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Joint Committee on Health debate -
Wednesday, 28 Jun 2017

Quarterly Update on Health Issues: Discussion

The purpose of this meeting is to allow the Minister and his officials and the director general of the HSE and his staff to update this committee on key health care issues. On behalf of the committee, I welcome the Minister for Health, Deputy Simon Harris. He is accompanied by the Minister of State with special responsibility for older people, Deputy Jim Daly, who I congratulate on his appointment, by the Minister of State with special responsibility for disability issues, Deputy Finian McGrath, and by the Minister of State with special responsibility for health promotion and the national drugs strategy, Deputy Catherine Byrne. I also welcome Mr. Jim Breslin, Secretary General of the Department of Health, and Mr. Tony O'Brien, Director General of the HSE. Mr. O'Brien is accompanied by Ms Anne O'Connor, Mr. Pat Healy, Mr. Liam Woods and Ms Rosarii Mannion. They are all welcome to our quarterly meeting.

I wish to draw witnesses attention to the fact that, by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to do so, they are entitled thereafter only to 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 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 or her identifiable. I also wish to advise them 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 longstanding parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

I ask the Minister, Deputy Harris, to make his opening statement.

I thank the Chairman and the members and I am very happy to have this opportunity to appear before this committee once again. As the Chairman has outlined, I am joined today by my ministerial colleagues, Deputies Finian McGrath, Catherine Byrne and Jim Daly. I congratulate Deputies McGrath and Byrne on their re-appointment and I welcome Deputy Daly to his new role as part of the Department of Health's ministerial team. I am also joined by the Secretary General, Mr. Jim Breslin.

I am pleased on more than one level to be here again. I have said on a number of occasions that our health service needs stability in its political leadership and direction. I am very glad and honoured that I, as Minister for Health, will have the opportunity to continue to work with this committee and with all involved in the Irish health service with the common aim of trying to improve the health service for our patients and staff. Although the name in the ministerial chair is the same, I welcome the opportunity to take stock and take a fresh look at this Government’s priorities and, indeed, the Oireachtas' priorities and to refocus our efforts to make things better for patients. The Taoiseach has made it very clear in his speech to the Dáil Chamber that delivering real improvements in our health services is a key priority for this Government. I will not deny that we face challenges. Over the last period of time, however, I have learned some valuable lessons.

Perhaps one of the most encouraging lessons is that there is an absolute abundance of good people who are making a difference in our health service. I am talking about clinicians, patient groups, policy makers and, indeed, Oireachtas Members, all of whom share the same goal, namely, to develop a health service we can be proud of. We need to harness that commitment. While we need to acknowledge the range of issues and challenges we face we also need to look at our success stories, of which there are many. Just yesterday I welcomed the publication of the third annual report of the national health care quality reporting system. It is very encouraging to see the improvements in a number of areas. Hospitalisation rates, for example, have decreased substantially for both diabetes and heart failure. During the last ten years, deaths following stroke and heart attack have decreased by 28% and 40%, respectively. Cancer screening and treatment services compare favourably against other OECD countries and rates of MRSA have fallen by 66% since 2006.

We have a range of policies and strategies in place to bring about further improvements. The Healthy Ireland strategy, the maternity strategy and the eHealth strategy provide great clarity on what is required in three important areas, as do the HSE’s national clinical programmes at a more operational level. I will shortly launch a new cancer strategy and the Minister of State, Deputy Byrne, will bring a new national drugs strategy to Government following a huge amount of work and engagement with stakeholders on her part. I also intend to shortly bring proposals to Government on the development of a human tissue Bill that will encompass opt-out arrangements for organ donation. This can actually help save more lives. All of these represent real progress in improving outcomes for patients and for service users. I have also learned the value of using the available expertise to inform solutions. Importantly, the strategies I have just outlined have all been developed with both patient and service user input. Who better to inform a strategy than those who have experience and valuable input to offer?

The value of adopting a cross-sectoral approach cannot be overstated. When I say cross-sectoral I am talking about collaboration within our health services and also across Government. This is clearly evidenced in the publication of the report of the Committee on the Future of Healthcare. The near unanimity in support for the report demonstrates that we as politicians can put aside our political differences for vital issues such as the goal of delivering a world class health service. I would again like to commend the work of all members of the committee, some of whom are also members of this committee, for the time and effort they dedicated to producing the Sláintecare report.

This is a critical milestone in the history of our health service. It provides us with a solid framework and guidance for the development of health services over the next decade.

There is no doubt considerable change and transformation is required. That is why the ten year timeframe is a key strength of the report. If we want to introduce meaningful changes on a sustainable basis, we need to be realistic about the timelines required to plan and implement large scale system change in services as important as health care. We must also ensure sustained buy-in to these changes, independent of intervening electoral cycles and the composition of the Government of the day. We need a new model of integrated care, centred on comprehensive primary and community care services. That fact is undisputed by any member of the committee. Our hospital system will simply not cope with the likely levels of demand in the coming years if we continue with our current model of care. Our hospital services are already showing the signs of considerable strain in meeting growing demand for services. Health outcomes and patient experience can be much improved by developing greater services in the community and by bringing about deeper and more seamless integration across the health and social care system.

Since taking up the position of Minister over a year ago, I have been clear that we need more capacity, both physical and staffing. This problem is being experienced right across the health system. A capacity review is under way which will report later in the year. It will give us a definitive assessment of capacity requirements across the system and provide a platform for planning and delivering health services in the years ahead. We all know we will not address capacity constraints overnight but building on the additional capacity already introduced last winter, we can, through targeted capital investment, start to equip our health services for the growth in demand that is being experienced. Since last we met, the Government has approved two major capital investment decisions in health facilities in the form of the national children’s hospital and the national forensic mental health facility. We also saw the opening of the new state-of-the-art emergency department at University Hospital Limerick. There is also a concerted effort under way to recruit and retain staff. While this is not without its challenges, the development of a more attractive working environment will go hand in hand with the roll-out of system improvements.

The number of consultants has increased significantly. At the end of April 2017, there were 2,884 whole-time equivalents. This constitutes an increase of 298 since April 2014. The number of non-consultant hospital doctors has also increased significantly from 4,982 at the end of April 2014 to 6,092 at the end of April 2017 to support service delivery and the progression of compliance with the provisions of the European working time directive. This was very important. Nursing and midwifery numbers at the end of April 2017 stood at 36,549 whole-time equivalents, having increased by 625 whole-time equivalents in the 12 months from end April 2016 and by 1,870 in the three years from end April 2014. We intend to build on these increases through further recruitment and retention initiatives. The new public pay agreement, which is under consideration by union members, provides improvements in pay which I hope will make the salaries we can offer in this country more attractive. However, the committee members know that pay is not the only issue which influences the attractiveness of a working environment. A number of initiatives are being taken forward by my Department and the HSE, including the continued implementation of the recommendations of the MacCraith group and the task force on staffing and skill mix for nursing, which is beginning to yield real progress.

Significant work is also being undertaken by the office of the chief nursing officer in my Department to widen opportunities for nurses to develop career paths as advanced practitioners or working in the community as part of the development of primary care services. An essential part of any development of primary care will be the agreement of a new GP contract which we have discussed many times at this committee. I am very pleased that the next phase of discussions is under way with the aim of developing a new modernised contract to facilitate the shift within the health service away from hospital services towards an integrated primary care service. I want to see a new contract which has a population health focus, providing in particular for health promotion and disease prevention and for the structured ongoing care of chronic conditions. The discussions which are currently taking place are wide ranging and ambitious in their scope. While there will be challenges for all parties involved, I am hopeful that with the goodwill and co-operation of all parties, significant progress can be made in these discussions. I have always said this was a huge body of work which would take the bulk of 2017 to do. That is indeed proving to be the case.

To achieve the responsive, integrated, effective system that we all desire, significant investment in information systems is needed. This came up often during the SlainteCare report process. We were coming from a particularly low base when the e-health strategy was first put in place. This is a prime example of a challenge which might have appeared too daunting to permit systemic change but we are beginning to see what can be achieved when a clear strategy is put in place. At end of May, I signed a commencement order and made regulations under the Health Identifiers Act 2014 allowing for access to the register of individual health identifiers and also for the use of the health identifier within the health sector, both public and private, for the purposes provided for in the Act. The latest legislative provision allows for the beginning of the roll-out of individual health identifiers by the HSE. While it will take some time to embed the number in all our health systems, the recent legislative action is a timely and important step and an enabler for an improved health information system.

In addition to tasking me with preparing a response to the SlainteCare report, the Taoiseach announced upon his appointment that bringing forward legislation on alcohol is one of his priorities. Committee Stage of the Public Health (Alcohol) Bill will likely recommence in the Seanad in this session of the Oireachtas. I appeal to all members of the committee and our respective political parties to give their full support to our progression of this critical piece of public health legislation through the Oireachtas. The Taoiseach also announced that bringing forward legislation to allow for a referendum on the eighth amendment in 2018 is one of his priorities. I await the report of the Citizens Assembly which I understand is due to be published very shortly. As members know, the report will be referred to the special joint committee on the eighth amendment which is to report its conclusions and recommendations to both Houses of the Oireachtas within three months of its first public meeting. I have been clear my view is that this is an issue with which we as a nation must now deal definitively. I want to be the Minister who brings forward the legislation to allow this important referendum to take place in 2018 but I am conscious of the body or work the Oireachtas committee will do over the coming months. I am committed to making all possible resources available within my Department to ensure we can act on any proposed change.

One of my personal priorities and that of the Taoiseach is to make progress on access-related issues. While there are may good parts of our health service, access is the key issue that causes so many of our citizens' problems. Reducing waiting times for the longest waiting patients must be a key priority. It is for this reason that €20 million was allocated to the NTPF in the budget 2017, rising to €55 million in 2018. I asked the HSE to develop waiting list action plans for inpatient, day case, scoliosis and outpatient services and they are now being implemented and making a difference. The inpatient, day case and outpatient plan focuses on reducing the number of patients waiting 15 months or more for inpatient and day case treatment or for an outpatient appointment by the end of October. The scoliosis action plan aims to ensure that no patient who requires scoliosis surgery will be waiting more than four months for surgery by the end of 2017. It is an extraordinarily ambitious but important target. During 2017, my Department will continue to work with the HSE and NTPF to ensure the best use of public hospital capacity and the private hospital system to meet the needs of patients waiting for inpatient, day case and outpatient services. We will ensure work begins to get under way quickly for 2018.

In turning to emergency care, I acknowledge first the distress caused to patients, their families and front-line staff working in extremely difficult working conditions in emergency departments in hospitals throughout the country. Data from the HSE indicates that the national situation saw an improvement from January to early May. Since May, there has been an increase in trolley numbers due to a series of factors including, increased emergency department attendances and elective activity, which shows that when one tries to perform more elective procedures, it has a knock-on effect in the emergency department, showing the clear need to increase capacity. My Department and the HSE are currently engaged in a process to commence winter planning for next year and to achieve an improvement in emergency department performance. The HSE is implementing a roadmap which sets out an approach to driving reduction in the number of patients waiting on trolleys and trolley wait times over the period from March 2017 to the end of the year 2018. Achieving improvements in access times for both scheduled and emergency care is a challenge for health services against a backdrop of growing demand but it is a challenge to which everyone must rise. I will be working closely with officials and the HSE to show that we can make a positive impact in this area. It cannot be beyond our health service or our country to improve this situation. My ministerial colleagues are also progressing a number of priorities within their areas of responsibilities and I am sure they will be able to outline these during the questions which follow.

I am very happy to be returning to work with the committee with a fresh mandate from the Taoiseach to deliver real and lasting improvements in our health services. Life will never be so dull that we have unanimity on everything-----

The Taoiseach and the Minister do.

Touché. We all agree on many important elements and, in any event, I attach great value to the views of the committee. I look forward to working closely with its members on our shared goal to better meet the health and social care needs of our citizens.

I thank the Minister and call on Mr. Tony O'Brien, the CEO of the HSE, to make his opening statement.

Mr. Tony O'Brien

I bid the committee a good afternoon. I appreciate the invitation to be here.

I am joined by my colleagues: Ms Anne O’Connor, mental health division; Mr. Pat Healy, social care division; Mr. Liam Woods, acute services division; and Ms Rosarii Mannion, human resources division. The committee requested information and replies to a number of specific questions. I will therefore confine my opening remarks to the following areas.

On the issue of acute services, balancing scheduled care and unscheduled care demands remains a challenge in 2017. Despite a sustained increase in emergency department, ED, attendances of the order of 6% and particularly in the over 75 age category, overall TrolleyGAR numbers for the year to date are lower than the comparable period last year. Improvements in ED patient experience time less than 24 hours have also been achieved with national performance currently at 97% compliance, with 12 sites achieving in excess of 98% compliance.

A high priority for the HSE is to continuously improve elective access to services for patients. A key objective in 2017 is to build on the successes in reducing waiting times achieved last year. The HSE, working with the NTPF and the Department of Health, has developed waiting list action plans over the last number of months for the inpatient and day-case, IPDC, waiting lists, outpatient waiting lists and in particular for scoliosis. Analysis of the IPDC waiting lists by the NTPF, as of February 2017, identified that 38,991 patients will be waiting greater than 15 months at the end of October 2017. The HSE has agreed a plan with the Department that targets a 75% reduction in this number by the end of October 2017. The HSE will reduce the number of breaches by approximately 23,000 through funded activity levels. The plan is supported by additional funding of €15 million through the NTPF, which would see an additional 7,000 patients treated through insourcing and outsourcing initiatives. Latest figures show that the HSE has already progressed treatment for almost 14,300 of these longest waiters.

The HSE has also published an outpatient waiting list action plan that is aimed at achieving a 50% reduction in the number of patients that will be waiting over 15 months by the end of October 2017. To put this into context, in February 2017, it was established that 191,016 patients would breach 15 months by the end of October 2017. Accordingly, our plan provides for 95,508 patients from this cohort to be seen by October 2017. Based on the most recent NTPF data, 36,000 patients have had their outpatient appointments under this plan. This means that the HSE is 12.6% ahead of that target.

Earlier this year, I announced a commitment that no paediatric patient would wait more than four months for scoliosis surgery by the end of 2017. I am pleased to confirm to the committee that the scoliosis plan now in progress addresses treatment of children requiring both spinal fusion and other spinal procedures. This includes insourcing in the children’s hospital group and the broader public hospital sector, as well as outsourcing initiatives, including private providers nationally and abroad. In tandem, the HSE is working to develop a long-term sustainable solution for scoliosis and paediatric orthopaedic patients in order that the four-month waiting time becomes the norm.

In quality and safety, the HSE continues to seek to improve the quality and safety of its services. The recent publication of maternity and hospital safety statements are important steps in measuring the quality and safety of our services and making this information available to both our patients and the wider public. The national patient experience survey is the largest single survey of the health care system to be conducted in Ireland. We will listen and learn from the findings of this survey to shape future health care policy and improve health outcomes for patients. The HSE is progressing some key service developments this year to continuously improve the environment for patients and staff. The new ward block in University Hospital Galway is now open. The new emergency department in University Hospital Limerick opened in May and is fully operational. Recruitment is under way for two additional intensive care unit beds in Cork University Hospital and for the opening of the acute medical unit in Midland Regional Hospital in Portlaoise.

In primary care, the HSE continues to expand its community intervention teams, CITs. The CIT and the outpatient parenteral antimicrobial therapy, OPAT, service is now operational at 13 sites, which are listed in the document. The number of patient referrals for the period January to May 2017 was 14,844. This has increased by 34% compared to same period last year and activity is scheduled to exceed 32,000 new referrals by year end.

Improving the infrastructure for chronic illness management in primary care is a key service plan target, involving structured GP care for those with type 2 diabetes and the recruitment of 49 additional front-line clinical posts in the areas of diabetes, chronic obstructive pulmonary disease, COPD, and heart failure. The hepatitis C programme is a multi-annual public health plan which aims to provide treatment across a range of health care settings to all persons living with hepatitis C in Ireland. Advancements in therapeutic treatments for hepatitis C have allowed patients to be successfully treated and fully cured from the blood-borne virus. Therefore, making it a rare disease in Ireland is becoming a realisable objective.

Improved commercial terms in relation to medication costs are enabling treatment for up to 1,600 patients this year, an increase from the 600 patients treated last year. Of note for this year is that all patients infected with hepatitis C through the supply of blood and blood products will now have been offered treatment, with success rates of more than 97% within the cohort.

This year's service plan makes provision for improved access to GP care for more than 9,000 children in receipt of domiciliary care allowance and through reduced prescription charges for people over 70 and their dependents. Charges are now reduced from €2.50 to €2 per prescription item and there is a reduction of the monthly cap from €25 to €20.

Demand for social care disability services continues to increase reflective of demographic trends and the service continues to respond pro-actively within available resources. Each community health care organisation, CHO, has now established a formal consultative process with service providers to co-ordinate and prioritise responses to emergency cases that are being delivered within the profile for the year. The year will see the allocation of the largest level of funding for school leavers and rehabilitative training in recent years. An additional allocation of €10 million has been provided to meet the needs of 14,005 identified individuals, equivalent to a full year cost of €20 million in 2018. A profiling exercise for each 2017 school leaver referred to our services has been completed and each CHO will be communicating a proposed allocation of places for service users and their families by the end of this month.

With regard to services for older people, home care and transitional care are being delivered within profile for the year while, in relation to long-term care for older people, the nursing home support scheme is being delivered on target with waiting times no greater than four weeks.

In mental health services, the implementation of Connecting for Life - Ireland’s National Strategy to Reduce Suicide 2015-2020 continues to be a key priority for the HSE. Significant progress is reported in the implementation of the actions set out in the Connecting for Life strategy, with activity initiated or planned for 2017 in 65 out of the 69 actions, which is a total of 94%. The Central Statistics Office has recently published provisional suicide data for 2016 which indicate a decrease of 11.5% on 2015 numbers. In addition, the National Self-Harm Registry Ireland also confirms a stabilisation and slight reduction in the rates of self-harm presentation to emergency departments.

With regard to recent reports that suggested that Ireland has the fourth-highest teen suicide rate in the EU/OECD region, it is important to note that this data related to 2010. In May 2017, EUROSTAT updated its OECD suicide rate comparisons based on 2014 data which shows that in Ireland, the suicide rates among young males and females aged 15 to 19 have decreased with Ireland now 19th across the countries studied, with an average rate of 4.64 per 100,000, which is now slightly lower than the European average rate of 4.67. We are working hard to bring about further improvements.

The HSE will continue to focus on the implementation of key actions in Connecting for Life and the forthcoming recommendations of the youth task force to improve access to and quality of services and supports for young people. Within the mental health division, there continues to be a focus on service improvement with a view to improving quality of and access to mental health services for all age groups, both for those who are already known to services and for those who present for the first time.

It is acknowledged that attending an emergency department can be a very stressful experience, and other alternatives are now being explored, including 7/7 day services and out-of-hours services. The contract for the new 170-bed national forensic mental health service hospital on St. Ita's campus in Portrane has been signed by the HSE and work on the site is under way. The hospital will replace the 94-bed Central Mental Hospital in Dundrum which was built in the 1850s and is no longer fit for purpose. The new hospital will play a national role in the provision of a modern forensic mental health service and it will enable the HSE to provide an environment that positively supports patient recovery with modern health care standards. That concludes my opening statement, and together with my colleagues, I will endeavour to answer any questions the committee may have.

I thank Mr. O'Brien. I am going to open the meeting to members for questions and contributions. I remind members that they might limit their contributions to five minutes, without curtailing discussion. They might also be precise in their questions. The same might apply to the answers.

We would never talk down the clock.

All speakers can be concise and direct.

I collectively congratulate the Minister and Ministers of State on their appointments and wish them the best of luck. The Minister said in his opening statement:

I am pleased on more than one level to be here again. I have said on a number of occasions that our health service needs stability in its political leadership and direction.

One has political stability and direction in North Korea but it does not necessarily mean that it is going in the right direction. I hope we can bring the Minister back to the centre from time to time. I do wish him well on a personal level.

I must again raise the issue of scoliosis. Reference has been made to it in both opening statements. I accept that a lot of effort is being made but a lot more is being said than done in terms of the output. A target has been set of a maximum four-month waiting list for scoliosis paediatric orthopaedic surgery, but there is a problem with the target, namely, the delay in diagnosis in the first place. I have it on good authority that children are waiting an inordinate period for an MRI scan because they have to be anaesthetised to undergo the scan. I have been informed there are significant delays in accessing MRI scans. I would welcome an elaboration on that. It is fine to have a time limit on the waiting times for surgery, but if a child is waiting an inordinate time for the diagnosis in advance of the surgery, it is a problem that must be addressed meaningfully.

I met the family members of children suffering from scoliosis recently and I am aware the Minister met them as well. The group was from Kilkenny and was called the Scoliosis Advocacy Network. The women involved are very powerful and their testimony was very powerful in terms of the evidence they gave about the suffering and delays their children had to endure. I do not wish to turn this into an emotive issue. I raised it in the Dáil and the replies from the Minister were very positive. The sum of €1 million was potentially identified in the National Treatment Purchase Fund to address scoliosis. However, diagnosis and prognosis are critically important if we are to alleviate the suffering of children who are affected and to give them an equal opportunity.

Child and adolescent mental health services, CAMHS, were raised this morning in the Dáil on the Order of Business, but I raise it in the context of Cork. There is no point in us pretending the service is anything but chaotic. The service is almost negligible in the South/South West hospital group area. I have heard about very worrying cases recently, including children being held in inappropriate conditions in St. Stephen's Hospital in Cork. We are making very little progress with child and adolescent mental health services and we must put a strong emphasis on it. I accept there are difficulties with recruitment but that has been ongoing for a long time.

I thank Mr. O'Brien for his opening statement. I was interested by his statement that, "Ireland [is] now 19th across the countries studied, with an average rate of 4.64 per 100,000, which is now slightly lower than the European average". Will he provide reasons for that reduction? Is there a potential template for other cohorts of the population where we are not seeing as rapid a reduction? It would be useful if we could learn lessons from that. Is it due to the national strategy to reduce suicide or is it due to changes in circumstances in the economy? I would like to hear the reasons or if Mr. O'Brien could elaborate on that.

My views on the GP contract are well known to the Minister and Mr. Breslin. I still do not understand why half the GPs are outside the room looking in through an opaque window at the discussions that are ongoing for a new GP contract. The Minister said all stakeholders should engage in a proactive way, but half the GPs are outside the door. The key stakeholders are those who will deliver the service. I believe the National Association of GPs, NAGP, should be in the room as part of the discussions in a formal setting along with the IMO to ensure there is a clear understanding of what the contract will be and that it will not have to be discussed again by others outside the formal setting after it has been agreed in the formal talks. It defies logic and credibility to say that half the people who are expected to deliver the contract will not even be in the room discussing it. It is not just about the GPs, it is about the bedrock of all the strategies we are promoting, be that the Minister and his party, my party, Sinn Féin, the Labour Party and other parties, including as part of the Sláintecare report. We all support the move from hospital-centred care to a primary care and community care model. I still urge the Minister at this late stage to address the fact that half the GPs are not present at the talks. Cé mhéad nóiméid atá fágtha agam?

It is a long one, though, is it not? I wish to raise the Herity report and the very tragic circumstances surrounding the death of Mr. Thomas Power. He died last Sunday week outside Dungarvan while he was being transferred to Cork. He drove to Waterford hospital as he did not feel well and he was subsequently transferred to Cork, but he died on the way there. I know there will be a full clinical review of the case. I do not like raising such issues as I am conscious of the families involved, but we would almost be failing in our duty if we were to allow it to pass without delving into the reasons it happened. If there are flaws in the service, as I believe is the case, we should address them. The Herity report is forming part of the overall acute cardiac service reviews across the country. If the Minister is reviewing cardiac services nationally, I do not understand why he would allow the Herity report to stand and to work out from there when everyone in the south east knows there is a deficiency in cardiac services. That is acknowledged by everyone. It is even acknowledged in the Herity report, which I believe is flawed. In the south east we have 170,000 people who are up to 90 minutes away from acute cardiac services. That in itself is a very worrying situation. I am concerned the national review will take the Herity report as being de facto and correct, and use it when assessing the overall national cardiac services. The Herity report should be withdrawn, and when the full appraisal is done, it should be a stand-alone one. The people of the south east deserve that much, as well as the Power family and others who may have suffered tragic consequences due to the inadequate cardiac services. I urge the Minister to examine that issue.

I add my congratulations to those who were reappointed and those who are newly appointed. I say well done to them all. I will try to keep my questions brief. I will take a deep breath and lash through them. The first one relates to Brexit.

We had the Department's Brexit committee before us. Its members were woefully unprepared for the delights coming in our direction with regard to Brexit. Have the arrangements for the sharing of services cross-border been Brexit-proofed? Do we have a Brexit-proof agreement with the North for the sharing of services in general and specifically in Altnagelvin? What concerned me was when I asked the members tasked by the Department of Health to deal with Brexit if they had ascertained the extent to which we are reliant on Britain for health care, they did not know. When I asked them the numbers, they did not know. When I pursued it with them, they advised that it was only when they got the invitation to the committee that it occurred to them to start asking those questions. I am prepared to be very surprised on this. I would like to hear that the Department is very prepared for Brexit and has a plan. It might be helpful if it was shared with the people on the Brexit committee because they were clearly not aware of it because they could not share it with me.

With regard to the consultants, an issue was aired at the weekend whereby 128 non-specialist consultants are being paid as specialist consultants. This is a question directly for the HSE. Some of this has occurred because of contracts of indefinite duration. We all know what they mean. We also know that when a person starts working on day 1 there is four years and the clock is ticking. The HSE's response to my parliamentary question pointed to this as very bad practice. When people are being paid as if they are on the specialist register when they are not, it presents a difficulty for patients because clearly they want to know the person they are dealing with has the qualification they believe they have. A CID is never a surprise.

Ms Mannion will be very familiar with this. A CID is never a shock because it takes four years to accrue an entitlement to a CID. From day 1, the clock is ticking and the knowledge should be there that every day a person comes to work he or she is accruing an entitlement to a CID. On top of the 128, which we all agree is not good, how many more are on the threshold of a contract of indefinite duration? They are legally entitled to it but no steps are being taken to ensure that situation does not arise. I am not suggesting for a moment that the HSE should try to avoid or evade its responsibility to issue CIDs because it should not, but it is creating the situation it gave out about in the response to my parliamentary question.

Deputy Kelleher raised the issue of GP contracts. The Minister says he wants it to be finished in 2017. Is the Minister confident it will be finished in 2017? Is he confident that all the i's will be dotted and t's crossed by the end of this year? If not, are there any contingency arrangements in place for the continuation of those discussions?

I apologise because I had intended to get the questions in and time ran away from me. I apologise for not having these question in in advance. If the answers are not readily available, I will wait for a follow-up. I understand the boards of the hospital groups are to be put onto a statutory footing. Every time I ask the question I am told it will happen. The Minister is nodding his head. I would like to know when it will happen. I would also like to know what the delay is because I cannot fathom what the difficulty is.

The bed capacity review is a little like Christmas in that it is always coming. We are told it will be any day now. Could we have a date for it? A bed capacity review is not needed to tell us there is a shortage of capacity. We will have that debate another day.

I have a question specifically for the HSE. This is not specific to me or my party because I have talked to other people about it. There are serious delays in responses to representatives and parliamentary questions. Is there a staffing issue? Is there something going on? People who have been here a lot longer than me advise there is a particular problem and that the delays are not normally as bad as they appear to be at this time. Will the Minister speak to how we might address that?

I understand my five minutes was as long as the previous five minutes. The Devereaux case was a very tragic case. We all acknowledged it was heartbreaking and devoid of humanity. We understand now that due to the intervention of RTE it would appear the issue has been resolved for that family. The show in question only runs for an hour or an hour and a half so it will not have time to deal with all of the issues that will come up and neither should it have to. Has any guidance been issued to staff to ensure it will not happen again and that common sense, humanity and compassion will prevail in circumstances where it is patently obvious they should apply? Has guidance been issued? If it has not, can the Minister advise me specifically on what is being done to ensure it will not happen again? It was an awful case and it was heartbreaking. They should not have had to go to RTE in the way they did. What will be done to ensure it will not happen again?

I congratulate the Minister and Ministers of State on their reappointment. I make special mention of my constituency colleague who has been elevated to Minister of State.

Can I have an explanation for the delay in assessing reimbursement applications for new medicines? The issue at hand is a delay by the HSE in processing reimbursement applications for new medicines which is leading to patients not getting access to these vital medicines in a timely fashion. It now takes an average 340 days post-authorisation for medicines to be made available to patients and sometimes it can take several years. Other European countries have systems in place which enable new medicines to become available to patients within six months to a year. The system in Ireland is pushing us behind our European counterparts. This is against a backdrop of savings being made as a result of the framework agreement on the pricing and supply of medicines? It will deliver savings of €785 million until 2020. Why is it that despite the savings, we are not spending on new and vital medicines?

The first time the Minister came before this new health committee there was a big emphasis on waiting lists. I gave the example of Bantry hospital in my constituency where a rehabilitation and endoscopy unit would alleviate the pressure on the bigger hospitals in Cork city. I remember at the time the Minister thought it was a good idea. Are there any plans for Bantry hospital?

Home help hours are an issue. Many people coming into my constituency office are either looking for more hours or to get on the ladder to have hours. We are finding it impossible to get any help. There are some very worthy causes and cases. Does the Minister have any plans to increase the budget for it? I would like the Minister's comments on the availability of GPs to take up jobs in rural areas and the securing and retention of GPs.

Would the Minister like to lead off on some of those questions?

Yes. I will try to be as concise as the Chairman requested. Deputy Kelleher asked about the situation regarding scoliosis. I acknowledge the huge work of the advocacy groups not only in advocating but also in trying to engage with the HSE to come up with solutions. One such example is the paediatric scoliosis services co-design group in which parents and advocates are involved with the HSE and the children's hospital group in looking at how to better ensure there is a patient-centred approach to service delivery. It addresses a number of the issues raised about how people are interacted with from the moment they enter the health service system until the moment they have their surgery and come out the other side, regardless of where they live in the country and what doctor or hospital they are referred to.

I will ask the HSE to comment in a moment on the issue the Deputy raised on waiting times for MRIs. I thank him for bringing it to our attention.

I am very pleased that significant progress is being made in the area of scoliosis. We have set a very ambitious target to make sure no child waits longer than four months. By the end of the year children awaiting surgery should not have to wait longer than four months. That will bring us in line with countries like the UK and the NHS but it is a significant and dramatic improvement on the scenario that families were facing in this country. We have seen good progress in the opening of the new theatre, additional theatre sessions, the recruitment and retention of more theatre nurses, the use of facilities abroad outside of this jurisdiction and the use of other facilities within the Irish health service.

The figures factor in a growth in the waiting list, in other words, new people coming onto the list as they are diagnosed. If nobody new was diagnosed a total of 312 patients would require treatment by the end of the year to ensure no one breaches the four-month waiting target but we have also factored in anticipated growth of approximately 135, which means that about 450 patients will need to be treated by the end of the year if we are to ensure we reach that target. I am pleased to say we are seeing weekly progress towards meeting the target. I am getting a weekly report on this. I thank everybody involved in that regard.

I will ask the Minister of State, Deputy Jim Daly, to comment on the south-west child and adolescent mental health service in a moment. As for the GP contract, first, I question the assertion by Deputy Kelleher that half of GPs or anybody else is waiting outside the door. There is significant cross-over between the two organisations in terms of membership. If the GPs to whom Deputy Kelleher has spoken are anything like the ones in my constituency or those around the country to whom I speak– perhaps the Chair can attest to this – one will meet many GPs who are members of both associations. I know people present different numbers but there is significant cross-over between the two organisations. This is a more inclusive engagement with GPs than we have ever had. Before I became Minister there was no formal engagement with the NAGP. It was not just half way out the door but completely out the door. There is now formal consultation with the NAGP. I have personally suggested to the NAGP that it should see this as an evolving process and an opportunity to be involved and be consulted. We cannot get away from the fact that the IMO has a signed framework agreement with my predecessors and with the Department with regard to being the negotiating body but there is a real opportunity for the NAGP and the IMO to have their imprint on a new GP contract. I share Deputy Kelleher's view on the need for buy-in from all stakeholders, including the NAGP in this regard. I envisage this as an important step in the evolution of the relationship between the NAGP and the Department and the State and I encourage its members to work within that framework and to build on that.

In respect of the Herity report, like Deputy Kelleher I express my sincere condolences to the family of Thomas Power on what can only be an unbearable time for them all. I have commented on the wider issues not the individual case, which will be examined in the normal procedures and they will establish the facts. It would not be appropriate for any of us to talk about that but on the wider issue relating to the Herity report, as Minister for Health I stand over independent clinical evidence when I receive it. I stand over it in the exact same way as Deputy Kelleher's party correctly stood over the report on cancer care when it was in government and, to be honest, when political parties in opposition then, including my own, were not helping Fianna Fáil out. I understand what it is like when one is in opposition and Deputy Kelleher understands what it is like when one is in government. The Minister for Health, whosoever he or she may be, has a long-established precedent of following independent clinical advice that has served this country well.

However, we are doing four things in respect of Waterford. Based on the Herity report, I will put in additional resources - this is covered and funded in the service plan - to increase the number of opening hours of the existing cath lab. That will ensure more procedures are provided in Waterford. Second, a mobile cath lab is on the way and will be there as part of an interim measure to reduce waiting times for planned cardiology procedures. Third, after the benefit of those two measures have come into effect, I am happy to have another independent review of the situation in Waterford to ascertain whether, as a result of the mobile cath lab and the additional hours, more people are using the service in the south east. Fourth, we will have a national review.

To be clear, the issue in the Herity report is the view that there should be a consolidated number of primary percutaneous coronary intervention, PPCI, centres around the country. That is the foundation from which I am starting but the review will be completely independent of Herity above and beyond that. If Deputy Kelleher and I accept, based on best medical evidence, that there can only be a limited number of those centres, the purpose of the national review is to decide where it is best to locate them to ensure the maximum possible number of people can access a centre within the required clinical time. That is an aspiration we all share and we want to get there.

The issue does not just affect people in the south east. There is no 24-7 PPCI centre in the midlands. If one lives in parts of County Kerry one has to go to Cork University Hospital. If one lives in counties Monaghan, Louth or Sligo, one also has to go elsewhere. The national review is needed given that in any country, there is only an ability to provide a limited number of such facilities and we need to see where it is best to provide them to ensure the maximum number of citizens have access to them. That is the rationale behind it.

Deputy O'Reilly has raised the issue of Brexit a number of times in oral and written parliamentary questions. I have received detailed analysis from my Department, which I will share with the committee. I will circulate it to members. It answers a number of the questions the Deputy asked regarding how many people in this country have used the treatment abroad scheme in the UK and Northern Ireland; how many have used the cross-border directive; what is the cost of that each way; how many Irish pensioners benefit from medical cards and medical services in the UK and how many British pensioners benefit here. The analysis provides a lot of the data Deputy O'Reilly was seeking. I had a Brexit meeting in my Department yesterday with the HSE and Department officials on those issues. The data are available. However, in fairness to everybody involved, a lot of those issues come under the broader issue of the common travel area and as part of the broader negotiation this country and the EU must undertake with Britain on the common travel area and the free movement of people. The same is true of the Department of Social Protection where a number of issues arise. I already have had a meeting with the UK Secretary of State for Health, Jeremy Hunt and have written to him requesting another meeting on Brexit. I have met the European Commissioner for Health and Food Safety three times on Brexit. I have had bilateral meetings where Brexit has been an agenda item with many health Ministers – more than a dozen – from around the European Union. I also have had engagement with the then Northern Ireland Minister for Health and I hope to be in a position to have engagement with the future Northern Ireland Minister for Health shortly, as we all do. There is a lot of work going on. As the Deputy is aware, we cannot negotiate bilaterally with the UK during the process of Brexit, as we have to negotiate as part of the EU bloc. We have provided significant data and information to the Department of the Taoiseach on the health needs from Brexit. In September, I hope to host a specific session on health as part of the all-island civic dialogue. We very much welcome the involvement of members of this committee, along with stakeholders from North and South. I will keep the committee informed in that regard.

Deputy O'Reilly inquired about consultants. I will refer that to the HSE and it will come back with the information. On the GP contract, I hope we will have enough work-----

I am sorry, but that is not what I asked the Minister. What I asked was whether the Minister is confident that an agreement will be reached. The Minister said that was his hope. Does he have confidence that the talks will be finished by the end of the year?

Yes, I have but I need to nuance it for one intended reason, namely, the last thing we need is another static document. The last thing doctors want is for a contract to be agreed and for that to be the end of it the discussion for another four decades, which is what happened the last time with a few bits added on as we go along. That will not serve the modern needs of the health service or of Sláintecare either. I expect by the end of this year to have a number of significant developments with regard to GP care as part of the negotiation but I also genuinely expect this will be an evolving process and there will be more to build on as we set about implementing a ten-year plan for the health service.

As for the hospital group boards, as I have said consistently since my appointment, I did not move ahead with putting them on a statutory basis because I thought it would have been extraordinarily contradictory to ask the Oireachtas on a cross-party basis to come up with a ten-year plan and, while it was at it, to legislate for a structure that may or may not be aligned with what was set out in the ten-year consensus. We have been proven collectively right in that regard because while the ten-year plan has regional structures, they do not align with the hospital group boards. As part of my consideration on how to implement Sláintecare I will have to decide whether we try to pursue the statutory element of hospital group boards as an interim measure or whether we actually wait and go ahead with the proposed structures outlined in Sláintecare.

There is a dearth of governance in the intervening time. I do not suggest it is a flashing blue light emergency but it is an issue.

The Deputy is right. As she is aware, we have put chairs in place on an administrative basis and we have tried to fill boards but I accept that we want to get them set up on a statutory basis. I am not sure that we should engage significant legislative and Dáil time if we can move ahead with the alternative structure. I just need a few weeks on that and I will report to Government and then to the Oireachtas on the issue. As Deputy O'Reilly probably knows also, I have announced my intention to move ahead with the HSE board and the legislation required for that this year, which will address the broader issue of governance that we have discussed previously at the committee.

The bed capacity review will be completed by September, to be specific. I disagree with the Deputy. A bed capacity review is required, because one cannot simply pluck figures out of the air. Beds in health care are much more complex than the beds in which we sleep at night in our homes. There are different types of beds. There are acute beds and a range of beds across the spectrum of care be it primary, social or acute. The worst thing we could do is just count the number of acute hospital beds we need or think we need without looking at the benefit or otherwise of primary care, social care and community beds, where we need them, the cost of doing this and taking account of the demographic pressures.

Representations from Members of the Oireachtas is a matter for the HSE.

On the Devereaux family, we have all shared similar expressions on this in the House. I had the pleasure of talking to Mrs. Kathleen Devereaux last night. She is reunited with her husband today. It is her 86th birthday and she is back where she should be, with her husband of 63 years. I am delighted that has happened but frustrated that it ever had to get to that point. I accept that these decisions must be made with regard to metrics in clinical decisions. We all accept that these are clinical decisions. However, having looked at the fair deal legislation, I believe there is enough flexibility within the current provisions to enable common sense and compassion to preside when these decisions are being made. When the issue came to the attention of the HSE nationally, I am pleased that it acted swiftly and in a compassionate manner to reunite Mr. and Mrs. Devereaux. I am frustrated that the compassion and common sense were not in place at an earlier stage at local level. I have asked the Department to examine the specifics of this case and, more important, to scan through the CHO areas to find out if there are other potential instances. I certainly hope there are not, but it is important to do that. My colleague, Deputy Jim Daly, will be reviewing the fair deal and might wish to comment on the issue shortly.

Finally, to respond to Deputy Murphy O'Mahony, I will ask the HSE to give its perspective on drug reimbursement. From my perspective, I read many reports in newspapers about how many drugs have been approved in the Department of Health and sometimes the information is not the same as the information I have. There are three drugs currently with the Department and I expect we will process them quite quickly. A number of others are expected within the next month or so and a number of other drugs are still being considered by the HSE. It is worth acknowledging that the pipeline of drugs is increasing every year, which is a good thing for our patients. Thank God, people are coming up with new ways of providing treatments and improving people's quality of life. However, the pipeline is getting bigger and more costly every year. We saw the great progress the country made with Orkambi, but we also saw the tortuous process involved. I recently travelled to Malta and signed the Valletta Declaration, along with seven other countries in the European Union, which states that we will work together on trying to procure drugs. We have talked a great deal about working together over the years but this was the first concrete step. Indeed, the first meeting of that group at official level is taking place this month. I will be happy to provide the Deputy with any other information I have.

On the waiting lists, I agreed previously and still agree that we must examine using capacity in smaller hospitals which do not have the pressures of emergency departments. There are already some examples of that in some of our smaller hospitals. I usually use the example of the RCSI hospital group, where a number of scopes that could have been carried out in Beaumont Hospital were carried out in Cavan General Hospital. Cavan General Hospital has an emergency department but it had spare capacity. The job is to identify spare capacity and the NTPF and the HSE are working on that. Perhaps the HSE can respond directly to the Deputy about Bantry.

The Minister of State, Deputy Jim Daly, can comment on home help hours but, as he said earlier, we must get to the point where we will have a statutory home care scheme. We cannot continue to tell people that we believe they should have a right to grow old in their own homes with dignity in their communities, yet when they put their hands up and seek any assistance the only statutory scheme available is the fair deal scheme. Fair deal is working very well now. It is well funded and the four week turnaround time is being met by the HSE. However, there is cross-party consensus that there must be an alternative route for a statutory home care scheme. We must ensure that is done sensitively and by engaging with older people. We will move on that consultation shortly.

The issue of GP retention is largely caught up with the contract. If one offers people a modern, fit-for-purpose contract they are more likely to want to work here. In terms of rural Ireland, if one offers them an opportunity to have a salaried contract rather than them having to set up a viable small and medium enterprise, SME, it might be more attractive. These issues are under discussion in the context of the contract.

To respond to Deputy Kelleher, I do not have specifics about Cork but I will get them. Obviously, I am also interested in them and in getting a handle on the situation in Cork. I will share that information with the Deputy when it is to hand. The issue is reflected across the country in various forms, but typically the same problems are arising. Despite expenditure of €850 million per annum and 1,100 additional staff in the last five years there are still huge challenges, particularly in the CAMHS area. I accept that it is tiresome to hear repetitively about the recruitment of staff and that some people will believe it is an excuse, but the reality is that it is very difficult to get consultant psychiatrists. It is not just a problem in this country but also in Europe, which is more worrying. Funding is not holding up these appointments and recruitment. It is a challenge for us and I am not sure how we will overcome it but we must continue to try. We were talking with the HSE before this meeting about the efforts it is making to address the recruitment issue.

CAMHS teams are typically operating at 50% to 60% of the levels that are recommended, which is obviously not where we wish to be. There are 67 CAMHS teams and three paediatric liaison teams. We are expecting approximately 18,500 referrals to CAMHS in 2017. Currently, 68% of children referred to CAMHS are seen within 12 weeks but I accept that one in three is not, which is not good enough. The recruitment issue underpins the frustration in this regard. One of the positives is that sanction has just been received for 100 new assistant psychologist posts for the early intervention primary care area. When that recruitment gets under way it should take some of the pressure off. We should be trying to divert people away from CAMHS and intervening at the lowest level possible. Once that takes hold I am hopeful that it will be a positive development. The service plan for 2017 identifies CAMHS as a priority for further development, including better out-of-hours liaison and seven day response. This is a strategic priority action against a background where the population of children is expected to increase by approximately 8,500. I intend to get my head around this issue. I will ask the HSE to give a presentation and briefing on CAMHS in the audio-visual, AV, room for all Deputies, because it is an area of concern nationwide. I do not have a monopoly of wisdom on the solution and I would like to share that load with Deputies across the House to see what other solutions people might propose to assist the HSE in dealing with it.

On the Devereaux case, I echo what the Minister said. The issue I have and which I have raised with the HSE is who was told about this. Why did these people have to talk to Joe? Was it really necessary to do that? I presume they met and interacted with somebody who is real and who heard that same story. There was an outcry of compassion from all of us when we heard the story, so one wonders about who they told the story to previously and who did not or was unable to react. We must find out which it was, whether they did not react or were unable to because of legislation, procedure, rules and regulation. We will get to the bottom of that case. As the Minister said, the case has been sorted but we have to ensure that such a case does not happen again and that the flexibility to facilitate compassion exists and is built into any systems we as legislators put in place to govern how clinical decisions are made in admissions.

I asked a specific question. In the intervening time have guidelines been issued to staff?

I will ask Mr. O'Brien.

We all hope that compassion is exercised, but clearly it was not. Is it the case that we now have to tell people to be compassionate and that perhaps guidelines might be appropriate sooner rather than later?

The Deputy will appreciate that this only happened in the last few days, but I will ask the director general to address the specific point. I was just offering a general comment on the matter.

Deputy Murphy O'Mahony raised the home help hours. Again, we all have an issue with that. It has taken a great deal of my time in the last week trying to get my head around it. We hope to start the public consultation on it within the next week to get the views of stakeholders, people who have been providing the service and so forth. To be fair, the fair deal scheme is a good scheme and is working well. Obviously, issues arise in it but, by and large, it is a positive experience and we wish to replicate that-----

I appreciate that. We hope to replicate that style of success by getting a statutory scheme of home care in place. Our priority is to get help into the communities and to let people live longer in the community and support them there. However, it must be put under statute. It is grossly unfair at present given how people can get access to hours in some parts of the country and cannot in others and how the level of service and oversight varies from area to area. We want to put it in a statute that applies across the board, but we must get that right.

The consultation will begin within a week. I can give that commitment. We will all be working together to try to bring that through.

There were two other questions which were not responded to. Deputy Billy Kelleher asked for an explanation of the decrease in suicide numbers.

Mr. Tony O'Brien

Those questions will all be taken. I will deal personally with the issue of scoliosis and outpatients departments and the parliamentary question issue. I give notice to Mr. Healy that I will be asking him to come in on the operation of the nursing home support scheme and to Ms O'Connor that I will be asking her to speak on the decrease in teenage suicide. Ms Mannion and Mr. Woods will be asked to comment on the issue of contracts of indefinite duration, CIDs, and consultants.

With regard to scoliosis, the final sentence I used was that the HSE is working to develop a long-term sustainable solution for scoliosis in paediatric orthopaedic patients. I also include issues of diagnosis in that regard. Through the children's hospital group, we are carrying out a thorough assessment of access to diagnosis and the likely conversion rate to treatment from outpatient referrals in order to ensure that we achieve what we have committed to, which is to bring the waiting time for treatment down to no more than four months for all those who are listed for treatment by the end of this year, including those who will be added to that list as the year progresses.

We also aim to ensure in the two subsequent years that we have sufficient capacity to deal with all those who will need treatment in a much more timely manner, inclusive of the time from outpatient referral to diagnosis including where MRI or any other diagnostic procedure may be required. For a period of time, we will need a treatment capacity more than double that which we have had historically. It is our general approach to waiting to always deal with those waiting longest first. That is why we are using the approach we are now using in respect of those who are on the existing treatment waiting list. We are using insourcing, outsourcing and international treatment to ensure that waiting list is effectively eliminated - four months would not be considered a waiting list - and will then bring forward the balance of the issue.

In respect of representations and parliamentary questions, a total of 3,570 parliamentary questions were asked in the period between 1 January 2017 and 24 May 2017, of which 2,566, some 72%, received an on-time reply, that is to say, within ten working days. That means that 28% are non-compliant. It is difficult to give comparators with prior years because following the last general election, approximately this time last year, new Standing Orders were adopted which reduced the target reply date from 15 days to ten days. This is monitored very closely. Mr Ray Mitchell, who is normally with us, is the official who normally deals with that monitoring. He is on a well-earned break this week. I am quite happy to share our monitoring reports with this committee or with anyone else. We check and very actively chase those who have not yet replied to questions. Something that sometimes causes issues, and the Deputy will understand what I mean by this reference, is that we can sometimes get 50 questions which are effectively on the one issue and it is required that they be dealt with separately. Our parliamentary unit is very happy to work with any Member who is experiencing difficulty in getting replies to questions. We will share that report and we are working to ensure that the importance of replying within ten days is understood throughout our system.

Does Mr. O'Brien have any idea how long the delays are with those 28%?

Mr. Tony O'Brien

I do not have that information with me but the monitoring reports answer that and I am very happy to share those with the committee through the clerk.

That was not intended in any way as a comment on Mr. Mitchell, who I deal with regularly.

Mr. Tony O'Brien

I know that, yes.

I understand and appreciate that the staff are under a phenomenal amount of pressure but several of my colleagues have reported to me that there was a perception of an inordinate amount of delay in the very recent past. It was not intended as a reflection on the staff.

Mr. Tony O'Brien

I understand that. The data that I have do not imply any particular degradation in performance in this area but it is difficult to compare one year with another given that there was -----

Given that it has changed.

Mr. Tony O'Brien

-----a very significant change in the turnaround times, which has obviously, on a transitional basis, increased the absolute workload. Overall, it will even itself out but it probably has not quite done that yet. I will ask Ms Mannion and Mr. Woods to deal with the issue of contracts of indefinite duration and consultants and then I will come to Mr. Healy.

Ms Rosarii Mannion

The record will show that this matter was dealt with very extensively at leadership team and directorate level at the meeting on 11 October 2016. Arising from that meeting, I was tasked with looking at the issue of contracts of indefinite duration, those not on the specialist register, and consultants in unapproved posts. To get an holistic view, those three facets need to be examined conjointly so that we are in a position to respond. I hope the Deputy will be familiar with the report which we published earlier in the year - "Towards Successful Consultant Recruitment, Appointment and Retention". On page 7, the Deputy will see that we have itemised this as a key issue in terms of flaws of governance and administration. This point was specifically picked up. Arising from that, we have been implementing the doctors integrated management esystem, which is giving us full data in respect of the items I have outlined. At this point in time, we have 52 potential contracts of indefinite duration.

Regarding those not on the specialist register, we have the details of where they are currently. What we are doing to address this is again set out in recommendation 1.1 of this report, which I believe has been shared with the committee previously. We are carrying out a specific examination on a site-by-site basis with each of the hospital groups. We have started that and we will be working through it. That will potentially take 12 months to really close off on this issue. There are three hospitals which we need to bring on board with this - Temple Street Children's University Hospital, Beaumont and Holles Street. We are very much on top of this issue. It is not ideal. It is not a situation in which we would like to be.

If one looks specifically at the breakdown of those currently employed who are not on the specialist register, one will see that 14 of them are in psychiatry. Earlier on in the meeting we had discussions around staffing, recruitment issues, waiting lists and so on in that particular area. Before 2008, there was not requirement to be on the specialist register so a lot of these are legacy issues. That is not an excuse, it is just the reality. We are working through it. Of those 14 who are in psychiatry, every one of them will have been assessed for risk and they will be working under supervision. There are clear service decisions which need to be taken regarding this issue but I wish to assure the committee that we are working through this, quite complex, issue. I invite the Deputy to come in to us if she has the time and we will go through that particular system. There are some excellent data available which we have not had previously and which will really assist us in the management of our medical workforce in the future.

I am conscious of the time but we are specifically looking at a much better approach in respect of job planning, workforce planning and sharper recruitment practices in respect of the medical workforce. Again, time will not allow for that today but we are happy to take the Deputy through a specific briefing on that if it is helpful.

As a point of clarification, there are 52 potential CIDs. Does that mean 52 people who are not on the specialist register or 52 people in total?

Ms Rosarii Mannion

It is 52 people who will potentially accrue a CID.

Does Ms Mannion know what stage they are at?

Ms Rosarii Mannion

I will give the Deputy the breakdown.

Are they all just about to-----

Ms Rosarii Mannion

No, they are not. We have 52 in the system. They are not all just about to accrue a contract of indefinite duration. I will not give a generalised response on that matter but I am happy to take the Deputy through what is actual and factual.

We can do that after. That would be very helpful.

Mr. Pat Healy

The nursing home support scheme is a statutory scheme set out in the Nursing Homes Support Scheme Act 2009. Section 7(6) of the Act sets out specifically what a care needs assessment is. It sets out the professionals who would undertake it, which include doctors - in our case it is geriatricians - nursing staff and occupational and physical therapists. When an application is made the first thing that is done is that a care needs assessment is undertaken to determine, based on the criteria, if a person qualifies or not. There are then a comprehensive set of guidelines established in the system as to how those care needs assessments will be undertaken. For some years, since the establishment of the scheme, we have established more than 30 local placement fora at the level of the local health office, as they were known. They have geriatricians on a multidisciplinary team. Social work is often also involved, along with the therapists, nursing staff and geriatricians. They work to a standardised, agreed model.

One reason I asked for a review to be done on this was that, as the Minister has said, there can be a question of standardised interpretation. Part of what we have to do, perhaps, is to make sure that our professionals, who are working on this in a very proactive way, are supported. This is to ensure that when rare cases do come up, as happened recently, they know the full extent of the flexibility they have under the scheme. I await the outcome of the review and the advice I get on this matter. What I intend to do is to establish a national forum to bring together the 30-plus placement fora in order that there is shared learning across the system on what is happening in different places and how things are progressing and in order that cases can be shared and so forth. That would provide a positive system to support the professionals involved in dealing with issues like this.

I apologise for coming back in here. Mr. Healy and I know each other a long time. I asked a very specific question. Has the HSE issued guidelines to ensure that this will not happen again? If the answer is "No", that is fine. If the answer is the organisation is currently working on it, that is also fine. I know what a care needs assessment is. We all do because we deal with them all of the time and we know the individuals involved.

Mr. Pat Healy

My own view is that the guidance we have issued is sufficient. What we will do once we have the output of the review is to put in place any further guidance or correspondence that is needed. We will also set up a national forum to support it. I want the outcome of the review before I make any final decisions on what should be done, however.

Mr. Tony O'Brien

Ms O'Connor will comment on the issues around CAMHS.

Ms Anne O'Connor

I will address the issue of CAMHS in the Cork area. As the Minister mentioned, there is a particular issue around staffing in some CAMHS. The services in Cork and in the CHO 4 area, which covers Cork and Kerry, are working at 50% of the provision envisaged in A Vision for Change. They have some vacancies but the total staffing allocation is an issue for them.

When it comes to CAMHS performance in general, we look at three components. One is the so-called pre-CAMHS, or what exists in an area that could help avoid the need for CAMHS. This is because we see that people end up in CAMHS in the absence of other local solutions. The Minister also mentioned assistant psychologists in that regard. In that area alone, 16 new assistant psychologist and seven qualified psychologist posts have been allocated because there had been a deficit there. We hope that this will make a difference to the numbers going to CAMHS because there is currently quite a high referral rate from that area.

We are also looking at how we can help the services with their medical staffing. There are a number of vacancies. Unfortunately the structure of CAMHS is such that there is a single consultant for a team in an area. There is one team for every 50,000 people and if the consultant is not there, that has an impact on an entire population. We are working with the area on that.

Deputy Kelleher mentioned the issues that were arising and the most recent report showed the area had more than 80 people waiting for more than 12 months. This has already been reduced due to work undertaken to ensure that children who need to be seen are really prioritised and that cancellations are allocated etc. I can reassure the committee that existing issues are being actively addressed. They have, however, very real challenges around staffing. They also have a particular challenge in their inpatient unit where eight beds have been closed. Our hope is that a new doctor early in the July rotation will resolve that for us. We have had additional consultant time but we have not had non-consultant doctor time. We are addressing that in the July changeover.

A number of things are happening in Cork that will hopefully improve matters. There are certainly challenges there, however, and we are working very closely with the division to give them additional resources and support. More importantly, we are working with them to look at other avenues for young people with mental health problems. It is important that we acknowledge that mental health for young people does not begin and end with the CAMH service and that other supports are there before children ever need to go the CAMHS. We are developing this as well through this new allocation. That is the update on CAMHS.

Mr. Tony O'Brien

We need to give teen suicide figures and the lessons learned.

Ms Anne O'Connor

The data we have on suicide are provisional data for 2016 from the Central Statistics Office. Overall, the data suggest that suicide across all ages has reduced in total by approximately 11.5%. Within that we can see a reduction for males of nearly all ages. The 55 to 64 age group is the one area where it increased in 2016. In women, there has actually been an increase in the rates overall. What we have then in 2016 is a 15.2% reduction in the rate for men and a 6.5% increase in the rate for women overall. The increase in females is in the older age range from 35-plus rather than in youth. The youth rate has reduced across both genders.

The Deputy asked if there was something there that we can learn from. There are a number of factors here. One is the environment. The economic environment, for example, has led to a reduction in suicide. The provisional data suggest that in 2016 we dipped below 400 for the first time. This is provisional, of course, so there has to be a health warning on it, but it has been published. A number of other things have happened in recent years to lead up to this. The Connecting for Life strategy, for example, has allowed for a lot of cross-sectoral work, particularly in looking at local area plans. This really allows for a cross-sectoral ownership of mental health, looking at voluntary agencies and all of the different State bodies working in an area to change the message around mental health. We are seeing a lot of that. We are seeing much more positive conversation around mental health, with our current Little Things campaign, for example. We are seeing much more help being sought and more young people feeling more comfortable talking about mental health.

As part of the strategy we are also prioritising certain groups. These include youth, people who are homeless and people who are LGBTI. We are working very proactively with a number of groups. It is a combination of all of these factors that has led to these results, along with very significant training. Through the National Office for Suicide Prevention we have invested in a lot of training in many organisations and State bodies. We are also working very closely with An Garda Síochána and all Garda trainees now get safeTALK and applied suicide information skills training, ASIST. Most youth workers and youth agencies have also now been trained. We offer mental health and first-aid training. The approach is multifaceted. It may be the case that greater awareness is having an impact but it is too early to say yet.

Is the HSE doing a detailed analysis of why this is the case?

Ms Anne O'Connor

The National Suicide Research Foundation, NSRF, in Cork is funded by the HSE. In addition, our Connecting for Life area plans have also just been launched. Five of these have already been launched nationally and a number of other areas have either completed their plans or are in the process of developing them. They will be launched shortly. In time we will be looking at the impact of these plans on areas but we are still at the early launch stages yet. The NSRF will, as it normally does, provide the data to match with other demographic detail etc.

On the recruitment of GPs, there are of course difficulties in rural practice and these are well documented. There is now a problem, however, in filling GP lists in urban centres. When a GP retires or when a GP has an assistant who then emigrates or moves on, there is great difficulty in recruiting replacements. GPs can obviously get ill or die when still in practice and this can be an unpredictable event. How does the HSE intervene in trying to anticipate the replacement of GPs coming up to retirement? We know that 33% of GPs are over the age of 55. Many retire and the HSE is unaware that this is about to happen. GPs can now practise until they are 72. How does the HSE engage in trying to anticipate the retirement of GPs and filling those posts before the retirement is announced?

Mr. Tony O'Brien

I will ask Mr. John Hennessy, who is our lead in this area, to provide a written response to that. In deference to the committee I did not bring as large a crew as I might have done because not every member appreciates that. I do not have all of that information to hand but we will certainly respond fully to that point. The issue the Chairman raises is a very real one. The age profile of our general practice in the community is a cause for concern, particularly if we are to be in the position to give effect to the significant and laudable aspirations of the Sláintecare report. This is a fundamental issue.

From the Department's perspective, I will just give a few statistics. There are currently 23 GMS vacancies in the country as of 1 June. As there are 2,493 GPs contracted to provide services under the GMS scheme, that is a relatively low percentage of vacancy. Less than 1% of the total number of GPs contracted to the GMS are vacant. The number of GMS patients associated with these vacancies is 14,495. A total of nine of these vacancies have been open for less than six months, six vacancies have been open for between six months and 12 months, and eight vacancies have been open for more than 12 months. A total of 18 of these vacancies, or 78%, are in urban areas and five of them, or 22%, are in rural areas. The rural practice support framework payment is associated with four of these. Where GP vacancies arise in the GMS then, the HSE must and does take all necessary steps to ensure continuity of service.

I am informed that all current vacancies are covered by a locum service and, therefore, a general practice service continues to be provided in all the affected areas. While I am not in any way downplaying the importance of this issue, it is useful to provide some statistics to give a sense of the context. There are 2,493 general practitioners contracted to the General Medical Services scheme and there are 23 vacancies.

While the Government is consistently and constantly trying to increase the number of GP training places in line with the commitment in the programme for Government, it is disappointing that not all the additional places were filled. This must be viewed in the context of the increase in GP training numbers in recent years. For example, the number of training places rose from 120 in 2009 to 186 in 2017, an increase of 55% in seven years. The number of places filled has increased by 43% in the same period. While it is right and proper that we do this for all the reasons outlined by the Chairman, including the average age of general practitioners, it is important to provide some facts.

While there may be only 23 vacancies, vacancies are no longer counted when a list is not filled and a general practitioner's patients are dispersed to surrounding lists. Many villages and towns no longer have a general practitioner, yet the vacant positions are no longer counted or identified. I am sure there are four or five practices in each county which, having failed to attract a GP, are no longer on the list.

That is correct

There may be 23 current vacancies but the number of areas that have lost their general practitioner and will never have another GP is far in excess of 23 because lists are amalgamated or dispersed to surrounding practices.

The Chairman makes an entirely valid point, which returns us to our starting point on the need for a new contract to make general practice a more attractive profession.

The next group of speakers will be Senator Dolan, followed by Deputy O'Connell and Senator Colm Burke.

I extend greetings to the new Minister of State, Deputy Jim Daly. I am also pleased to see the old ministerial faces from the Department. I submitted four questions to the Department, the first of which relates to the welcome commitment given by the Taoiseach in his first address to the Dáil following his appointment to ratify the United Nations Convention on the Rights of Persons with Disabilities by the end of this year. The Taoiseach's commitment allows the Minister of State, Deputy Finian McGrath, off the hook in the sense that the commitment he gave previously has been restated by someone else in government, which is good news. As the clock ticks towards 31 December, what work must the Department do to facilitate the implementation of this commitment? The Minister referred to the declaration of liberty, the decision support service and a small amount of work to be done on the Mental Health Act. He was shy, however, about setting specific dates by which the various measures required to facilitate ratification will be implemented.

I am unhappy about the failure to even attempt to answer my question in which I sought an estimate of the extent of unmet needs and supports for people with disabilities and mental health needs. In requesting an estimate, rather than precise figures, I deliberately asked a pass rather than an honours question, as it were, because I know it is not always easy to provide exact figures. Of the 11 paragraphs in the quarterly update, ten take us on a tour of strategy plans, current funding levels, pilot projects, policy orientation and commitments to standards and safety. While this information is useful, it does not address the question. The closest we get to an answer is in the final paragraph, which notes that the Health Service Executive is engaged in a review of current service requirements and crucial unmet needs in planning and prioritising service requirements for 2018. This, the statement adds, is informed by best practice and so forth. However, we are not given even a hint of an estimate of the number of people who may need personal assistance or the quantum of services required to enable people to continue to live in their homes, not to speak of in the community. How can the Department usefully engage in a review of current service requirements and unmet needs if it unable to provide these data or does it have the information but has decided not to release it? It is a serious matter when the Department does not even provide a guesstimate as to the level of unmet need in a range of core areas.

While I do not wish to stray into the issue of the Devereaux family, in that context we spoke earlier about the statutory underpinning of the fair deal scheme. I know people with disabilities aged under 65 years who are in nursing homes. Who can say there is not a connection between the lack of provision or planning for provision in the community and that fact? The Minister referred previously to the need for a statutory underpinning of the community side. This must be done across the board, rather than exclusively for older people, if we are to bring some balance to the equation.

My third question related to section 38 and 39 bodies. My sense is that the answer is very much about industrial relations and personnel development issues. I asked what was the impact for organisations related to the sustainability of person-centred services from which there will be greater staff migration to better paying roles. I was not asking about industrial relations or human resources issues. I am told that people working in section 39 organisations are not public servants. Are those working in section 38 organisations public servants? The point at issue is that we want to have quality public services. If an organisation on one side of the road is funded under one section of the Act and another organisation on the other side of the road providing the same services is funded under a different section, one could swap over. The issue is that staff will cut their teeth in one and then migrate to the other. While I wish them luck if they can do that, it leaves one organisation to face the problem of staff churn and related issues.

On 30 May last, when I raised this matter in the Seanad with the Minister for Public Expenditure and Reform, Deputy Donohoe, he stated he would "anchor this matter in current negotiations through the concept of affordability." He continued: "I am aware that the decision that we make about public service pay will have consequences for other organisations that are not of the public service but provide public services". Has the Department of Public Expenditure and Reform engaged with or knocked on the door of the Department of Health in the meantime given that an agreement has been concluded which could advance this issue?

My final question related to the determinants of health, although the word "determinants" was not used. I raised this issue as a result of a meeting at which representatives of a number of groups addressed the joint committee on the impact of services or lack thereof on other areas of health. The response brought me on another tour, this time of the national disability implementation strategy. This strategy, which is about to be published, should have been live a year and a half ago because it was intended to follow the strategy that concluded in 2015. This means there has been no strategy in place for the past 18 months.

The comprehensive employment strategy, which should have been introduced in 2013, did not commence until the end of 2015. To cut to the chase, may I assume that the Department has no issues regarding services in other Departments that would help people to migrate - I use that word advisedly - from the health area to education, employment and other supports in the community?

Are there no poverty issues? The SILC statistics show increased levels of poverty for people with disabilities. Are there no social housing issues? The information we have received has told us that difficulties in this regard have increased by 16% or 17% over the past three years. Employment is a chronic issue. If we are trying to move people on after school or people who become disabled as adults, how do we get them into work if nobody on that side is taking things up? Accessibility and transport are other issues. I thank the witnesses for their work but I do not find a lot of value in the text I have received.

I welcome the witnesses and congratulate the Minister, Deputy Harris. I am happy he is still Minister for Health. I note from his statement he has learned the value of using the available expertise to inform solutions, which is good to see. I also welcome the Ministers of State, Deputies Byrne and Finian McGrath, and congratulate the Minister of State, Deputy Jim Daly, on his appointment.

The Minister's opening statement referred to the increase in the number of consultants to support service delivery and the progression of compliance with the European working time directive. Has the increase in consultant numbers been eaten up? Is there a net gain in working hours or is it simply the case that we cannot have consultants working 70 hours a week? From memory, I understand the European working time directive limits the working week to 48.5 hours. Are we just complying with employment law or has there been an impact on hours worked and the services delivered to patients? I seek some information on that.

Is there any good news in respect of the recruitment of nurses? We repeatedly refer to consultants but we all know that health care necessitates a team approach and nurses are vital in the delivery of services in Ireland.

The Minister, Deputy Harris, and Mr. O'Brien referred to primary care. I understand Mr. O'Brien referred to a 34% increase in primary care referrals. Is there an impact on the demand on acute services, taking demographics into account? Is increased activity in the primary care setting reducing pressure on acute hospital settings? Are we transferring work or providing better care to certain people? Are we layering on more types of care and still allowing a cohort of people to languish? What is the impact of the movement of care on people's lives?

Mr. O'Brien provided great information on scoliosis treatment and the four-month target. Are there data to show any other child patient cohort has suffered as a result of this improvement? Has the diversion of the resources into scoliosis treatment left children with, for example, cancer, worse off? Have others suffered?

I refer to the reduced rate of teen suicide. My initial instinct was this was a result of the environment and economy rather than interventions. Perhaps services in the community have had an impact, rather than the economy. I would not like to think we are attributing success rates to something the HSE may have had nothing to do with.

Does the Minister have an update on the National Maternity Hospital? Is an update available on the operation of crisis pregnancy agencies and the type of information most people think is not suitable for vulnerable women in such places? I ask the Minister to comment on the female who was sectioned, who, I believe, is under 18 years of age and was forced to become a mother without wanting to become a parent. Can the Minister update us on anything regarding that case?

The Minister will receive a report from the Chair of this committee on the national maternity strategy implementation, which we discussed before the Minister came to the meeting. I do not want to ruin the surprise, but the first line of that report refers to 20-week scans. We listened to Professor Kenny from Cork who spoke about what I can only describe as the rationing of 20-week scans. The scans are being performed on women who are more likely to have a child with a defect. From memory, I understand one a week is provided to the non-high-risk group. A women who is 25 years of age and gives birth in Sligo, for example, rather than one of the Dublin teaching hospitals, may not have a scan.

Children are being born with undiagnosed birth defects. If those defects were diagnosed at a 20-week scan they could have received better treatment. They may have better outcomes if dealt with in a teaching hospital. It is very concerning that children who, along with the families and extended families, would have had better outcomes are being delivered in hospitals without staff having the correct information. Is there any update on the provision of 20-week scans? We seem to be an outlier compared to the rest of Europe.

The Minister of State, Deputy Byrne, is new to the area of health promotion. She probably heard I am obsessed with the HPV vaccine. There was a catch-up programme. Is there any information on the figures in terms of herd immunity?

In the context of the Sláintecare report, perhaps Mr. Breslin or someone from the Department could provide members with information on the alignment of hospital groups, community health organisations, regional health organisations and other matters we have discussed over the past year in terms of whether we can quantify results. We need defined populations and we need to know with what we are dealing. I am sure the witnesses are sick of listening to me going on about that but we have to keep going.

I do not want to overdo it on the couple who were separated in a nursing home but the case involved common sense and compassion. If the system involves an algorithm, and somebody inputted data into a computer and it said "No", we could blame the computer and algorithm. Human beings with hearts and pulses are making decisions. It was not a very difficult decision. It could not have been difficult to accommodate the couple. Who makes the decisions and how can they not tick the right boxes? It would make one wonder. Perhaps we would be better off with a computer that said "No" as then the file could be examined. Clearly, the human beings involved in the system are not able to do their job right if a vulnerable couple had to fight for the flexibility to allow compassion to be applied to their case.

I congratulate the Minister and Ministers of State, and wish them every success. I am delighted that a Minister of State from Cork is dealing with the Department of Health. I look forward to working with everyone.

I refer to future planning of hospital services for Cork. I note the last line of the report I received. As I have said, the population of Cork city and county has increased by 130,000, from 410,000 to 542,000.

Senator Buttimer and I had a meeting with the Mercy Hospital group a few months ago. Last year, they had to cancel 40% of their elective surgery because of admissions through the accident and emergency department. Their major problem was that there was an increase in 12% in the over 80 age category of patients being admitted through that department. It is more difficult to discharge them and, therefore, they had to be admitted. It is in that context that I asked about new hospitals for Cork. The final line in the reply I received is that there is no definitive decision that Cork will be included in the next national plan. However, this is a priority area. Major funding has been allocated for hospital development in Dublin. Three or four new developments are going ahead in the city but there is a need for a centre of excellence in Munster and not just for Cork. The Minister needs to focus on that rather than diverting services to Dublin. Will he respond to that? The other aspect of this I am concerned about is UCC seems to be doing the driving on this matter. This is not a criticism of UCC but any new hospital must be patient-focused and located where it is needed and not necessarily where a third level institution needs it. We need to get hold of this project and not allow others to make the running. I ask both the HSE and the Minister to respond about where this is going and where we will be in six months on this issue because I will not want to repeat the same comments then. I may not be an Oireachtas Member in six years but I do not want someone else coming in here in then to ask the same question. I would like clarification on where this project is at in respect of current planning, identifying a site and forward planning.

The second issue I would like to raise relates to respite care. I have a serious concern about this in the Cork area, particularly in respect of provision for people with disabilities. I have met a number of parents who cannot access respite care. In fairness, I received a detailed reply dealing with the HIQA issue and the maintenance of standards, with which I fully agree. However, this is also about forward planning. I asked whether the HSE has age profiles of those with disabilities who require respite care and of their current carers. For instance, I was contacted by a man who will be 80 next month. He drives his daughter to day care in the COPE facility, which provides an excellent service, in Cork every day. He drops her off in the morning and collects her in the evening. The journey is between 15 and 20 miles each way. He will not be able to do that forever and, therefore, I am wondering about the long-term planning in respect of services for people such as his daughter. Will the Minister outline what is being done to identify the numbers involved and to facilitate these carers who have been providing the necessary care at home for years?

I hope people do not take up me wrong on the third issue I would like to raise, which is the increase in the number of administration and management staff. I am a little confused by this. This relates to governance. When was the decision taken to increase staff numbers and how was it taken? The number of staff at senior level has increased from 201 to 289 in two and a half years, which is a 43.5% increase. Has a clear plan been set out for recruitment at administration and senior management levels? At what stage is there a cut-off point? This has been a phenomenal increase in numbers in comparison to other areas. I previously instanced that the number of public health nurses in the same period increased from 1,460 to 1,499, an increase of 39, yet on the most recent figures, the number of administration and management staff increased by more than 1,900. Where is the cut-off point? I would like to identify each of the 71 positions that were created. Some detail has been provided on that but I am still not satisfied as to why that increase occurred. Will somebody outline the cut-off point? Will the increase in senior management numbers continue? What is the final target number? There are 289 management staff now. Will that number reach 350 this time next year? What is the plan? That has not been in the public domain.

Finally, I refer to the issue of hospital doctors. I understand that 40% of doctors are non-Irish graduates. We brought in the McRae report which set out clear plans for retaining graduates. Has a review been conducted of whether this report has achieved anything and whether additional changes are needed to retain graduates or to attract them back to the State? Ireland is first among OECD countries for bringing in doctors from outside the jurisdiction and, indeed, from developing countries. It is a serious issue that the Government and the HSE have not got a handle on yet.

I might bring in the final two members, given there is pressure on time.

I am not sure it is a good idea.

We agreed five minutes.

Nobody adheres to that and, therefore, it does not matter. I will not repeat questions. I congratulate Deputy Jim Daly on his appointment. He is a good parliamentarian and I am delighted he secured this role. I also congratulate the other Ministers who were reappointed. Perhaps some were nervous but fair play to them. I am delighted for all of them. As a group of Ministers, they are approachable regarding issues, whether they are national or local, and I appreciate that. I cannot say that about every other Department but considering it is such a difficult Department, they are all approachable and I thank them for that.

I will focus on a number of issues, some of which I have raised previously. They are mostly national issues but one or two are local. The eHealth issue is critical and somebody will have to bite the bullet. We have had many disasters as a country as regards IT projects costing a fortune. It has led to reticence among Departments spending large capital amounts on such projects. I had to come in and sort out the Leap card implementation. Now there is an issue with electronic health records. I am a big supporter of the public services card and making that a G2C or a C2G card. Public services cards, travel cards and health records should, with layers of security, eventually become one. Security can allow for access at whatever level and fraud would be reduced immediately but that is for another day. I would like a commitment from the Minister that he will be brave enough to kick the ball off significantly in this space in the capital plan that will be announced following the summer because this is a fundamental health issue. It features in our future of health care report. I know of somebody quite close to me who has spent two and a half weeks in hospital. After two and a half weeks, she has found out the hospital had two charts on her, which they have now brought together. That is insane. Basically, we are unsure about some of the readings and they have to start all over again.

That is just one example.

Fundamentally, if this is all carried out through a proper, electronically recorded system, then that information should be at everyone's fingertips. Some people I know of across some hospitals have systems and pilot projects in place and, by all accounts, they work well. This is not rocket science. The scale of it is huge and the Department will have to spend humongous amounts of money, but someone must kick the ball to ensure this happens. I ask the Minister to do so. I will support it 1,000%. I have been on about it for years. When I was in government, we did not have the money, but someone must kick it off. The problem for the Minister is that it will not be physical building, no one will see the results of it and there is no political capital in it. However, it is the right thing to do and I encourage him to do it.

To move on to political capital, I have had a number of discussions about buildings. I represent Tipperary, and we have two of the worst accident and emergency department situations, namely, at South Tipperary General Hospital and University Hospital Limerick. The new chairman of the latter and I come from the same area. We were together at the opening of the emergency department, which is a fantastic facility. I am open to correction but I think there has been an increase of over 30% in the number of patients going through it, so it is a victim of its own success in that sense. However, the real issue here is speed and capital development. I will take South Tipperary General Hospital by way of example. We had this glorified announcement about the provision of a super-hotel, temporary hotel or whatever the hell it was called at the hospital. I will not get into the politics of this, so the Minister should not worry, but it was a pre-announcement and an overstatement and it should not have happened. I am trying to help the Minister here. It will not be in place for this winter, never mind last winter, when it was said it would be in place. In the long term, unless the Minister says otherwise, I presume South Tipperary General Hospital will be included in the capital plan because it is as clear as the nose on one's face that it is desperate. I remember my time as a Minister with responsibility for housing. Is there a way in which the Oireachtas, myself, as an Opposition spokesperson, and others here can put forward some form of process to fast-track the development of critical capital infrastructure in, say, six to eight hospitals throughout the country? We could all unite politically behind that because it is desperately needed. I had to do this for housing. Can we do it for hospital infrastructure? The Department will have capital, to be fair, but the time it will take will be huge. We cannot bypass the law but measures can be taken from a planning point of view. If the Minister wants to come back to me separately on this, I will work with him on it.

I wish to jump in on the discussion about cardiac issues. I am trying not to overlap with previous speakers' comments to be fair to the Minister. There is the issue of what happened in Waterford. Like everyone else, I am very sorry for the family involved. My wife's family come from south Kerry. I ask the committee to imagine trying to get to Tralee or Cork from Ballinskelligs or Waterville or to hospitals in the region from west Clare or north Sligo, and all the issues relating to these places. The cardiac issues in the north west are very similar to those in the south east. This probably exists already, to be fair to the witnesses, but has a map been produced which shows the critical times it takes to get to every hospital? If it exists, may we have it? I have not seen such a map. If we had sight of it, then we could examine solutions - politically and collectively - here with the witnesses. Unfortunately, this will happen again and again, and we need to take a bit of the politics out of it. We need to plan for this.

The next issue I wish to raise is home help. This is a bugbear of mine. I am trying to help the Minister again. When I began in this spokesman role over a year ago, home help hours were a critical issue. They still are, but the biggest issue now is not the hours but the people. It is the bane of my life. I have two neighbours in their 80s who have 21 home help hours. However, they have never had 21 hours; they have had ten, and very recently, until a very good intervention by a member of the HSE, they were going to be down to two hours. Through working perhaps with the Minister for Finance or someone else, is there a mechanism whereby we can encourage more people out there to be trained up one level and work in this area where it is financially more viable? A lady I know provides home help hours but it is financially only viable for her, given child care and everything else, to provide a certain number of hours. It is not worth her while doing 20 or so hours so she does ten. Can we change this equation? We need these people. It saves the taxpayer a huge amount of money. We all know that the more home help hours, the more we save because nursing homes are so expensive - €1,200 or €1,400 a week - and a bed in an acute hospital costs over €1,000 a day. It is like a step, and if we can keep people from getting into the second or third step by increasing home help hours and getting more people into it, we will obviously gain.

By the way, I agree with Deputy Kelleher about the issues in general practice. I think we passed a motion here on this. It is illogical that one GP organisation is outside the window in these discussions. It is quite obvious that we will have to look at direct GP contracts as part of the solution to this in certain areas where the viability of being a GP is very questionable. I also agree with the Minister about the statutory home care scheme and I will work with him on it. I have always agreed with him about this. Will Mr. O'Brien send out a diktat across the HSE to remind people of common sense because of what happened to the elderly couple this week? Not everyone can get on "Liveline", to be fair.

The model 1, model 2, model 3 hospital relationship must change, particularly when it comes to emergency care. I represent Tipperary. We have a fine hospital in Nenagh that does what it says on the tin. We have Ennis Hospital and there is also St. John's. They have minor injuries units. They do not open for long enough and the pathways to the kinds of procedures they should be doing need to be widened out a little. It would not take much to do so, which will alleviate somewhat the crush and the scale of the situation in Limerick, so I ask the Minister to consider extending the hours, evaluating the safety issues involved and examining various actions that might be taken.

The real issue I wish to discuss in this regard relates to intermediate care vehicles. I have asked about this before. It is farcical that, first, there are not enough of them on the road, second, that there are not enough trained people to operate them and, third, that the vehicles only operate Monday to Friday most of the time. The bugbear we all have is that hospitals should not stop operating for two days each week. If one does not get one's scan reviewed by a Friday, one must wait until Monday. That is insane, but it is a matter for another day. I am really asking about intermediate care vehicles. Such vehicles are, I believe, are part of the solution. They can be used to move people from model 1 hospitals to model 2 hospitals, etc., in order that they do not take up the critical acute beds in Limerick and they can be seen in Nenagh for their aftercare or pre-care or whatever it is. There are not enough of these vehicles on the road. It is simple as that. They are not operating. I know about this because the Mid West hospital group is probably the one that has been in this role the longest.

I have always been of the view that we need to introduce some form of public scrutiny or scorecards when it comes to the numbers of GP referrals - individuals names would not be included- when it comes to emergency theatres in particular. It is quite obvious that in some cases and some areas, certain GPs are referring much more than others. Why is this? It does not make sense. Obviously, some GPs will have bigger lists and we can extrapolate out all of this, but something should be done in this regard. Another issue falls within the same area of publishing for public scrutiny the percentage of work of consultants in private versus public hospitals. I am not saying I have all the answers, but there is not enough public information on either of these two matters and not enough public scrutiny as a result. Both matters cause issues if they are lopsided, where a GP is making too many referrals and the proportion of private versus public work, particularly in public hospitals, carried out by a consultant is on such a scale as to cause difficulties down the road. Those are my questions and they are all different from everyone else's.

Deputy Durkan had to go to the Chamber for Question Time.

I have a few questions. Mr. O'Brien's opening statement referred to a 6% increase in accident and emergency attendances, a significant number of which are patients over the age of 75. Patients aged over 75 will stay longer in hospital and have more complex needs. We certainly need a response to our ageing population and changing demographics. As stated in the Sláinte report, perhaps some of those patients do not need to be in hospital and can be looked after in the community, either in model 2 hospitals, and not ending up in accident and emergency, or to be maintained in their nursing homes by employing community intervention teams to supply services to these lower level hospitals. I ask the Minister to comment on that aspect.

Mr. O'Brien mentioned that 14,300 people who have been waiting longer than 15 months will be taken off the National Treatment Purchase Fund's procedure list. Into what category do they fall? When representatives of the National Treatment Purchase Fund appeared before the committee some weeks ago, they addressed long waiters who were waiting for day case or simple procedures. It was not really taking people who needed complex procedures off that list.

Mr. O'Brien's opening statement indicated that 191,000 people have been waiting longer than 15 months for an outpatient appointment. It is proposed that 50% of those would be dealt with in 2017, which equates to 95,000, some 36,000 of which have been dealt with already. How has that been achieved? How was it possible to remove 36,000 from the long waiting list?

I ask the Minister to give an update on the access programme for cannabis products in cases of epilepsy, muscular spasm, MS and intractable vomiting as a result of chemotherapy.

Mr. O'Brien has said that the Sláinte report represents a once-in-a-generation opportunity to reform our health service. The Minister has stated that he is happy to deal with areas outlined in the report that are compatible with Government policy. It will hardly reform our health service if it is confined to areas incompatible with Government policy. I ask him to comment on that point.

It was in the report rather than what I actually said. We will come back to that.

The cross-border health care directive may not be commonly known. If a patient who requires a treatment that cannot be provided in this jurisdiction can locate to an institution or doctor that can provide that treatment outside Ireland, the patient is entitled to receive that treatment and have the cost reimbursed by the HSE.

I wish to sow an idea in the Minister's mind. Deputy Kelly asked about the development of urgent treatment centres sitting beside accident and emergency departments. A number of GPs in the mid-west have proposed to the CEO of the UL hospital group the development of urgent-care centres which keep people out of the accident and emergency department, but supply them with an intermediate service between GP out-of-hours and accident and emergency. Deputy Kelly spoke about the huge increase in attendance in University Hospital Limerick - perhaps the modern new accident and emergency department is a victim of its own success.

The Minister can add those questions to his list and I ask him to answer the last tranche of questions.

I propose to take them in the sequence in which they were asked. I believe Senator Dolan's questions are for the Minister of State, Deputy Finian McGrath.

I thank Senator Dolan for raising a number of very important questions. I will address as many as possible and some of the HSE officials, particularly Mr. Pat Healy, might like to expand on particular items.

The Senator asked for an update on the UN Convention on the Rights of Persons with Disabilities. I intend to ratify it and we have moved forward in recent weeks. We have had weekly meetings involving the Departments of Justice and Equality, and Health. We are dealing with the blockages relating to the deprivation of liberty and the Assisted Decision-Making (Capacity) Act. We have consulted with the HSE, the National Disability Authority and the Mental Health Commission, and have made major progress, particularly in recent weeks. As previously mentioned, we have met parents, disabled people and advocates. They have been lobbing me on this issue. We have been involved in a listening process. I have met individuals who have given me advice on how to progress the convention.

One important aspect of the UN convention is the decision-support service, DSS. Interviews have been held in recent weeks and we are coming to the conclusion of those. I am optimistic about having a director and a project manager in place as quickly as possible.

I will meet the Taoiseach and the Secretaries General before the summer recess to again drive the UN convention. The Senator probably heard that in his speech. The focus is on trying to move this forward as quickly as possible and develop the co-operation between different Departments.

Can the Minister of State give some dates?

I cannot give the Senator dates.

That is problematic.

We gave a date before.

The Taoiseach has said it will be ratified by the end of the year, with things to be done by then.

Yes. We have dates ourselves, but I do not want to announce them. We have lots of dates and deadlines, but I do not think it is appropriate now-----

Is the Minister of State confident that there will be no hold-ups from the Department of Health and that we will have ratification by the end of the year?

Absolutely 100%.

Go raibh maith agat.

I would be very confident. Everybody is working very closely together to resolve the issues.

There is very positive momentum going on between the Departments of Health, Justice and Equality, and the Taoiseach, and me. That is the current situation.

I would appreciate if I could finish the points rather than be interrupted. I have been waiting here for a while and I wanted to get back in on a few things.

Listening to some people, one would think not much was going on in the disability sector. It is important to remind people of the huge amount of work going on in the disability services and the disability sector. Recently, 9,800 people in receipt of domiciliary care allowance for sick and disabled children have been given medical cards, which has a very significant impact on families with disabled children. We have also had the restoration of the carer's grant, which 101,000 families are receiving. Some €1.688 billion is being invested in disability services, an increase of 6%.

Senator Dolan spoke about figures, estimates and plans. I know from my day to day job that, for example, we are dealing with 1,500 school leavers every year. There has been a major improvement since last year. The families of all those 18-year olds leaving over the next week or so have been told what service they will be attending. That was a problem when I first came into office and one we also have to deal with.

We will be offering 8,400 residential places, 182,000 respite nights and 1.4 million personal assistant hours for 2,400 people with disabilities. We will deal with 24,800 day places and 2.75 home support hours for 7,500 people. Those are the kind of numbers we are dealing with. Regarding emergency cases, we will have €16.2 million supporting 395 people this year. In that sector we will provide support for 210 emergency respite places. These are the kind of figures we are talking about.

I agree with the Senator's point on unemployment and poverty. The high level of unemployment among the disabled is totally unacceptable and I again raised this issue at Cabinet last Tuesday. We have a target of increasing the employment of people with disabilities in the public service from 3% to 6%.

Some Departments have a good record in this, where up to 3.6% of employees are disabled. I welcome that, but a hell of a lot more must be done. We also have the national disability inclusion strategy which it is hoped will make a huge difference to people's lives. I am bringing forward these practical, hands-on, measurable actions. Make Work Pay is a group which is working to make it worthwhile for a person with a disability to take up employment. I have already mentioned the comprehensive employment strategy. There are many actions ongoing. On the points raised on section 38 and 39 hospitals, and I might ask my colleagues from the HSE to develop this as well, I agree that the staff migration to better paying organisations is an issue-----

I do not want to interrupt but someone's phone is interfering with the recording.

I hope it is not myself. To return to section 38 and 39, staff migration is an issue. I have raised it with the Minister for Public Expenditure and Reform, Deputy Donohoe. I agree that we must retain people in these services, because otherwise the services are going to be damaged. This is in the interests of people with disabilities. I am working closely with the Department of Public Expenditure and Reform on this issue.

On the issue raised by Senator Colm Burke concerning respite care, we have to develop the respite care service. I accept that argument. We have started work on that. For example, last year we planned for 182,000 respite overnights and 41,000 respite day places. We also have 210 new home support hours for families. I mentioned earlier that families should not forget that we have restored the carer's grant, which was formerly known as the respite carer's grant, which amounts to €1,700 per family. That allows people to access and buy respite services. We have choices in respite services. We have to make plans for such services, and we have many such plans. The COPE foundation was mentioned. In 2016, the COPE foundation got €47.5 million in funding, but in 2017, we are going to give it €49.6 million. That €49.6 million includes €317,000 in a full year for respite services and a €45,000 once-off payment for the extension of the day service building. We are investing in the services, but we are also reforming the services in the interests of the person with disability.

On Senator Dolan's point about progress in other Departments, disability is not just part of the health, social protection or justice areas. It applies right across every Department. The national disability inclusion strategy contains many themes, which are equality, choice, joined-up policy, public services, education, employment, health and well-being, person-centred disabilities services, living in the community, transport and accessible places. In all, 32 key objectives are identified. The whole issue of disability has to be broadened out and the services have to be developed.

My focus is on three things. First, we must reform disability services. Second, we must invest in disability services. Third, we have to design the service around the person with the disability, whether it is a physical or intellectual disability.

Perhaps some of my colleagues might answer some of the other queries.

Before there is another contribution, the Minister of State, Deputy Daly, has to attend the Seanad at 5 o'clock. If there are any questions the Minister of State wishes to address, he might do so prior to the next contributions.

I appreciate that. Deputy Kelly's point about home helps is very valid and we have to take a wider look at that issue because it is going to be a greater challenge. Something that we are all picking up on the doorsteps as practising politicians is that people cannot be found to do the hours, even if the hours are available. We have to look at incentivising it in some way across Government, be it through-----

The taxpayer would save money if the home helps were incentivised to come and do the work.

I agree. It is a very creative suggestion and one we have to take on board coming up to budget time. I acknowledge that very constructive contribution.

Mr. Pat Healy

I wanted to respond to the points made by Senators John Dolan and Colm Burke on the issue of planning. Senator Burke raised the issue of respite, and as the Minister of State, Deputy McGrath, has said, we set out in the note the specific increases for COPE, plus some of the losses of beds due to HIQA compliance. On the specific planning data he referenced, while we do not have them for the Cork area, we do have them nationally. Looking at the age profile, the recent Health Research Board, HRB, report which informs our contribution to the Estimates process and so on would indicate that 49% of people currently registered are 35 years of age or older, which clearly has implications for planning, particularly with the ageing issues in some of the cohort of that population.

On respite, at a national level, approximately 90% of those waiting for respite live at home. That is important. We have identified just over 2,000 places nationally, and 400 a year are looking for respite care. As Deputy McGrath said, we came up with an innovative approach this year in terms of new in-home respite to deal especially with emergency cases because there is a greater level of need there, and we are prioritising that in the current share.

The broader figures of need have recently been identified based on the 2016 figures with a five-year horizon. All that would fit in. There are roughly 500 new residential places a year for the next five years, and around 400 a year for change of needs. That is an indication. We have many other figures concerning day care and education and training, and all those will be used to inform our consideration of Estimates for 2018.

In the negotiations between the Department of Health and the HSE for 2018, we have made respite one of our priority issues.

I should have acknowledged at the very start that a number of significant things have happened over the past year. I am very pleased with my answer to the first question. I have not received a substantial answer to the question about the extent or estimates of need which have not been met. I have information about what is being done, and that is fine, but I have not received a response to my question, which is quite worrying. I want to put that on the record.

On the issue of section 38 and 39 hospitals, I am delighted that the Minister of State has been speaking to the Minister of Public Expenditure and Reform, Deputy Donohoe. I specifically asked if the Department of Public Expenditure and Reform has been in contact with the Department of Health on this issue. I also asked about the pressing areas that need to be moved on. The answer laid out eight, nine or ten areas that are the headings in the disability strategy implementation plan. I asked the Department whether, if a handful of these items were moved to other Departments, it would rightly take pressure off the Department of Health and have resources directed to where they should be.

Mr. Jim Breslin

There have been discussions between the two Departments on the issue of the section 39 agencies. It is not something that was dealt with in the recent pay negotiations because that was restricted to public service employees, and whatever way it is cut, section 39 employees are not public servants. That is the position of the Department of Public Expenditure and Reform and the Department of Health. If there were reductions to salaries in those agencies in the bad times, how will that play itself out? It is not correct to say that every employee in a section 39 agency had the very same reductions as the standard right across the public service.

There may, however, be organisations where they did and employees will come forward and say to their employer in light of what is happening in the economy they believe they are entitled to have some of the reductions restored to them. That will raise funding issues, and that was the point that the Minister for Public Expenditure and Reform, Deputy Donohoe, made. It is unlikely to happen all in one go and it is unlikely to happen in a standard way as happened in the public service because they were not reduced in a standard way. It will have to be done on a case by case basis.

Will that happen?

Mr. Jim Breslin

Certain section 39 employers have been in discussions with employees, including through the Workplace Relations Commission, WRC, mechanisms around this issue. It is likely to play out across the usual industrial relations machinery. If in doing that it raises funding issues they will become the subject of discussion between those organisations and their funders, the HSE being the primary source of funding for many of them.

My concern is not the employees because there are plenty of people to fight that battle but its effect on an organisation that is trying to provide services. The Department is emphasising handing the money over. I am trying to focus on the effect on service provision. That will vary in different places. It has to be a concern for the Department that some services will become less sustainable or unsustainable because of people choosing where to work.

Mr. Jim Breslin

If that were to happen, it would be a concern. It is a bit premature in that the funding of the restoration of public servants' pay increases has yet to be fully addressed. What happened this year and the new national negotiations have not formed part of budgetary allocations. There are many steps to follow before the budgetary implications are properly washed out.

I have three other points for Senator Dolan. I met the national voluntary bodies' network and it made that point very strongly to me because it is concerned about staff. We are anticipating this and have to respond to it and I am very conscious of that.

In respect of support between different Departments and the choices for people with disabilities, the Senator knows that my political position is that every single person with a disability has to be treated equally and that we have to change the mindset of Irish society. There is fantastic co-operation between the Department of Health under the Minister, Deputy Harris, the Department of Social Protection and other Departments particularly in recent weeks in dealing with the recommendations on making work pay and the medical card and earnings issue for people with a disability. In recent days I have been working closely with the Department of Transport, Tourism and Sport. We have to ensure that every Department is focused on people with disabilities and their views so that they can have equal rights and make their choices.

The task force on the personalised budgets, which I set up a couple of months ago, chaired by Christy Lynch, is coming up with an interim report in the next week or two. The final report will be done by December and it will focus on giving people with disabilities more choices and personalised budgets to have services for themselves. A lot of work is being done to push out the equality agenda for people with disabilities but I accept we have a hell of a lot more to do. We have, however, done a lot in the past 11 months.

In response to Deputy O'Connell's question about the increase in the number of consultants and non-consultant hospital doctors, NCHDs, doctors getting more regular work hours and sleep leads to an improvement in service, but the increase in NCHDs was largely to deal with the European working time directive. The increase in the number of consultants is a separate and distinct issue that should lead to service improvements. The HSE may want to comment further on that.

I am very pleased with the significant progress on the National Maternity Hospital. When there was a lot of public concern a few weeks ago I asked for a month to ensure engagement with the National Maternity Hospital, Holles Street, and the St. Vincent's Healthcare Group. The officials and the Secretary General in the Department have done Trojan work in engaging with the hospitals and the Sisters of Charity have made a very significant decision to withdraw from the St. Vincent's Healthcare Group. Several things happened immediately, including that the Sisters of Charity stepped down from the St. Vincent's Healthcare Group board. That is a concrete and tangible example of the ultimate separation of church and State. I acknowledge the huge contribution that order made to health care. That has dealt with one of the most significant concerns people had in respect of this, that there would be religious interference, whether real or perceived, in any shape or form in the provision of maternity services which nobody wants to see happen. Any concern about a religious ethos has been removed.

The other concern was who would own the asset the State was going to invest significant taxpayers' money in. There is still engagement between the Department and the St. Vincent's Healthcare Group on that. That engagement has been positive, constructive, and everybody is trying to find a satisfactory solution. I hope to be a position to report progress on that to Government and the Oireachtas very shortly.

I am pleased that the Deputy raised the issue of rogue crisis pregnancy agencies because I have been extraordinarily concerned about the idea that someone who finds herself in a vulnerable position due to an unexpected pregnancy, or some other difficulty, seeks advice and support from somebody who is rogue. We have seen despicable examples in this country of nonsense, mistruths and disgusting things said to women in a very vulnerable position, which is not information. I was serious about trying to put concrete measures in place to rectify this. After significant engagement with the Department we arrived at the conclusion that the best way to address this was to regulate the professions of counsellors and psychotherapists. Someone who wants to call himself or herself a counsellor or psychotherapist must meet standards and be regulated and the person going to get information can see the plaque on the wall to say this is a regulated, authorised, legitimate counsellor or psychotherapist.

This is an extraordinarily difficult area to regulate. It has been tried for many years in the UK but it has not been done. I am pleased we are going to do it here. I went out to public consultation to give stakeholders an opportunity to have their say. We received approximately 84 submissions and last month after reading those submissions I decided to proceed with the designation of two distinct professions under the Health and Social Care Professionals Act 2005. Each of these professions will have its own register under one registration board. I have communicated this decision to CORU, to the relevant professional bodies and to anybody who took part in the public consultation process. I committed to do this work and have done it in advance of the summer recess. Now I will turn it into the necessary regulations to designate these professions and these regulations will be drafted by the Office of the Parliamentary Counsel and will require the prior approval of the Dáil and Seanad. I hope to be in a position to bring these to the Houses in September. This will be a very significant measure. There has been cross-party support for it.

Why can the Minister not do it in the summer?

There was a commitment-----

I was just-----

I was about to say in the next sentence that I want to acknowledge the work of Deputy Howlin who brought forward a Bill in an effort to progress this. He worked with the Department on it and this committee scrutinised the Bill on 30 March which recommended that it should not proceed to Committee Stage because we were going about the regulation of professions.

I assure everybody that designating these two professions, counsellors and psychotherapists, is a policy decision I have taken. We have had the consultation, written out to people, and to the counsel and we have set up the register. Now the Office of the Parliamentary Counsel has to draft it and I expect to lay it before the Dáil and Seanad in September for their approval. I hope when we get to that point we will have the co-operation of all Members to pass it into law as quickly as possible. We will then have done something in this country that many jurisdictions have struggled with and not been able to do.

On the issue of abortion, the Deputy will understand that I do not want to comment on a specific case other than to say that the full resources in my Department in whatever way they are required will be available, in so far as the committee may wish, to assist the special Oireachtas committee examining the eighth amendment following the recommendations of the Citizens' Assembly. I have made clear my personal view, which is that I want to see a referendum on the issue of the amendment in 2018. I am respectful of the body of work the committee has to do, but that is my view and the view that has been expressed by the Taoiseach in the Dáil as well. I understand we will see the report of the Citizens' Assembly arrive in the Oireachtas. It is an important body of work for us to consider. Under law, tomorrow I will lay before the Oireachtas the annual report I am required to do in respect of the Protection of Life during Pregnancy Act to show how many people availed of terminations under the provisions of that Act in the year just gone by.

The national maternity strategy is clear on the issue of anomaly scans. No woman should be at any disadvantage based on geographical location and there needs to be equitable access to these scans. We will shortly be launching the implementation plan for the women and infants' health programme, which is responsible for delivering the national maternity strategy, and I expect to see the issue of anomaly scans addressed in it. In the interim, it is important to send out the message that, while not available in every hospital, anomaly scans are available in every hospital group, so every woman in this country should have access to an anomaly scan. That is an important message.

Senator Burke raised the issue of Cork and future planning. The Senator is entirely correct. Cork has seen a huge increase in its population but, like many parts of the country, has not seen an increase in terms of its health capital infrastructure and bed capacity. It would be foolish not to plan now not just for the current population but for the future projected growth. I know that this is an issue about which the Senator is passionate. I visited the Mercy University Hospital with him in the not too distant past and I understand representatives of the hospital are looking to meet me to discuss this. I will do that in the next few weeks. It might be useful to meet Oireachtas Members from Cork - if the Senator wishes to arrange it, I would be delighted to facilitate it - to address the challenge being posed to us in terms of putting in place a plan in order that we can prepare for the mid-term capital plan.

I will ask the HSE to answer the Senator's questions on the increase in administration and management staff and we will get more detail from Ms Mannion in a moment, but I will make two points. This is an area that deserves significant discussion by this committee, perhaps when there is more time. What we mean when we talk about administration and management is important. We must ensure we are using the correct labels. What one person might think is the job of an administrator, another might have a very different view on it. It is important we get a bit of clarity on that. To make the point, we had a question earlier about the perceived delays in answering Oireachtas Members' parliamentary questions. The person responsible for answering those parliamentary questions is an administration staff member. If there was a delay in the processing of the medical cards, people would rightly be on to me about it. The people processing the medical cards may well be in the administration or management sector. Every time we set up a new multidisciplinary team, there is an administrative challenge.

We have also come through a period whereby many posts had been suppressed. The Senator has probably heard through his clinics - I have certainly heard through my own engagement - health care professionals saying that the support structures were not in place to empower the health care professional to get on with his or her job. I will ask the HSE to answer it, but that is my initial response. However, Sláintecare poses significant questions in this regard because it speaks about the significant restructuring and reconfiguration of our health service. The question the Senator asks about what the management structure and the numbers will look like in the context of the implementation of a ten-year plan is something on which I would like the HSE to hear his initial thoughts. It will be a question I will be considering in the context of the implementation plan.

I thank Deputy Kelly for his series of questions. I say sincerely that, as well as being questions, they are some very fine ideas that merit significant and serious consideration. I will try to answer some of them. In terms of eHealth, he is entirely correct. It is exciting that there is now a political consensus that we have got to do this. He is right that, after many years of ICT projects in different areas of the country not working, there is perhaps a reticence in many parts of the public service. I am proud that that is not the case in the health area. I was very proud when we had the extraordinarily difficult cyber attack that the health service in this country held up extraordinarily well. People worked incredibly well and the investment that had been made paid off. The health sector showed a leadership role within the public service at that time.

We have now begun to roll out the electronic health records for newborn babies in hospitals in Cork and Kerry and it is about to go to the Rotunda Hospital. There is a roll-out plan for it. As I stated, I have signed the commencement order and the regulations for the individual health identifier. The Deputy is right that there is a big bill attached to this, but I will not be found wanting in terms of prioritising it in the context of the needs of the health service and forthcoming capital planning because it unlocks a lot of potential within the health service. I am struck by the issue of eReferrals. It used to go through 16 pairs of hands from when the GP wrote a referral until it got to the consultant. The GP can do it now while the patient is sitting in the clinic and send it off to the consultant. That frees up a lot of capacity in the system.

On speeding up capital development, the challenge the Deputy has posed to me is something on which I would be interested in working with him. I will revert to him on it. Is there a way of fast-tracking critical infrastructure if we consider there to be a real capacity shortage in the health service, which we all do? To address his question bluntly, I want to see South Tipperary General Hospital included in the capital plan because, from my visit there, I think it is badly needed.

There is a map in terms of cardiac care. I have one and will make it available to the Deputy and the committee. That is the approach to take. While there is a powerful campaign and quite important issues in the south east, there are issues in other parts of the country too. It needs to be looked at nationally.

On the issue of home help, we should take up the question about how we encourage more people to take up the role. I will liaise with the Department of Education and Skills about it.

The Minister for Finance might have a role in this too.

Okay. I will liaise-----

There are people for whom it may be worth their while. We will end up saving money.

We will. The statutory scheme, the consultation process to which we are hoping to launch in the coming days, will begin to address that question. If working in a sector that is defined under law and structured, many questions will arise such as who regulates it, who can provide home help, and the qualifications and background needed.

On the model 1, 2 and 3 hospital relationship, we are due in the programme for Government to review the minor injuries units. I share the view that they could be open an awful lot longer. On pathways needing to be widened, that is an interesting point on which I will come back to the Deputy.

On intermediate care vehicles, the Deputy is correct that we have increased the budget for the national ambulance service this year. Much of that increased funding was for intermediate care vehicles. More than 90% of transfers between hospitals are being done by this service rather than the arrangement of ad hoc situations in the past.

The point about getting data, without naming people and geographic areas, on what GPs are sending people to emergency departments is a valid one. I will take it further. However, I note that I launched the national health care quality reporting system yesterday and there are a couple of interesting indications in it, county by county, such as how many people in County Tipperary are being referred for chronic obstructive pulmonary disease, COPD, or for this, that and the other to various emergency departments. The Deputy is right that if we scrutinised it, it might give us some more indications.

I thank the Chairman for the questions.

The question about the consultants was the last thing.

My apologies. I will undertake to examine if it is possible to analyse the public-private mix. That makes sense.

The Chairman is entirely correct that the first tranche of National Treatment Purchase Fund, NTPF, funding was for largely low-complexity, high-volume day case procedures. That is not the full extent of the fund's work this year and it is looking at including complex orthopaedic procedures as well. It will be a mix of day cases and inpatient cases, including some quite complex procedures.

I am pleased to tell the committee that the cannabis access programme is going well in the sense that the expert group is working away diligently. It had another meeting either today or yesterday and is due to provide me with a report next month. I will be pleased to come back and discuss that with the committee at a time of its choosing.

On Sláintecare, the reason I slightly interrupted the speaker, for which I apologise, is that there is a remark being attributed to me of which no one can find any record whatsoever of me ever saying. That is quite frustrating because I say an awful lot of things on the record for people to attribute to me if they wish. As recently as last week, I also said on the record at the Committee on the Future of Healthcare that I believe that this is a once in a generation opportunity to get this right. It is good to see that the director general and I are on the same page on this issue. I never suggested that it is only about moving ahead what the Government thought was a good idea. I said it was encouraging to see that a number of things in Sláintecare are already things that have been identified by Government, but by the health service, if that makes sense. National standards such as the Healthy Ireland framework, the eHealth agenda and the new GP contract are items that are already under way. In addition to that, it is in relation to the new stuff that I am duty-bound as a Minister to come back with an implementation plan.

The challenge with voluntary care, to which I am happy to rise, is in the sequencing of change. If one had the funding and were to provide everybody with automatic entitlement to free GP care in the morning, one has to ask whether we would have the GPs to deal with it. As one increases entitlement one has to build capacity and if one does it with the wrong sequencing it will become an issue.

The second issue is funding. I accept the committee did some costings but it would also concede - with a degree of pride, I believe - that there is agreement on how we would fund it and there is agreement on how much it would cost. I am looking forward to going to Government with my views on an implementation plan before the summer recess. I am really committed to advancing this as it is a really honest, diligent effort by politicians not to be partisan with the health services but to lay the foundations for the future. There was an idea for urgent treatment centres and I will certainly reflect on that with colleagues in the Department.

Deputy O'Connell asked about HPV.

I acknowledge my predecessor, Deputy Marcella Corcoran Kennedy, for the Healthy Ireland programme and thank her for all the work she has done. I hope to be able to implement the national drugs strategy in my role as Minister for State. Deputy O'Connell is right that there has been a significant fall in the numbers of young girls having the HPV vaccine. This is a very serious development for a large number of girls who may develop cervical cancer later in their lives. The Department of Health and the HSE are working to counteract the misinformation connected with the vaccine, which undermines our national vaccination programme. As parents, we understand that there are risks with all vaccinations. I once sat on the opposite side of the room and I listened to parents speaking about the HPV vaccine, as well as the counter-arguments from the HSE. I am not a medical professor but the Minister attended the national vaccination conference where he heard about the safety and effectiveness of the vaccine and the work being done to increase the uptake by girls as part of the school immunisation programme. All parents are given an immunisation pack outlining what a vaccination is about, what diseases it will be effective against and the risks. The Minister can comment more on the conference.

We have to take every single opportunity to call out the people who consistently tell mistruths about this because it will cost people their lives. Every year approximately 300 women get cervical cancer and 100 will die. The HPV vaccination has been tested to within an inch of its life and is internationally recognised as saving lives. Due to misinformation and scaremongering being put out by some people - some of whom should know better - it has led to a significant decrease. The HSE, my Department and I will continue to put forward the benefits of HPV and I appeal to all colleagues on all sides of this House - and I know there is cross-party support on this - to take every single opportunity to debunk the myths. It is straightforward. If one wants to give medical advice, become a doctor. If one does not want to become a doctor, do not give medical advice. If people give medical advice on Twitter and other social media, confuse people and engage in scaremongering, it will have a detrimental effect on the lives and well-being of girls and boys in this country. It will cost lives so there is a responsibility on all of us - the health service and the political system - to show leadership. It is a very important vaccine.

When we realised the rate was dropping we had catch-up programmes and the immunisation section of the HSE did some work on it. Is that having any effect? Are we having an impact on the falling rates? This is so serious that it needs to be reviewed every three months. The decline has been so rapid that it is not good enough to have an annual review. The current rate is 83% but if we get down to 75% it will all have been a pointless exercise. I take issue with the Minister on one point - pharmacists can give medical advice too.

Mary Harney started the good work on this and Senator James Reilly was very supportive-----

There was cross-party consensus.

-----but it will all come to nothing if the figures get down to that level. If what elected Members and the HSE are doing is not helping, we need to do something else. There are 40 girls walking around today who will die from cervical cancer because of the reduction in the vaccination rate. They could be daughters of any of us.

Mr. Tony O'Brien

I can give more information but some of it is not good information. In a past life I commissioned the first health technology assessment on the HPV vaccine and I regard the campaign against the vaccine as nothing short of emotional terrorism. Unfortunately, however, so far it has been successful. Vaccine uptake rates in 2014-15 were 87% and they fell to 72% in 2015-16 but provisional data for the current year indicate that only 50% of girls received the first dose in September or October 2016. There has been some improvement on that in the programme this year but the net effect renders hundreds, if not thousands, of teenage girls at risk of a substantially preventable illness. The campaign is absolutely without evidence or foundation and those who are engaged in it are literally playing God with people's emotions and lives. We are committed to redoubling our efforts to counter this misinformation and to restore confidence in what, in conjunction with the cervical check programme, can be a hugely effective campaign to substantially reduce both the incidence of and loss of life from cervical cancer and other conditions.

I thank Mr. O'Brien for his bad news.

I asked about OPD waiting lists.

Mr. Tony O'Brien

There are a few questions for the HSE. I will deal with a number of them and my colleagues, Ms Mannion, Mr. Woods and Mr. Healy, will deal with the others. The 34% figure in my opening statement related specifically to the community intervention teams, in what is an OPAT-focused programme. Two things occur. Either there is admission avoidance, in the form of discharge from an emergency department into a community-based care system, or there is an earlier discharge. The programme specifically relieves admissions or discharge pressure in acute hospitals rather than layering on something new. We are seeking to avoid referrals to emergency departments altogether by making this a viable option for general practice.

I categorically state that the specific, targeted scoliosis programme is not to the detriment of other patients.

No existing service will be degraded as a result. There may be an opportunity cost in that if we were not doing this, we could be doing something else. There will be no existing level of service compromised as a result of this.

I did not include the information about the rates of teen suicide in my opening statement to claim any particular credit, but to counter a significant amount of misreporting - it is not so much disinformation - based on old data and the desire to correct current understandings. This is a very significant issue.

I will ask Mr. Liam Woods to address the issue of waiting lists.

Mr. Liam Woods

The Chairman asked about outpatients and how the 14,000 was achieved. There is a weekly rate of reduction in long waiters of about 2,800 and that is continuing in the system. The reduction is achieved through the targeting of long waiters within the normal outpatient process. That is the figure that was referred to.

There were a number of other questions. One was on the increasing consultant numbers and whether it reflects European working time directive, EWTD, compliance or additional clinical decision-making hours. By and large, it is the latter. We are monitoring EWTD compliance in NCHD terms. Growth in NCHD numbers could be more closely aligned to EWTD compliance but not always. Sometimes it is also additional.

A question was asked about nurse recruitment. Nurse numbers in the HSE acute division are up nearly 600 in the current year; 220 of those are permanent and the balance, 377, are students who will graduate at a future point.

The HSE is actively involved in the hospital services in Cork and the designed new hospital. The observations made about UCC are noted.

I will also mention eHealth. A laboratory system is going in nationally. There is a national radiology system referred to as NIMIS. There is a maternity system for women which is an electronic health record, EHR, for women and infants. It has started to roll out in Cork and Kerry and is spreading nationally. It is working very well.

On the issue of the scorecard, there are data on GP referrals. The Minister referred to it. Not all patients attending emergency departments are referred by GPs. The propensity to be referred by GPs varies around the country. We have the data and can make them available. They are the questions that were related to acute areas.

Mr. Tony O'Brien

Will Mr. Healy comment on the issue of home help recruitment?

Mr. Pat Healy

The points made by Deputy Alan Kelly on home help are noted. For the information of the committee, we are making progress on the issue of trying to ensure the hours individuals are employed are meaningful in terms of being a full day or a full week. The history has been of a large number of people with a small number of hours, perhaps ten or 20. We engaged with the unions last year and it was agreed that as people leave our employment and we recruit home helps, we match them to full-time employment. Good progress is being made on the issue Deputy Kelly raised. We are on a good trajectory. It would help in increasing the availability of staff. On the point about incentivisation, we will work with the Department and Minister on any initiatives on that front.

Deputy Durkan had to go to the Dáil to ask a question. He has returned so we will give him the last word.

I will be kind. I apologise for being absent twice during the meeting. If there is no time to answer my questions this evening, I will be happy to accept a written reply.

Is there a trouble-shooter in the system who monitors the capacity to deal with unforeseen accidents or emergencies that arise at any location throughout the country? We did that many moons ago when I was a member of the health board. We did practice drills that showed up any inadequacies and showed management if there was capacity and capability.

The Minister mentioned the word capacity which we became very familiar with in the course of the meetings of the Committee on the Future of Healthcare. As I said before, I believe we can work out all these things mathematically. We can identify the extent of a deficiency in any area. We can identify where it is at and how to counter it. To what extent, if at all, has that concept been employed by the HSE to identify a lack of capacity in certain areas whether it is hospital beds, nursing staff, doctors, consultants or any other aspect of the service? It is only when the service is tested that its weakest point shows up. It is that which determines what is the service.

I will comment on the unattractiveness of GP practices in city and country at present. There is an ongoing negative attitude in the commentary on health services and it is unhelpful. Nobody wants to go to work in a place that has an aura of negativity hanging over it. They do not want to be victims, and rightly so, of the general criticism of the system. We have to improve the system but, on the other hand, we have to be conscious that people who work in a particular situation at any given time like to feel they are doing a job that is appreciated. An issue that comes up from time to time is quality of life in the workplace and job satisfaction. If one removed that from the delivery of vital services such as the health services, there would be a serious void which would show up to a greater extent.

Home care packages have already been mentioned so I will not go over it again. There is a case which has received publicity in the past number of days. I compliment those who dealt with the issue when it became a national issue and an emergency issue. Capacity needs to be put in place within the system to deal with the human elements that arise from time to time for which there is no set piece on paper. There is no tabular form that can be referred to. There is a necessity to be able to take the situation and deal with it. That applies to medical cards too, which is an area in which it is improving. It does not only apply to health services; it applies to all services throughout the country. That is the way it is.

Drug costs have been referred to already. I compliment the Minister on his work so far in experimental drugs. I do not know if we can resolve it permanently or not. I am strongly of the view that the Single Market should apply in this as it does in everything else. If one is ordering a product on behalf of 500 million people, one certainly has greater clout than if one is ordering it on behalf of 5 million people. I would ask that special emphasis be put on bringing it to the fore as soon as possible.

I have two final points. The first is on orthodontics. It is something that causes awful problems in households and huge expense. Parents go to the ends of the earth to borrow money to carry out orthodontics. We have a system of category one, category two and category three. Category three patients never get treated at all. Category one patients get treated on a long ongoing basis. It is not a satisfactory system. Will somebody please identify what the problems are and try to deal with them in a way that is more dependable and efficient and which reflects a modern society?

The last point I will make is on the disability sector. I compliment the Minister and Minister of State on their reappointment and the new Ministers of State on their appointment. I wish those who have moved on to other places the very best. Mid-term reviews are always difficult times. It is good to see people back in the roles they have become familiar with. I have always held the view that if one has an agenda in a Government Department, one has to bring it forward. If it is a five-year plan, one better bring it forward to six months because it will take five years to implement the six-month plan. What is the extent to which adequate resources remain available to the Department and the Minister to cater for the transport needs, day care, respite care and residential needs which seem to be merging to a greater extent now? I have spoken about it before, as has everybody else.

The same people are carrying the burden for many years. They get tired and worried. We do not always respond in the way that we should, but follow a blueprint that seems to have the answer, but does not always work out that way. The blueprint can work to the detriment of Ministers as well, as they will be informed of the prototype, which is usually trotted out to defuse the Minister's concern and anxiety about the lack of progress or whatever the case may be, but we need to come to grips with this in so far as we can.

In response to the point on social media and the vaccination programme, yes, serious damage has been done to the vaccination programme on social media. The problem is that public representatives have to ask themselves if the points made on social media are accurate. It takes time before there is a rebuttal. My advice is that there is no point responding in the newspapers such as the The Times or The Sunday Times to a point made on social media. One must respond to it through social media. Otherwise public confidence in the health system will be eroded, and it will be eroded before the Minister or Minister of State has had time to get to grips with the situation.

I thank Deputy Durkan. I invite the Minister, Ministers of State and Mr. Tony O'Brien to make their final comments.

Most of the points made are for the HSE. I acknowledge that Deputy Durkan has consistently raised correctly the issue of the drug costs and that we should utilise our membership of the European Union in this regard. I could not agree more with him. I have attached a significant degree of importance to this since coming to office. In fact at the last meeting of European health Ministers in Luxembourg two or three weeks ago, I took the opportunity to raise the matter. We are beginning to see finally the building blocks of people working together, because none of us, regardless of whether one is a large or small country, can afford to do it on our own any more. I am confident that we will see further progress. The officials from my Department will be at meetings with officials from a number of other countries, exploring concrete steps we can take in that regard.

I agree with the Deputy's viewpoint on orthodontics. We all see the impact of this service though our constituency work. It is an important and sensitive issue in the life of a young child or adolescent. We have a commitment in the programme for a partnership Government to provide timely access to orthodontic care. Already the HSE has undertaken a procurement of orthodontic services with a number of private service providers. This commenced towards the end of last year and we now have treated an additional 11,080 patients who were on the waiting list for the longest time. The HSE is looking at procurement locally, including service level agreements, SLAs, with dental schools. Orthodontics is an important area and one to which we attach priority.

Mr. Tony O'Brien

Deputy Durkan is absolutely correct on social media. The HSE has increased its social media presence quite significantly in terms of monitoring and communications. At the risk of sounding pithy, I make the point that all the people who do that work are clerical and administrative staff too. There is a bit of theme coming through.

In relation to emergency management in the health sphere, the HSE carries the statutory responsibility for emergency management. In the last period we have developed the national emergency operations centre, which is the centralised control system for all of our emergency resource deployment. We have also significantly increased our emergency planning capacity. It is now formally part of the brief of one of our national directors. We also have a head of emergency management and we carry out frequent risk assessments and drills. Fortunately our national risk assessment on terrorist related emergency health care related incidents remains low, but we have observed very closely what has happened in our nearest neighbour in terms of recent events and have engaged directly with our counterparts in terms of lessons learned and so on. Clearly in the health space, mass casualty events are more likely to come from transport related incidents and so on. We carry out live exercises in that space and are working on conjoined planning on a cross-public sector basis with the Defence Forces, the fire brigade services and An Garda Síochána who would be in the lead in the context of a security related incident. I am pleased to say this is an area where we are well prepared, notwithstanding all the other challenges that the health service has in responding to emergencies, which is what we do. We have gone through a very elaborate process of ensuring that we are well prepared.

The recent cyber security threat to our health service, to which the Minister referred, is a textbook example in that we followed our major incident approach.

The issue of morale has also been raised. I am glad it was, because it is not necessary to denigrate the quality of what our 100,000 plus staff do in order to make the case that we need to improve the health service. Others do that.

On the issue of cyber security, in the National Health Service, NHS, in the United Kingdom they were susceptible to more risk and more targeting. I think they lost 40 hospitals for a whole weekend. The BBC celebrated with a special programme on the work of the cyber security team in the NHS. We in Ireland took some steps, protected the entire health service from attack and the headlines we got were actually critical in that same week that we had successfully rolled out a maternal and infant information system to create Ireland's first so-called digital babies, real babies, of course, with a digital identity. The contrast was, of course, not lost on me. We have a terrible habit of looking for the negative in our health service, when there is tremendous work done day-in and day-out by the staff who work in it. They showed resilience under the cyber security attack, which is not yet over is but was one example.

On the general point made in respect of the fair deal scheme affecting the Devereauxs, this is a people business, it is delivered by people and people sometimes make judgments that they regret afterwards or which they would change. There is a great phrase that covers it, that "to err is human". I would not jump up and down on an individual who made a decision in good faith. The important thing is that the decision in caught and corrected. Clearly "Liveline" is a national institution originally under Marian Finucane and now under Joe Duffy. What we need to do of course is to make sure that people understand that it is not the place they go to, to get issues resolved. Just as I once appointed and continue to have a confidential recipient in the area of residential disability services, we will be giving serious consideration to how we have our own "talk to Joe", response so that things can be resolved even more speedily and more effectively. Not that I want to steal the real Joe's thunder or anything, but I do not want people to have a feeling that in order to get common sense applied, where things have not worked out well initially that it is necessary to expose his or her life to national radio. That adds a further trauma. We will look to see how we can improve on that.

Chairman, may I respond to a question on disability raised by Deputy Durkan?

We have prioritised a lot of the issues that he raised, in particular emergency residential respite day services in the next nine to ten months. These services are very important key dimensions to disability services. It is all very well to go along and talk about the rights of people with disabilities but we need to have the services for them. That is my focus at all times.

Other issues, such as what happens when people with disabilities are school leavers safeguarding adults, were touched on by Mr. O'Brien. We have a very good service with a confidential recipient who is very good at working with the families of those with a disabilities. People who are concerned about vulnerable adults, and such cases, can contact that service, so that we have that in line as well.

The other direction we are taking is to have therapy posts, we have an issue with the number of posts.

The final issue is the new rehabilitation strategy, and we are looking at the idea of exploring a pilot day service. These are all important issues in respect of disability services, but let me emphasise the services have to be reformed, we have to invest in them but also we have to design the services around the person.

On behalf of the joint committee I thank the Minister, Deputy Simon Harris and Ministers of State, Deputies Catherine Byrne, Jim Daly and Finian McGrath for coming before us. I thank Mr. Tony O'Brien, Mr. Jim Breslin and the officials from the HSE for giving their time to this committee.

As there is no further business, I propose we adjourn. Is that agreed? Agreed.

The joint committee adjourned at 5.40 p.m. until 9 a.m. on Wednesday, 5 July 2017.
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