Joint Committee on Health debate -
Wednesday, 22 Feb 2017

Quarterly Update on Health Issues: Discussion

Chairman

This is a quarterly meeting with the Minister for Health and the director general of the HSE. The purpose of this afternoon's meeting is to allow the Minister and his officials, and the director general and his staff, to update the committee members on key health care issues. On behalf of the committee I welcome the Minister for Health, Deputy Simon Harris, who is accompanied by Ministers of State, Deputies Marcella Corcoran Kennedy, Finian McGrath and Catherine Byrne. I also welcome the director general of the HSE, Mr. Tony O'Brien, who is accompanied by Mr. Liam Woods, Ms Rosarii Mannion and Mr. Jim Breslin. If I have left anyone out, please excuse me. I thank Ms Pamela Carter of the Department and Mr. Ray Mitchell of the HSE for their assistance regarding the questions submitted by members.

I draw the attention of witnesses 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 on a particular matter and they continue to so do, 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 the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. I also wish to advise witnesses that any submission or opening statements they have made to the committee may be published on the committee's website after this meeting. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I ask the Minister to make his opening statement.

Minister for Health (Deputy Simon Harris)

Since our last meeting, there has been a significant spotlight on aspects of our health service which are of great public concern and which I will address in my opening statement. However, at the outset, I want to be very clear that my resolve and my determination to improve our health service has only been strengthened. Members know that I believe this requires an all-party effort and that this committee and the Committee on the Future of Healthcare are vehicles for building the kind of political and societal consensus we need in the delivery and future direction of our health service. I am happy, of course, to be held to political account for the challenges and problems we face but I would also like to acknowledge that my engagements with the Oireachtas have continued, in large part, to be constructive and co-operative in nature.

As I think members would expect me to, I am going to start with waiting lists. I hope that everyone understands that I believe, as Minister for Health, I should express my genuine feelings on the impact on patients of waiting too long for treatment but it is wrong to characterise my honest response to their suffering as my only response. I want to focus on what we can do and what we are doing to address waiting lists and waiting times for patients. This has been a consistent focus of mine since becoming Minister. During 2016 there were growing numbers of patients waiting excessively long times for inpatient or day case treatments and the trajectory being forecast by my Department and the HSE was stark. Consequently, with limited additional resources, I unapologetically targeted resources at the specialties with particularly long waiting lists, such as scoliosis and orthopaedics through the winter initiative funding.

The HSE put in place an action plan to halve the number of patients waiting 18 months or more for their inpatient or day case procedures. Through that action plan, over 11,500 patients came off the inpatient-day case waiting list from August to December 2016. Also in 2016, the National Treatment Purchase Fund, NTPF, undertook an endoscopy waiting list initiative to arrange for the provision of endoscopy procedures to all patients waiting over 12 months. By the end of December, over 5,500 people had come off that waiting list. However, as members know, overall waiting list figures rose in January 2017. I am disappointed by this increase but not surprised as our hospitals responded to the ongoing pressures of high emergency department attendances and admissions during this peak winter period.

I am also aware that it will take some time before waiting list figures will start to go down. This year, waiting list initiatives have been planned and scheduled to take into account peak emergency department activity in hospitals and times when the private sector capacity is most available. Scheduled care will be the main priority from spring through to winter 2017. Some €20 million has been allocated to the NTPF, rising to €55 million in 2018. The NTPF is starting with a dedicated €5 million day-case waiting list initiative with the aim that no patient will be waiting more than 18 months for a day case procedure by 30 June 2017. It is expected that in excess of 2,000 patients will receive treatment through this process and it is expected that patients will commence receiving appointments for treatment during March.

The main areas of focus will be those lists with large numbers of long waiting day case patients, namely, ENT, ophthalmology, general surgery, dental, urology and vascular surgery.

The HSE is also producing a waiting list action plan for 2017, which will outline waiting list initiatives to be driven by hospitals and hospital groups. I expect to receive this plan by the end of the month. This plan will concentrate on reducing the length of time patients wait for an inpatient, day case or outpatient appointment with the aim that by the end of October no patient will wait longer than 15 months. While I consider this is still far too long, it would mark a significant and solid reduction in waiting times with the aim of building on it to reduce waiting times even further. In order to ensure the best outcome for patients waiting, the HSE and the NTPF are working together to utilise all available capacity, public and private, and the plan will be supported by the NTPF’s proposal for the remaining allocation in 2017. I am also considering what further measures should be taken to ensure patients have access to more timely procedures and, in that context, I am of the view that a number of individualised targeted initiatives are required. I have visited a number of hospitals in recent months and am particularly concerned about waiting lists in the specialties of gynaecology, particularly in Cork, and cardiology, as well as waiting times across a number of specialties in certain regions. I have asked the HSE to address these specialties in particular in the action plan it has under development.

I want to make specific reference to scoliosis. While some progress was made in 2016 as a result of the extra investment in the scoliosis service, it is clear there is much more to do to provide the level of service that is needed. Additional funding has been provided - €2 million was made available under the winter initiative in 2016, which saw over 50 additional children and teenagers treated and receive their procedures for scoliosis. While this investment made some progress, there is much more to do to. I recently met with the CEO of the children’s hospital group and the CEO of Our Lady’s Children’s Hospital, Crumlin. I can confirm that the new theatre will provide the additional capacity for scoliosis procedures from April, following the recruitment of additional theatre nurses. An orthopaedic surgeon post in Crumlin hospital will be filled by June. This means that from July, the hospital expects that the theatre use will be further increased. The HSE is now working on a specific action plan for scoliosis, which it will submit by the end of the month. I will be happy to share it with the committee. This is all with a view, as the director general has said, to making sure no child or adolescent waits longer than four months by the end of this year for a procedure. It would bring this country in line with other jurisdictions, including with the NHS.

I will briefly address the situation regarding our emergency departments throughout the winter period. I acknowledge the distress for patients and their families and the impact on staff caused by overcrowding. I also acknowledge the intensive efforts by staff, management and the HSE on a daily basis to work to ensure that patients receive quality care in a challenging environment. While the number of patients waiting on trolleys continues to be far too high, over the last couple of weeks emergency department congestion has been easing in many hospitals. I commend all the teams across acute hospitals and social care that work together on a daily basis. I acknowledge the achievements they made, particularly on delayed discharges, which reduced from a high of 659 earlier in 2016 to a low of 496 on 15 February 2017. In addition, we have seen extra patients avail of aids and appliances, 900 additional home care packages and 90 newly opened beds in the Mercy hospital, Cork, University Hospital Galway, the Mater, Beaumont Hospital and Mullingar hospital. I have repeatedly made clear that if we want to break the vicious cycle of overcrowding, we will have to do things differently. That involves extra bed capacity, extra staff capacity and also doing more in primary care. During the last year, over 100 additional hospital consultants, almost 250 extra non-consultant hospital doctors and nearly 500 additional nurses and midwives have been employed by the HSE. In addition, my officials are working with the HSE to develop a national integrated strategic framework for health workforce planning with the objective of recruiting and retaining the right mix of staff. I expect to receive a report and implementation plan during 2017. Members will know that the bed capacity review is a commitment in the programme for Government and is now under way. I am keen the review is progressed sufficiently to enable it to feed into the mid-term review of the capital programme, which will take place later this year. While the review will consider capacity requirements over the next decade or so, I am also anxious for it to have a short-term focus and determine how capital investment over the coming years can be targeted, given the current pressures being experienced within our hospital service.

Information technology can also play a significant role in underpinning a more integrated approach to managing waiting lists which would achieve a more patient centred approach. One of the critical enablers of any integrated waiting list management system is the unique individual health identifier, IHI, which was given a legislative basis in 2014. The system of identifiers will be deployed across the public and private health care system. The electronic health record became a reality in December 2016 with the arrival of Ireland’s first digital babies in Cork and the deployment of the IHI register in the health sector.

I will take this opportunity to acknowledge the tremendous commitment and dedication of all our health care professionals working throughout the health service. I am very pleased we have reached agreement with the IMO, the HSE, my Department and the Department of Public Expenditure and Reform on the issue of the restoration of the living out allowance for non-consultant hospital doctors. The agreement reached with the IMO and management provides for restoration of this from 1 July 2017 in the context of the forthcoming public sector pay negotiations. It also provides fulfilment of the Government's commitment to implement the recommendations of the MacCraith report, which will see a review of the continuing education requirements of NCHDs undertaken under the auspices of the WRC between March 2017 and May 2017. I am very pleased the IMO will now not proceed with the ballot for industrial action. It is a very welcome development for our health service.

I will take this opportunity to address the recruitment and retention of nurses and midwives. I, my Department and the HSE recognise the importance of recruiting and retaining nurses and midwives within the public health service. It is also recognised that the fall in numbers employed between 2008 and 2013, from 39,000 to 34,000 had to be addressed when the moratorium ended. There are many initiatives under way to improve staffing levels throughout the country. The HSE is offering permanent posts to 2016 degree programme holders and full-time permanent contracts to those in temporary posts. The HSE ran a three-day open recruitment event over the Christmas holiday period which will be the first of a number of events this year. In September 2016, the HSE set up a project group to review nursing workforce planning, recruitment and retention. This group is due to report back to the national director of HR this month.

The Government is committed to 1,000 additional permanent nursing posts in 2017 as part of the programme for Government. These posts are provided for in the HSE’s service plan. The HSE’s management is committed to engaging constructively with the INMO to address its concerns and to address a range of initiatives. I appeal to everybody to redouble their efforts. We have just under two weeks before the INMO is due to commence working to their contract. It is not in the interest of the health service. The INMO, the HSE and Government would like to see a resolution to this. We all need to work together on that.

I should circulate the rest of my statement to allow members to ask some questions, which I know are on people's minds. I will deal with issues on the national children's hospital, prescription charges, patient safety and a number of other areas but in the interests of time I am happy to have my script circulated.

Chairman

Unfortunately, the Minister's script-----

Deputy Simon Harris

Has it not been circulated?

Chairman

It arrived at 1.25 p.m.

Deputy Simon Harris

It is circulated.

Chairman

I now ask Mr. Tony O'Brien to make his opening statement.

Mr. Tony O'Brien

I will touch on a couple of areas. In terms of the financial position, the draft 2016 financial outturn figures for the health service indicate net expenditure of €13.528 billion against an available budget of €13.514 billion giving rise to a small adverse variance of €14 million. The delivery of a €14 million or 0.11% in-year variance represents practical financial break-even, given the scale of the health services overall resources, and means the HSE is not starting a new financial year in 2017 with a very significant incoming deficit. It clearly shows the benefit of receiving sufficient funding early in the year, including the €500 million received mid-year, to set achievable financial targets for health service managers, clinicians and staff. It also demonstrates the health services ability to deliver when set achievable targets and, in that regard, I thank all of our management and staff for their hard work and efforts. I also acknowledge the support received from the Department of Health, including its assistance with meeting excess costs associated with the State Claims Agency.

The Minister has already outlined issues to do with the winter initiative and, in the interests of time, I will take those as read.

On the issue of acute hospital waiting lists, I will take this opportunity on behalf of the HSE to apologise once again to all patients who have had a poor experience either in terms of waiting times or communications with our services. A key priority for the HSE is tackling long patient waiting times and ensuring timely access to treatment and care. We fully acknowledge that patient waiting times are unacceptably long in certain specialties and this, to some extent, reflects the need for greater capacity and staffing in certain specialties within our services. It is also essential that we fully optimise our public capacity.

Each year in our hospitals more than 3.3 million patients attend outpatient services, while one million have a planned day case procedure and approximately 100,000 people have an elective inpatient procedure. Between January and November 2016, more than 1.5 million inpatient and day cases were completed in our acute hospitals representing an increase of almost 30,000 when compared to the same period in 2015. It is fully acknowledged that waiting lists in certain specialties including ophthalmology; ear, nose and throat, ENT; orthopaedics, urology; and general surgery have seen significant increases in the number of patients waiting for treatment. It must be noted that both the challenge of availability of consultants in these specialties as well as hospital capacity have contributed to this increase.

The key issue for patients is how long they are waiting and based on national treatment purchase fund, NTPF, figures published in January, 36% of patients are waiting less than three months for an inpatient day case procedure, IPDC, 58% are waiting less than six months and 2% are waiting over 18 months; 93% of adult patients were treated within the national target time of 15 months for IPDC; 69% of patients were treated within the eight-month national target; and the proportion of patients waiting over 18 months fell from 4.5% to 2% at the end of December. A key focus of the HSE waiting list action plan 2016 was to reduce the number of patients waiting the longest times for inpatient and day case procedures. The HSE's target, approved by the Minister, was that we would reduce the number of patients waiting over 18 months by 50% and that there would be no more than 1,800 patients waiting for more than 18 months. We exceeded this target and the number of patients was reduced to 1,738 due to the treatment-removal of over 11,500 people from the waiting list.

An important feature of the 2016 waiting list was optimising our public capacity as well as outsourcing activity. For example, 200 cases were undertaken by Cappagh National Orthopaedic Hospital for other hospitals, the Mater Hospital undertook 24 spinal and scoliosis cases on behalf of Tallaght Hospital. University Hospital Limerick carried out work for the Saolta group and Kilkcreene Orthopaedic Hospital carried out work for the Midland Regional Hospital in Tullamore. We will build on this approach in 2017 with particular reference to orthopaedics, scoliosis, ophthalmology, vascular and ENT services.

In 2017, the HSE is working with the NTPF to develop an action plan for inpatient day case and outpatient waiting lists to deliver on the 2017 target that no patient would be waiting longer than 15 months by the end of October. It will set out specific actions by groups aiming to optimise existing public capacity within hospitals and groups and targeted outsourcing for those specialties where there are known capacity challenges. The approach outlined will be underpinned by strong oversight and governance by hospitals and groups and at national level. With specific reference to scoliosis, the HSE has set a target of four months for treatment of scoliosis and is finalising a comprehensive plan in this regard. This will require a range of solutions given the capacity challenges in the Irish public and private system.

The eHealth Ireland programme within the HSE has had some success in 2016 creating the first digital hospital in Ireland delivering the infrastructure for an individual health identifier to be "turned on", completing the implementation of e-referral into every acute hospital and beginning the implementation of e-prescribing in the community. In 2017, the eHealth Ireland programme will continue to move towards an electronic health record, EHR, for Ireland. While the full EHR business case is being considered, the programme is working to put in place foundations that enable an innovative and yet considered progression to delivering a digital fabric for the way in which health care is delivered. As well as these foundational programmes of work, the eHealth Ireland team will continue its work in new and innovative arenas. Genomic sequencing for epilepsy patients will continue, the implementation of an artificial intelligence mobile "friend" for patients with bipolar disorder will be piloted and digital supply chain management to the door of patients with haemophilia will be delivered. All of this will be achieved within the current HSE IT budget. If we were to invest even 1% more in this area, the team is confident that it could deliver striking benefits to the system and 1% more would still be 1% less than the average EU country. This concludes my opening statement.

Chairman

I thank Mr. O'Brien. We will now open up the discussion to members of the committee. We will take members in groups of three. The first group consists of Deputies Alan Kelly and Louise O'Reilly and Senator Colm Burke.

Deputy Alan Kelly

I welcome the delegation, which is slightly smaller this time. We have more Ministers on this occasion. I hope this delegation will be the same one that will be in front of us in a few months time. I am sure all the Ministers would agree with that. Given the times we live in, I wish them the best of luck. The situation in accident and emergency departments has improved recently but one would expect it to improve given the time of year. Is there a way in which we can change the pathways system regarding those who are being crammed into accident and emergency departments in tier 1 hospitals and better use the under-utilised minor injury units across the country? There are people who end up in accident and emergency departments in tier 1 who should not end up there. There are other options. It is creating a dynamic in those hospitals that is debilitating from a capacity perspective. I am most familiar with the mid-west. There are minor injury units in three locations yet the situation in Limerick, which I visited recently, is terrible. Is there not a way in which we could use these units better because the capacity there is not being used and it would help?

I will ask a number of questions about capital because I am a bit confused. The Minister announced an investment in respect of a new accident and emergency department for Galway in the past week or so but I would have expected that this would have been announced as part of a capital plan that is meant to come out in a few months time. However, it was pre-announced. I am sure the Minister of State, Deputy Finian McGrath, will take an interest in this. Where are we in respect of the proposed new accident and emergency department for Beaumont Hospital? Will this be part of the capital plan? It is something that has been projected numerous times.

The Minister visited Limerick. All I will say is that there is an expectation regarding an accident and emergency department because I will not be unfair to the Minister and say that there was a promise or put words in his mouth. The CEO of the HSE confirmed to me that this accident and emergency department is to be opened in the last quarter of this year. There is an expectation among the clinicians, staff, management and the general public that it will be opened before the summer. Will this happen? I have a response from the chief executive of the University of Limerick Hospitals Group, Colette Cowan, who said it can be opened but will need €2.7 million. As we all know, the accident and emergency crisis in Limerick is probably the worst in the country. I am sure the Chairman agrees with this. Can this figure of €2.7 million be found? The recruitment process is ongoing. It would be very much appreciated if it could be because it would alleviate certain significant issues that exist there. One end of the county I represent uses Limerick while the other end uses South Tipperary General Hospital. Ratio-wise, they are probably the worst two in the country in terms of overcrowding in accident and emergency departments.

This brings me to South Tipperary General Hospital in Clonmel. I know there has been a lot of political talk about potential avenues regarding accommodation. What stage is this at? A national tender that has been put out. I expect that this will be part of the future capital plan as well. It must be prioritised. The situation is incredible. Will we ensure that it can be part of the capital plan upfront and built in the coming years or are we going to go through some temporary offering for a long time from which we may not get the results?

I would like some clarity on that.

In fairness, Mr. O'Brien and the Minister acknowledged the staff and management. I have my own issues, as have a number of members, with the Health Service Executive, HSE, management but there are some brilliant people working in the HSE. Some of them took grave offence to some of the comments made recently by the Department, Ministers and the HSE. Generalisations do not tend to work, so I am glad that was clarified.

With regard to the waiting lists, the Minister and Mr. O'Brien went into considerable detail on that, and my colleagues will have many questions so I will not take up all the time, but how can we be certain that the figures outlined here are correct following the experience we have had in recent months?

Regarding the national maternity strategy, of which I am a huge supporter, are we on track as regards funding that? We must bear in mind that there is a capital requirement with regard to planning the new maternity hospital. There are four hospitals - three in Dublin and one in Limerick - and there is a capital requirement of €1.5 million in 2017 which is not being provided for. That suggests to me that in year 2, we are already behind. This is an excellent strategy, which this committee examined in detail, but if that funding cannot be found for the design of the new maternity hospital, what will be the position?

With regard to the children's hospital, which will come up in detail from my colleagues' questions, when will the Minister have the report that will tell him how in the name of God we ended up with the costs that have been outlined? The original cost was €450 million. It increased to €650 million and now, by all accounts, it is €1.2 billion. He might not have all the answers now but he has told me previously in correspondence that he will have them. When will the Minister have that report, which is referenced in the document he provided? I am sure all of us would like to find out about it.

I have some final questions. A review is ongoing of ambulance services across the country. It started in the mid-west. What is the purpose of that review? The Minister wrote to me stating that there will be no cuts in the mid-west, and I thank him for that, but what is the overall purpose of the review?

As it was one of the first issues I raised with the Minister on his appointment and my being appointed to this role, I am delighted about what has been done with regard to scoliosis in the recent past. There was a national outcry following the "Prime Time" programme, and rightly so. Many of us had been dealing with this issue for some time. I am delighted with the changes that are happening and the funding that has been found. My only issue is the reason it was not happening anyway. There is a concern that if the pressure builds up, consultants and clinicians can be found, theatres can be opened and money can be found. If that is the case, people will ask why it can be found for that area and not for somewhere else. I agree with what is happening.

That brings me on to the issue of Orkambi. What is the position on that? What is the position on Respreeza for alpha-1 patients? There are 21 people on that drug on a trial basis and they are worried that at the end of this month or early next month they will be taken off it. What is the position on both Orkambi and Respreeza because there are 40 more patients waiting to go on the latter? I understand 13 other countries are using this drug so why are we not signing off on it?

An issue in which I take a personal interest is e-health. I support the changes that are happening. A number of us sit on the Committee on the Future of Healthcare. I believe the issue with regard to IT systems across the health care service is chronic. I presume the various projects that have been outlined are being piloted in different hospitals and across various disciplines but a public services card is being produced separately to that by the Department of Public Expenditure and Reform, which is something of which I am a huge supporter. If this public services card is to be used effectively for everything in terms of one's interaction with Government services, and eventually will go to consumer services into the future, will somebody please tell me that under the e-health initiative the patient number will correlate with the PPS number and that they will be interoperable? If they are not, it will be one of the most stupid initiatives of all time.

Deputy Louise O'Reilly

I thank the Minister, the Ministers of State and the delegation from the HSE. I have a few questions so I ask the Chairman for his indulgence. First, we discussed this issue previously and Mr. Woods will remember the discussion about the 107 nurses required in accident and emergency departments. I refer to an agreement reached between the HSE and the Irish Nurses and Midwives Organisation, INMO, and SIPTU last August on a jointly agreed review. At the time, Mr. Woods was fairly clear in telling us, to the shock of the unions, that the specialist ring-fenced funding for the 107 nurses needed to cope with the people on trolleys in accident and emergency departments, which all the witnesses say they do not want but which keeps happening so there is a need to treat them, was not in the HSE budgets. When I asked the HSE about that they said that the Department of Health had not provided for those. I do not want to put words in anyone's mouth, and Mr. Woods can refresh my memory if I am wrong, but could we find out what is happening with regard to those 107 nurses? I know the INMO wants to see those nurses recruited, as does any poor soul on a trolley in an accident and emergency department.

Second, I refer to something not in the statements provided, namely, the stretch targets, which we have discussed. I cannot see any scenario whereby that does not put pressure on hospital managers to bring in patients from the private sector because they are a target. That is Mr. Woods's word, not mine. If something is a target, it has to be achieved. Mr. Woods has set targets. He has also set what he described as stretch targets, which I assume is whatever the target was last year in addition to additional ones, for private patients being treated in our public hospitals, presumably at the expense of our public patients although Mr. Woods can correct me if I am wrong on that.

With regard to e-health and IT, one of the answers given to a question I submitted states that there is a need to recruit additional resources and that this requires departmental approval and Department of Public Expenditure and Reform, DPER, sanction. What amount of additional resources does it require? When was the approval from DPER sought? What was the answer? If it has not been sought, why not? This is supposed to be a priority. We could sit here all day and tell each other about the wonderful benefits of improving IT systems, and none of us would disagree. That might be a very pleasant conversation but given that we all know we have to go down that road, when will the decision be taken, if it has not been taken already, to seek the sanction from DPER?

In response to the same question Mr. Woods said that the waiting list action plans will not specifically incorporate technology supports but that the Minister is open to evaluating new approaches and that he will ask the National Treatment Purchase Fund, NTPF, to lead a project team to undertake such a feasibility study and report to him within six months. That is great, but I put it to the Minister that there is no time like the present so we might move on that. It is one of those fantastic subjects on which we all agree there is a need to move on it. I wonder why we have not done so.

I will not bore the witnesses with my views on the NTPF because they know them but it appears from reading the answers to the questions I submitted that the NTPF will be reviewing itself in terms of its performance, targets and so on.

When I asked questions about the National Treatment Purchase Fund, NTPF, previously I was told that a robust monitoring framework would be put in place. My view of such a framework is one that would have external oversight. However, from my reading of the answers that have been given to questions, and I am open to correction on this, it appears the NTPF will be reviewing itself. One does not need to be a genius to figure that one out. If we are all reviewing ourselves we will all do terribly well. Will Mr. O'Brien outline what checks and balances in terms of targets, monitoring and evaluation of the NTPF are in place, given a considerable amount of public money has been invested in it?

With regard to commitment that children in receipt of domiciliary care allowance will be awarded a medical card, according to the answers I have received, the extent of this initiative is to be reviewed. The programme for Government indicates that 10,000 children will benefit from this initiative. We submitted a parliamentary question on this initiative and costed it prior to the last budget. We came up with a figure of €17 million to cover the cost of it. The HSE obviously did some work on it, because it put a figure of €10 million for this in its budget. What is the latest delay on the implementation of this initiative? Not a day goes by when at least one family does not contact me directly or my office in Swords to ask when this will be introduced. It must be one of the most announced Government measures ever. It is last July since I tabled a cross-party motion on this measure, which was accepted by everybody. No barriers are being put up to this by any Deputies or Senators. We all want to see it introduced. Yet when Mr. O'Brien responded to a question I asked, we learned that there will be another review and assessment and further delay on introducing this measure.

I refer to a question that was answered directly to me with regard to the 20-week anomaly scans. I apologise for having so many questions but there were plenty in the submissions. Louise Kenny from Cork University Maternity Hospital appeared before this committee last week and she made a very clear statement about the need for the 20-week anomaly scans in terms of the risk to children and the risk to women, both to their health and to exposure to unnecessary interventions and procedures. These are screening scans, so they are essential. I asked on a few occasions when these scans will be available. Can the witnesses put a date on it? If they have not set a target for this, I strongly suggest they do so. When will every woman in Ireland who wishes to be able to access that scan, or when can they ensure that the scans will be offered on a routine basis to women - as they are in most developed countries - and available in all of the 19 sites? I have asked about this a few times. It is not something we need to review. There is a general acceptance among health professionals that these scans are necessary. When will we see them being made available?

Mr. O'Brien got a big clap on the back for money management. Does he think there will be a budget deficit in the HSE by the middle of the year? Does he foresee there being a financial overrun by the end of this year? I am interested to know if the HSE has a sufficient budget. I put this question in the context of people being surprised by the outbreak of flu. In the context of how Mr. O'Brien will organise the management of the money for the remainder of the year, does the HSE have a sufficient allocation?

In response to a question I asked, Mr. O'Brien stated that the waiting list action plans will be available by the end of February. It is now 22 February and we are six days away from that date. These are a series of plans. Are they all being saved for the big day or has Mr. OBrien received them in stages? Has he any information on the waiting list action plans that he might be able to share with us now? If not, perhaps he could give a commitment to share those on the last day of February when they will all be magically received.

Chairman

I thank the Deputy. I call Senator Colm Burke as the final member to ask questions in this section.

Senator Colm Burke

I thank the Minister, the Ministers of State and the HSE management for being here today and dealing with the issues that we want to raise. I wish to turn to my questions Nos. 34 and 36. Question No. 34 relates to the gynaecological services in Cork and about a time commitment. I always get worried when we talk about setting up committees to review something. One of the requests by the obstetricians and gynaecologists in Cork University Maternity Hospital was that a six-bed day-care unit would be opened. What timescale would be involved for putting that in place?

My second issue relates to the waiting lists. We had meetings in early January, but as I understand it no progress has been made in real terms in dealing with those waiting lists. A total of 42% of all of the waiting lists for the entire country is in Cork University Maternity Hospital. More than 4,000 women are involved. I am concerned that we will be back here in two months time and no progress will have been made on that issue. We might get clarification on deadlines and targets in dealing with that issue.

A further issue relates to the dermatology unit in the South Infirmary Victoria University Hospital. It is treating double the number of patients being treated in the unit in St. Vincent's Hospital in Dublin. I understand that the only space available for secretaries to work in the unit in the hospital in Cork is in under the stairs and patients are waiting on a stairway to go into clinics. The response I got to this, and it is the shortest one I have seen in regard to a major unit, both in terms of ENT and that dermatology unit, is to the effect that very little action will be taken regarding the difficulties they are dealing with. Those in the unit have set out quite clear plans for what needs to be dealt with. The staff are working extremely hard and they have even opened on Saturdays to deal with some of the issues to ensure a backlog does not develop. The response I got is not adequate. I wonder if some more progress can be made on it.

I wish to raise a further issue related to question No. 33, and I am intrigued by the answer I got to it. It relates to the breakdown of staff in various departments of the HSE. I am glad to note that the total number of staff has increased quite substantially but I wonder about our priorities in that area. The total number of staff has increased to more than 107,000 from 99,000 in 2014. I am glad to note that the number of care staff has increased by more than 2,142, from 16,000 to more than 18,000, but I am a little concerned that management and administrative staff have increased by 1,647. I am also concerned about how those figures are presented to me today. The annual report of the HSE in 2015 set out that the number of managers had increased from 4,700 to over 5,000 but I am told today that the figure is 1,445 because staff under grade 8 are being re-classified as not being in management. Some massaging of figures is happening and people are not being honest with us. How many staff members, who have moved up to grade V, grade VI and grade VII, are going under the radar in terms of the HSE being honest with us about this matter? The number of administrative and management staff increased by 1,647 in two years. The number of public health nurses increased by 39, from 1,460 to 1,499, in the same period. In the past 12 months there has been a decrease in the number of public health nurses.

One imagines we should be prioritising the area to have people out in the community working to keep people out of the hospital services. I am concerned about how we are approaching this.

We are the second highest spender on health in the Organisation for Economic Co-operation and Development, OECD, in real terms. Are we making best use of funds and do we now need to do a detailed review of the management structure in the HSE? An increase of 1,647 administrative staff members in two years is huge and I am not happy. The 2015 annual report stated the number of managers went up by 300. I am getting the response that it is not confirming what management increased by in real terms because the figures are being presented in a different way. That is not fair to us or to anyone in the public. We need the exact figures, presented in the same way that they were for the year ending 31 December 2015. I ask for that to be clarified.

I have asked about forward planning in the HSE for recruitment of medical consultants and medical staff. I thank the staff of the HSE for their work on it. I have received a detailed presentation about doctors in each hospital. That presentation was given to me in January 2014. The last time I asked this, in November, I was told that the information was not available. Surely this should be updated by the HSE every six months for forward planning? It would establish the number of consultants who will retire over the next 12 months to two years in order that the positions can be advertised in advance and not after the consultant has walked out the door. In the response, it shows there are 130 people in either locum positions as consultants or on an agency basis. We should be able to avoid that if we do forward planning. We do not appear to be doing it. If one goes back to the old health boards, 15 or 20 years ago, there was forward planning for consultants retiring. We abandoned that when the HSE was set up. I ask that such a procedure and what we are given today be constantly reviewed every six months in order that management at senior level are aware of where the vacancies are likely to arise and the action that has to be taken.

I have just spoken to someone who came back from a medical conference in the United States last week, having met six registrars with whom the person had dealt and trained in Ireland but who now are working within 100 miles of one another in Canada. We are losing some very good people because we are not doing enough forward planning. I ask that this matter be focused on and for a review every six months in every hospital to make sure we can advertise in advance and not 12 months after the person has gone out the door.

I thank the witnesses for the work presented here today. We need to review why 1,647 additional people entered administration and management in such a short period.

Chairman

I thank the Senator. Would the Minister like to start with some of those questions?

Deputy Simon Harris

I thank the Chairman. With the agreement of the committee, it might be best if I respond to whatever is appropriate for each person and then ask the director general to continue.

I thank Deputy Kelly for his questions. I know he has been championing better pathways for emergency departments for some time. I think he is right. I will ask the HSE to outline the increase it has already seen in the minor injury units this year compared with last year. More needs to be done. This needs to be looked at as part of the review of this winter, which I expect to start in March, to plan for next winter. Is it about opening them longer, is there a benefit in opening them for longer and if opened for longer, would fewer people go in? The next piece for the pathways is the new general practitioner, GP, contract, which I am sure we will get into later. I know the Chairman has an interest in this. Could GPs do more to prevent people from having to go to the emergency departments in the first place?

On the capital for both University Hospital Galway and Beaumont Hospital, I have announced funding for the design phase for an emergency department for University Hospital Galway. That is an important part of the delivery of a capital project, as the Deputy knows from his own time in Cabinet. I expect that will be done in time for the Galway project to be considered in the context of the capital plan. A new emergency department for Galway is a priority. It is in the programme for Government and the Government will have to reflect such priorities when it reviews the capital plan, which I expect to take place this summer.

Beaumont Hospital is funded for the design phase this year with a view to it being considered and acted upon in the mid-term capital review. The Minister of State, Deputy Finian McGrath, met the chief executive officer of Beaumont Hospital as recently as last week. We saw ten extra beds open there which helped Beaumont quite a lot over the winter. The Minister of State and I continue to pursue that.

The Deputy is right about Limerick. I want to see this emergency department opened in Limerick as soon as it is completed. I have given a commitment to work with colleagues in the HSE and the Department to ensure that happens. Incredible work was being done by a brilliant staff and manager when I visited Limerick emergency department a number of months ago but in appalling infrastructural conditions. The idea that there is going to be a brand new emergency department sitting empty is not acceptable.

Deputy Alan Kelly

So the Minister is hoping to get it open?

Deputy Simon Harris

I am working to try to fulfil that, as the Deputy has asked me to today.

Deputy Alan Kelly

I thank the Minister.

Deputy Simon Harris

I will take the South Tipperary General Hospital in Clonmel and Our Lady's Hospital Cashel together, since the Deputy and I visited both of them together. The HSE and I believe we can do more in Cashel. I will ask the HSE to comment on that. I expect to receive a paper in the next couple of weeks about what we can do in Cashel while admitting that will require funding and it will be my responsibility to try to find that funding. There has been a tender competition in Clonmel. I will ask the HSE to update the Deputy on that. Clonmel and Cashel have to be a priority and have to work together. The Deputy asks if it should be a temporary offering or if a longer capital plan should be waited for. If there is a temporary solution that can alleviate pressure in Clonmel, that should be progressed, because the situation in Clonmel is not acceptable. I acknowledge that it has made good progress through its own efforts on overcrowding.

I am glad that the Deputy raised the issue of management because I did not get through all of my statement. I have travelled to nearly every hospital in our health service and I have met some brilliant managers. I do not accept that everybody is the same in any organisation. There are some really good managers, and we want everybody to be really good. The performance and accountability framework agreed with the Departments of Public Expenditure and Reform and Health and the HSE talks about the four metrics against which a manager should be measured. It includes such things as budgetary control, access to services, quality, safety and the harnessing of the workforce. I have written to the director general and he will be reporting back to me shortly with an important piece of work on how that framework is being abided by and implemented by each manager. I want to see a health service in which we point out excellence and say we would like more of that. I could give a number of examples of excellence. It is important that this becomes the norm and the expected benchmark across the health service. That is what my comments were referring to. They were not that all managers are bad because that is not my experience in the health service at all.

The Deputy picked an important issue on waiting lists and how we can be sure they are accurate. I asked the National Treatment Purchase Fund, NTPF, through its audit function, to look at the waiting list practices in each of the hospitals that featured in the "RTE Investigates" programme. That is prudent and an important step. The NTPF is not an arm of the HSE. It is an independent statutory agency that reports to me.

Validation is a word at which people sometimes shudder but if we are targeting limited resources, it is important that we know that the lists are accurate, that there are not people on the list twice, who are deceased or who have been referred to more than one consultant for the same procedure. The individual health identifier proof of concept piece has a role to play in this as well. It will be important if we can track everybody by individual health identifier, rather than by finding Mrs. Murphy.

Funding is an issue for the national maternity strategy. I know the Deputy is a strong advocate for it and that this committee has taken a big interest in it. Extra funding was provided, some in the Deputy's own time, of €2 million extra in 2015, €3 million in 2016 and another €6.8 million in 2017. There is a need for more funding.

The Deputy has outlined some of the important related capital projects, including those associated with University Hospital Limerick, the Coombe, the Rotunda, and the move of the National Maternity Hospital from Holles Street to St. Vincent's University Hospital, in respect of which move I hope and expect to be able to lodge a planning application in the coming days. It is not just a question of funding. With the exception of Holles Street, all have to be considered in the context of the capital plan.

It is also a question of implementation. The doctors and clinicians who appeared before the committee talked about that. The new national women and infant health programme in the HSE is important. One of the things we have done very well in this country was the cancer strategy. It was implemented by my predecessors in the face of a lot of political opposition at the time. The cancer control programme was set up as an independent, distinct body working within the HSE. It had its own director and really drove change. We now have a director appointed to head up the national women and infant health programme and implement the national maternity strategy. The programme director is in place. There will be a clinical director for that programme taking up office on 1 March.

I appreciate the raising of the national children's hospital because it provides me with an opportunity to clarify this. I am frustrated that some of the information circulating on costs is somewhat misleading. I have not received the definitive business case so I cannot confirm commercially sensitive figures. It has not come to me to bring it to the Government. I expect that to happen within a very short number of weeks. It is currently with the HSE and is to go to my Department. What I can say, however, and what is important to say is that the figure of €650 million, which was referred to by the Committee of Public Accounts, was a core construction cost figure. The documents at the time in question will show that it did not include equipment or the education facility for students, nor did it include some shared infrastructure and services to be used by St. James's Hospital in addition to the children's hospital. It did not include retail. Therefore, there are a number of issues that were not included in the €650 million. It did not include ICT but it was always expected that, at some point, we were going to arrive at this. The €650 million included the building of the children's hospital and the two satellite centres. The other pieces need to be appraised by the Government. The Government has yet to make a decision on this. I expect to bring the definitive business case to the Government shortly.

People who are working very diligently on this project are accused, as professionals, of overruns, etc., and this is not fair. If construction industry inflation were factored in at a rate of 3%, it would have a bearing on the matter. According to the figures given to me, we are now, in 2017, seeing construction industry inflation of more than 9%. It is absolutely right and proper that the Committee of Public Accounts scrutinises this entirely. There is a very competent bunch of people heading up this project. I look forward to being able to bring this matter to the Government shortly and sharing what is currently commercial information. I hope I am being helpful in putting that information on the record of the committee.

I have corresponded with the Deputy on the ambulance service. I will ask the HSE to answer the question further. We are investing additional funding in our ambulance service this year. The budget increased by over €3 million this year but €1 million of that is for new developments within the service.

On scoliosis, the Deputy is right. When I came to office, we did make targeted investments. More than €2 million was spent on scoliosis and 50 additional children and teenagers had procedures carried out in 2016 who otherwise would not have had them done. There was outsourcing to other public hospitals and to private hospitals. Was it enough? No. Should it have taken a "Prime Time Investigates" programme? No. Did I mean it when I said I was ashamed? Yes. What are we going to do about it now? We are going to have the action plan on scoliosis. We are going to make sure that when people say theatres will be open in April, they will actually open. We are going to share with this committee the action plan on scoliosis at the end of this month to show how we are going to arrive at a point where no child or teenager will wait longer than four months by the end of this year.

On the issue of Orkambi, I understand it is still being considered by the HSE leadership team. The legislation in 2013 was very clear. The HSE has to make a decision. If there is a funding requirement, the question of where it will be found is my responsibility. I am waiting to hear about this. I hope and expect the consideration of the matter will not go on for long. Patients need certainty and answers.

Deputy Alan Kelly

What about the other drug, Respreeza?

Deputy Simon Harris

I will ask the HSE to comment but I understand the HSE leadership made a decision on that. I will ask it to speak to that. In fact, I will ask the HSE representatives to speak on the other questions asked by the Deputy before moving on to those of Deputy O'Reilly.

Mr. Tony O'Brien

The evaluation of Respreeza has been completed and, based on the clear recommendation from the national drugs committee, it is not recommended for reimbursement on clinical grounds.

Deputy Alan Kelly

It is recommend in many other European countries.

Mr. Tony O'Brien

I cannot speak to that. What I can tell the Deputy is that, in accordance with the legislation that pertains here, which is very specific and requires consideration on a number of grounds, a detailed review has been carried out by the national drugs committee. Its recommendation is not favourable. The leadership team of the HSE will not be proceeding with a decision that is at odds with the recommendation of the national drugs committee.

Deputy Alan Kelly

Can we have more information? That is incredibly disappointing. What is happening to the 21 people on the drug now?

Mr. Tony O'Brien

First, it is important to say that, contrary to some media reports last week that suggested we made the decision related to the VAT process, there are a number of individuals who have been part of a drugs trial. The decision as to whether to continue to provide the medication to those patients is a matter for the drug company. The HSE has never funded the provision of that medication.

Deputy Alan Kelly

It is running out this month.

Mr. Tony O'Brien

If the Deputy wants some more information, I will be happy to provide it. I did not expect to be discussing Respreeza today. I will be happy to follow up with information for the Deputy.

Deputy Alan Kelly

Will we be able to obtain information on why it was turned down?

Mr. Tony O'Brien

Yes.

Deputy Simon Harris

That would be important. Deputy Alan Kelly is raising an important issue. The law of the land is clear on the process. It is clinicians who examine drugs but I take the point the Deputy made on other countries funding the drug.

I ask that, as a group of public representatives, we make a call on this in light of the point the director general makes. When a drugs company allows patients to gain access to drugs on an early basis for clinical trials, that should not in any way be used by the drugs company as linked to a process on the question of reimbursement. There is no reason in the wide earthly world why those patients should have their medication terminated. In the past, I have seen drug companies leave patients on drugs. I refer to those on the early access programme. This committee may wish to make a decision on this but I would certainly appeal to the drugs company today.

Deputy Alan Kelly

It is just very surprising. The drug has been passed in Italy, France, Germany, the Czech Republic, Austria, the Netherlands and Spain, and it is under consideration in Britain.

Deputy Simon Harris

I do not have the commercial details. The Deputy and I do not know the engagement that may have taken place or the offers that may have been made by the drug company in those countries. This is why the HSE will follow up with the Deputy.

Deputy Alan Kelly

I accept that.

Deputy Simon Harris

It is important that drug companies do not-----

Deputy Alan Kelly

I understand. There is something there we do not really need to talk about. I understand that there has to be a balance in regard to this.

Deputy Simon Harris

With respect, we should talk about it a bit because the drug company has an obligation.

Deputy Alan Kelly

I mean that the Minister cannot get involved in the decision-making process.

Deputy Simon Harris

Sure.

Deputy Alan Kelly

Of course we should talk about it. I presume this is a matter that can be reviewed pretty quickly if there is different engagement in regard to the parameters applied by the drug company.

Mr. Tony O'Brien

As a matter of general principle, we are always open to further engagement with any pharmaceutical company beyond the end of an initial process. My answer - I will give the Deputy full details - is that this has been determined on the grounds of the clinical benefit derived or provided by the medication concerned.

Deputy Alan Kelly

Is it that it is not a cost issue but more a question of clinical benefit?

Mr. Tony O'Brien

There is always a consideration of the financial impact but the decision has been made primarily on the basis of clinical benefit, but I will provide the Deputy with fuller details. I do not have the file with me.

The Deputy asked some questions about local injury units in respect of South Tipperary General Hospital and ambulance services in the mid-west. I will answer on the mid-west. I ask Mr. Woods to comment on Clonmel and local injury units.

Mr. Liam Woods

The volume of people going through local injury units is up 11% this winter by comparison with last winter and, in fact, up 29% in one site, St. Columcille's. We ran an online campaign and a radio campaign, which we are re-running for the very purpose the Deputy describes, to make people aware of the service that is available. We are seeing an increasing uptake.

On Clonmel, the community intervention team has been very successful and has delivered and supported the hospital well over the winter. We are already proceeding, under the winter initiative from 2016-17, with the investment of €700,000 in the 11-bay unit in the hospital, with which the Deputy is probably familiar, while we are considering the wider capacity question. As the Deputy rightly states, the framework agreement is now in place for us to go to tender for portable solutions for hospital sites across the country. The first example of that may well be in Clonmel.

Mr. Tony O'Brien

It is normal practice to carry out rolling reviews of the effectiveness of the deployment of ambulance services, particularly in the context of the significant increase in demand for such services that we are seeing. These reviews are not about cutting services, but about ensuring the disposition of ambulances at particular times and in particular places corresponds as effectively as possible to the known pattern of demand. That would be as true in the mid-west as it is in other locations. This is an ongoing process, particularly in the era of dynamic deployment which relates to the totality of the ambulance fleet.

Deputy Alan Kelly

The Minister has twice confirmed to me in writing that there will be no cuts in services. I would like to make a point about the non-critical transport services.

Mr. Tony O'Brien

Is the Deputy referring to the intermediate care vehicles?

Deputy Alan Kelly

Yes. I see a significant role for such vehicles. It was outlined that they would be in place, but they are basically non-existent in the mid-west, for example. They are not available when they are needed. I encourage those who are taking part in conversations as part of the review to consider the role of those vehicles. The Chair knows about the position in the mid-west, with which we are familiar by sight and example. When we talk about bed-blockers, we should bear in mind that intermediate care vehicles can be used to facilitate the transport of patients in post-care to places like St. John's Hospital in Limerick and Nenagh and Ennis hospitals. Many of the services to which I refer stop on a Friday. The health service has to go seven days a week now. I would like those thoughts to be incorporated into the analysis that is being done.

Mr. Tony O'Brien

Absolutely. The Deputy is correct about the strategically important role of intermediate care vehicles. We think that role will grow in the future. When I was in Limerick in recent weeks - the Deputy might recall that we were in contact with each other on Twitter on that occasion - I heard directly about the benefits for the movement of patients among the hospitals in the mid-west hospitals group that are being derived as a result of the direct deployment of an intermediate care vehicle to that group. The use of such vehicles will need to expand nationally in the coming years

Deputy Alan Kelly

I think it is critical. I thank Mr. O'Brien for his answers.

Mr. Jim Breslin

Would the Deputy like me to answer his question about the interaction between the public services card and the individual?

Deputy Alan Kelly

I just want to know whether they are interoperable.

Mr. Jim Breslin

They are. They are designed to work.

Deputy Alan Kelly

I am greatly interested in the public services card because I was involved in the development of the Leap card. I was absolutely shocked to hear that we are creating a new health number rather than using the PPS number. I still think it is wrong. In fact, it is crazy. Can the public services card be used to access all the health information of someone on the side of the road?

Mr. Jim Breslin

Legally and administratively, they work hand in glove. The legislation underpinning the individual health identifier sets out that. The identification of a person that is facilitated by the public services card is a very hard and secure level of identification. We will not replicate that in any way. We will rely entirely on it. The person who assigns an individual health identifier will have access to the public services card identification database to make sure the person receiving that identifier is who he or she claims to be. We will seed all of the health systems using the Department of Social Protection's public services card databases. That is all governed by a memorandum of understanding that is being signed off by the Department of Social Protection, the Department of Health and the HSE. The two numbers are not one and the same because of the experience internationally. People are very sensitive about their health information. The difficulty that arose in other jurisdictions where these two structures were combined was a reduction in the uptake of the public services card by people who were afraid that somebody with access to their social welfare or personal public service number could dive in and access sensitive clinical information about their health.

Deputy Alan Kelly

If I am unconscious on the side of the road after an accident, will a paramedic who has taken out my wallet and found my public services card because he needs to find out everything about me be able to go into the health system and pull out all the information he needs in relation to me?

Mr. Jim Breslin

Yes. That would be more than sufficient. They will operate on that basis. They will not suck health information over into the Department of Social Protection other than by means of a privacy-assessed and protocol-driven process. We will avoid doing that.

Deputy Alan Kelly

Okay.

Mr. Jim Breslin

If we were to do that, we would raise all kinds of privacy concerns.

Deputy Alan Kelly

I understand that. I thank Mr. Breslin.

Chairman

As a number of members of the committee are waiting to contribute, I ask the Minister, in the interests of conserving time, to respond to the questions that were asked about nurse recruitment, stretch budgets, domiciliary care allowance and anomaly scans.

Deputy Simon Harris

Sure.

Deputy Louise O'Reilly

I asked about the NTPF as well.

Deputy Simon Harris

The Deputy has a keen interest in the NTPF.

Deputy Louise O'Reilly

I have a keen interest in seeing the end of the NTPF, as the Minister well knows.

Deputy Simon Harris

I do. I will answer the questions relating to me and I will ask the officials from the HSE to answer the questions about staffing levels and stretch targets. They will also set out where we are at with the anomaly scans, although I would like to emphasise that the national women and infants health programme is prioritising such scans. I want to see how much information the committee can be given here today.

On the provision of medical cards to those in receipt of domiciliary care allowance, I have not seen the answer that was mentioned but I want to make it crystal clear that there is no review. I intend to go to the Government in the coming days to seek permission to publish the legislation. I absolutely acknowledge the Deputy's point that all Members of the House have agreed that there may not be a need for pre-legislative scrutiny. I do not mean to be presumptuous about what the committee will do. If there is no pre-legislative scrutiny, we will be able to get on with bringing the Bill through both Houses as soon as possible. The HSE is working on the establishment of a portal to enable people to register for this scheme. In all likelihood, it will be similar to the system used for registering for free GP care for those under the age of six and over the age of 70. There is no review.

Deputy Louise O'Reilly

Why did I get a response saying that the Department is currently reviewing with the HSE and the Department of Social Protection the data in respect of the number of children covered by domiciliary care allowance who do not have a medical card to get the most accurate possible current estimate of the net additional cost of granting medical cards to this group?

Deputy Simon Harris

The Deputy is right. The cost of this might fluctuate. There could be a child at home today whose parent is granted domiciliary care allowance. Equally, as the Deputy will acknowledge, the overall number of people in receipt of medical cards is decreasing as people return to work and lose their cards three years later.

Deputy Louise O'Reilly

Emigration might be another reason for the decrease in the number of people with medical cards.

Deputy Simon Harris

It could be because of the recovery. We will have that debate somewhere else.

Deputy Louise O'Reilly

"Let's keep the recovery going".

Deputy Simon Harris

I know that the important health matter raised by the Deputy is a matter of genuine concern for people. I expect people to be able to see this legislation next week. I have already asked the Government Chief Whip to get it into the House and through both Houses as quickly as possible. While I do not wish to speak for the HSE, I am aware that it is preparing people to be able to register for this.

Deputy Louise O'Reilly

If the review finds out that the cost is more than €10 million-----

Deputy Simon Harris

No, that will not-----

Deputy Louise O'Reilly

That will be accommodated.

Deputy Simon Harris

Correct.

Deputy Louise O'Reilly

Nothing will delay it.

Deputy Simon Harris

I am giving the Deputy my word that nothing will delay it.

Deputy Louise O'Reilly

It has been delayed for long enough.

Deputy Simon Harris

Legislative change is needed here. I hope and expect to bring the legislation to the Government on Tuesday so that I can get the Bill published and bring it through both Houses as quickly as possible.

Minister of State at the Department of Health (Deputy Finian McGrath)

I strongly endorse what the Minister has said. Domiciliary care is a major part of the programme for Government. Deputy O'Reilly mentioned that an allocation has been made to cover 10,000 children and referred to the slight delay associated with the review of data. I think the confusion arose when the numbers were being finalised. Like the Deputy, I have direct experience in this regard. We all get regular queries from families. I think this will benefit approximately 11,000 children. That is my personal view. We need an accurate estimate. As the Minister has said, the legislation will be before the Oireachtas shortly. We are all working closely together and pushing it very strongly.

Deputy Simon Harris

I will endeavour to meet the Our Children's Health group next week to provide an update on the timing.

Deputy Louise O'Reilly

For the record, I do not think this is a slight delay. I think it is a huge delay for people who are waiting on it.

Deputy Simon Harris

Sure.

Deputy Louise O'Reilly

I welcome the fact that they will see it soon.

Deputy Simon Harris

It has been suggested that the NTPF reviews itself. As the Minister with responsibility for appointing the independent non-executive board of the NTPF, I think we need to be careful not to impugn the professionalism and expertise of the people on that board when we make comments. I do not suggest that the Deputy has done so. The board of the NTPF, which is the structure through which the NTPF is analysed and monitored, is appointed by the Minister of the day. I think it is quite a robust reporting structure. I have met the chairman of the board and other members of the board on three occasions in the ten-month period since I became Minister. The Department of Health is liaising closely with the NTPF, which is a statutory agency of the Department. I have made my point about the board of the NTPF. I apologise if I picked up the question wrongly.

Regarding the Deputy's suggestion about the waiting list system, I endeavoured to deal with this matter constructively in the Seanad last week.

Deputy Louise O'Reilly

I want to come back to the NTPF.

Deputy Simon Harris

Sorry. Go ahead.

Deputy Louise O'Reilly

It has been stated in response to a question that the performance of each hospital in the context of listed criteria will be monitored on a constant basis.

My reading of the reply is that it would be monitored on a constant basis by the NTPF. It is a State agency but-----

Deputy Simon Harris

It is accountable to me. The acute hospitals division within my Department monitors the fund and reports to me on it.

Deputy Louise O'Reilly

Do the senior staff in the NTPF work for the fund or for another State agency? Are they on secondment?

Deputy Simon Harris

The Deputy may be asking a question to which she knows the answer. The current chief executive officer is on secondment from the HSE but the position has been advertised publicly and the recruitment campaign to fill that post is under way.

Deputy Louise O'Reilly

Is it a substantive post as opposed to a post within the HSE? The staff in the Department, the HSE and the NTPF are closely connected. Officials who worked for the HSE now work for the NTPF and there is interchangeability. The reply to the question is, "the performance will be monitored". Is the Minister satisfied that there is robust monitoring of the NTPF by the NTPF itself, which is what the reply suggests, or does another entity, body or committee assess whether the fund is providing value for money?

Deputy Simon Harris

There are two parts to the answer. I would be dissatisfied if the NTPF, the HSE and the Department were not working closely together and were not closely linked because that is the only way we will solve the waiting list challenge. The Deputy is entirely correct. The interim arrangement in respect of the head of the NTPF is not to the satisfaction of any of us given the enhanced role the fund is taking on. That is why the position has been publicly advertised. Regarding the official on secondment, it is clear that the NTPF reports to the Department and to me. The board is appointed by me but it is right and proper, bearing in mind what previous Ministers decided to do with the fund versus what I have decided to do, that there should be a full-time, publicly advertised appointee as CEO of the NTPF.

Deputy Louise O'Reilly

Who will monitor the NTPF.

Deputy Simon Harris

Yes. I am satisfied that the structures are robust enough but my Department has a role in this regard. The NTPF is accountable to my Department as one of its agencies. I often hear misinformation relating to the fund. The Committee of Public Accounts has examined the operation of the fund and I expect it will continue to keep an eager eye on its work because it receives a significant amount of taxpayers' money. I recall reading a committee report which was favourable in respect of value for money from the NTPF. The Deputy is correct that it is important that we should continue to monitor the fund but I am satisfied that the structures are robust.

Deputy Louise O'Reilly

NTPF staff compiled the lists about which RTE made the programme. The Minister can understand why people will question the NTPF but when committee members do, the answer is that the NTPF monitors itself. That is not a satisfactory answer.

Deputy Simon Harris

NTPF officials monitor the people they pay with taxpayers' money to deliver a service, not themselves. The NTPF outsources services to public and private hospitals, saying, "We are paying you this to provide that", and they monitor that. Their role in many ways is to contract services and to make sure they are delivered in an efficient way within budget for patients.

Deputy Louise O'Reilly

Is the Minister satisfied that they are doing a good job?

Deputy Simon Harris

I am.

Deputy Louise O'Reilly

Fair play to the Minister.

Chairman

The Deputy also asked questions about anomaly scans and a deficit in the HSE budget this year.

Mr. Tony O'Brien

I will ask Mr. Woods to comment first on the 107 accident and emergency department staff and the stretch targets.

Mr. Liam Woods

The Deputy was referring to staff that were part of an expert group conclusion around nursing boarded patients, who have been represented previously by the INMO before the committee as requiring funding. It is correct to say they were not included in the HSE service plan. They are still part of discussions between the HSE and Department in respect of how we move forward with the INMO but that is a work in progress.

On the stretch targets, the Deputy referred to maintenance charges for private care provided in public hospitals. The origin of this dialogue is the Committee on the Future of Healthcare. Last year's stretch target was €50 million in total; this year it is €44 million. The acute system delivered in terms of its total target as anticipated. Specific comment was also made in last year's HSE service plan, which carries into this, that any shortfall would not lead to reduced service and we are clear about that. The private income public hospitals recover comes primarily from people who present through their accident and emergency departments. Hospitals are not seeking private patients to achieve income targets.

Deputy Louise O'Reilly

A target is set when we want people to reach it. I am relieved that there will be no comeback if they do not.

Mr. Liam Woods

There is a management of the income and that is normal in the same way there is on the cost side. There is, however, no suggestion that there is a requirement to attract private patients to balance hospital budgets, which was underlying the Deputy's question.

I refer to the question on technology. Many of the HSE's technology proposals, including the electronic health record and so on, will support waiting list management because they are all about scheduling patient care and flow. Projects that are universal to the health environment are also relevant in this area. We can support specific projects around using smaller technology solutions to support common waiting lists across hospitals within a group, for example, on an ongoing basis as we go through a year. They tend to be relatively inexpensive.

Mr. Tony O'Brien

On the questions about the budget, the committee might forgive me for saying that it can be a tough audience sometimes. I have been attending the committee for four years. For three of those, the only consistent theme has been the kicking of the HSE and the various people who work for it on budgetary matters. It is reasonable in the first year there has been a virtual break-even situation that I would acknowledge the work that has been done by people throughout the system to achieve that and, in particular, the decisions made by the Oireachtas around the funding of the HSE in 2016 which enabled that to occur. Where it is possible to give people reasonable performance objectives, they have shown their ability to deliver.

We are not planning or foreseeing a financial overrun this year. I will reiterate the two points I made at the launch of the service plan. Given the scale of the service, it is worth noting that there is no provision for contingency. That is a standard in the way we fund public bodies. Should there be a significant unforeseen public health emergency, therefore, we do not retain a separate fund for that. That would be something we would have to report to the Minister on if we encountered that. In the context of the enormous appetite for pay restoration and so on, the service plan does not currently provide for that. Notwithstanding those two points, we do not foresee financial overruns in 2017.

Deputy Louise O'Reilly

Is the restoration of the allowance to NCHDs included in the budget?

Deputy Simon Harris

It is not. As I tried to say in my opening statement, the anomaly payment was part of the talks with the public sector unions earlier this year and that matter will be dealt with centrally by Government.

Chairman

We will move on to Senator Colm Burke's questions about obstetrics and gynaecology.

Deputy Simon Harris

Most of the questions are specifically for the HSE. I will ask the director general and his team to deal with the structure and management posts because detail is important in respect of those headline figures. The Senator asked whether we would review management structures within the HSE. There is a commitment in the programme of Government, and the decision made by the Dáil to establish the Committee on the Future of Healthcare was with a view to coming up with the most appropriate structure once and for all, which we will not tinker around with following every election or ministerial change. I expect that to be dealt with in that context.

The Senator will be aware that I visited CUMH in January. I was pleased I did so because I met an incredible bunch of clinicians who are highly motivated to do good by their patients but who are extremely frustrated. The Senator can talk about how waiting lists are measures in various parts of the country and so on.

When I looked at the waiting lists in Cork, it was clear that an issue needed to be addressed. Many steps have been taken in recent weeks to try to put a plan in place to address them. CUMH gynaecological services are referenced in my letter to the director general for the waiting list plans for 2017, which I am due to receive next week as a priority. I am due to meet with the same group of clinicians in the very early weeks of March in Leinster House. I will keep Cork Oireachtas Members informed about the meeting. I might ask the director general to touch on the service matters.

Mr. Tony O'Brien

I will ask Mr. Liam Woods to talk about the CUMH issues and I will ask Ms Mannion to talk about the staff census issues.

Deputy Louise O'Reilly

I asked a question about anomaly scans. We are in that general area. I wish to be very specific. I asked exactly when the scans will be available to all women? In the interests of time, could the date be provided? If there is not one, then I ask that the witnesses would put their hands up in that regard.

Mr. Liam Woods

On the issues relating to CUMH, in addition to what has been outlined, the waiting list proposals that we have received on top of the recruitment proposals that are already in the response, some of the recruitment for the expanded use of theatre in CUMH is already within the funded level of service. I have received proposals from the South/South West hospital group in terms of the operation of services to meet the gynaecology waiting lists and to bring them back to reasonable timescales.

Senator Colm Burke

Two months have passed. Do we have a time limit for when we can have it up and running rather than bring the witnesses back here again in two months' time?

Mr. Liam Woods

The Minister has indicated that the overall waiting list plan is due for completion at the end of this month. We already have proposals in this area and they will be part of the overall plan.

Senator Colm Burke

Will there be extra time in theatre? The theatre is open three and a half days a week. There are two theatres but the second is empty. Will we have it open five days a week as part of the plan?

The other issue relates to the six-bed day care unit. What is the timescale for that? We can talk and we can refer to committees but if we are back here this time next year it will not sort out the problem. Are there target dates?

Deputy Simon Harris

There is no question of anything being referred to a committee. We are going to publish a waiting list plan next week, at the end of this month, and in response to Deputy O'Reilly’s question, we will share it with this committee. I expect that significant measures to reduce waiting times in CUMH will be a part of that. In fairness to the HSE, the detail of those measures will be in the plan.

Mr. Liam Woods

In response to the points made in respect of the South Infirmary, the areas to which reference was made are subject to capital submission to the HSE. There is a dialogue going on. As part of the review of our total capital availability under the mid-term review, we will respond to the group in terms of what we can actually do. It is seen as a priority. The point made about the nature of the current facility is fully accepted.

On the point about anomaly scanning, the new clinical lead for the women and infants programme is taking up office on 1 March and one of his first acts will be to put in place arrangements for access to anomaly scans across the system. As the committee is aware from previous responses, that is not universally available. From recall, it is only in approximately six of the 19 units at the most. Peter McKenna, who has been appointed as clinical lead, will undertake a very quick review of that and seek to put arrangements in place in the short term for access across the country and then identify the requirements both in terms of personnel, facility and equipment to deliver on that in the medium term. The most urgent task will be to arrange access where it is not available from within our current capacity or by brief expansion. After that, there will be a requirement to recruit and equip. That is referenced further in the response. That is all I have to say in response to the questions.

Chairman

I thank Mr. Woods. There was one other question about managerial numbers rising by almost 1,700.

Ms Rosarii Mannion

The question from Senator Colm Burke focused on workforce planning and management and administration. Priority 4 of our people strategy specifically looks at workforce planning, which is why we are in a position to provide that good data on the consultant medical workforce. That will be available for all other grades as we progress through the year.

Specifically with regard to management and administration, the question sought the data to be presented in an identical format as our annual report 2015, page 6, which is the way it was presented. I am really happy to get behind that and to provide the specific breakdown in terms of the number of staff who hold grade III, IV, V, VI posts or whatever. It is reasonable and fair to have a differentiation between the various components of management and administration versus the senior posts within the organisation, which in many cases will require a professional qualification. I would be happy to provide all that detail and I will send it to the committee in the next week.

Senator Colm Burke

I still think an explanation has not been given as to why management and administration has increased by 1,647 whereas public health nurses who operate at the coalface have only increased by 39. It does not make sense.

Ms Rosarii Mannion

I would be very happy to provide details to the committee.

Senator Colm Burke

I have the detail, but what I am saying relates to our priorities within the HSE. I do not criticise anyone in the HSE because there may very well be a logical reason why 1,647 additional people are required in administration and management. Surely to God, however, there should be proportionality in respect of front-line staff, which does not seem to be the case. The number of public health nurses increased from 1,460 to 1,499, an increase of 39. In North Lee in Cork there are 68 nurses, ten of whom were genuinely on sick leave or maternity leave over a 12-month timeframe and they were not replaced. We do not seem to have the coalface as a priority and I am somewhat concerned at that.

Mr. Tony O'Brien

I will give some detail because I would like to be clear. The fact that someone is employed on an administrative scale does not mean he or she is not at the coalface. They include people who check patients in clinics and those who support the public health nurses and consultants. A couple of years ago when I visited a wide range of services, one of the chief things paramedical and specialist staff said to me was that they were spending far too much of their precious time carrying out back-office functions which in the past were done by administrative and clerical people whose posts were completely frozen during the worst of the recession. There has been a conscious effort to improve skill mix so that professional staff can spend their time applying their professional skills. That is part of the answer. Ms Mannion will give the committee, through its secretariat, the full response to the question.

Senator Colm Burke

I thank Mr. O'Brien.

Chairman

We will move on to questions from some other members because time is precious. I call Deputies Kelleher, O'Connell, Durkan and O'Mahony.

Deputy Billy Kelleher

I will try to be brief. Some of the questions I had anticipated raising have already been answered. Mr. O'Brien said that this committee has very often been critical of the HSE in terms of budgets. I remind him that I have always been on his side when it comes to budgets because I have always tried to secure more funding for the HSE.

Mr. Tony O'Brien

That is definitely true.

Deputy Billy Kelleher

It reminded me a little bit of the charge of the Light Brigade at Balaclava whereby Lord Cardigan and his senior officers could be compared to the HSE being sent out to charge with inadequate resources and one inevitable outcome, namely, a budget deficit and a cutback in resources at the end of the year. In fairness, we must be honest with ourselves in terms of what can be achieved when it comes to budgets. Some of the service plans that were forced on the HSE - as opposed to being presented by it - in recent years were not achievable and inevitably we ended up with cutbacks at the end of every year.

I highlight these issues because they are important. In orthopaedics, for example, full surgical teams were on standby yet there were cancellations of all hip implant surgery due to there being no implants. That is the reality of what was happening in recent years. It was not Mr. O'Brien's fault or the fault of the HSE, it was due to a lack of planning and foresight. Sometimes the Department of Health is a bit like Lord Cardigan in blaming somebody else. We must be honest with ourselves. It is easy to consistently criticise the HSE and sap it of its capacity to deal with the challenges. We must be careful in that regard.

Deputy O'Reilly raised the issue of private patients in public beds. There is a perverse incentive at stake in that a hospital can now charge private patients in any public bed.

There is no doubt there is a perverse incentive for private patients to be treated in public hospitals because hospital management is under significant pressure with regard to budgets, and consultants will get paid by the private health insurance companies. If there was not, the Government would not have changed the legislation. It was changed for budgetary purposes which was quite evident at the time.

I remember listening to the speeches and the rationale behind it. It was changed for budgetary purposes to incentivise and encourage private patients to be treated in public beds. Prior to that, there was a 20% designation. At the same time as we have private patients being treated in public hospitals, we have public patients who cannot get into the public hospitals for treatment. There has to be a revaluation of that moral dilemma. Private patients should be treated in private hospitals, unless there is clinically no other way. The purpose of private health insurance is that private health patients go to private hospitals which, in turn, frees up capacity in the public hospital for public patients. At the very least, there should be an independent assessment of whether there has been a major increase in the volume of private patients going through public hospitals, thereby reducing capacity for public patients in public hospitals. I have many consultants, insurance companies and private health care providers informing me it is happening. And they are all wrong? It is a perverse incentive, as was outlined at the time during the change of policy in the Health (Amendment) Act.

The Minister referred to the bed capacity review as an important part of the planning process, looking over the horizon, taking into account demographics, changes in medical practice and all that flows from the modernisation of medical services. The other important issue in this context is workforce planning. This would have to be looked at in tandem. Otherwise, there is not much point in having a load of beds and no nurses or vice versa.

At one stage, there was a proposal to have a new grade called theatre assistant like they have in the United States and elsewhere. There was a lot of resistance to it, however. One of the major problems identified in the delays with scoliosis and other orthopaedic operations in Crumlin hospital and elsewhere was the lack of theatre nurses. Where are we with regard to the setting up of this new grade? Has it fallen by the wayside because of resistance or for other reasons?

With regard to waiting lists and accountability, the Minister referred to gynaecology and obstetrics in Cork and elsewhere. We have committed consultants and professionals across the health service, as well as committed administrators and management. At some stage, however, reasons have to be given as to why we have inordinate delays in some hospitals and not in others. It is important there is absolute transparency with regard to waiting lists across the whole of the Health Service Executive, HSE, including with consultants. The public is entitled to know that if one goes to X hospital, one will wait so long, while if one goes to Y, one will wait a different time. This allows comparisons to be done. With comparisons come competitiveness and accountability and all that flows from that.

This question is for Mr. Jim Breslin. The National Association of General Practitioners represents 1,600 GPs, while the IMO, Irish Medical Organisation, represents about two thirds, if not half, of that number. As it stands, the National Association of General Practitioners is outside the door while the IMO negotiates with the Department on the most important contractual discussions to take place in 40 odd years and which will set down the bedrock of health care delivery in the primary care setting. It is extraordinary the majority involved are not even sitting down to discuss the matter. Why is the Department speaking with the smaller organisation when it should be speaking with the larger one? It would be like going into Parliament to talk to the smallest parties as opposed to the largest party. It beggars belief.

We all hope that society will buy into the national children's hospital and it will be a beacon of a modern state, delivering modern care to the people we should cherish most. I hope every effort is made by the Minister, the Government and those charged with the responsibility of ensuring the national children's hospital is represented, that there is a voice for it, it is not delayed any further and it is not undermined by misinformation or a lack of information.

I met some of the parents of the children with scoliosis who are on waiting lists and I raised it in the Dáil in November 2016. The "Prime Time Investigates" programme touched everybody. One would have to have a heart of stone not to have been touched by it. Why is the system so inactive and cold to that call which was going on for a long time with regard to this particular issue? I accept there are many challenges to and draws on HSE resources. However, a system would want to be wholly inflexible and lack any compassion not to have responded to this matter in advance of the RTE programme. We need to be conscious of that. Delaying surgery for an inordinate period, which had a negative impact on people's health, did not rest easy with the public. It should not rest easy with a system which allowed it happen in the first place.

On the broader review of maternity and cardiac services, as well as broader services in general, when the capital programme is being assessed, are all the strategies underpinning the various deliveries of health care assessed first and then the capital plan put on top of that to ensure we have continuity of strategy? There have been concerns in the past, not just for the past six years, that there can be undue influence from a political perspective as to where capital spending should go when it should be based on what is required by the health services, as opposed to what is required by a political party or a Minister of the day.

Chairman

I thank Deputy Billy Kelleher for his-----.

Deputy Billy Kelleher

Short, brief and concise contribution, unlike previous speakers.

Chairman

He hit it on the button. It was ten minutes.

Deputy Bernard J. Durkan

It was a sterling performance from Deputy Billy Kelleher.

Deputy Kate O'Connell

Following on from Deputy Kelleher's statements on scoliosis, no one watching the "Prime Time Investigates" programme could not have been moved by it.

I believe people are more likely to become just numbers when people in management positions have no clinical expertise and administrators have no medical training and are not bound to any medical ethics, as doctors and members of other professions are. Management structures within the HSE should contain people with clinical experience, though not necessarily doctors, and they should make the decisions. By having administrators who are not bound by any medical ethics, we ended up in the situation in which we find ourselves. It is a shame that this was exposed on "Prime Time Investigates" and that the Minister had to intervene. I commend him on his intervention and I have great hope for the unit being opened. Ireland and I thank him for that. It is shameful that this happened under the watch of Mr. O'Brien and I have to question his ability to do the job in this regard.

I find it difficult to understand why all the management and staff of the HSE were thanked today for their wonderful work when no company, except maybe one in a small cottage industry, can be said to have staff who are all operating to the best of their ability. There are people in the HSE, in management and among front-line staff, who go beyond their duties every day, working extra hours for no pay, but I am surprised the questioning of people's ability has been taken so personally. We have seen the impact of poor management and it is fully within the rights of this committee to question the competence of certain people.

Somebody spoke of giving the HSE a kicking in the context of the budget but we are elected members of Dáil Éireann and Seanad Éireann and nobody should take it personally that we should question the use of taxpayers' money in light of what has recently been exposed in the media.

Perhaps Ms Mannion could share her response to Senator Burke's question with the rest of us. Can she outline where the extra 1,400 or 1,600 staff to whom she referred originated? I have strongly suspected for a long time that people are being recycled around the system. Can she also say how they ended up in the position they are in? I would like to get one of those digital babies from Cork. We did not get them in Dublin.

Chairman

They are on their way to Holles Street.

Deputy Kate O'Connell

I thank witnesses for their answers to the question of the anomaly scans. We discussed the national maternity hospital last week and found that many hospitals were only scanning high-risk women. Professor Kenny from Cork stated that, in 1% of cases, there were structural defects in the non-risk group, amounting to 230 children born in this country every year with problems that were not identified pre-birth. There are catastrophic outcomes, while in other cases it all works out, but doctors and midwives are being put in a very awkward position where a child is born in a regional hospital with a problem that could have been identified prenatally. This causes huge stress to families, has bad outcomes for our children and costs a huge amount of money to limit the damage and transfer the babies to Dublin hospitals for surgery. It is a shocking statistic for a country this size and it is shameful. What is the HSE going to do about it?

There is a spiralling rate of neural tube defects, such as spina bifida and more severe forms of encephalopathy, but two thirds are preventable. One child per week is born with a severe birth defect that could have been prevented with adequate prenatal nutrition, one of the cheapest being folic acid which costs a pittance at €2 for a box of 50 to prevent the commonest preventable major congenital anomaly worldwide. It is a pity that the Minister of State at the Department of Health, Deputy Marcella Corcoran Kennedy, has left. Dr. Boylan, who is the expert and was here last week, said that the solution was fortification of foodstuffs with folic acid. People may not want it but it is a water-soluble vitamin and there no issues with men having it by accident as it is harmless to them. We have been talking about birth defects and scans but if we could prevent things from happening in the first place there would be knock-on effects for families and costs in the health service. In light of the €13.5 million spend to which Mr. O'Brien referred, can we not try to cut costs while at the same time having better outcomes for families?

How much public money is being spent in 2017 on disability services? Will the Minister of State give an indication of where the money is to be spent? Perhaps he could send us a note in reply. Will he also give us an update on the Grace case?

Mr. Woods spoke of portable solutions. Will he elaborate on those? I see caravans and trailers but maybe I am wrong. These things are short-term fixes to massive problems. The data show that we have huge demographic pressures and this seems to be a Band-Aid policy. I do not get why we are going for portable solutions and I find them quite disturbing. Pre-made units were brought into Crumlin some seven years ago.

They literally came on the back of a truck and they had to be plumped in. I believe that happened about seven years ago. Is that the sort of portable solution or is it akin to the library that used to come to us in the van years ago in Westmeath? I am wondering what is a portable solution. I ask people to use plain English in giving the answer.

Chairman

Before I call Deputy Murphy O'Mahony, I wish to convey apologies on behalf of the Minister of State, Deputy Corcoran Kennedy, who had to go to speak in the Seanad.

Deputy Margaret Murphy O'Mahony

I would like to thank the Minister. Is he gone?

Chairman

He is gone temporarily; he will be back

Deputy Margaret Murphy O'Mahony

It is a pity he is gone. I am a bit concerned about the WhatsApp saga that happened during the week. I was going to ask him, obviously not to declare his candidature or otherwise here, but to give a guarantee that the leadership contest, irrespective of whether he is involved, will not affect his dealings with the Department of Health. Hopefully, he can answer that when he comes back.

Mr. Jim Breslin

We have seen no reduction anyway.

Deputy Margaret Murphy O'Mahony

Good. Not yet anyway; maybe after the parliamentary party meeting tonight. Here he is.

Deputy Simon Harris

I apologise to the Deputy.

Deputy Margaret Murphy O'Mahony

It is okay. With the WhatsApp saga during the week-----

Deputy Simon Harris

Was the Deputy on it?

Deputy Margaret Murphy O'Mahony

I am obviously not asking the Minister to declare his leadership intentions or otherwise here, but I ask him for a guarantee that the leadership contest, irrespective of whether he is in it, will not affect his dealings as Minister for Health.

I already spoke on this to the Minister in the Chamber. Obviously, there is a hospital like Bantry General Hospital in every constituency. That hospital is a really good and well-run hospital, but is obviously starved of funding. As I pointed out to the Minister in the Dáil already, with a little bit of funding it could do amazing things and could ease up the whole waiting list saga in Cork city.

What are the Minister's plans to ensure people are enticed to apply for GP positions etc.? As far as I know, some positions are getting no applications. Obviously, something is wrong and something needs to be done. What are the Minister's plans to entice people to apply and obviously to keep them, particularly in rural areas? A big campaign was run last year to entice nurses to come home from abroad. I have heard several stories of nurses finding it difficult when they come home to get their NMBI PIN and to get set up and running within the hospitals to which they have returned.

Mr. O'Brien has gone; everyone is avoiding me this evening. In his absence, let me say I am very disappointed about the Respreeza saga. I ask him to keep me informed. What can we do? I definitely will be looking for further engagement on that because it is shocking.

I thank the Minister of State, Deputy Finian McGrath, for coming here this evening. I praise him on his work ethic. He always has an open door for me, as an Opposition spokesperson. I am very grateful for that. I have spoken to him several times about the waiting list for assessment. There is no improvement. While the Minister of State has good intentions, not enough is being done. Children, in particular, are waiting for a long time for assessment and then have to wait a long time for treatment if necessary. As we all know, early intervention is very important. It is at crisis point with the lists so long.

I ask the Minister of State for an update on the ratification of the UN convention.

People are very concerned about the delay in medical cards for those who receive domiciliary care. They are wondering if they should apply in the normal way given that this is taking so long.

Chairman

I call Deputy Durkan. He might like to make a limited contribution.

Deputy Bernard J. Durkan

All my contributions have been limited and with the passage of time have become even more limited. As the Chairman knows, I am a very simple country boy and have simplistic solutions to everything, including some of the complicated issues raised by Deputy Kelleher.

I see two issues. First, there is overcrowding in accident and emergency departments. This has occurred every year for the past ten years with no change. The same applies to waiting lists for elective surgery despite the corrective measures. I welcome all the measures that have taken place and the extra funding made available in the current year over last year and the proposals for the future.

Regarding overcrowding in accident and emergency departments, what research has gone into the reason for the persons being there in the first place? Have they come of their own volition? Have they come following referral from their GPs or have they come as a result of being on a waiting list for elective surgery for a period of two or three years, or whatever the case may be? I would like precise answers to those questions because I believe I know the answers to them.

When a patient first presents for elective surgery, to what extent has an examination been done as to whether at any given time there is sufficient capacity in the system to deal with the volume? It is simple mathematics. I know people will tell me it is not possible to interrelate mathematics and medicine, but there is a certain merit in it.

We appear to be closing down step-down beds in the public sector. This has happened gradually over the past 15 years on the basis of health and safety and so forth. I know the institutions concerned. I was on the visiting committee of some such institutions previously. I cannot understand why that is happening. It surely would be of huge benefit at this time to try to make available the maximum number of those beds at a time when beds are at a premium in the public hospital system.

Why was it not possible to identify the extent of the urgency of the particular scoliosis cases without having to wait for an investigative programme by RTE? Surely it was known to everybody along the line that there were a number of patients in the system. Their individual suffering is not recognised by everybody because we do not all know where it is happening. However, somebody knew what was happening and decided to put them on a waiting list. As the Chairman will know, this arises all the time with hip replacements. It is not unusual to find a person hobbling along with one crutch, having suffered in silence for a long period of time, eventually being told, "Sorry, there's a problem; we had a bed for you yesterday but we won't have one again for two months."

There is an examination of capacity. What is the optimum required to address the accident and emergency department problems, from where the patients are coming and the hospital problems in terms of waiting lists? Is it due to a lack of surgical facilities, such as theatres and theatre staff? For example, in the past 24 hours I have dealt with a case where a serious operation was scheduled to take place, but had to be postponed because of a lack of theatre staff. It was an urgent procedure involving a child. Parents and patients of whatever age are vulnerable. That should identify the scale of what is required to provide the services for the next three years.

We should not have a shortfall the following year. We should address the issue, identify the core problem and deal with it. That may mean increasing the services dramatically to cater for our population. When people tell me we have an ageing population I feel sensitive about it and look in the mirror. There is also a very young population contributing tax to the system. I would like a comment on that.

It is very obvious that if a person discovers a particular drug can have a dramatic impact on his or her condition, he or she will want to have it. That the person is in his or her little world and reaching out for something to alleviate the pain is a natural reaction. I know the Minister and the HSE have done some work on this recently but we live in a single market. If the drugs are approved, available and paid for in Milan, Berlin or other places, they should be available here too at the same cost. The European market is 500 million people. It is more lucrative for a drug company to deal with that number than to deal with three or seven million. How much time and energy do we devote to ensuring we get the benefits of being part of the 500 million?

Why was it not possible to identify the full extent of the waiting lists in our hospitals? We have asked that question several times. RTE was able to discover it in a couple of hours or that is how it looks to me. The information does not seem to filter down to the area that matters, and if it does not, there is a problem. It cannot and will not be dealt with until that happens.

Everybody thought it was a good idea to centralise the services. I never believed it was a good idea. This is not a criticism of the HSE but I never believed it was the appropriate body to deliver services nationwide and it is not. The people working in the medical card section are decent people and work very hard where there is a huge demand. I cannot understand how a cancer patient may have to wait while bank details and other documents are submitted and the patient's condition is deteriorating. Nobody seems to think about that. It would be quite simple to issue the medical card in the first instance. Safeguarding the patient should be the priority.

I could go on and on. If we can get the answers to some of my questions and to those my colleagues have put, we will solve health service problems we have been trying to deal with over the past ten to 15 years.

Deputy Simon Harris

In the interests of efficiency I will answer the questions that are relevant to me and ask the HSE to come in.

Deputy Kelleher is correct that the policy of treating private patients in public beds should be kept under review. It arose when there was no mechanism for private patients to be charged, which was not equitable in a public health service. On foot of his sincere interest, and it is a prudent thing to do, I will ask the Department of Health to produce a report on this matter, how it has grown and its impact on bed numbers, and I will share it with the Deputy and this committee.

I am very pleased to hear the Deputy refer to bed capacity being tied to recruitment because I have consistently heard people on the airwaves saying time and again that if they had more beds, the crisis would be solved. That is not a fitting comment for some of those people because they know that in their own hospitals beds are closed - for example, there were 90 closed yesterday - due to staff shortages. While I accept there is a bed capacity issue, the beds of themselves are not a realistic answer. Only beds that can be staffed are a solution. The two must go hand in hand. The bed capacity review should be able to inform the recruitment needs of the health service.

Theatre assistants are a sensitive issue. This is a sensitive time for industrial relations and engagement with unions in the health sector but I hope that in the context of the public service pay talks, new grades in the health service will be considered seriously. In other countries theatres function well with fewer nurses and other assistants. That enables the nurses to deploy their skills more appropriately in the acute hospitals.

The comments on waiting lists are fair because there is a role for management and one for consultants. We have to get away from the idea that the consultant owns the patient to the extent that until the consultant sees the patient who has been referred to him or her, the patient cannot have a procedure. We saw a good example of what I describe as pooling in the Royal College of Surgeons of Ireland, RCSI, hospital group, which includes Beaumont, Cavan and Our Lady of Lourdes in Drogheda, such that if a patient was offered a procedure in Beaumont but there was no capacity there, it would be offered in Cavan or Louth. As a result, waiting lists in this hospital group reduced significantly compared with other hospital groups. Deputy O'Reilly’s integrated waiting list approach supports this. Pooling and using the group structure to maximise capacity will have to be a priority for our waiting list efforts in 2017.

On the issue of the National Association of General Practitioners, NAGP, and the Irish Medical Organisation, IMO, it is not for me to adjudicate on who has the most members nor is it for me to adjudicate on why there are two different organisations or a doctor joins one or both, as many general practitioners I meet tell me they have. On taking office I said, and I meant it sincerely, that there is a need for the GP contract discussions to be inclusive. The process I have put in place, following advice from officials, consideration and engagement, is much more inclusive than any we have had on general practitioner, GP, matters. In the past the NAGP was left out in the cold, looking in the window, as it were. In this process the IMO, which has a long-standing history of negotiating as a representative body and has a framework agreement, not one signed by me but signed by the Department of Health and the IMO, is negotiating a new contract with the NAGP being afforded a formal consultative status that it has never before had. I have received correspondence from this committee on that but I am trying to balance the need to ensure the process is as inclusive as possible with ensuring my Department honours an agreement and framework already in place. I would say to the NAGP that this process enables it to have a greater role than ever in any discussion on any matter to do with general practice and the Department of Health. I will meet the NAGP in the coming weeks and will tell it to take that step and build on that. A new GP contract is crucial but I have to respect a framework agreement with the IMO and show willingness to ensure the voice of the NAGP and its members is heard. I am trying to get that balance right in an appropriate manner that enables us to deliver a new GP contract.

Deputy Billy Kelleher

Who is resisting putting them in the same room?

Deputy Simon Harris

All these people are terribly grown up. It is not my job to adjudicate on different people's motives, memberships or-----

Deputy Billy Kelleher

Is there Department of Health resistance to it?

Deputy Simon Harris

No. The Department of Health, in my view, in a time of great industrial relations uncertainty, when everybody is trying to bring industrial peace, must be respectful of a signed agreement with the IMO regarding negotiations on the GP contract. However, we must also work out a mechanism whereby we make sure all GPs have a voice in the process. I would argue that if one considers my comments on this issue and indeed my actions, specifically a willingness to have formal consultative status bestowed on the NAGP as a building block, it reflects very favourably on the position taken by my predecessors regarding the NAGP. This is a step on a road and it should be taken in the interests of patients. The GPs I meet all around the country say they are members of both bodies. I want to make sure people's voices are heard but I must operate within the constraints of a framework agreement and another body that also wants to be involved. This is the best model I can come up with, on the advice of my officials, to make sure we fulfil the various competing priorities in this regard.

Regarding the issue of the national children's hospital, to which Deputy Kelleher referred, we have heard much in this committee and others about its location. It is important to say that I have statements of support in front of me in respect of St. James's Hospital and getting on with co-locating with that hospital. The statements are signed by the group clinical director of the Children's Hospital Group; the clinical director of the National Children's Hospital in Tallaght; the chief director of nursing of the Children's Hospital Group; the clinical director of Our Lady's Children's Hospital, Crumlin; the clinical director of Temple Street Children's University Hospital; the director of nursing of the National Children's Hospital at Tallaght Hospital; the director of nursing at Temple Street Children's University Hospital; and the director of nursing at Our Lady's Children's Hospital, Crumlin. I have seen the statement of support from the three professors of paediatrics in the three Dublin universities, who collectively support the campus at St. James's. They are Professor Owen Smith of UCD, Eleanor Molloy of TCD and Alf Nicholson of the RCSI group. Therefore, while the debate on the site has been ongoing for so long, many a clinician in this country has put pen to paper to endorse it. I agree with Deputy Kelleher that they need to get on with the project as quickly as possible. This is exactly what I want to do. I want to be able to let every member of the Houses and, much more importantly, every taxpayer and parent in this country see exactly the cost behind this hospital. However, I ask people to take on board the comments I have made today on the fact that the €650 million figure and the other figures in the media do not compare apples with apples. When I receive the definite business case, I will do my own due diligence. I will bring it to Cabinet and present it to the Houses and to members of this committee.

I wish to assure Deputy Kelleher regarding the capital plan. Yes, priorities in the plan need to align with the priorities of the health service and the plans the health service has for the delivery of a number of its strategies. I agree with the Deputy in this regard.

Most of Deputy O'Connell's questions were for the HSE. My colleague, the Minister of State, Deputy Corcoran Kennedy, is not here to respond to the issue raised of folic acid. Deputy O'Connell is probably aware that safefood ran an award-winning campaign called "Babies Know the Facts About Folic" in 2015, the evaluation of which is under way to try to inform a new campaign for 2017. I take the point Deputy O'Connell makes and I will ask Deputy Corcoran Kennedy to revert to her directly. The 2015 campaign was designed to address the increasing rate of neural tube defects and aimed to communicate the need for all sexually active women to take folic acid daily, whether or not they are planning a pregnancy.

Deputy Kate O'Connell

As the Minister knows, I am a community pharmacist. My concern is that I do not believe that campaign worked. I know we are to have a review of it but - at the risk of boring the members - I said here last week that I have worked in areas from the most deprived to the most affluent and have often seen very well-educated people just taking random multi-vitamins. The issue is not being addressed but is so easily fixable. I see it as a priority that has a very simple solution.

Deputy Simon Harris

I agree with the Deputy and bow to her professional knowledge in this regard. I will ask the Minister of State, Deputy Corcoran Kennedy, to liaise with her directly on the matter.

I am sure Deputy Margaret Murphy O'Mahony is a WhatsApp fan. I thank her for her question. I thought I had walked into the wrong meeting when she was discussing WhatsApp, leadership contests and so on. While one cannot account for certain colleagues' sense of humour or lack thereof, I assure her that my priority, regardless of any decisions made in my party or by me personally, remains. I am doing this job to the very best of my ability and working with Members across the Houses to do so. I hope both the Secretary General and director general will continue to see that in my work rate in the Department of Health and my interactions with the HSE.

Regarding Bantry General Hospital, an issue Deputy Murphy O'Mahony has raised with me on the floor of the Dáil, I make the point that there must be a bright future for our smaller hospitals. We must consider utilising all capacity within the health service. While there will always be certain specialties and issues of acuity that are best dealt with in larger hospitals and centres of excellence, using every piece of capacity must be what we are about. The hospital group structure affords this opportunity to explore how best to use it.

I am glad Deputy Murphy O'Mahony raised the issue of what we do about a part of the country which, no matter how a post is advertised or a GP sought, still finds itself without a GP. Again, I know the Chairman was - and indeed still is - very much involved in the No Doctor No Village campaign before he was elected to the Dáil and I know this issue is very strongly felt in parts of rural Ireland. I contend, though, that it is also an issue in areas of urban deprivation, whereby the business model of being a self-employed general practitioner may never quite stack up but the societal and health needs of a doctor and a medical practice in such an area is compelling. This is why, as part of the GP contract negotiations, we will consider salaried GPs and how one supports funding GPs where the business model does not work.

I have heard about the issue of nurses and the feedback on the NMBI and registration times from a number of people and I am engaging on the matter. I want to hear from the NMBI about this.

Deputy Murphy O'Mahony asked the director general of the HSE to keep in touch with her regarding the issue of Respreeza. I am sure he will. He was only out of the room momentarily. From my perspective, there are two parts to this. The first part is that we need to follow the law of the land on any drug, and the law of the land says the drugs committee considers something and the HSE makes then a decision. The drugs committee is made up of clinicians. It is important clinicians make decisions and not Ministers. The law, since 2013, is that the HSE leadership team makes a decision whether to reimburse. Sometimes it will make the decision to reimburse but will not have the money and will ask the Minister what he or she will is going to do about it. That is the legal process. The second part - I do not ever intend to stop saying this as long as I am in this job - is that the issue of drug companies and how they engage with the taxpayer and the patient through their representatives is very important. We cannot have price-gouging. I am not talking specifically about Respreeza. No matter how big the health budget is, it will always be a limited pot, very difficult decisions will always need to be made and we need to continually, as public representatives, make sure in our representations that the pressure is not all one way. The pressure should not be merely on the HSE to provide funding; the pressure must also be on the drugs company, and the question of what it is going to do must be asked. I suggest that sometimes on the floor of the Dáil Chamber, while people for absolutely the best reasons rise to ask about the availability of a drug, this only ends up inadvertently increasing the price the drug company demands for the drug. This is a challenge we must all balance.

I will ask the HSE to respond to Deputy Durkan's technical questions about the research being carried out and the kinds of patients turning up. I am asking these questions because if we are to break this vicious cycle of overcrowding which, as the Deputy said, has been ongoing for a decade or more, we must get to the bottom of it. For what it is worth, though, I think we need to consider how we decouple our emergency department attendances from our elective procedures. Currently, when one gets really busy, it directly impacts on the ability to do the other. This leads to waiting lists. Therefore, as part of the capital plan, we should consider how we can increase capacity to carry out more elective procedures, separate and distinct to the acute hospital. I was in Galway the other day. The people of Galway rightly want a new emergency department. The current situation is appalling. However, they also ask whether another site, Merlin Park, can be used to carry out some of their elective procedures. This is the way we need the health service to think.

I agree with Deputy Durkan's comments on the Single Market and drugs. I raised this with the European health commissioner when I met him in Brussels about three weeks ago and I have already signalled to him my intention to put this on the agenda for the next meeting of EU health Ministers.

Industry is very organised in terms of collaborating but member states are not. As a result, our patients and taxpayers are suffering somewhat. The Minister of State, Deputy Finian McGrath, will respond to the questions relevant to his remit.

Deputy Finian McGrath

I thank members for their questions on disability issues. I also thank and commend my colleagues on their support in regard to the issue. Disability is not just a health issue. It is a broader issue for all of us and we should all focus on it. Last Monday, on a visit to the Brothers of Charity Services in Galway, I visited a centre where I met a group of small business owners who a year ago set themselves a target of creating 100 new real jobs for people with disabilities under the EmployAbility project of the Department of Social Protection. On that occasion, I was invited to open an envelope and read out the result of their effort. The result was that they had created 101 new jobs in small businesses across Galway. As I said, disability is an issue that crosses all Departments and every aspect of all of our lives.

Deputy Kate O'Connell asked about expenditure on disability services under this year's social care disability service plan. It is important that everybody would be aware, particularly my colleagues in opposition, that under budget 2017, €1.688 billion will be spent on disability services, which is an increase of 6%. In regard to the Deputy's question on where this money will be spent, the spend will be on 8,400 residential places, 182 respite over-nights, 1.4 million personal assistant hours for 2,400 people, 24,800 day places, 41,000 day respite sessions and 2.75 million home support hours for 7,500 people. These are the key aspects of the plan. Spending on emergency cases in 2017 will be €16.2 million in support of 395 people and 185 emergency residential places. Under the new home support scheme, home respite for emergency cases is being increased to 210. In other words, rather than people going into respite care outside of their homes the respite care will be provided in the home, giving parents and so on a break.

In regard to new directions and school leavers, major progress has been made in respect of 18 year olds and €10 million has been provided to support 1,500 18 year olds in day service supports. There has been major progress in this area in the last 12 months. In a lot of areas, 100% of the issues have been resolved and in others 93% to 97% of the issues have been resolved. In terms of the move from congregated settings, €100 million in capital funding has been provided for the next five years, which equates to €20 million per annum. This means that this year, 223 people will be moved to community living and 50 additional homes will be purchased. That is how money allocated to the disabilities area is being spent. We need to ensure that it is spent wisely. I have a vision and a plan for this area. There is also a strategy in place for the disabilities area. We need to ensure the focus is on the person with the disability.

Deputy O'Connell also asked about the "Grace" case. The Government is committed to the establishment of a commission of inquiry. There will be no fudge on this issue. I was annoyed by some of the commentary of Members of the Oireachtas and others in the media on this issue. That commentary is wrong. We are all committed to Grace and any other victim of alleged sexual abuse. I intend to get the truth, justice and action. Some actions have already commenced even though the commission of inquiry has not yet commenced. The Conal Devine report and Resilience Ireland report addressed this issue. These reports were then examined by Mr. Conor Dignam, who then drafted the terms of reference for the inquiry. I recently cleared those terms of reference with the HSE. The HSE intends to publish the Resilience Ireland report and Conal Devine report next Tuesday. The terms of reference for the inquiry are currently being examined by the Attorney General's office. As I said, there will be no fudging on this issue. In the meantime, a number of schemes are in place around safeguarding vulnerable adults in institutions. We also have a national policy on safeguarding vulnerable persons at risk of abuse, a top-class safeguarding committee chaired by Professor Patricia Rickard-Clarke and a confidential recipient, Leigh Gath. There is a lot of working going on in regard to the protection of people with disabilities.

Deputy Margaret Murphy O'Mahony raised the two very important issues of delays in assessments and the lack of therapies. I share the Deputy's concerns. There has been a major reconfiguration of HSE disabilities services over the last number of years. So far, €8 million in funding has been made available to support 200 additional posts. Prior to Christmas, an additional €4 million was provided to support the filling of the 75 vacant therapy posts. There are some gaps in the system and some problems around recruitment of staff in particular areas, including Dublin. I acknowledge that, as identified by the Deputy, there are gaps in Cork, Waterford and Offaly. We need to do more. I am working closely with the HSE and the Department to ensure that full implementation of progressing disability services takes place by the end of 2017.

On the UN convention, this issue has moved on a stage as well. The Disability (Miscellaneous Provisions) Bill 2016 was brought to Cabinet before Christmas and Second Stage of the Bill commenced just after Christmas. I had expected the Second Stage debate to conclude last week but because of other events of which Members will be aware, there were changes to the Dáil schedule. That debate is scheduled to take place later tonight such that I hope the Bill can progress to the next Stage. We are determined to ratify the UN convention but we want to do it properly. We are way ahead of some of the other countries that have already ratified it in that we already have in place a lot of the services which they propose to put in place. As I said, we will ratify the convention because it is important that we do so. The delay in this regard is related in part to the issues which arose around the Assisted Decision-Making (Capacity) Act 2015 and issues around deprivation of liberty. I appeal to colleagues to work with me to ensure conclusion of the Second Stage debate on the Bill tonight such that we can progress it through Committee Stage and enacted as soon as possible. Much of what happens in regard to ratification of the convention is dependent on members. As Minister of State, I am determined to ensure that we ratify it.

I would like to clarify a point I made earlier regarding the terms of reference for the inquiry. I have cleared the terms of reference with the Department of Health, not the HSE. I hope I have responded to all of the questions relevant to my remit.

Mr. Tony O'Brien

I will ask Mr. Woods to respond to Deputy Durkan's question on the issue of demand and capacity and to Deputy O'Connell's question regarding the definition of a portable solution.

On private health insurance, the issue raised by Deputy Kelleher is an important one. However, it is important to bear in mind that although the level of utilisation of private health insurance has fluctuated little over the last decade, it currently stands at around 50% of the population. The private health care sector in Ireland is not big enough to meet the demands for services of that proportion of a population. In addition, there are a wide range of services that are best provided currently from the multidisciplinary university level teaching hospitals that are in the public sector, particularly trauma and some major interventions. In the context of what is happening now, patients who present with private health insurance and who consent to so do generate a bill to their private health insurer.

In the past, whether a bill could be raised was entirely dependent on the fairly antiquated and out-of-date designated beds process. This meant that in many instances the public health system was not recouping any income for patients who were being treated privately. We have gone from one clearly unsatisfactory situation to another. The notion that all privately-insured patients could and should be directed to private hospitals is not a realistic option at present. The private hospital system is simply too small.

Deputy Billy Kelleher

Clinically, certain patients have to be treated in a public hospital. However, many electives are being done in public hospitals when it could be argued they could be done in private hospitals.

Mr. Tony O'Brien

One could. We have some knowledge of this from our attempts to use private hospitals. They are not currently awash with unused capacity. Certainly the initiative this year, which will be managed by the NTPF, is specifically to use such-----

Deputy Billy Kelleher

Public hospitals are not exactly awash with capacity either.

Mr. Tony O'Brien

I am not saying they are. I am saying it is a very important issue.

Deputy Billy Kelleher

We should keep an eye on it. There are competing interests in it. There are budgetary matters, consultants and many things.

Mr. Jim Breslin

Deputy Kelleher made a point that the legislation allowing charging to take place regardless of whether a patient is in a designated bed or not was done for budgetary purposes. The Deputy is correct in what he says. However, I do not know that it was done to incentivise a growth in private practice. It was done for budgetary purposes because, as Mr. O'Brien said, there were private patients in public hospitals whose consultants were getting a fee for treating them on a private basis, but the public hospitals were getting nothing. The implication of that was the public system was subsidising the private one. The policy decision was made to try to remove that subsidy, and have the private patients bear the cost of their treatment in the public hospital. Private health insurers sometimes equate that with whether one gets a private bed or not but the bed is the cheapest part of one's stay in hospital and it is all the things done to one that account for the majority of expense. At present private patients in a public hospital, regardless of their position in that hospital, is being charged for the cost of their treatment, or at least an approximation of the cost of the treatment. That was done to remove a subsidy and there was a good bit of policy work done around that. That is a separate issue as to whether private patients should continue in public hospitals in the future. That is a big call. I think that is for the Committee on the Future of Healthcare to decide on, and to examine the repercussions of that. The policy rationale for the legislation was to remove a subsidy. I do not believe it was to try to incentivise a growth in private practice. As the Minister said, we can do a report on that.

Deputy Billy Kelleher

I am not advancing that the policy was to incentivise. It was a budgetary matter. However, the knock-on effect is incentivisation for hospital management to look at private patients in a whole new light.

Mr. Jim Breslin

Hospital managers do not make admission decisions; clinicians do, so arguably the situation has not changed.

Deputy Billy Kelleher

It is in the consultants' interest as well if they are being paid. All I am asking is that it would be monitored independently and evaluated to see whether or not there is-----

Deputy Simon Harris

We can look at the work in the Department and report back to the Deputy.

Mr. Tony O'Brien

In regard to the reports which we have promised on both Respreeza and staffing, they will come to the committee via the clerk for the benefit of all members.

I will ask Mr. Woods to respond to the questions on portable solutions and demand capacity issues.

Mr. Liam Woods

Deputy Kate O'Connell has correctly identified that portable solutions are not a strategic response to the medium-term needs of the population for health service provision. There are two types of solutions for which we have tendered that would allow hospitals and hospital groups to move more quickly than potentially bricks and mortar-type solutions. One is a solution where a third party provider may arrive on site, bring a facility and operate that within the public environment. The other is where a facility is provided and the staff come from within the current health sector employment or through some growth in that. The intention is simply to provide a short-term flexible option while the longer-term discussions around capacity are under way. It is not intended to replace or in any way supplant that and, indeed, it would not have that capacity. However, there are a small number of interesting proposals that hospitals have looked at that would give them protected scheduled care and, in particular, protected day care space. There is such a proposal for Merlin Park in Galway. We want to try to create some central support for that kind of initiative. The intention of the framework agreement was to leave the groups in a place where they could flexibly consider that as part of response to both waiting list and demand.

There is a strong place for mathematics in health, as the Deputy rightly implies. We have population health doctors and epidemiologists whose job it is to study the nature of demand and the changing nature of demand. We have commissioned and received reports on trends in emergency work, in elective work and, indeed, the source of admissions, that is, the percentage of people that may come through a GP or by direct walk-in. Around 47% of people nationally go through a GP first, but there is a lot of variation. In Dublin, only 24% of people go to a GP first, whereas in Letterkenny maybe 54% would go to a GP and in Cork, it is 47 %. The variation is primarily driven by proximity to service, which is well understood. The age cohort and triage categories of people presenting are also well understood.

Deputy Bernard J. Durkan

It may be well understood but how far down the road have we gone in terms of transmitting the understanding into dealing with the issue? If someone dealing with the public identifies a 20% deficiency in the degree to which the service can be provided, how does one transmit that into dealing with it? It is a 25% deficiency in the costs and the layout and the facilities that are there. That is where mathematics comes into it.

Mr. Liam Woods

At the moment that work is feeding into capacity deliberations, as the Deputy describes. The Director General referred to the need to look at models of care, and where care can best be provided. It may be possible in the future to provide the vast bulk of services such as ophthalmology in the community. Work is under way doing the kind of modelling the Deputy refers to. The use of that data is to bring it from a theoretical, mathematical place to identifying the sort of service we need, and the volumes, and then feed that into the capacity work that is currently under way. It informs the plan.

Deputy Bernard J. Durkan

When can we expect that?

Mr. Liam Woods

The wider capacity study is a matter for the Department of Health. As was referred to earlier, it is already commencing. I would expect that will be this year, but colleagues in the Department may have an answer to that.

We also look at what is happening in elective surgery and understand those trends. That feeds into the same process in terms of understanding demand and capacity.

Deputy Bernard J. Durkan

Is this a new initiative?

Mr. Liam Woods

Our public health doctors have understood what is happening within the system for some long time. Using it to project service delivery is quite normal. It was the basis of input into the maternity strategy, the cancer strategy and cardiac services. Clinical planning, along with demographic planning, is a key input to planning any service, and has contributed to the planning of a number of services that have successfully developed. In terms of the Deputy's point on trolleys, and the wider need to access scheduled care, the key input now is to use this kind of information as part of capacity-planning for the future.

Mr. Tony O'Brien

At the moment, apart from nought to 18 year olds, a diagnosis of cancer does not confer automatic eligibility for a medical card. Following events of 2014, we have had a series of reports from a clinical advisory group. We are just working through the last of those reports which will, probably in parallel with the extension of eligibility for the domiciliary care allowance and subject to a dialogue with the Department, Ministers and probably Government, will create a context in which we move away from the financially-based means test to a more needs-based approach to the granting of discretionary cards. I hope that the issue of patients recently diagnosed with cancer will be dealt with through that forum.

Chairman

Being conscious of time, I am just going to move on. We have been here for three hours now.

I would like to go back to the Minister's reference to the GP contract negotiations. As he knows, the committee wrote to him following a meeting two weeks ago stating that there was a strong feeling within the committee that both groups should be given equal status and parity of esteem within those contract negotiations. The Minister has referenced the framework document again today, which seems to be an inhibiting factor in terms of allowing both groups to have equal status. This GP contract will underpin general practice for perhaps the next 20 or 30 years. It will be the central component of moving from hospital-centred care to primary-centred care and it will most likely be a GP-led primary-centred service, particularly dealing with chronic illness. If we are to have the best outcome of those contract negotiations, we feel it is essential that both groups have equal status. This is about the patient and getting him or her the best service. We need to get the best contract to give the patient the best service. In that context, will the Minister tell us the reason the framework document is inhibiting equal status for both groups? Unless both groups are involved in the negotiations, we will not get the best contract and outcome for patients.

The topic of governance has arisen in many of the committee's hearings. Will the Minister outline how the Department interacts with the HSE in terms of governance, accountability, transparency and responsibility? For instance, the maternity strategy was discussed at this committee on two occasions. Our maternity hospitals in Dublin have a mastership model of governance while our maternity structures do not have that autonomy of governance. Professor Kenny feels that if they had the same autonomy of governance in Cork as is to be found in the maternity hospitals in Dublin, which have the mastership model, they could improve the quality of service they provide to their patients, including the shortening or elimination of waiting lists. We expect clinical excellence of our clinicians, but we must also have managerial excellence from our managers. Deputy Kate O'Connell referred to doctors having an ethical responsibility to do their best. How can we ensure that our managers have the same responsibility to deliver excellent outcomes? We need a governance that is transparent and accountable. Perhaps Mr. O'Brien and the Minister would address those issues.

I call Senator John Dolan, who will be followed by Senator Keith Swanick and Senator Kieran O'Donnell.

Senator John Dolan

I thank the Minister, his team and the HSE team for the answers I received to the questions I had submitted. I had four questions. I wish to commend the Department of Health, which I think, sadly, is the only Department so far to mention its public sector duty in its statement of strategy. I consider that critical. The Department picked up on that as well in terms of the UN convention and treating those with disabilities and mental health issues on an equal basis. I underline and appreciate that point. Those are leads that could be followed by other Departments and the Minister of State, Deputy Finian McGrath, may be in a position to make that point to others as he is going along.

My first question concerned the statement of strategy, particularly where it stated that it would develop policies and proposals to promote community-based supports including innovative enhanced housing options. My question asked what kind of policies were in place and there was a pretty decent answer to it. That said, there was a lot of detail about processes and structures but there are still almost 4,000 people with disabilities on the social housing waiting list for the past four years. People might ask what this has to do with health. However, the connection between those with disabilities and health is that they are stuck in congregated settings. Men and women of 35 years and 40 years of age are living at home with their parents, which is not acceptable. These are interlinking issues. I note the comments of the Minister of State, Deputy McGrath, regarding congregated settings. However, even if more than 200 are taken out of those settings this year, the answer I received suggested that one third of the total number which, off the top of my head, I think is approximately 2,700 will be moved by 2020, but there is still another two thirds. This does not seem to me to be a priority that is being pushed but rather something that remains "in process". As I understand it, there are more than 1,000 young people aged less than 65 years in residential and nursing homes. I strongly relate that fact back to the lack of supports for people in the community and the shaving away year after year of after-supports in the community. Those are my comments. There is a huge amount of ground to be made up to get beyond having processes and strategies and to making things happen for people.

I will come back to the issue of personal assistants in a moment, because it relates to another question. The Minister of State, Deputy McGrath, made some comments on it.

My second question related to foetal anticonvulsant syndrome, FACS Forum Ireland and the drug - I will mispronounce it - valproate. Will the Minister and those from the HSE outline what has been done to enhance diagnostic process and standard operating procedures within the HSE? What has been done to improve patient safety warnings and adequate implementation of the European Medicines Agency's ruling of 2014? I want to be sensitive and measured when speaking on this issue. Parents invest all of their emotion and love in their children. There is no big deal about that - it is a fact - but they probably do not realise how much emotion and love they have until they have to deal with difficult issues and this is one of them. We have already mentioned some other issues this afternoon. A helpful response was provided, but for me it is still short on issues such as good governance and practice. I am not convinced that we have got to that point.

It would be useful at this stage if the Minister were to have a short meeting with representatives of FACS Forum Ireland to get the ball rolling and to energise those in the Department of Health and the HSE to work with them. I see the Minister's intent but I am not convinced. As a public representative, this is about being assured that good systems are in place. I am making a reference. One of the quite a number of conditions that can be caused as a result of prescribing this to women with epilepsy is neural tube defects. It is just a coincidence that it has already been mentioned. In the first paragraph, the response acknowledges strongly what is required. It goes on to state that the HSE is aware of the issues but, when we get onto the bullet points and particularly towards the final part on monitoring the effectiveness of the communications and follow up, the language used includes "could be urged", "could be repeated" "[c]onsideration of [an] opportunity to conduct" and "[s]uch collaboration could". Perhaps it is the way it is written but I am not getting a sense of urgency.

Thanks to our health services, children born today have 60, 70, 80, 90 or maybe 100 years of life ahead of them. For these children and others that could be 80 or 100 years of disability life years. It is 60 for their parents, give or take. It is not like us codgers here who may have three, four or five years on average at the end of our lifespan. This is a big ticket item for many people.

The European Facts Forum estimates that over a 30-year period there could be 270 to 360 children with developmental problems caused by Valproate. There are 100 children with malformations at birth such as neural-tube defects and cleft palate. The director of clinical genetics in Our Lady's Hospital, Professor Andrew Green, has a database indicating that there are currently 43 children with this diagnosis. It would be helpful to have a short meeting with this group. There are obviously parents involved in it, but there are a number of organisations that can help practically to start moving on the message and toolkits.

I now want to move on to the question of personal assistants. Before the last quarterly review, I said that personal assistants' hours are particularly crucial in enabling those with disabilities to live independent lives. However, no explicit reference was made to personal assistants in the statement of strategy. There were strong commitments made to independent living, however, which I am pleased to hear about. The answer has laid out a number of things that aid independent living.

This brings me to some helpful information I have been given. There is a division between personal assistants' hours and home supports. I am pleased to see that because when I was a member of the Eastern Regional Health Authority, 15 years ago, we got reports that bundled everything. The Minister of State, Deputy Finian McGrath, has told us that there are 1.4 million personal assistants' hours this year for about 2,400 people. His target last year was to provide 1.3 million, yet his activity was 200,000 more than that, so let us be clear. Forgive my percentages, but there is probably 6% or 7% less provision of personal assistants' hours this year than was the outcome last year. That is on the basis that the target was 1.3 million, while the activity level was 1.5 million.

We find different numbers, but basically the same outcome, when one looks at home support hours. That tells me that there will be fewer personal assistants' hours provided this year than last year. Can someone please tell me what has changed to dampen the need for that service? For 2,400 people that works out at fewer than 600 hours per person per week, which is two hours per day. There is an extremely strong rationing of that service. We know that there is a significant unmet need.

I knew a lady for many years who passed away two years ago, and she had about 70 hours per week. They were not sliced and diced among seven or eight other people. I am not saying they did not need them but that is not the spirit of personal assistance. We will have problems until we get moving on that.

I had a straightforward question about funding for the mental health aspects of A Vision for Change. It has come to the end of its tenth year and has been a difficult period. There is probably more pressure around mental health now. It is also a co-morbidity issue for people with other conditions. They are serious matters and I am unhappy with the reassurances that have been given.

Others have referred to the Disability (Miscellaneous Provisions) Bill. I know that while the Minister of State is keen to progress the legislation, it is frustrating that events have overtaken us in recent weeks. The Minister of State said that to move it quickly to Committee Stage a lot of the process will depend on the committee. I am concerned that the Bill, as published, has dropped the word "equality" from its Title. I will not get too upset about that, other than to say that on Second Stage in the Dáil, the Minister of State said he would deal with a number of issues on Committee Stage. His Dáil colleague, Deputy Broughan, said that in his 25 years in the Oireachtas he had rarely, if ever, seen a Bill introduced by Government where a Minister stood up on Second Stage and said: "By the way, we're going to introduce a number of amendments on Committee Stage." There are a number of serious matters that nobody has had sight of and which will come in on Committee State. Beyond labouring the point too much - and I say this with absolute respect - for people with disabilities it has gone beyond another timeline commitment.

The State promised to sign the international convention and ratify it. Ratification is a solemn international promise that the Government will get on its bike and get on with the work. I met my European colleagues at the weekend and know that we are well ahead of quite a number of European and other countries. If there is honesty to the Irish approach, the Government should say it will put a decent, cross-departmental package in place for the next budget. There are a lot of issues involved, including employment, health and social protection. That would give people confidence that it is not a stalling tactic, although I am not suggesting it is. People do not have that confidence now. That would put Ireland back on the front foot and start things moving.

Senator Keith Swanick

I will be concise in my contributions because I understand that important parliamentary party meetings are happening in half an hour. I was absent earlier because there were statements on symphysiotomy in the Seanad, so some of my points may already have been touched on.

I thank the Minister of State and the HSE team for answering some of the questions I submitted. Things have moved on concerning scoliosis and I welcome that. I understand that the St. Senan's Hospital campus in Enniscorthy has been taken off the market and may be used as a third-level campus.

I want to refer briefly to the Alpha-1 anti-trypsin deficiency situation. As the committee knows, some 350 people suffer from that terrible disease. People literally cannot catch their breath and are suffering from chronic obstructive pulmonary disease or COPD. We all need to redouble our efforts and have a moral responsibility to resolve this matter. The US Food and Drug Administration has approved the drug Respreeza, as has the European Medicines Agency. It is already available in Italy, France, Germany, the Czech Republic, Austria, the Netherlands and Spain.

I also wish to comment briefly on the GP contract. I want to clarify that before becoming a Senator I was secretary of the National Association of General Practitioners. I feel strongly that in order to have a successful outcome to this matter we need equal status. I often use this comparison - would we have had a successful Good Friday Agreement if all the stakeholders, including Sinn Féin, the UUP and the DUP, had not been around the table? I think the answer is "No".

While I respect what the Minister is saying about the formal consultative process, can he see a way to ensure that if the NAGP engages in it, equal status might be achieved as the process proceeds and before it concludes? For it to be successful, all GPs must be on a level footing. As the Chairman said, it is about patient care at the end of the day. Let us be clear that if the NAGP is not granted equal status, the medical profession will see it as a cosy cartel between the IMO and the Department. That would lead to bad feeling and perhaps the failure of the talks. I do not want that to happen. I want a good contract to come out of this. It is a contract that will be in place for many years and it is important that we have equal status and equal negotiating rights for all organisations involved.

Next, I turn briefly to the Orkambi situation. I missed this earlier on. A meeting of team leaders is to be held. Is that HSE or departmental team leaders?

Deputy Simon Harris

HSE.

Senator Keith Swanick

Fair enough. I understand the team will meet every second month. Do we have an exact timeline for when the meeting will occur? Obviously, it will result in a recommendation for Cabinet and it is important to have an exact timeline on it. Will it be next week or the week after? We saw today another passionate presentation from CF sufferers and their family members. As we know, every day counts for these people. As such, an exact timeline would be appreciated. I ask the Minister to outline it.

I brought the following matter up as a Commencement matter. It relates to the Institute of Community Health Nursing. As the Minister knows, our public health nurses do great work in our community and primary care system. Will the Minister, the Department and the HSE engage with representatives of the institute on their funding. They are being woefully underfunded now.

We have had the European health consumer index and some people place different weight on the data that comes out of that. One of the countries which has successfully managed waiting list times is Macedonia. The Minister is probably aware of this. Macedonia has reduced waiting times to approximately six months with a simple online live system. GPs can go online in the consultation with the patient sitting there and access consultants' diaries, see what physicians have vacancies and refer appropriately. That system can also be used for diagnostic scans. Can we look at adopting, reviewing or investigating such a system?

To recap, my main question is on equal status for the NAGP and the possibility of the medical profession perceiving a cosy cartel. I also asked for a finite timeline on Orkambi.

Senator Kieran O'Donnell

I thank the Chairman for facilitating me as a non-member. I have two items to bring up, one of which is specific to Limerick and one of which is general. My question on Limerick refers to the new state-of-the-art accident and emergency department at University Hospital Limerick and is directed to Mr. O'Brien and Mr. Woods of the HSE and to the Minister. A commitment was given that the new accident and emergency department would be opened this coming March and that was deferred to May. We have seen in the most recent national service plan that there is talk of it now being October. I have spoken to the HSE and the Minister about this. It is critical that we stick to the May timeline. Recruitment is under way and the unit is due to be completed and fitted out over the next month.

The people of Limerick have waited a long time for this. It occurs against the backdrop of a reconfiguration which took place in 2009 when Ennis, Nenagh and St. John's accident and emergency departments were closed over a period with a commitment to establish a new department. Included in the reconfiguration plan - and this is where I want to compliment the HSE - was a proposal to collocate a 138-bed hospital at the University Hospital Limerick site. That did not come to pass.

In the last month, however, the acute hospital unit and, more particularly, Mr. Woods have approved the design phase for a 96-bed acute unit at the University Hospital Limerick site, adjacent to the new accident and emergency unit. I welcome that. The commitment I want today from Mr. O'Brien, Mr. Woods and the Minister is that if the accident and emergency department is ready in May, it will be funded to be opened in May.

The second issue with which I want to deal has already been touched on by a number of speakers. I have a personal interest in cystic fibrosis. My wife has a niece who is a sufferer and is a candidate for Orkambi. I know the significance of this. Mr. O'Brien has stated that the national drugs committee is not recommending this.

Deputy Simon Harris

That is a different drug.

Senator Kieran O'Donnell

I apologise. The Minister might give an indication as to where Orkambi is at and set out the timeframe. Modern medicine makes a difference. I understand the discussions with the drug company and am not going there, but it is important to get some sort of clarity around the area.

I want a commitment today to the new accident and emergency department in Limerick. If it is ready to be opened in May, I ask that it is funded and supported so that it is operational in that same month. I want that commitment from both the HSE and the Minister.

Deputy Simon Harris

Senator O'Donnell is constantly and understandably on my case about the emergency department in Limerick because it is a very important issue in Limerick. I visited the current emergency department with the Senator and it is wholly unfit for purpose. It would be a cause of great frustration to see a brand-new ED sitting idle while people worked in extraordinarily difficult environments. Patients are in a very difficult environment. The commitment I have given Senator O'Donnell, which I intend to honour, is that we will work together to ensure we can open that when it is ready. It is something I want to work with the HSE on. It is a small gap that we need to bridge and I am committed to working with the Senator and the HSE to see we do.

Senator Kieran O'Donnell

If it is ready in May, will it be funded to be opened in May?

Deputy Simon Harris

I am working towards ensuring that we can open the ED when it is fully ready to be opened. Senators Swanick and O'Donnell and many other colleagues brought up the issue of Orkambi today. The 2013 Act is very clear that the HSE leadership team has to make a decision to reimburse or not and then there is a middle one where we reimburse but we have no money. That is a matter on which the HSE is now adjudicating. I feel strongly, as does the HSE, that the process must be reaching a conclusion at this stage and that it is vital to patients to create certainty as quickly as possible. I have been highly critical of the drugs company in the past but I do not want to go there now, as Senator O'Donnell says, because I want to see this process brought to an end. I do not want to see patients waiting anxiously any longer. I want to bring forward an answer, whatever that answer may be, as quickly as possible. I hope to be able to do that in the coming short weeks. That is as specific as I can be this afternoon.

Senator Keith Swanick

That will be the recommendation to Government.

Deputy Simon Harris

That is if a recommendation is necessary. I do not want to pre-empt the decision of the HSE, but I hope to be able to give cystic fibrosis patients in this country a definitive answer on this situation in the next few weeks.

I will certainly look at the suggestion regarding Macedonia. We need all the suggestions we can get on this and if there is good practice, we will look at it. I would be happy to meet with the Institute of Community Health Nursing. The Senator raised the matter with me in the Seanad. On the issue of Respreeza, the director general has committed to coming back to the committee with an update. My understanding is that the drugs group, which is a group of clinicians, did not recommend reimbursement, but we will come back with more detail to see where we are at there. I appeal to the drugs company in relation to those patients who are still on the drug. There is no need in the wide earthly world to end access to the drug for those patients. The two issues should be completely decoupled.

Senator Dolan asked about the FACS forum. It would be appropriate for me to ask the HPRA to meet the FACS forum. I have no difficulty in meeting with the forum also, but the other meeting might happen in advance.

Some of the issues Senator Dolan raised, specifically regarding labelling, warnings and patient information, relate to the Health Products Regulatory Authority, HPRA. I will ask the HPRA to meet with the FACS Forum. Perhaps the Senator will correspond with me about that and I will ensure-----

Senator John Dolan

Will the Minister also confirm that he is happy to meet it?

Deputy Simon Harris

I am happy to meet it as well. With regard to A Vision for Change, my colleague, the Minister of State, Deputy Helen McEntee, is taking care of that. A successor document will be developed which will complete the process of modernising mental health services and effectively promoting mental health. It is envisaged that this successor policy will include detailed implementation arrangements - implementation being very important - underpinned by a multi-annual investment plan which will inform the allocation of resources in future years. The Department has now awarded the contract for the review of A Vision for Change and an analysis of international evidence and best practice in the development of mental health services, including a review of the current delivery of services in this country. This review will provide evidence to determine the policy direction for a revision and a successor to A Vision for Change. The review will also have regard to both human rights and health and well-being objectives. An oversight committee will be established within three months of completion of the review to oversee the development of a new policy based on the outcome of the expert review.

The rest of the issues are matters for the Minister of State, Deputy Finian McGrath, with the exception of the very important matter of the GP contract. Let me try to be constructive in this regard. I want to bring all parties with us, but the people I and GPs are most concerned about are the people I work for, the patients. We need a new GP contract. The GPs need one, as do I, the Department and the HSE. Primary care needs it too, because we cannot get to that without it. To clarify, I have no intention of this process resulting in a static document at the end which becomes the GP contract for another 30 years when we will return to look at it again. I see this as an evolving process. The engagement on the contract is under way under the framework agreement that is in place with the IMO. It is not an agreement I put in place but an agreement that has been in place between the Department and a long-established trade union, which has been accustomed over many years to that role. In addition, let us do something that has never been done previously by any of my predecessors, which is engage with the NAGP in a formal consultative role, and let that process work its way through.

I have met the NAGP and I will meet it again. I think very highly of many people in the NAGP and of their constructive approach to these issues. However, at this stage my message must be let us get on with it. I do not believe any one or two organisations should be able to have a veto or stay on the process. I have tried to put in place a process that is more inclusive than any other. I want a contract that has the acceptance of both organisations. We must get on with it. I appeal to both organisations to play a constructive role in the various processes they have available to them. I expect to have further engagement with the NAGP on this matter.

Chairman

The framework document appears to be the inhibiting factor in allowing both groups to be viewed with equal status. What is the inhibiting factor in the framework document?

Deputy Simon Harris

The framework document commits the Department of Health, and therefore the HSE, to engaging on GP contracts with the IMO. Long before my arrival, the Department of Health had a long-established history of negotiating with the trade union. Senator Swanick referred to the peace process in Northern Ireland. I hope we do not need a peace process for GP organisations here. Some GPs have decided to set up another organisation. It is a fine organisation with fine members. Many of them whom I know and have met wish to play a constructive role. I would like to have one GP organisation in order that we could get on with it, but that is not the situation. I am doing my best to try to create a hybrid model that enables both organisations to have a voice in the process. I ask both organisations to recognise that this has not been the position previously. It was not the position regarding free GP care for children under six years of age and it was not the position on the roll-out of the vaccination programme to new babies. This is a new role for the NAGP. Senator Swanick asked about future engagement, future roles and it not being a static document. Let us see where the process brings us. Let us try to get results from this process and see if that can be built on into the future.

Regarding the national maternity strategy, masterships and so forth, I had a good meeting with Professor Kenny and her colleagues in Cork University Maternity Hospital, CUMH, which I mentioned earlier. They have strong views on the importance of clinical autonomy, ring-fenced budgets and so forth. I have asked Professor John Higgins of the South-South West hospital group, and Mr. Kilian McGrane, the new director of the national women and infants health programme, to report back to me on the range of issues that were brought up at that meeting. The national maternity strategy refers to such structures, including masterships, as evolving over time and says that no single model fits all, but legitimate issues are being highlighted by Professor Kenny and her colleagues.

My final point relates to governance. It is fair to say that we must bring a degree of certainty to the governance structures relating to the HSE, the Department and the Minister. It is not fair on any of that triumvirate so far. We had a situation where the HSE had a board. That board was abolished with a view to the HSE being abolished. The HSE is still functioning but there is no board. I hope that the Committee on the Future of Healthcare will put this issue to rest once and for all. People working extraordinarily hard in our health service day and night have a right to certainty about their future structure and how they will continue to make a contribution to the positive development of the health service. If the Committee on the Future of Healthcare reports in April, which is the deadline, then by the summer we will begin to have a sense of the direction of travel in terms of answering the important question the Chairman raised regarding governance, accountability, roles and responsibilities. We would all serve the development of our health service well if we could answer that question by the summer.

Deputy Finian McGrath

First, I accept the point about public duty across all the Departments. I strongly stress that we all have a public and civic duty in respect of disabilities. All Departments have to take responsibility in that regard. I have been monitoring the Departments over the past seven or eight months and some of them have an excellent track record in including people with disabilities and also in progressing them. For example, the Departments of Arts, Heritage, Regional, Rural and Gaeltacht Affairs, the Department of Social Protection and the Department of Health have an excellent record in terms of their vision and strategy. They are listening to people with disabilities. I consider them examples of good practice. To take a simple example involving the arts and the disabilities sectors, there is a huge movement in the disability sector towards involvement with the arts. The funding from the State is not coming from the Department of Health but through the Arts Council. There is much radical change taking place and many examples of good practice. The same is happening with employment too. Some Departments have an excellent record. All Departments have a target of 3%, but I am asking them to try to get it up to 6%. Already, some Departments and sections of public services are up to 3.6% and 3.7% in terms of employing people with disabilities. These developments are happening.

The housing issue mentioned by Senator Dolan is very important and we must deal with it. I have made many detailed representations to the Minister for Housing, Planning, Community and Local Government, Deputy Coveney. I have visited many community housing projects, and I intend to develop that. The Senator is right that we need more social and affordable housing for people with disabilities and we must ensure they are included in the housing plans. My objective is to ensure that happens.

Regarding the question about personal assistants, I accept there was some confusion around the time of the budget and the launch of the services. However, we should consider what happened in 2016. In the national service plan for 2016 the HSE priority was to provide 1.3 million hours of personal assistant services. However, it exceeded expected activity level for personal assistant hours by approximately 200,000 hours. In 2017, the HSE expects to deliver 1.4 million personal assistant hours, which is an increase of 100,000 hours on the 2016 target, to 2,357 adults with a physical or sensory disability. In the HSE's national service plan for 2016 the priority was to provide 2.6 million hours to more than 7,300 people with disabilities. The actual number of home supports provided in 2016 is very important. In the national service plan for 2017, the executive expects to deliver 2.75 million home support hours to more than 7,400 people with disability. This is an increase of 150,000 hours over last year's target. This reflects the responsive nature of personal home assistant support services.

With regard to the actions taken by the Department of Health to support independent living, I am working closely with the Department on this.

We have set up the task force on personalised budgets. This will give people with disabilities more control over the budgets and, I hope, more personal assistance hours as well. I know this will not affect all members of the disability community but it will affect between 8% and 11% of them.

Senator Dolan made a point about shaving. I am keen to point out strongly that there will be no shaving of disability services. The idea is to invest and reform. That is my plan for the coming years.

Senator John Dolan

I have no wish to delay people. The Minister of State has just read out two of the paragraphs that came to me in the answer to my question. The target of 1.3 million hours in 2016 was exceeded by 200,000. Unless my arithmetic is way off, the figure comes to 1.5 million hours. The Minister of State has confirmed that 1.4 million hours are available this year. That is 100,000 more than budgeted for last year but 100,000 less than the activity from last year. In itself, that is shaving. That is approximately the same amount of shaving as the overall increase in the disability budget the Minister of State adverted to for this year. Anyone can look at the figures. Unless my arithmetic is wrong, it means that 6%, 7% or 8% is gone off the activity level from last year. The target at the beginning of the year was 1.3 million hours but it turned out to be 1.5 million. This year, the service is planning to provide 1.4 million hours, which is 100,000 hours less than the provision for last year. It is ironic that this is happening to a service that is so central to people. The same is happening with home supports; at least the percentages are the same in the drop.

My point is proved by the answers I have received. There continues to be shaving of important community services for people with disabilities. Is it any wonder that young people with disabilities - these are people under 65 years of age - are going in to nursing homes and being subject to signing up to the fair deal scheme? This is going on. This is a fact.

Deputy Finian McGrath

There is absolutely no way Senator Dolan can claim shaving in respect of services for people with disabilities. I have said that social care funding has been subject to an increase of 6% in the budget. I have pointed out strongly that the budget for 2017 is €1.688 billion. That is accepted by all.

I will come back to the committee with a more detailed breakdown and I will prove it to the committee clearly. The reality is that in 2017 there has been an increase of 150,000 hours over the targets for last year. That is my figure and it is the figure I am operating from.

Senator John Dolan

The figure is 100,000 hours less than what was actually delivered to people.

Deputy Finian McGrath

The figure is 150,000 over last year's target.

Senator John Dolan

A total of 100,000 hours are not available this year to people throughout the county who got those hours last year. Let us be clear about it-----

Deputy Finian McGrath

I am clear about it.

Senator John Dolan

They were not getting a king's ransom of a service. The service is already significantly underfunded.

Deputy Finian McGrath

I take Senator Dolan's point, but let us get this right.

Senator John Dolan

There is less this year than last year.

Deputy Finian McGrath

Of course I accept the Senator's point; we have to do it every year. My colleagues in the HSE and the Department of Health push strongly for more personal assistance hours. I will come back to the committee with more detail on the breakdown and the figures. I am saying there is an increase of 150,000 hours over last year's target. That is my position.

Deputy Simon Harris

I wish to make another point. Senator Dolan reminded me of the point when he referred to the fair deal scheme. One of the most important things we will have to do this year relates to the area of the Minister of State, Deputy McEntee, who is working on this with the Minister of State, Deputy McGrath. They will be trying to move to the statutory scheme for home care and home help. Senator Dolan is correct. I have met families and people in the past-----

Senator John Dolan

That is a good way of solving it.

Deputy Simon Harris

I think it is a significant option. If we are telling people under the age of 65 years – it is happening in the country today – especially those with disabilities, that the only statutory option is to go into a nursing home, then that is not acceptable. We should try to create another pathway. It would not be an exact replica of the fair deal scheme but it could be a similar type of scheme for people to avail of services in their home. We will launch the consultation process on this shortly and I would welcome the input of committee members.

Deputy Finian McGrath

I left out my reply to one important question that Senator John Dolan raised relating to the UN convention. Ireland signed the convention in 2007. We are committed to signing the convention. Earlier, I referred to the barriers to the convention, the Assisted Decision-Making (Capacity) Act 2015, the deprivation of liberty issue and the reason for the delays in the Bill. I pointed out clearly during the debate that when the general scheme was approved by the previous Government, the deprivation of liberty provisions were to be advanced as Committee Stage amendments. This was a simple acknowledgement of the complexity and importance of the issue. I will also address the issue of equality when I am responding to some of my colleagues in the Dáil. I am open to ideas and amendments. We have already hinted at that when it comes to Committee Stage. When the Bill goes to Committee Stage, many of the issues raised by my colleagues in the Dáil will be included in the legislation.

Senator John Dolan

The Minister of State has more than hinted that he is open to it; he has actually been clear about it.

Chairman

I thank the Minister for Health, Deputy Simon Harris, for coming in this afternoon. I thank the Ministers of State at the Department, Deputies Marcella Corcoran Kennedy, Catherine Byrne and Finian McGrath. I thank Jim Breslin from the Department of Health. Finally, I thank Tony O'Brien, Liam Woods and Rosarii Mannion from the HSE.

The committee adjourned at 5.25 p.m. until 1.30 p.m. on Wednesday, 8 March 2017.