers are named for each hospital group, for each community health organisation, for the national ambulance service, for the primary care reimbursement service and for the nursing home support scheme.

Accountable officers are required to prepare a financial plan for the year. Each plan sets out the actions they will take to meet the agreed performance targets across the domains of access, quality and safety, human resources and doing so within the financial allocation. The commitment to the plan and associated targets is formalised as part of the individual’s personal targets under their individual performance agreements with their line manager. All CEOs of hospital groups and chief officers of community health organisations have confirmed acceptance of the requirements under the enhanced performance and accountability framework. Financial plans have been received from all hospital groups.

The framework requires early and assertive action to be taken in response to indications of an agreed target not being achieved and supports and interventions will be activated. It is the responsibility of the accountable officers to produce remedial plans and to deliver on the agreed actions to bring performance back into line.

The additional funding provided has allowed us to deal with financial risks emerging from the beginning of the year and our expectation is that the health service will remain within budget for the year in respect of the core service areas. For the entire Vote, at the end of August, actual expenditure for the year to date is €9,145.1 million, against a profile of €9,149.5 million, which indicates a positive variance of €4.4 million.

There is a positive variance on current expenditure of €18.5 million, which relates to the Department and non-HSE agency spending. This largely relates to profiling issues rather than underspending and will predominantly reverse by year end. There is a negative variance of €15 million on capital spending which substantially reflects higher construction costs for profiled activity. The HSE will manage the portfolio to ensure that the variance is eliminated by year end. With regard to the year end position, it is anticipated that while there may be some areas that will experience overruns, these will be offset by underspends in other areas, resulting in an expected neutral budget versus actual position at year end.

Of significance, however, is the fact that the HSE’s projected neutral position is prior to consideration of the State Claims Agency, SCA. The full year outturn for SCA is difficult to predict and manage as the level of settlements are determined by court decisions rather than by the issue of management of the health service but we are aware of pressures and the position will require close monitoring for the remainder of the year.

Both the health service and the Exchequer face a huge challenge in the coming years due to growth in the cost of recently introduced medicines, combined with a pipeline of very expensive medicines. New medicines pose affordability challenges for health care systems worldwide and also risk absorbing scarce resources which Governments will need to address a range of demands across the health service. By way of context, in 2015, the HSE reimbursed €1.9 billion on supply of medicines and appliances for the community drugs schemes and the high-tech arrangements, covering approximately 74 million separate items. Almost €1.3 billion went to pharmaceutical manufacturers - a 5% increase on 2014 levels. In addition, expenditure on drugs in hospitals was estimated to be in excess of €300 million in 2015.

Detailed preparation for the negotiations began in 2015 and involved a State team of officials from the Department of Health, the HSE, the Department of Public Expenditure and Reform and the Office of Government Procurement. The formal negotiation process with the Irish Pharmaceutical Healthcare Association, IPHA, began in March 2016. The State's team objective was to improve the assessment and reimbursement process for new drugs and to secure significant price reduction so as to enable continued access to new and existing drugs for Irish patients while reducing growth in the HSE’s overall drugs bill. As I am sure the committee is aware, the negotiation process was not straightforward. When I took up office as Minister for Health in May, I was briefed on the state of play. The best offer that the industry was prepared to make did not meet the affordability challenges that the health system faced. In turn, I briefed the Government to this effect and advised it that the HSE intended to exercise its statutory powers to reduce medicine prices to affordable levels. I am glad that in the light of this development the industry reassessed its position. After another intensive period of negotiation, the process resulted in an agreement which will provide substantial additional savings on the future drugs bill over the coming years.

The new agreement, which runs to the middle of 2020, is projected to result in savings, that is, expenditure foregone, of €600 million from IPHA companies, with a further €150 million in savings anticipated from non-IPHA companies over the lifetime of the deal. The new agreement contains a number of features which represent clear additional value over the terms of the previous 2012 agreement. Members of the previous health committee will see some of their own reports' recommendations reflected in this agreement. It also addresses a number of issues raised by the Report on the Cost of Prescription Drugs in Ireland issued by the Joint Committee on Health and Children in 2015, including the expansion of reference basket of countries used to set prices in Ireland from nine to 14 countries. Lower cost countries such as Greece, Italy and Portugal are included for the first time. Annual price realignment will ensure that the prices of medicines in Ireland reduce in line with price reductions across the reference countries. There will be an increased rebate in both PCRS and introduction of rebate in hospitals. Also included in the agreement is a 30% reduction in the price of biologic medicines when a biosimilar medicine enters the market. The issue of affordability is now central to the new agreement with an affordability clause to capture the five year cost of new medicines as part of the assessment process included. This process is also aligned with the requirements of the Health (Pricing and Supply of Medical Goods) Act 2013. This ensures that reimbursement decisions will take account of the budget impact of an individual medicine, the opportunity cost of treatment and the resources available to the HSE as allocated by the Dáil.

The agreement with the IPHA is only one of a suite of measures that must be progressed if we are to ensure that we maximise the value of the State’s expenditure on medicines. One such initiative relates to biosimilar medicines. I have asked officials in my Department to assess the whole area of biosimilar medicines and to work on the development of policies which will support the uptake of such medicines as they become available. I note that Deputy Kelleher has recently published a Bill on this issue and my officials are examining this legislation. I propose to consult with Deputy Kelleher on the matter in the coming weeks.

To date this year, we have seen improvements in emergency department overcrowding, with a decrease of almost 5% in the number of patients waiting on trolleys. Hospitals have been driving improvements in patients’ experience times in emergency departments, with 82% of all patients completing their emergency department episode of care within nine hours of registration. Also, hospitals are working to ensure that no patient waits over 24 hours in the emergency department and by August the number of patients waiting over 24 hours has reduced to 2%, down from 5% in January.

While these may seem like small steps they are, nonetheless, steps in the right direction and derive from a co-ordinated policy and operational approach across primary, acute and social care to tackle the multifaceted nature of emergency department overcrowding. Under the framework of the emergency department task force, I have been driving a four pronged approach, involving a range of initiatives, to alleviate pressures on emergency departments.

There is so much more to do in this space. First, my Department and the HSE continue to implement measures to increase hospital avoidance by developing alternative services to emergency departments, EDs, such as community intervention teams, GP out-of-hours services, as well as GP minor injury and diagnostic services. Second, increasing hospital capacity has been and remains a priority. Some 300 new hospital beds have been introduced into our system, new EDs have been developed in Kilkenny and Limerick, the number of consultants in our health system has increased by 80 full-time equivalents and the number of nurses by more than 200 so far this year. The third series of measures has been focused on supporting timely patient discharge from hospitals. Under the 2016-2017 winter initiative, which I will refer to in a moment, I have placed a strong focus on reducing delayed discharges. Fourth, the special delivery unit has carried out review visits to almost all hospital EDs to evaluate how EDs can improve patient flow and drive improvements in how hospitals respond to peaks in demand for emergency care.

The reductions we have seen in trolley numbers and the improvements in patient ED experience times, particularly in the important context of significantly-increased attendances and hospital activity this year, indicate that last year’s winter initiative has clearly had an impact on ED overcrowding. Consequently, I was recently pleased to welcome the HSE announcement of this year’s winter initiative 2016-2017, for which we provided €40 million of additional funding. Key measures include providing an additional 950 home care packages targeting nine specific hospitals, the provision of an additional 58 transitional care bed approvals weekly and the expansion of community intervention team services across four sites to support five acute hospitals. This will benefit more than 6,500 additional patients. An additional 55 acute beds and 18 additional step-down beds will be made available while minor injury services in Dublin are to be expanded to provide for an additional 100 patients each week. Funding for aids and appliances is to be increased to reduce delays in patients being discharged back to their homes. Funding is also provided for an increased focus on flu vaccination for health care staff and the wider community. I am firmly committed to achieving a real impact on ED overcrowding as a result of the 2016-2017 winter initiative and I am chairing a weekly meeting with the HSE and my Department to monitor progress and to see exactly how we are getting on week on week in terms of implementing this ambitious plan.

It is my view that integrated, patient-centred approaches to winter planning, as has been done in the winter initiative, are key to ensuring that the health service effectively manages peak winter pressure times in our EDs in order that patients experience a safe and high-quality health service in the setting most appropriate to their needs. I hope that when the committee sees and reads this winter initiative document, as it has been doing, it will see that the answer to all the issues in our acute hospitals and the pressure points cannot simply result in the acute hospital coming up with the solution. We must have that integrated approach of looking at what we can do in the community, in social care, in delayed discharges and in home care. We have tried to take a much more integrated approach in this year's winter initiative than perhaps in the past.

Moving to scheduled care, it has been and remains a concern to me that the number of patients currently on waiting lists has continued to increase over the last number of months and I wish to assure the committee that this Government is committed to driving the necessary process improvements and providing the resources to tackle this issue, as is evident from the programme for a partnership Government.

In direct response to these recent increases, at my request the HSE has provided an action plan aimed at reducing the number of patients on waiting lists to be implemented in the latter half of 2016. The focus of this plan is on those waiting the longest for inpatient or day-case procedures. The HSE is committed to reducing by half the number of patients waiting more than 18 months for these types of procedure by year end. Again, within current resources, the National Treatment Purchase Fund recently launched an endoscopy waiting list 2016 initiative which will also assist in reducing the waiting list and waiting times for endoscopy procedures for those patients who are currently waiting more than 12 months. It is expected that around 3,000 patients will receive their endoscopy procedures under this initiative. Furthermore, €7 million of the overall €40 million allocated for the winter initiative is to be utilised to fund a targeted waiting list programme for orthopaedic, spinal and scoliosis patients to be implemented in designated sites by year end in Beaumont, Tallaght, Tullamore, Waterford and Galway. Separately, €1 million has been provided to the children’s hospital group on a once-off basis to address the cardiac cath lab and scoliosis waiting lists at Our Lady’s Children’s Hospital in Crumlin.

The programme for a partnership Government, as colleagues will be aware, clearly commits to €50 million in 2017 for waiting list initiatives, with at least €15 million of this allocated specifically to the National Treatment Purchase Fund. My Department, in conjunction with the HSE and the National Treatment Purchase Fund, is working on developing a framework for the waiting list initiative in 2017. I welcome the views of colleagues in this regard.

As budget day draws closer, we are obviously in close discussions with the Department of Public Expenditure and Reform regarding increased costs and additional health priorities in 2017. These discussions include the funding required to maintain our existing levels of service, funding for priorities included in the programme for partnership Government and the supply and confidence agreement and also funding to allow for the delivery of our capital programme in 2017. Clearly, these discussions are taking place in the context of the fiscal constraints imposed by both the need to maintain economic stability and our requirement to remain compliant with the fiscal stability pact, most particularly the expenditure benchmark and the imperative to use fiscal space to support Government priorities. In the recently published mid-year expenditure report 2016, the Department has been allocated an additional €73 million for 2017 to support expenditure pressures arising from demographics. While welcome, it is likely that the actual amount required will exceed this allocation, as we deal with a larger and older population with more acute health and social care requirements, increased demand for new and existing drugs and rising costs of health technology. The costs of providing for retired health care staff and payments under the State Claims Agency are also rising, increasing the cost of health above that necessary to just meet the health demands of a growing and ageing population.

With regard to funding for new developments, the priorities will reflect the Government’s programme planned over a three-year period. This is an important point. We need to look at the multi-annual picture here. Where do we want our health service to be over a period of time and how are we going to take the health service on that journey? Budget 2017 provides us with an opportunity to begin that. We also need to look at what we are going to do in year 2 and year 3. There are 132 commitments in the programme for partnership Government in respect of health, of which many have a financial cost. I think that is out of an overall number of more than 600 recommendations, of which many have a financial cost. It will be necessary to carefully prioritise and phase the initiatives having regard, as I have already outlined, to the fiscal constraints within which our country must operate. I would welcome the input of this committee today and as we continue to undertake this exercise on where it believes the priorities should be around new developments over a multi-annual period of time.

With regard to capital, notwithstanding the challenges arising from the impact of inflation, we will see major initiatives such as the National Children’s Hospital, the new mental health hospital in Portrane and a substantial number of more modest but necessary projects across the country which are currently under way. In addition, the HSE has developed an ambitious e-health programme and, through the Department and the office of the chief information officer in the HSE, has now built significant momentum and support. There is an opportunity to further build on this in 2017.

While we have secured a significant increase in funding for the health services for 2016, let me assure the committee that I do not underestimate the challenges involved in the delivery of a safe and efficient health service for the Irish people. We must maintain our focus on improving the way services are organised and delivered and on reducing costs in order to maximise the ability of the health service to respond to growing needs. We cannot just presume that the answer is throwing money at the challenges. We must look at how we can better provide and organise our health services right across the spectrum of health care.

In order for Government to have the confidence to prioritise additional investment in our health services in 2017 and beyond, it is essential that those managing and delivering the service demonstrate good practice by delivering the best possible health care within the limits of resources that have been made available by Government each year. I want to thank all of the health care staff and management who I have had an opportunity to interact with as I have travelled around the country. I acknowledge the very good work they are doing in often challenging circumstances. It is important that by living within the budget this year, we are provided with an opportunity to move on to new developments that we all want to deliver in terms of improving patient outcomes.

To conclude, I thank the members for inviting me here this morning and I will be glad to supply any further information that they may require.

I thank the Minister. We will take some question from members. I ask members to keep their questions concise in order that we can all have a number of opportunities to contribute.

I thank the Minister for a very comprehensive overview. I wish to raise a couple of points on the issues he has discussed. The first point is about the cost of drugs. I want to know what the actual total cost is. The Minister mentioned a figure of €1.9 billion in reimbursement and another €300 million in relation to the hospitals. That brings us to €2.2 billion. I presume there is another €300 million or €400 million on top of that which we are technically paying out on pharmaceuticals. Does the Minister feel that we could be doing a lot more in order to reduce that overall bill? We have one of the highest expenditure levels per capita on drugs and pharmaceuticals compared to other EU countries.

The second issue relates to waiting lists. I receive a lot of complaints from medical consultants in the HSE who have their own contracts but want to do more work. They cannot get the beds and cannot get operating time in theatres. If they were allowed to work in other facilities without affecting the hours they put into the HSE, a number of people could be taken off the waiting list. I heard recently of six patients in a public hospital who were referred to a private hospital for hip operations and the HSE picked up the tab, which was €10,000 for each patient. Four of the patients had private health insurance cover but the money was not claimed from the insurer because they were on a waiting list in a public hospital. Should we not look again at the fact that we cannot give experts the beds or the facilities but other facilities are available to them to carry out operations?

Since 2009 a lot of cuts have been made affecting junior doctors, such as in education grants. A huge proportion of junior doctors are not Irish graduates and all Dublin hospitals have problems getting junior doctors. Is this issue under review for 2016 and 2017? It is a crucial issue that we are losing a huge number of very good people. I am not talking about increasing salary but about restoring some of the grants which were removed from them in the past five or six years.

We have concluded a very good drug agreement and I thank all the State agencies which worked very hard on it. We got such an agreement because of the decision taken by this Oireachtas in 2013 to put legislation in place which enabled the HSE to set the reimbursement price, were the Government of the day not satisfied that it was getting the savings that were needed. When Government was informed by the HSE that it intended to use this legislation, which received cross-party support and was recommended by the previous health committee, it got people back to the table and achieved substantially larger savings than we would otherwise have achieved. This is an example of the good work that can be done by Oireachtas committees which then feeds into legislation and into a real benefit for the taxpayer. The Senator is right, however, in that we need to do much more. There is a medicines management group within the HSE and it has a number of ongoing projects. There is a potential saving with regard to oral nutritional supplements of €5 million per year and there is ongoing monitoring of preferred drugs and prescribing trends. It is continuing to review high-tech medicines used in assisted reproductive technologies and is developing EU authorisation processes for these medicines. It continues to look at ideas suggested by Deputy Kelleher in his legislation on biosimilars, on which I hope we can have a good engagement in this committee at a future date, and at enhancing evidence-based prescribing and optimising patient safety through a reduction in medication-related adverse events. We are continuing to strengthen the audit function in respect of making sure we are paying the right prices in the case of dispensing fees. There are a number of things we need to continue to do in this area.

The Senator's point about beds and operating theatres echoes complaints I hear from consultants and surgeons on a regular basis. I visited Cappagh Hospital recently, where four of its six theatres are closed not because they did not have the consultants but because, under activity-based funding, they had run out of parts. They had run out of the replacement hips and knees they needed to carry out procedures. That creates huge frustration among patients who are waiting and creates huge issues in regard to retaining skilled professionals in this country. I do not refer to this particular hospital but people are turning up for work and are not able to work to their optimum, meaning patients suffer. For this reason I have made a decision to allocate additional resources to Cappagh in the budget for my Department and within the HSE service plan for 2017. We have allocated €3 million to Cappagh for 570 orthopaedic patients to receive funding through the winter initiative which will eliminate the hospital's 18-month target. We have done the same for scoliosis and orthopaedics.

The Senator asked whether I would be open to considering other arrangements and I want to be careful how I answer that, on account of the contractual positions that exist. I hear what he said on the need to provide our surgeons with the opportunities to carry out surgeries. The Senator will have seen that, in my five months in this job, I will not be imprisoned by ideology on this and I want whatever it takes for patients to be seen more quickly. My preference would be to strengthen the public system so that doctors and surgeons have the necessary facilities but I will keep his suggestion in mind.

There was a question on NCHDs and this was a point made to me when I first engaged with junior doctors on taking up this role. While there are pay issues across the public service that are dealt with centrally through our colleagues in the Department of Public Expenditure and Reform, there are issues above and beyond pay that can have a real impact on recruitment and retention of our health care professionals. I hear, loudly and clearly, the point on the need to provide the same training opportunities and career advancement as exist in other jurisdictions not too far away from here. This also follows the report which we are working our way through at the moment. This is a priority area.

We have not listened to NCHDs often enough in the health service and their voice has not been heard enough outside of the normal industrial relations mechanisms. In terms of policy engagement it is important we do not just hear the voice of certain grades within our health service but that of everybody. A very good initiative undertaken by the HSE is the creation of the lead NCHD role. In every hospital I visit, junior doctors and NCHDs are making me aware of their presence. The lead NCHD tells me what his or her team can do in the hospital to improve practice and process. All lead NCHDs are brought together by the HSE senior management on a regular basis to have an input and this is something I want to see more of. It is about issues other than pay, such as recognition, listening and the opportunity to feed in to decisions as well as training opportunities.

My first question relates to the Estimates and the new structure within the HSE, about which I heard from Fergal Bowers. There is an advertisement on the HSE website at the moment for 21 senior managers. People often say there are too many chiefs and not enough Indians in the health service and the HSE is not helping its own cause with that advertisement. What are the estimated costs of that? Every shilling spent on senior managers is not spent on front-line staff.

My next question is on waiting lists. In the other committee, we had a presentation from the chief information officer and he outlined the decades of underinvestment, as well as the fact that we still lagged behind the rest of the EU with 3% of our budget going towards investment. Hopefully, e-strategies will form a big part of cost savings in the future so can the Minister give some detail on the level of investment over the medium term in e-health? I corresponded with the Minister on the Comhliosta system we are proposing, a model for which exists in Portugal. Is an integrated waiting list part of the strategy which is on his desk and, if so, how much money has been put aside for it?

Much of what the Minister said on drugs pricing is to be welcomed, especially the idea of getting people back to the table to talk.

On page 18, on the topic of principles and processes for the assessment of new medicines, a series of criteria are identified. Are they weighted? If so, what gets the highest weighting? What way are the criteria weighted? In the same section, a table identifies decisions made at the level of what is called "HSE leadership". Who specifically are the people involved?

The Minister was talking to my colleague Councillor Natalie Treacy about her mother, Mrs. Vera Ronan. I am interested to know what has been put aside for expenditure. The Minister stated there are 950 home care packages but dementia-specific and intensive home care packages were also promised which would facilitate people with injuries, such as Mrs. Ronan, in coming out of hospital and being rehabilitated in the community. These packages were promised but were not delivered. We are obviously working off a very low base with this. Are any of the 950 care packages specific to neurorehabilitation? While we have the report and strategy, we do not have any specific dates for implementation. Any information the Minister can give us in that regard would be most welcome.

There is a lot in that. Although I will give some information now on HSE structures, I suggest that I obtain for the committee a detailed note on this because the information came from the HSE as opposed to being based on a decision taken by my Department. The HSE will be here with me on 10 November for our quarterly meeting. To give the Deputy a little information, my understanding is that there has been a vacant deputy director general post within the HSE for quite some time. Some members will obviously be aware of this. There is a need to shake up the structure in respect of how people are reporting to the director general and the HSE. This involves a realignment of roles. I will obtain a detailed note for the Deputy on the specifics, including the costs.

My information is that there will be a significant cost. However, it is really a rearranging of the chairs. There will not be very many additional personnel with respect to the vacancy that exists. I am sure it needs to be filled. The Minister will understand that people do not like to see what I am describing, particularly in the case in question. I saw the details on Twitter; Fergal Bowers was tweeting it. That is not really acceptable. This should be done in a more structured way.

I have not seen that. It is a fair point that the HSE should brief the committee on this. I have not seen the specific advertisements the Deputy is referring to but I would imagine that quite a significant number of the staff in question are replacement staff. There is a myth about management numbers in Ireland because those in the HSE and NHS are pretty much aligned. In the NHS, 4.8% of staff are classified as management. In our health service, the figure is 4.9%. However, I take the point the Deputy is making.

Twenty-one jobs have been advertised-----

I would imagine many of them are replacement posts. I will revert to the Deputy on that.

With regard to e-health, I am really pleased to hear the Deputy say what she is saying. There has been a tendency in this country, and perhaps in others, to be dismissive of investments in technology and ICT and to ask why all the money is being spent on computers. This investment is vital. The National Treatment Purchase Fund publishes its waiting list figures every month. While we can all agree the lists are far too long, none of us, including me, can delve down into the detail to the extent that we can determine how many times Mrs. Murphy is on a waiting list and how many doctors she has been referred to. That level of detail is needed to make informed policy decisions. We will have €50 million for a waiting list initiative under the commitment in the programme for Government. How best can we direct that?

I was taken by the Deputy's view on the Portuguese model. I have asked that it be considered in the context of the technology being developed in respect of waiting list initiatives. I would be happy to engage with the Deputy further on that. There has been historic under-investment in this country on ICT. We are seeing a new dawn regarding the work of the chief information officer and the e-health agenda. There is a lot of good work taking place in this area. By this time next year, every one of us will have an individual health identifier, IHI, whereby, for the first time, we will be individually recognised by the health service. This is really important.

I am also considering using technology for basic tasks. Some 15% of people on waiting lists are not attending their appointments. My saying this is not blaming the patient. If one is waiting a year for an appointment, one might forget about it. It is not unreasonable for this to happen. We should consider how we can do simple things with ICT, such as reminding people about their appointments using SMS. Obviously, the do-not-attend figure results in a huge cost to the health service. It is much higher than it should be. I agree with the Deputy in this regard. In the service plan and the budgetary process, I want to see progress on the health investment levels. I hope the Deputy will see this reflected in my plans in the coming weeks.

Before I refer to the question of new medicines, I will refer to Councillor Treacy. I had an opportunity to have a brief conversation with her when we met in RTE recently. She has done superb work on highlighting an important issue. I recently met representatives of An Saol, which is doing considerable work highlighting the really complex needs of their loved ones. They have an absolutely understandable desire that the State, the health service, provide more than just somewhere for loved ones to reside and instead provide an opportunity so those loved ones can live their lives to their full potential. Very interestingly, the proposals the An Saol representatives made to me in my conversation with them were based on the better use of the resources already being provided to their loved ones. It is proposed that, instead of putting an individual in his or her thirties into a nursing home, one could actually reallocate the funding. This is actively being considered. An Saol has recently engaged with the HSE on this. I am to meet Councillor Treacy shortly. There is a date in our diaries. I look forward to seeing what we can do to assist on the broad issue she has been highlighting.

As the Deputy says, there is a strategy in regard to all this. An implementation plan is due to be published this year. This is where we need to get to, so we can align with our implementation plan the views of all the campaigning groups that have highlighted deficiencies in this area. I look forward to the opportunity for Councillor Treacy, An Saol and other groups to feed into this process. Senator Kelleher has a keen interest in this and we have engaged on it.

With regard to the criteria and new drugs, the criteria are obviously the health needs of the public, the cost-effectiveness of meeting health needs by supplying the item concerned rather than providing other health services, and the availability and suitability of items for supplier reimbursement. Nine criteria are listed. They are outlined in the Act of 2013 and they are not listed in order of priority. The challenge for the HSE is to balance all those competing criteria. At times, they do compete. The list of criteria needs to be considered.

The HSE leadership team comprises the directorate and also the HSE drugs group, which comprises clinicians. Within days of coming into office, I was being contacted by people saying that if I did not provide such a drug, certain men or women would die. That is not a decision I am qualified to make. It is not a decision that any of us as politicians should be making. What we have tried to do, therefore, is evident in the new agreement. There has been progress made in this regard although the process is still far from ideal. We need to examine what other countries are doing in this regard. What we have tried to do is put in place a very clear set of criteria. These criteria are to be considered by a HSE drugs group, comprising a group of clinicians. It is the decision of this group to go to the HSE leadership team. Ultimately, recourse to the Government will still be needed should there be a funding requirement above and beyond the funding available to the HSE.

I am going to Bratislava shortly to an EU health Ministers' meeting. I want to engage with colleagues on what other countries do because I believe there has to be a better way of doing this. Bearing in mind that many of us in this room will be Ministers on some occasions in our careers, I do not believe any of us want to find ourselves in a position in which the Cabinet or individual Ministers are playing God. It is not desirable.

A very useful part of the agreement concerns looking forward, or the scanning exercise that will be carried out annually between the Department, the HSE and the industry. In advance of the Estimates process next year, rather than this year, people will sit down to consider the pipeline of drugs. That would better enable me, or whoever is in this role, to determine how funding might be put aside for the three, four, five or many more drugs that are coming down the tracks. Currently, we can be taken by surprise somewhat. Of course, we all want our loved ones to have access to a new drug that becomes available. We must currently scramble somewhat to assemble facts, so scanning ahead for 12 months is a better system.

Is the Minister saying all nine criteria have equal weighting?

Yes. I am saying they are not weighted.

There is no weighting, so I presume they all have equal weighting. The directorate and drugs group comprise the people referred to as "the leadership".

Do they meet regularly or as and when required?

They meet quite regularly because they are required quite often. I have known them to meet nearly on a monthly basis at times. Meetings are as required but regular.

As and when required.

I thank the Deputy.

I welcome the Minister and his officials. The Minister made an informed contribution. It is important that we interact with him and policymakers from all sides to ensure value for money and policies are brought forward that will underpin our basic commitment, collectively, to improve health services. I do not expect detailed answers, but I would like some insight.

On the National Treatment Purchase Fund, NTPF, the Minister has said he is not ideologically driven in how health care is accessed as long it is accessible and affordable and the waiting lists for inpatients, outpatients, day cases and so on can be addressed. Have comparisons been made, for example, of the cost to the public purse of performing orthopaedic surgery in various public hospitals and between public hospitals and the private sector? Very often, we simplify comparisons and do not compare apples with applies, but we need to do so in this case to ensure the public system is providing value for money and, equally, the private system is providing value for money and that NTPF money is not being eaten up in a manner that was unintended. Is that information available?

Senator Colm Burke has referred to an issue that has arisen in orthopaedics in Cork and elsewhere in recent years - hospitals running out of implants. The South Infirmary Hospital was told at the end of September 2013, for example, that that was it for the year. That is exceptionally frustrating for patients on waiting lists and senior, experienced, professional clinicians who want to get on with their job but who have to park surgical procedures, which is unacceptable. There are huge funding difficulties, but there has to be a more imaginative way to ensure a pipeline of implants for knee, hip and other replacements. Can the Minister be more definitive? The issue of clinical staff being unable to perform their duties in expensive operating theatres has to be examined.

There is a reward for management in keeping hospitals full of healthy patients or patients who need low level medical support because if they admit high dependency patients or patients who need surgery, it will eat into their budgets. We, therefore, need to be imaginative in how we address that issue. Senior managers have told me that if beds are full of patients who do not need major surgery or interventions, they can stay within budget, but if they fill them with patients who should be in the hospital, it eats into their budget. That is a perverse way of doing business, but it is happening in all the hospitals in the public system. They are penalised if they ramp up activity and do what they are meant to be doing. We have to examine this issue.

As I am ranting a little, I will move on to the drug pricing agreement, which I welcome. It was a confident move by the HSE and the Minister to say they would activate the legislation if more flexibility was not displayed by the pharmaceutical industry. However, in the next few years, there will be major challenges in funding health care generally and drugs specifically. High tech drugs are coming on stream and more novel, innovative medicines are available. That will continue to happen. Is there a robust enough system in place to negotiate with powerful and influential organisations? I do not cast aspersions, but is the system robust enough to enter into negotiations with these organisations, collectively and individually, and assess whether the State should fund these medicines? Private Members' Bills have been introduced which would have put the onus on the Minister of the day to play God. I do not accept that should be the case. The issue should be depoliticised to the point where there will be a system in place under which, at the end of the day, an entity or a group of people will still have to make a call on whether a medicine should be made available that, unfortunately, could have life or death implications. If all the funding is spent on medicines, that will have life or death implications in other areas of the health service. The pharmacoeconomics group does its job, but I wonder whether we should revisit this system to ascertain what is best practice outside the country. The Minister has said he will visit Bratislava, for example. There were be a significant increase in the number of medicines coming on stream in the next five to seven years. They will be expensive and almost tailor made to individuals through genetic profiling and so on.

On the emergency department task force, I criticise and compliment in equal measure; therefore, I am reasonably fair. The Minister has said €40 million is available for the winter initiative and to ensure the numbers of home care packages and home help hours will increase, which means that more patients will be moved out of hospitals. However, after almost every initiative that has been implemented during the years, 700 and 800 patients remained in hospitals who should not have been there. They are referred to as delayed discharges. We were at a figure of 1,000 at one stage, but it has been pared back to 660 or 680. Is there a systemic failing or is there insufficient capacity in the community care, social care and primary care systems? We have had this problem consistently.

We have siloed budgets. I have dealt with two cases in recent years in which high dependency home care packages were required for two children. They were in Crumlin hospital and could not be transferred because they were from the country. One cannot transfer budgets. One manager in the midlands told us that they could not bring in the child because they did not have funding for the high dependency home care package, yet management in Crumlin hospital wanted to move the child out, while the parents wanted to bring the child home. One has to wonder if there is any ability to cross-manage budgets in a way that would make sense for everybody. Clearly, that would have been in the interests of the hospital, the patient and the parents and it should have been done. Reference was made to the HSE, various directors and so on. Could we end up siloing everything again under the various headings such as community care, social care, mental health and so on? When the Minister examines this issue, he should ensure there is flexibility at directorate level, otherwise we will end up with these difficulties.

On e-health, Deputy Louise O'Reilly referred to the challenge in large organisations in introducing new technologies - whether they have the capacity to implement and develop them. There is major resistance to them, but sometimes they just do not have the capacity. Have the HSE, the Department and the hospital groups the capacity to embrace these new technologies and ensure staff will be able to use them?

I thank the Deputy. He has made many points and I will try to go through them as quickly as I can.

With regard to the National Treatment Purchase Fund, NTPF, the Committee of Public Accounts did some work on this a while back and found there was value for money from the fund, although there is a case to do more. The activity-based funding model we are moving towards will enable us to have a much quicker look at value for money. It will create data on, for example, how many procedures were done in a certain public hospital for a certain amount of money, which will provide us with a level of data in regard to public hospital costs which, to be frank, we do not have to the quantity we need.

I want to be clear in regard to the NTPF that I am very eager it does not just do outsourcing but also does insourcing. This is not all about private hospitals or private health. It is about accepting we have too many people waiting too long and we need to come up with a pragmatic solution. I believe the Deputy and I share a view on this. Some of our public hospitals have spare capacity. We should be funding them to do the procedures. The job of the NTPF is not simply to come in and outsource everything to the private sector. It will have a dedicated fund to get through the waiting lists in the most efficient and pragmatic manner for patients, be that in a public or a private hospital. However, I make the point that there is spare capacity, and Cappagh hospital is an example of spare capacity within the public service that we have tried to ramp up through winter initiative funding.

The other part of the value for money question we have to consider is where there is not capacity. There are parts of the public sector where, even if it is more efficient to carry out procedures there than somewhere else, there may not be the capacity there today, whether in terms of theatre nurses, whom we are having a difficulty attracting, or in terms of the infrastructure of the building. These are all issues we have to address but they are not going to be addressed today or tomorrow. The patient is waiting and, therefore, the value for money question becomes less relevant and it becomes a question of where we can get the patient seen now.

The Deputy made a point about running out of money for implants. This is a huge challenge and we have to do much better. I believe the NTPF will provide a pipeline of work that will enable us to better predict what we actually need to do. When I met NTPF representatives recently, I was very encouraged that they were able to say that if I provided them with X million euro, they could do a certain number of procedures, and if I provided Y million euro, they could do a certain other number of procedures. This will provide a degree of certainty to the Irish patient that X number of tens of thousands of operations will be done in certain specialties under the NTPF and this will bring down waiting times for those procedures. That is something we badly need.

The Deputy referred to the group structure, which is something we need to stress-test much further. The whole idea of the group structure is using each hospital within it in the most effective way. There will be the acute hospital, the level 2 hospital and the level 3 hospital. Moving patients between hospitals to get them to the most appropriate setting for their needs is happening very well in some hospital groups. I note the links between Beaumont Hospital and hospitals in County Louth, such as Louth County Hospital and Our Lady of Lourdes Hospital, and in Cavan. We see patients being moved from Beaumont Hospital and getting a procedure done very quickly in Cavan Hospital. To be frank, that is not happening enough in every hospital group and it is something we need to do more on. I agree with the Deputy on that.

With regard to the drug pricing agreement, the Deputy is correct that we are facing a huge challenge, not just in this country but globally in terms of the availability of drugs. We have a very good and proud record in this country of providing our patients with access to new drugs and we bear up very well in terms of international comparisons. The drug pricing agreement is not going to see us, in any way, shape or form, spend less on drugs but it will see us have some degree of headroom to purchase new drugs for our patients. The robustness question is a fair one but I am satisfied that the State showed its robustness this time. The industry certainly found this in the sense that it had thought it would be able to put in place a deal that would achieve a certain amount of savings and it ended up delivering a deal with the State that has brought a significantly larger amount of savings.

The point both the Deputy and I are grappling with, and it is a point on which I would appreciate the committee's help, is how we can do this better and what is best international practice. I am talking to other European health Ministers in this regard. I have heard ideas from the Deputy's own party in regard to the creation of a fund. I am not against that and I believe there is a logic to it. However, there is still a difficulty as to how it can be funded enough, how we know how much is enough, who accesses the fund and what are the criteria. As an Oireachtas, or as a committee, we can do a very useful body of work. I would certainly appreciate the views of the committee in terms of best international practice in this regard.

Another point I would make in regard to the drug pricing agreement, which I believe shows the robustness of the State's side, is the frequency of the price realignment. We do not have a static deal that states we are paying so much for every drug for the next number of years. There is an annual pricing realignment built in that can see us benefiting on a year-on-year basis from price reductions, obviously with reference to a larger basket of countries, including a number of lower-priced countries that were not included previously.

In regard to the winter initiative, I am convinced the key to making progress in our emergency departments lies with delayed discharges. The figure I was given yesterday in regard to delayed discharges is 629, which is still far too high, and while it has been higher and has been lower, it needs to be much lower. As I have tried to delve into this, I have found a number of reasons as to why there are 629 patients in hospitals today who medically do not need to be there. For example, there is a degree of capacity in the private sector in certain geographic areas to provide home help. If one goes to a certain hospital on the north side of Dublin and goes into its bed management room and looks at the people listed on the whiteboards, they will have funded home care packages but they do not have anyone to provide them. It is an issue the HSE is working on. While we are making some progress on that, it is partially to blame for that large figure.

There is the issue of nursing homes. This is a very big decision for any patient to make and the State should not be imposing a decision on what nursing home an older citizen wants to go to, or if the person is not in a position to make the decision, where their family wants them to go. The person might want to go to nursing home X but there might not be a place in that nursing home today or tomorrow. We have to grapple with the fact that it is fine that the person gets to wait for a nursing home as it is their decision, their dignity, their life. However, is there not somewhere better for the person to be, other than the acute hospital bed? This brings in the whole question of transitional beds and we see in the winter initiative the commitment to opening more transitional beds.

Let us not ignore the elephant in the room. The Deputy makes a significant point that the silo mentality is something we have to look at. I have resisted saying too much on this because I know the Committee on the Future of Healthcare, of which a number of members of this committee are members, is looking at structures. I want to try to get to this cross-party agreement on the ten-year plan, as we all do, which is a huge body of work. I personally believe there is significant merit in looking at how hospital groups and CHOs operate. If people are protecting budgets, with the hospital protecting its budget and the community protecting its budget, and the person in the hospital who needs to send a patient home today does not actually control the budget for home care, that is a problem. I intend to act on it but I would like to see if we can arrive at a conclusion as part of the work that is ongoing in that committee and I do not want to wrongly interfere. However, I accept the silo piece is a legitimate point of criticism and something we need to deliver on.

I am glad the Deputy raised the point about children. There is a view at present that we are just building a national children's hospital, which we are, but we are doing so much more than that. We are building a hospital in Dublin and we are building satellite units in Dublin but we are also putting in place a paediatric model of care so any child, anywhere in this country, will be under the umbrella of a children's hospital group. Therefore, we will not have silly situations which have an adverse impact on our children because they are stuck in one hospital because someone else will not talk. I intend to bring that paediatric model of care to Government shortly. I am also engaging with the boards of the existing children's hospitals. I have met two of them and am meeting the final one in the morning. I intend to bring the heads of a Bill to Government to move on with that new integrated model.

With regard to e-health, I am now satisfied that we have the capacity which we clearly did not have on the State side and the HSE side for a long number of years. Excellent work is being done by the chief information officer and the e-health group. As a GP himself, the Chairman will know GPs are streets ahead of the acute hospital sector in terms of technology. When a person goes into a GP, they are not tripping over paper files. The Chairman should see the pictures I get sent of the paper files being stored in hospitals - there are warehouses full of paper files. GPs have proven they can grapple with the e-health agenda and they are doing it. We now have e-referrals in place where many GPs, at the click of a button, are able to refer a patient onto an outpatient waiting list. The analysis my officials have done is that before that happened, the referral would have passed through 16 pairs of hands before the referral was made. We will very shortly have e-discharge so the GP hears back that the patient is out of hospital and also receives the patient's notes. We will have the individual health identifier and, ultimately, we will have the electronic health record by 2020. There is a huge body of work going on and I am satisfied it is going well.

I am here representing Senator John Dolan and I will be asking a question he particularly wanted me to ask. I also have a couple of questions of my own. One concerns the area of social care in general. I have worked for Cork Simon Community, Cope Foundation and the Alzheimer Society of Ireland and I am a social worker by trade.

As far as I can see, social care is the Cinderella of the health system in Ireland. This is the case in any part of the system, whether one has a neurological disease or dementia or is a parent of a child with severe disabilities. There are problems in every part of the system. Social care, as part of the health system, is not functioning. I hope the Committee on the Future of Healthcare makes recommendations on building a successful system.

Home care is a major part of the health system. The 950 additional home care packages are welcome, but they do not meet the demand. There are not enough and they are not getting through to those who need them. The national dementia strategy earmarked 500 intensive home care packages, which is a very modest number considering that 55,000 people have dementia. To date, only 85 people with dementia are benefitting from that.

Social care is the Cinderella, home care is growing but is still not anywhere near meeting the demand and services are not getting through to people or are always appropriate. Some forms of home care involve personal care. A person with dementia may not necessarily need to be dressed, but may need to be reminded to eat. It is important that the form of care we are offering to people is correct.

Deputies doing constituency work will be more aware of that than anybody else because people are coming to their offices with concerns. We need to know what will happen in 2017 in regard to that. Will there be significant additional investment in home care? Will it be able to cater for people who have, for example, dementia specific needs? This issue is not going away and has a major impact on the mainstream system. Even if one is not bothered by home care, as someone coming from my perspective might be, the number of beds and delayed discharges are having a major impact. I would like the Minister to comment on that.

I am also concerned about waiting lists. I received some information from my neighbour, who is a gynaecologist in Cork, about gynaecology waiting lists and I was shocked. I understand the highest number of women in the country, 4,090, are waiting for outpatient appointments and 662 women are waiting for gynaecological surgery. This is a critical issue for those women, especially those who have been waiting for a long time because their condition may be worsening.

Senator Dolan referred to the implementation of the UN Convention on the Rights of Persons with Disabilities. Has that been provided for in the Estimates for 2017? What is the status of the statement of the departmental strategy in terms of implementing that convention?

My major concern is social care and, within that, home care. I am anxious to hear from the Minister on that, in particular with regard to the budget for next year.

I thank Senator Kelleher. I bow to her expertise in this area. She knows the sector very well.

I refer to the Cinderella charge. I do not want to dismiss legitimate criticism and problems the Senator outlined but in terms of what we are spending on the social care division - we may have to have a conversation about how this translates into services - the disability budget is €1.5 billion, the fair deal budget is €1 billion and there is another €700 million budget for older people. This is linked to my opening statement, in which I said we need to make sure funding is spent in the correct manner to deliver the services that people actually want to see delivered.

Senator Kelleher and Councillor Tracey convinced me that is not the case. People I have met have told me they are not seeing the service they want to be delivered. They have come up with better ways of delivering their own services within the same level of resources. A detailed body of work has been done.

I cannot get into specific Estimate discussions because discussions between my Department and the Department of Public Expenditure and Reform are ongoing but the area of home care and home help remains an absolute priority for me and the Minister of State, Deputy McEntee, as the Senator knows. She is continuing to engage and I hope I showed some good faith in terms of the winter initiatives where, as the Senator said, we increased the number of home care packages quite significantly, by another 950, in recognition of the points she made. There is a significant correlation between the inability of someone to act as a home care package and the likelihood of that person ending up in hospital and remaining there for much longer than he or she medically needs. We are ad idem on that. How we translate that into benefits on the ground is what we need to work on.

As the Senator has outlined, some people have very complex needs, and have the right to be cared for in their community and home and to live in their home and community for as long as they possibly can. The rigidity of the current system is something we need to examine. The Minister of State, Deputy McEntee, is doing a considerable amount of work on this and I hope we will be able to show, in the multiannual sense, as discussed previously, incremental progress to get us where we need to get to.

I will examine gynaecology waiting lists in Cork and revert to the Senator in terms of ascertaining the current situation. My Department is scoping a winter waiting list initiative for 2017. If we get what is committed to in the programme for Government in the ongoing Estimates process in terms of waiting lists, we will examine how best to spend that money. We will target particularly challenging waiting lists. We will start with people who have been waiting the longest, which is the fairest way of doing it. We do not need to have a national treatment purchase fund, which is a convenient tool for keeping waiting lists low but ignores the fact that some people have been waiting a very long time. We will also examine specialties where there are particular limitations or challenges.

In the current year's Estimates, funding has been allocated for the HSE to develop the women and infants health programme, which comes under the national maternity strategy. I am very proud to say that we have a national maternity strategy. It somewhat boggles the mind that this is the first time we have had one. It is a very impressive document, and now we need to bring it to life. The women in health programme in the HSE will do that.

The UN Convention on the Rights of People with Disabilities is a priority project for my colleague, the Minister of State, Deputy McGrath. He is working extraordinarily hard across a number of Departments to deliver this. It involves health, justice and other areas of Government that need to be pulled together. The plan is to try to get this done by the end of the year, but I will ask the Minister of State to update Senator Dolan and the committee by way of letter on the current position.

It needs to be included in the Estimates because there will be costs.

Without getting into the specifics of the Estimates, this is a priority in the programme for Government. There is a very clear commitment that this will be delivered on. I expect that will, therefore, be reflected in the HSE service plan for 2017.

I thank the Minister.

I thank the Minister for appearing before the committee. The first issue I want to speak about is the State Claims Agency, which is mentioned in regard to budgets. I want to focus on maternity care, in particular cases where a woman goes into a hospital to deliver a child and something goes wrong at the birth, for whatever reason - I am not saying it is the fault of the HSE or a doctor. I would like to highlight to the committee and the Minister the process women and families have to go through when mistakes, alleged or otherwise, are made.

The Minister referred to the national maternity strategy. When women go into hospital to have children and something goes wrong, they have to go home and deal with children who, while they are alive, may have a disability as a result of birth. Women and families have to go through a process to be heard. Parents do not expect this to happen to them and they have children to care for who may need additional physiotherapy and all sorts of care.

The process involves State legal teams, and women also have their own legal teams. Every gynaecological examination needs to be done by two sets of people. Life is bad enough for the women this has happened to and who have been left with children to care for. The State helps in terms of the provision of services such as the Central Remedial Clinic or whatever. It is something on which we need to work.

It is barbaric that a woman would have to be examined from head to toe, foot to knee or wherever by two separate sets of medical experts. To my mind, women are degraded and demeaned by that.

It is something, for the sake of the women of this country, that we need to consider and speed up this process. If something has gone wrong then we must learn lessons from the incident. From the patient's point of view, the process has huge mental health implications. People may say they are well and do not intend to pursue the matter further.

Deputy Louise O'Reilly mentioned the HSE structures and a tweet by Fergal Bowers that I did not see. I strongly advise against anything like that happening while the work of the ten-year health committee is ongoing. I am on the committee, as is Deputy Louise O'Reilly. Who else here is on it? It would be regressive if the HSE went about fixing itself without the involvement of the Committee on the Future of Healthcare because that is the purpose behind the establishment of the committee.

It is great news that 80 consultants have been recruited this year. I agree with the Minister that things other than pay matter to people. For example, training opportunities, grant supports and clear career pathways from junior doctor to the Holy Grail of being a hospital consultant. Appointment to a consultant position is usually the ultimate aim of dedicated clinicians. It is imperative that we support career pathways and do not lose people that have been educated in this country. My sister is a hospital consultant and she emigrated to Australia. I am sure she cost the State a fortune to educate but she will never return. We must look at recruitment. We need to provide support to junior doctors and non-hospital consultant doctors in order for them to progress in their careers. One of the great failings of the health system is that we do not have enough indigenous trained medical people who are used to our system. Instead, they are leaving the country.

In terms of drug pricing, the Minister mentioned assisted reproduction and high-tech drugs. The Minister need not give me answers today to the following questions as I can get them off him again. Was he referring to drugs that are used for IVF or any sort of assisted reproduction? Have the drugs been removed from the high-tech list? Are they no longer allowed on the list? What is the position?

A drug called Humira is used by some hospital consultants in IVF treatment. The drug is made by AbbVie and is not licensed for IVF treatment but for another purpose. The patient must pay the full price of €1,550 for two injections of the drug. People do not like to talk about the cost associated with assisted reproduction or IVF but it is astronomical. Many of the drugs used in this process are high-tech drugs. The drugs are necessary and allow people to have much longed-for children.

My next question is on the classification of high-tech drugs. I am a community pharmacist but I used to be a hospital pharmacist. We need to consider how drugs are classified as high-tech. Ten years high-tech drugs were launched with bells and whistles, we all got very excited and we all had one small fridge. Now community pharmacies have huge fridges full of high-tech drugs. We need to consider why drugs are classified high-tech. I am not suggesting that the following is the case but perhaps drug companies are going down the route of making them high-tech when ordinarily they would fall into a different classification.

People are positive when we negotiate better deals with drug companies. I want to mention something that happened during a recent debate in the House on a motion which covered among other matters the reimbursement for blister packing or phased prescriptions. A Deputy mentioned that the synthetic cannabinoid Nabilone is used for pain relief. The item is a particularly popular with the pain consultants in St. Vincent's as one tends to see spots of drug prescribing. The reimbursement price increased from €400 to €1,200 for a monthly dose or treatment of the drug. That meant in practical terms that a patient was prescribed the drug by the doctor, got their drug from his or her community pharmacist and went home. Then the HSE rightly stopped paying for it because the price had trebled. Sometimes when the Government cuts off the supply of a drug there is a legitimate and logical reason for doing so. There are some Deputies who, on the one hand cannot say it is great that prices are going down while, on the other hand, asking for a drug to be in use. They cannot talk out of both sides of their mouths

Is the Deputy keeping this conversation all to herself?

We might as well all go home.

I am messing.

In light of the presentation at the ten-year health committee, e-health is very positive. I would like be able to criticise the system but GPs are moving to a paperless system and we are using a unique patient identifier system. The person who gave the presentation said Ireland was being very progressive as a country by introducing e-health. The initiative will be up and running and streamlined within 18 months. It will lead to a huge cost saving initiative. I compliment everyone involved in bringing the scheme on board.

Chairman: I thank the Deputy.

It is my understanding that the structure Fergal Bowers tweeted about has been put in place. Deputy O'Connell is right to say that the move should not have been done without recourse to the other health committee. I am sure any costs associated with the scheme will have to be incorporated. I ask the Minister for a clarification.

I thank Deputy O'Connell. I might start with this subject. I do not want a misconception or a linkage between 21 posts being advertised - we should have invited Fergal Bowers to attend - and the Fergal Bowers tweet.

I was not the one who mentioned a link.

I am not suggesting that the Deputy did so.

There are generally more than 21 managers.

There definitely is not a link. The Director General of the HSE has decided, as is his prerogative rather than mine, to restructure how people report to him within the HSE. He issued a circular to his staff outlining how people can report to him, subject to him filling the deputy director general post. That is the extent of the matter.

I take very seriously the point made by Deputy O'Connell. The committee has heard me make the point already that I have ideas about things I would like to see changed and improved in terms of structure. I have resisted doing so out of respect for the fact that we are trying to do something that we have never done before in this country - a ten-year plan with buy-in from all of us. It is important that we do this work and I echo and reinforce that message with the HSE.

As Deputy O'Connell mentioned, the way we treat women and patients in this country when they experience a tragedy or an adverse event in our hospitals is shameful. It is something that we should be collectively ashamed of. The system is far too adversarial. People who were preparing for a time of great joy - bringing a new baby into the world, bringing a child home and starting a family - have all of a sudden had that joy replaced with the most unbelievable grief and bereavement, in some cases, or extreme challenge in the case of finding that these parents now have the responsibility of rearing their child who has significant care needs above and beyond what anybody would have expected. We need to reform this system. As the committee will know, both the Tánaiste and Minister for Justice and Equality and I are working hard to carry out reform. I do not want to stray into her policy area. The Tánaiste has outlined that she will bring forward legislation on periodic payments.

Families do not want to go to court to get a lump sum payment. They want the care needs of their child met for the rest of their child's life. The only people who benefit from the current system are the legal eagles. We are funding a system that benefits the lawyers and not the patients. We can no longer do that and we are not going to do so.

Where my piece of the jigsaw fits into all of this is the piece on open disclosure. Since taking up this job I have had an opportunity to meet some people who have had bad experiences of the health services as well as, thankfully, many people who have had good experiences.

What the people who have had bad experiences and have experienced tragedies wanted was answers. They wanted to know what happened. As the Deputy correctly said, they wanted to get a sense that the system was learning, that they told somebody what had happened and that it was not going to happen again. The way people have been treated in our health service in regard to this, historically and in the not too recent past, is not acceptable.

Equally, on the other side, we have health care professionals who want to be able to provide that information in a safe environment. They want to able to provide the patient and the patient's family with information. We need to put in place a structure and environment for everybody in which to do that safely and in an informative manner at the quickest point possible. As part of that legislation, I will be bringing forward a piece about open disclosure, which I believe is very important. I know the Tánaiste is working on putting in place a much less adversarial system that should remove the occurrence of some of the dreadful experiences that the Deputy has outlined. For my part, I want to create a culture within the health service which, in fairness, we are already trying to embed, around making sure that we support people at a very vulnerable time. There is obviously a very strong patient involvement in the development of the national maternity strategy, as the Deputy will be aware. There were two patient advocates who fed into this strategy. Also, I recently launched the national bereavement standards for when things go badly wrong and people are bereaved for a variety of reasons within our health service. Again, it was very important that the voices of the people who had been bereaved and who had an opportunity to meet at the launch in Farmleigh are also being fed into the process.

We have a lot of work to do on this. The way we have treated women in our health service has been completely unacceptable. However, if one looks at the building blocks that have been put in place in very recent times such as the new national maternity strategy, the national bereavement guidelines, the policy of open disclosure, the movement to periodic payments, wanting to build a new national maternity hospital, which we have to build and which we cannot allow bureaucracy obstruct, and the women and children's health programme within the HSE, I believe we are at a very significant moment in making sure that we learn the lessons of the past.

On the issue of career pathways, I could not agree more with the Deputy. One of the more enjoyable moments of this challenging job I find myself in is that every time I meet people in the health service, they tell me they want to do more. I do not mean that flippantly. Every single representative group that I have met tells me that they are skilled professionals, which they are. They say that they could be doing more, whether they are radiographers, pharmacists, dentists, doctors, GPs or nurses. What we need to do now is make sure that everyone in the health service is doing to the optimal level what they are qualified and able to do. It exciting work and it will see real benefits for patients. This idea that other jurisdictions would offer better career pathways, better educational opportunities or better further training opportunities is something we must grapple with and that is a priority for me.

I am very pleased with what the Deputy said about drug pricing and the narrative around that. I find myself, as Minister for Health, having to bite my tongue, which is not a thing I like to do very often. I follow Deputy Durkan's lead. The moment I say, or anyone in my Department or the HSE says, that we are going to provide a drug is a moment in which we write a blank cheque for very large drug companies. When drug companies talk to me about patients' interests, it is my job to look after the patient and the company's job to look after itself. When we can align the two, it is ideal. However, I am very clear where I stand and I do not need anybody reminding me about patients' interests. That is our job in the Oireachtas, the Department of Health and the HSE. Therefore, it is important that there is a process in place. It is important that we try to find an even better one. It is so frustrating for people. I know that because they tweet me, talk to me, e-mail me and meet me on the streets. They tell me that they want this drug provided and want to know why I will not tell them I am going to provide it. What I will say to this committee and what I say to those people again today is the moment I say we will provide this drug is the moment I tie the hands of the HSE in the negotiating process which will hopefully lead to the provision of that drug. It is a balancing act.

In terms of high-tech medicines, the line I referenced about assistive reproductive technologies is the fact that we are keeping under review the classification of the high-tech medicines and the effectiveness of the drugs on that list. I will get the Deputy a more detailed note on that.

I thank the Minister. I call Deputy Durkan and ask him to bite his tongue after three or four minutes.

Having made it this long, it would be a terrible sin to bite my tongue and disable myself before I start. I thank the Chairman. I congratulate the Minister and his officials for coming before the committee and engaging so openly and readily with it. This is a big challenge for the Minister and for his Department. The challenge in health has been there for at least 15 or 20 years. Targets have been set many times in the course of that period. However, they are moving targets. By the time one attempts to achieve the target, it has moved again. From what the Minister has told us, I would conclude that he is moving in the right direction. The Minister will know better himself whether he will be able to hit the targets in one fell swoop. That remains to be seen. However, it would be hugely beneficial to the morale of the health services, the morale of patients who are on waiting lists and the morale of the people generally in the country.

Health services affect every single household in the country. Various other services affect them for a period of their lifetime, but health services affect them for their entire lifespan. We are allegedly growing older, some of us more quickly than others. The point at this stage is that it is a better job to be able to take corrective measures halfway through a cycle rather than waiting until the end of the cycle when one realises that one's targets are not going to be met. I recognise the danger there is of becoming a hostage to fortune and allowing outside interests to dictate where one is going. The best of luck to the Minister with it.

Deputy O'Connell rightly made the point about legal issues. I mean no disrespect to my legal colleagues, of course. The fact of the matter is simply that patients in general, but more often than not women, find themselves in enough difficulty facing a traumatic situation without having all of the legal consequences trotted out before them and having to undergo all the probings that take place associated with that. Why is there not a system without prejudice that would initially examine a situation without making the Department liable for endless costs and whereby there would be some recognition of the trauma through which the patient has gone as a result of an accident or whatever the case? One does not have to concede. There are procedures for doing this. I do not know if such an approach has been found possible. I was involved over the years, as I am sure was everybody else here, with different patients who found themselves in that situation. It is deplorable. At the end of the day, when and if the case goes to court, having cost millions of euro in legal costs as well as everything else, the compensation has to take place. Why not look at it at the beginning, try to cut the ancillary costs and move towards that?

To what extent can one avail of the benefit of membership of the European Union in the control of drugs? It is a large market of 500 million people. When I was a member of a health board we had this argument. There is always a tendency for the drug manufacturing companies to exert power and influence to the detriment of smaller countries and allegedly smaller markets. We are not a smaller market. We are a very large market. We require and demand the best that is available through that.

The issue of waiting lists is something that has been going on for years. The Minister is moving in the right direction with his initiative. Hopefully, the combination of the primary care centres on the one hand, strengthened services through the GPs on the other hand and step-down beds will enable a more accelerated programme to develop. Over the years I have tabled a number of parliamentary questions on the effect of the primary care centres on the waiting lists in their adjacent hospitals. The answers I received were not convincing. I have visited some of the hospitals adjacent to primary care centres and have found that the patients in many cases are referred past the primary care centre and on to the general hospital. That should not be happening.

There is another issue that my colleagues have made reference to around attracting, educating and retaining medical staff of all levels in the country. That is a problem.

Unfortunately we are not likely to have the climate they enjoy in Australia. We will never have it. It will not happen that way. There has to be some other way we can encourage our qualified medical people to remain in this jurisdiction, at least for a while, to benefit the health services here and to benefit themselves.

To what extent does the Minister see the GP contracts featuring in this in the first instance? Does he see an opportunity there? We have had much criticism of the GP contract in recent years and dissatisfaction, particularly in rural areas but also in urban areas. To what degree does the Minister see the possibility of dealing with it? This is the first step. If this cannot be resolved at an early date, then the other down the line issues will accumulate and continue.

I am suspicious about the availability of drugs at a very high cost. They are under patent for a certain number of years but it worries me when I see the costs associated with them. Whatever moral pressure can be used, even if it involves using the resources of the European Union, it should be done.

I congratulate the Minister on the initiatives so far. He mentioned who has control over some aspects of policy in the HSE. The Minister has control and he needs to exert it. The delivery of the services is under the amorphous mass of the Minister, the Department of Health and the HSE. The HSE is the instrument which delivers at the coal face. There is a tendency from time to time for policy decisions to emerge as if they were by gradual growth and development over time. Not all of these decisions are soundly based and I am concerned about them. The important thing in all of this is that the decisions ultimately rest with the Minister. In the old days one tabled a question in the Dáil, which was answered by the Minister and one received the reply immediately. That was in the days of the health boards. We did not have to wait for anything. Then the HSE came on the scene and when that happened we received no answers at all in the House on issues relating to what the HSE was doing. That was appalling. Five years ago a change was made to the effect that we wait for 15 days and then get the answer. It is an improvement but more needs to be done.

I thank Deputy Durkan and I assure him I am very clear on how policy is made in health, and in every other area. Health policy is made by me, in consultation and with the agreement of the Oireachtas, advised by the Department. The job of the HSE is to get on with implementing and delivering it and dealing with operational matters. It has a lot to keep it going on this front in a very busy health service. We work very well with it in this regard.

I thank Deputy Durkan for his kind words. I agree with him that the health service faces a huge challenge. This is the case not only in Ireland but throughout the world. We see the impact of health debates in many other countries. There is a tendency to always believe faraway hills are greener. People speak to me about the NHS as though it were a magical wand solution and if we just lifted it and put it in Ireland everything would be wonderful. However, if access information on the NHS, for example through Google, we will see references to doctor strikes, financial sustainability and bed capacity issues. These are many of the issues we are debating at this meeting today. There are challenges in every system and there is no such thing as a perfect system.

I am genuinely positive about this, and while I was getting all of the messages of sympathy wishing me well in Angola, as it were, and telling me to be careful of the poisoned chalice, I do not buy that. Many positive things happen in our health system and I am more convinced of this than ever. This is not to in any way belittle or dismiss the huge challenges that exist for patients and staff in areas of health service. If we look at the five-part series on RTE, "Keeping Ireland Alive", which showed the many excellent practices going on in the health service, and matters such as life expectancy and how we deal with things such as cancer, cardiac care and stroke and the progress being made in Ireland - this is not a political point as it has been made over successive years by health care professionals - we have a lot going right.

The key issue is whether we can do what we have never done before, which is stop playing politics with the health service. This does not mean stopping holding me to account for the day-to-day running. I get this, and there is plenty for which to hold me to account on a day-to-day basis. That is fine and that is politics, but can we do something we have never done before, which is agree, no matter who wins the next election, the one after that or the one after that, on a direction of travel for the health service? If we can do this we can break the cycle.

What is happening at present is very straightforward. Ministers turn up in Hawkins House, spend a period of time there and have a few ideas but because they may be following a Minister of the same party or a different party, everyone has a different emphasis. People make changes and begin a process. Then the Minister moves on, a new Minister comes in and the whole thing starts again. When I speak to health care professionals, managers and patients' groups, it is not fair to say people are fed up of reform in the health service, but they are fed up with little bits of reform and never getting to complete the journey. In this respect the work done by Deputies O'Connell, O'Reilly and others on the Committee on the Future of Healthcare cannot be underestimated. If we can get this piece right we can set the health service on a path of which we will all be very proud. The country has done it before. It has done it on the economy and on Northern Ireland and the peace process. We need to stop accepting the premise, as Deputy Durkan certainly does not, that the issues in the health service cannot be addressed, albeit they are serious challenges.

The Deputy is right about the morale of staff in the health service and of patients. We have a duty to provide them with a sense of a forward looking direction of travel. This is not me sitting here suggesting we can rectify every issue today or tomorrow, because we certainly can not, but we can make inroads into all of the challenges we face in an incremental way. I have a duty of care to staff and patients to outline to the Oireachtas in the coming weeks how I intend to do this.

I agree with Deputy Durkan on providing opportunity and space in the health service to provide information to patients who have had a bad, negative or tragic experience. The Deputy is right that sometimes, very sadly, things just do go wrong and there can be a genuine tragedy. In such a case the patient and staff need information. I believe open disclosure, the policy we have in place but underpinned in legislation, will address this.

I agree with the Deputy on drugs. We cannot allow countries to be picked off by one another. We are in a common market. It is more complex than I presented it, but we need to examine how we can work at European level. I have begun these discussions informally with colleagues and I hope to continue them at an EU Health Ministers meeting next week on an informal basis. Some countries have already grouped together informally and they are beginning to see the benefits.

I am glad the Deputy raised the issue of primary care centres. They have a huge role to play but not if we view them as only bricks and mortar. I was in Senator Colm Burke's area recently, where he was a councillor for many years, for the commencement of works on what will be the largest primary care centre in the country. It is fair to say there was palpable enthusiasm and excitement from the residents. It is the largest public investment project on the north side of Cork in 30 years. It is a huge project and will provide a central focus as the place for people to access primary care. This is important.

Infrastructure is clearly important, and we must provide the bricks, mortar and facilities, but what is more important is what happens in the primary care centre. The parliamentary question asked by the Deputy, which was legitimate as the Deputy's questions always are, is very difficult to answer because if the primary care centre is only largely providing current GP services and a few other important services, but not anything above and beyond what is being done at present, people will end up in emergency departments. We need to look at what is being done in acute hospitals which does not need to be done there which we could provide in primary care.

This brings me to the next point the Deputy asked about, which is the issue of the new GP contract. I know the Chairman has an interest in this and has raised the issue with me. To have a new contract we need two sides which both need something and I believe we have this. I hear very clearly from GPs that the current contract does not work for them. It does not enable or empower them to do what they believe they can and should be doing, which is what I also believe. It also does not work for the State because it does not enable our GPs, who are our primary care providers, to do all they can. Therefore, the mythical Mrs. Murphy finds herself in hospital because she cannot access services at primary care level, which our GPs are qualified and trained to deliver. A big example of this is chronic disease management.

The data on chronic disease management indicates that the number of people developing chronic disease is increasing, with people above the age of 50 years often suffering from two or more chronic diseases and people developing chronic disease at a younger age.

If we cannot manage chronic disease in the primary care setting then no matter what we do in the acute hospital setting we will not address the challenges and, in fact, they will grow. We intend to commence a contract negotiation process by the end of this year. Along with my officials and the Health Service Executive I am looking at a number of options in this regard, including the most appropriate arrangements to engage with GPs and other primary care stakeholders. I am eager not to go down a silo route in terms of having a conversation with only one group of health care professionals in primary care only to find out at a later stage that another group is doing work in this area, such that we end up duplicating work. There is a piece of work that needs to be done in regard to engagement with all primary care stakeholders on issues such as what the future of primary care will look like. This process need not go on for a long time. We need to advance that process and to then commence the contract negotiations and put in place that structure by the end of the year. Work in that regard is ongoing. That could play a major role.

There are things that we are doing today in terms of helping keep people in their communities. For example, the purpose of a community intervention team is to ensure that an older person is kept rehydrated within his or her home such that he or she does not end up in the emergency department. Deputy Durkan will be aware that under the service plan for this year, an additional 1,030 patients will benefit from community intervention teams and another 6,643 will benefit under the winter initiative. We are particularly and unapologetically targeting frail elderly patients so as to avoid their having to be admitted to hospital in the first instance. All of the data indicates that when an old, frail person goes into hospital this can have a detrimental impact on his or her health. If we can keep elderly patients in their home, and well in their homes, they can live longer and more fulfilling lives.

I thank the Minister and his officials for being here this morning. I hope the Minister enjoyed his day in the real capital last Monday, where he was very welcome as well.

I concur with Senator Kelleher on the importance of the UN convention being ratified, on which issue the Minister of State, Deputy Finian McGrath, is working hard. It is imperative that we ratify that convention for those people living with a disability. I agree also that into the future health services must be above politics and we must work together on a cross-party basis, regardless of which party or parties are in government, to ensure a plan is put in place.

Senator Swanick, who is unable to attend this meeting and has sent his apologies in that regard, and I have reviewed the winter initiative programme together. We hope that its objectives and aims come to fruition. It was reported that some of the additional 300 beds provided under last year's plan were unused as a direct result of a lack of nurses. Does the Minister have any plans, aside from the daft - for want of a better word - plan of the Minister for Jobs, Enterprise and Innovation, Deputy Mitchell O'Connor in regard to tax incentives and so on, to entice Irish nurses and doctors who went abroad back to Ireland?

I thank the Deputy for welcoming me to Bandon the other day. We had a good day all around Cork but I was particularly happy to tell the people of Bandon that their community hospital is not only safe but will be invested in and has a bright future.

On the UN convention, I echo my comments to Senator Kelleher. This is a priority issue not only for me and the Minister of State, Deputy Finian McGrath, but for Government and, I believe, the Oireachtas. We must get this convention ratified and we will do so. As I said, there is a lot of work going on in that regard.

I am grateful for the Deputy's comments in regard to political consensus. It is important that we strive to have in place a strategic plan that can provide everybody working in the health service with a degree of certainty, which feeds into my response to the Deputy's second question. If we can tell people working in the health service or aspiring to work in it exactly where we plan to take the service and how we propose to develop it, it makes it a more appealing place to work. People do not want to work in an environment that is constantly changing according to plans and policy.

The Deputy is correct on the beds issue. We must ensure that everything we put into the winter initiative can be delivered. The Deputy will have noted from my comments in the media recently that I was not happy to sign off on the winter initiative initially. We want the metrics to be clear. We are providing €40 million of taxpayers money to the HSE to make improvements for patients and staff and we need to know what we are getting for it. Therefore, we stress tested the initiative and identified what is provided for and so on. I do not apologise for demanding that level of detail and I am pleased that we got it. The HSE has clarified that the 300 beds provided under last year's winter initiative are fore-funded to be open this winter. I expect all of them to be open this year.

The Deputy raised an issue in regard to nurses. She is correct that there is a shortage of nurses and nursing graduates not only in Ireland but across many countries. There number of nurses employed in the public health service in Ireland increased by 1,163 between August 2014 and August 2016. This means the number of nursing staff has increased from 34,375 to 35,712. That is not to suggest everything is rosy because the numbers did fall by 4,000 from 2007 to 2014. I hope that any nurse watching these proceedings will not think I am suggesting we are back to the levels we would like to be at. We have a journey to go in that regard. There are already a number of initiatives under way to try to improve nurse staffing levels throughout the country. The most important initiative is offering people a permanent job. We are not going to keep nurses in this country if they are only being offered a two or three month contract or temporary work when they know they can go across the sea to the UK or to Northern Ireland and get a permanent post. In fairness, my predecessors were not in a position to offer permanent posts for a number of years. These are now back on offer. All of our nursing graduates this year will be offered permanent jobs in the Irish health service. This sends out the important message that we are open again for business in terms of recruitment. It will take time to build up confidence. This is about the issues raised in the exchanges I had earlier with Deputy O'Connell, Senator Burke and others around career and training opportunities. We need to ensure we keep nurse training opportunities in our health service well funded. That is a priority for me.

The HSE has launched an international staff nurse recruitment campaign, the purpose of which is to attract nurses back from the UK to jobs in Ireland, with a particular emphasis on nurses who left Ireland in the past few years. These nurses are being offered relocation fees of €1,500, payment of their nursing registration costs with the Nursing and Midwifery Board of Ireland and payment of post-graduate education costs. This campaign is ongoing. Approximately 420 applications have now been received, with 83 people having accepted job offers. There are a number of other interviews scheduled to take place. This scheme remains open. There are a number of other issues, which I will not discuss in this forum, that nurses believe will make the viability of a nursing job in this country more appealing and sustainable, on which engagement continues. There is a body of work yet to be done in this area.

I, too, would like to raise some issues with the Minister. The Minister referred to activity based funding in his opening statement. I would like to explore the issue of moving from activity based funding to outcome based funding. In a situation where one doctor sees 50 or 70 patients and another doctor sees 30 patients, the doctor who sees 70 patients will have doubled his or her activity but he or she might not have doubled the outcome. The same applies in regard to hospital doctors who see an excessive number of patients in that their activity will be greater but the quality of care may be diminished by the fact that they are overwhelmed with work. Perhaps the Minister would consider moving from an activity based funding model to an outcome based funding model in regard to patients, procedures and quality of service.

There is huge benefit to be derived from the integration of services. In terms of IT, communication and medical records there is a huge amount of efficiency to be generated by having in place greater communications. We need to move to health records storage and access via cloud such that when a GP sees a patient he or she can access records to find out what treatment was provided by the hospital and so on. This improves communication and the quality of care to a huge extent. Perhaps the Minister would comment on that point.

The community health organisations are currently being developed and will be rolled out in the couple of months.

They are coming from the top down rather than from the bottom up and are viewed with some suspicion, notably by general practitioners. GPs would like local integrated care committees, LICCs, such as those in place in County Kilkenny to be examined. Under this model, all the components in the care process - general practitioners, consultants, nurses, HSE management, therapists and so forth - come together, treat each other as equals and reach an agreement on the best way to stream people in hospital. If we can stream people into hospital efficiently, we can avoid them ending up in casualty departments unnecessarily. They can be streamed directly into a bed or through a medical assessment unit, which avoids circumstances in which everybody ends up in the casualty department. The problem with casualty departments is that they have a catch-all function. Local integrated care committees are a more practical solution than community health organisations.

On recruitment and retention, if we can develop what I will describe as magnet hospitals that provide high quality care, these hospitals will attract high quality graduates. This has been achieved in Kilkenny. People want to come to work in the local hospital because its services are so well integrated. The hospital deals with complex cases and more ordinary cases are looked after in the community. This is the model the Minister wants.

Open disclosure is extremely important. As practitioners, we intuitively want to make open disclosure, which is the modern way of dealing with problems. It is not necessarily the case that a practitioner making an open disclosure is admitting that he or she was negligent or did something wrong. The option he or she or took may not have been the correct one or may not have had the best outcome. I ask the Minister to comment on the points I have made.

Where we want to get to with activity based funding is exactly as the Chairman outlined in terms of what we, namely, patients, citizens and taxpayers, are getting for the payment for that activity. This must also take outcomes into consideration, which means not only whether a procedure was carried out but how the procedure in question went. I must be honest and stated we are some distance from achieving this in terms of the development of the metrics required. This is, however, the journey we want to take.

Regarding integration of services, I know the Chairman is familiar with this issue as he briefed me previously on the success of a number of general practices in networking and using technology. An example is where a general practitioner is able to send an electronic record when he or she is on holidays. The primary care setting, specifically general practice, has been significantly ahead of the acute hospital setting in this area. We need to advance this process and the holding of health records in the cloud will be the key. I add the caveat, however, that data security issues arise in this context because health records will be privately held and made accessible to various medical stakeholders.

On local integrated care committees, I will visit the hospital in Kilkenny on Saturday. I hope to have an opportunity to meet the primary care group I am hearing so much about when I attend the Irish College of General Practitioners study day in two weeks. This group is an example of best practice and I am aware of a somewhat similar model in place near my home town in Wicklow where general practitioners are interacting with St. Colmcille's Hospital in Loughlinstown in a manner that is working very well. The Chairman's comments made sense but I will obviously await the outcome of the Committee on the Future of Healthcare's deliberations on structure. I am aware the Chairman is a member of the committee. We are promoting local integrated care committees nationwide. Dr. Fawsitt has provided great leadership in this area and is promoting the further development of LICCs on behalf of the Health Service Executive.

On recruitment and retention, the Chairman is correct that hospitals operate as centres of excellence and engage in best practice, they will increasingly attract people to work in them. The hospital groups will also help in this regard if we are able to recruit people on the basis of the hospital group rather than the individual hospital. Each group includes a range of hospitals offering various services and we will need professionals to move between hospitals in the group. I will not get into the business of naming hospitals but people will be more likely to gravitate towards a job in a flagship hospital, for example, one which is linked to a university. We are now recognising that the university and group are all linked rather than the individual hospital. This creates a different and perhaps enhanced environment. The Chairman is correct, however, that recruitment and retention are still major challenges for all health services, not only the Irish health service. We are moving into an era of reinvestment in health and providing a degree of certainty in terms of the direction in which we are moving. We are advancing the recommendations of the MacCraith report, reviewing GP training place numbers and the GP contract and ensuring nursing graduates are offered jobs. If we can sustain the current level of progress for a period, it will put us in a better place.

We requested that the Minister engage with the joint committee on the mid-year review of the Department's Estimates for 2016 and consider the proposals for expenditure in 2017. Perhaps some of his officials wish to contribute.

While we will do whatever suits the Chairman, we have provided a detailed hard copy briefing to the joint committee on the state of play. In terms of the multi-annual budgeting approach we need to take to new developments, I would very much welcome the input of the committee. Members will have seen the programme for Government, which contains 136 health commitments, many of which require financial resources. These commitments need to be triaged, to use a medical term, and I would welcome the committee's input in that regard during the multi-annual periods. Perhaps we will engage further on that issue.

Will officials from the Department be willing to engage on an ongoing basis with Oireachtas staff to establish the most productive means for committees to engage on voted expenditure? What we seek is two-way communication without barriers.

There will certainly not be any barriers. I and my officials will be willing to engage with the joint committee. I will make an offer I meant to make earlier. Compared with other Departments, the health Vote and health system are complex. If there is a benefit in having an official briefing provided to members on the structure of the Vote, I would be happy to make such a facility available.

The joint committee adjourned at 11.15 a.m. until 9 a.m. on Thursday, 13 October 2016.
Top
Share