Quarterly Meeting on Health Issues: Discussion

The purpose of this morning's meeting is to engage with the Minister for Health, the Department of Health and the HSE in our quarterly meetings on the current issues that face our health service. On behalf of the committee I welcome the Minister, Deputy Simon Harris. I am aware that he will be accompanied by a number of his Ministers of State who will attend as they become available.

I also welcome: Mr. Jim Breslin, Secretary General of the Department of Health; and from the HSE, Mr. Paul Reid, director general; Ms. Anne O’Connor, chief operations officer; Dr. Colm Henry, chief clinical officer; and Mr. Liam Woods, who I understand will be joining us as well.

I wish to draw the attention of those in attendance to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him or her identifiable.

I also wish to advise witnesses that any opening statements they have made to the committee may be published on the committee's website after this meeting.

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

I call now on the Minister, Deputy Harris, to make his opening statement please.

I thank the Chairman and will take Deputy Kelly's constructive suggestion and be brief in my opening statement because I have circulated it to members and I am aware that they want to get into the questions and answers section of the meeting.

I am pleased to be here today and to have an opportunity to be joined by my Secretary General, Jim Breslin, and also by the chief executive of the HSE, Mr. Paul Reid, and his team.

I do not wish to cover the same ground that my officials already did last week at this committee but I am conscious in being here today that we are meeting in the context of Britain's intention to leave the European Union at the end of this month and the very real possibility of a departure in a no-deal scenario, according to the British Prime Minister's statement of intent to leave on 31 October, come what may. I want to acknowledge the enormous amount of work that has been undertaken by the health sector at a governmental level, from the Department of Health, the HSE, the Health Products Regulatory Authority, HPRA, the Pharmaceutical Society of Ireland and so many others. I also want to acknowledge those beyond the governmental and State level, namely the stakeholders we have been working with collaboratively - the Irish Pharmaceutical Healthcare Association, the Irish Pharmaceutical Union and so many others - in preparations in the official, agency and industry sectors.

I want to assure the committee and, more important, the public that we are focused on being as ready as we possibly can be. We are well prepared to troubleshoot issues as they arise in the days and weeks following Brexit and to minimise any disruption to citizens. I also want to assure the committee that a citizen of Ireland will be able to access the same health services after 31 October. Patients will continue to avail themselves of health services on an emergency and planned basis when travelling to the North or the UK. There is a commitment on the part of both Departments that the established North-South co-operation in health matters will continue. This is so important, as has been the goodwill and a deep embedded culture of working together North and South when it comes to health matters.

At the request of Government, my Department finalised legislation yesterday which we brought to Cabinet to provide benefits to residents of Northern Ireland similar to the those of the European health insurance card in the event of a no-deal Brexit. This is something that has been very much welcomed by all parties in this House, in Northern Ireland, and by society in the North in general. This was an idea that we had already dealt with in the Brexit omnibus Bill, in terms of North-South and east-west reciprocal health arrangements. We have gone a step further here where, if a Northern Ireland citizen finds himself or herself ill while on holidays in Spain or France or somewhere else in the EU, we have agreed to assist them in meeting the costs. With the co-operation of the Oireachtas and this committee, Chairman, my intention is to pass that Bill into law in advance of 31 October; I look forward to working with the committee in that regard.

Supply lines for drugs and medical devices are all being examined. Significant buffer stock is already held within the domestic supply chain. There is no need to stockpile medicines by either a patient, a pharmacy or a hospital. This is an important message for our citizens and for our health service to hear. To do so would hamper access to medicines by those who need them when they need them.

Brexit has been a key focus for all of us but there are many other ongoing health service issues.

I understand the Chairman has invited the executive director of the Sláintecare programme office to attend a meeting of the committee later this month. As such, I will not dwell too much on that aspect other than to say that since we last met, we have taken several significant decisions towards the implementation of Sláintecare. One of the most significant of these relates to the publication of the de Buitléir report on removing private practice from public hospitals. I have made clear my view that this should be done. It is entirely unfair and inequitable to have private practice continuing unabated in public hospitals while public waiting lists lengthen in many specialties. It is an unfairness that must be addressed. I hope there is similar clarity from all parties in the Oireachtas on the need to tackle this issue. I accept that many colleagues here have offered that clarity, but it is not forthcoming from some others. The expert group did a good job of tackling this complex issue and I thank Dr. Donal de Buitléir and his team for their work. I intend to consult with stakeholders and colleagues before returning to Government later this year with a response to the recommendations and an implementation plan.

Another significant development is our decision regarding the restructuring of the health service, the effective dismantling of the HSE as currently constructed and the establishment of regional entities. Since I was last before the committee, we published the capital plan, which outlines more than 250 projects across the country, the provision of 480 new beds, 30 new primary care centres, 58 community nursing units, and significant investment in mental health and disability projects.

We are planning for the winter period, which is essential to do. I hope to be in a position to announce additional resources for winter planning as part of budget 2020 to reduce delayed discharges or transfers of care, get people back into the community, increase home care provision and improve access to the fair deal scheme and to transitional care. I expect the chief executive officer of the HSE will comment on the significant work being done by the HSE in this area.

Next Thursday, we will launch the HSE's flu vaccine campaign. This year, for the first time, on foot of a recommendation from the National Immunisation Advisory Committee, a quadrivalent vaccine will be offered, which provides a substantially greater level of protection to the population compared with the vaccine given in recent years. We have had good leadership from politicians across the political spectrum on the promotion of vaccination efforts. I note that Deputy Kelly spoke recently at the Global Vaccination Summit about the importance of vaccination programmes. I ask all members to encourage at-risk groups to get the vaccine, including healthcare professionals. More broadly, we must continue to emphasise our support for vaccination programmes and work to debunk the myths associated with them. I could say a great deal more on this, but I must allow time for the other speakers.

Thank you, Minister. I invite Mr. Reid to make his opening statement.

Mr. Paul Reid

I thank the Chairman and members for inviting us to attend this meeting of the committee. I am joined by my colleagues, Ms Anne O'Connor, chief operations officer; Dr. Colm Henry, chief clinical officer; and Mr. Liam Woods, national director of acute operations. The Health Service Executive (Governance) Act 2019 commenced on 28 June 2019. On that date, the newly established board of the HSE met, with the Minister in attendance. Under the Act, the board is now the governing body of the HSE, accountable to the Minister. I look forward to working with the board and providing every support and assistance to the members in their work.

A key priority for the HSE is to maximise the provision of safe services, within the funding with which we are provided. This is a significant challenge for the HSE in the context of the increasing level of demand for our services. Demand is rising due to an aging demographic, more complex service demands and ongoing societal and economic change. The latest reported financial position, as at July 2019, shows a deficit of €281 million, or 3.1%, with 43% of that relating to operational service areas and 57% relating to pensions and other demand-led areas. The comparable figure for the same period in 2018 was 72% higher at €485 million, or 5.8% of the budget, with 80% of the deficit in the operational service areas. The greatest cost pressures within our operational services are in respect of providing residential placements to service users with an intellectual disability and the provision of specialist emergency care within the acute hospital setting to a growing population of older and frailer patients.

Costs in respect of pensions, the State Claims Agency, the primary care reimbursement service and overseas treatment are largely driven by policy, legislation, demographics and the macroeconomic situation and are not generally amenable to normal in-year financial management. I have directed relevant national directors, community healthcare organisation chief officers and hospital group CEOs to identify and put in place additional measures to limit, to the greatest extent practicable, any overruns within operational services.

The measures to limit overruns include greater emphasis on controls around agency spend, overtime and staffing levels. Monthly expenditure limits have been agreed and are being monitored closely, including at a monthly financial management meeting which I chair and all the community healthcare organisation chief officers and hospital group CEOs attend. This is a challenging process but we are committed to embedding an improved culture of delivering within the budget allocated to us by the State. Doing so will put us in a stronger position to secure investment for the future, which is in the best interests of patients, service users and their families.

The 2019 HSE capital plan, which was recently launched, forms part of a rolling ten-year investment plan for health. Modern infrastructure and equipment are a crucial part of the provision of a quality health service and, ultimately, a positive patient experience. An allocation of €642 million was allocated this year to continue the delivery of more than 91 projects across the country and initiate another 73 projects for acute and non-acute services. Fifty-eight community nursing units, CNUs, are at planning and design stage and €85 million has been allocated to deal with infrastructural risk, replacement of equipment and replacement of ambulances. This investment will provide increased capacity across the health service and support the delivery of Sláintecare.

Budget 2019 provided for the establishment of the Sláintecare programme implementation office at the Department of Health, with €20 million allocated for the establishment of a ring-fenced Sláintecare integration fund. This fund will test new ways in which we can bring care closer to home, including putting the patient and client at the centre of service design and delivery. Across the country, 122 projects have been selected for funding. A total of these are from HSE or HSE-funded services and include projects supporting individuals to prevent and manage their chronic conditions and projects to enhance community care services and mental health support services. These projects will run for a period of 12 months from initiation and processes will be put in place to enable successful projects to be scaled for national implementation over time.

The HSE and the Sláintecare programme implementation office are working to progress the full range of Sláintecare reform programme actions and projects. We have also been working to establish higher-order priority work programmes over the next two years, which have the potential to transform the way care is delivered and experienced in Ireland. These programmes will be jointly led and implemented by the Department of Health and HSE and will cover the design and implementation of regional health areas. This is essential in ensuring we have better enabled delivery organisations fully focused on delivering services that meet the needs of the local population. In addition, the priority programmes will deal with service capacity and service access. This will address the implementation of the health service capacity review recommendations across acute hospital and community care services, while also reducing the inevitable demand for beds in the coming years.

Winter preparedness planning is a core component of annual operational planning in the health service. It is essential to ensure service provider organisations are prepared for the additional seasonal pressures associated with the winter period. Analysis has shown significant levels of growth in emergency department attendance and admissions over the past winter seasons, outstripping population growth by more than 2.75%. The winter preparedness plan was developed by the HSE through a collaborative process across all key services, including community operations, acute hospital operations and the national ambulance service. The plan sets out the core components of an integrated winter plan and seeks to guide those developing their local plans in terms of essentials that must be considered. Through this proactive planning and action, combined with the assistance of the public in following winter season guidance from the HSE, including availing of the flu vaccine programme, we will endeavour to provide safe and efficient services.

In August of this year, the HSE launched the new gender neutral human papilloma virus, HPV, vaccine programme for girls and boys in their first year of second level. Information packs for parents are being provided through schools by the local school vaccination teams, which have now started to give the first dose of the vaccine. The implementation of this new programme is backed up by campaign materials including videos, social media posts, radio advertisements and the hpv.ie website. The provisional uptake of the HPV girls' programme is approximately 70% for 2018 to 2019, which is an increase from 64.1% in the previous school year. It is important to acknowledge the powerful work of the late Laura Brennan in promoting the HPV programme. She made an enormous impact in communicating the benefits of this important life-saving vaccine and encouraging parents to get informed via the Get the Facts resource.

The new paediatric outpatient and urgent care centre, Children's Health Ireland, at Connolly Hospital Blanchardstown opened in July.

This opening is a major milestone in the new children's hospital project. Since opening, the latest available figures indicate that 645 children presented to the urgent care centre at Connolly Hospital and 94% of children were discharged home. The average time spent by patients in the urgent care centre is 112 minutes. The urgent care centre will continue to extend the hours of operation on a phased basis. It is expected that 25,000 children and young people will visit the urgent care centre every year, leading to a reduction in emergency department attendance for children.

Since opening, the latest available figures indicate there were 514 attendances to the Connolly Children's Health Ireland outpatients department. When fully operational, this new facility will provide 17,000 outpatient appointment attendances annually. This new facility and service is a welcome development and will contribute to significant reductions in general paediatric outpatient waiting times for patients and their families. I thank Children's Health Ireland and all concerned for their work and commitment in getting this facility operational.

We agreed to a period of 12 minutes for each member for questions and answers and there will be a second opportunity to ask questions if everybody observes this limit. Everybody should have an equal opportunity.

I thank the witnesses for attending. What is most interesting about the opening statements is what is not in them. The hospital consultants, nurses, midwives and allied health professionals are saying the public health system is on fire. They are talking about more than 1 million people waiting for healthcare. That was not mentioned anywhere in any opening statement. More than 500,000 men, women and children are waiting to see a consultant but that was not mentioned in any opening statement. Already this year 10,000 women and men over the age of 75 have waited on trolleys in emergency departments for more than 24 hours. That also was not mentioned in any of the opening statements.

When the Minister's predecessor, the now Taoiseach, Deputy Varadkar, held office in 2015, he said the Government would ensure no man, woman or child would wait more than a year and a half to see a consultant. It was pointed out at the time that even if the Government hit that target, the waiting list in Ireland would be the longest in Europe. That was the extent of the ambition of the target. In 2015, the then Minister and now Taoiseach said the number would be zero and when the current Minister took office in 2016, that number was 13,000. An extra €3.5 billion has been allocated to health spending since but that number has increased from 13,000 to 106,000 men, women and children now waiting more than a year and a half to see a consultant. For every one person who was waiting three years ago, there are now seven. That is a crisis in anybody's book. None of this has been mentioned in any of the opening statements.

What does the Minister say to all these people and why has he not mentioned this crisis in his opening statement? Why has the HSE not mentioned the crisis in its opening statement? What does the Minister say to the 10,000 men and women over 75? What does he say to the 106,000 men, women and children waiting more than a year and a half for an appointment? What does he say to the children with special needs in our county waiting three and half years for help? Why has he not spoken about any of this and what does he have to say to them as they wait and suffer, with many of them deteriorating while they seek access to the public health system in Ireland?

It is kind of ironic that I come to a health committee meeting and when I am asked not to deliver my opening statement but to take it as read, the second comment from a member of the health committee critiques what is not in the opening statement. As the Deputy knows, opening statements are a brief summation of some current issues. He knows the meat of these meetings comprises what we discuss through questions and answers. If the Deputy so wishes, the next time I attend this committee I can provide a lengthy opening statement and read it in great detail. Deputy Alan Kelly and others would rightly criticise me for doing so. I ask Deputy Donnelly not to be pedantic in that regard.

The Deputy will note that a significant portion of my opening statement speaks to the greatest potential crisis facing our country at the end of this month, which is Brexit. He might excuse a Minister coming before a sectoral committee and highlighting what the Government and its agencies are doing about it.

I say to the people mentioned by the Deputy that we absolutely must do better. Since I became Minister, fewer people have waited for a hospital operation. Fewer people are waiting today for a hip or knee operation or a cataract procedure.

I say to those people that when Deputy Donnelly's current party was last in office, it did not publish outpatient waiting list numbers. When Deputy Micheál Martin was Minister for Health and Children, he did not publish statistics for the outpatient waiting lists and we had did not have a clue about them. It took my party and Deputy Kelly's party to go into government and decide to publish those numbers. A Fine Gael-Labour Government was the first to publish them.

I say to those people that we have agreed a reform plan for the next ten years, which we have never done before in the country. It is Sláintecare and I think we all agree on it. It will reorientate healthcare. We have made major progress with inpatient waiting times. In fairness, the Deputy's party has played a constructive role in that, which I acknowledge. We have not made anywhere near as much progress as we need to with outpatients. We will have to reorientate the health service to do it. What does that mean practically for somebody waiting today? It means the new GP contract, which I agreed with GPs and which 95% of GPs voted in favour of because they recognised it as a good deal for general practice, will see from the start of next year conditions such as asthma, chronic obstructive pulmonary disease, heart failure being treated in the community for the first time. These conditions treated through the outpatient process currently. I hope members have visited Connolly Hospital's urgent care centre to see the facility at work. As its chief executive said, it means approximately 500 more kids on the outpatient waiting list will be treated, as it targets those who are waiting longest.

The Deputy specifically referred to consultants. Earlier this week, I wrote to the Irish Medical Organisation, IMO, inviting its representatives for talks next week on how we can sort out some of the consultant recruitment and retention issues, which are very real. Those talks will begin with the Department of Public Expenditure and Reform, the HSE and my Department on how to resolve those issues. We sat at this committee last year discussing how to sort out supporting general practice and we have done so. We worked our way through with nurses a deal that came about, although admittedly after industrial action. We need to do the same with consultants as we need more of them.

This will require a multifaceted approach and doing a number of things, including shifting more to the community, which is exactly what Sláintecare is starting to do. We will have to ask our GPs to do more and give them more resources. There will have to be more consultants in hospitals. I fully accept the points made by the IHCA and IMO about consultant numbers. There is no disputing those numbers.

The problem is there is nothing wrong with what the Minister has said. All of those things must happen but we have been listening to similar explanations for years. The reality is things are getting worse and faster. We have gone from 13,000 to 106,000 people waiting more than a year and half for an appointment. That has happened in just three years. The Minister is correct as the one measure that seems to be working relates to the inpatient waiting list and surgery. However, that is working because the National Treatment Purchase Fund, NTPF, has been turned back on. It worked very well in 2009, 2010 and 2011 and it brought waiting times down to months. It was turned off and the numbers increased again. I acknowledge the Minister's indication that having it turned back on again was a Fianna Fáil priority. It is working and we believe it needs to be expanded. This should not be a long-term measure, as we need a public health system that can deal with this, but it is required for the short term.

I can bring this to an individual case. Last night I spoke to a mum in Wicklow whose child has been waiting three and half years for therapy. She was very annoyed. On the same day received a letter from the HSE stating there had been further delays and the child would not be seen, she received a leaflet from the Minister indicating Rugby World Cup dates. She asked how taxpayers' money can be spent on a leaflet indicating world cup dates but not for her son to have therapy over three and half years. What does he say to her?

I understand that while the lady may make the point, the Deputy knows better and taxpayers' money was not spent in the production of such literature. While he is protected by privilege, I am sure he would not wish to accidentally slur me in that regard. I do not know the details of the case. Does the Deputy know the therapy in question?

The type of therapy would determine my response to the question. We have provided funding for an additional 100 therapy posts in the health service this year. We need more speech and language therapists, occupational therapists and others. The Deputy's party froze such recruitment, sadly, which should be acknowledged. The Deputy may have the solutions today but a recruitment moratorium was introduced by his party. He is the party spokesperson on health.

That Government introduced a recruitment freeze, stopped hiring speech and language therapists and occupational therapists and did not replace those who were on maternity leave. We are endeavouring to catch up. Not only that, we are also trying to do things differently. The Minister for Education and Skills and I have brought forward an integrated programme of speech and language therapy and occupational therapy in schools, including in our constituency, for the first time ever. It is showing real benefits in west Wicklow and other parts of the country. I would like to see us make further progress made in budget 2020.

Is the Minister aware that parents in County Wicklow are waiting three and a half years to access therapy for their children?

I am absolutely aware of the position on access to speech and language therapy, occupational therapy and other therapies. That is why we are recruiting 100 more therapists. It is also why we are reforming the model of delivery. I will be very happy to discuss the details, but I take the Deputy's point.

I obviously do not intend to cast a slur on the Minister, but is he saying the leaflets he delivered were not printed, designed or delivered using public funds?

Very well. I thank the Minister.

I move to recruitment, an area in which there is a crisis. Throughout the country there is a crisis in the recruitment of consultants, while individual hospitals face crises in the recruitment of mental health professionals, therapists, nurses, midwives and many other grades. The Minister has written to the Irish Nurses and Midwives Organisation. Has he also written to the Irish Hospital Consultants Association to offer to hold talks?

Not yet, but it is my intention to involve as broad a group as possible in dealing with the issue of consultants. The reason behind it is one of sequencing. Without getting into a big discussion on industrial relations and taking up the committee's time, I note that the INMO is a member organisation of the Irish Congress of Trade Unions. It is a party to the public sector pay agreements and we will engage with it first. That is the appropriate way to proceed. It is the long-standing tradition. I do not speak for the INMO in any way, but I would like to arrive at a point where there would be collaborative and joint talks. I hope the initial meetings will be with the INMO, but I would absolutely like to see them broadened to include the IHCA which body is effectively making the same points about recruitment.

It is. Does the Minister accept-----

The Deputy has one more minute.

We have 12 minutes overall. Is that correct?

Does the Minister accept that pay for new entrants is a major deterrent in recruitment?

Yes. I know and accept that the committee is under time constraints. I said it at the INMO conference and publicly during the summer. I absolutely believe pay parity is an issue, but I do not believe it is the only one.

The de Buitléir report is a big part of it.

I appreciate that there is more than one issue, but when does the Minister intend to move to reverse consultant pay inequality for new entrants?

I do not blame the Deputy for asking the question, but I think he understands we have to engage and negotiate with consultants. We have not yet sat down in a room with the INMO to begin the discussion. I hope it can start some time next week, after the announcement of budget 2020. We will have to look at what has been done for other public servants and the pace at which it has been done. There must be equity. We must also be cognisant of available resources, especially in the context of a potential no-deal Brexit. I see it as the phasing of conversations. I accept that there is a media challenge in recruitment and retention and that pay parity is part of it. However, there must also be a second phase which must be about substantive reform, including reform in line with the de Buitléir report. We cannot continue to stand over private practice in public hospitals, something on which I hope the Deputy will support me.

We might come back to that issue. Last year there was a focus on reversing the financial emergency measures in the public interest, FEMPI, cuts for GPs, for which provision was made in the budget. Talks had to happen, but provision was made, which meant that the Minister, the Government, the Department and the HSE had space in which to begin to reverse the FEMPI cuts. Will such provision be made in the budget to allow for the reversal of the new entrant pay disparity for consultants if the talks succeed as I hope they will?

That is a valid question. We will have to see how the engagement with the Minister for Finance and Public Expenditure and Reform goes. It is primarily a matter for him, as is public sector pay policy. The Deputy is right; provision was made for changes to the GP contract. It was not revealed publicly for negotiating reasons, but there was space. There was no space for nurses, but we still managed to find resources for them. The practice varies. It is a matter for the Minister for Finance on which to make a call at budget time.

I wish to pick up on one point. A new GP contract not been issued. The Minister has just revised the existing contract.

It is a significant revision, of which 95% of GPs voted in favour.

The Minister should not oversell it and should be clear. It is not a new GP contract.

It will increase GP income by about €15,000.

GPs say it is not a new contract.

They also say it is a very good development.

Indeed, but it is not a new GP contract.

I thought Sinn Féin was being positive and constructive these days. I read that somewhere. It is a very welcome development.

I am, but I will not let this issue slide either. It is not a new GP contract. The Minister pats himself on the back enough. Is he aware that 82 patients were on trolleys last night in University Hospital Limerick?

Yes; I am aware that that is the Irish Nurses and Midwives Organisation's figure.

Yesterday the Minister's boss, the Taoiseach, apologised to the patients who had been left on trolleys. There were 81. Now there are 82. There does not seem to be any change in that regard. The Minister will be aware that the trolley count started when Fianna Fáil was in government. We know that September was a record month and that the number now stands at 82. Does the Minister have anything he would like to say to the staff and patients this morning? I have been there and spoken to the nurses. I was there when we took industrial action several years ago to have additional staff recruited. It was hell on earth then, when the number was always below 40. Is there anything the Minister would like to say to the people in question? The Taoiseach apologised to them yesterday and acknowledged how stressful it was for staff. The figure is only moving in one direction.

I thank the Deputy for raising the point. I echo the Taoiseach's words yesterday. What staff and patients at University Hospital Limerick want to know is what are we going to do about it. I cannot remember when, but I visited Limerick a couple of months ago, I visited CervicalCheck staff. I called into the hospital where I saw the significant progress being made in the development of the 60-bed ward block. The mid-west has been really badly treated in the reconfiguration agenda which I do not intend to reopen. I see why it was decided to centralise several services in University Hospital Limerick, but it was never given the beds required. I see the clinical director of the hospital, Dr. Gerry Burke, regularly highlighting the inequity in bed numbers. I will reverse that trend and the Deputy will be pleased to know that it is not just talk from me. If she visits University Hospital Limerick, as I know she does, she will see that work on the 60-bed ward block is well under way. In this Oireachtas I have been under significant political pressure from Senator Kieran O'Donnell, Deputy Kelly and others from the mid-west to move ahead and do something quickly. We went ahead with the 60-bed modular ward block.

I also see in the figures I have been given that about 68 additional staff have been hired in Limerick in the last four weeks, including 48 in nursing. The chief executive may wish to add to this, but we are genuinely putting extra staff and beds in place. As to what we can do right now, I have called a meeting tomorrow on the position at University Hospital Limerick and in the mid-west. I expect people to come from the hospital, but I also expect to meet the HSE and the Department. One of the issues about which I heard from hospital management when I visited and about which I have heard from Oireachtas colleagues is that the number of delayed discharges from the hospital is much higher than it used to be. Traditionally, there would have been about eight, but that number has now reached 47 or 48.

I have been talking to the chief executive about increasing funding for transitional care services in the region. I offer my apologies to Deputy Harty, as I should have mentioned the representations he has made in that regard, but I was looking in his direction. We will also be making provision for winter planning in budget 2020 to be announced next Tuesday. In the short term my message to people in Limerick is that more beds are coming. One can see in looking out the window that they are under construction. Also, there are 68 more staff members working in the hospital than there were five weeks ago. In the immediate term I want to see what we can do to improve social care services to help to decongest the hospital.

It is interesting that the Minister is only now looking at that issue. Improvements in transitional care services should have been made a long time ago. There were warnings about all of this when the reconfiguration was carried out against the wishes of the staff. They pointed out what was going to happen and it did. I must also reference my colleague Deputy Maurice Quinlivan who has sought 14 times, on the last count, to engage in a Topical Issue debate with the Minister. The Minister must be an extremely busy man because he has never turned up once, which is regrettable.

He should call me some time. I am always available.

I am sure the Deputy does.

I see the figures which show that new primary care centres are being opened.

I will use an example from my constituency, which I have raised with the Minister many times. There is a primary care centre in Balbriggan and while I keep asking the Minister if it will get additional staff, he keeps telling me it will not and nor is there a plan to put in additional equipment. If built, these primary care centres are not being adequately staffed. Similar to other points that have been made here, I can point the Minister to people in my constituency who have been waiting 36 months for therapeutic interventions for their kids. They have been told they must wait a year before their kids can get onto lists and so on. We are aware that the lists are lengthening.

If one considers a primary care centre that may just have a general practice doctor in it but no additional facilities - especially in an area such as Balbriggan where the population is growing - apart from the buildings, does the HSE have a workforce plan? Mr. Reid will be more than familiar with this issue. Can the Minister share such a plan with us and point us in the direction of X number of staff? They are not coming to Balbriggan because while I do not know how many times I have asked this through parliamentary questions, the answer always is that services will be provided from within existing resources. This means there will be no additional staff, despite the growing population. Is there a workforce plan for all of these new primary care centres that are being built or are under construction? Does that plan mirror Sláintecare and will it provide therapies within the community? Thus far, it has not. The Minister will be aware that since the primary care centre in Balbriggan opened some two and a half years ago, Sinn Féin has been campaigning for diagnostic facilities for the centre but people still must travel all the way into a hospital in town for a simple X-ray.

To be fair, Deputy O'Reilly highlights this issue on a regular basis. Yes, through the PA Consulting capacity review report there is an indication of the additional staff we need in primary care. The director of the Sláintecare office, Laura Magahy, is currently working with the HSE to turn that into a workforce plan. Ms Magahy will be before the committee on 23 October. To be honest with Deputy O'Reilly, the short answer is that we need some 4,000 extra people working in primary care. Through the Sláintecare office, I intend to map out how we get from here to there. Despite the very difficult constraints under which we are operating in the context of a no-deal Brexit budget, I expect to begin to make progress on that in 2020, as well as to map out how we can build on that in each of the following years. Ms Magahy has done a considerable amount of work on this. The end point is that we need some 4,000 more people if we are to make sure that our primary care centres and our primary care teams are operating at full capacity. The decisions on how that staff is divided out is the responsibility of-----

Could the Minister take a step back to where these 4,000 additional staff for primary care centres are coming from? These are for the primary care centres the Minister is talking about opening in the short to medium term. Those staff would have to be in college now or there would have to be some plan. If they are not in college now, then they will not be in post in time, and the facilities will not happen. Will the Minister please step back to that?

Yes. It is 4,000 staff over the ten-year period to deliver Sláintecare's working in the community. Obviously, the Deputy will be aware that not every one of those staff may necessarily be working in a primary care centre. It is an additional 4,000 staff. I take the Deputy's point that we have to be recruiting and training enough people and this will be part of the workforce plan also.

But they are not in college at the minute.

I am sure many of them are but as the Deputy will be aware-----

What is the plan for the additional staff? Assuming the current cohort coming through our colleges does not all emigrate, and to be honest the Minister knows they are emigrating, and in the event that the Minister manages to massively improve the retention rates for new graduates, we would still need, at this juncture, to have additional people in college to be able to skill up in that area.

We will need to increase training places in some areas but as part of the reorientation, we also will see people who work in our hospitals today who will be working between our hospitals and our communities, as well as people working in new and different ways. It is not quite a direct case of 4,000 more people requiring 4,000 college places-----

I fully appreciate that.

I do not want to use the Deputy's time but I am conscious that the chief executive may want to add to that also.

Mr. Paul Reid

I want to reinforce one of the early priorities of Sláintecare since we announced the launch of the new regional health organisations, which is to set out a process over the next nine months to develop a roadmap for the transition process, how to get the new regions, what is the staffing configuration and what investment is needed for capacity in acute units and the community facilities. One issue - on which we have to come back to the Government - is for an implementation plan for the regions that will involve integration and the workforce plan. This process will include the numbers and the allocations. I am absolutely committed to where the Deputy is around our need to increase capacity in our primary care centres.

We have a lot of buildings and we now need to support them with the adequate resourcing.

That does not really answer my question. If I go back to my constituents in Balbriggan, what will I say to them? Is it more of the same and none of anything different for a while?

If I were to go back to the Deputy's constituents, I would say exactly the same and would not say anything different.

The responses had no reference to including a plan for the relevant facilities, the diagnostic equipment or anything like that. I hear very clearly what has been said, and at some point in the future this may be addressed.

I know that time is limited and I have a question on the working group on contraception. Has the Minister received that report? When the Minister receives the report, is it his intention to publish it? By way of observation, I note the Department has established a task force. While I do not mean this in any disrespectful way to Mr. Breslin, the women's health task force is headed by a man, which is a bit of an own goal. Will the working group on contraception report be published? The Minister has said that he does not have it yet.

I will deal with the second question first. I note the Deputy took a different viewpoint on the women's health task force from that taken by the Royal College of Physicians of Ireland, the Royal College of Surgeons in Ireland, the Institute of Obstetricians and Gynaecologists, the National Women's Council of Ireland, and the European Institute of Women's Health, all of whom welcomed the establishment of the task force. That is fine. It is not chaired just by a man. The task force is co-chaired by the Secretary General, who happens to be a man. When one is the Minister, one cannot find a more senior official in the Department to appoint than the Secretary General. One can be a committed feminist and be a man. It is very important. I am sure the Secretary General is-----

I am sure Mr. Breslin has a raft of feminist convictions, but that is not the point.

I am sure he is-----

I made an observation that I believe it was something of an own goal.

And it was not, because as Deputy O'Reilly may or may not have known, the co-chair of the task force is Peggy Maguire, the head of the European Institute of Women's Health, who at the launch said she had never seen anything in any other European country as comprehensive with regard to trying to co-ordinate women's health policy.

On the issue of the contraception report, I have not yet received the report. I expect to receive it in the coming days. I have a sense of what is in it but I have not yet received it. I believe that the Deputy has a sense of what is in it also. We need to do much better around the access to contraception. We need to arrive at a point where contraception is free. The Deputy asked if I will publish the report. I can see no reason I would not publish it. I would like to publish it and I would like to brief party spokespeople on it. Without having the report, I believe that we all know that if there is to be change in this area, it will require legislative change and a fair whack of funding. How we do both is something on which I would like to engage with the committee. I hope to get the report this week, in the next couple of days. I will let the Deputy know when I do.

I have a range of questions for the Minister. I will have a quick-fire round now with some priority questions as they will take a bit of time, and I will ask more in the second or third time I come in, or both. My initial questions, just to prepare the Minister's officials, relate to the children's hospital and to what is going on in the mid-west, which the Minister has touched on. My other question relates to gynaecological services in Letterkenny. If I have time I will also ask about CervicalCheck. As I have said, I will have other questions later.

I refer to the minutes of the National Paediatric Hospital Development Board, NPHDB, and the children's hospital programme and project steering group over the last months of this year. I have a copy of the minutes and their sub-committee minutes here and I have gone through them. Will the Minister supply this committee with all minutes of the boards and sub-commitees to the Chairman within a week? I presume the Minister will do this and I would appreciate that. This is the first request.

The NPHDB minutes of 3 April state that the finance and construction committee received a report wherein it was reported that additional monetary risk had been identified on provisional funds. It also stated that this was going to affect the timelines for the hospital. I am aware that Mr. Reid has written to the board members looking for this revised timetable. Perhaps Mr. Reid will send on this letter to the committee, and the response, if he has it. On 29 April, on the procurement sub-committee meeting, the minutes express concerns around the costs as they are appearing.

I have spoken to people and we all know there are further issues concerning this hospital. At this point at the beginning of October what is the status of the timelines for the delivery of the overall project? Has the Minister been informed of any issues regarding the timelines and, if so, when and by whom? I direct the same question to Mr. Reid.

At what scale are the costs escalating? I remember once being accused by the Taoiseach in the Dáil Chamber of exaggerating in that respect. The figure I mentioned at this committee has been superseded and increased on and the Taoiseach admitted in effect admitted that since. What scale of an increase are we talking about or is the Minister aware of?

I ask Mr. Reid, in particular, to advise what concerns he has relating to the costs and timelines in accordance with the reason he wrote that letter? Obviously, he has read the minutes of the board meetings, as I have.

I thank the Deputy for his questions. My answer is "yes" in terms of access to all the documentation and minutes. It is important we continue to engage transparently with these committees and we will certainly make them available. On 12 June when Fred Barry came before this committee, he pointed out, as did the PwC report and as we all know, that outside the GNP process other issues that can arise, including contractors submitting claims. I am aware, although not of the scale of it, that extra claims have been submitted. I believe this committee has been made aware of that previously also. However, an extra claim does not necessarily result in that claim being paid. The Deputy will remember when he and I were discussing this a number of months ago that a number of claims submitted ended up crystallising into a much smaller amount than was claimed for. Obviously a project of this scale and complexity, the largest construction project ever in our health sector and one of the largest public sector construction projects in Europe, will have claims submitted as the project goes on. It is important the National Paediatric Hospital Development Board can continue to deal with that in a commercially sensitive way. I have no information of a rise in costs other than the fact that claims are being submitted, dealt with and managed, and that is the normal flow of this project.

The Minister has no concerns about rising costs yet or about the projected timeline.

Before dealing with the timeline, I will finish dealing with the costs because I do not want to conflate the two. On the costs, my views are exactly as outlined by Fred Barry when he last came before this committee, namely, there are some issues of risk outside the GNP process - that is not new and that has been said many times - and the National Paediatric Hospital Development Board has to manage that. I have no further information to add to that at this point.

On the timeline, as the HSE said when this query was first submitted, with a project of this scale some parts of it can run ahead of schedule and some parts of it can run behind schedule. Overall, I have been informed that the project is still scheduled to be completed in 2022 and opened to the children of Ireland in 2023 on time. I visited the hospital, as I know the Chairman did, and huge progress is being made on it. The Connolly part of this is open. I know this is an issue of intense political scrutiny, and it should be as it involves a great deal of money. The hospital will have a massive health benefit. The progress being made on this project is phenomenal. I reiterate the invitation sent to the committee and encourage all the members to visit the site, meet the management on the site, ask questions, meet the BAM people, and see the progress being made. I think they would all find it very valuable. Does Mr. Reid want to come in?

And Mr. Breslin.

Mr. Paul Reid

I will come in first. I spent three and half hours yesterday on the site with Fred Barry and all the team. I would state the obvious. It is fantastic to see the project above ground and to see the scale of it. It is a massively complex site in the middle of a mostly residential but also industrial area. Inevitably it will be a difficult project but it is reassuring to see the progress that is being made.

On the issue of cost overruns or delays, I specifically had a conversation with the team on that yesterday and the feedback I got was exactly as the Minister relayed. They have had a number of submissions from the contractor through which they are working.

What scale of submissions have they got?

Mr. Paul Reid

In terms of the costings of them, I do not know.

Can Mr. Reid come back to the committee and advise us of those?

Mr. Paul Reid

Absolutely. The said to me yesterday they need the time to engage in detailed negotiations with the contractor. They are not accepting anything they have had submitted at all.

I understand they are at a fairly significant scale.

Mr. Paul Reid

I have no doubt. I certainly did not get facts, numbers or details of them on the site but they asked me for support from ourselves and the officials on the continued negotiations with the contractor. Obviously, I reassured them of that.

In terms of the complexity and the timeline of the delay, I pushed them that we must continue with the timelines, to which we are committed, and as part of the negotiations, that must be in the mix as well. It is early days in terms of what has been submitted. I think this will happen throughout the project given its nature.

I accept negotiations have to happen. In terms of the scale of this, the months that will take will affect the timelines, and the scale of the claims go way beyond what the team expected. There are significant issues on the site. From a cost point of view and a timeline point of view, they will impact significantly-----

I have not been advised of them either.

-----because the negotiations-----

It is important for me to say that.

Obviously, it will take a number of months.

Sure. I just need to be clear that I have not been advised of a change in the timelines for the construction by 2022 or the opening in 2023. The only cost issues I have been advised of are the same ones of which the chairman of the board advised the committee on 12 June, namely, that developers can submit claims as they go along, and, as the chief executive officer has rightly said, those claims are often robustly defended.

Has there been any change in the design of the hospital?

Mr. Paul Reid

Not to my knowledge.

A presentation was made to the board on 3 April, which basically outlined issues relating to costs and timelines. Mr. Reid might send a copy of that to the committee in the next week or so. If there was a further update on that presentation, he might send it to us also.

Has Mr. Breslin anything to add?

Mr. Jim Breslin

Other than to say this is a huge project so the claims, as standard in a project, will come in over the course of the project. I do not want to predict it but we have talked at the committee about the aggressive nature of some of that and Fred Barry has outlined how robustly it will be defended. I do not want to predict it but my expectation is there will still be claims that will be argued over once the hospital is occupied and operational.

Will this affect the actual project timelines?

Mr. Jim Breslin

To date, as the Minister outlined, they are working to the programme and some parts of the work are ahead of schedule and some of parts of it are behind schedule. That will be revised continually over the period but we have no information that the programme itself is at risk in terms of the opening time.

We will see in the coming weeks and months.

Regarding University Hospital Limerick, UHL, I got mobilised into politics because I opposed the Hanly report. I have a sign up in my office from that time. There was the Teamwork report and all the other reports. In fairness, the Minister was one of the first Ministers to come in here and say that reconfiguration in the mid-west was a complete and utter disaster.

I am a mid-west TD and a number of colleagues here are from Clare and Limerick. The situation in UHL is the worst I, or any of us, have ever seen. I want to take this out of party politics, genuinely, because I live among these people. I live over the road from this hospital even though I am in a different county. This is something I take a personal interest in every day. I have never ever seen the situation there as bad as it now. I have never seen so many people affected. I am referring to patients, their families and the staff. I have never had so many staff come to see me. The issue is simple. The reconfiguration never worked. The resources were not put into it. Let us take the politics out of the issue. The mid-west is now being discriminated against. That can be shown by a comparison of key performance indicators and resources in UHL versus - we picked this hospital randomly - Beaumont Hospital.

I have seen that.

We are way behind. There are short-term, medium-term and long-term needs. In the short term we need more transitional beds and more nurses and doctors. It is obvious what needs to happen to integrate the services with non-acute services. What Maria Bridgeman is trying to deal with in the hospital is also impossible.

The Deputy can have one further minute and I was to allow the Minister to reply.

We have a 60-bed modular unit but it will not be delivered in the timeline originally put forward.

We need to be honest about that. I do not wish to make a political point of it but it will not be delivered until the following year. Let us call a spade a spade. The 90 bed unit will not be provided for in the three-year capital plan. The issue is the estimated €40 million differential in terms of what is needed to bring the mid-west group of hospitals to a particular level versus current funding. Approximately 130 doctors, 200 health and social care professionals, 150 nurses, 160 additional beds and 50 to 60 transitional care beds are needed. The existing MRI scanner, donated by a philanthropist, is 14 years old and is continually breaking down. In regard to 82 people currently on trolleys, 30 of them could be facilitated if the hospital had a new scanner. The hospital does not have the €6.5 million required to buy a new scanner or the €1.2 million to rent one. For God's sake, will the HSE please put together a package in the interim for this area? People are suffering at a level I have never before seen in my political career. My colleagues across politics are saying the same.

Deputy Kelly needs to give the Minister an opportunity to respond.

We need intervention and we need it now.

I will respond first and then Mr. Reid will comment. I appreciate Deputy Kelly saying that he does not want to make this political and that he has made it a plea for the mid-west. In the interests of fairness I want to note that Senators Maria Byrne and Kieran O'Donnell and Deputy Michael Harty, who also represent the region, are here. This is a massive issue for the people of the mid-west. I have shown a willingness to respond to it. The issue which all of the members have asked me to advance first is bed capacity. They have also asked that in advance of any capital plan being published, we proceed with the 60-bed modular unit. I agree. It would be nice if it had opened yesterday or even today. We could have done with it opening yesterday. However, it is now well under way.

Members have asked, above and beyond that, what more can I do. In other words, while we are waiting for the extra capacity to come on stream what more can I do in regard to transitional care and the MRI scanner. I am due to meet tomorrow with the HSE and officials of my Department in regard to the mid-west, where I will consider all of the issues that have been raised by my Oireachtas colleagues. I will ask Mr. Reid to comment now.

Mr. Paul Reid

The pressures on Limerick are very significant, as highlighted by Deputy Kelly. I have spent some time there, including in the emergency department and with the local manager and the group manager. Deputy Kelly highlighted the cost of purchasing or renting a scanner, which would be a very significant cost investment. We have spoken with local management on this issue. Mr. Liam Woods, the national director, is working with local management on how we can accelerate the immediate deployment of a scanner for the area. We accept that a second one is needed and we are working with local management to deliver it.

I do not want Mr. Reid to take this the wrong way but the response is pathetic. This is a crisis.

Sorry, Deputy, we understand your frustration and we all share it but-----

It is discrimination at this stage.

I call Senator Colm Burke.

I welcome the Minister, Mr. Reid and their officials and I thank them for being here today. I agree with Deputy Stephen Donnelly that we have a huge problem in terms of consultant recruitment. I mentioned at previous meetings that 16,000 additional staff have been recruited to the HSE in the last four years. I have also raised concerns about the disproportionate recruitment of staff, with a 24% increase in managerial and administrative staff versus an increase of as low as 3.6% in hospital staff.

On the consultants issue, the Minister referenced an invitation to a meeting to the Irish Medical Organisation, IMO, to discuss, among other things, the two-tier contracts in regard to consultants. Will the Minister clarify what process will be engaged in with the Irish Hospitals Consultants Association, IHCA, which feels excluded? It was indicated a number of months ago that there would be engagement with it, but it has not yet occurred. In the last number of weeks in particular it is at sea with regard to what is happening. At what stage will engagement take place with the IHCA in regard to the process and how it will be involved in this area?

An additional 500 consultants were recruited over the past five years, but a number of consultant posts are currently occupied by locum or agency consultants at huge cost. We can only fast-track a reduction in this cost by putting in place a better structure of employment. It is extremely important this is done. Before I continue, will the Minister clarify when it is proposed to engage with the IHCA, which represents the majority of consultants across the country? Five years ago, it represented 2,500 consultants but it currently represents approximately 3,000. When will the engagement with the IHCA take place?

I appreciate Senator Burke's ongoing interest in this area. As I said earlier, I accept that there are serious recruitment and retention issues in the health service, which are particularly acute when it comes to the issue of consultants. That is not just my view. We specifically asked the Public Sector Pay Commission to examine the issue and it acknowledged that there were recruitment and retention issues in regard to consultants. I want to build on the commission's findings and have an engagement with consultants on how we can rectify those recruitment and retention issues. I genuinely believe that pay parity is an issue but I do not believe it is the only issue. We need to examine Dr. Donal De Buitléir's report, and the OECD which I commissioned and published on the same day as I published the De Buitléir report, in regard to what other countries do regarding work practice as well.

Next week, my Department and the Department of Public Expenditure and Reform and the HSE will commence engagement with the IMO. We are commencing the engagement with the IMO because it is a member of the Irish Congress of Trade Unions and it is a party to the public sector pay agreements. On the question regarding whether I want to see those talks broadened out after initial engagement, yes I do, but it is a matter for discussion with the IMO as well.

The IHCA has submitted more than 100 claims with the Workplace Relations Commission, WRC, on the issue of new entry consultants. I would much rather that we worked out a way forward in relation to this matter through direct engagement but I will not tear up the rule book in regard to normal industrial relations. Senator Burke mentioned engagement. I was not in a position to attend the IHCA conference for an important personal and private reason. My colleague, the Minister of State, Deputy Jim Daly, made himself available to attend that conference and was told that he would not be given a speaking slot, until the morning of the conference where they reversed the decision. We are more than willing to engage with consultants but we have to engage in the context of a brave and ambitious reform agenda through which we can deliver Sláintecare. Those who put together the Sláintecare report asked me to put in place a Sláintecare implementation plan, which I did. For the first time ever, we have a cross-party approach to healthcare reform in our country. I am very proud of the plan which a minority Government produced with the Opposition. That plan also states that we have to change working patterns. I was also asked to commission the De Buitléir report. To see it immediately dismissed by representative bodies is very disappointing. They should be open to engaging on the substance of it.

In response to Senator Burke's question, we will engage with consultants, commencing with the IMO. I do want to see the engagement broadened out to other consultant organisations as well. I want to resolve this issue. I am already on record in regard to, in my view, the unfairness around pay parity. We have to engage in the context of the available resources, a no-deal Brexit and a reform agenda. The resolution is not just pay. Pay is an element but so too is reform and access to theatres for young consultants. It is also about how we can engage our consultants in our primary care network and primary care teams and about how the new advanced nurse practitioners can take some of the workload in terms of care off some of our doctors. I am excited that we are going to finally engage. I would have liked this engagement to happen much earlier but I am pleased to now have agreement with colleagues in the Department of Public Expenditure and Reform and other places to commence it. I think we can start a conversation about an exciting journey of reform that will help with recruitment and retention.

The IHCA, which represents the majority of consultants, believes it has been sidelined. I am asking for a commitment that it will be involved in some way in the negotiations.

It very much feels sidelined and that there is no engagement with the Department. My understanding is that in recent weeks there has been little or no engagement on the way forward and the IHCA was not even aware an invitation was being issued to the IMO. It is concerned that there was no communication of any description. Whether we like it or not, it represents a majority of the consultants in the Irish hospital structure at present.

It is not a case of liking it or not liking it. I am entirely neutral on what representative body a doctor decides to join. I represent people, as does Senator Burke. My job is to deliver a reform agenda for the health service, and consultants are crucial to this with regard to paying them a decent wage, addressing issues of pay parity, and engaging on the reform agenda. There should be no confusion on this matter because it is quite straightforward. We engage-----

If a group-----

Just let me-----

If a group has the view the Department is not engaging with it, it will get entrenched, which appears to be what has happened over recent weeks. I apologise for raising this but in recent days I have had a number of robust conversations on this issue and I am not putting forward the view of any one organisation. I am putting forward the view of ordinary consultants who work very hard in the health service. They feel they are under pressure because they cannot provide a service because they do not have the support of consultants who should be in place. They feel excluded from the process.

To be helpful, no one-----

Let us have some engagement.

I will try again to be very clear because I do not want-----

I know what the Minister is saying but I am asking for engagement in the next two to three days to reassure them-----

There will not be engagement in the next two to three days. To be very clear to Senator Burke, the position of the Government is that we will put in place a budget to deal with a no-deal Brexit that could take place as early as the end of this month.

I am aware of that.

The priority of everybody in the Government and the Department is to ensure we have a settlement for the health service that the Minister for Finance can deliver in the Dáil on Tuesday. This is the first priority. When the budget is concluded on Tuesday, the Department of Health, the Department of Public Expenditure and Reform and the HSE will begin engaging with consultants. In the first instance, we will engage with the Irish Medical Organisation because it is a member of the Irish Congress of Trade Unions and it is a party to the public sector pay agreements. Fair is fair in this regard. We engage with those who have engaged on the public sector pay agreements.

These decisions involve me but they also involve my colleagues in the Department. To be helpful, I absolutely see a role for the IHCA and I take fully the point made by the Senator. I want it to be engaged. There are many excellent representatives in the organisation. They are very sincere and want to make a difference. In case I did not say it clearly enough, I hope and expect that after initial engagement with the IMO, the talks will be broadened to include other representative bodies such as the IHCA. This is the process I am following. No one need be excluded and no one need feel entrenched. There will be engagement on the immediate issues of recruitment and retention. The CEO attended the IHCA conference and I will ask him to speak on the matter.

Mr. Paul Reid

I have had direct engagement with the IHCA on a number of occasions. I met Mr. Martin Varley four months ago, before I took up this role, and I have had a number of meetings with him since. The HSE has directly engaged with the IHCA on a range of issues. I and the chief clinical officer, Dr. Colm Henry, have had meetings with clinicians and clinical directors. There is a lot of direct engagement with consultants.

Specifically with regard to the IHCA, reinforced from my days at the Department of Public Expenditure and Reform is that we must respect the industrial relations process, which has a channel to work through in the first instance. I can only expect that the IHCA will be involved in the process at some stage but we must respect the process as it leads out. In my direct discussions with the IHCA and at its conference I said very clearly it must be part of the solution. It relentlessly challenges us on a range of issues, very understandably. Some of the issues are service related but the IHCA has also challenged us on our capital plan, Sláintecare and the de Buitléir report. It must be part of the solution as well as identifying some of the major issues. I said this very clearly at the IHCA's conference and to people directly. There has been direct engagement with the IHCA and I expect it will be part of the process at some stage, but we must respect the industrial relations process.

I accept that. All I am saying is that over the last number of weeks a different message seems to have been conveyed to them and I am concerned about that.

I want to move on to another issue, namely the elective hospital in Cork. There appears to be a structure set up within the HSE with no involvement by either of the local authorities in Cork or the university. There seems to be a committee that nobody knows anything about. We need to move on with the project in terms of identifying a site and then moving into the planning process, which will take some time. Both local authorities have indicated to me that they have not heard from the HSE and that there has been no engagement. I am concerned about that because this is an overall plan not just for Cork city but for all of Cork and the south west region. I am a bit surprised at the silence surrounding this project. I do not want to see a repeat of what happened with the Mater hospital, which went on for 25 years because we cannot afford that in Cork. I seek clarification on that issue and would like it in writing.

I thank Senator Burke who has been on the case about the need for an elective hospital and better capacity in Cork for some time. We have included the project in the capital plan but the Senator is rightly putting us under pressure to make sure that the preparatory work, in terms of sites and so on, is done quickly so that we do not have a gulf between now and the significant capital coming on stream. In the interests of time, I will ask the CEO to revert to the Senator in writing. We are eager to ensure - and I know that Mr. Reid shares this view - the process is inclusive of the bodies to which the Senator referred. We will revert to the Senator in writing if that is acceptable to Mr. Reid.

Mr. Paul Reid

Ultimately, this has to come back through a Sláintecare process which will be across a range of agencies and engagements. In fairness to the hospital group, I presume it is doing some bottom-up thinking in preparation but ultimately it will be a Sláintecare process, which has to be inclusive. I will revert to the Senator on it.

There must be engagement with the local authorities which has not happened to date.

I ask Mr. Reid to send that information on to the committee as well as to Senator Burke. Deputy Durkan is next and he has 12 minutes.

I have 12 whole minutes. I thank the Chairman for that.

The Deputy should use them wisely.

Is that an Irish rather than a standard 12 minutes?

I will ignore the ribald commentary from my colleagues. I seek clarification but am not attempting to have a swipe at the Minister or his officials. Over the years I have repeatedly asked questions about the adequacy of the health budget to meet the challenges faced by the health services in the course of the year. At the beginning of every year I am always told that the budget is adequate and at the end of the year we find that it is not and there are reasons for that. Every Department is asked at budget time to make projections for the year ahead and within each Department there are components which make a contribution but something is going wrong all of the time. There is some shortfall that is not being addressed. This is not a criticism of anybody at all and I am not making any political point here. In terms of the delivery of the health services to the general public, we need to know that we have reliable information coming from reliable sources so that we can budget accordingly. What is the answer to that question?

If Deputy Durkan has difficulty using his 12 minutes, I am happy to give longer answers if that will assist, but I do not think he will. Deputy Durkan is right to raise the issue of the health budget. There is a number of parts to the answer. First, we must be honest about the fact that the Oireachtas makes decisions outside of budget time. The Oireachtas rightly decided this year that we needed to sort the nurses' industrial relations dispute which was not budgeted for. We decided, through the various industrial relations mechanisms, that we needed to solve the SIPTU dispute. We also decided that we needed to do more on Brexit and more in relation to Cervical Check. Deputy Durkan, as a long-serving Member of this House, knows that budget day is a moment in time, albeit an important one, but in a dynamic environment like healthcare, decisions can be made after the budget which can have a significant impact. We will see evidence of that this year as well. I am interested to hear Mr. Reid's views on this. There is an issue around making sure that we have better data and information in health to prepare us to engage in the budgetary process. I must say, honestly, with the arrival of the new CEO and the new board structure, the financial information and data coming from the HSE in the context of that process is like night and day, so dramatic is the improvement.

I am pleased to say that when the Supplementary Estimate figure for health becomes clear in the coming days, it will be a very significant reduction on what was required last year because of very intense financial oversight by the CEO, the board and HSE managers and staff across the country and I thank them for their work in that regard. The final point is that if we are talking about better outcomes and better value for the taxpayer's investment, then we must focus on the reorientation of the health service. We must do more in the community and we must deliver Sláintecare. I know that Deputy Durkan is a passionate supporter of the latter.

Mr. Paul Reid

In terms of delivering against budget at the start of the year versus the end of the year, there are three forces that managers in the HSE and I must manage. The first is obviously improving the services that we are delivering, which Deputies are quite rightly challenging us on in terms of where we are today; the second is providing a safe environment for all users of our services; and the third is doing all of that within the budget allocation that we have been given by the Oireachtas and Government. They can be competing forces on a daily basis but we must make judgments throughout the year to keep those forces in balance together. How are we doing that? If one takes my opening statement on where we are this year in comparison to last year, one can seen a strengthened financial performance which I put down to a few factors. We are now operating at a level where each hospital group CEO and each community officer attends a monthly meeting with the chief operations officer and the national director. We go through slides, hospital by hospital, group by group, CHO by CHO, on service performance and financial performance. They all have allocated budgets, month on month, to report back against. That may sound like basic financial governance but it is really important and it is having an impact. We have hospital group managers owning their budgets and CHO group managers owning theirs. They are committing to actions for the following month and next Tuesday we will go through the whole process again. The basic discipline of strengthening our financial management processes across the organisation is proving beneficial. I can demonstrate that by pointing members to the current position on our budget this year compared to the same time last year. Apart from the fact of being down on the same position last year in terms of the overrun, the mix is also important.

If one looks at the €16 billion budget that the HSE was allocated for the delivery of services, €12 billion of that is for operational services, where we can hold individual managers, hospitals and CHOs to account. On that funding, we have challenged the CHOs and everyone else not to go above €100 million, which is accounted for by our acute and disability pressures. The other €4 billion of the €16 billion budget relates to pensions and demand-led services. We can get our arms around some aspects of that, like drugs reimbursement by using more biosimilar products, for example. We are now challenging every clinician in this area and we now have data telling us which consultants in what hospitals and hospital groups are using biosimilars. This is a much more cost-effective use of our drugs budget. We have put a gain-sharing agreement in place with some hospitals and clinicians, whereby they are rewarded for the use of biosimilar products which makes a significant saving for us. We can do a lot in some areas. In summary, if one looks at our budget for this year, the largest part of the €281 million overrun, at 53%, is in the demand-led areas where we are under pressure. In fairness to the operations systems, they have a stronger control over and grip on the finances.

Regarding data, Members will be well familiar with the lack of a robust financial management data system across the health service. There are remnants of the various health boards and the different systems that were in place in various areas. I will not go back over the past but at the next board meeting on 18 October we will discuss and seek approval for an investment plan for a new integrated financial management system.

This system will be integrated across hospitals, including acute hospitals, community healthcare organisations, CHOs, and our section 38 organisations. One of the pressures we have to deal with as part of this process is the management of finances within section 38 hospitals. In summary, we will have improved financial controls and management processes, we are investing in a new financial management system, we will have greater clarity on what individual hospital groups and CHOs can control and will be able to hold them to account for those matters, and we will have to balance service pressures with patient safety pressures to mitigate risks, an issue which many members have raised.

I accept that there are some improvements, but it is not good for morale in the hospital system or the health system, or for the morale of officials in the Department or anyone else involved, for us to be seen falling short of the target for one reason or another, or to do so again for a different reason in a subsequent year. That does not wash with the public or staff. It frustrates the staff. I am not being negative about it but, as a former Opposition spokesman on health, I would have thought that, when the Estimates are being drawn up at the beginning of the year, various known unknowns or unknown unknowns, as a certain president used to say, would be brought into play and their likely impact over the course of the year calculated. I would have thought a prime cost, PC, sum would be included for issues of which the health service was not yet aware to ensure and safeguard the veracity of the Estimate. The veracity of the Estimate at the beginning of the year is crucial. We can increase the number on waiting lists by any amount while still maintaining the veracity of the financial Estimate, but that does not solve the problem; it does not deliver. If we do not start delivering very quickly, confidence will be lost.

I will move on. The Chairman can tell me when I am running out of runway.

The Deputy has another two minutes.

I will provide an example. There is no maternity cover at all for speech and language teachers. That affects a sensitive group of people who require speech and language therapy as part of their treatment. A teacher dropping out for six months, or less than six months, while no cover whatsoever is provided results in the child's general behaviour taking a downturn. That is not fair to the child or the parents. It frustrates and annoys parents. It appears to be a simple issue to resolve. It would certainly not cost billions and it should be dealt with.

I recently met a constituent whose child has scoliosis. When that issue was highlighted on television a couple of years ago, we thought that it was going to be resolved very quickly. It was not as if 2 million patients were affected; it was a particular cohort. Delivery of services for that cohort should be the responsibility of a particular group within the health service.

Who is responsible for failing to deliver in those two specific areas? Dealing with these issues would not undermine the integrity of the general delivery of health services.

I thank the Deputy for highlighting two important areas. With regard to speech and language therapy, I am pleased that in this year's budget, we provided funding for 100 additional therapy posts across the country. That was a big ask of the Minister, Deputy Finian McGrath. Deputy Murphy-O'Mahony also highlighted the need for these 100 additional posts, which I acknowledge. I am informed by the HSE that it expects all of those posts to be filled by the end of the year. That will be one of the most significant increases in many years. As I said in discussion with Deputy Donnelly earlier, I do not believe that this, in itself, is enough. We are going to need to build on it in the future and we also need to look at how we deliver the model of care. The pilot speech and language therapy programme in schools is an exciting model. This has been done in the UK for a number of years and it has resulted in significant progress in respect of waiting times. That is the role I would like this programme to fulfil.

With regard to scoliosis, I can provide the Deputy and the committee with an update in writing on our progress. Responsibility lies with the children's hospital group, Children's Health Ireland. There has been extraordinary focus on this area. Additional staff have been provided and there was a significant increase in the number of operations performed last year compared to the previous year.

I need to be honest; we have a number of complex cases in which a number of different medical issues above and beyond scoliosis are at play. In 2016 we carried out 224 procedures in this area, whereas last year we carried out 418, so I am satisfied that there is a massive focus on this area. Of course, we need to continue improving. Perhaps Mr. Reid would like to add to that.

Mr. Paul Reid

I will quote the same figures and there are further figures that I can supply. The number of expected interventions in respect of scoliosis has been significantly ramped up. I will make two quick comments with regard to the Deputy's points on maternity cover and staff morale. I am with the Deputy in respect of staff morale. One of the priorities on which I have led personally since joining the HSE is, with my leadership team, to work and engage with staff to improve staff morale. It is not always a matter of finance; it is also about the pressures staff are under every day. We need to give them support and confidence.

There are arrangements in place with regard to maternity cover. As the Deputy knows, we arrange agency cover, which comes at a significant cost to us. A large proportion of our agency spend goes on maternity cover. Approximately 35% of workers in the HSE are on various types of reduced hours or reduced working arrangements. This is largely because the greater proportion of our staff are women. We should support that and I encourage such support but it does result in a demand for agency support. There is provision for maternity cover within the various settings.

I will move on.

Before the Chairman moves on, I have been fairly negative but I would like to compliment the Minister and the health services on the recently announced upgrading of Naas General Hospital. It was much appreciated. It is long-awaited and will be enjoyed by the vast number of people who will attend it from the catchment area throughout County Kildare.

I welcome all of the witnesses. I thank them for coming before us. As the Minister is aware, Bantry General Hospital is the only rural model 2 hospital. Last December, the Minister announced great things for the hospital, including the endoscopy unit and rehabilitation services. Where does that all stand at present? Will the Minister guarantee that the overspend on the national children's hospital will not affect the plans for Bantry? The hospital provides a great service to the people of west Cork. It helps people avoid travelling to the city, where they would take up bed spaces, so when Bantry General Hospital is running well it is a win-win situation.

I will ask my colleague, the Minister of State, Deputy Daly, to comment on this in a moment. The Deputy probably will not mind as much if he comments on it now, in light of his recent political decision.

I am very sad about his decision but the Deputy may be very happy about it. As the Deputy knows, the Minister of State has taken an active interest and has led for me on this issue because he is a representative of the constituency. Deputy Murphy O'Mahony has rightly continued to highlight this issue and I thank her for doing so. I will answer with regard to the national children's hospital and then Deputy Daly may go into the specifics regarding Bantry. Let me be very clear; the national children's hospital will have absolutely no impact whatsoever on this project or any other capital project. The reason for that - I remind Deputy Kelly that he will get another 12 minutes shortly - is that in compiling the summer economic statement, we made a decision to put aside additional resources for the national children's hospital. As a result, all of the various projects across the country which many people said would not go ahead-----

Why is it a three-year plan instead of a five-year plan?

Some 250 projects are included in the capital plan we have published. One of these is the national children's hospital and 249 are other projects.

The Minister does not expect us to believe that.

Can I bring the Minister back to Bantry please?

The national children's hospital will therefore have no impact on Bantry General Hospital. The announcements we made on that great day on which we visited Bantry with the Deputy will absolutely stand. The Minister of State will now go into the specifics.

I thank the Deputy for her continued support for Bantry. She has been very consistent on it and that is much appreciated. I was at a meeting with the management team in the hospital on Monday. We met the CEO of the hospital group, Mr. Gerry O'Dwyer, and the CEO of Cork University Hospital, CUH. The team from the department of surgery in CUH was also present with a view to increasing the available theatre time. As the Deputy knows, the theatre is only open two and a half days a week. We are making consistent strides towards getting that theatre open five days a week in order to build greater theatre capacity within the greater Cork area. That is very good news and positive not only for west Cork, but for all of Cork because some of the waiting list in CUH can be dealt with in Bantry when this is achieved. We are making good progress on that front.

The endoscopy unit has been confirmed in the capital plan. There will be a meeting in the HSE tomorrow with regard to the detail of the capital plan.

It is on track and progress is being made on it. I assure the Deputy that the rehabilitation unit announced by the Minister on his visit to Bantry is still very much to the fore. It was discussed at length at our meeting last Monday with the hospital group and the management teams of CUH and Bantry hospital and will continue to be discussed at those monthly meetings.

I ask the Minister of State to keep me informed on further meetings and what happens at them. I am willing to attend any such meetings if invited.

That is no problem.

I am glad the Minister raised the issue of the flu vaccination. He stated that a different strand of injection will be used I ask him to elaborate on that. What are his plans to educate the public and encourage them to avail of the vaccination?

I will ask the chief clinical officer, Dr. Henry, to address the vaccine and how it differs from that offered previously. We will launch the HSE influenza campaign next Thursday and will encourage healthcare professionals and those in at-risk groups to avail of the vaccination. I am encouraged by the significant and welcome increase in the number of people over the age of 65 who got the flu vaccine last year. I welcome the incredible work of staff in our hospitals and community health organisations who are encouraging peer vaccination. However, in spite of the significant increase, not enough healthcare professionals avail of the vaccination. I would welcome cross-party support on this issue and would support all of us speaking with one voice. We will run several advertisement campaigns and have a large public launch to address the importance of the flu vaccine. I encourage healthcare professionals to get the vaccine. It will protect them and those with whom they come in contact. There has been progress in this regard in recent years, but we need to see more. Dr. Henry will address the question on the new vaccine.

Dr. Colm Henry

We tend to track our projections for flu based on the experience in the southern hemisphere. According to reports from Australia, there was an earlier than expected peak in flu-like illnesses there but it did not sustain. That bodes well for us in the northern hemisphere in terms of the likely impact of the flu. It is the H3N2 strain, for which the vaccine is effective. Based on the experience in Australia, which largely informs our experience during the winter, there may be an early onset but it will not be sustained. The impact will be low in terms of severity and the strain of flu is susceptible to the vaccine we will introduce.

Is the HSE modelling its plans on that basis?

Dr. Colm Henry

That is what we do because the flu season in Australia comes before ours. They give us their flu.

I welcome the Minister's proposal to extend the medical card to those under the age of eight from those under the age of six. What about a nine year old with special needs? While I welcome this, it is important that all children with special needs, regardless of age, get a medical card. Are there plans to extend the card to such children?

I welcome the Deputy's support for our plans to extend access to free GP care for children. It will ultimately be extended to children under the age of 12. I want the parents of primary school children not to have to worry about the cost of going to the GP. The budget will decide the pace at which we can do that. The Taoiseach and I have publicly stated that we would like to extend it next year to those under the age of eight. That will require legislation, the support of the Oireachtas and agreement with the IMO on the fee to be paid.

The Deputy raised a fair point regarding equity and people who do not fit within certain age cohorts. With the support of Fianna Fáil, we changed the law to provide every child with special needs in receipt of domiciliary care allowance with an automatic entitlement to a medical card. That was championed by the Minister of State, Deputy Finian McGrath. All Members will be aware from their constituency clinics that the measure has helped many people in terms of no reviews and so on. That is one change we have made. Anyone who has a disability and receives domiciliary care allowance automatically receives a medical card. That is welcomed by all members.

On broader eligibility, I am conscious that Ms McGahey will appear before the committee to deal with Sláintecare at the end of the month. The Department will commence a significant body of work on eligibility, encompassing who should be eligible, who should pay, what constitutes universal healthcare and how we will meet costs. We will examine those issues. I agree with the Deputy. My policy position is that once we provide for those aged under 12, as we should, eligibility should be extended based on income and need rather than being in a specific age cohort.

What is the position on access to a medical card for people with cancer? My office is finding it very difficult to get medical cards for people with cancer. The rules seem to change. It is alarming that a significant number of people who were successful in getting a medical card received a review form the following day or week. The review is almost immediate, which, obviously, is upsetting. What is the position in that regard? Is everybody diagnosed with cancer eligible for a medical card?

Every child with cancer is automatically entitled to a medical card.

Adults do not have automatic entitlement to a medical card on the basis of on an illness. Applicants are assessed on financial grounds and for the discretionary medical card. If one does not qualify on financial grounds, one may qualify on medical grounds under the discretionary application process. The number of discretionary medical cards issued continues to increase month on month, as is evident from the figures we published. The Deputy has hit on an important point. I do not wish to take up too much of the committee's time, but recently I met Mr. John Wall, who has terminal cancer and highlighted his difficulty and that of many-----

He is from County Clare.

He is. He highlighted his difficulty in navigating the medical card system. I also had a very good meeting with representatives of the Irish Cancer Society. I have asked Mr. Wall and certain other stakeholders, including the Irish Cancer Society, to meet the primary care reimbursement service, PCRS, and consider providing better patient information on how people with an illness can navigate the medical card system. We provide medical cards for persons with a terminal illness. There is an emergency medical card and a discretionary medical card that can be granted if someone has a terminal illness that is not reviewed. Currently, such cards are issued if someone has a terminal illness and is likely to live for approximately 12 months. Mr. Wall has asked me to consider, as the Deputy probably would also, people who will live for 13 months, 14 months, two years or three years. It is not an exact science; it is medicine. Thankfully, people are living longer because of medical improvements. I have committed to reviewing this issue and examining the definition of a terminal illness and how the medical card system interacts with it. These two issues relate to Mr. Wall. We are due to meet again at the end of November. I will keep the Deputy updated in that regard.

That is welcome. There seems to be inconsistency. It should be at least six months before a review form arrives in the post.

I acknowledge that the committee is very busy, but the new head of the PCRS section of the HSE is eager to engage with stakeholders. The committee may wish to meet representatives of the PCRS and the medical card section and provide feedback. We constantly try to improve our processes. The HSE has done a very good job in going online with medicalcard.ie. When I first visited the medical card centre in Finglas, there was paper all over the place which had come in the post. One can now apply and upload documents online. One can take a photo on one's iPhone and submit it. One receives a text message in order to track a submission. There is always room for improvement. If there are difficulties in that area, we should work together to address them.

The Deputy has one minute left.

My last question is for my constituency colleague the Minister of State, Deputy Jim Daly. He must admit that the position on homecare packages is almost at crisis point. People are crying out for such packages. Those who pass the assessment are being told that there is no one available and that the HSE will get back to them when something becomes available. They are left in that position for months. It is very cost effective to keep people in their homes and provide them with a small amount of help. Are there plans to increase the provision for this area in the budget? What is the position in that regard?

Unfortunately, I cannot comment on the budget which is above my pay grade. It will be a matter for the Minister for Finance, Deputy Donohoe, next Tuesday. The Deputy has made a valid point on homecare. Everyone in the room shares the frustration at people receiving HSE approval for two hours help per week but being placed on a waiting list. That is very frustrating for all of us. There are more than 6,000 people who want homecare but cannot access it. I wish that was not the case. It would cost approximately €50 million to clear the list.

Is it a recruitment problem?

The Deputy asked me what we were doing about it. I have outlined the problem. A statutory homecare scheme is being designed, the details of which I intend to unveil in January. We have committed under Sláintecare to introduce it in 2021. The scheme will operate along the lines of the fair deal scheme, in that it will be statutorily available when sought.

What we could do for the next 12 months is interfere in the current system and put a band aid on it, but instead we will take the time to devise an entirely new scheme of homecare support that will not have the postcode lottery aspect that bedevils the current scheme. We have done significant work on the issue raised by the Deputy of the availability of staff to deliver the service and also ensuring there will be a regulatory aspect to the service in order that we can regulate and stand over it.

While that is welcome, it seems to be somewhat aspirational and a long way off. I wish it could be even half sorted now. The Minister must free up a few bob.

While I do not want to eat into anyone's time, I thank the Minister of State, Deputy Jim Daly, for his leadership in reforming the homecare system. I hope he will still be in place in May 2020. We can try to progress the statutory homecare scheme. I assure the Deputy that in the context of our winter planning and budget 2020, additional resources for homecare services will be an absolute must. We are trying to address the issue.

I thank all of the delegates for coming. I will start with a number of questions about the hospital consultant issue, even though many others have also contributed on it.

My concern is that ten years on from the recession, we are not making inroads in recruitment. Sláintecare, on which many members of the committee worked a number of years ago, is a roadmap for a period of ten years, but it will not be doable if we do not have the necessary front-line staff. For example, Beaumont Hospital recently lost three dermatologists to the private sector. It now has only one whole-time equivalent in dermatology and 400 patients have been referred for dermatological treatments in the private sector or elsewhere. Here we are again, with consultants being poached by the private sector. In the Bons Secours Hospital in Cork the last 12 appointments have been made from Cork University Hospital. There is a huge amount of leeching. An emergency department consultant left Tallaght Hospital recently to enter the private sector. I understand the argument about the market and consultants, but when one looks at the sub-specialties where there is very little private work such as emergency medicine, psychiatry and paediatric radiology, these are areas in which we have some of the most acute recruitment problems. We continue to recruit administrative staff, as Senator Colm Burke pointed out, but we are losing front-line staff such as nurses, consultants and the people we need to do the work on the front line. I know from talking to hospital consultants that they are very disheartened.

Reference has been made to the IMO letter, but we must consider the issue of false economies and locum staff. A locum anaesthetist in Bantry was paid €415,000 to do a job last year which is far in excess of the salary of a permanent consultant. Tet locum consultant had no role in education, training or any of the other work in which permanent consultants engaged. To my mind, the total cost to the health service is almost €600,000, which is not sustainable. There are 108 consultants who are not on the specialist register, SpR. As members know, they are concentrated in regional hospitals, which is a huge risk. While I did consider naming the hospitals in question, I decided that it would not be fair to the representatives who are here. There is a figure of €3 billion in State Claims Agency costs, 90% of which comprises health claims. We are training the most doctors, exporting the most and then poaching them from developing countries which is in breach of WHO guidelines. Despite plans, including implementation plans, and so forth, I am very concerned that we will end up in a situation where we will not have the expertise required. There was an acceptance a number of years ago that the country was on its knees and that we would have to put our shoulders to the wheel.

Many consultants are running out of patience. I am concerned that we are dumbing down our health service and dumbing down quality. It may get to the point of no return and we may never be able to implement Sláintecare. Perhaps the Minister or an official can tell me how many consultant posts around the country are unfilled. What is being spent on locums and temporary staff?

Another massive issue is the annually increasing spend on the National Treatment Purchase Fund. This obviously has its benefits in that people get treated, but it is not a sustainable model of care for treating patients in the system. It was always expected to be a sticking plaster for areas in which there were capacity issues rather than an attempt to stop a haemorrhage. It was not supposed to export our patients.

The consultants claim that €20 million per year will attract consultants home. They claim they will not work on the same corridor as someone who earns more than them for doing the same job. It seems very reasonable. I agree with the Minister that it is about far more than pay, but it must start with pay parity. Something has to be done and some way forward has to be found. These people are not just doctors, they are the people who are running the system and who have corporate knowledge of the Irish system. If we lose the goodwill of the consultants, we will never be able to implement Sláintecare.

On her point about the WHO, I assure Deputy O'Connell that we take our obligations very seriously. We are investing a lot in training doctors to be sent back to developing countries, but I take the Deputy's point.

We are not really doing that as charity. They are keeping our universities afloat.

No, we actually fulfil our WHO obligations in this way, but I take the Deputy's point. I would like to put some figures on the record of this committee, because I believe they are important. I accept there is a challenge in respect of recruitment and retention and that pay parity needs to be addressed. I have said that, I believe it, and I do not disagree with Deputy O'Connell in that regard. There is the whole-time equivalent of 3,153 consultants in the Irish public health service. More than 600 additional consultants have been recruited over the past five years and 139 additional consultants have begun working in the health service over the last 12 months. While I accept there is a challenge in respect of recruitment and retention, people are sometimes of the opinion that there are now fewer doctors and that we are losing doctors. The statistics do not show that. More than 600 additional doctors have entered the health service over the past five years, including 139 over the past 12 months. That does not take away from the point Deputy O'Connell makes about the very significant issues in recruitment and retention. The CEO will speak to vacancy levels and so on in a moment.

I am deadly serious about sitting down with consultant representative bodies to do two things. I want to address the immediate challenges with regard to recruitment and retention, of which I accept pay is an element. I also want to build on the Public Sector Pay Commission's findings. The Deputy should remember that we, as a Government, saw this as such an issue that we asked the Public Sector Pay Commission to carry out a body a work on it. The commission told us to sit down and engage and I want to do that.

I will need the help of the consultants to do the second thing I want to do. Deputy O'Connell talked about the delivery of Sláintecare, into which she has put a lot of work and a lot of her personal time. It is disappointing that, every time we move forward with an element of Sláintecare, I hear from the representative bodies that they do not agree with it. The speed at which the de Buitléir report was dismissed by representative bodies is very disappointing. The Deputy talked about international comparisons. The OECD report I commissioned, which we also published that day, shows that Ireland is out of sync with other countries in respect of private practice in public hospitals. Phase 1 - and it will have to be phase 1 because sequencing is important - will have to be talking about the immediate recruitment and retention challenges, of which pay parity is an element. That needs to be done before we can talk about reform. We will start that process with the INMO next week. I want to expand those talks to include other bodies such as the Irish Hospital Consultants Association in due course.

We will then need to move to phase 2, which will have to be about the Sláintecare reform agenda. I accept that one cannot be done without the other. We have very hard-working doctors working under a lot of pressure and they need to realise that the political system and I want to support them.

Mr. Paul Reid

I may call on the chief accounting officer when I am finished. On the issue of pay, I will restate my own position. Having spoken directly with consultants and the consultants' association, there is no doubt that this is an issue of equity which is capable of causing an issue of morale. It is also an issue of recruitment and, equally, of retention. People are having different experiences when they go elsewhere. Having said that, the second point I want to make is that I have spent a lot of time with the chief clinical officer in direct engagement with consultants across the acute system. I agree that we need their goodwill and that we need to hear their voices and the issues they are raising with regard to service delivery.

There is fairly regular direct engagement between clinical directors and consultants across the system.

There are significant vacancies throughout the country. The Minister referred to 39 such vacancies. There have been 144 in the past 12 months by my count. There are 78 recruits in the final stages of assignment, which should further enhance recruitment numbers. There are approximately 377 posts vacant across various disciplines. Some people claim there are approximately 500 such vacancies but the registered number is approximately 377. We have several initiatives for consultants led by our national doctors training and development unit, which is looking at what we can do to attract applicants to certain specific disciplines.

On the Deputy's final comment, we must address some work practice issues apart from pay as part of a process of engagement with consultants. There are significant challenges attracting consultants to certain elements of the acute system. That is a factor with which we will deal regardless of whether the pay issue is settled. These are challenges in certain acute settings. The committee has a list of them.

There is a significant morale issue. It is difficult for a doctor working in a busy hospital in Dublin to hear that a locum doctor in Bantry who can put on his coat at the end of his shift and walk out the door is being paid €415,000. A permanent consultant cannot walk out the door, go home and cook dinner for his or her children, but the guy in Cork who can walk out is getting one and a half times the salary but none of the hassle, if one wants to call it that, or the training and development. One can understand why people lose faith in the system.

I ask the Deputy to put her question.

I am sure the Minister and the Department are aware of the increasing evidence on the harmful effects of vaping, which has emerged in recent years and is becoming very popular. All present are aware of the expansion of the industry onto high streets and, clearly, how profitable it must be if rates and so on can be paid on such a number of outlets for these products. If the products are to be marketed as a smoking cessation aid, they must be subjected to the normal regulatory approval processes and procedures. However, it appears that they are a technological drug delivery device. If they are not smoking cessation products, they are, essentially, glorified cigarettes. The formulations of nicotine used are addictive.

I ask the Deputy to put her question.

The product is highly addictive. It has been formulated to penetrate the lungs and blood system to a greater extent than cigarettes do. The raw material is nicotine, which tobacco companies have plenty of and want a market for. Somewhat like the Minister's thinking on vaccination, I am instinctively inclined to ban vaping altogether but I realise that is not possible. Will achievable regulations be brought in? Are we going to protect our children by banning these products? Will there be education on them in schools? It seems that much capital was spent on smoking cessation and we now have these new products, some of which are 20 times as addictive as cigarettes.

The Deputy should give the Minister an opportunity to answer.

Does the Minister have plans in that regard?

The behaviour of large tobacco companies in moving into this space is unethical and despicable. They are targeting our children. It is clear what they are doing. Large cigarette companies, which know the war on tobacco is under way and that we are heading towards a tobacco-free Ireland, are mooching into a new area. I was in a petrol station a few nights ago. Some time ago, the Oireachtas decided to bring in plain packaging and block the advertising of cigarettes. However, when I looked behind the counter in the station, I noticed that all of that advertising has been replaced by advertising for e-cigarettes. I am appalled at the number of Oireachtas Members who ask me to meet representatives of vaping companies.

I will never meet them, so Members - I am not referring to anyone in this room - can stop asking me to do so. This is a new arm of the tobacco industry, it is a threat to our children's health, and we need to call it out. What are we going to do about it? We will first ban the sale of e-cigarettes to children, people under the age of 18. We will bring draft legislation to Cabinet this month, I think, to do that. We in the Houses of the Oireachtas have a really good record of taking public health decisions on a cross-party basis, and I look forward to working with the committee in that regard.

Beyond the sale of e-cigarettes to children and the benefits or otherwise of vaping as a cessation tool, it is fair to say the evidence is evolving at a very rapid pace. HIQA did an assessment of this in 2017. I have now asked the Health Research Board, HRB, to look at the potential harmful impacts of e-cigarettes, vaping or whatever one wishes to call it. Its response is due next March. Step one, then, is to ban the sale of e-cigarettes to children. Step two is to look at the HRB evidence in March and see what further action we need to take. My instinct, not as a doctor but as someone who talks to doctors, is that there may be - may be - an understandable logic to a person already on tobacco moving to e-cigarettes. However, that is very different from targeting 14, 15 and 16 year old kids with nice, colourful things and children's flavoured e-cigarettes and advertising them to try to get around our rules on plain packaging. We will therefore have to take this very seriously and be very vigilant about it. The first step forward is banning the sale of e-cigarettes to under-18s.

Before I call our non-members, I wish to go back to an issue Deputy Kelly raised. We have a very serious problem in University Hospital Limerick. The problems facing hospitals in general are capacity, consultant numbers and diagnostics. One of the critical points in Limerick is the lack of a second MRI scanner. I know that Mr. Reid mentioned the HSE is considering whether to buy or lease a scanner, but the absolute urgency of a second MRI scanner in Limerick cannot be stated strongly enough. Many people in hospital are waiting unnecessarily for MRI scans to determine whether they are admitted or discharged or to make proper diagnoses so they can have proper management plans. I refer in particular to neurological conditions but also cancer. Unless Limerick is supplied with a second MRI scanner, the problems we see there every day, 70 or 80 people waiting on trolleys, will remain. Trolleys are just a manifestation of what is happening within the hospital itself. Casualty is not the problem; the problem is what is happening in the house of the hospital. There must be a second MRI scanner in Limerick immediately. What will the Minister do about this?

I hear the Chairman very clearly and in the strongest possible terms. I ask Mr. Woods to update us on the HSE's position on how we advance this.

Mr. Liam Woods

I had dialogue with the group chief executive last week. Like the Chairman rightly said, on that day I think there were 44 patients in the hospital awaiting an MRI scan, which is clearly a key factor in patient flow. I will come to the Chairman's main point presently. What we have done in the short term is bring MRI capacity outside of the hospital where we can but, clearly, this only works to a certain extent. The NTPF has worked with us in this regard, which has been helpful, over last winter and in this part of the year. The underlying point, that Limerick requires a second MRI scanner, is agreed, and we are looking at options including, as the Minister said, winter funding. I think the quickest option is to acquire a leased MRI scanner. The timescales around acquisition and building would be longer. We will therefore look at the option of putting a leased MRI scanner on site as part of our winter programme. The implication for us is a cost that I think has been referenced at approximately €1 million to €1.4 million, but a second scanner is a key requirement that is fully accepted, so we are working with the group on what that would look like on the ground.

What is the timeline, then, for the provision of the scanner? Will it be provided this year? Will it be provided before Christmas?

Mr. Liam Woods

Subject to funding decisions, I think we would be looking at a timeline that would require some level of procurement. Clearly, we would look to accelerate that as quickly as possible, but we would require some level of procurement and perhaps a little guidance from procurement colleagues on that. Such a transaction tends to take six to eight weeks to complete, as I understand it. The other challenge we face is simply to address the challenge of the funding that is required for the hospital. We do, however, recognise the need for the scanner and are keen to move on it.

Can we then expect a second MRI scanner in Limerick in the next eight weeks?

Mr. Liam Woods

We will need to come through the Estimate and our winter planning process, which is ongoing. We will be clearer after that.

Our intention is to seek to do that, but I would like to address a couple of uncertainties before I commit entirely to that.

Is there an expectation that the scanner will be there before the end of the year?

Mr. Liam Woods

That is the desire, subject to recruitment and funding. It is a critical issue.

I know that a number of colleagues will want to bring this up, and I am more than happy for them to do so. To be helpful and constructive, I ask the chief executive to arrange for the HSE to have a meeting, as well as its meeting with midwest representatives, within a fortnight to discuss issues in the hospital in Limerick and in the hospital group, specifically the issue of the MRI scanner. If we could arrange that, it would be great.

I thank the Minister. The second point I wish to make concerns the trolley problem. In the month of September the number of people on trolleys was 40% higher than in the same month last year, so whatever reforms are happening or whatever the Minister is doing is quite patently not working. I will give him some examples. Moving away from trolleys, there are patients suffering greatly because of bed capacity problems, not necessarily just because they are on trolleys. There are patients for whom we as GPs must fight to get them into the system. It is not just a matter of asking for a consultation; it is actually a fight to get people into the system. There are patients in the midwest who have cancer and who have been waiting six months for a basic diagnostic procedure. A number are cancelled or time out. I was in contact with one patient this morning, an elderly gentleman who has been waiting for surgery for a number of weeks. He was admitted on Sunday night and fasted all day Monday and all day Tuesday, and today is Wednesday and he still has not had his surgery.

The Minister cannot just dismiss these issues by saying the numbers are improving. There are real stories behind each one of these patients. I do not think he recognises the urgency of that. I just did not get a sense of urgency this morning from the opening statements he and Mr. Reid made. I just want the Minister to respond. How urgently will he address the bed capacity issue and the consultant capacity issue? I understand from what he said today that he has now written a letter to the IMO. He committed to doing that before the summer recess. He did it on the last day of September. He has not contacted the Irish Hospital Consultants Association. The recruitment and retention of consultants is a huge barrier because it can be proven that if a consultant or two are added to a team, that waiting list drops immediately. Addressing recruitment and retention is therefore the key to reducing the number of people on waiting lists and trolleys. What urgency does the Minister attach to this matter?

I hope, politics aside, that the Chairman does not doubt the commitment I attach to the urgent needs of our patients. Nobody has a monopoly of concern or compassion for them. In the Chairman's region, when he and others approached me and said they could not wait for the capital plan and that something had to be done about bed capacity in Limerick, we went ahead together and found the funding in advance of the capital plan to proceed with the 60-bed modular unit. Unlike previous Governments, which during boom times decided there were too many hospital beds in the country - that gets airbrushed from history now - and shut them down, my record is that in every single year I have been Minister there have been more beds in the Irish health service.

Looking at recruitment and retention truthfully, we had a major issue with GPs, a major issue with our nurses and midwives and a major issue with our consultants - and others, but I will take just those three significant groups. We have worked our way through the GP process. We have more to do, but the GP community itself has endorsed by 95% the arrangement we reached. I know that the Chairman, while acknowledging there needs to be a new contract, has welcomed the progress in that regard. With the nurses and midwives we have come up with an agreement that will see more money put into nurses' pockets, which was ratified by 66% of nurses and midwives. My next big body of work on recruitment and retention in the health service concerns consultants. As Minister for Health, however, I find that on some days I come into the Houses of the Oireachtas and everybody wants to get very irate about the overspend on health while, on other days, I come in and before 11.30 a.m. we have probably racked up a bill of €500 million or more. There are competing demands in the health service. That is why we must reform it. I know that that is why the Chairman is passionate about it, but so am I.

I am absolutely passionate about reform in the health service. We would like to do it a million times more quickly, but we have taken major decisions in the past six months alone such as on the agreement with GPs, the breaking up of the HSE into new structures and engagement with consultants. We are genuinely putting the building blocks in place. As Minister, I will, rightly, be held to account on day-to-day issues, but I am satisfied that the things to which I have referred are the blocks that will build a better health service. A compelling case has been made by members today, as well as by colleagues from the mid-west, as to why we need to move on the question of MRIs. As it sounds like the lease model will deliver on it much more quickly, we need to explore it urgently and rectify it.

The director general of the HSE, Mr. Paul Reid, gave evidence on reaching the budgetary targets each year. When the service plan is published, the first line is always that it will be challenging to meet demand and demographic change and provide for the introduction of new services. Having a "challenging" budget implies that the HSE will not be able to deliver the services it wants to deliver. If it goes over budget, it is because it is delivering more services to deal with the unmet need that has built up. If we are to meet our target and come in under budget, there has to be reform of the system because it is inefficient. Senator Colm Burke referred to the number of non-front-line staff employed every year. It must take a huge number of non-front-line staff to run an inefficient service. It is absolutely essential in respect of Sláintecare that there be urgency, but I do not get a sense that there is that urgency in the implementation of the Sláintecare report. How urgently is the Minister addressing the issue?

I am addressing it urgently. I hope the committee and the Oireachtas will help me to deliver the bits that are not just the nice fluffy bits. We can all say we are in favour of more homecare services - Sláintecare - and dismantling the HSE, which is the right thing to do. The HSE and the excellent people who work in it know that its current structure is not configured correctly. It is a thorny issue to tell people that they have to change the way they work. Today a consultant is allowed to engage in private practice in a hospital in Limerick, while there are 80 patients on trolleys in the same hospital. There will be a moment when people will have to nail their colours to the mast and I cannot wait until we get to that moment. Are people in favour of Sláintecare and what it actually means, or they in favour of it as though it was a Rose of Tralee-type concept? I am in favour of the delivery of Sláintecare, which will mean big and significant changes. It will mean paying consultants more and tackling issues such as pay parity. It will mean greater bed capacity, but it will also mean no more business as usual. It will mean fewer managers in the health service and ultimately lead to a voluntary redundancy scheme as we streamline management. Where there are two finance functions today, one for community services and one for hospitals, there will have to be one. Front-line staff who are brilliant and do an excellent job will have to look at different ways of working and we will have to remunerate and support them accordingly. The Chairman is beyond reproach on this matter. I accept his bona fides, but I know the clear views of everybody in the House, including Deputy Kelly, on the de Buitléir report. I challenge every political party represented in the Dáil to issue a statement this week confirming whether it is in favour of the de Buitléir report.

There are nine non-members of the committee in attendance, which is an indication of the importance of health issues in this Dáil. I will give each of them an opportunity to ask one question. This is not an open forum and we have to respect the permanent members of the committee.

I have raised this issue in the Dáil in the past couple of weeks. I am referring to the south-east palliative care centre, which is part of the Dunmore wing of University Hospital Waterford. The top three floors will house 72 acute beds run by hospital management, with the bottom two floors being a new, state-of-the-art palliative care facility. Local Oireachtas Members, including some of the Minister's colleagues and the Minister of State, Deputy Halligan, got a tour of the facility last week. Palliative care will be run by the CHO but the problem is that only €300,000 has been allocated as a start for staffing and revenue funding. People in the south east are scandalised by the fact that the building is built, fully equipped and ready to be opened but has not yet received the revenue funding. We have met with officials who have told us that even when they get the funding they will have to recruit staff and we could be talking about a year or more before the unit becomes operational. How much will it cost to fully staff the palliative care unit? Why was the funding not given much earlier, given that we knew this was going to be completed and fully equipped in the summer of this year? It could be lying idle for months or a year but patients in the south east deserve the same palliative care options as people in other parts of the country.

In responses to parliamentary questions, the Minister said there would be an allocation arising from the overall funding for palliative care in the Estimates. Will the full allocation, of €4.5 million or €4.6 million for next year and €5 million for subsequent years, be given in the Estimates so that the unit can be fully opened?

I am having a meeting tomorrow with Deputy Cullinane and Oireachtas Members from Waterford on a cross-party basis. I respect the way they work on a cross-party basis on issues of importance in the south east as it is effective. I am very aware of concerns of people in the south east over this issue. They have a new state-of-the art facility in the shape of the Dunmore wing, which will house an incredible palliative care facility. My understanding is that the south-east palliative care centre was constructed at a cost of €31.26 million and I thank the Waterford hospice movement which I think has agreed to provide €6 million to the HSE towards the cost of the lower level and level 1 palliative care services. There is incredible community support for this and it will be the first inpatient and day service specialist care unit for the south east and will also cover Carlow, Kilkenny, south Tipperary and Wexford. When fully operational there will be 20 inpatient bedrooms with individual gardens for anybody who requires the expertise of specialist palliative care multidisciplinary teams.

There is an allocation of €300,000 for this year for this hospice and for a number of others. Deputies Donnelly and Brady will be aware of one in Wicklow. We cannot open the centre now until we have the certainty that the €4.8 million will be in place for 2020. I am very hopeful that we can resolve this matter together this week. I do not want to get involved in the minutiae but there will be a time lag as it will take time to recruit the appropriate staff to provide the services. We have the funding of €300,000 to begin the process and my job is to make sure we have the funding for 2020 so that management can proceed with certainty.

I ask Senator Kieran O'Donnell to put one succinct question.

Like my predecessor, I will have to give some kind of preamble. My question is specific to University Hospital Limerick. I have looked back at the overcrowding data on individual days for the past month and there has been an average of 67 people on trolleys. In September last year the average was 44.

This is no longer a political issue, it is a human rights issue. I am seeking confirmation from the Minister that there is a radical plan to address this issue. The 60-bed modular unit is under construction and my understanding is that it will be completed by June next and operational by September. I understand also that planning and design in respect of the 96-bed acute block is under way. Following this historical reconfiguration there will be more than 150 additional beds but until such time as the 60-bed block is in place, we need a radical plan to deal with overcrowding at University Hospital Limerick. Today, there are 47 people awaiting discharge. The figure for this time last year was eight. Owing to the lack of beds in Limerick, the focus must be on discharges. Can the Minister give a commitment in regard to the transitional funding under the fair deal scheme?

The Minister referenced the MRI scanner. The existing scanner is at breaking point. If it were to break down, would it take six or eight weeks to replace it? The situation has reached crisis point. An MRI scanner needs to be provided with immediate effect. Six or eight weeks is too long for the people on the ground. When will a radical plan and transitional funding be put in place for University Hospital Limerick to improve the discharge rate and provide a new MRI scanner?

I thank Senator Kieran O'Donnell for consistently raising the issues in regard to the mid-west. The Senator is correct in terms of his remarks in regard to the 60-bed modular unit. I know we are only as good as the next thing we can do for this region and that it is important that we do an awful lot more. I get that. We do have a plan to increase bed capacity by 150 or more, with the 60-bed modular unit well under way.

There are three areas we need to address. We need to examine how we can work as a group. As mentioned by the Senator, reconfiguration has happened. It happened many years ago, long before I became Minister or a Deputy. We do still have capacity within other hospitals on occasion. We need to look at how we use the group and the community together. During my recently unannounced visit to Limerick and the hospital, I spoke to people from the area and to staff at the hospital and they all expressed the view that there is more that can be done in respect of the smaller step-down hospitals. We need a plan.

We have waited 70 years and nothing has happened.

I am giving my view on the matter.

When will we get this plan?

I am coming to that. I have heard very clearly members' views on the issues of diagnostics and the MRI scanner. It is the view of all members, echoed by the CEO, that we could free up capacity and get people in and out of the hospital a lot quicker if we had an additional MRI scanner. I get that. There is need for consideration of how best to achieve that and there is a funding requirement which we need to examine. The Senator asked about social care and if, while we are waiting for additional beds, we can do more to help to get people home and into transitional care. I expect to be in a position next week on budget day to put together a winter package that will include an increased social care dividend. In terms of a timeline, I have suggested that the HSE should meet mid-western representatives in two weeks' time to see how we can progress these issues together.

I understand a meeting with the HSE and the Department on, specifically, the mid-west and the community hospitals has been arranged for tomorrow.

Yes, sorry. I will be meeting the HSE and the Department on this matter tomorrow.

The Minister might update us on the outcome of that meeting.

I will update Oireachtas Members.

The next two contributors are Senator Byrne and Deputy Tóibín.

I welcome the Minister and his officials to the meeting. I, too, want to raise the hospital issues but there are number of points I will make that might support it. On the MRI scanner, I note and welcome that the timeline for provision is pre-Christmas and I take on board that a complementary plan for the better use of associated hospitals in the group will be put in place. There are other issues that need to be addressed, including recruitment of an MS nurse, for which I have been fighting for a year. I have been told that funding is in place, that the position has been advertised but the recruitment has not progressed as it there must be a sign-off at a national level from on high, which ties in with the situation nationally in terms of recruitment. Recruitment will help to address the issue of lengthy periods spent on trolleys and waiting lists for scans.

If there was an MS nurse in place, people would not be taking up hospital beds. The lack of recruitment and an MRI scanner are leading to huge problems in the hospital. All of the problems need to be addressed together. I am interested in hearing the Minister's comments on the plan for the better use of other hospitals associated with the group.

I thank Senator Byrne for being in constant contact with me on this matter and for visiting St. John's Hospital with me, with which I know she has a long affinity and connection. I know also, because the Senator raised it in this House a few weeks ago, that her view is that St. John's can and should do more and that it has a proposal for a 120 bed ward block, to which we will give consideration. We first need to do the infrastructural upgrade of that hospital in terms of fire safety and so on. The Senator will be aware that those projects are proceeding.

On the scanner, we have had a useful conversation this morning on the benefits of an additional scanner to the mid-west region in terms of trolley numbers. The HSE and the Department will stress test that proposal and we will see if we can make progress in that regard. On the MS nurse, while I am not familiar with the specifics, I am aware that the Senator has been championing that recruitment for some time. An additional 68 staff were hired in the hospital in the last five weeks, more than 40 of whom are in the area of nursing. I will undertake to make inquiries in regard to the MS nurse recruitment and I will hand over now to Mr. Reid to comment further on the mid-west in general.

Mr. Paul Reid

What has been put in place pre the winter plan is a €10 million additional injection across the system, of which the mid-west is part. This funding is, largely, funding directed by the Department and the HSE in terms of current expenditure, to try to address, pre the winter plan, some of the issues in terms of transitional care beds and to relieve pressure under the community support scheme, the nursing home support scheme and in respect of home help provision. There has been some improvement in the last few weeks in terms of delayed discharges, which we would expect, in turn, to impact on trolley numbers.

I want to assure members that in terms of delivery all of these matters are urgent and a matter of priority everyday for our managers. In terms of trolley count, including in the mid-west, over a three week period in September there was an increase of approximately 6.5% in people into our emergency departments, which is very significant. I visited University Hospital Limerick and many of the acute hospitals throughout the country. What we are seeing, particularly in the past few weeks, is an additional requirement for older persons coming through our emergency departments. As members will be aware, in our acute settings the rate of admission generally is one in four or 25%. In the case of older persons, it is one in two. As I said, we are seeing a significant surge of older persons into emergency departments and, thus, a significant increase in terms of admissions. The additional investment made ahead of the winter plan will have some benefit over the next few weeks as well as it starts to work back through the system.

On recruitment, in the period from July 2018 to July 2019 we recruited 2,895 staff. Since the start of January this year, 1,138 staff were recruited into the health system. The latter is a mix of nursing, midwifery, consultants, management and administrative staff. On management and administrative staff recruitment, which I have examined in detail, 85% of these staff are front-line support staff. We do have an issue and we will be reviewing the centre of the HSE in terms of management overhead. However, I would like to reassure members that much of the recruitment is primarily targeted towards front-line services.

My understanding is that the MS post requires sign-off by the national director of recruitment. There is a recommendation for three such posts, but one would be welcome.

More than 4,000 women have been affected by the disaster within the CervicalCheck programme in terms of delayed smear test results. Sharon Butler Hughes played a pivotal part in exposing the laboratory computer glitch which resulted in the delay of thousands of screening test results.

She has been forced to break her privacy in recent weeks by going public about her concerns in that area. The timeline with which she and thousands of other women have had to deal is shocking. She was in contact with the Department on numerous occasions from the beginning of the year to at least 11 July. The HSE and the Department knew in April and evidence is emerging that they were speaking in briefing notes provided for elected representatives during that period.

On 9 July, she phoned the Department of Health and was told by an official that the Minister was fully briefed but on 10 July, the Minister stated that he only found out about the issue at about 6 p.m. I understand that the Minister cannot know about everything that happens in the Department as it is a massive affair. However, given the significant number of scandals that have occurred with regard to CervicalCheck and the period of time during which they occurred, would it not be the case that a Minister would say "if something does wrong here, raise alarm bells straight away and make sure I know"? The defence that the Minister did not know what was happening in the Department with regard to this issue over a period of months, while the Department and the HSE knew and thousands of women found out is not good enough. If a crisis had been occurring over a couple of months in a small shop in the Minister's constituency-----

Could the Deputy ask a question?

Sharon Butler Hughes is very disappointed by the fact that the Minister stated that her view is incorrect. Even though she supports the MacCraith report, she is also disappointed by how that aspect has been reported in the report and she wants to meet the Minister. I know the Minister will meet her but he has set out a precondition, namely, that he will not speak to those particular issues. Will he meet her without preconditions?

I want to formally and publicly thank Sharon Butler Hughes for the work she did in highlighting this issue. I am very pleased that on behalf of the HSE, the CEO apologised about the IT glitch and that he took very swift action about commissioning an independent external rapid review. I thank Professor MacCraith for carrying out that review. He did not pull his punches. He was very clear about the areas where improvement is needed. However, I am also very conscious that I have exceptionally good and committed public servants in my Department who do an excellent job and who come in every single day, as do staff in the HSE, to do their very best to serve the public. What I do not intend to do is reopen the findings of the MacCraith report. I very much look forward to meeting Ms Butler Hughes. We will arrange that shortly. At the meeting, she will have an opportunity to discuss anything she wishes to discuss.

When one is corresponding with someone, it is very useful to be very honest with him or her. I accept the findings of the MacCraith report, which is very clear about what I knew and when I knew it, in full. Most importantly, I am excited by its recommendations in terms of how we can make CervicalCheck even more responsive to women. Mr. Reid and I, along with the CervicalCheck staff in Limerick, believe that the idea that someone would have to ring the Minister's office to find out where her smear test is constitutes a sign that we need to really improve how people can track their results. That is what Sharon has helped to unearth. Some of Professor MacCraith's recommendations in that regard are very helpful. They include the idea that women should be able to track electronically. I accept the MacCraith report in full. I thank Sharon Butler Hughes for what she has done and look forward to meeting her.

Unfortunately, when it comes to our national newborn screening programme, we are way behind international best practice. We only screen for about four rare diseases through what is commonly known as the heel prick test. Italy vastly expanded its screening programme over a very short time to include 40 rare diseases. This was done during one year. I know the Minister has engaged with the Italians. Unfortunately, our failure to meet international best practice has had a devastating effect on families across the board, not least some of my constituents - Les and Lynda Martin and their family. They have three young children, two of whom, commonly known as Cogs and Kiwi, have a rare genetic disease called metachromatic leukodystrophy, MLD. I know the Minister met them recently.

Unfortunately, Ciaran Martin received a late diagnosis because when he received the heel prick test, it did not test for MLD. His diagnosis has come far too late, his illness is terminal and he has only a short time left to him. It is a heart-breaking and devastating issue that has been traumatic for his family. Les Martin has begun a campaign to expand our national newborn screening programme. I know the Minister recently appointed Professor Niall O'Higgins as chair of the national screening committee, which, hopefully, will meet before Christmas to lay out its programme. A number of things need to happen.

Could the Deputy put his question to the Minister?

We need a commitment that priority will be given to carrying out a review of our national newborn screening programme to bring it in line with international best practice. I do not know whether the Minister is aware that Senator Norris is looking at drafting legislation in this area.

We will give the Minister an opportunity to respond.

I have looked at this and I do not see any primary legislation relating to the screening programme. Is there a need for legislation? If so, will the Minister commit to providing a money message for that legislation because we owe it to Les Martin, Cogs and Kiwi and all the other children and others with rare genetic diseases that, unfortunately, have not been diagnosed?

I thank Deputy Brady for his question. I know what a sincere help he has been to Les, Lynda, Cogs and Kiwi. This is not a party political issue. Both of us have got to know the family very well. It is fair to say they have done a really important job in highlighting issues regarding our newborn screening programme. I hope to meet Les Martin again in the next couple of weeks and I invite the Deputy to come to that meeting with me. I must be honest. I have been very honest with Les Martin, Senator Norris and others. My gut feeling is that we should expand our newborn screening programme because when one looks at European and international norms, as my Department has done, one can see that some countries screen for fewer diseases than we do but many countries screen for far more. It is fair to say that Italy probably screens for more diseases than nearly any other country but from memory, we are behind the European average in terms of what we screen for. I think we should screen for more diseases.

However, I have told Les Martin and others and will continue to say that these are clinical decisions as well. Under the Scally report, we have set up a new national screening committee, which was referenced by Deputy Brady. I appointed the very eminent Professor Niall O'Higgins to chair it. From memory, I appointed the other members of the steering committee this week and we will announce them in the coming days. I hope the first meeting of the committee will take place, if not this month, then next month. I have asked that the committee's first body of work be to review our newborn screening programme in line with international best practice. We currently screen for eight conditions. Should we screen for more? I think we should but I have explained that this is a body of work that the screening committee needs to do.

With regard to legislation, different countries have done different things. Some have legislated in this area while others have not. Senator Norris has brought forward a Bill, which I have spoken to him briefly about, but we have not yet engaged with it in detail. I am committed to meeting him as well. Let me meet Senator Norris and let the screening committee get its work under way. This will be its first body of work. Perhaps the Deputy and I could meet the Martin family in the next two or three weeks.

I will be brief, which is a pity as I had more than one question written down. This time last year, the Government made a commitment to hire an additional 114 assistant psychologists, which it more or less followed through with. My understanding is that 300 people turned up for those interviews so we have roughly 186 extra people looking for a job and we talk about recruitment and retention. According to information I received, some of those who were appointed to these 114 posts have already left their posts without carrying out any proper assessments or whatever responsibilities they had in their positions.

One individual spent their last week sending out 300 cancellations of appointments. I wanted to raise this issue at this forum because, as we are all aware, Ministers do not know absolutely everything that is going on. I wanted to flag the issue and I wanted Mr. Reid to know how difficult it is on both sides, because I am a realist. The issue is that somebody within management is not giving the proper information to the relevant Ministers. They are not cracking the whip, considering that there is a duty of care and responsibility with 114 new assistant psychiatrists. Many of them are not allowed to carry out any work. How many of them have left without doing anything? If one person can send out 300 cancellations in a week, is there any possibility we can find out the truth? Surely somebody in management with responsibility should be held accountable for that. I would like to know who.

Mr. Paul Reid

I will ask Ms O'Connor to take that.

Ms Anne O'Connor

The Deputy is correct that 114 came in. I do not know the details on who cancelled sessions but I do know that there is a review of the initiative being undertaken by the University of Limerick. We hope to have the final report soon, around now. The initiative was very different when we started with it. There were different views on bringing in assistant psychologists. We brought in 20 staff-grade psychologists at the time. We have conducted a full review with the university to determine how the initiative has worked and to learn from whether we should expand it or operate differently. I will have the results in the coming weeks.

Is it possible to get an answer from the Department or will Ms O'Connor forward me the information?

Ms Anne O'Connor

On the 300 cancellations?

Somebody here must know that, when 114 assistant psychiatrists were hired initially-----

Ms Anne O'Connor

We can certainly find out how many are there.

Could Ms O'Connor send that information to the committee, as well as to Deputy Buckley?

The interim report from the University of Limerick on that service was very positive. There were substantial projections for making serious inroads regarding the waiting list for ancillary services or other services, such as child and adolescent mental health services. It is a very positive development that we welcome, notwithstanding the Deputy's queries on some specific aspects.

We have three more speakers, namely, Senators Conway-Walsh and Devine and Deputy Brassil. They are, of course, welcome. They should be brief and ask one question.

I thank the Minister of State, Deputy Daly, for the work he has done and I wish him well for the future. I thank him particularly for coming to Belmullet hospital and for the courtesy he showed to the staff there and to those protesting outside. I am aware of the issues discussed with him. We will have a follow-on meeting, including on the commitments he made on the day.

I had several questions, as the Minister of State can imagine. I am glad he is back. The question I wish to ask is on Erris and the primary care centre. Expressions of interest were sought some months ago for a new primary care centre in Bangor Erris. What is the status of that? I am a bit concerned that those who submitted the expression of interest have not been contacted yet.

Once expressions of interest are sought, does it mean there is an absolute commitment to the capital funding for the primary care centre and the necessary staff? I am prioritising this question today because there are very serious circumstances in that the general practitioner covering the area is moving to another area, which will leave us without one. I acknowledge the positions for Bangor and Glenamoy have been advertised separately but the only solid way forward is to have a fully staffed and resourced primary care centre in Bangor Erris to meet the needs of the population there. The assessment of needs has already been made.

I thank the Senator on the question on a primary care centre for Erris. I do not have specific information. Does Ms O'Connor?

Ms Anne O'Connor

I would have to check the position of that. I honestly do not know the timescales.

Can Ms O'Connor answer the overall question, on seeking expressions of interest? Does it mean there is an absolute commitment to developing the project, funding it and resourcing it?

Ms Anne O'Connor

My understanding is that it is one of the centres to be set up under the arrangement.

One of the challenges in terms of people coming forward would be the availability of GPs, which is a challenge in that area. There is a commitment to it but I do not have specific details on it and I will have to check that out for the Senator.

I ask that the HSE would give me a written answer to that, and to prioritise it and to understood the seriousness of the situation for the population in Erris.

Ms Anne O'Connor

I will.

We will come back to the Senator in writing on it.

I want to concentrate on the national children's hospital, which is located at the end of my street. The Minister met some of the residents from the area when they attended the health committee on several occasions and he knows their concerns about the impact on their surroundings, their neighbourhoods and their homes, which are still collapsing, as well as the ongoing difficulties with the environment around the construction, which is going to continue for at least another decade with the development of the maternity hospital.

I want to raise two linked issues. A second revised application has been lodged with An Bord Pleanála. In December 2015, 120 people, including myself, put in observations and submissions. They have not been informed of this second revised planning application and there has been no notification. I believe we are entitled to that. It is kind of under the radar and we need to be informed of the process, if that is what is occurring. Does the Minister or the HSE have a revised timeline from BAM in regard to the operational services of the national children's hospital? Will that be made public and when?

I will ask the HSE comment on that. I acknowledge that living near any major construction project will obviously cause significant disruption in an area. As I said when Senator Devine introduced me to some residents here at the health committee, I think it is very important that the hospital constructors are good neighbours and keep people informed as to what is going on and consult with them. I was told there were engagement fora in place. The residents had expressed to me a view that more senior people need to attend those to keep them fully informed and I have passed that on. Obviously, it is an unavoidable reality that when a major construction project goes on in an area, it causes a degree of disruption. Trying to keep people informed and have good lines of communication open is basic good manners, and I would be very eager that this continues to happen. Mr. Reid may have something to add.

Mr. Paul Reid

As for the revised planning application or plan which may indicate a variation of the current plan or the master plan that is on-site, I do not have the specifics of that and we can check with the development board. As I mentioned earlier, I spent some time yesterday on the site with the developers. One thing that is quite impressive is that the first office one sees on the site is the community development office, which is located where people exit the Luas. That is the way it should be in terms of demonstrating the commitment to the community and community gain. From my previous life on local authorities, I know it is important for the residents to be kept on board throughout the process. We can come back to the Senator in regard to the specific terms of any revised application, as I am not fully aware of it.

There is the revised application, the notification to those who made the 120 original submissions and observations, and the revised timeline for the opening operation of the hospital.

Mr. Paul Reid

In planning terms, if there is a revised application or a variation, it would be through a normal planning process, which would facilitate some public engagement on it. However, I cannot comment specifically as to-----

Will the HSE let us know so we are aware of it and we have it on the record?

Mr. Paul Reid

Yes, and I will also provide information on the timelines.

Mr. Reid will see from the contributions thus far that the issue around delayed discharge is a theme throughout all our hospitals. By way of figures, the number of delayed discharges in University Hospital Kerry this year is in excess of 3,000, which is almost in line with the trolley count for the year. It does not take a genius to realise that if we solve one problem, we will go a long way to solving the other one. Something else that is adding to the trolley count is the lack of availability of doctors on the on-call, late night service and at weekends. There are specific difficulties for doctors from South Africa and other countries in regard to getting registered. If that could be moved on, we would resolve a lot of that particular issue as well.

I understand the medicine reimbursement review has now been concluded. There is not much public information about what the next steps will be or for what the review will be used. Will the report be made publicly available? What will the review be used for and what are the next steps? Are there specific recommendations in the review? Will this be a one-off process or an iterative process, which it is in other jurisdictions such as Scotland?

I have not received the medicines review report yet. My understanding is that the work has now concluded and I expect to receive it shortly. Yes, it is my intention to publish it. It would be sensible to have it as an iterative process, as it is in other jurisdictions. When I receive the report, I would be happy to meet Deputy Brassil on it. I will also make it available to the committee.

We will take the second round now. I propose it will be ten minutes per question to allow every member an opportunity to come in, as well as to allow Deputy McConalogue in at the end. Is that agreed? Agreed.

Is there a nursing embargo in place right now?

Nurses have informed me that they have been told by Cavan and Sligo hospitals that a nursing embargo is in place and there are no jobs. Are they being misled by the hospitals?

No. The chief executive is better placed to speak on this. There is a strategy where we will be taking on an additional 1,000 extra staff across the health service this year, including many extra nurses. We can see that in the nursing numbers already. There is a requirement, however, that our hospitals only hire those they are funded to hire. It is just like schools and every other part of our public services. There are more nurses this year than last year. There will continue to be more.

In the interest of time, the Minister has suggested that I was being pedantic earlier on. In real terms, is there a hiring embargo in Sligo and Cavan hospitals for nurses? Are they hiring or have they been instructed, for whatever reason, not to?

There is no central policy of a recruitment freeze in the health service. It is about living within funding budgets.

Are Sligo and Cavan hiring nurses?

Mr. Paul Reid

We can get the breakdown across all the acute hospitals and community settings. The facts are that we have recruited 1,138-----

I am not asking that. It was a straight question. We are pressed for time. Is Sligo hiring nurses?

Mr. Paul Reid

Positions will be approved on the basis that they are within budget and approved by the national plan.

Mr. Reid is not answering the question and is just setting context. Are Cavan and Sligo hiring nurses at the moment? Yes or no?

Mr. Paul Reid

I will ask Mr. Liam Woods to give details of which areas are recruiting.

I do not need which areas are recruiting. I need to know if Cavan or Sligo are hiring? Yes or no?

Mr. Liam Woods

The Deputy’s question is if there is an embargo on the recruitment of nurses in Cavan and Sligo. No, there is not. There are limits within the affordable limits.

Are they allowed to hire at the moment?

Mr. Liam Woods

Yes, they are.

Not if they have funding. Can they hire at the moment?

Mr. Liam Woods

They can hire and have made proposals as part of their two hospital groups.

At the moment, Cavan and Sligo hospitals can hire. Is that correct?

Mr. Liam Woods

They can.

I want to pick up on Claire Healy's case. I know it was discussed at length at the committee two weeks ago but I want to come back to a statement we got from the HSE. Due to the long wait in the public system and that she was high-risk, Claire Healy went private. She is a CervicalCheck patient and went to a hospital. She was sent a letter which stated:

Thank you for referring the above patient to the CervicalCheck colposcopy clinic at University Hospital Kerry. Unfortunately, we are unable to give this lady an appointment as her referral smear was done in the private sector.

That is not about prioritisation or that it will take a bit longer to see her. Her doctor was told in writing that the hospital will not be seeing this patient. The HSE statement stated “it cannot direct acute hospitals’ colposcopy on matters relating to screening” whereas it clearly has. Since then, the HSE has come back and said that it accepts, with hindsight, that the email from the official may have led to confusion.

Will the HSE go further and accept that instruction went out from the executive that was flat-out wrong? Calling it confusion is an insult to the hundreds of women who desperately sought help and were told they could not have it because of a clear instruction from the HSE. Can it be accepted that this instruction was wrong?

Mr. Paul Reid

I accept it should have been clarified not in the way it was. The instruction that went out on 16 August clarified it firmly from the HSE's position.

Will Mr. Reid accept that the original instruction was confusing? The suggestion is that people were confused by what they were told by the HSE. Can he accept that the HSE got it wrong and then corrected it?

Mr. Paul Reid

Our original communications certainly caused that confusion. I am happy-----

I know it caused confusion. This is playing with words. If people are told not to see private patients, one is not confusing them. Instead, one is telling them to not see private patients. Will the HSE accept that in telling hospitals to not see patients who had a private test that they were not confusing those hospitals but telling them something they should not have told them? Is that fair?

Mr. Paul Reid

Exactly. We told them on 16 August is that patients should be seen based on clinical need.

I know. Can Mr. Reid answer the question I asked?

Mr. Paul Reid

Yes. It should not have gone out in the manner it did. We were happy that we clarified it on 16 August. It should not have been communicated the way it was.

Coming back to an issue raised by Deputy Tóibín about Sharon Butler Hughes. I appreciate it is an individual case but I am asking this with her permission. Her clear understanding is that the Minister will agree to meet her but he has ruled out discussing certain issues with her. I think I heard the Minister say to Deputy Tóibín that he will discuss anything with her. Is that the case? Will he meet her without conditions as to what she wants to discuss with him? Her belief is that he has ruled out discussing the very issues about which she wants to talk.

While the Deputy has the permission of one person to discuss an issue, there is more than one involved. I have a duty of care to the good decent public servants who work in my Department and do their very best in their jobs. I know the Deputy acknowledges that as well.

In my correspondence with Ms Butler Hughes, which I have seen published somewhere, I said I am happy to meet her and I accept the findings of MacCraith report. I thanked her in that letter and publicly today for what she did. I accept the bona fides of my officials that they do the best job that they can, that they work hard and come to work every day to do a good job. I defend them in that regard. I have no intention of meeting anybody to reopen the MacCraith report. The CEO carried out an external independent review-----

I understand. On this, however, she is specifically referenced in that report. She now wants to meet the Minister to discuss that.

She is and so too are officials in my Department.

Absolutely and they should feel free to discuss that with the Minister as well. I do not want to misrepresent what he said. My understanding is that he agreed to meet but with preconditions as to what will be discussed. Is that correct?

I outlined in the letter what I thought would be useful and on what we could not make progress. Clearly, there is a difference of opinion between Ms Butler Hughes and a civil servant in my Department. I cannot adjudicate on that.

Is the Minister willing to discuss with her?

Yes, of course. The Deputy knows me well. I am not going to be so discourteous as to tell somebody they cannot speak or say what they wish to say when I meet him or her.

I was looking for clarification.

On overspending for the year, has the Minister a full-year Estimate at this point? It was up to €281 million for the end of July. Has he an Estimate for the end of the year?

Mr. Paul Reid

We have not at this stage. For the final quarter of this year, as per my circular yesterday, we have instructed each of the hospital groups and CHOs to work within their monthly targets. The figure that brings us up towards the end of the year is the one we will work towards over the next few days. The only areas that we have said we are facilitating some overspend on budget are acute hospital services and disabilities.

We are days away from the budget, which must have an estimated figure. When will we have that figure?

I expect the figure to be crystallised in the coming days. There is engagement going on between my Department, the HSE and the Department of Public Expenditure and Reform. When we have that figure, if the Oireachtas is to approve a Supplementary Estimate for the health service, we will have to come back to this committee and it will have to be voted through this committee. Then we will have a chance to scrutinise it then. It will be crystallised over the coming days.

Whatever that figure is, last year it was added to the base for this year. Is that the intention again? If it is, say, €300 million, will it be paid for out of next year's budget, meaning less funding available next year for business as usual?

Being very honest and not wanting to withhold information, that would very much depend on a call the Minister for Finance will make between now and budget day.

I want to come back to access. The Chairman suggested that he felt no sense of urgency from the Minister. I am not saying the Minister does not care. We all care. However, I do not get a sense of urgency from the healthcare system or the political leadership, which is the Minister. I reiterate that I have read back through all the opening statements and there is no mention of the crisis in access. We have the worst access that we have ever had in Ireland. We have the worst access for patients through the public system of anywhere in Europe. The Minister said he is deadly serious about wanting to sit down with consultant representative bodies, but then he cites what I think are unintentionally spurious reasons for meeting the Irish Medical Organisation, IMO, first and not the Irish Hospital Consultants Association, IHCA. The IHCA is fully compliant with industrial relations criteria to represent consultants, as of course is the IMO. We have seen no movement on pay inequality in recent years, even though we know we have the lowest level of hospital consultants anywhere in Europe. We know this is a major contributor to the inhuman waiting lists, yet there has been no movement in what is a pretty small number to reverse that. The Minister is still going ahead with building private facilities into the national children's hospital and the national maternity hospital in spite of the de Buitléir report, while stating that he supports that report.

I am not going to dwell on the attacks on Fianna Fáil, but just to correct the record, because I know the Minister is keen on the record being straight, he seems to be suggesting that the last Fianna Fáil Government took a load of beds out of the system, and for some bizarre reason he is increasingly referencing Deputy Micheál Martin, presumably as some pre-election warm-up. Between 2000 and 2004, Deputy Martin was Minister for Health and he added more than 1,000 beds. In respect of the 14 years of the previous Fianna Fáil Government, the number of beds when it left Government was 1,000 more than when it came in.

The reality is that while I accept that the Minister cares, as we all care, the question is around prioritisation. I do not see it and I do not feel the urgency. The total health expenditure voted through this House over the past three years under Deputy Harris as Minister is about an additional €3.5 billion, and in spite of that, access to public healthcare has collapsed. If this is indeed such a priority, how has access collapsed given such a massive increase in funding for healthcare?

There are a number of questions there from Deputy Donnelly. First, and I see him regularly making this point, I am not building private health facilities. I am building rooms under the current rules that Fianna Fáil was happy with in government, which allow those rooms to be used for private facilities. The Deputy talks about the consultants a lot. I would like him to go and talk to them about the use of those rooms because they would point out that they have a contractual right today to do private practice in public hospitals. Unless the Deputy wants our doctors not to turn up at work, under their current contract they have a right to use those rooms. I want to change those rooms. I want them to be public rooms. I do not want any private practice in public hospitals. I would welcome Fianna Fáil's position on that. I see on the Fianna Fáil website that it commits to the de Buitléir report on removing private practice from public hospitals. The Deputy should say that. It would be very helpful. If Fianna Fáil is in favour of removing private practice from public hospitals, we agree with this and we should get on and do it together.

On the beds argument, we will have this another day, probably in some television studio during some election, I hope in May 2020. The number of day case beds might have risen but the number of inpatient beds fell at a time of economic growth in our country, and that is very regrettable. I look forward to debating that point.

Access to the health service has not collapsed. There is an absolutely serious issue with outpatients and a lot of the criticisms the Deputy makes regarding outpatients are valid. I accept them. We must do a hell of a lot better in relation to outpatients. However, with inpatients it has dramatically improved. The number of people waiting for hospital operations has improved. Access to primary care, including the fact that we have expanded eligibility for free GP care, has improved. I hope in the budget to expand access for more children to free GP care and to dental care. That access is improving. The fact that there are 100 more therapists means that access is improving. If the criticism was of outpatients, I would take it and I should be held to account, but in general access has not collapsed.

Just to be clear, it is the conundrum of how, with €3.5 billion in additional spending, there are more than a million people now on the waiting lists who were on them three, four, five or six years ago. That is the question.

There are 3.3 million outpatient appointments every single year. We are doing more in the health service every year. Our population over the age of 65 is growing. Our birth rate is growing. The complexity of cases is growing. More and more people are now being seen quicker in many aspects in respect of many of our waiting lists, but we do have real pinch points in outpatients. I do not believe that a ball of money will fix that. It might help but doing more through general practice, primary care and the Sláintecare reorientation is the only way we will do it. I welcome the fact that we now publish outpatient waiting lists so the Deputy can ask me questions about it, which Opposition spokespeople were not able to do in the past.

It is really amusing to see the lads bickering over which of them made a bigger hames of the health service. It has a touch of the old Daz and Surf off it, to my mind.

We will do Sinn Féin's record in the Northern Ireland health service now in a minute.

We could be here all day debating that.

Then Sinn Féin walked off the pitch.

We would also have to talk about partition and we all know Fine Gael does not want to talk about that. With regard to Limerick, the Minister was talking about the additional beds and the building. Just in terms of this winter, how many of those beds are going to be open, if any? In the absence of those beds being open, what is being done to move the patients in the short term? In the short term, there are 82 people on trolleys and they need somewhere to go. I understand that at some point in the future there will be beds in the unit. The pressure is already on them and they are not even been built, commissioned, staffed or anything. The Minister referred to the new staff coming on stream. Will he express that as a percentage or figure relative to the number of actual vacancies?

There is an emergency department task force. I was on it years ago when it had a different name. We had our regular meetings and they were important, but we were accustomed to meeting at very short notice when there was an urgent need for it. Does the Minister not think there might be an urgent need for the emergency department task force to meet this week, perhaps as opposed to just hanging on until their next scheduled meeting, which I think is more than a week away?

I will have to come back to the Deputy with the recruitment versus vacancies ratio unless my HSE colleagues have it. I do not have it to hand.

I could help the Minister with that.

The Deputy might even know the answer to the question she asked.

Yes, it was hovering about 50%, I think.

I will follow up on that. The Deputy is right and again she knows the answer to this question. The 60-bed modular unit is not going to be open for this winter. I am not putting it forward as a solution to this winter. I am just putting it forward as a commitment to increasing capacity in the mid-west. What we are going to do this winter is a perfectly reasonable question. Two things have emerged from our conversations today. I gave a commitment that the HSE would meet mid-west Oireachtas Members within a fortnight. One is whether we can improve diagnostic access in the hospital. There seems to be an acute issue in terms of accessing MRI facilities, which hospital management and representatives think could, if resolved, really help patient flow. The second thing is in the whole area of social care and delayed transfers of care. Can we, through the budget next Tuesday, provide additional funding for more home care and more transitional care in the winter period?

The emergency department task force is due to meet next Thursday. I think that is a sensible time to meet because by next Thursday I will have clarity in respect of winter funding. The task force can usefully meet on that occasion. Obviously, when the emergency department task force is not meeting, it does not mean I am not meeting very regularly with the HSE and the Department and remaining in touch with other stakeholders daily and sometimes several times a day. The meeting next Thursday will be after the budget on Tuesday and I think we will be able to have substantive conversations.

In advance of that does the Minister not think it would be advisable even to meet the co-chairs of the task force?

I am more than happy to do it. One of them is in the room and the other one I am happy to meet as well.

That is grand. I will get her to give the Minister a buzz. Mr. Reid referred to gain sharing in terms of the use of biosimilars and suggested that the money could be ploughed back in. With regard to gain sharing and the conversion of agency staff, this is something I have spoken to Mr. Reid's colleague, Mr. Mulvany, about ad nauseam and, God help him, he never gives a different answer, to be fair.

We all agree agency staff are more expensive. It is not something anybody can dispute. Where a hospital manager can convert expenditure on agency staff, can the money be used to recruit additional directly employed staff at the cheaper, more cost-effective rate? Alternatively, if he or she manages to make the savings by converting from agency staff to directly employed staff, however reluctantly, does the money just go towards deficit remediation, as I suspect?

Mr. Liam Woods

I will take that. As the Deputy rightly says, we are encouraging a conversion from agency staff to whole-time staff. The resources available for agency staff are available to fund full-time staff. We would, therefore, deliberately uplift the headcount ceiling of a hospital that previously had staff employed through an agency. We would encourage it because, as the Deputy will be aware, it is better in both safety and financial terms. We are approving posts like that.

That is brilliant. Could I be given a number? I presume that if that is the aim, a target has been set. I am aware that targets were not set previously. What Mr. Woods just said would be pretty meaningless if no targets were set. Where targets are set, what is the conversion figure? How many directly employed staff have been taken on?

Mr. Liam Woods

What I would have access to most readily is the number of conversions during the year. I will make that known to the Deputy, if that is acceptable. We are encouraging the conversion of as many as possible. There is agency expenditure of just over €400 million in the whole HSE. Approximately half of that is in hospitals. We are encouraging as much conversion as we can within-----

But no targets are being set.

Mr. Liam Woods

The target is to convert as many as possible. There is no limit. It is an objective to convert as many as we can. I will share the information we have with the Deputy.

Is Mr. Woods monitoring where a whole-time equivalent on the roster is converted into a directly employed member of staff or where the money is reinvested in direct employment? I would be genuinely fascinated by the figures.

Mr. Liam Woods

Once the hospital is operating within its funded limit, as in this case, the answer is "Yes". The funding is available to fund the new post.

If they are not operating within their funding limit, however that is decided, that money just goes-----

Mr. Liam Woods

No. I am just being clear that there are limits.

I appreciate that.

Mr. Liam Woods

In most circumstances, and in any I have seen, what the Deputy described is what is happening. The resource exists to permanently fund a nurse permanently approved for a ward, for example.

The Minister referred earlier to consultant numbers and the level. How many are locums and how many are not entitled to be on the specialist register, even though they have a lawful entitlement to a contract of indefinite duration, which I would not interfere with? What steps are being taken in this regard? I have seen correspondence indicating there is no specific supervision of doctors who may be using the title "Consultant" but who are not entitled to be on the specialist register. I can send that on. What are the numbers?

I will ask Dr. Henry to respond.

Dr. Colm Henry

On the first question, there are approximately 307 locums. There is a mixture in that number. Included are short-term replacements, such as replacements for maternity or illness, and persons whose posts have been approved through the consultant appointment committee and are awaited. Others are more long term.

On the second question, there are two groups of consultants on the specialist register. One comprises approximately 40. This category pertains to the period before 2008, when there was not the same requirement for the appointment of a consultant.

I am well aware of that.

Dr. Colm Henry

They are less of a concern to us because they are well established in the system.

I am talking about the new ones.

Dr. Colm Henry

Since then, there have been about 100, of whom one third are associated with mental health. We have put in place a governance arrangement for the consultants through discussion with their respective mental health directors or the clinical directors in their hospitals to ensure we can assure patients going to them that they are keeping up to date with best practice, that they attend conferences within the hospital or meetings with their mental health directors and that they are keeping their education and training up to date. Many of the doctors are well established and enhance services within their hospitals. Our aim is to get them on the specialist register if they are entitled to be on it based on the criteria under which they are currently established.

I am referring specifically to the ones who are not established. It is not known to patients. I share the concerns expressed by Mr. Justice Kelly in that regard.

I have three more questions. When will the clinical lead for abortion services be appointed? I have a question on the Rosalie unit in Castlerea. I am in touch with somebody in the constituency and she has raised the matter again with me again. There has been some discussion on converting the building into accommodation for adolescents. Could I have an update on that? I advise the Minister that nine people were transferred from the Rosalie unit, much against the wishes of the community. Three of them are now deceased. It is a matter of great upset that it is just not known what is happening.

My final question is on a constituency-related matter. A private company has put up a planning permission notice of its intention to build a private hospital in Swords. The Minister might outline the extent of State involvement in that enterprise.

I would like to see the clinical lead for abortion appointed as a matter of urgency.

Mr. Paul Reid

That post has been advertised. We are hopeful of an appointment after proceeding to interview.

That is on its way.

Mr. Paul Reid

It has been advertised.

That is a priority.

On Rosalie home, I do not know whether Ms O'Connor is best placed to speak about it.

Ms Anne O'Connor

I am aware there has been extensive engagement with many people over quite a long period on the Rosalie unit. I understand seven had transferred, with four more to go, and then two to go, and with the transfer being over the next two to three weeks. The facility is to be used as a mental health hub with two day hospitals, for psychiatry of later life and for adolescents. They are day services and not accommodation.

It will not be accommodation.

Ms Anne O'Connor

No, they are day hospitals.

The hospitals will be for psychiatry of later life and for adolescents.

Ms Anne O'Connor


The final question was on the private hospital in Swords.

Anybody who decides to build a private facility does so on his or her own initiative. Obviously, there is a record of the State sometimes striking agreements and the like, largely through the NTPF, but that is independent of me. It should be independent of me. Any decision to build a private facility, insofar as it adds capacity, is good in the short term.

It has to be for a certain cohort. It does not have capacity for most of the poor unfortunates in Swords.

I am not talking about any specific units because I do not have a role in that regard, but we do use private capacity, funded for public patients, while building up public capacity.

Has the State a role in this particular enterprise?

I have no involvement in it.

Has Deputy Kelly a question?

Many. This is a quick-fire round. I have tried to be non-political in this matter. There is not enough urgency attached to the mid-west by the Minister and Mr. Reid in particular. I am not going to tolerate what is going on there anymore. I have to hold people to account to a level that has never been seen before. It is going to happen. I spent all morning dealing with cases in the hospital in Limerick. Every time I walk out of the room, that is what I am dealing with. A politician should not be doing that. It is not that I do not want to do it. I am sure the Chairman has to do the same. It is not our role in life and it is not how the health service should function.

The 60-bed modular unit is a year behind. I am not even going to go on about that. That will not solve much. It is not even possible to have infection control. I encountered a case where the staff did not know what was wrong with a woman, yet they could not isolate her because they had not the capacity. They ended up having to take her to a room in Nenagh.

Nenagh is not even ready for that. There are so many issues here. I put it to Mr. Reid that this needs an individual and complete piece of work. It needs a complete, separate entity. It is not Mr. Reid's fault; I have good time for Mr. Reid, which I have put onto the public record, and we have worked closely together. I am not going to tolerate this any more, however. I have been at this for 14 or 15 years but have never seen this before. It is now October and can one imagine what it will be like in February? What the HSE is trying to do relating to budgets is fine, but over the next years the whole thing needs to be recalibrated. It is not currently being discriminated against, but the mid-west needs a €40 million uplift on the current side, not just the capital side, in relation to everything I said earlier. If it does not happen, then the mid-west will be discriminated against. The HSE or the Department cannot say that I did not come up with short-term ideas for how to deal with this. I have recycled these proposals over the last three or four years as the health spokesperson. As for the MRI scanner, one can compare Limerick hospital with Beaumont Hospital to see how far behind Limerick is. I have referred to the situation with doctors and nurses and have spoken on transitional packages. I propose that Limerick hospital be turned into a seven-day hospital. It would help if most things did not stop at 5 p.m. or 6 p.m. on Friday. The pathways towards the minor injury units in Nenagh and Ennis need to be extended. I have been saying this for years, and the Minister will admit it.

It would help to take the pressure off what is going on there.

We need intermediate vehicles in order that people are not stuck inside for the weekends. The current way of transitioning people out of the hospital and into step-down facilities is not working. I am dealing with Maria Bridgeman and Colette Cowan all the time. They are two fantastic people and I have no issue with the management and the staff down there. They are working but they are working in an environment that is impossible. I ask Mr. Reid to please take this on board. He should trust me when I say that I will take this to another level. If I have to live inside the hospital, I will do it as an Opposition spokesperson.

With regard to gynaecological services in Letterkenny, the Minister has had correspondence on and is aware of a number of issues in respect of a case in 2017, some of which has been in the media and some of it which has not. There was another case in 2019 and a further case has been brought to my attention within the past 48 hours. Will the Minister indicate if he is going to launch an investigation into what has been happening up there or not? What has the Minister done with the information that has been provided to him over a number of years? I am aware of a case of a woman who has issues and is waiting for her situation to be dealt with in St. James's Hospital as a result of being pushed down from what happened in Letterkenny, over to Derry and now down to St. James's. This is on top of the two other cases of which the Minister is aware. I ask the Minister to please tell me that he is going to do something on it.

On the issue of medical cards for patients with terminal cancer I thank the Minister for meeting Mr. John Wall, who is a brilliant guy as we both agree. Mr. Wall was very happy to meet with the Minister, and fair play to the Minister. I have no issue there. The Minister, however, has a budget coming up in a week's time. The provision of funding in this regard would be small money in that context and unless the Minister provides funding in the budget, with all the will in the world he will probably not be the Minister in one year's time. He needs to provide for it in the budget. This is a real decision. It is small money. The 24-month profile is probably the way to go. It is an interim step. It seems like a cruel thing to say but this is a way to deal with it. I ask the Minister to put this into his budget.

The Minister has received a letter from Tony O'Reilly about his wife Julie O'Reilly. Julie was the lady who died from endometrial cancer and she was one of the 221. I will not get into the details here. Mr. O'Reilly has asked for an investigation into how his wife's medical details ended up with a newspaper. Mr. O'Reilly has written to the Minister about this. Personally, I would like to know how this happened also. It should not have happened. I have a copy of Mr. O'Reilly letter to hand, which the Minister has acknowledged. I ask that the Minister address this issue.

Will the Minister clarify how many women have had their Royal College of Obstetricians and Gynaecologists, RCOG, results? As it will be over by the end of the month, surely the Department knows by now what percentage of the total have those results.

I am deeply worried by Mr. Reid's opening statement with regard to section 38 and section 39 organisations. This is not Mr. Reid's fault but it is his problem. Some of these are about to fall over.

If those organisations fall over the State suffers, and the people suffer to a point. This committee has been through this, as has the Committee of Public Accounts. We need to put this on a different footing. Somebody needs to stop this and turn it around. A good few of these organisations are getting loans just to stay afloat. This cannot continue. What is going to be done about it?

I have two final issues, one of which is the recruitment freeze. I have raised this question previously and we have all played games to the effect that there is no recruitment freeze, and others have also raised it. In effect, there is a recruitment freeze. As for control and expenditure discussions, I have heard the Minister say that one cannot win in this regard. It is a good kick-back argument, which I understand, but when it comes to front-line services and the issues I have just outlined in the mid-west, the reality is it is affecting front-line staff such as nurses and doctors. As with the issues mentioned by the Minister regarding the capital plan the two biggest jokes among the Minister's own staff, including management, is that the capital plan does not impact on capital projects down through the years. They just laugh at that. The second issue they laugh at is the idea that there is no recruitment freeze. The Minister's own people laugh at that; they do not believe it. When it comes to front-line staff, especially nursing and other posts, I ask the Minister to please show the necessary flexibility.

My last question is very important. I dealt with it in the committee last week and it relates to CervicalCheck and the audit. I could not get a clear answer last week-----

I am sorry Deputy but the four questions-----

I am done now.

There are four answers for all of those questions.

I could not get a full answer so I just ended up making a statement. Tell me if I am wrong, it would be just a yes-no answer. When the new audit comes into place for CervicalCheck, it will begin on the day after the last audit finished. In other words, there will not be a gap period where there is no audit. I said this last week and nobody contradicted me so I presume I am correct in that. If I am not, then there is a serious problem.

There are a number of questions there for the Minister. I do not know what sequence he would like to take them.

We will take the last question first because it is a simple question in a way.

Dr. Colm Henry

On the interval cancer audit, as I explained last week the purpose of it was to replace what was clearly a flawed audit - as described in the report - with something that is internationally benchmarked and informed in its design by patient involvement. We will have that work completed by the end of this year. The Deputy asked if anybody was left out of that. The RCOG report provided women with a diagnosis of cervical cancer up to 2017 with the opportunity to have their screening reassessed by RCOG. As for anyone left in a gap, there will, of course, be an opportunity for any individual requests to come through-----

That is not what I asked. This is scary stuff. The audit has to begin the day after the last audit finished. That is it, or else there is a big problem. Trust me. I know what is going on here. It has to start the day after the last one finished.

When we get the report of the groups-----

It has nothing to do with the report. That is a decision for the witnesses here. I understand that.

I think we will have to take guidance from the expert group. Instinctively I agree with Deputy Kelly that there should not be a gap.

There were a couple of questions in Deputy Kelly's contribution. On RCOG, I truthfully do not have the breakdown of how many meetings have taken place. If I did have them I do not feel we should be getting into that granular detail. I would rather allow a situation whereby-----

I just want the percentage and to know that it is going to be complete.

My understanding is that the meetings commenced the week of the 23rd and will take approximately eight weeks to complete. We will receive the aggregate report at the end of October. I do not have any more data-----

I just want to make sure this is going to be delayed.

There has been no indication to me it will be delayed. On Tony O'Reilly's letter I will make sure I personally see that and respond to it. I am aware that Deputy Kelly has been a great support to John Wall - he said that to me - but I hear the Deputy on the issue and I am conscious of doing something.

On the issues in Letterkenny I have been informed that under the patient safety protocol - as I usually would be - that there is a review ongoing. I do not know if Dr. Henry or Mr. Woods will help me in this regard.

There was another independent report done by Dr. McKenna and sent in. This is going nowhere and it needs to change track fairly fast. I would be happy if the Minister could just indicate that it is being taken care of. The Minister does not have to give-----

Dr. Colm Henry

I can respond to Deputy Kelly on that.

There will be a review of safety and the quality of the service led by an independent chairperson. There was a case involving a delayed diagnosis of endometrial cancer, following which improvements were made, including having a dedicated clinic to deal with post-menopausal bleeding and a nurse to track referrals, assessments and investigations to make sure there would be no further delays. However, in view of concerns, the hospital group is reviewing delays in the diagnosis of endometrial cancer or the assessment of post-menopausal bleeding. There will be a review by the hospital group led by an independent external chairperson.

Dr. Colm Henry

The terms of reference and membership will be decided in the coming weeks.

Mr. Paul Reid

On the issue of recruitment, I spent a lot of time across the system in my first four months. In fact, tomorrow I am due to spend time in an acute setting to demonstrate my leadership and experience the issues people are encountering. I have no doubt that recruitment is part of the solution. We are going to inject and have been injecting. I need to indicate that we have recruited 1,138 people this year. We are almost 500 above our budgeted for headcount this year, or, to be precise, 485 above the planned improvement. Therefore, we have recruited and are continuing to recruit. We recruited 60 in August and are targeting dedicated recruitment. For example, we are in the process of recruiting graduate nurses, with a significant number of contracts offered on the community and acute sides. We want to recruit these graduates. As the national director, Mr. Liam Woods, said, we want to reduce our spend on agency staff as part of that process. I have no interest in increasing that spend and would rather have full-time staff. That is not a philosophy but a drive towards best practice.

On the issue of section 38 and section 39 organisations, I acknowledge that there is no extra focus being put on them. My communication yesterday was across the system, including section 38 and section 39 organisations, in managing the significant issues with which some of them are dealing. It has been presented to us a number of times and we have had some engagement with many of them. Certainly, the Catherine Day report sets out how we need to work with the section 38 and section 39 organisations in a stronger way. On controls and our management of the spend, they are the exact same controls we have in place across the HSE system. We value what they do and they are important, but we have the same controls in place.

I want to raise three questions, the first of which concerns the minor ailments scheme. It was also raised by the Irish Pharmacy Union. What is the proposal? I understand that under the IPU's proposal, if the minor ailments scheme was to be introduced nationally, there would be about 1 million fewer prescriptions written and that there would, therefore, be a huge saving from the point of view of GPs. There is a huge number of items that pharmacies cannot give out without a prescription. Is this issue being looked at both from a cost savings point of view and also from the point of view of saving time for GPs?

The second issue concerns step-down facilities. One of the issues in many hospitals arises where someone is admitted for reasonably minor surgery and has to be detained for two to three days. We then find that he or she is in hospital for anything up to seven or ten days. Is enough work being done to identify step-down facilities where the State would enter into a contract for the provision of these facilities? It would be far cheaper than having people in hospital and there would be a faster turnover in hospitals. Have we made any progress in trying to advance the provision of structured step-down facilities in each of the regional areas? I can go back to 2004 or 2005, when there was talk of building co-located private hospitals on public hospital grounds, when we should be looking seriously at building step-down facilities reasonably adjacent to public hospitals. Is that issue being looked at?

The other issue concerns children with disabilities.

I understand a few places such as the COPE Foundation and St. Michael's House which deal with children with disabilities have a scheme in place under which children with disabilities can stay with another family for a weekend to provide respite care for their parents. Could we have an expansion of that scheme? There are a huge number of families who want to make a contribution and they can do so by providing care for a child with disabilities over a weekend and, at the same time, giving some respite to his or her parents. It is a very effective way of providing the service. Is there any proposal to roll out the scheme further? I know that it has to be carefully established and managed, but it is up and running and operating well. Families who have become involved have found it extremely rewarding. At the same time, it is extremely helpful for parents with children to care for a child with disabilities.

I would appreciate responses on those three issues.

I will deal with the first two. The Minister of State, Deputy Finian McGrath, will take the question about children with disabilities.

On the minor ailments scheme, I am very glad that the Senator raised the issue because representatives of the Irish Pharmacy Union came to see me in the not-too-distant past. It has been a really constructive partner on Sláintecare and in coming up with ideas. It has also been an extraordinarily good partner on Brexit preparedness in the group chaired by the Secretary General that works with external stakeholders. I acknowledge that contribution. We have run a minor ailments scheme on a pilot basis and I believe it has shown very good results. If representatives of the IPU were here, they would be talking about the fact that it has been operated on a pilot basis for a long time and ask why it could not be expanded. It is a fair point. When I most recently met IPU officials, we asked that the IPU and the Health Research Board look together at how we could design a comprehensive minor ailments scheme in order that we could address exactly the points made by the Senator. In return for doing this for the pharmacies, it would have a benefit for the hospitals. I will check to see the exact stage the conversations are at and revert to the Senator in writing.

On the issue of step-down facilities, again, I agree 100% with the Senator. There are two answers to his question. The Minister of State, Deputy Jim Daly, who had to leave to take questions on promised legislation in the Dáil and the Minister of State, Deputy English, have pulled together a group in the areas of housing and health to look at how we can meet needs in communities. We do not just look at building houses; we also look at the position where, if we build what used to be kownn traditionally as retirement villages within communities, we can decide whether it actually helps to keep older people in their community and out of hospital. That is one body of work. The second is that in the new integrated regional structures we will be mapping out exactly what they wlill be. We talk about capacity a lot in the health service. There are real capacity constraints. One area in which we potentially have spare capacity, or capacity that could be better utilised is smaller hospitals and community nursing units. As part of the Sláintecare mapping exercise for each of the new regional organisations, that issue will be looked at.

On the respite care issue, it is part of the plan for respite care services that children will stay with families. I am well aware of the issue because St. Michael's House and the COPE Foundation in Cork are involved, as the Senator said. It is part of Jigsaw. We have 8,600 people in residential care and in the region of 27,000 in day services. Within respite care services, this year there will be 180,500 overnight stays and 3.08 million hours in home support services. These are part of mainstream respite care mservices. During the summer we opened our 12th respite care house. Although it did not get a mention anywhere, 12 new respite care houses have been opened. The final one was opened in the middle of the summer. I thank the HSE for being on target.

As part of the respite care service, we have families coming forward to volunteer to assist other families, particularly those with high dependency young children and young adults with disabilities. To the question of whether I believe in it, the answer is "Yes". To the question of whether I support it and would encourage its expansion, the answer is absolutely "Yes".

There is a group in society which we know as carers.

There is a group of families who do very valuable work by providing services for young children and adults with disabilities, which we must support and I will support them. During the year we have moved 160 people out of residential homes, and away from an institutionalised setting, but put them into community settings. Part of the process involves those who have no extended family, and people are often left in institutions in cases where their family members have died or it is very difficult for the family. We need to provide more support.

Senator Burke asked about the families. There are approximately 800 families involved, which should be supported, and assistance expanded.

Can we get additional funding to expand what is already a very good scheme?

Yes. We are in the middle of the working on the Estimates and I fought a good battle yesterday in government in terms of those particular issues, and I will keep fighting.

I thank the Minister of State.

Will maternity cover for the speech and language service be addressed in the short term given that there is a recurring difficulty? For some children who require speech and language therapy their condition will worsen as will their quality of life due to a lack of speech and language therapy. Is an insurmountable cost involved if one were to provide cover in those sensitive situations?

I ask some of the people who have accompanied me to provide the information from the HSE; I will come back to the aspect concerning the speech and language service.

Ms Anne O'Connor


I am sorry to interrupt Ms O'Connor; we have already made a very significant investment in extra therapy posts this year.

I refer to 100 posts that the HSE is working to fill by the end of the year. I thank the organisation for its diligence in that regard.

One of the conversations we had earlier, which the CEO also addressed concerned the mapping exercise of what the workforce plan looks like for each of our new regional areas. The Deputy has been a big believer that we should return to regional structures. We are now doing that. What is the appropriate number of therapists, nurses, doctors and everyone else that we need in each region based on the population? I expect that the HSE, working with the Sláintecare office, will make really good progress on that in the coming months. The Deputy will be able to have a interesting exchange with the Sláintecare office when its personnel attend here at the end of this month.

Without pre-empting the budget, do I expect that we will be able to begin to make progress or build on the progress to date in 2020? Yes, I do, but we need to look beyond that. We need to have an understanding, as an Oireachtas, of what the next number of years look like. I mean if we do this in 2020 then what more do we need to do in 2021 to 2023 to get to where we need to get to in terms of speech and language therapy?

I unapologetically believe that the model has to be about more than just the health service building up its pool of therapists and the Department of Education and Skills building up its pool of special needs assistants and resource teachers. It has to be about using the dynamic that is the Departments of Education and Skills and the Department of Health working together. We have a pilot in place. Indeed, part of Deputy Durkan's constituency and certainly part of his county is involved in that. The model has been used in other countries where it works really well. Instead of a child going to a speech and language therapist, the speech and language therapist or occupational therapist goes to the school. We do not have the evidence base yet and await the evaluation of the programme but from talking to parents and teachers I already know that the service is beneficial . Yes, I think we can make more progress in 2020. Does Ms O'Connor wish to add anything?

Ms O'Connor is going to comment.

I will give my information first. The reply received was that there was no maternity cover for speech and language therapists. As a result, the patients or children receiving the therapy can no longer get the therapy for the duration of the maternity leave. To my mind, that seems like a minor issue that can be dealt with relatively easily. Can it?

Ms Anne O'Connor

Across all of our clinical posts, and not just in speech and language therapy, we try to prioritise replacement. With such a high level of a female workforce, referenced earlier, we can have very high rates of maternity leave, which we do not always cover. It depends on the criticality of the post and how long a person will be gone. We take into account a number of factors but we can end up paying for a post twice when somebody is on maternity leave and we replace her. That is not to say we never do it. We do, but we must take into account the wider context in terms of affordability within the area. We do not automatically replace everybody who goes.

Deputy Durkan has raised an important issue about services. Families have come to me about the fact that maternity cover is provided in other professions. This is a genuine issue. We must accept that if children with disabilities miss speech and language therapy it is not a good thing. There are preschool speech and language services now. As the Minister mentioned, there is on-site therapy in mainstream education. Last year, €2 million, I think, was provided to develop speech and language therapy in schools. However, we must tackle the issue of providing maternity cover. Deputy Durkan has made a very important point about a lack of maternity cover and I have heard the same message from families.

I raised the issue because, as I am sure the Minister understands, a child's therapy is interrupted for a period that results in the setting back of the services available to that child. His or her quality of life is affected because one cannot repeat that phase of a child's life. It is gone.

Scoliosis is an issue that I raised initially. Given the severity of scoliosis, the concerns of parents of the children affected and the discomfort experienced by children with scoliosis, is there a system to prioritise these children for treatment? Can we be sure that the system works?

In terms of the national treatment purchase scheme, is it possible to ascertain the nature of the cases referred for treatment in Northern Ireland, the UK or wherever? Is it possible to ascertain the precise type of condition referred? Are patients referred through the private sector in terms of the scheme? Is it possible to do so? I presume that can be done. Are there facilities that provide the same services lying idle in this country due to the scheme? My information is that there are. If we have the facilities then we should not let them lie idle.

I am glad to see that a new regime of HPV vaccination has commenced. Obviously it will be more effective than previously for a whole lot of reasons. I believe there are two series of the new vaccine. One is a series 7 and the other is a series 9, which is being utilised. Series 7 is the one that is receiving attention at the moment. All children are referred for the series 7 vaccine as opposed to series 9 which, for all I know, is a better vaccine. I would like an explanation on this.

Is it possible to conduct a forensic examination at all levels of the number of agency staff that have been employed in the public health service? Is it also possible to examine whether the money might be better spent in having permanent or temporary rolling staff?

On speech and language therapy, I reiterate the points the Minister of State and I have made. I fully agree with Deputy Durkan. The issue that he has raised highlights the need for us to create community teams in areas. I say that because where an area becomes so wholly dependent on any one healthcare professional, and things can happen in all of our lives in terms of career breaks, maternity leave, paternity leave and whatever, we obviously need to make sure that we do not build a system that is wholly reliant on one healthcare professional. That is why I think the reforms we are bringing in through the creation of our community network teams, but also our work with education, lessens that reliance on any one individual.

What Members are seeing is that we are continuing to increase investment and staff numbers, yet we are continuing to see some of the challenges that Deputy Durkan has outlined. That is certainly the direction of travel.

On the treatment abroad scheme and-or the cross-border directive, I have a very long table, which I will send to Deputy Durkan and circulate to the committee, that shows the procedures. The major ones are orthopaedics and ophthalmology, for which people travel abroad. I am glad that Deputy Durkan raised an interesting point about whether the taxpayer is funding treatments abroad that we should be doing here. The short answer is that in some cases we could be doing better in Ireland. For example, I constantly hear about ophthalmology and people going to the North to have their cataracts removed. We have opened a new theatre in Nenagh at a cost of €1 million last year, which it is fair to say has dramatically reduced the number of people waiting for cataract procedures and dramatically increased the capacity for this country, not just that region, to meet the cataract demand in the health service. We must be looking constantly for opportunities - one might use the term low-hanging fruit - where we have level 2 hospitals, which back in the day were big emergency hospitals but no longer have an emergency department and have capacity. Of course, that requires staffing, so it is not always as easily done as I have outlined. The theatre in Nenagh is an example of where we are trying to do more here than we previously had the capacity to do and people had to go abroad. We had to send children abroad for the treatment of scoliosis. Nobody here, including me, thought that was acceptable, and we are now building up the capacity of our theatres and surgeons to ensure we can have a sustainable service in Crumlin and Temple Street and ultimately in the new children's hospital.

To respond to the question on the HPV vaccine, I will have to rely on Dr. Henry to respond to that technical question or to revert on it.

Dr. Colm Henry

I will revert to the Deputy on that question.

I thank Dr. Henry. I also raised the issue of agency staff.

I will ask Mr. Reid to respond to the question on agency staff.

Mr. Paul Reid

A number of members raised that issue in their contributions. Obviously, we want to reduce our spend on agency staff. The total spend is just around €400 million, and I will be happy to share the breakdown of the expenditure. We spend about 32% on support staff, which is mainly health care assistants, and 64% on medical and nursing staff, which is broken down between community and acute services. Our agency spend is just over 5% of our total spend in terms of payroll. It is something we wish to reduce. In terms of equivalence, it is about 5,500 head count. It is a marginal element of our overall spend that we want to reduce. It is a flexible resource that we need to utilise, where we have to utilise it.

Chairman, is it possible to get a graph of that information?

Mr. Paul Reid

Yes, we can do that.

I invite Deputy O'Connell.

As the Minister knows, and I made it very clear that I feel strongly about the issue of vaping. Large tobacco and cigarette companies are mooching, so to speak, into vaping. To bring it back to another issue, the rise of the global cannabis market is predicted to be €123 billion by 2028. It seems very clear that big tobacco is involved in this market as well. It is similar in ways to the way that vaping has taken off. As somebody who only has facts and science to rely on, it is becoming increasingly difficult to win the argument and it is actually easier at times just to say nothing and pretend that one does not know anything about things because the level of angst if a person stands up to something like this is to some people not worth it. In my mind it is worth it. I feel particularly strongly about this issue, and while I am a major supporter of and am pro-decriminalisation of drugs, I feel very strongly about the statutory instrument signed at the end of June, which is contrary to the legal advice provided to this committee and contrary to the Health Products Regulatory Authority, HPRA, advice. In the HPRA report of 2016, Cannabis for Medical Use - A Scientific Review, the first paragraph of the executive summary states:

To date there is an absence of scientific data demonstrating the effectiveness (efficacy) of cannabis products.

It goes on to refer to conditions "such as those for which there is a public interest". I am concerned that, due to public interest and a ferocious campaign for the authorisation of medicinal cannabis, we have somehow diluted our drug regulations. The HPRA is only supposed to license and authorise medicinal products, and cannabis does not fit into that category. We do not yet have any trial data, which is important to take on board, as it is for any other drug.

When it comes to public health, we are depending on big tobacco, via vaping, to tell people how to tackle a nicotine addiction. How are we to deal with a market, which is potentially worth €128 billion, and is currently worth €60 billion to €80 billion, that purports to have a miracle product that will cure everything? We, as elected representatives, have to protect public health. This feeds into the phenomena of fake news, anti-vaxxers, and significant marketing and online influencers. We will face a public health nightmare in five or ten years because we will have diminished our regulation standards. Could a pharmaceutical company challenge the Department on this? Someone could rock up with cannabis, which does not have to go through the normal trials or regulatory process, while that company might have a drug that has gone through the trials and ticked all the boxes, and yet is not getting a marketing authorisation.

I also have an issue with the HPRA's remit, which at this point in time covers medical products. The product being allowed onto the market, albeit with limited access, is simply not a medicine. Populism has succeeded here to some extent. It is easier to use a statutory instrument than to legislate on this issue. I could be wrong but as a pharmacist, I feel strongly about drug regulation. Any dilution of regulations will lead to public health issues in the future. I realise I am standing alone on this issue because it seems like I do not want to give sick people and children this miracle medicine. However, claims have been made about treatments that simply cannot be true and that eat into the sound advances made in public health. Have the HSE or the Department predicted how we will deal with the challenges that will no doubt arrive on our doorstep in a number of years? They will have arisen under the Minister's watch because of a statutory instrument that allowed a product with no scientific basis onto the market.

We do clinical trials all the time in Ireland and an expert group comprising scientists, neurologists, and others put the guidelines for this programme in place. We have met HPRA officials and they have satisfied themselves about the programme. The authority's advice stated that if access to cannabis were permitted for medical purposes, it should only be initiated under the direct supervision of an appropriate medical consultant.

The Deputy referred to populism. I withstood massive political pressure from this Oireachtas when it endeavoured to pass irresponsible legislation without grounding in science. It wanted to set up a cannabis research authority, whatever that was going to do, among other things. I am instead putting in place a confined access programme as a last resort for three specific conditions, which is grounded in the HPRA-----

I understand, but there are no trial data.

No, there are not. However, this programme will enable us to gather information. It is only operated under the advice of a medical consultant and is in line with what other European countries are doing, including Denmark-----

The Minister knows that I am fully aware of that. The next project being advertised is medicinal mushrooms, farcical as that sounds.

Will the HPRA authorise those also? Will we continue to erode institutions and knowledge and bend facts?

I understand consultants will have to prescribe the cannabis. However, the limited legislation that preceded the statutory instrument stipulated that it would have to be prescribed by a consultant in the relevant field. A neurologist would have to prescribe it for a neurological condition and so on. My understanding is the statutory instrument does not specify.

It is prescribed by the treating consultant.

There is more flexibility in that regard.

I understand the Deputy's concern, but there is possibly less flexibility in this case. GPs could apply to the ministerial licence scheme, whereas only a treating consultant can apply to this programme. The treating consultant is the safeguard. There is no pseudoscience involved. A medically qualified consultant who is treating someone has to satisfy himself or herself that this is worth doing in his or her medical opinion. It is not a political decision. At one stage some people here would nearly have had me giving out the cannabis. That will not be the case. It will be done under very strict medical regulations for a set period of time.

I accept the Deputy's view because it is a fact that the evidence on the medicinal benefits of cannabis is scant at best. It is not an authorised medicine.

I know all of this.

I am just telling the Deputy that that is my view as Minister for Health. I am not disagreeing with her view that there is no evidence base for cannabis as a medicine. However, it is the medicine of last resort. If a medically qualified consultant treating someone for one of the three relevant conditions believes it could help, he or she is allowed to seek the licence. We spent a significant amount of time setting up the programme and bringing together an expert group, but we were criticised for doing so. The guidelines for the programme have been designed by doctors, scientists, pharmacists and others.

I understand that and the Minister knows how I feel about it. It is important that I outline my views.

I refer to biosimilar products and the legislation needed to allow community and hospital pharmacists to substitute them, as was done in the case of generic products ten years ago. Is there any proposal from the Department to allow pharmacists to substitute biosimilar products? The Minister knows that legislation is required as the current legislation only allows for the substitution of exact molecules. My understanding is this could result in a health saving of between €70 million and €100 million, which would cover the cost of free contraception for the women of Ireland for a year. When the Minister goes to the Minister for Finance, he could save him €100 million and then bill him €100 million.

We discussed the issue of contraception at length at the committee on the eighth amendment and the Government's approach was that contraceptives would be provided free of charge. I understand there are budgetary constraints, but we made a promise in that regard. We identified that almost 50% of crisis pregnancies occurred owing to a lack of contraception and education. In the light of the upcoming budget and the time that has passed since the referendum, it is high time we followed through on the commitment given. I know that the Minister has set up a new working group to consider the matter. It is high time simple things like this were done, if for no other reason than as a gesture to the women of Ireland for the nigh on 100 years of reproductive persecution they suffered. Such a gesture could undo some of the bad of the past.

I agree with Deputy O'Connell 110% on the issue of contraception. I expect to receive the report of the working group in the next few days which I will publish or make available to Members of the Oireachtas quickly. I want to work on the issue in a collaborative way. The Deputy is right. As I said to Deputy O'Reilly, a significant financial commitment will be required, but there is more to it than that because we will also have to change legislation, set up systems and so on. There will be a lead-in time, but I am 100% committed to making contraception free. I have committed to doing so without receiving the report, as it will simply guide us on how best to go about it. I expect to be in a position to have discussions in the coming days with Deputies O'Connell and O'Reilly and others who are interested in the issue.

I commend the leadership of the CEO of the HSE on getting on with dealing with the matter of biosimilar products. We are already beginning to see the benefits. We need to build on the scheme in order that it can grow and become a normal part of budgeting and the financial flow in the health service.

For our part, on the Deputy's question, we will be publishing our national biosimilars policy by the end of this year.

The substitution of generics did not work until pharmacists could do it. It was clear 15 years ago. Substitution of biosimilars cannot be achieved if the legislation is not there for pharmacists.

I thank Deputy O'Connell.

I will have to reflect on that.

Can I ask one brief question?

No. We will move on. Sorry. We have been here for more than four hours. We will have one question from everybody to wind up. The Minister is under pressure for time.

I am always under pressure for time but I am delighted to be here.

Deputy Brassil will be followed by Deputy McConalogue and then we will go back to the spokespersons and Deputy Durkan.

I thank the Chairman for leading by example. I will be exactly that - brief and to the point.

I have just come from a briefing from the IPU. I note that the Minister works well with that organisation. For an organisation, it is non-adversarial and non-confrontational and sometimes it might deserve to make more progress for adopting that approach than other organisations that have a different attitude and might get farther because of the noise they make.

On the minor ailment roll-out, the pilot scheme has been successful. I must declare an interest because I am a practising pharmacist, as is Deputy O'Connell. We need to get that rolled out. There are 2,000 pharmacists ready, willing and able to help and who want to do it. It would be a major benefit to the health system to get that rolled out and to make progress on it immediately. Will the Minister put a timeline on that?

As a profession, we are the last group on which there has been no progress on reversal of the financial emergency measures in the public interest, FEMPI. The Minister has made a commitment in that regard. We would like to see progress because we deserve it. We are willing to work with the Minister.

On progressing the profession, a new contract is needed, as was the case with the GP profession, and progress was to be made on that. The Minister will find a willing partner in rolling out a new contract to develop the service to embellish what we can add to the health service. The Minister will find us more than willing to work co-operatively with him in that regard. I highlight those three issues in the hope we can make progress on them.

I am aware of Deputy Brassil's commitment and knowledge on this as a professional, as is Deputy O'Connell also. I said, but want to repeat, that the IPU, particularly in relation to Brexit, has been an extraordinary organisation to engage with. I made the comment at the last external stakeholders meeting, "If only we could all be as collaborative on other issues." It has been brilliant in stepping up to the plate. I want to formally thank it and others - all the various stakeholders and manufacturers. The second point about the IPU is it approaches dialogue with me and my Department in a solutions-oriented way. Deputy Brassil's commentary is fair. The IPU is so constructive that we need to make sure we move on some of its suggestions.

I will have to come back to Deputy Brassil on their minor ailment roll-out. As I stated to Senator Colm Burke, where I left it with the IPU is that the union and the Health Research Board were to interact and look at what such a roll-out would look like. I will write to Deputy Brassil on where that is at.

The Deputy's second and last questions kind of roll into one. In any negotiation about fees and fee reversals, we must look at it also in terms of contract reform and service levels. The commitment that I gave at the IPU conference still stands. We will sit down with the pharmacists at the start of 2020 on both matters.

I thank the Chairman for the opportunity to ask a question. It relates to the need for additional permanent residential places for persons with an intellectual disability, ID, across the country but specifically in community healthcare organisation 1, CHO 1, which is in the north west. As matters stand, the only funding coming forward at present is going towards decongregation, which is important, but there are a number of people in the community whose families are under unbearable pressure in caring for somebody who should be in a residential place.

Additional funding is needed to address that because it is simply not sustainable. I seek an update on the funding for permanent residential places from the Minister.

I am bringing up a specific case that needs to be dealt with out of frustration. This relates to somebody who was awaiting such a permanent place for a number of years but, because of the circumstances, had to go into an emergency placement in January last. That person's care has been catered for since then by moving the person around three different respite centres because the person needs two-to-one care but the centre needs to be a closed centre when the person is there. If the person was in one respite centre only, it would mean nobody in that area would get respite. The person, therefore, has been moved around three centres. Twice over the past ten months, a permanent external placement has been identified for that person but the funding fell through. It means that, ten months on, the respite care for many people in the community is being affected and, of course, the placement that the person has is not what it should be because the person should be in a permanent residential centre. I have followed the case closely. It is unacceptable that it has not yet been dealt with. I will pass the details on to the Minister and I hope I will not have to be back in three months, which would mark a year since the point when this person was first moved around various respite centres. On the broader point, can the Minister provide an update on the need for funding for permanent residential places alongside de-congregation?

I thank the Deputy for raising the issue. I note the importance the Deputy attaches to it by the time he has had to spend here to raise it today.

No doubt there is significant unmet need when it comes to both permanent residential places and emergency places. We are endeavouring to prioritise both in our budgetary discussions, which, as he can imagine, are tricky considering the environment in which we are operating. The HSE has done some good work in this regard. Ms O'Connor might like to elaborate on that. Regarding the individual case, I would be pleased to receive the information from the Deputy and to pass on to the HSE, and we can revert to him directly.

Ms Anne O'Connor

There are a few things we are looking at.

We are challenged on the emergency front. That may be what the Deputy was referring to. On decongregation, we have moved 160 people this year and we will continue to decongregate.

Where we have an urgent need for a placement, depending on the needs of the individual, we are challenged on two fronts. The first is that the cost of placements can be extremely high for individuals. The second is we cannot always get them. Often we have a variety of providers who assess people and we make arrangements and they fall through. That is particularly prevalent in certain parts of the country.

We have an extensive piece of work looking at all of our placements at present because in reality we should get away from emergencies. We should not be dealing with emergency placements - that is the language we use. By building in earlier intervention with families and by building in respite care, which we discussed earlier, we can reduce the emergency nature of placements. On the work we are doing, we are looking to see how we can work better with providers to prepare for people who have more complex needs because that is where we become particularly challenged.

Everything is becoming an emergency because nothing has been dealt with given the places are not available. It is only when they become an emergency that cases are dealt with and, in the meantime, people are under unbearable pressure. It is only emergency cases that are out there because standard ones are not getting dealt with and they have outstayed the respite and home care options for catering for people's needs in many circumstances.

I thank the Deputy. We have limited time; 20 minutes. Deputy Donnelly has a maximum of five minutes or three minutes, if he can aim for it.

I will try to hit five.

I will start locally, for the Minister and I. We received figures, recently enough, that the CHO for our area has sanction for 14 mental health professionals to support children with disability - an extraordinarily important and worthy set of supports.

Not a single one of those has been filled. From the 14 sanctioned posts, zero has been filled. This means children with disabilities all over Wicklow are not getting the mental health supports they are meant to be getting where posts have been sanctioned. Will the Minister provide an update as to why so this is such a chronic problem, and will anything happen?

I thank the Deputy, who has raised a very important matter. I share his concern because, as he correctly states, we have sanctioned the funding for these 14 posts. I have also been in contact with the HSE seeking an update. I do not know if Ms O'Connor has an update or whether she will revert to the Deputy and me.

Ms Anne O'Connor

I do not know why they have not been filled. I would have to check.

There is funding in place.

What is going on is extraordinary. My next question concerns an MRI machine for the Carlow-Kilkenny region. People raised €250,000 in 2016 and the Minister met them in July 2018, saying the money would be released within weeks for the building in which the machine would be placed. As of last week, when they approached me, nothing has happened. The Minister gave a commitment in July last year, but why has the funding not been released? Will the funding materialise?

I am pleased the Deputy asked about this as I am asking many questions about it. The short answer is that the MRI for Kilkenny is absolutely funded. I thank the Friends of St. Luke's Hospital Carlow-Kilkenny, one of whom has been in direct contact with me, for the incredible fundraising work that the local community has done with this facility. We are putting in more than just a new MRI and there will be a new waiting area. It is quite a sizable investment, to which the community has contributed much. It has planning permission and the next step is to go to tender. I have asked the HSE to come back to me with the date on which it intends to go to tender. I expect to have that information from Mr. Reid very shortly. I assure those people, through Deputy Donnelly, that the project will go to tender very shortly. I have met representatives of the hospital management and HSE estates. It is a major need and opportunity for the hospital.

The question for them is whether the money for the building has been provided for.

Yes. It is in the capital plan. The next step in the sequence is going to tender.

I thank the Minister. On the maternity strategy, we have discussed at this committee before the fact that the Coombe was meant to be moved in parallel to the national children's hospital. The Minister stated he would do his best to release funding to get that process moving. Has that happened?

Yes. I like to be constructive and take on board constructive suggestions, and the Deputy made one on this matter. Deputy Donnelly and I spoke in the Dáil about how the children's hospital construction had to conclude before the new building for the Coombe could be built, but the Deputy rightly suggested that we should be doing preparatory work in this regard. In the capital plan we worked with the HSE to identify funding to appoint teams for each of the individual hospitals so some of that preparatory work could be done. Perhaps I could write to the Deputy with some of the detail.

I thank the Minister.

The short answer is "Yes".

There are two bits to my final question, although they are not necessarily related. It might be more of a question where the HSE might come back to the committee. There is a fundamental difference in views as to what is going on with nurses not being hired. I have heard the HSE statement and the caveat that there is no embargo in place but there may be conditions where financial plans have not been sanctioned and therefore hospitals do not have permission to hire those personnel. Will the HSE or the Department, whichever is the correct group, come back to the committee with a detailed explanation of what is going on? There are 82 people sitting on trolleys in Limerick as we speak, but the nurses seeking jobs there have been told an embargo is in place. Will the witnesses come back to the committee with a realistic picture of what is going on? Which hospitals are actively hiring and which have been told that, for various reasons, they cannot currently hire those personnel?

As I stated, there are 82 people waiting on trolleys in Limerick as we speak, and although some will get beds today, more people will walk into the hospital throughout the day and tonight. There are measures that could be taken today as opposed to long-term strategic and infrastructural capacity-building measures. Home care package numbers could be increased as an emergency measure and there could be a pause on some non-urgent elective care. More supports could be given to GPs very quickly so that patients who do not need to come into accident and emergency departments would not do so. The nursing vacancies could be filled very quickly. We know the numbers throughout the country for people waiting on trolleys is bad, but at 82, does the number for Limerick signify that this a crisis? Could emergency measures therefore be taken so the people in Limerick could see some improvement right away?

As I have said to colleagues, and as Mr. Reid has said today as well, a couple of these measures have already started. We have put €10 million into the system in trying to provide extra social care support. Limerick will clearly benefit from some of that. For example, we are seeing the number of delayed discharges finally beginning to fall after weeks of it rising. It is still very high but it is decreasing. We had another good engagement today, particularly with members from the mid-west and the Chairman, about doing something on diagnostics. We are taking that away and we have agreed that HSE representatives will meet members from the mid-west within a fortnight to see how to progress the issue. The core of the Deputy's question was what we can do now, as we are almost in winter, to improve flow, social care etc. I expect that on budget day next Tuesday, we will be in a position to announce funding for the winter, from which Limerick and other parts of the country will benefit. We will focus on the short-term measures of assistance.

Is it possible to get the information for the committee?

I do not want to put words in the Minister's mouth, so I can stand corrected. One of the co-chairs is here but will both co-chairs of the emergency department task force be contacted before engagement takes place? It is important. I know a planned meeting is to take place.

I understand the sequencing in terms of the budget etc. There is a pressing need to have that meeting.

Earlier I raised capital matters and the provision of diagnostic equipment for the primary care centre local to me. To be fair, I asked many questions and I am not sure that one was answered. If it was, I can check the record. What is planned in this regard for Balbriggan, as we have been campaigning for this for two and a half years, and scanning facilities and diagnostic equipment are essential?

The dual diagnosis programme was on the HSE website but I have been advised that it has been removed. I have been contacted by campaigners to say their fear is that the programme has somehow been stalled or shelved. The Minister might be able to provide an update.

Women and men have been affected by mesh implants. Will the Minister give an update on this? I know he has met some of them, as I was there for both meetings. It is not just women who have been impacted but because they highlighted it, men are coming forward to say they have felt an impact. These women have shared their harrowing and horrific stories with the Minister. My information is that very similar cases exist among the men affected by this and it is no less severe, painful or awkward to speak about. Those women had the courage to come forward and there are men in the same position who would be happy to inform the Minister about what is going on with their health.

Those are mainly questions for the HSE but I will comment on the mesh implants issue. We had a meeting and I thank Deputy O'Reilly for facilitating it. I had a follow-up meeting with Mesh Survivors Ireland and I have committed to another meeting. I need to get back to it with a date for another meeting, which will probably be next month. The Deputy is welcome to attend. Dr. Henry can update us on the commitments made to the group.

We have provided an uplift for diagnostic equipment in the capital plan and the HSE must map out where that is going. In fairness to Deputy O'Reilly, she asks on a very regular basis about Balbriggan's diagnostic equipment. Perhaps we can update her or at least promise to revert to her on the matter. Ms O'Connor can speak to the dual diagnosis programme.

Ms Anne O'Connor

I am not aware there was an issue with the dual diagnosis programme so I will have to check to see why it has gone from the website.

I would be very grateful for that. My campaign was contacted about it.

Dr. Colm Henry

I will revert to the Deputy on the vaginal mesh issue.

I hate to be pejorative at any time and especially at this time of the day. I refer to a decision made by this Minister and the Minister for Communications, Climate Action and Environment on 2 January and 3 January this year. It relates to the transposition into Irish law of the EU directive on ionising radiation.

That obviously affected the practice of chiropractics. The Minister at the time indicated that he intended to bring in regulations to ensure that a high standard was applied and that we were complying in some way with the requirements. My information is that since then, not all European countries have complied with the legislation at all. The particular issue was pursued vigorously by an individual for a period. If that individual had the pain that I have in my back at this moment, he might not have been in such hot pursuit. Will the Minister have a look at that again to see whether it might be possible to regulate in a way that would meet the requirements of the European Union?

Deputy Durkan and I have had many chats about this. As he knows, I held out on this one for a while. I understood the views being put forward by a number of Members of the Oireachtas. I have to be careful in what I say because I think there is a legal challenge and legal correspondence in my Department in respect of this. The bottom line was that in order to comply with the directive, one needed to prescribe certain professionals and in order to do that, they needed to be regulated. As the Deputy knows, chiropractors in our country are not regulated although in other countries they are. It varies significantly across the European Union. I am of the instinctive view that they are a group that should be regulated, but there is a long list of people seeking regulation. On the advice of the chief medical officer and others, I asked that the Health Research Board would look at the regulation of chiropractors, risk and so on, and I am awaiting that report.

Has the Minister stimulated them in their urgency to reply?

I will certainly seek an update and revert to the Deputy.

Deputy O'Connell is next, for one question.

I have five minutes, not one question. Pulling all the stuff together than I have been talking about in the previous two rounds, has the Department plans for a massive public health campaign in terms of identifying what we can learn from where we failed before? I refer to the vaccination rate with HPV vaccination dropping to 52%, which was not on the Minister's watch but it did happen, and to the great effort by all the witnesses, the late Laura Brennan and many others such that we collectively have got that rate back up. In terms of public health education, if we look to some of the developing countries such as Rwanda with its vaccination programme, the programme is front-loaded with education and their system has worked well. We are failing because we probably did not cop on quickly enough to the power of the Internet and of false claims. As the Minister knows, I have my Bill, which is waiting to progress. It is clear from the conversation about measles and mumps that people do not seem to realise how serious these conditions are. The generation that saw these conditions is largely older. My own mother is a retired public health nurse who specialised in infectious diseases so I am very much aware of the dangers associated with them. However, it is very hard to fear what we cannot see. Are we going to do anything to try to mitigate the risk of the propagation of false claims? I am thinking of something to do with the value of science and fact, our institutions, the value of research and development. Organisations such as the Irish Cancer Society clearly have public health as their remit. There is a need to identify those whose remit is probably not public health but the bottom line on their balance sheet. Beliefs are hard to change and I believe the only way we can do that is through education. There is a shift whereby people are not going to listen to the celebrity chef as to what they should take to cure their terminal cancer. However, the Department and the Minister need to pre-empt what is coming down the road in terms of slick marketing campaigns to get into people's pockets, essentially, and in some cases into the pockets of the Department, I would say, in terms of the funding of medicinal cannabis.

The Deputy has one more question.

No, I am at 2 minutes 52 seconds. The Minister recently mentioned a flag system for news and I welcome that. I discussed this before at a Facebook event. I am not sure how we would do it in terms of the Internet but I like where the Minister is going with it. It is very important. As we saw with the HPV vaccine, it is really hard to roll back. The lie has got around the world before the truth puts its boots on. One has to stand for something or one will fall for anything. That is why I feel so strongly about this. On the HPV vaccine for the boys, I congratulate everyone involved in the roll-out. In light of its success, have we plans to vaccinate the second, third, fourth, fifth or sixth-year pupils? There seems to be such an appetite to do it. I know it is another bill and the Minister is probably always presenting bills but the money will be saved in the long run. I am sure there is a sum there for the cost of fixing the decline in HPV vaccination in terms of cost of life but also cost to population health.

I thank Deputy O'Connell for her support on public health in general and her advocacy in this regard. We have made really good progress on vaccination together as an Oireachtas. The HSE has shown incredible leadership in this area. It shows how when the health service really puts its mind to something, we can make progress. When we engage with others outside our initial health family, our friend, the late Laura Brennan, obviously being a key example of that, but also lots of other organisations and people, we can see the energy and the movement that creates. We launched the Vaccine Alliance on 10 September. I am very excited about this. We specifically put Science Foundation Ireland on it for that very reason. It is doing its scoping exercise on the work it should do now. They have Barnardos, USI, lots of doctors, parents and patient advocates. It is a really good mix. David Robert Grimes, whom the Deputy knows, is a really powerful advocate and is on that group. It is to come back to us with what it thinks we should do.

One of the issues in any public awareness campaign, as the Deputy will know, is the need to target certain groups. When we look at vaccinations and pseudoscience, the impact is not uniform across all of us. We need to do a little bit of work in terms of what works for different parts of society. The short answer is that we have major plans for pushing back on misinformation regarding vaccines. The point the Deputy is making at to how we broaden that out into other issues is a good one and I will reflect on that.

On the HPV vaccine, I am delighted we got this done and that it is rolling out. I am hearing really good things back in terms of uptake rates. I am in the realm of anecdote at the moment but am hearing from GPs and others that they are seeing a lot of demand. They are seeing parents coming in asking for vaccines for their older sons. The medical advice available to me currently is not to do that but we did the catch-up programme for girls and we still have it so I am keeping it under active review. There is not a current proposal for it. Obviously people can get it but have to pay for it after first year. We will keep it under review.

On the meeting the Minister is proposing with mid-western Deputies regarding the issues at University Hospital Limerick, and the expansion of the role of model 2 hospitals, which we also discussed today, could the Minister add to the agenda the issue in respect of two modular theatres for Ennis? He spoke about the delivery of ophthalmology services in Nenagh and there is a proposal that Ennis would become a centre for day-case ear, nose and throat surgery, but it would need two modular theatres to deliver that service which, again, would take pressure off University Hospital Limerick.

I am more than happy to do so.

I had a note to deal with a drugs rehabilitation programme. The Minister responsible is not present. We might have an update as soon as possible on that one. It is an area that we need to discuss.

If it is of help to Dr. Henry, I think Deputy Durkan meant the word "valent" not "series" when it came to the vaccine. There is a bit of correspondence coming in to us. If it saves Dr. Henry and allows him to answer now, a few people are telling us it is not the most up-to-date vaccine that is being administered. I do not think that is right, because I checked it last night. My understanding is that it is the most up to date.

Perhaps he does not have the answer but that is okay.

On behalf of the committee, I thank the Minister for his time. I also thank Mr. Reid, Mr. Breslin, Ms O'Connor, Dr. Henry and Mr. Woods.

The joint committee adjourned at 1.45 p.m. until 9 a.m. on Wednesday, 9 October 2019.