Quarterly Meeting on Health Issues

We are now in public session. This morning's meeting is a quarterly review of the health service with the Minister for Health, Deputy Harris, his officials along with the chief executive officer of the HSE and his staff regarding the current state of our health service. On behalf of the committee, I welcome the Minister and Mr. Jim Breslin, Secretary General of the Department of Health. I understand that a number of Ministers of State will attend later this morning. We will welcome them as they arrive. I also welcome Mr. Paul Reid, chief executive officer of the HSE, Ms Anne O'Connor, chief operations officer, Mr. Liam Woods, national director, acute operations, and Dr. Colm Henry, chief clinical officer.

I would like to draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given. They are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. I advise witnesses that any opening statements they make may be published on the committee's website after the meeting. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I ask the Minister to make his opening statement.

I thank the committee members for inviting me to attend today. I am pleased to be joined by the Secretary General of the Department of Health, the chief executive officer of the Health Service Executive and senior HSE officials, and to have an opportunity to update the committee regarding current issues.

Regarding Sláintecare, officials at my Department have been engaging with stakeholders to gain insights into what they want and expect from our health services. One of the resounding messages to emerge is the need to have a clear and coherent plan. Sláintecare is now that plan. I am pleased to say that the implementation of Sláintecare is now well under way. Planning and co-design for the new regional health areas have begun. Co-design is an important part of Sláintecare and means that patients and staff who live and work in the region play a part in setting up that regional structure. Following consultation with the Sláintecare office, I will make a recommendation to the Government on the exact structure of each region early in the new year.

A forum to provide a regular platform for dialogue between the State and voluntary providers of health and social care services is also being set up. It will have an overarching mandate to build a stronger relationship between the State and voluntary providers for the benefit of patients and service users. The forum will meet for the first time in December. I had an opportunity to address an initial meeting of that forum, and I thank Mr. Peter Cassells for agreeing to chair it. The integration fund of €20 million is supporting 122 projects across the country and, via that €20 million, we will hire 300 additional staff to work in the community. In each of the Deputies' constituencies, therefore, Sláintecare projects are now up and running in each county delivering reform in health services on the ground in our communities.

To reduce community waiting lists, an important and sensitive issue, we will spend €60 million between now and 2021 to employ an additional 1,000 community healthcare staff by the end of 2020. These will be people able to treat our citizens closer to home. In recent years, we have seen a significant increase in the number of primary care centres. Some 127 primary care centres are open, but it is fair to make the point that we need to staff them better. Deputy O'Reilly has made that point vigorously and regularly. We have fine buildings and they are needed because they bring about a new and better way of working and new opportunities for our patients to access services locally. We need to increase the staff in those facilities now, and that is what these 1,000 additional staff, the Sláintecare workforce as I like to call them, are about as well.

I am acutely aware that along with any long-term plan, and we do need a long-term plan, we also need to address the issues facing us today. I acknowledge the challenges facing emergency departments in our hospitals and I accept that in some it is particularly difficult for our patients and staff. The Government allocated a budget of an additional €26 million to assist the HSE over the winter. Specifically, this funding was to support and improve access to the fair deal scheme, helping our citizens to get into nursing homes quicker and to also provide additional home care, transitional care, aids and appliances and other local actions to facilitate timely hospital discharge and reduce congestion.

Specific funding has been allocated to local winter action teams to support initiatives at local level. This is important. Everything cannot just be about the Department of Health, the HSE and Dr. Steevens' Hospital deciding what individual areas are doing. This process has to be about resourcing and empowering local winter action teams to enable them to respond to issues as they arise in their regions. I am pleased to confirm a range of new and additional measures to alleviate pressures on accident and emergency departments. The HSE has reached an agreement with the National Treatment Purchase Fund, NTPF, to open up to 190 extra hospital beds in the coming weeks. When we factor in these 190 extra beds with the 40 additional beds in the modular unit in Clonmel, due to open in the new year, that brings us to a total of 230 additional hospital beds that will open between now and the start of 2020.

Importantly, the NTPF has written to each hospital group and, as of today, I confirm that 83 beds have now been approved, of the overall 190 beds. These additional beds are in Letterkenny, Tullamore, Waterford, Cork, the national children's hospital and Limerick, in St. John's Hospital.

It is a matter that Senator Kieran O'Donnell has pursued with me as well.

The NTPF is continuing to engage with hospital groups to finalise the details of the additional capacity but the message is very simple. If a hospital has opportunities to open additional capacity in its facilities, a nearby hospital or a level 2 or level 3 hospital, we will look at how we can fund that through the NTPF. I commend both the NTPF and the HSE on the collaborative way they are working in this regard. There are 230 additional hospital beds, including the Clonmel modular unit, and it is a very significant increase in capacity on top of the €26 million already provided.

I confirm that in the coming week, I will sign a new statutory instrument to reduce the cost of attendance at a minor injury unit to €75. For many years, people have commented on the fact that it seems a little bizarre that we are trying to encourage people to attend a minor injury unit if it is the appropriate place to go but the cost of going to the minor injury unit was the same as the cost of going to an accident and emergency department. That is €100 if a person does not have a medical card. In an effort to further incentivise use of our minor injury units, I have decided to reduce the cost to €75. That statutory instrument is currently being legally drafted and I expect to be able to sign it in the coming week. I know the HSE will then implement it with immediate effect. It will also provide an opportunity locally in the 11 minor injury units across the country to reinforce the importance of using the minor injury unit where we know people can be in and out in 90 minutes, two hours or even less time for many conditions. That is without needing to go to the accident and emergency department, which is good news.

I am also working with Government colleagues to identify some additional funding for more social care supports on top of what we have already done. There is €26 million already in a winter plan and additional money is going to the HSE for the NTPF to open more beds; this relates to the 190 additional beds and the 40 beds in Clonmel. On top of that I expect to be in the position within the next week to make further announcements on additional funding for extra support for home care, transitional care and some very good and innovative ideas that HSE colleagues have been working on at a hospital group level in recent days and weeks. I wanted to update the committee on those new measures to try to provide additional assistance to our health service at what is a very busy time.

We have seen significant progress on waiting times for scheduled care. It is not often heard or articulated but we should be clear that as a result of increased activity and the ongoing work between the HSE and the NTPF, the number of patients waiting for an inpatient or day case procedure - a hospital operation or procedure - fell to 66,594 in November from a peak of 86,100 in July 2017. Month on month we are seeing in this country the number of people waiting for a hospital operation falling and the number of people having their hospital operation in less than three months is increasing. Approximately 32% of people were getting their hospital operation in three months or less in 2017 and that figure is now 42%. More than four in ten of us are now getting a hospital operation in 12 weeks or less, which is the Sláintecare target. We must build on that and increase the 42% figure even further. We have seen an overall reduction of 23% in the number of people waiting for a hospital procedure. The number of patients waiting more than three months has fallen by 21,400, or 37%, from July 2017 to November 2019. There are fewer people waiting for a hospital operation and more people are being seen more quickly in connection with that operation. There are fewer people waiting longer for such hospital operations as well.

We speak of waiting lists as if they are part of a global conversation but we can consider some of the specialties. Ophthalmology relates to the treatment of eyes and the number of people waiting over three months for a procedure in this area fell by 63% from July 2017 to the end of November 2019. In the ear, nose and throat specialty, the number of people waiting over three months for a procedure fell by 58% from 2017 to 2019. The number of people waiting over three months for a cardiology procedure fell by 33%. The world and its mother knows there are major challenges in our health services but it is important to acknowledge the progress being made by very hard-working staff, coupled with significant investment from the Government, in decreasing waiting times for hospital operations or procedures.

The key must now be our outpatients. We need to consider how we can drive down the length of time people are waiting to see a hospital consultant. That is why we will use a significant amount of the additional resources being provided to the NTPF to put in place further targeted measures in this regard. We have seen the outpatient waiting list fall for three months in a row and we will see it fall for four months in a row.

For the first time in a long time the number of people waiting to see a hospital consultant is falling month on month, although it is still far too high. My conversations with consultants will focus on how additional money for them will be about reforming how they work and how we make sure that public patients are not continually pushed to the bottom of hospital queues over those who can afford to pay for private health insurance. We will be working with the HSE, the NTPF and the Sláintecare implementation office to produce plans for 2020 that will build on the progress that has been made to date. We are working to identify initiatives that will meet the objectives of Sláintecare. This is not the bad old days of the NTPF turfing out money to private hospitals. Any initiative funded through the NTPF in 2020 must meet the Sláintecare objectives and must include innovative approaches to increase activity, avoid hospital attendances and better utilise our smaller hospitals and our primary care centres. The NTPF is not the NTPF of the Celtic tiger, when it was just a funding pot for private hospitals. It must be used as an access fund for the public health service as well.

A key focus for 2020 will be on moving care to more appropriate settings. We have a number of specialties working in this regard, including ENT, orthopaedics, dermatology, ophthalmology, urology and gynaecology. There are significant opportunities to make progress in those areas in 2020. We will also be seeking to maximise the use of advanced nursing practitioners. The days of everything being done by the doctor is an outdated model. We have extremely well-qualified nurses in this country and advanced nurse practitioners who can lead clinics and provide entire episodes of care. We also have physiotherapists who can manage orthopaedic clinics and people who can provide ophthalmology services in the community. This extra funding must be about reform as well.

I would like to comment briefly on the UK Royal College of Obstetricians and Gynaecologists, RCOG, aggregate report on cervical cancer and the CervicalCheck programme. As the committee will be aware, on Tuesday, 3 December, I published the aggregate report of the independent expert panel review led by RCOG. The committee will have an opportunity to discuss the report in detail on 18 December, when it will hear from both patient advocates and the college. I do not intend to fill either of those spaces but it would be remiss of me not to make some comment.

I thank the expert panel who conducted this review and, in particular, all of the women and their next-of-kin who agreed to participate in it through the examination of the performance of the CervicalCheck programme. The findings and conclusions contained in the review provide reassurance and, I hope, assist in restoring confidence in our programme and address its importance and quality, while also highlighting the sad and painful reality of the limitations of all of our screening programmes. RCOG was asked to do this body of work for two reasons. First, we felt, and rightly so, that the women of Ireland who had had cervical cancer deserved to have an independent clinical review of their screening history. Second, the Government and I, as Minister for Health, wanted to be able to answer the questions that women were asking at a very difficult time for our screening service, namely, "Can I have confidence in our screening programme?" and "Is our screening programme working effectively?". The good news is that the report finds that the CervicalCheck programme is working effectively and, crucially, that women can have confidence in the programme. As I said earlier, the committee will have an opportunity next week to tease through the report in much greater detail with RCOG. The key conclusions of the expert panel are that the CervicalCheck programme has undoubtedly saved the lives of many of those who participated in the review, that the programme is working effectively and that women can have confidence in it.

The panel emphasises that it is important to recognise the serious impact that screening failures have on the lives of women and their families. Cervical cancer is a disgusting and devastating disease that disproportionately affects younger women. It takes the lives of approximately 100 Irishwomen every year. Some 300 women will get a diagnosis of cervical cancer each year. Screening, in every country in the world, inevitably will have limitations. There are limitations when it comes to cytology-based screening but this should not be taken to suggest the programme overall is not working. As Minister, I have to reference the importance of the programme and how effectively it is working but that is not to in any way not acknowledge the significant pain and trauma of those who have cervical cancer and those who have been caught up in this awful debacle in regard to the non-disclosure of an audit. If we are to achieve our goal of making cervical cancer a rare disease in this country, effectively eradicating it within a generation in Ireland, it is vital that women continue to attend for screening and that we continue to build on the considerable progress in other areas over the course of this year. Smear test turnaround times, an issue on which I have been rightly scrutinised at this committee on many occasions, have stabilised. I thank the staff of CervicalCheck and the HSE for their incredible work in this regard. Implementation of Dr. Scally's recommendations is well under way.

In the first quarter of 2020, which is only weeks away, we will move to HPV primary screening, becoming one of the first countries in the world to do so. I have written to the HSE to ask it to consider the recommendations from the review in the context of this crucial project to ensure it absolutely is delivered by the end of the first quarter of 2020. I know it absolutely will be.

I am also pleased we have put in place another key element in restoring trust and confidence not just in screening but in our health service. This is the patient safety Bill, which committee members will scrutinise here and in the Dáil. It will commence in the Dáil tomorrow. It will bring about mandatory open disclosure. As Dr. Scally said, when things go wrong in the health service, people want a sincere and genuine apology. They want to know there is an understanding of what happened and an assurance it will not happen again. The patient safety Bill will focus on open disclosure and will signal a new era for the health service. The legislation will establish a robust and future-proofed framework for mandatory open disclosure. Importantly, it will require notification of serious patient safety incidents to the external regulator, be it HIQA or the Mental Health Commission. No doubt, this will contribute to national patient safety learning and improvement.

Importantly, mandatory open disclosure will apply not just to the public health service but also to the private health service. For the first time we will extend the remit of HIQA to the private health service. The new patient safety Bill places clear responsibilities and obligations on health service providers to ensure mandatory open disclosure occurs and external notification to the regulator takes place. It is a significant cultural and legal change.

I understand the committee is interested in the care of women who have been affected by the use of mesh implants. I have met the mesh survivors group on a number of occasions, most recently on 11 November, and I have listened to their personal stories. I acknowledge very sincerely Deputy O'Reilly's work in this regard as an advocate and, perhaps, an interlocutor on occasion, for the advocacy group with the Government and the Department. I acknowledge the very constructive way she has put forward their case and engaged with me. I want to be very clear that I am fully committed to ensuring that all women who develop mesh related complications receive high-quality, multidisciplinary and patient-centred care.

Since the issue came to my attention in late 2017, an ongoing priority focus for the Department and the HSE has been to understand the clinical and technical issues and to put in place the necessary structures for, and the provision of, care for women who have been affected by the use of mesh. It is very clear to me when I meet the women and hear their stories the trauma, pain and agony they have been put through. Quite frankly, there has been physical agony and mental anguish. I requested the chief medical officer to do a body of work. He thoroughly examined the issue and prepared a report for me on the safe and effective provision of mesh procedures and responding to women experiencing mesh complications. We published the report in November last year. It includes a number of significant recommendations in a number of key areas. It also put a pause on the use of mesh in Ireland until we get to a point when we can be satisfied that all of the recommendations have been met. The HSE has advised that a package of care is now available for women who have been identified with urgent or immediate needs. In addition, the HSE's service plan will ensure the continued implementation of the chief medical officer's report on transvaginal mesh as a priority action. We are also continuing to progress the delivery of care pathways for women, including a specialist, multidisciplinary national mesh complications service.

I am also looking at the issue of access to medical cards. I had a very good discussion with the group and Deputy O'Reilly about whether we can provide a medical card in circumstances where somebody has been through the service and an identified issue has been established. I believe we can make progress. I have been asked to put in place a process for the voices of women to be heard and I have made a commitment to do this. We are developing proposals on an independent compassionate process for women affected by mesh to have their voices heard. I have written to Mesh Survivors Ireland in this regard. Work is under way. I am happy to deal with any questions in this regard.

I do not underestimate the significant challenges our health service faces but I do not accept that everything in the health service is bad or in crisis. Every day our staff do an excellent job of providing high-quality care to many people. We are making progress when it comes to waiting lists. Today, I announced a significant number of measures on additional capacity in the health service and additional resources for the winter. We will build further on this in the days and weeks ahead.

Mr. Paul Reid

I thank the committee for the invitation to attend this meeting. 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 for acute operations.

The latest financial position, from the end of the third quarter, shows a variance from budget, including first charge, of €319 million, or 3%.

Of this, €119 million or 37% is in respect of our operational service areas. The comparable figure for the same period in 2018 was almost 100% higher at €636 million, with €507 million of that overrun, or 80%, in the operational service areas. Pension and demand-led areas account for €200 million of the variance as of September 2019.

A key priority for the HSE is to maximise the provision of safe services to the people we serve while operating within the funding provided to us. This continues to be a significant challenge in the context of the ever-increasing level of demand for our services. This demand is influenced by factors such as a growing population, an ageing demographic, changes in technology and clinical practice, as well as ongoing societal and economic change. We have continued with our intensive focus on current year financial management and financial planning for 2020. Senior managers across the organisation have been engaging with us regarding activity and expenditure and the related challenges of operating within available resources. The greatest cost pressures within our operational services are in respect of providing residential placements to people with an intellectual disability and the provision of specialist emergency care within the acute hospital setting, particularly in the context of an ageing population with increasingly complex needs. The costs within our pensions and demand-led areas are in the main driven by policy, legislation, demographics and the macroeconomic environment and are not generally amenable to normal in-year financial management. State Claims Agency reimbursements are also within this area, and there is a significant and ongoing focus on mitigating, in so far as is practical, the underlying risks and issues that give rise to claims.

A key focus for our ongoing financial management efforts has been on improving compliance with our pay and staffing controls, including whole-time equivalents, WTEs, agency and overtime. Although staffing levels will increase again in 2019, any increases must be managed in a way that is both planned and affordable. This necessary adjustment to the controls on pay and staffing is proving difficult but it must become part of our normal way of working. I acknowledge that this is a challenging process, but I and the board are committed to ensuring that there is an improved culture of delivery within the funding provided by the State. I fully believe that this will put us in a stronger position to secure investment for the future, which ultimately will be in the best interest of our service users and their families.

My monthly financial meetings with community healthcare organisation, CHO, chief officers and hospital group CEOs will continue to year end. All areas are very clear about their allocated financial limits and performance expectations up to year end to mitigate in so far as practical any deviations from those limits, thereby reducing the extent of any challenge to be dealt with in 2020. The discipline of these monthly financial meetings will continue throughout 2020. Indeed, I met all the hospital group CEOs and CHOs just yesterday. The HSE's national service plan for 2020 was adopted by the HSE board and submitted to the Minister for consideration. The approval process is well advanced and I expect that the plan will be published within the next week.

The Minister has made some comments on winter planning. Following on from the briefing provided to the committee in September of this year on winter preparedness planning, the HSE has prepared a detailed winter plan, which was launched in November. The plan clearly reflects the year-on-year growth in demand for unscheduled care services that is growing at a rate of in excess of 5% in attendances and 2.7% in admissions over a mean annual population growth of 1.7%. In response to this increased demand, an additional €26 million has been provided to year end to fund a combination of nationally and locally managed initiatives aimed at improving overall patient flow from community, through the acute hospital and back into the community.

A sum of €19.2 million from this funding is specifically focused on egress initiatives, including home care packages, improving access to the nursing home support scheme or fair deal, and transitional care beds for patients awaiting nursing home places. The initiatives have in fact been in place since October in preparation for the anticipated winter surge and have enabled the system to respond. Nine local winter action teams are in place and are co-chaired by the relevant community healthcare organisation chief officer and their hospital group CEO colleagues.

The balance of €6.8 million has been distributed on the basis of population associated with each of the winter action teams, and this is funding initiatives such as enhanced community intervention teams; additional frailty intervention therapy teams, FITTs; aids and appliances to assist in discharge; enhanced triage capability; and additional bed capacity in private facilities. The HSE at national level and at winter action team level is also engaged with the National Treatment Purchase Fund, NTPF, in providing enhanced access to diagnostics, which will improve overall patient experience times and alleviate pressure in the emergency department and wider hospital services.

On Sláintecare, the HSE and the Department of Health continue to engage and work collaboratively on its implementation. A key element of this work is service redesign to plan for the implementation of the new regional health regions and social care delivery structures. In parallel with this work, I have also commenced a review of the HSE staffing and structures at the centre of the organisation as part of the preparatory work to inform the service redesign for the HSE to become a more strategic and patient-focused national centre.

I mention employment levels and recruitment. In October 2019, our overall employment levels stand at 138,080 personnel, equating to 119,473 whole-time equivalents, WTEs. This represents a total growth in our employment levels this year of 1,616 WTEs and year-on-year growth from October of last year of 2,562 WTEs. Our continued growth is important in the context of our overarching pay and numbers strategy. We have filled and continue to fill approved and funded development posts in order to maintain and enhance key services for patients and their families. In parallel, we are working to ensure levels of agency, overtime and pay costs, which reached unaffordable levels by the end of 2018, are brought within what is affordable and sustainable during 2019 and into 2020. We have continued to grow our workforce, and year-on-year the largest of this growth in WTE terms, is in our staff categories of nursing and midwifery and patient and client care, which predominantly concerns healthcare assistant staff, with both categories showing growth of 650 WTEs and 646 WTEs, respectively. In percentage terms, our largest year-on-year workforce growth is in our medical and dental staff category, which has seen a 3.7% increase since October last year. Similarly, it is also the largest staff category growth in percentage terms this year to date at 3.4% growth. Notably within these figures, our consultant workforce has grown by 142 WTEs year-on-year, with 135 WTEs of this increase recruited since January 2019. As we draw to a close in 2019, we will continue to proceed with the approved and funded development posts in tandem with the requirement to keep within an affordable funding level that is sustainable both in 2019 and 2020.

We will open the discussion to members, starting with Deputy Donnelly.

I thank the witnesses for coming here this morning. I would like to start locally with Purple House Cancer Support in Bray. It is an incredible cancer support service that the Minister for Health and I know well. It supports families and cancer survivors all over Wicklow and in south Dublin. It has to leave the premises it is in on an extremely urgent basis. It has found a fantastic premises that will allow it to expand its services and it looked for €650,000 from the State with a view to doing matched funding. After conversations with the Minister, staff from Purple House Cancer Support have told me that figure came down to about €400,000. They told me they met the Minister twice and he made promises around that amount of money. They then said the amount promised dropped from about €350,000 to €400,000 down to €150,000 and that yesterday they got a letter which one of the Minister's team took them through. That letter made no reference to any amount of money, it said there would be no money in 2019 and that they could apply for capital funding in 2020 but that would be considered in the round with a lot of other applications. This is what the staff in Purple House Cancer Support have said to me. I know the Minister and I both support this service. Will the Minister deliver on the promise of around €350,000 to €400,000? If not, can the Minister tell me why the staff in Purple House Cancer Support believe that promise was made by him?

As the Deputy said, both of us know Purple House Cancer Support very well. I also know all the other cancer support groups across our county well and that in my time as Minister, the level of annual funding for Purple House Cancer Support has significantly increased by €100,000. It now receives annual funding of €175,000 and no other cancer support group in County Wicklow receives such funding. I am sure the Deputy's concern for cancer patients in Bray is shared by a concern he would have for Greystones Cancer Support, Arklow Cancer Support, West Wicklow Cancer Support and Wicklow Cancer Support. When one is Minister for Health, one is Minister for the whole country and one is a Deputy for one's whole constituency. I have worked with Deputies in this committee on these matters. For example, I have worked with Deputy Kelly to secure funding for Tipperary Cancer Support Centre and there is a process to go through. Funding can be provided for Purple House Cancer Support and I have engaged with my Secretary General and the HSE on this matter.

That funding will assist Purple House Cancer Support in finding a new premises and I have had discussions with its representatives in that regard. I do not relate all the discussions I have with my constituents, although of course my constituents can do that, but I believe that funding can be found. I have had significant conversations with officials in the HSE and my Department about that matter.

I am also very much aware, as is the Deputy, of the rules on procurement and governance and that business cases and valuation reports are needed. The letter that was shared yesterday with Purple House Cancer Support in an effort to be helpful provides some useful information on the next steps that need to be taken. For example, the letter specifically states that while Purple House Cancer Support has produced a business case, it has not made a formal submission for capital funding. The business case it has put together contains some of the information required but not all of the required documentation. The letter included an offer that the local HSE estates office would assist with documentation and in completing the process. It also made a number of other important points, including that the HSE would need a valuation report if taxpayers' money is to be spent. The Deputy and I understand that. If that were not the case, serious questions would be asked in the Committee of Public Accounts and other places.

A technical report on the suitability of a building would also be needed. It would be unusual to designate one building because generally, when one is spending taxpayers' money, one would look at a range of properties. I am aware of the property concerned and the reason the group believes it is suitable, and I can see why that is the case. My message to the Deputy and to Purple House Cancer Support is that we should work together on this. I am more than happy to work with Deputy Donnelly. We can make progress but there are rules, processes and procedures that need to be followed. With the greatest of respect, a demand from the Deputy or anybody else issued through the local media is not how to bring about the spending of taxpayers' money. That should be done by investing in good services and taking the very helpful advice provided yesterday by the chief officer of the HSE in the area in question on what would be required.

I have met representatives of Purple House Cancer Support and discussed this issue at length. They feel strongly that they have been misled by the Minister. Rightly or wrongly, that is what they are saying. They believe that promises made in good faith, which they took in good faith, are not being honoured. The Minister and I both appreciate that proper procedures must, and will, be followed. The representatives of Purple House Cancer Support have gone sale agreed on a property and the question they and I ask is when, in the context of right and proper procedure, they can expect to have an answer from the State on whether they can proceed. That is what this comes down to for them.

These are great questions for an Opposition Deputy to ask a Government Deputy in the local constituency. I am sure doing so produces great clips for social media showing the Minister in the position of not being able to confirm certain things. My colleagues from the most senior levels of the HSE who are here today have procedures and processes that they need to follow. My advice to Purple House Cancer Support, both as a constituency Deputy and the Minister for Health, is the same today as it was yesterday, the day before and the day before that. It should follow the process, meet local HSE officials and provide the information that the chief officer of the HSE requires and has requested in a letter. I believe progress could then be made-----

I appreciate that.

-----in the same way that we made progress when Purple House Cancer Support identified a funding need and its funding was increased by €100,000. The Deputy and I both know Purple House Cancer Support well and no one doubts that it provides an excellent service but there is a process that needs to be followed. Let us follow that process together. I will meet the Deputy and we will go through it.

That would be great. I acknowledge that the process needs to be followed. The question that Purple House Cancer Support is asking is how long the process will take. It is a reasonable question to ask and the representatives of Purple House need to know the answer. Does it take a week, a month or six months?

If Deputy Donnelly and I, as constituency Deputies, sit down with the HSE locally, we can make quick progress on this matter. I would be more than happy to meet the Deputy and work this through with him.

I thank the Minister.

I will not, as the Minister for Health attending a meeting of the Joint Committee on Health discussing national health issues, get into the granular detail of the purchase of a single property. That would be wholly inappropriate.

I will move on to St. Joseph's dementia care facility in Shankill, which is a national issue.

It is just outside our constituency.

It is the best and largest dementia care service anywhere in Ireland. The Minister and I both know it is under imminent threat of closure because the funds being provided by the State do not come anywhere close to covering the cost of the service it runs. The National Treatment Purchase Fund, NTPF, has taken a look at the books of the centre and broadly agrees with the cost that it says is required, so it is not looking for anything that is not needed. The HSE has moved on day care, which is welcome, but that only accounts for 7% of the facility's budget. The other 93% is spent on residential care and the negotiations with the NTPF are going nowhere. The Minister has promised categorically, in the Dáil and on the airwaves, that St. Joseph's will stay open.

I want to know what the position is now.

If the board does what the Minister asks in appeal, it will enter next year running a deficit, which directors of an organisation are precluded from doing. My understanding is that a letter issued to the Minister yesterday, which I presume he will receive at some point today, laying out the board's inability to do that. The board will meet tomorrow week, or in eight days, to consider whether it can keep the facility open. If there is no movement, the board may feel it has no choice but to withdraw from the deed of agreement with the NTPF. That would mean that from 1 January there would be no fair deal funding for the fair deal residents in the facility. While St. Joseph's would endeavour to keep the residents there for as long as possible, the reserves of the St. John of God organisation are gone and ultimately the residents would have to leave. The situation is extremely urgent. The Minister has repeatedly promised that what is about to happen should there be no intervention will not happen.

I ask the Minister to consider the following two solutions. A block grant needs to be provided for one to two years, or for an appropriate timeframe, to cover the gap between the NTPF amount, which is approximately €1,350, and the run-rate, which is approximately €1,750. The NTPF fair deal scheme is under review. St. Joseph's, the staff, residents and their families need to be given time in the context of that review. Option one is the provision of a grant from the HSE or the Department of Health that bridges the gap until a new NTPF rate is agreed as part of a new NTPF strategy. Option two, which St. Joseph's is open to, is that the HSE takes over the beds as section 39 beds. The urgency of this matter cannot be overstated given that the board is meeting in eight days. Is either of those two options viable and could movement be achieved in the next eight days?

I thank the Deputy for raising this serious issue and for his active work in this area as well. The Deputy is correct that dementia care is different from standard nursing home care. I have visited St. Joseph's, as I am sure he has. The level of care provided there is exceptional. The needs of the residents are extremely complex. We need more facilities like St. Joseph's, not less. I believe St. Joseph's to be a model of excellence when it comes to the provision of care for people with dementia.

The Deputy rightly acknowledged that the element directly within the control of the HSE was swiftly resolved. I thank the HSE for engaging and providing additional funding and certainty about the day-care centre. I appreciate that an overwhelming 93% of St. Joseph's costs pertain to the residential service, which is funded through the NTPF. The Deputy and I know that I am precluded by law from becoming involved in the negotiations. I call on St. Joseph's, as I have repeatedly done, to exhaust the NTPF appeals process. The NTPF has made known to the HSE and, I think, St. Joseph's, that its appeals process will be expedited. St. Joseph's needs to exhaust that process. If that brings a resolution, we will all be happy. The Deputy's question, as I understand it, is what will be done to keep St. Joseph's open if that process is exhausted swiftly and does not deliver a resolution. My message today is as clear as it was on day one - we will find a mechanism to keep it open. I need everyone to follow the rules in terms of exhausting the NTPF process. That is not to suggest that people are not doing so. No doubt, there are many other nursing homes monitoring this case.

As I informed the Deputy last week in the Dáil, I will use every legal instrument and lever available to me to keep this facility open. That could mean lots of different things. My priority is that the people living in St. Joseph's remain there and that the service continues to be provided. I have made that commitment several times and I am working daily to fulfil it. I will also work with the Deputy in this regard. As he mentioned, the board will meet in eight days so no time should be wasted. He also mentioned that St. Joseph's had written to me. I have heard that from a number of people but to the best of my knowledge, my office has not yet received that letter. I certainly have not had sight of or read it. I presume I will receive it today and I will act swiftly to try to provide helpful guidance to St. Joseph's on how to move forward.

The appeals process which the Minister has asked St. Joseph's to exhaust puts it in a position whereby it is potentially legally compromised. It is a three-month appeals process. The Minister said it can be expedited.

That is great but if it starts trading next year with a known deficit and no letter of comfort or agreement in place, it is in a difficult position. I ask the Minister, his officials or the NTPF - whatever the right group is - to engage with the board in a meaningful way before it meets next week and provide it with some comfort. It might be short-term financial comfort - whatever it is - so that it can at least trade through the appeal process without contravening the laws regarding boards of directors.

My clear understanding is that the NTPF did provide an assurance that the existing agreement could roll over, which would remove any immediate threat to any resident, but I can certainly get this reinforced. The Deputy's point is right-----

Not to the directors though.

However, the Deputy's point about the need to provide people with that assurance and to bring the right people together is correct. Can I also suggest that another group of people needs to be involved, namely, St. John of God? It is quite amazing that we have a conversation so many times about St. Joseph's and somewhat ignore the fact that it is under the patronage of the St. John of God group, which receives more than €100 million of taxpayer funding each and every year. Surely it has the ability to also provide assistance here. St. John of God's relationship with the State needs to be examined in that context. I hope that the St. John of God group, which, I am sure, is following this conversation as well, would see how it could assist as well considering that it receives more than €100 million of taxpayer funding each and every year. I will keep in touch with the Deputy about this.

We must move on.

I am assuming we will get another round if we have time because I have quite a few questions. I will get to them very quickly. I thank the witnesses for attending. I know the issue of mesh implants was mentioned in the Minister's statement. I welcome the constructive engagement we have had and the progress that has been made but I would like to see a date for when the medical cards will be issued and access to the translabial scanner will be officially available. We know that it is coming and the engagement has been extremely constructive but at this stage if the women could get some firm dates it would be very helpful. It might be more appropriate to correspond with me on that. I have no difficulty with that.

The next issue is the departure of Dr. Kevin McCarthy from the children's chronic pain clinic at Our Lady's Children's Hospital, Crumlin and Temple Street Hospital. This issue has been covered fairly extensively in the media but has also been raised directly with me by constituents. Dr. McCarthy does an extremely important job. He provides pain relief to children. I do not know how he does it. I am being told is that there has been no formal communication with parents to date. When I say I am being told this, what I mean is that I am being told by parents whose children are under the care of Dr. McCarthy. I know that the consultant group at Children's Health Ireland has written to senior management. It is asking a number of questions that I want to put here.

The questions relate to an immediate clarification of how Our Lady's Hospital, Crumlin plans to deliver a pain service once Dr. McCarthy has left. There does not seem to be a plan. When I say there has been no formal communication with parents, what I mean is that nobody has sat in a room and told parents how pain management for their children will be dealt with when the consultant departs. I am seeking an assurance that the reason for Dr. McCarthy's departure will be addressed, including the lack of funding. He was very clear and explicit as to why he was leaving. He cited the lack of funding and provision of support services required for the safe running of a multidisciplinary pain management team. Obviously, reassurance is being sought that the families of affected patients will be informed formally. Obviously, these families all know because it has been in the media but they have not received formal notification that the pain consultant will be departing and, more importantly, nobody has told them what the care pathway for their children will be. These are children who suffer really severe pain and if they are under the care of Dr. McCarthy, as the Minister well knows, notwithstanding all the facts, they are children who have been on a waiting list because a person does not get to see a consultant overnight. He or she must wait so these children have waited a long time and are now under the care of a consultant but that consultant is departing and there appears to be no care plan in place.

I thank Deputy O'Reilly for raising this issue. I will ask Mr. Woods to come in in a moment but I want to say a few initial things in this regard. I have also been contacted by many parents in recent days who have told me of the excellent work done by Dr. McCarthy.

I do not believe I have met Dr. McCarthy directly but I have been given extremely positive feedback from parents of children he has seen. I understand that a pain specialist in Children's Health Ireland who operates between Crumlin and Temple Street will leave at the end of the year to take up a post abroad. The Deputy is dead right. It is not acceptable that parents have not been contacted. I have asked about this and have been assured that Children's Health Ireland is now in the process of contacting each of the families who attend the service to update them on the treatment plans for their children. A benefit of having Children's Health Ireland as one structure running our children's hospitals is that they are now working with pain specialists and clinical leads in paediatric anaesthesiology to see how Dr. McCarthy's patients can be appropriately reallocated to continue service. It will also advertise for a replacement post.

I will ask Mr. Woods if he has any further detail to add.

Mr. Liam Woods

I was discussing the matter with Children's Health Ireland yesterday. The multidisciplinary team the Deputy referred to includes provision to go back out for a consultant. That is being prioritised through the consultant recruitment process. There is also a need, probably most immediately, for additional advance nurse practitioners to support patients and families. That is one of our top priorities working with Children's Health Ireland. The wider multidisciplinary team will require physiotherapy, psychology and occupational therapy. Children's Health Ireland has given us a clear expression of what that would require. We will support immediately with advanced nurse practitioners and then recruit a consultant, which we are doing now.

The Minister covered communication with families but I will also follow that up with Children's Health Ireland.

Children's Health Ireland is only now recruiting a consultant. Did Dr. McCarthy not hand in his notice two months ago, in September?

Mr. Liam Woods

Recruitment is already in process.

How far advanced is that process? It takes months to recruit a consultant. Incidentally, I wish the HSE good luck with that project because there are 500 vacancies.

Mr. Liam Woods

The Deputy is right in saying that there is a challenge in recruiting consultants. It is going through the consultant recruitment process in the next couple of weeks. The timescale to recruit a consultant of that specialism could be up to 12 months. Children's Health Ireland and the HSE are very aware of that. The immediate actions which Children's Health Ireland can take relate to the balance of the multidisciplinary team, which can support patients and families. The advanced nurse practitioner is very important in that regard.

Is there an advanced nurse practitioner in post?

Mr. Liam Woods

Yes, and I understand the requirement is for a second one.

There is one in post and the requirement is for a second one. Has that post been advertised?

Mr. Liam Woods

I will confirm the position in writing regarding current staffing and the additional advanced nurse practitioner post because I do not want to mislead.

Has an advertisement been placed for the consultant or the advanced nurse practitioner?

Mr. Liam Woods

The advert for the consultant is not out because it is in the consultant recruitment process but it will go out very shortly.

Mr. Woods knows it will probably take 12 months to recruit this essential front-line consultant. The post has not been advertised despite the fact that the consultant in question handed in his notice in September. It is hard to believe that this matter is being treated with any degree of urgency. That anything has been done may have more to do with media coverage than anything else. That is wholly unacceptable. Children's Health Ireland has known since September. It is in receipt of heavy duty correspondence from consultants who, as Mr. Woods will know, do not often write letters and are often reluctant to get involved in these matters. Nearly three months have elapsed without an advertisement for the vacant post being placed. Parents are probably following this meeting online because some of them contacted me to say they knew it was taking place this morning. This information will not fill them with any confidence. I respectfully suggest that the Minister inject some urgency into this process because it does not appear that much has been done in the past couple of months to address this urgent matter.

In an effort to be helpful, I accept that many of the Deputy's points are fair. She and I, as the Minister, as well as the committee need to have an assurance regarding how Children's Health Ireland now intends to inject that urgency.

I will ask Ms Eilísh Hardiman, the CEO of Children's Health Ireland to formally communicate with this committee in response to Deputy O' Reilly's very direct questions. The Deputy wants to know what is going to happen between now and the recruitment of a new consultant and how quickly that new consultant can be recruited. She also wants to know, crucially, about communication with each of the families on the clinical pathways.

It is my understanding that this committee has helpfully suggested that there should be hearings on mesh in January. In addition to the correspondence I sent to Mesh Survivors Ireland recently, it would be my intention to have clarity on those issues in advance of those hearings.

We look forward to that.

I want to raise the issue of overcrowding and associated risks in the Rotunda Hospital. HIQA conducted a review of the Rotunda Hospital which I will not read out in full because, quite frankly, it shames the people on the other side of this room. The issues raised are very serious. HIQA says that the cot spacing between babies is inadequate. It also says that there is no additional or spare neonatal intensive care unit capacity in other units nationally and therefore the national neonatal intensive care system is in a precarious state as the Rotunda caps its admissions. On the adult high dependency unit, it says that there is a lack of space around the bed to allow for full resuscitation to be instigated and the necessary equipment to be brought into the room. I will not read all of this out for fear some pregnant woman is watching this and ends up terrified. These are issues that have been raised with the Minister and the HSE on more than one occasion. Why has Mr. Reid not met representatives of the Rotunda Hospital yet? Is there a reluctance to meet them? Why did the Minister not attend the meeting with the Rotunda Hospital that was scheduled recently? I understand that officials from his Department attended. A face-to-face meeting has been sought to raise issues that are of very serious concern. The Rotunda serves my constituency. My area is probably the biggest user of the hospital, notwithstanding the fact that the hospital is in the city centre. As Mr. Reid will know, my constituency has the fastest growing population in the State. These are services that are absolutely vital and demand is only growing. I understand that demand is falling nationally but in the constituency that the Rotunda serves it is growing. When will steps be taken to make the Rotunda Hospital a safer place for women, babies and staff?

I have met representatives of the Rotunda and have visited the hospital on numerous occasions. I was in direct contact with the Rotunda as recently as the last couple of days. I was not in a position to attend the meeting to which the Deputy refers. To be clear, we need to do something to help the Rotunda - of that there is no doubt. The plan is to move the Rotunda Hospital to Connolly Hospital in Blanchardstown but that will not happen today or tomorrow. In the interim, things need to happen and I accept that. I also accept that the Rotunda has put forward a plan. I am the Minister for Health in the Department of Health and we work with officials from the Department of Public Expenditure and Reform. We need to see an agreed plan put in place between the hospital, the CEO of the hospital, who is also the Master, and the HSE, which is then presented to Government. That plan must then be assessed against the public spending code and so forth. My understanding is that relatively recently the Rotunda and the HSE arrived at an agreed plan for interim works and my officials were briefed on that plan last week. Now we need to look at moving that through the public spending code.

To be very clear, we need to take action on the Rotunda Hospital. I am not saying that we are waiting for the Rotunda to move to Connolly, as I have read in some reports. The fear of the people working in the Rotunda today is that nothing is going to happen until the big move but that is not the case. We needed to arrive at a point where there is an agreed plan with the HSE. I will ask Mr. Reid to elaborate further on that.

I ask Mr. Reid to address my first question as to why he has not met representatives of the Rotunda yet.

Mr. Paul Reid

On the first question, I am certainly not avoiding meeting people from the Rotunda or anywhere else. In my first six months in this job, I have spent most of my time travelling around the country, visiting acute care settings and meeting the management on site. I have spent less time, to date, in the Dublin hospitals because I wanted to make my presence felt around the country. That said, I have been in the National Maternity Hospital at Holles Street and am very happy to meet management at the Rotunda. I certainly have not been avoiding them.

On the overall issue of capital investment, as the Minister has said there has been engagement with the hospital in an effort to arrive at an agreed plan for such investment on site.

Mr. Woods will be able to comment further on that but certainly there has been engagement with the hospital by our estates team. I am quite happy to meet them and certainly have not been avoiding them. I have met hospital groups, hospital CHOs and chairpersons of boards all across the country. I have probably met more in the last six months than any previous director general.

It is not a competition. As I understand it, a request for a meeting was made and it should be granted. That said, I am happy that Mr. Reid has confirmed that he is not avoiding such a meeting.

Mr. Liam Woods

In response to the Deputy's question, I met the Master in the last couple of weeks. As the Minister said, there has been a meeting and the Rotunda management has made a proposal to address the key risk identified by the Deputy, namely, capacity in the neonatal intensive care unit, as well as some other facilities. We are currently in a process and are engaging this week with the RCSI group, the Rotunda and our colleagues in the Department of Health to move that proposal forward. The risk is clearly identified and is being actioned.

I thank Mr. Woods for that clarification. Again, the issues in the Rotunda are not new but there does not seem to be a massive sense of urgency about addressing them. I welcome the fact that people are now committing to attend meetings that they were always going to attend anyway, apparently.

I have a question about the use of debt collection agencies, which I have raised previously. I abhor the practice of using debt collection agencies to chase people because the people being chased are sick. I wish to bring to the witnesses' attention one example of the practice. An elderly lady who has a medical card needed a hip operation. She could not wait for a public appointment so her family clubbed together, with money they did not really have, to ensure that she could get an operation privately. Following on from that, she developed septicemia and was admitted to hospital. However, because she had previously been a private patient, she was brought into the private wing of the hospital. This elderly lady who had septicemia did not know where she was being brought. She was brought to the private wing in the hospital. She now has a bill for €4,000 and is being chased by a debt collection agency. This is one example and-----

Does the Deputy have the name of the hospital?

Yes, I have the name of the hospital but I do not want to name it because the woman is terrified of being identified-----

She went into a public hospital and ended up on a private ward. Is that correct?

She ended up in the private wing of a public hospital. She went in through accident and emergency and was brought up to the private wing. She now has a debt collection agency chasing her. The woman has a medical card and should not have been brought into the private wing. We spoke about similar scenarios when we were discussing women who went for private tests in the context of CervicalCheck and the Minister confirmed that even if a woman had a private test, she could go back into the public system. This woman, through no fault of her own, was filtered back into the private system and now has an outstanding bill and is being pursued by debt collectors. Nobody in the debt collection agency cares about the fact that the woman has a medical card, or about her means or her capacity to pay. All those in the agency care about is recovering the debt. I believe the use of debt collection agencies should cease because it has no place in the public health service. No compassion is being shown to this woman. When a case goes to a debt collection agency, it is taken out of the public system. A debt collection agency is just a company that is interested in recovering a debt; it does not care how the debt was incurred.

The Minister will respond.

This might be an issue for my HSE colleagues. The Deputy and I both want to remove private practice from public hospitals but my initial sense of this is that one must opt to go private. I do not want to comment on this specific case without knowing the details and those details should be given to the HSE. However, my clear understanding is that if a patient is brought into a public hospital, he or she would have to opt to be a private patient. Maybe "opt" is the wrong word but the patient would have to say that he or she is a private patient. There is no doubt this woman was not a private patient. She would not have the means to be a private patient and did not have private health insurance. I respectfully suggest that my HSE colleagues take the details of the case, although I know the Deputy is making a broader point. The specific case to which she refers sounds very traumatic and perhaps my colleagues can provide some clarity for the Deputy.

On the broader point-----

Deputy Alan Kelly is next.

Sorry Chairman, but Mr. Reid was just about to answer the broader question.

Mr. Paul Reid

On the specific case, I am more than happy to see the details and have the case reviewed. On the wider point, there is very significant pressure across the whole of Government in terms of debt outstanding to the taxpayer and there has been a process in place for a number of years to recover such debt. Obviously the HSE features very significantly because of the level of debt that is outstanding. There has been an ongoing process, led by the Department of Public Expenditure and Reform, across all Departments to improve debt collection and it is only right that we should do so. The agencies that we have engaged are quite professional and are well respected, which is the way it should be. I am very happy to investigate anything that is inappropriate but we have highly respected agencies working with us.

Thank you. I now call Deputy Alan Kelly.

I will raise two issues with the witnesses on this round of questioning. The first issue is overcrowding in the mid-west, which is catastrophic and the second is matters arising from the RCOG report published last week. A total of 190 extra beds have been promised and 83 were announced recently. How many of those beds are for the mid-west and where are they located? The minor injuries unit and the €75 charge is irrelevant.

Mr. Paul Reid

It is not irrelevant.

Let us measure how irrelevant it is in the coming months. People do not go to the accident and emergency department in Limerick or Nenagh-Ennis because of the difference between €100 and €75. It is not the case and I know that because I live there.

Will Mr. Reid visit University Hospital Limerick, UHL, with a delegation of this committee in the coming days?

Mr. Paul Reid

I am quite happy to visit. We can arrange a time that suits.

I appreciate that.

Mr. Paul Reid

Just to say, I have been in UHL and have spent a lot of time with staff there. I spent some time in the accident and emergency department and with local management, staff and union representatives.

Fair enough. Mr. Reid has answered my question and I appreciate that. I also appreciate the fact that we have quarterly committee meetings with the Minister. Unfortunately, this might be the last one but I appreciate-----

We will see. I appreciate that Mr. Reid has agreed to visit UHL because several committee members would like to go the hospital with him in the coming days. I am not interested in dramatics but in solutions. I have written to Mr. Reid about UHL and the mid-west more generally. Deputy Harty is also from the mid-west and knows that what is going on there at the moment is catastrophic. I had to beg for a new CT scanner, which is due to be delivered on Friday, because it was so obviously needed. I have made a comparison between the resources at UHL and at Beaumont Hospital and the disparity is frightening. These are similar hospitals in similar areas. While it is true that apples cannot be compared with apples or oranges with oranges in the context of hospitals, the differential in staff numbers, including doctors, nurses and administrative staff, is huge and makes no sense. The reconfiguration of hospitals in the mid-west was done at the wrong time and without sufficient money. We all know what happened and it is not the fault of anyone in this room but we are now left in a dreadful situation, where people, including members of my own family, are afraid to go into UHL. I do not blame them. The differential across support staff, administrative staff, nurses, medical staff and other health care professionals is huge. I will not even bother going through the figures, which were provided by the HSE. In terms of the number of beds we are looking at 432 versus 659. I know that Professor Keane is currently preparing a report but I do not have any faith in that process because the amount of time spent there was very short. I do not want a report to be published that is about process but not about resources because the two go hand in hand. We cannot solve problems in the mid-west without dealing with the resource issue. People are afraid to address the resource issue.

It is then perceived as blame. I am gone beyond worrying about blame. Of course there are process issues but the resource gaps here are ginormous compared to other hospitals. I put forward a range of interim short-term solutions. I have listed them multiple times on the record of the Dáil and in the committee and they have all been ignored. I am really worried about the narrative being put out and being influenced with regard to UHL from a HSE corporate point of view versus what is real on the ground with the staff and management in the hospital, whom I do not blame because they work as hard as they can.

A report has come out in the past 48 hours by two eminent NHS doctors, Dr. Chris Moulton and Dr. Cliff Mann. It shows that since 2016 of those who have been waiting in an NHS emergency department for between six and 11 hours almost 5,500 have died. If we extrapolate this data what does it mean for us here in Ireland? I ask the Minister what we will do. I ask him not to list all the stuff about the MRI and a few extra beds because I have heard it all before. They will not have the impact. I live there. It is chronically bad. It is catastrophic. People will die in the coming months. What are we going to do? I am begging the Minister. We need solutions. People living near me will potentially die because of this and this is despite the fact that everyone in the hospital is working so hard. Please, this is a last request to the Minister.

I thank Deputy Kelly for raising the matter. I do need to say, because he made the comment about the MRI, that he and colleagues, including Senator Kieran O'Donnell, at a previous committee meeting stated that based on their conversations with staff and management in University Hospital Limerick the hospital needed a second MRI and that if it got that second MRI, and the record of the committee will show this, up to 30 beds a day could be freed up. I do not mean to throw the words of the Deputy back at him but that was the view.

That is slightly high but I get the Minister's point.

Perhaps it was 20, although I thought it was 30. I then had conversations with very senior managers in University Hospital Limerick who confirmed the same to me. We have now delivered this.

I was asking for it for six months.

I accept that but it has been delivered. As the Deputy said, it will be in on Friday and it will start taking images on 19 December. I want to see a correlation. I was told if this investment was made we would see say 20 beds a day freed up as a result. The Deputy may not fully agree with this but anything he has asked me to do in a tangible sense in Limerick we are doing.

No, the Minister is not. I will give him an example.

Let me finish.

The pathway for St. John's, Ennis and Nenagh-----

I will talk about St. John's for a second. I want to say one thing about processing. The Deputy might not agree with me but I have to say it. The Deputy asked about the 83 beds. There is funding for 190 extra beds. We have asked every hospital in the country to put up their hands and state how many more beds they can open if we fund them. They are still coming in and 83 have come in. Of that 83, 15 are in St John's and they will open next week.

Yes, I know but-----

That is fine. The Deputy just asked me the question as to how many of the 83 and it is 15 and they will open next week. If there are more in Ennis and Nenagh we need to hear them.

There are tonnes of them but the Minister has to change the pathways to do that.

Let those proposals be put forward but they have not been.

I have put them forward.

I do not mean this rudely but not put forward by the Deputy but by the management of the hospital.

The management cannot put forward proposals if it does not have the resources to man the beds in the first place. It is impossible. The Minister is asking management to put forward proposals when it does not have the resources. It is impossible.

The reality is that there is a situation and we can accept it or not. There are serious issues with regard to capacity in University Hospital Limerick and I am not getting away from it. There are serious issues. That is why we are building the 60-bed unit.

That is the 60 beds that Senator Kieran O'Donnell promised on radio with me would be in place by this year.

It is being delivered by us. We are delivering it.

I will play it back.

We are delivering it.

Deputy Kelly is playing politics.

I am not playing politics.

In fairness, I do not think-----

-----with something that is hugely important.

I am very passionate about this.

If the Senator wants to have a conversation he can have it outside.

I do not think we are going to play politics with this.

It is a very serious issue and we all know this. There is an issue because we need more of our doctors from University Hospital Limerick going to the smaller hospitals.

As Deputy Kelly has said several times, he lives there. It is not happening. Surgeons are going to St. John's in Limerick but other doctors are not. They are not doing it. We can put more services and see more patients in smaller hospitals, including those in Deputy Kelly's constituency that he knows very well, but we need some of our senior doctors to leave University Hospital Limerick, get into their cars and visit the smaller hospitals. I really mean this. I know it and I can stand over it.

Why is it not happening?

Exactly. That is a question for management in University Hospital Limerick and the HSE-----

No, it is a question for Mr. Reid, to be fair.

Mr. Reid will comment on it in a moment. Deputy Kelly is asking what can we do now. We have increased home care and we will increase it more. We will increase transitional care more. There is a proposal from Limerick on a new community frail intervention therapy, FIT, team and two extra physiotherapists and occupational therapists. I expect to be able to approve that funding in the coming days. We will open the 15 beds in St. John's next week. The MRI will arrive on Friday. The 60-bed block is under way. I am genuinely trying to work with everyone to come up with ideas.

There is a process that would help in the short term and I do believe this.

Can I just say-----

Mr. Reid wants to make a comment.

Fair enough, work away.

Mr. Paul Reid

We had a conversation and the Deputy corresponded with me previously. Quite rightly, he raised the issue of the CT scanner. Following a conversation with the committee we progressed and his feedback was welcome. Following the previous committee meeting, we arranged a meeting for the hospital group CEO, the national director and the chief operations officer of the HSE to meet all of the Oireachtas Members interested in the hospital group. I understand it was a very productive meeting and the hospital group CEO set out the various aspects of what the group is doing.

She was not there, actually, it was her assistant, and there was a health debate on at the same time in the Dáil.

Mr. Paul Reid

I appreciate that. The Deputy asked me what developments have been taken on board and I will list a few. The new Nenagh ophthalmology centre has been opened to relieve capacity in the group. There has been an increase in robotic surgery, and the perinatal mental health service has improved. There have been developments in community midwifery, the early transfer home service, the clinical and recovery support unit in Nenagh, the vascular hybrid theatre in University Hospital Limerick and a new medical assessment unit in Nenagh. Extra graduate nurses, nurses, clinician and professional resources have been put into University Hospital Limerick and other hospitals in the group, and Mr. Woods can speak more about this. As the Minister has just said, there are other short-term developments on track, including the 60-bed unit.

Mr. Paul Reid

Just let me finish please. There is the acute fracture unit, the MRI, the new Ennis outpatient department, Ennis theatres, the expansion of the neonatal unit and phase 2 in Nenagh hospital. They are significant investments.

I know every single one of them. Some of them have been going on so long that I have been involved in them myself and I have been supporting them, advocating for them and getting resources for them for a considerable amount of time. However, let us just reflect on what Mr. Reid and the Minister have said. I accept some of the new positive changes. I put them forward in proposals myself. That is not the issue. The issue is whether these actions will deal with the accident and emergency beds crisis and the staff crisis we face in the mid-west over the coming months. I need to know whether these actions will work. The answer to the question given by the Minister and Mr. Reid was to list of all of the actions, some of them dating back years. If this is the best they can put forward, we will know in the coming weeks and months whether they will work.

We did not dream them up. They were not our actions. These were not Mr. Reid and myself-----

That is passing the buck to management.

No, it is not, it is actually accountability. The Deputy holds me politically accountable. He comes in here and rightly says that I must provide this and if I do not he gives me a very hard time. These are suggestions that came from the hospital when it said that if we gave it a second MRI it would free up a certain number of beds a day. We cannot agree on the number but let us say 20. The hospital said that if we opened more beds in St John's it would help alleviate the pressure. I do not want to use up Deputy Kelly's time, and I am not in a rush, but there is a reality with regard to the statistics at University Hospital Limerick that I want to put on the record of the committee. The total emergency department attendances in Limerick from January to October, as I do not have the figures for November yet, were down on last year. There were 638 fewer people.

People are refusing to go there.

The total emergency department attendances by people aged over the age of 75 is down by 110 this year on last year. Total emergency department admissions are down by 2,320 this year compared with last year. Total emergency department admissions by people aged over 75 are down by 907.

This hospital is seeing more beds, through St. John's, a second MRI, the 60-bed modular under way, extra nurses and fewer people going to it, so there is a process piece. It is not blame at all. I must say, and I know that the Deputy is also passionate about some consultant work practices, that there does need to be change.

I have no problem with that.

There is more private capacity and private practice going on in the Deputy's regional hospital than the average hospital.

I agree, and there should not.

While people, including that 95 year old woman, are waiting downstairs in the emergency department, which is a disgrace -----

----- private practice is going on in the hospital and there is more of that in the Deputy' hospital, if I may call it that, than elsewhere.

I agree, and why is that allowed to happen?

I am not managing the hospital.

Mr. Reid is managing the hospital.

Mr. Reid is managing the whole health service.

The Minister should wait a second. He has just outlined something I completely agree with. In fact, ideologically, the Minister has moved in my direction.

I am coming the Deputy's way.

Exactly. I have always publicly supported the Minister for that.

Let us get this coalition going.

One has to laugh at some stage.

The Deputy should conclude his contribution.

The Minister should listen to what he has just said. Why is this happening? He is in charge of the HSE. The HSE is around us here but this practice is happening. Why is it allowed to happen? The Minister quotes statistics, like the volume of beds. No one wants to do a comparison with Beaumont. No one wants to do a comparison with diagnostics, beds, resources, human resources. Why is that? I had to go and do it myself and dig out all the Department's own data. It is shocking by comparison. When I hear the Taoiseach in the Dáil citing Beaumont, not as best practice but good practice, it galls me when I think of all the people who are trying their best with so few resources in Limerick. The answers to the Minister's questions are around him in this room. If it is down to management, then management at the highest level has to be held accountable as to why we have a discriminatory situation in respect of resources for the mid-west as opposed to other areas of the country. What is going to happen over the coming weeks and month? I do not want this to happen. I have had very close family members in that hospital recently. What is going to happen? There will be judgment on what the Minister and Mr. Reid have just said in the coming months.

I think Mr. Woods wishes to respond.

Mr. Liam Woods

I acknowledge the Deputy's point that it is difficult to compare resources because one is looking at apples and pears sometimes. As Beaumont is a national neurosurgical centre and a national transplant centre for nephrology, there are differences.

I accept that.

Mr. Liam Woods

That does not negate the point, to be fair, that to compare normal emergency department flow is very valid. When we look at our own activity-based funding data, and I am happy to share this, the cost per case in those environments does not vary a whole lot. Some work has been done to look at the level of resource, and activity-based funding does this, associated with each case. That has been helpful in examining the relative efficiency across the system. I will not speak on that much now but there has been much work done on this which I would be happy to share to help move further on that.

I ask that Mr. Woods please do so.

Mr. Liam Woods

On capacity, the analysis in the Sláintecare report and subsequent commitments around that are critical to resolving challenges in Limerick. I am in Limerick myself and I am conscious that the staff can feel they get a lot of critique. It is important to acknowledge that excellent work is done.

I could not agree more.

Mr. Liam Woods

The ophthalmology practice in Nenagh is now leading at a national level and drawing in work from the county -----

That is not the issue, though.

Mr. Liam Woods

----- which is very good.

The issue is the emergency department, lads.

Mr. Liam Woods

The Deputy asked about solutions relating to the elderly. The investments around that will be very important. The work in Ennis will be critical and the work in the community intervention team, CIT, across the road from the hospital is also hugely supportive of frail elderly management. Part of that is reflected in a reduced admission rate for those over 75 years, which is a very positive outcome that we need to grow. From speaking to our geriatricians, we know we can maintain more people in the community. The primary care investment of up to 1,000 staff, which is indicated has a key part to play. It can play a key role on those hospital sites, which could support Dooradoyle. Limerick is looking at a further 92-bed expansion at further remove, but that is a larger-scale building project.

I thank Mr. Woods. I apologise that I did not welcome the Minister of State, Deputy Catherine Byrne. I thank her for her attendance. I now call Senator Colm Burke.

I thank the Minister and the chief executive for their submissions. I will focus on one or two issues. I have raised the issue of cataract operations in Cork over the past six or eight weeks.

The Minister will be aware there is a huge problem regarding cataract operations being done in Cork. Last year, the South Infirmary Victoria University Hospital sent out more than 600 cases to the NTPF. I have made a submission to the Minister, which I understand has also gone to the HSE, that were an extra theatre put in place in the South Infirmary Victoria University Hospital, ten or 12 cataract operations could be done a day, five days a week. There are five consultants in that area in that hospital but they each have only one day per week in theatre. As a result, they are dealing with very serious eye complaints and, therefore, cataract operations are pushed to the back and are not being dealt with. I am advised that were there a second theatre dealing with this, the problem would be resolved and that it would pay for itself within a year and a half to two years. The cost is €3 million. Can I get a detailed reply to that submission? Many people are travelling outside of Cork, some to Northern Ireland, and it is the direct result of the facility not being there to do the operation.

The second question relates to the growth in the population of Cork. Much work has been done around new hospitals in Dublin and we are talking about three elective hospitals around the country. They are vital for the areas for which they are designated. What progress has been made in respect of Cork or when we can progress the process? Even if we identified a site this morning, it would take at least two years to go through the design and planning process and being realistic, it would be three years before reaching the stage of putting in foundations. It needs to be prioritised in Cork. A huge amount of work is going out of Cork at present because it lacks the capacity to deal with all the work that is there. There is a population of more than 550,000, which will grow dramatically in the next three to four years, when one considers the development of new offices and all the companies expanding in Cork. There will be an automatic growth in population, as well as catering for the work out of Limerick, Tipperary, Waterford, and Kerry.

I thank the Senator for raising these matters. On his proposal to use the South Infirmary for cataract operations, as an example I refer to the investment we made through the NTPF working with the HSE in Nenagh hospital, where the hospital group came forward with a proposal to say that it had underutilised theatres and with an investment of about €1 million, from memory, that it could open a centre of excellence for cataract procedures. That has dramatically reduced waiting times and waiting lists for cataract procedures. My opening statement noted the significant fall we had seen in the waiting times for ophthalmology. The Senator has sent his proposal to myself and the HSE. I suggest that the HSE and NTPF, working together, could consider that in the context of 2020. I do not know enough about the individual projects but to be clear, we are very eager, and it is Government policy, to use the NTPF resource, which is now up at €100 million, to increase capacity in the public health service, where possible, rather than using the private health service. It is necessary to use the private health service from time to time but where possible, the public health service should be used. We certainly will look at it through that prism. I will also ask Dr. Henry to comment.

On the population of Cork, which the Senator consistently and robustly raises, he is correct about the population of Cork having grown so much and that the bed stock and health service needs to grow to fit the population. I have received initial proposals and feedback from the South-South West hospital group on its views on an elective hospital for Cork. Under the Sláintecare implementation office, we established an expert group to look at what an elective hospital is, without being smart about it. Different countries do different things, so it is asking what is provided in an elective hospital and what is not provided.

There are different models around the world. We expect to be in a position at the start of 2020, which is only weeks away, although it sounds ages away, to move forward on site selection. Dr. Henry might wish to add to my points on both issues.

Dr. Colm Henry

First, in regard to eyes, it is not just a question of additional theatre capacity because it is a matter of how we use existing theatres. Treatment for macular degeneration sometimes constitutes an inappropriate use of a theatre. A treatment room could equally effectively and safely provide the same treatment. The consultant ophthalmologist community in Cork has raised this. There have been successful endeavours in Nenagh and the Royal Victoria Eye and Ear Hospital whereby we commissioned additional work in theatres through the NTPF, addressing something that lends itself readily to such initiatives, namely, day-case cataract work.

With regard to scheduled care, as the Minister said, the most important point is to get the design right and consider the scope of what a scheduled care hospital would look like. Let me give two examples. In the Golden Jubilee National Hospital, Scotland, there is a large scheduled care hospital that runs a range of services, right up to services that require intensive care, overnight stays and quite intensive, complicated surgery. Another example is Omagh hospital in the North. It is a scheduled care hospital that does not have inpatient beds at all. There are day hospital beds. The design is crucial because it has to address waiting list needs as they stand and as they are projected, and our population needs. There has to be a model of care that is sustainable, particularly in view of the recruitment and manpower required. The work the Minister said is ongoing will come to a conclusion soon. Once the scope of scheduled care centres is decided, it will inform the design, location and so on of the schedule care hospitals.

There are five cataract consultants. It is probably the highest number in any hospital outside Dublin. They are technically being under-utilised in regard to eye surgery and cataracts. There is a practical proposal, costing €3 million, that would pay for itself in one and a half to two years because fewer people would be referred to the NTPF. It is cost neutral. It is a detailed proposal from the clinical director in South Infirmary Victoria University Hospital. I ask that it be considered seriously.

On the second issue concerning the hospital in Cork, growth in Dublin is continuing but growth in Cork will escalate at a fast pace over the next ten years. We need to deal with this hospital issue immediately. There are now 130,000 additional people living in Cork without one extra hospital bed open in the period. That is a lot of people. There is also a change in demographics. I ask that the hospital be given priority.

Dr. Colm Henry

On the first question, I agree the great proposal for the consultants in Cork needs to be considered seriously in the context of the waiting list and the hospital's ability to tackle waiting lists. As I said with regard to scheduled care hospitals, the design has to be right. That informs the model and size of the hospital, and so on.

Let me move on to a totally different issue, namely consultants. The number of consultants has increased from approximately 2,100 to more than 3,100 since 2009. Can we get current figures? Various figures are being bandied about and we have do not have accurate figures. How many consultants are in permanent pensionable posts, how many are locums and how many are working in an agency capacity? Can we have a breakdown of those numbers? It is important to know the numbers. There is a great deal of information in circulation and it is very hard to understand who has the real figures. I am looking for clarification. I fully accept that more posts have been created but we have not got clarification on the number in situ who are permanent and pensionable.

The second issue I wish to raise regarding consultants, which I have raised previously, is the lack of planning for consultant retirement.

With regard to colposcopy and obstetrics and gynaecology, there is quite a large number due to retire over the next three to four years. What amount of planning is occurring? I am sure the retirements are happening in other areas also. Planning does not appear to be occurring. Posts seem to be advertised once a person is retired and, therefore, locums have to be brought in to fill them.

I received telephone calls from three different hospitals about people who are advised to meet Mr. Reid but who do not raise any concerns about any issues in their hospital because they want to give a good impression of what is happening there. Staff are actually being advised not to raise concerns. Is the feedback staff have about very genuine concerns not being fed back directly to Dr. Henry? I have heard staff from three different hospitals raise this issue. The only ones who seem to be raising genuine concerns are staff who are about to retire and who feel they are not going to lose out by doing so. There has to be a different approach to ensuring the HSE is getting a true account of the difficulties staff are facing in particular hospitals. The matter needs to be approached in a different way. I have heard reports on this matter from three hospitals in different parts of the country. I am raising this because I believe it is true and accurate.

Mr. Paul Reid

I will take the second point first and then address consultant numbers and the recruitment process.

On the second point, I do not know what the Senator's examples are so I cannot comment specifically on them. I can say the following, however: in the six months I have been here, I have been around most of the settings, everywhere from Letterkenny and the west and south-east coasts to the Dublin locations and the midlands. I have been to hospital, acute, community, social care and section 38 settings. In those visits, I do not spend my time just with management. I have a brief 35-minute meeting with management and I spend at least four hours walking around talking to staff. I generally spend my lunch with a group of staff who decide they want to sit beside me. I get regular and frequent feedback on the issues from staff. This has been very valuable for me. It is the way I operate. It is a management style I have and it has informed me greatly about some of the challenges we face in tackling some of the pressures in the health system. I have been very open with staff and I have been very engaged. From the feedback I have got, I believe staff feel there is now a chance to raise the real issues they are experiencing. I have spent a significant amount of my time on staff engagement. I spend at least a day and a half per fortnight out in the settings. That is how I operate. The feedback indicates very informally the real issues that arise in the various settings, not just the acute settings but also the community settings. The Minister was touching on process earlier but the feedback is informing me about a number of issues, the first being how those at the HSE centre really need to consider what they are doing and make sure it is adding value for staff at the front line in services and social care. As I said my opening statement, that is a process I have commenced already. We are going to examine what we do in the centre and ask whether it adds value for front-line staff. If not, we will stop it. I have very firmly flipped my focus onto our front-line service delivery teams to determine the issues that arise for them and how we need to address them.

In our staff satisfaction survey, which was published just last December, there were some very real issues arising over control culture. People were feeling very motivated in their own jobs but not connected to middle and senior management. They did not feel they were able to raise issues. That is something I am very conscious of and that I want to change. That is why I am spending my time in the acute setting. I reassure the Senator that I am very happy to tackle or examine any specific issues the Senator has. My personal style is a leadership style. I have been in the private sector, the not-for-profit sector, central government, local government and now the HSE. I can only demonstrate by what I do. I have outlined what I do.

The second issue, that of consultant posts, is a very genuine one. We are all aware it is not just an Irish issue but that it is also a global one.

We are making progress, but it is slow. We want to recruit more consultants. We have more capacity to recruit more consultants and more funding in our plan next year to do so. We are seeing the beginning of a more positive trend this year. As I mentioned, year on year we have 142 extra consultants and 135 since January. The net figure, because we are losing some, is an increase of 90 consultants this year, which is the start of a trend.

Deputy O'Reilly mentioned the time lag. It is too long. We are running some pilot projects on doing that more locally and that is probably a better way to progress quickly, but we will work with the Public Appointments Service, PAS, in that regard. We have some numbers by speciality across the country, that is, the number of consultants we have by country, by speciality and by hospital. We will be happy to provide those to the committee.

Can we get details of the number of locums and agency consultants as well?

Mr. Paul Reid

Yes. We have locum consultants and-----

We can get a true picture of the situation.

Mr. Paul Reid

We can give a full breakdown table.

Send those to the committee, Mr. Reid. Thank you. Does the Minister wish to respond before we move on?

I believe Mr. Reid has dealt with the questions.

Senator Colm Burke will have another opportunity to contribute. I call Deputy Durkan.

I wish to make a few comments. First, we must acknowledge the success of using the National Treatment Purchase Fund to cut waiting lists for various procedures, as there has been a considerable drop in the number of people on them. For example, in the case of inpatient or day case procedures the number fell by 20,000 up to November 2019. That is a major achievement. There are still two tranches of 20,000 each to go to bring the figure down to zero, which should be our aim. Do we have the commitment and procedures in place to continue on that line and to reduce the waiting lists to the necessary and desirable extent? It is no use to say it is at a tolerable level now. We must continue with it down to the wire, as it were.

My second question arises from Deputy O'Reilly's comments on the replacement of consultants. If a consultant is due to retire, presumably notice is given by the consultant in advance. Why not adopt a procedure whereby whatever reappointment procedures are required are put in place instantly? I realise there is an argument that sometimes they are not approved or they could be on a list waiting for approval, but why not appoint them temporarily? We must get away from the nonsense of this weighted procedure that is so laborious. There are procurement procedures that must be complied with, but there should be no gaps in the provision of service. It must be a seamless provision. There can be no gaps in the entitlement of the public to have a continuous health service. That should be borne in mind.

The Minister will be aware that we occasionally come across glitches, as occurred in our local hospital. I am loathe to be parochial but everybody else does it. Even you, Chairman, have been known to do it from time to time. There is a rise in political testosterone, on both sides, during the approach to general elections and one must make allowances for that, but that should not distract us from the issue of making a simple intervention that can be very cost effective. The Minister has seen the issues in our hospital. Some of them are ongoing and some are periodic. I am aware that provision is being made at present, but I wish to raise two matters. First, we need to know whether there are vacant spaces in our hospitals, particularly where patients are in corridors and awaiting treatment and where ambulances are waiting outside the hospital to deliver their patients and cannot do so for obvious reasons. We must carry out an audit of the spaces that are available or that can be converted as a matter of urgency. It is not rocket science. It is very simple.

We must also examine the cost. In most cases the question to ask is: "Why are all the waiting spaces, the emergency department and the corridors full?" We must find out what is causing the problem. Is it because there are no doctors or an insufficient number of doctors available? Is it because an insufficient number of beds are available or insufficient space where beds or trolleys can be put? Incidentally, there is no reason that a trolley cannot be put in a ward while awaiting transition instead of having patients in the front row at the entrance to the hospital, which is bad for hospital morale and bad and dangerous for patients. It is bad for the morale of the staff and that is dangerous because there will eventually be stress, which causes other problems, and health and safety issues. Could an urgent audit be carried out to ascertain the amount of spaces that can be supervised and in which beds or trolleys can be placed, rather than having them in corridors where patients, visitors and staff have to bump into each other? I have seen cases where blood samples are being taken, people are being fed, patients are being visited, people are getting seriously ill and so forth in those circumstances. It is absolutely unacceptable that this should be happening. There is no reason for it to happen if there is covered space in the grounds. If not, it is quite simple to get temporary accommodation that would meet that requirement. It is not expensive. We must look at the things we can do quickly to make it safer, better and more comfortable for patients.

On the issue of child mental health, we have all encountered situations where there are acute cases of autism and behavioural problems. The patients are in obvious difficulty and their parents are at their wits' end trying to find something that meets their requirements. I believe it is possible to provide an adequate service. It is necessary to do so. One of the things that is urgently required is a number of mental health programmes in-house where the child can be put on a programme that is corrective and has the required amount of supervision over a specified period of time, which is readily recognised. Could that be done as a matter of urgency? The mental health sector has always been regarded as the Cinderella, but at some stage we need to recognise that there is a growing problem in that area. There is no necessity for it. Two parents called to see me last weekend. They are desperate to find a way to solve the problem for their child. The child has a profound disability and sudden, unexpected behavioural breakdowns. In those circumstances, we should provide the service that is necessary. It is not massively costly. It is simple, but we must provide the programme.

I have come to the last issue.

Does the Deputy want to get answers?

Of course, I do. I will be glad to get those answers for a start.

I will let him back in again.

Mr. Paul Reid

Regarding the audit of available space and better use of space, all the hospitals are looking relentlessly at every available space they have and any capital funding that can free up emergency flows and so forth. They bring forward some very good proposals and have been funded. In most of the emergency departments I have visited we are seeing good, innovative ways to improve patient flows in acute settings. One of the challenges is to scale up those initiatives and have a level of consistency across all emergency departments.

To reassure the Deputy I will give a few examples of what is happening across the acute settings. There is a very good innovative process with streaming. Patients who come from GP referrals with adequate information can be referred through the ED and onwards. That is happening very well in a number of areas.

Somebody mentioned ANPs, advanced nursing practitioners earlier. The use of ANPs in our emergency departments, EDs, and indeed clinicians and advanced medical assessment units are very successfully moving on patients with specific needs much more quickly. Triage processes, which can differ in many EDs, have been very successful. Emergency clinicians in EDs prove very beneficial and help patient flows so that we do not have the congestion that has been seen. Much of our patient advocacy services specifically in terms of some mental health issues that the Deputy just spoke about on our EDs are working very well for us.

A number of initiatives are taking place. Our challenge is definitely to use space, on which I am sure we have a very accurate picture across the way, but more importantly to scale up some of those good initiatives which are happening around the place. What I am seeing is very innovative and something we can scale up and roll out as part of the solution.

Ms Anne O'Connor

As part of our improvement programme for our acute hospitals, members of our special delivery unit audit those hospitals. The issues that arise in EDs are often symptomatic of challenges across the entire site. It is important for us to look at the totality of the beds. They go into a hospital on a given day and audit everybody in a bed to see who is in the bed and whether they should be there or if they should be somewhere else. That work goes on all the time. They have been focusing on our most challenged sites recently to ensure the best use is made of all the available beds. I assure members of the committee that that improvement work is constantly ongoing.

I might say a word about mental health and children. We currently have 71 community teams and we have beds. Interestingly, we hear much about people awaiting mental health beds. At any one time at the moment we might only have one or two people on a waiting list for an acute mental health bed. Our challenge relates more to the different needs of different groups of children. Deputy Durkan mentioned autism. Where we have children with different types of needs, they are not necessarily appropriate for acute mental health beds. We are developing an approach focused on in-home intensive support and in-home intensive respite. That will come with a range of behavioural supports so that children can stay at home and be fully supported with behavioural and other supports. That will be growing again in 2020. We are trying to differentiate between children who have different needs and to ensure we are providing the right supports in the right place for them.

Earlier I said 83 beds of the 190 have been approved. Running a live tracker here, I now believe it is 107 beds because 25 for Tallaght have now also been approved. Therefore 107 of the additional 190 we hope to open have now been approved. If we stay for the day we might get that figure up even further. It is 107 and we can keep the committee updated as the numbers come in.

I thank the Deputy for his initiatives. We had a very good visit to Naas General Hospital last Thursday night. We saw a very hard-working management team and staff in a very busy environment. Thankfully, that hospital has had a slight decrease in trolley numbers this year, on which the staff are to be commended. There has been a decrease in attendances at the ED this year, but a significant increase in attendances of people over the age of 75. When we were in that ED last week I was struck by the age profile. Further to Ms O'Connor's point, it raises the broader discussion about the profile of the people ending up in EDs and whether more can be done to help them not end up in them, through doing more in our nursing homes, through more of the statutory home care scheme and through enhanced primary care teams. That is the message I took away from our visit to Naas General Hospital last week.

The endoscopy unit needs to go to tender in early 2020, which is the intention. That will greatly increase the capacity for scopes. The very dedicated clinicians there have long been promised this. They were about to get it and then the economy crashed. That is badly needed. I was excited to hear that that would give rise to the possibility of building two extra wards which would also provide more capacity.

The Deputy asked how we can get that waiting list to zero. He very kindly and fairly noted the progress we have made in reducing the number of people waiting for hospital operations. If we are very honest, we must acknowledge the number will never be zero, as the Deputy knows, because people will always be joining the list. It is much more important to focus on how long they are waiting. Many people who go to see a doctor today and are referred for an operation would not necessarily want the operation immediately.

The Sláintecare committee proposed that people should not wait longer than 12 weeks. When I became Minister, about 32% of people in 2017 were having their hospital operation in 12 weeks or less and that is now up to 42%. The right question for us all to ask is how we can get that 42% up to 100%.

We have discussed at length some of the ways we can do that.

Ms O'Connor may wish to add to what was said about CAMHS. Thankfully through the investment we have made in the new assistant psychology posts and the 20 psychology posts in primary care, we have 114 assistant psychologists now working in primary care - certainly funded posts - and we have 20 psychology posts in primary care since last year. We have seen a 20% reduction in the number of people waiting for child and adolescent mental health services. If it is the Deputy's child or mine, we need them in straightaway. Those lists are reducing and we need to build on that further.

One of the reasons for that reduction is that we are widening the range of services we are providing. Not everybody needs to go through the CAMHS. For some people an assistant psychologist might work. On the other end of the spectrum, we will open the Portrane hospital next year. We need to look at the entire range of mental health services available and not channel everybody through one route. We need to broaden the capacity through a variety of ways.

Ms Anne O'Connor

We are also working closely with schools to try to support children in the environments they should be in. Some of our CAMHS teams reach into schools far more. As the Minister said, it is about trying to meet children's needs where they are best met rather than in specialist mental health services all the time.

Deputy Durkan may ask one more question.

The Chairman will be glad to know I am about to conclude. I do not intend to go on for as long as everybody tends to go on, but I will go on a little while-----


That is a relative term.

-----represent my constituents at least as well as other people tend to do.

I do not believe that all the people with severe child mental health issues come to me. I have four on my list and I am dealing with them daily. I am not dealing with them very satisfactorily because they are frustrated. In the past couple of weeks one of the four got on to a programme which was necessary. In one case the child severely injured themselves and was referred to an emergency department. They had to wait all day in the ED from 8 a.m. until night and had to come in the following morning again. This is where we need to marry up the services. It should have been possible for somebody somehow, somewhere to identify the child as an urgent case. The child, who had suffered a really serious injury, should have been taken out of the queue and put somewhere else to be dealt with. I am asking for a close examination of CAMHSs with a view to addressing the issues that arise regularly. Some of them are life-threatening and can cause danger to the child and other family members, and danger to staff as time goes on.

We should find out from all hospitals where there is overcrowding in EDs if any wards are closed or if any spaces are available in the hospital that can be utilised as wards and opened as a means of allowing a smooth throughput of patients.

I thank the Deputy.

I am nearly finished; my last question is coming up. I insist on having parity will all my peers, which can be difficult from time to time.

The Chairman might not remember I was a member of the first ministerial drugs task force a long time ago. We seem to have drifted away from the original purpose of the exercise. At that time methadone was a means to an end. Now it seems to be an end in itself which is not what the task force at the time was interested in. Do we have a focus on the way that we should deal with the drugs issue and drug abuse with a view to providing the means whereby the patient can come off drugs?

They should be enabled to get onto programmes that will get them off drugs and offer them an incentive for doing so, both for the betterment of their own health and that of their families and the community in general.

There are ways of doing that. Methadone has been in our communities for many years, providing help for people with addiction problems to live their lives. Many people have been on methadone for some time and want to stay on it. Sometimes it is difficult to change people's attitude to moving from one service to another. Methadone helps them to achieve their daily tasks. Another drug, Suboxone, can be used instead of methadone but it is not for everybody because people with other medical issues cannot take it.

To answer the question on what are we doing about the drug services in our communities, we have the national strategy of Reducing Harm, Supporting Recovery. We work on the ground with the HSE, statutory agencies and other bodies to bring people with addiction problems through recovery and support and, above all, deal with their families. The stigma of addiction is still alive and well in our communities and we are trying to tackle that and create a health-led approach to the national drugs strategy. It is about reducing the harm and helping people who have been on methadone for a long time to have a different focus in their lives.

Methadone will continue to be very much a part of the service that is provided for people who are in addiction but services will also be provided by level 1 and level 2 GPs. Considerable work is being done with people in programmes on a daily basis, trying to facilitate them to go forward and live normal lives. I meet and speak with many people who are on methadone and it is like a long-term illness for them because they need a certain amount of methadone to continue to function. Level 1 and level 2 GPs and pharmacists are doing their best to help people with their doses and the prescription of methadone will continue for some time. It is not the be-all and end-all of drug treatment but it is a means by which people can be looked after on maintenance programmes. That is what is happening.

That is why it is so important that the national drugs strategy is seen as a health-led document, rather than a criminal justice document, and people who have specific illnesses relating to their addiction to alcohol and drugs are guided through the services in their communities. The HSE and some of the primary care service centres across the country provide methadone clinics and needle exchange clinics. People are visiting these centres on a daily basis. They are not separated, they go in the same door as other patients and participate in the healthcare system. One of the biggest problems is the stigma relating to addiction and to the families of addicts. People who are trapped in addiction experience that stigma every day, particularly when they are living in communities where their families can also be targeted.

I will come back in again shortly.

Of course.

Mr. Paul Reid

I will comment on CAMHS. Ms O'Connor gave some data about HSE initiatives. In 2017, a task force was established by the Government, of which I was a co-chair with the Minister of State with responsibility for mental health and older people, Deputy Jim Daly, and we produced the end report. That set out a range of actions in respect of CAMHS initiatives that were to be put in place and those actions still hold true. Many of them have been done but more need to be invested in. One of those actions that was launched recently was a helpline to support young adults at points of distress in their lives. The National Forensic Mental Health Service, based in Portrane, is also coming on stream. It will have a state-of-the-art, dedicated CAMHS unit with dedicated beds. The facility is due for completion before the end of the year. I have been in the hospital and it is a fantastic facility that will be commissioned next year.

A number of committee members have raised an issue about the general pressure on our emergency departments. It has been raised in the context of UHL, Naas hospital and more generally. My assessment of the past six months suggests the following, much of which is Sláintecare related. When considering the pressure points on our emergency departments, we are going to have to stand back and look at what we are going to do differently because if we keep investing in the same way we have been, we will continue to get the same results.

I could not agree more.

Mr. Paul Reid

I will give a few components of the solution as I see it. Both the Minister and the Deputy have spoken about what they have seen in emergency departments. My experience of visiting nearly all the 24-7 emergency departments around the country is that a significant cohort of patients should be treated in a different way and in a different setting. A significant proportion of people who attend emergency departments are members of our aged population. These people have chronic illnesses and multiple illnesses. This is not a criticism because people are not attending emergency departments when they should not be. We must create new routes for their treatment. We need more GPs. I have met people from the training college to discuss the matter and it is positive that it looks as if more GPs are coming on stream. We need to invest in that and that is a part of our Sláintecare solution. Pharmacies can play a much better role in the context of treatment and care in the future. The contract for pharmacists will be negotiated next year and that will give us an opportunity to look at what levels of care can take place in a pharmacy setting. The first thing we need to do is to reduce the entry points into acute settings.

I listed a number of good, innovative triage processes, including advanced medical assessment units, having emergency department consultants in the emergency department all the time and having GPs in the emergency department. There is really good innovation and the challenge is to scale that up across the country. It is an issue of capacity in hospitals and the Minister has outlined some relief that will be part of the solution. We also need more egress points, as the Minister touched on, which means more community and step-down beds and more investment in nursing home support schemes, which we will have in 2020 when we launch the service plan.

We would be misleading the public if we were to say that we will make matters better in a few weeks or months by doing this or that. We have a key performance indicator in respect of trolleys. I have worked in capacity and workflow management all my career and we have what is called a lag indicator which looks at the measure at the end of a congestion point. We must develop a way of looking at our setting that looks at the whole workflow management process. That is about entry points and how to reduce pressure on them at capacity, how in-house flow can be improved and the need for more settings for patients who are egressing. This will not be solved in weeks or months and I did not convince anybody that it would be solved in that timescale when I took this job. This is a relentless process in which we must invest for the coming years through Sláintecare. We must stick to the plan. That is the longer-term solution and that is when we will be doing justice to the public.

I do not agree entirely, but I will come back in again later.

Would the Minister like to comment?

I will comment briefly on the issue of drug addiction. I want to reinforce the point the Minister of State, Deputy Byrne, made about stigma. I spent approximately two hours at a private meeting of families impacted by addiction last night. It is a weekly addiction family support meeting in Dublin which I was kindly allowed to attend. The issue of stigma came up over and over again and the fact that we always talk about the addict but not the impacts that addiction has on family members. One person has an addiction and the ripple effect means that it affects nine to a dozen others. The Minister of State and I will look at how we can put in place better supports for the families of people with addiction in the coming weeks.

There is another element of stigma that I heard about at the meeting last night and at a number of recent meetings. We are trying to open a supervised injection facility in the centre of Dublin because there is so much evidence that it works but, sadly, some politicians from across the political spectrum are objecting to that and engaging in NIMBYism. This process was started by the then Minister of State with responsibility for the national drugs strategy, Senator Aodhán Ó Ríordáin, and has been championed by the Minister of State, but, sadly, others are delivering literature, tweeting and adding to the stigma for the sake of trying to get a few cheap votes locally. I echo the calls that have been made to end the stigma. Shame on those politicians who are involved in NIMBYism. They should come along to the briefings at this committee, meet people with addiction and their families, know what they are talking about and should know better.

We will now bring in Deputy Murphy O'Mahony and I will then offer a break if people wish to take one. We have been here for two and a half hours. Committee members and our guests can consider that.

I am more than happy to take a break but I have an engagement at 1 p.m., however the Chairman wishes to factor that in.

The Minister will need a break after me.

We will all need a break after Deputy Murphy O'Mahony.

I welcome the announcement this morning of the provision of 190 additional beds. Will the Minister explain how this figure was arrived at? How were the locations arrived at?

That is a great question. We are all trying to find extra capacity to deal with the immediate problems. We know we need to do better in terms of building more hospital capacity and more community capacity in the coming months and years. Basically, it is a call out to the system, and I echo that call again today. If a hospital manager or a hospital group manager believes that he or she can open capacity, that there is a space in the hospital, that staff can be recruited or that there is a smaller hospital or community down the road where capacity can be opened quickly, then I want to hear it. I am not interested in people promising to open capacity next July. If a manager believes that he or she can open up capacity quickly, then the NTPF is working with the HSE to provide the funding. From talking to the NTPF and the HSE, we estimate that the figure will be approximately 190 beds. A total of 107 have now been approved. Applications are still coming in. When the Deputy goes back to her constituency and to Bantry, she will see that the invitation is there for everyone to apply quickly. In fairness, Deputy Murphy O'Mahony is not only raising the issue at this stage - she raises it all the time. People have been asked to apply by the end of this week or certainly in the coming days.

Will the Minister outline his thoughts on the free family planning programme? The committee discussed that matter previously. Several ladies have come to me lately who are interested in getting the Mirena coil but it is too expensive. It is probably good value for money in that there are five years of contraception from it and it controls heavy periods, etc. Depending on which doctor they go to, women have to pay between €250 and €300. That is expensive for many people. It is not fair that if a woman is badly off she cannot afford contraception.

I agree with the Deputy 100%, with the caveat that it has to be a matter of choice - I know the Deputy would agree with that too. We asked our group in the Department to bring together all the different units involved in this area in terms of eligibility and the likes as well as health and health policy. We published the report. My officials and others, including representatives of the Irish Family Planning Association, came before the committee in recent weeks. The clear direction of travel here has to be free contraception for every woman in Ireland. The question for those of us around this table - it is a genuinely bipartisan question - is how we phase it and ensure that there is choice. My view of the world is that in 2020 we should begin the legislative process with the group most in need. My reading of the report and my engagement with the Irish Family Planning Association and others suggests that this group is made up of younger woman and women in traditionally vulnerable groups.

People mentioned elections. I genuinely believe that before we go into the general election every party in the House should try to agree on a cross-party basis, as we have done on other contentious issues, that, whoever wins the election, we have a direction of travel. We should agree that between year X and year Y we are going to travel the journey to free contraception. It requires legislation. We can give out free condoms. We are already doing that. We have expanded the national condom distribution service this year and vending machines are going in across colleges. There is a legislative requirement for contraception when going to the doctor and the pharmacy. We should legislate for the availability of free contraception on a phased basis by the end of 2020 or the start of 2021, but we need to agree the roadmap to get to full coverage.

Paediatricians made a statement this morning about the unsuitability of direct provision and the impact on children's lives. I presume the Minister heard the report on "Morning Ireland". They are convinced the children will suffer as adults if they grow up in a direct provision centre, given the way they are being run now. Will the Minister outline his thoughts on that matter?

I did not hear the report but I am not surprised to hear that view. Let us consider what direct provision and emergency accommodation for people coming to our country are about. This is about people coming from what can be a highly traumatic environment and fleeing oppression to another country. We can all imagine the trauma of that. We can only begin to imagine the trauma of that for a child. It is fair to say all of us are grappling with finding the right solutions from a housing and accommodation point of view. I note Mr. Justice McMahon's documents proposing significant reform to direct provision.

We are committed to making those improvements. We have to take, and we are taking, a whole-of-government approach to this. The job of dealing with immigration, refugees and direct provision does not fall solely to the Department of Justice and Equality. We had a Cabinet committee meeting on this earlier this week. My Department is putting in health supports as well. That is important.

We have a major issue that we have to nip in the bud. It relates to the creeping racism in our political debates around this. I am not going to get into specific examples but I believe we all need to call it out. Whoever is in government will face this challenge. The Department of Justice and Equality is doing an excellent job on behalf of Irish citizens in responding to Ireland's international obligations to take in, support and give céad míle fáilte to people fleeing oppression. That means all our communities providing support. It means all of us providing enough resources and supports for those communities. My Department will not be found wanting in that regard.

Is direct provision the ideal model? Absolutely not, but the Deputy and I need to be able to answer the question of what is the ideal model. In the midst of a housing shortage we need to be realistic. We need to make our direct provision far better. We need to implement the recommendations of the McMahon report and that is what we are doing. My Department and the HSE need to put in place the wraparound services and that is what we are doing.

I have spoken to the Minister previously about the GP contract. As the Minister is aware, in Bandon we had few or no applications for two positions. Throughout west Cork there are pockets or areas that have no SouthDoc cover at night-time due to the low number of GPs available. What is happening with the contract? I know the Minister understands the importance of a new contract. The other contract is too old to be working under. GPs do not want to work as GPs any more. It is serious.

There are three parts to this. The Chairman raised the matter with me in the Dáil last week. The first part is to acknowledge that we need to train far more GPs. I am pleased to see that the number of GPs entering training is increasing. That is not a political statement. The Irish College of General Practitioners and others are welcoming this. We are now training more GPs than ever and that is good news.

The second part is how the hell we ensure they remain as GPs and how we keep them in Ireland. The GP contract is an important part of that. A doctor can now become a GP in an era that will be post FEMPI, one in which doctors will be better resourced and supported not only financially but in terms of paternity leave, maternity leave, increased rural allowance and a fund for areas of urban deprivation if a doctor is working there.

The third point is the immediate issue. What I have just said is good and important but the third point is the immediate issue. There are areas today that need a GP tomorrow. I commend what the HSE is doing in this regard, which is trying to be flexible in terms of how we can do practical things to incentivise a GP to stay in an area. This may include things like trying to find premises for the GP, integrating the practice into a primary care centre or trying to assist with ancillary staffing. These are things that make it a little more likely that a GP will agree to go into a given area. I know the HSE is working on several areas throughout the country. I think there is locum cover or GP cover in all of them. Certainly, that is what I understood from my latest briefing note, but people want a permanent GP.

That is a sticking plaster.

People have an intimate relationship with the GP, and it is an important one.

Next is my usual question seeking an update on Bantry General Hospital, the endoscopy unit and the rehabilitation unit. Are we on plan and on target?

To the very best of my knowledge, my colleague, the Minister of State with responsibility for Bantry and mental health and older people-----

He is not here, but I note Deputy Murphy O'Mahony and the Minister of State are getting on far better these days since his announcement.

There is love in the air now.

The Deputy does not mind me saying these things - there is less sting in it. I will get the Deputy a written update on this, but to the best of my knowledge they are on track.

Another thing under the portfolio of the Minister of State at the Department of Health, Deputy Daly, is the home help situation. We speak about it here a great deal. I have one particular case involving a 71 year old lady with a terminal illness. She has been approved for only five hours per week since October but it is not up and running. If the Minister does not mind, I will send him the details. Obviously, given that she has a terminal illness, this is very important.

The measure on below-cost alcohol selling that was brought in last year or legislated for is still not up and running. I heard on the radio again - we would be lost only for it - that the Minister is in favour of it.

Yet, some of the Government partners may not be.

I must have missed that radio programme as well.

It is all on the news.

I am passionately in favour of it, as is the Deputy.

We passed this landmark legislation. A hell of a lot of people put a large number of obstacles in our way. Vested interests with deep pockets attempted to stop us passing the Public Health (Alcohol) Act 2018. I acknowledge that we passed it together with civic society and public health advocates. I thank people for their co-operation. We have enacted a number of parts of the Act, including that relating to advertising restrictions. Since last month, one cannot advertise alcohol on any public transport or in any public transport station. It is kind of amazing that this has happened so quietly.

Alcohol cannot be advertised on children's clothing. Alcohol advertising in cinemas is severely restricted. Alcohol cannot be advertised near schools, crèches or playgrounds. It is good that some of the measures have come in.

I want to bring in minimum unit pricing. I will explain why I do not buy into the baloney which suggests that we cannot bring it in until Northern Ireland does so. Scotland did it without waiting for England. It is about to be done in Wales, but the authorities in England are not about to do it. I remind the Deputy that we are talking about a certain type of alcohol. We are not talking about high-cost alcohol. That is the whole idea. I do not believe 16 or 17 year old lads, some of whom cannot drive or should not be allowed to drive, will get into their cars and drive for 90 minutes to buy a few cans of Dutch Gold. That is not the way the world works. We should move ahead with minimum unit pricing. It is up to me to make a call on when to bring in the memo. It makes sense to wait for a degree of certainty in respect of Britain and the Brexit date. There is a great deal of uncertainty in that regard. We might have a degree of certainty very shortly.

It might get a push tomorrow.

I would like to move on this very early in the new year.

I would like to put my final question to the Minister of State, Deputy Finian McGrath. I spoke to him a while ago about the lack of residential places in west Cork. Many elderly parents of adults with special needs in the area are afraid of getting sick or getting old. This is breaking them down. They are afraid that they will be too shook to be able to look after their children or that they will pass away. They need certainty about the availability of places. I ask the Minister of State to address this.

In recent months, we have been negotiating with the HSE and the Department of Public Expenditure and Reform on the 2020 HSE service plan. The issue of residential places has been one of my top five priorities during those negotiations. We need to deal with many issues, including day services and personal assistance hours. The bottom line is that we have a cohort of elderly parents whose adult children with intellectual disabilities are in need of residential places. We have not yet finalised the service plan. The need for new residential places for people in critical need is a major issue for me. I accept the Deputy's point that we need to focus on these issues. We are going to exceed €2 billion in the 2020 HSE service plan. We need to ensure that we have priorities in the context of that €2 billion. Elderly parents of adults with intellectual disabilities are very worried about the future. They have a right to residential places for their children. I am determined to facilitate that. I would say we will know more about this in the next week or so.

The Minister of State might come back to me on it.

I will come back to the Deputy with the details. It will probably be next week.

I want to acknowledge their pain and worry.

Yes, absolutely.

I thank the Minister of State.

I am going to offer Deputies and Senators and the witnesses who are in attendance an opportunity to take a break for ten minutes. I suggest that we should come back at 11.45 a.m. Is that okay?

I am happy to work through the break. I have to leave at 1 p.m. When we come back, we should have enough time for members to ask any remaining questions.

Is the Minister happy to take a break?

I am happy to take a break.

We will return in ten minutes.

Sitting suspended at 11.34 a.m. and resumed at 11.52 a.m.

The figures in the Minister's opening statement on the reduction of the number of patients on inpatient waiting lists, which are compiled by the NTPF, are very welcome. They show a fall from 86,000 to 66,000, approximately, over two years. Will the Minister give us a breakdown of how those figures were achieved? Are they people who died on waiting lists, who sought treatment outside the jurisdiction through the cross-border directive, who went to private services to receive their treatment or who received treatment through our own health service? Is it possible that the raw figures from the National Treatment Purchase Fund can be provided to the committee so that we can see how that reduction was achieved?

I may have to ask the NTPF to compile it but we will write to the committee with that information.

I have sought the same information at a number of previous committee meetings but unfortunately it never came.

It was not from me, or if the Chairman has sought it from me, I apologise.

The Minister might redouble his efforts in providing that information, if he could.

We will certainly ask for that. It should be easy to provide the information because the benefit of the NTPF is that one can track the patient through his or her entire journey. It is not money that goes into an overall budget but is individually allocated to a patient. I assure the Chairman that there is a direct correlation between the significant increase in funding for reducing waiting lists and the reduction of waiting lists.

I left out a category where people are provided with a service through the National Treatment Purchase Fund through either the public or private system. Will the Minister give us a breakdown of that?

I will also send the committee information on "do not attends". I do not have a specific figure but we see an average of 450,000 to 500,000 people missing hospital appointments each year. There has to be something behind that and we are digging for information about that. It is much higher in some areas than others. Some areas send out text reminders and some do not. The entire number of patients waiting for an outpatient appointment is some 500,000, and 500,000 people are missing appointments, so we need to look at what is happening with the "do not attend" figures.

People are getting follow-up appointments for operations that have not even happened.

We have had several meetings about workforce planning. An issue that was raised was the creation of panels for appointments.

There is a problem in respect of those panels. I understand that those panels will be concluded next year and that a new panel system will be drawn up. On that issue, I am aware of a speech and language therapist in a hospital who has been approved to move to a different hospital but cannot because the recruitment process for the position she holds is frozen, not funded, not approved or whatever is the term. There is an issue in respect of panels and, in particular, the geography associated with panels. One may be a specialist in the south of Ireland and when a vacancy arises one is offered a position in the north of the country, which is not practical for one to take up. There seems to be a problem in respect of the constituent parts of panels and the way people are offered jobs from those panels. The Minister might clarify that when replying.

Deputy Margaret Murphy-O'Mahony raised the issue of GP vacancies. The particular problem that arises when somebody retires is the way that post is filled. I want to make a practical suggestion to the Minister. The panel system for interviewing GPs is out of date. The marking system might be out of date also because when somebody retires, it is important to have local information on the way that GP panel is filled. Having the retired GP who has just vacated the position as part of that panel is important because he or she may well have been head-hunting for somebody to come onto that list before he or she retires and would have a good deal of local knowledge about who would be the most appropriate person to take on the list. It is often the case that a list is drawn up, the system of offering it to the first, second or third person is gone through and by the time the person who wants the job or could take it is reached, he or she has moved on. The marking system is disconnected from the practical availability of GPs on the ground because the longer a panel is unfilled, the less chance we have of getting somebody from that existing panel. The input of the retiring GP or much more local input in the interview process would speed up the filling of that position.

The MRI scanner in University Hospital Limerick, UHL, is long overdue but very welcome. I am disappointed that it will operate only from 9 a.m. to 5 p.m., Monday to Friday. The MRI scanner is essential to reducing the number of people waiting for admission to the hospital and confining its use from Monday to Friday does not make the best use of it. It should operate for longer hours during the week but it also should function at weekends to clear the backlog of MRI scans, not only for patients in casualty but also patients on waiting lists. Consultants in the mid-west are now advising public patients to get their scans done privately because they will not get them done publicly in a timely manner. It is important that the Minister should consider the opening hours for that scanner.

Mr. Reid referred earlier to theatres in Ennis hospital. It is essential that the theatres in the hospital be upgraded. Two new modular theatres are required to allow inpatient day-care procedures to be carried out. That would take a lot of pressure off UL and allow ear, nose and throat surgery in particular, about which we have spoken previously, to be developed in Ennis hospital in the way ophthalmology services have been developed in Nenagh. It would be critical infrastructure to put in place to solve the problems all of us have mentioned earlier in respect of UHL. The Minister might comment on using our model 2 hospitals to the maximum advantage.

Mr. Reid also mentioned hospital avoidance. It is critical that we expand our community intervention team, CIT, services to allow frail elderly people remain in their homes. CIT services are essential for that. There is an axis between CIT GPs and public health nurses.

If they do not exist within the community, people will end up in accident and emergency services unnecessarily when they could be managed at home.

We mentioned previously that it is essential to expand community diagnostics. That is one of the pillars of the winter plan for the mid-west but I am not aware how GPs or others access those community diagnostics because information is not available on that.

On the timeline for scheduled care hospitals, site selection will happen next year. In terms of the process, it will then have to go to design, procurement, tendering, building and commissioning. What is the timeline for an elective hospital to take in patients? Is the children's hospital consuming funds that should be going to all of those other services? The Minister might give us a timeline for that in respect of elective hospitals.

My last question relates to ophthalmology services in the mid-west. The waiting time from seeing the consultant to having surgery is reduced but the waiting time for an initial visit, even though one may have a diagnosis of a cataract from an optician, needs to be removed. One presents with the diagnosis. A diagnosis process is not necessary but getting to that first visit is still taking two to three years in the mid-west. I accept the time may be shorter after one has been seen but the time between being referred and being seen is still two to three years. That is my first tranche of questions for the Minister.

I thank the Chairman. I will ask my colleagues to come in on some of the questions because they are more appropriate to them, particularly the point the Chairman made on panels.

On GP vacancies, I agree with the Chairman. We need to listen to him on that in terms of his professional experience but also his knowledge in terms of what is happening on the ground in rural parts of Ireland. We may or may not agree on this but I am clear as to what we need to do about increasing the pipeline of new GPs and trying to keep them in Ireland. I accept that we need to do more in terms of the contract but as I said earlier, there is an immediacy now in some communities. We are already seeing on an ad hoc basis communities stepping up after the crisis emerges, meeting with the HSE and asking how this can be fixed. We are seeing good examples of some of the collaboration taking place. I saw it in Kerry recently where the community and the HSE locally are working together but only after the vacancy arises. One of the points the Chairman is making is that there should be greater community involvement at a much earlier stage. We know that, say, Dr. X is due to retire so we should start that process earlier.

The Chairman's comment on the marking scheme is fair. There might be an issue in terms of a GP choosing their successor, which is not what he is suggesting, but we need to get the balance right. I ask that the HSE witnesses would reflect on what the Chairman has said and revert to him on it. As an issue arises, I believe the HSE is doing a very good job of engaging with the community but can we plan better further out?

Ms Anne O'Connor

In terms of medical recruitment and the medical workforce in general, we have established a medical workforce oversight group that both myself and Dr. Henry co-chair to examine how we currently recruit and retain our doctors. A core part of that is GPs because we are very conscious of the need to future-proof in terms of Sláintecare, community health networks and our process around engaging with the Irish College of General Practitioners and all of that. GPs are key in that in terms of our approach so we can certainly look at the points the Chairman raised in respect of the interviewing and the replacement process.

I might pick up on a couple of other points. The MRI scanner in University Hospital Limerick is opening 9 a.m. to 5 p.m. to begin with. However, the contract with the provider has the capacity to extend that. If the demand requires longer hours, we can certainly introduce those.

I agree with the Chairman on the expansion of CIT services. We are looking at CIT services. We will be looking at increasing the CIT capacity and the community frailty intervention team in the community in the mid-west. We want to focus our efforts on making sure that we have CITs, that they are integrated into the broader primary care service delivery and linked with acute hospitals also. That is very much part of our plan, and the mid-west is part of our plan for 2020.

On some of the other issues, the opening hours of the MRI scanner are a matter for local hospital management but as the Chairman referenced, there is a point about looking at the two scanners in the totality.

On the issue of the elective hospitals, the realistic timeframe is about four years.

We can look at how we can tighten that - perhaps through standard designs and the like for the three - but we are not yet at that stage. I have never suggested that these are things that can be done today or tomorrow. They are very much a key part of Sláintecare, which is a ten-year plan. I hope that they will be delivered during the first half of the implementation of Sláintecare. We would have a much better outlook regarding what they will constitute - sites and the like - by the first quarter of next year.

The Chairman's point about inpatient day cases versus outpatients is valid. It is one we have discussed quite regularly and one that the NTPF, the HSE and the Department are eager to move on in 2020. Patients do not differentiate between the outpatient and the inpatient nor should they. If I have a problem with my eye, I need to see a consultant. When I see the consultant, I might need a cataract operation or whatever. That is the wait, that is the total time. The question is whether we can put in place a system that takes someone through the entire process and whether the NTPF can help fund that whole journey, taking somebody through the outpatient clinic to having the procedure done and out the other end. The way we differentiate between outpatients and inpatients is not the way real life works for people.

There are very exciting proposals, with which the Chairman will be familiar, regarding community ophthalmology and a view that a lot more can be done in that context. In the context of that specialty and half a dozen others to which I referred in my opening statement, we can press "go" on a few in 2020. That would make a significant difference.

I am not sure whether Ms O'Connor answered the question about community diagnostics in the mid-west and whether GPs know how to access community diagnostics under the winter plan.

Ms Anne O'Connor

The honest answer is that I am not sure. In terms of the work we are doing with the mid-west, the head of primary care there is very engaged with us in terms of the roll-out. That is where we have the CIT and the FIT proposals coming through.

In terms of how GPs access community diagnostics, I would have to check what the mechanism for communicating that is. I am sure there is some mechanism that has been thought through but I do not know the answer to it.

We will write to the committee.

Ms Anne O'Connor

We will come back to it.

Will the Minister and his officials contact the committee? What about modular theatres for Ennis?

That is a matter for the HSE.

Mr. Paul Reid

I am looking at the update given on 14 November. I cannot confirm the actual date. I am not sure whether Mr. Woods has it.

Mr. Liam Woods

No, I do not. It was a point raised by the Chairman in the meeting with the Deputies from the mid-west. We undertook to take it away and discuss it with University Limerick hospital group, so I will come back to the Chairman on the matter.

I understand that a business case has been made.

Mr. Liam Woods

I do not have an update here so I will come back to the Chairman with one if that is helpful.

My questions have been answered to the best of our guests' ability.

I was in contact with the Minister of State, Deputy Finian McGrath, recently about an issue involving Western Care and the allocation of spaces for adults with special needs. Deputy Murphy O'Mahony and the Chairman also raised this issue with the Minister of State, who indicated that he is focusing on it. I wish to highlight the case of families where a child or adult with particular needs relating to Down's syndrome or another condition has been under the care of their parents and the parents have become old and infirm or have passed away. I feel particularly strongly about this because when the parents pass away, the vulnerable individual really has nobody to stand up for him or her, apart from Members of this House or other public representatives. There is a particular case in Mayo involving a young man in his early 30s. Both his parents are deceased. My understanding is that Western Care gets a budget allocation and is to provide services in the community. In this case, it is not delivering the service because the individual is not getting residential care and no budget is available for him. The net impact is that this young man does not have a stable environment. People like him want to be under the care of Western Care and live out the rest of their lives in a stable environment. While I know this is a priority for the Minister of State, can he give me any indication as to when a space for this gentleman, about whom I have been tormenting the Minister of State since last June, will become available? I want the gentleman to whom I refer to remain anonymous.

I am aware of this case.

The important thing to say is that emergency residential places constitute a very important issue in the debate on the service plan. As I said earlier, there will be a significant increase in resources over the €2 billion figure regarding the HSE service plan. I want to personalise this in one way because I agree with Deputy O'Connell that the important thing is to focus on the families and the person with a disability. In 2020, we plan to have 8,358 residential places. We have 33,700 day respite sessions, 166,00 respite overnights and 23,000 day places so these are the kind of plans that are in place. One goes back to the core question. Every year, we have a number of people in those situations. I am pushing very strongly for the extra money and resources. I have been talking to the Minister - even over the past few days. The Minister gets it. He is very supportive of me. Do we need more residential places for people in critical need who have no family? That is the phrase I am using. The answer is "Yes". I hope to see some of those new residential places come into play in the next couple of weeks. That is my view at the moment but I do accept that when we are having a debate about budgets and the service plan, when one digs deep, one must pick out priorities. I accept the Deputy's point about those adults with disabilities whose parents are dead. Under the UN convention, these people have a right to a service so we must push that. I am confident that there will be major improvements in the service plan for 2020.

It was reported that about 10% of GPs have taken up the termination of pregnancy service. A couple of GPs have contacted me regarding an anomaly within the system. The example I have been given is a girl in west Dublin with a full medical card who had to travel to another part of Dublin to get a GP to carry out her termination of pregnancy. There is an anomaly within the PCRS. Any GP providing the service can claim the fees for the termination of pregnancy but that same GP, who is not the person's regular GP, cannot prescribe Implanon or another long-acting reversible form of contraception. It seems like a missed opportunity when the individual looking for the termination of pregnancy is eligible under the medical card system. This is not about getting extra eligibility. It is about someone who is already deemed eligible for medical card services being able to avail of services such as the insertion of Implanon by the GP who carries out the termination of pregnancy in the short period of time - either on the day or a short period of time thereafter. My understanding is that it is just a matter of the PCRS allowing within the portal for the GP performing the termination to claim as opposed to the default GP with whom the girl is registered in her own area. Am I making any sense?

I thank the Deputy for raising this issue. It does indeed sound illogical because, obviously, we want to provide all the care to the woman there. Mr. Reid and I will have a look at that, see if that can be fixed and revert to the Deputy and the committee.

The Minister of State, Deputy Catherine Byrne, is not here. Regarding methadone, I am delighted to hear that the Minister met with the families of people involved in the methadone scheme or who have had their lives ravaged by addiction. I am very supportive of the Minister visiting the families. For many people, particularly in these Houses, it is fine to talk about people in the abstract, be they in a methadone programme or direct provision centre or any sort of centre, as if they are a different type or sort of person but, as I am sure the Minister saw last night, these are normal people from normal families who walk among us and have just been hit in some unfortunate way and touched by the ravages of drug addiction. I very much welcome the Minister's visit last night. Methadone treatment is almost regarded as being negative. There is a perception that if somebody is on 10 ml of methadone for the rest of his or her life, that is somehow a bad thing.

To my mind, it is a good thing. If they need a maintenance dose to keep the show on the road and keep their lives in line, it is good to have that relationship with their prescribing doctor and their pharmacist to keep them on the straight and narrow. I very much welcome this and any additional supports that can be given to families. I welcome any measures that highlight what they have to deal with in their lives, the impacts on other children in the family and the extended family, and also people's positions in their neighbourhoods and communities. Stigma has been mentioned this morning. Families who have been ravaged by drugs often face strong push-back in their communities. I welcome any moves to support those families.

As was reported yesterday, in recent times there has been a significant increase in the incidence of mumps in our population. In Samoa, we have also seen a shutdown with the outbreak of measles. All of this is part of the global dumbing down when it comes to vaccination, fake news, the Wakefield generation coming of age and such. The net impact of the mumps outbreak is that we are going to have a generation of young men who will have fertility problems when they seek to start families. Is there any plan to try to highlight this? I have always thought that the young people who are affected are probably the key. If a young man discovers that his parents chose not to vaccinate him against mumps when he was a child, and now his future in terms of having children is going to be severely impacted, is there any plan to wake that generation up to the impacts of previous decisions on their healthcare? In terms of measles, the Minister said some time ago that he was exploring mandatory vaccinations and was seeking the position of the Attorney General. While I do not agree with mandatory vaccination in a normal setting, it is now high time we addressed this. We have the situation in Samoa. The UK has lost its measles-free status, as far as I know. This issue is encroaching on us and perhaps we should be prepared, if there is a confluence of events that leads to an outbreak here, to protect the population if we had to. I would be grateful if the Minister could give us his thoughts on that.

I thank the Deputy for her comments. After my meeting last night, I am just so conscious of how grateful families impacted by addiction are that she and others raise these issues and that we talk about them here. They feel they are never talked about. We do not talk about addiction enough in Ireland but we talk even less about the impact of addiction on the family. The Deputy is right that the reason we do not do so is that there is a nice, cosy consensus and an ignorant view that this only happens to X type of person or in Y type of place. That is complete and utter bull. The phrase I kept thinking of last night is "There but for the grace of God go I." This could visit any of our homes or communities. Frankly, it is visiting all of our communities. A woman told me last night how the first time someone she knew became aware that her son was addicted to drugs was when she was sitting down watching Coronation Street. There was a knock on the door and she asked her husband to get up and open it and there were two men in balaclavas with baseball bats standing at their hall door looking to recover a drugs debt. This is a reality for people and we have to start talking about it. It is a real health crisis, a public health epidemic. There is a lot of that same ignorant stigma that we have around other social issues and the notion that it only happens to certain types of people. That is nonsense and we need to call time on it. In this committee or in a future configuration, we should be doing more on this. I intend to do a lot more on it. The UK has a helpline for families affected by addiction. I want to explore how we can look at this as well. We need to do a lot more.

On the issue of mumps, measles and mandatory vaccination, the Deputy is passionate about the whole area of vaccination. The current status in terms of my own thought process and policy development is that I am awaiting a report from the Health Research Board, HRB. I asked it to do a body of work on what could be effective. I am not interested in a stunt or something that looks like we are doing something. I want to do something. I have asked the HRB to look at what other jurisdictions have done that has proven effective in terms of combating vaccine hesitancy. I am expecting that report any day now and by the end of the year. I will read it alongside the advice of the Attorney General and come forward with policy proposals.

My view is that there may be issues with the Constitution in the context of education and schools. People have a constitutional right to a primary education. How a constitutional right interacts with a particular issue may present a challenge. If, however, we are really serious about vaccination, we know that it happens prior to primary school. It actually happens when children are in crèches and other childcare facilities.

I make a plea to Early Childhood Ireland and others regarding the fact that there is nothing stopping crèches and childcare providers from making it a requirement for parents to show that their children have been vaccinated in order for them to be accepted by those facilities. This has become the norm in terms of how we deal with our family pets. It is quite astonishing that it is not the norm when it comes to dealing with children. If I were to send my child to a crèche, I would like to know that not only have I done right by her in terms of getting her vaccinated but that she is going into an environment where she cannot pick up other illness because other people have failed in their duties to protect public health. All of us should be calling on crèches and childcare providers to make this part of good practice and guidelines from today. I do not think there is any reason that this should not happen.

In terms of the Deputy's question regarding an effective campaign, I have heard her talk about how we can have an effective campaign for the generation that were not vaccinated - the Wakefield generation, as the Deputy refers to them. She is dead right. It is a really important campaign that we could run in colleges, etc. The Vaccine Alliance is looking at what is effective in terms of public awareness campaigns. I will certainly feed that back to it. The final point I want to make on vaccinations is that I had meetings with the social media companies recently. Social media has been a really great tool but would Brexit have happened, would Donald Trump have been elected, and would the uptake rate relating to the HPV vaccine have dropped so significantly if we did not have social media? Who knows. We certainly know that the spread of disinformation and misinformation on social media has contributed significantly to a decrease in vaccination rates, particularly around the HPV vaccine but also in respect of other vaccines. At the meetings, I was encouraged somewhat that they were doing some things and that they are certainly realising, even from a business model point of view, that their users expect them to do more. I am still a little concerned with Google wanting to keep as its "secret sauce" information relating to how one becomes the number one hit on a Google search. When I search the word "vaccination" on Google, I do not think it is acceptable that I get anything other than a reputable source of information at the top of the results list. We have agreed to keep in touch and work with Google. It has agreed to come in and speak to the Vaccine Alliance. A lot more work definitely needs to be done in that area.

Mr. Breslin, Mr. Reid and a few others were present at last week's meeting of the Committee of Public Accounts. The purpose of the meeting was to discuss primary care centres. I do not want to land the issue on them this morning but, in the context of Sláintecare, it is fundamental that we move things out of acute settings and into the primary care setting. There were 341 primary care centres planned from 2008 onwards. The matter was reviewed in 2012. It emerged at the meeting of the Committee of Public Accounts last week that no one has reviewed position of the centres in light of Sláintecare in order to see if they are fit for purpose in terms of what we want to deliver. There is no definition of what constitutes a primary care centre or a primary care team. While I am not completely hung up on that, if we are going to move towards treating defined populations, then, in the context of the connection between acute care and community care, it is imperative that the system that was embarked upon in 2008 is modified and made fit for purpose. If we are going to add diagnostic centres, we have to ensure that capacity exists among the 341 that are planned. Obviously, we cannot have 341 diagnostic centres but capacity must be there - dotted around the country - and it must be possible to add things so that we are not going to have to buy sites next to centres or whatever. When we are doing Sláintecare, it is about ensuring that we are not already tying a stone to our leg while we are doing it. We should be able to do it with the plans that are already there. We can modify them as we go. I was a bit concerned last week that it was almost as though the primary care thing was put on a shelf and left there and was operating separately from Sláintecare when it is integral to its success.

Mr. Paul Reid

I thank the Deputy. I do not disagree with her sentiment or direction of travel in terms of the role of primary care centres and Sláintecare-proofing them. As we were outlining just last week, of the 340 we have 127 in place, another 77 are in progress and 30 are committed to in our capital plan. What we want to do now is exactly as the Deputy outlined.

We are now looking forward to a new way of treatment and care to which there are various elements, as I touched on earlier. The first element is GPs, the second is pharmacies, and the third is the primary care centres, both in terms of entry points and egress points. In my visits to many such centres around the country, I have seen various levels of capability and resourcing. Centres that have a GP on-site, such as the one I visited last week in Waterford, are very successful. Young children and those seeking paediatric services come in to them as well, which takes huge pressure off the acute settings. The centres are very successful when they have the skills and resources in place. There are other that are fine centres but which do not have the skills, resources, and diagnostics needed to equip them. As we look forward to Sláintecare and talk about new pathways, I am very committed that the investment in the next 77 centres and the infrastructure of the current 127 must be Sláintecare-proofed. In terms of the existing centres, the first element is the €10 million investment committed to in our service plan, as part of the budget, which will rise to €60 million. That will give us the capacity for 1,000 extra staff resources on the community side, of which a significant proportion must be in our primary care centres.

There are five non-members here, who I will group in the interests of time. I will take Senator Kieran O'Donnell and Deputy Brassil together, followed by Senators Byrne and Conway-Walsh and Deputy Bríd Smith. I suggest that they ask two questions each, rather than making statements.

I thank the Chairman for facilitating me. I have two quick questions. I welcome the fact that the HSE is providing funding for 15 beds to be opened at St. John's hospital in Limerick. However, I have learned from my own inquiries made on Monday that those 15 beds have not been in use for the last three months. At the same time, there is continuous and severe overcrowding at University Hospital Limerick. By all means, we should push for the new MRI scanner there, because it would be fantastic. Why were those 15 beds not put into use three months ago, when there is such a big crisis in Limerick on a continual basis?

The building of the 60-bed block is under way, and the 90-bed block will be going in for planning permission shortly. What measures is the HSE taking, at both national and local level, to ensure all existing bed capacity is being used? What is being done to ensure all the beds in University Hospital Limerick, St. John's, Ennis, Nenagh and Croom hospitals are being used on an ongoing basis? I was shocked to hear that 15 of the 89 beds in St. John's have been out of use for the last three months. That is unforgivable and unacceptable. It was a breaking point and a red line for me. The Government is willing to give whatever resources are required, so I need an answer to these questions. When did the witnesses first know about the 15 beds and why were they not brought into use three months ago? What is being done to manage the beds in the five hospitals in the group, namely, UHL, St. John's, Ennis, Nenagh and Croom? I was at a mass in a village in east Limerick on Sunday, where nursing homes were advertising that they have spare capacity. Is due diligence is being done to ensure available nursing home beds and step-down facilities are being used? I am looking for solutions here. Deputy Kelly noted that we are all looking for solutions, and we must use the existing resources to the maximum. I ask the witnesses to address why the 15 beds in St. John's were not put to use three months ago, and whether we are making use of all the available bed capacity in the region.

First, Mr. Reid's synopsis of how to deal with the entry point crisis in emergency departments is identical to what the Sláintecare report came up with. The primary focus is the treatment of patients elsewhere in the community. The question is how quickly we can make that happen. I welcome Mr. Reid's inclusion of a bigger input from the pharmacy community, with which I agree. I take this opportunity to recognise that the proposed cuts to pharmacy funding are no longer going ahead, for which I thank the Minister and acknowledge his work in the area. I would add the use of electronic records in emergency departments to fast-track patients, monitor waiting times etc. to Mr. Reid's synopsis.

Our health budget of over €17 billion is up there among developed countries, as it is a high spend per capita. Based on his six months in the job, does Mr. Reid think it possible to start getting value for the money we are spending? Cataract operations are still being carried out in the North of Ireland on a regular basis, for example. Buses go up there from Kerry and Cork. I send patients up there on public transport and they are seen within a number of weeks. Yet, every time I submit a query to the HSE about a cataract operation for a constituent, I receive the standard reply that the waiting list is 18 to 24 months. Surely there is a better way of doing this. We give that money back to these patients, so it is coming out of the same pot. It is quicker and more convenient for a patient in the far south of Ireland to travel up to Belfast to get a cataract procedure done. I cannot see any reason why the system in this country cannot deal with that.

Mr. Reid also spoke about delayed discharges-----

Time, Deputy.

I am nearly done. Delayed discharges in Kerry approached 4,000 bed nights this year. The trolley count for the same period was also around 4,000. A pilot scheme has been initiated which aims to get patients who are not in need of acute beds into community settings. What progress has been made on that, and what is the likelihood that it can be extended full time? The figures correlate, so if one problem is solved, it will go a long way to solving the other.

I thank the Deputy. I call Mr. Reid. I am sure he has made a note of all those questions.

Mr. Paul Reid

I will make few comments on the various issues raised. My analysis is definitely in line with Sláintecare. I have not invented anything different. However, I have seen a significant amount of innovation all across our acute and community settings. While Sláintecare is a new direction in terms of pathways to care and devolved regions, we can also scale up and roll out much of what is good in our hospital and community settings. I have seen a significant amount of that in terms of emergency departments, process flow, oversight of bed capacity within a unit, electronic monitoring of beds and centrally managed hubs. We can scale up and roll out much of that innovation, on top of the direction of flight of Sláintecare.

We have to scale up better pathways for treatment. That requires more GPs, more primary care investment and more utilisation of pharmacies. I agree about electronic solutions. Electronic health records will take time and investment. We know it works where we have put it in place. There is a shorter pathway we can take, which is to have a shared record of patients' care between the GP and the acute setting the Chairman has been talking about quite a bit. That is an incremental step that we can take in advance of the major investment in the electronic health records.

On budget spend, outcomes and related issues, an OECD report was published in the past couple of weeks. It is quite good and has a synopsis of this. It demonstrates that health expenditure is above the EU per capita average. Life expectancy in Ireland has increased by almost six years since 2000. The report also states that our general public healthcare is comparable with other OECD countries. It highlights some particular issues that we have with obesity and alcohol, and the demands that places on our services. It is a good report and I recommend browsing it. We have a high standard.

There is a significant difference between being alive and living.

Mr. Paul Reid

Sure. On wider issues, I made a point earlier about the investment that we have made. We have an extra €1 billion in health expenditure this year compared to last year, an increase of 6.3%. From what I have seen, investment in the areas we have spoken about is key, as is investing in a different way for the future. We are finalising next year's service plan at the minute and it will start to make that step. As the Deputy will be aware, the way that we can relieve the pressure on acute settings is by investment in community settings. Our service plan for next year starts to make that shift in an incremental way, which is valuable. There is a challenge for us, as I said in our opening statement, about how we manage with the funds that we have in an effective manner to make the right decisions and investments, and to hold local management to account. It has to be about safety, improving access and managing within a budget. Those are three relative challenges that have to be run in parallel, though they are not always conflicting.

I made the point in my opening statement that we have done the State some good this year with our oversight of the health spend. The overrun will be less than half that of last year. The overrun last year was €650 million plus a €150 million first charge for the following year. It will be significantly less than half of that by the outturn this year. That has largely been through the discipline of working with line managers, holding people to account and making sure that we are recruiting in the right places. I know recruitment has been difficult for everybody. We have to make sure we are recruiting where we have a budget and that we are recruiting skills that add to service delivery. The point I made earlier is that we are looking at the centre of the HSE to see what size it should be in the future. I believe it should be scaled down and that we should devolve more of what we have in the HSE centre to the regions to some hospital acute settings and community settings. We have to look at it very differently. That is about management of finances.

With regard to delayed discharges, I spent some time in Kerry in a hospital in an acute setting and in a community setting. I was a little frustrated on the day I was there when it was highlighted that there were some beds available in the community and we had delayed discharges in our community setting. We immediately convened a meeting that evening with the relevant CHO and the hospital manager. The CHO has worked to increase capacity through a number of initiatives that it has put in place since. Some beds were available in Killarney at the time and some of those are being utilised. Some of that is now built into our winter action teams. Kerry has a good interface and integration between community and acute settings. A number of initiatives in community settings are giving relief to acute settings. While they have a challenge in delayed discharges, they had some good initiatives working in a way that we want them to in the future. I hope that answers the Deputy's questions.

Senator Kieran O'Donnell asked a specific question on St. John's hospital and why 15 beds are vacant. We know the questions and need the answers.

Ms Anne O'Connor

I was at St. John's hospital on Friday. I understand it had two consultants who retired and it is reliant on two locums. A third locum has been brought in.

They retired in February and June. The hospital had plenty of advance notice. Why were 15 beds left idle for the last three months?

Ms Anne O'Connor

I understand there was a challenge in having adequate medical oversight of those beds.

That is not good enough. I am sorry. We have a crisis in Limerick at all times. That answer is not sufficient for me or the people of Limerick. Fifteen beds were idle in St. John's hospital. We were in here just over a month ago highlighting the need for an MRI scanner. We were asked to do it by management and we did it willingly. At the same time, there were 15 beds idle in St. John's. An elderly lady was on a trolley for 48 hours in University Hospital Limerick while 15 beds were idle elsewhere. Ms O'Connor needs to give a satisfactory explanation as to why that happened. When did people at HSE corporate level first become aware that the 15 beds had not been in use in St. John's hospital for the last three months?

We have got the question.

Ms Anne O'Connor

On the broader question of how we know about vacant beds, I have a daily call with the senior team. It is not just about the beds in the five acute sites but the beds available in some of our community facilities too, such as step-down-----

I asked a very simple question and I have limited time. When did Ms O'Connor first become aware that 15 of the 89 beds in St. John's hospital had not been in use for the past three months?

Ms Anne O'Connor

I became aware on receipt of the proposal. I was at the hospital last weekend.

The proposal only came in last Friday.

We are pleased to have the Senator at our meeting. We have got his question and I ask him to please allow the witness to answer. If he is not happy with the answer, perhaps it will be forwarded to him.

I think the pertinent question is why the central HSE was not asked to open these beds earlier.

That is what I am asking.

The HSE and Department of Health became aware of these beds not being open when we put out a call to the system asking if there were any more beds around the country that could be opened. It is inexcusable that 15 beds in St. John's hospital were not open during a crisis in bed capacity in the UHL hospital group. I also find it inexcusable that doctors from the acute hospital are not willing to go to some of the smaller hospitals such as St. John's. I referred to those two issues when speaking with Deputy Kelly earlier. The process needs to be fixed and there needs to be management accountability. We saw this on television last night and on the front page of a newspaper in recent days. As soon as the proposal came in for the 15 beds, we wrote the cheque.

On the management of beds for the entire group, what is the process whereby-----

We got the question.

It is a supplementary question.

The Senator has asked it already.

The Senator has asked it already. I will call Ms O'Connor and then we will move on.

My specific question is about the management of the beds for the other hospitals in the group.

Ms Anne O'Connor

The group is responsible for managing the oversight of beds within acute hospitals. At national level, we look at all of the beds in order that we know how many beds are closed or blocked daily, primarily due to infection. We know that yesterday, across the national system, 111 beds were closed. We also look at the daily availability of beds in community settings. The approach through winter is a key focus for us, to make sure that people are stepping out of the acute settings altogether and moving into relevant step-down facilities and transitional care. At this time, nobody is waiting for transitional care approval. We are trying to match patients from acute settings to community settings and to ensure that people who are ready to move can move.

On Deputy Brassil's question about delayed transfer of care, we are doing a great deal of work on that. Last year, the Minister of State, Deputy Daly, commissioned an independent review on delayed transfers of care. We have been looking at how we record people who are ready to leave acute settings, etc. Since we started to implement our winter initiative in September, one of the key measures that we have looked at is bed days lost. We will always have people in beds but how long they are there for is our challenge. We have reduced the bed days lost by 20% since September on foot of the initiatives we have put in place. We are proactively trying every day to move people who have been waiting the longest from acute hospitals into more appropriate settings.

I welcome the Minister, and Mr. Reid and his team. I want to raise a number of issues and I will focus on Limerick. The last time I was here, I mentioned that the blood clinic in UHL closes at 12 noon on a Friday and it needs to be open longer. It is stopping people from being discharged or some end up being sent to the hospital because there is nobody to read their blood count.

In regard to the beds at St. John's, while I welcome the announcement this morning, when I inquired two weeks ago and brought it to the Minister's attention, my understanding was there were 20 beds at that stage. I want to know if five beds have disappeared since that time.

I welcome the centre that was opened last Wednesday by the Minister of State, Deputy Daly, on behalf of the Minister. Mr. Reid referred to new ways of doing things in regard to the discharge of patients. There is a proposal in the capital plan for 120 replacement beds at St. John's hospital. If that was brought forward, it would certainly help to free up the beds in the hospital so procedures could be carried out.

I have a question for the Minister of State, Deputy McGrath, regarding respite. He has a fund for respite homes. St. Gabriel's School and Centre in Limerick has a six-bedroom respite unit ready to go and the HSE released funding recently for a staff member to manage the facility. However, funding to get the rest of the respite centre open is what is necessary. I have spoken to the Minister about it. Will he visit the facility the next time he is in Limerick? It would certainly help young people with disabilities.

My question relates to Valproate. Does the Minister have the Valproate response project report on his desk? Has he been in contact with OACS Ireland and Epilepsy Ireland about this? I asked him before about a public inquiry into this. Is he still open to an independent inquiry or investigation into the prescribing of Valproate, given the teratogenic effects of it were widely known, even back to the 1970s, as well as the increased risk of foetal anticonvulsant syndrome around it? I am asking about an inquiry into who knew what when, and why it continued to be prescribed when there was so much evidence worldwide on the impact it might have.

I have a question for the Minister of State, Deputy McGrath, in regard to the transition period - I do not want to say handover period - for service users going from Western Care to Praxis Care. What is the protocol around the transition period? I have concerns around this. How do we ensure the organisations to which we are signing over the budget have the capacity and have done their recruitment and everything else to have the services and supports in place? The Minister of State knows that for the condition of autism, routine and familiarity are so important. I am concerned that new teams are going in and there is no transition period, so there is no time for the service user to get used to the new practices or that can be done in a way that is streamlined.

I have a question for the Minister. I noted his statement on the RCOG report.

I have ideological issues with the way CervicalCheck has been outsourced. I acknowledge that but I also acknowledge that the Minister needs and wants, and I accept that women must have, confidence in CervicalCheck, that it has to be used, that it is a good thing and that it saves lives. I want to get that out of the way, and I am not confused about it at all.

I am, however, very confused about one aspect of the RCOG report. The NHS screening programme guidance for applying duty of candour in disclosing results, on page 6, states: "... sometimes it can be hard for screening services to know how to distinguish between a false negative/false positive that has occurred because of the limitations of screening and a false negative/false positive that has occurred because something has gone wrong". I am curious as to why that "something has gone wrong" has not tweaked the Minister's interest in investigating what went wrong in the labs. Consistently, in the highlighted court cases that we know of involving women who are still alive and women who have died, they successfully sued the laboratories and have been paid big sums, not out of the goodness of the hearts of those laboratories, but because "something has gone wrong" and, clearly, they are acknowledging that when they pay out vast sums. I want to know why the Minister is not curious that "something has gone wrong", and why we are not examining what went wrong in those labs.

I will give a quick analogy. If there was an accident at Dublin Airport and five or six people were killed, would we investigate the causes and what might have gone wrong, or would we say that those deaths are within the statistical norms of aviation globally, Dublin Airport is working to appropriate health and safety standards, so why would we bother investigating what went wrong? I would like an answer from the Minister as to why he is not interested in investigating what went wrong in those labs. It is connected with my consistent appeal for the figures in regard to which labs the 221+ women's smear tests were carried out in. I am curious as to why that does not bother the Minister. He is comparing the results of the RCOG report for Ireland with the results for the NHS. However, the NHS has acknowledged that sometimes things go wrong but we do not seem to acknowledge or own up to it.

I believe the Minister is going to reopen the audit, which has been closed for a year and a half. In that year and half, some women have had serious results. The best friend of my secretary, who works in Leinster House, is dying from cervical cancer. She was under constant screening because she had a procedure in 2009. The woman, her community and her friends have had to fundraise to have the audit carried out privately and it has cost thousands of euro. It has shown that, in four previous years, the screening had serious, discordant results that were not picked up and then, all of a sudden, she was diagnosed with stage 4 cancer. What can the Minister do for women who are caught between the date the audit closed and when it is going to reopen. When will it reopen?

I apologise but I have to attend a vote in the Seanad. I will pick up the answers.

We will hear the answers now. I call Mr. Woods.

Mr. Liam Woods

In response to Senator Byrne regarding the blood clinic in Dooradoyle, I will come back to the Senator directly or through the committee with an answer, and I will ask the groups to look at that. She asked whether five beds disappeared and the answer is they definitely did not. As the Minister said, there is now funding available through the NTPF to open all beds, so there are patients moving from Dooradoyle.

The figure was 20 and then 15 was mentioned.

Mr. Liam Woods

I hear that. We have funding to open all beds that we can reasonably open in the near term, so that should not be an issue. I will confirm that. On the capital proposal for St. John's that the Senator referenced, I am aware of such a proposal and that will fall to be considered in the HSE capital plan. The final question concerned a respite centre, which is not my responsibility.

I will respond to that. Respite is a very important part of our disability plan and the disability programme for the past 12 months.

It is also part of our reform agenda. We have just completed our 12th new respite house. As a result of the €10 million we got last year, we have 12 new houses up and running throughout the country. We are planning for 33,000 day respite places and 166,000 overnight services after Christmas and in 2020. Respite is a very important part of the agenda. These services are now up and running and will be developed. With regard to St. Gabriel's, I would be delighted to take up the Senator's offer. We are looking at that particular case at the moment. I would be delighted to visit St. Gabriel's and to talk to the staff and families. That is a very important part of my job. A very important part of developing services and of the reform agenda is making sure that the interests of the families and the people who work in the service are protected.

Senator Conway-Walsh has left. With regard to the protocols for transition to get new teenagers going, a lot of preparation is done before 18 year olds move into adult services. Approximately 1,600 people, having hit 18, come into adult services every year. The good news is that we managed to secure an extra €13 million to develop these services and to keep them safe. Every 18 year old that comes out of youth services is now guaranteed a place at an adult day service. That is essential. There has to be preparation for that transition. Most sensible services provide that a few months before people move on to a new service. Many services provide key workers, link workers and meetings with families and parents. If members have any concerns about a particular service, they should not hesitate to contact me because we have to ensure that transitions are as stable as possible for people, and particularly for adults with autism, as these transitions can be very difficult for them and for their families. The 1,600 who come out every year generally do get a place and get on with it. If there are gaps, members should not hesitate in letting me know.

Will the witnesses comment on Senator Conway-Walsh's questions on valproate?

Dr. Colm Henry

I can furnish the committee with a written reply. The Senator is quite correct in saying that there has been knowledge about valproate for many years. This knowledge was heightened, as it were, in February 2018 when the European Medicines Agency introduced new restrictions. Following that, we instituted a communications and support programme to increase awareness among women of childbearing age. Through working with OACS Ireland, Epilepsy Ireland, and a support team we established, we identified 40 families who may have been affected by valproate. Through that we developed a diagnostic pathway in Crumlin hospital, again working with the agencies I mentioned and members of OACS Ireland, including a consultant geneticist and paediatrician. Following on from that pathway, some of these patients and their families will require supports. We are committed to providing those supports. The Senator is, however, absolutely correct. There has been knowledge about anticonvulsants in pregnancy for many years. It is also true that the degree of the knowledge and the strength of the evidence has become more powerful over time. Our response has, therefore, become more powerful over time. From her own work, the Senator will know that people have been alerted to the use of anticonvulsants in pregnancy. As part of this work, we are introducing nurse practitioners to work in the area of women in pregnancy who are on anticonvulsants, in recognition of the greater risk presented by these drugs, even beyond valproate.

I believe the Senator asked about a report. She asked whether those in the Department had it on their desk.

Dr. Colm Henry

Yes. We did provide a report summarising all of this work.

I was just following up as the Senator is not here to do so.

When will that report be ready?

Dr. Colm Henry

We have provided the report to the Department of Health.

When will it be published?

Will it be published?

Mr. Jim Breslin

It was not prepared for publication but I do not believe there would be an issue in doing so. We will look at it and make sure it is-----

We will send it to the committee providing there is no issue with publication. We will just check first.

With regard to Dr. Henry's comments on specialist nurses to help people through pregnancy, on valproate-----

I am sorry. We will let Deputy O'Connell in on another round. Deputy Bríd Smith had asked questions on the Royal College of Obstetricians and Gynaecologists, RCOG, report and on audit.

I thank Deputy Bríd Smith for raising these questions. I had intended to say this to the 221+ group in writing first but, in the interests of clarity, the €2,000 payment recommended in the Scally report will be provided to the people who participated.

Why did the Minister say "No" initially and then change his mind?

I did not say "No" initially. Just because a headline said that I did, it does not mean that is the case. I received a letter from patient advocates last week and I said that I would come back to them on the issue.

Why did the HSE write-----

I will allow Deputy Kelly to speak in a minute.

I considered the factual position. As Deputy Kelly knows, when one is a Minister one is given advice and information and one then considers it and makes a decision. Some were of the valid view that Dr. Scally had recommended that a payment of €2,000 be made to people who engaged with this process because they went through considerable expense and inconvenience. Those who participated in the RCOG process also incurred costs and expenses in seeing clinicians and so on. I will be confirming that in writing. I know Deputy Bríd Smith did not ask about that directly but I thought it was pertinent to what she said.

This woman participated in none of these reviews. She was left out of everything.

I will get to that in a moment. I just wanted to make that point because it would be disingenuous not to do so while I was here. I do not have a lack of curiosity with regard to what happens in the labs, as the Deputy suggested. In consultation with the patient advocates, we commissioned work on the laboratory breakdown for the 221+ group. I shared that with the patient advocates and with this committee and I have taken questions on it in the Houses of the Oireachtas.

Has that report been published?

It has certainly been sent to this committee. If the Deputy does not have a copy I will provide her with one directly.

I do have it but I was told that it had not been published publicly.

As the patient representatives and this committee both have copies, I consider it published. It is freely available to Members of the Oireachtas, patient advocates, and anyone else who wants it. I have spoken about it at length in the Dáil.

We have also seen Dr. Scally's reports in which he found serious difficulties with regard to procurement and a number of other issues. I do not have his words in front of me, but he did say that he did not find anything to be substandard or that there were any safety concerns. On top of that, we now have the Royal College of Obstetricians and Gynaecologists answering the question as to whether the programme was working effectively. As I said to the Chair at the start of this meeting, I am conscious that this committee is hearing directly from RCOG next week and that it would be clumsy of me to endeavour to explain its work when it is more qualified to do so itself.

I will now address the question on audit. Dr. Henry may wish to add to my response. I know a number of groups are doing work on interval cancers, following Dr. Scally's recommendations. Audit is a really good thing. This debacle arose from an audit that was intended to disclose but never did, thereby causing people a lot of pain and hurt. It is really important that we get audit right. That is a key recommendation made by Dr. Scally. Deputy Kelly has made a point vociferously several times and I believe Deputy Bríd Smith is making a similar point. They are asking about the people affected today. There is no audit ongoing. When the audits recommence, will these people be covered? I cannot pre-empt the expert group review but my view is that these people absolutely have to be covered. Dr. Henry may also have a view. There cannot be a gap in my view but, obviously, I want to follow the expert group's recommendations. Dr. Henry may have information to offer the committee in that regard. This might be helpful but-----

What will happen for this woman? The community has had to raise funds. It is a poor working-class community but it has had to raise funds in order that she could have an audit done privately. She wanted to know what went wrong. She has now found out through a private audit. It is curious. I have a letter from the HSE. This woman gave me a copy. It says that the HSE will give her the slides as long as she tells it where her audit is being done because it has to be sure about that.

I thank the Deputy. We have the question.

It suggests the HSE was not sure about the laboratories that were carrying out the smear tests in the first place. What went wrong for her and for the women who have been paid vast sums of money?

With respect, I do not know what, if anything, went wrong because the Deputy is talking about an individual case.

Is the Minister not curious as to what went wrong?

I am aware of the limitations of screening, as is the Deputy. I am aware that cervical cancer is a most devastating disease and that it disproportionately affects younger women. I would like Dr. Henry to talk about them.

The NHS says something else can go wrong and that something else seems to be missing.

We have the Deputy's question.

Dr. Colm Henry

With regard to the laboratory report, when one looks at laboratories one sees a whole range of quality assurance measures. As we know from the laboratory report provided here, the number of false negatives is very small in the context of the overall workload of the laboratory. It is therefore very difficult to draw conclusions. There are other measures which are equally, if not more, important such as the number of false positives. These can cause much distress and unnecessary interventions and, in some cases, invasive surgery. Another measure is the number of high-grade findings. Because of the huge numbers in each laboratory, it is difficult to draw definitive conclusions from the report.

One other point worth making is on the timeline of the cervical cancer screening programme which started in 2008. One would have expected a higher degree of findings at the beginning of the programme because no screening programme had existed beforehand. There are a number of confounders when one tries to examine the relative performance of false negatives in each laboratory, for example, the timing of the laboratory for the programme and the demographics, that is, the population that that laboratory will serve.

On interval cancer, I acknowledge that Deputy Kelly showed an interest in this matter in previous hearings. There cannot be any gap in this regard and we recognise the position of the Royal College of Obstetricians and Gynaecologists on an interval cancer audit. It is worth reminding people that the core purpose of interval cancer audit, in fact any audit, is learning and improvement. Interval cancer audit tied to the duty of candour, as prevails in England and Wales, mean that the results of false negatives would be communicated to everyone.

This is not just interval cancer audit but full audit.

I am not getting-----

I am sorry, Deputy Smith, but-----

There have been many interruptions.

Representatives of the Royal College of Obstetricians and Gynaecologists will be before the committee next week.

I am aware of that. I want the Minister to acknowledge that something else can go wrong. I read from the chapter-----

The Deputy is welcome to attend that meeting.

Taking up that point, no minister for health anywhere in the world would suggest that things cannot go wrong in a health service, beyond the limitations of any procedure. Of course, that is the case. As the Deputy knows, determining that in Ireland is an adversarial process which needs to be reformed. That is why we have asked Mr. Justice Charles Meenan to do a body of work on tort reform. He is due to deliver an interim report any day now and definitely by the end of this year. I hope that report will guide us in how to deal with things better without people having to go to court on all occasions.

Women are going to court-----

The Deputy and I cannot determine-----

-----because that "something else" is not being identified.

The Deputy's time is up.

Dr. Colm Henry

It is important to note that the Royal College of Obstetricians and Gynaecologists, in its report, notes that the degree of discordance found in its exercise, looking back in an unblinded way, is no different from a much larger exercise carried out in England and Wales on a much greater number of people. This is the only occasion on which we have had such an investigation of the cervical screening in a robust and methodological way in this country.

That is not correct. If it was, laboratories would not be paying out millions of euro to women who had discordant results.

On mesh, can the Minister advise if it is his intention that the suspension will remain in place pending the outcome of the deliberations of the task force? I received correspondence from the Minister on a European urogynaecology task force report that is due. Will the suspension remain in place?

The suspension will remain in place until the chief medical officer and chief clinical officer advise me and the HSE to the contrary. As I informed the Deputy at our meeting, there are no imminent plans to lift that suspension and there is much work to do before we would be in a position to do so.

I thank the Minister. Mr. Reid referred to bringing agency work to what he described as affordable and sustainable levels. My views on agency work are well known and I do not think anyone will disagree with me that it represents a very expensive way to run the health service. Has Mr Reid set targets in respect of personnel, money and conversion? In the event that a hospital manager is proactive in taking the initiative on this issue, on which there appears to be a lack of leadership, and manages to convert from agency to directly employed staff, will the money saved be put directly into staff or will that dependent on remaining within budget?

Mr. Paul Reid

We want to reduce our agency spend. All budget holders have a target this year and next year to reduce it. Some areas have been quite innovative in converting to full-time equivalent staff. To provide some context, 94.6% of our budgetary spend on labour is direct labour, so 5.4% is agency spend. The predominance of that is in medical and healthcare assistance.

How many millions of euro does that represent?

Mr. Paul Reid

I will get the Deputy that figure in the moment. It represents 5% of our total payroll. As the Deputy will know, 80% of HSE employees are women and a high proportion of the workforce, some 35%, works reduced hours. We want to support this as it is important.

There will always be a level of agency spend and we are very open to anybody who is creative in reducing it. It is 5% of the total.

My question was very simple. Have targets been set?

Mr. Paul Reid

They have been set for this year and next year.

Will Mr. Reid share those with us?

Mr. Paul Reid

They will be in our service plan.

Are they for money savings or hours saved?

Mr. Paul Reid

The target is for reduced money spend on agency services.

A target has been set.

Mr. Paul Reid

There is a target this year and next year as well.

The urgent care centre in Connolly Hospital Dublin did not open at the promised time. As has been acknowledged, this was due to an inability to staff the unit and recruit consultant paediatricians. The Tallaght urgent care centre is planned for 2020. Does the HSE have a staffing plan in place? The number of consultants in the system appears to be insufficient, with a shortfall to the tune of 500. The Minister will be aware that the consultants have expressed no confidence in him and that view is shared by many. I do not intend that in a personal way but it is a matter of public record. We have a recruitment and retention crisis among consultants. We discussed the case of a pain consultant for Crumlin earlier. The urgent care centre is only open on a nine-to-five basis at the moment, which is not what was promised, and the centre in Tallaght is due to open in 2020. Will it open on time? Can the Minister say with any degree of confidence what the opening hours will be, given that both he and the Taoiseach gave a commitment that the urgent care centre in Connolly would be open from 8 a.m. until midnight, seven days a week?

The urgent care centre in Connolly Hospital Dublin is currently open from 10 a.m. until 5 p.m. I would like those hours extended by an hour either side, that is, from 9 a.m. until 6 p.m. Children's Health Ireland is working on that.

I have no confidence in some of the work practices of our consultants - absolutely none - when I see private practice and income being put ahead of the public health service. I am sure the Deputy will stand with me when I table proposals shortly to pay consultants much more money. In return, however, consultants will be expected to work in the public health service. It will also be expected that public beds will used for public practice and public patients, as in the case that was so well articulated by the Deputy earlier. It may make the Deputy politically uncomfortable but on this issue, I believe the gap or difference between us is smaller than on many other issues. The Fianna Fáil Party has not yet made its position clear on this issue, whereas the Labour Party, Sinn Féin and Fine Gael have. We believe consultants should be paid much more but if they want to do private practice, they should do it in private hospitals, not in our public hospitals. We will have to pay them much more to do that.

There is no free money here. Nurses and midwives did not get any free money. When they were offered an enhanced contract, better pay and conditions and improved career prospects, they agreed to a number of changes to work practices, as did our GPs. So too will our pharmacists and dentists, and likewise our consultants. No one is protected beyond reproach or scrutiny. I am certainly not but nobody else is either.

We will have a plan on Tallaght. I am sure Ms Éilish Hardiman, the chief executive officer of Children's Health Ireland, who is responsible for this facility, can brief the committee on this matter. The Tallaght urgent care centre is due to open towards the end of next year. We will have tabled significant proposals long in advance of that offering consultants much more money to work in the public health service and I emphasis the public aspect of the health service. I need to make this point, because one will not hear it anywhere else. Throughout the 2000s - the years of economic boom - there were approximately 7,000 doctors working in the Irish public health service. There are now more than 10,000 doctors in the health service. While we have vacancies and there is more to do, there are approximately 3,000 more doctors working in our public hospitals than there were in 2007, 2008 and 2009.

I listened to Mr. Reid's comments on overcrowding in accident and emergency departments and I accept his point on changes that have to be made in other areas to ensure these problems are solved. I am with him 100% on that but the problem of resources is staring us in the face.

If I see changes in resources, particularly the area I pointed out, I will go with the Minister immediately. If I do not see changes in resources, I will not because the Minister ultimately has that choice to make. I have pointed this out numerous times. I am staying with him but only for a short time because if he does not deal with the resources gap, that is his issue. That is just reality.

Will he respond regarding John Wall and the medical card? Deputy O'Reilly, myself and others have raised this. It is a genuine case and a genuine issue for terminally ill patients. We should react positively.

I previously raised an issue with the Minister and Mr. Reid of a woman for whom it cost more than €100,000 to get her gallbladder out. That happened over 11 weeks and involved two hospitals. I never received a response. How can a gallbladder operation cost more than €100,000 and how can someone spend 11 weeks in hospital? It is insane and multiple hospitals are involved as well as the public-private issue. It was meant to be investigated but I never received an answer.

On 5 December at 2.25 p.m. a letter issued from the HSE stating that all the people in the RCOG review were not getting the €2,000. I welcome what the Minister and the Taoiseach have done today but the fact is that the people around the Minister here, representing the HSE, wrote to the 221+ group and told them they would not get it. There is no joined-up thinking. The Minister might reflect on that. Why did that happen?

I refer to the Bernadette Kiely case, and I mention her name only because it is public, in the context of non-disclosure and the issues surrounding that. Representatives from RCOG will be before the committee next week but has the Minister initial concerns he would like to share with us? How does he feel when Lorraine Walsh, Stephen Teap, Vicky Phelan - people whom he knows well, as do I - say they have no confidence in the RCOG review? If these people do not have confidence based on what we publicly know, that is scary. Why in that review was there a default that anyone whose slides could not be found were sent concordant letters? Surely they should have been concordant and discordant, and a small number should have said there was something missing and a decision could not be made. That would have been logical. I refer to those who have serious concerns about the credibility of the review. I was not filled with encouragement last week when the college was unable to answer some basic questions. A small number of these women would like an independent assessment of their files. I am sure that will happen anyway, but unlike the now-resolved matter of the €2,000, can we please just deal with this now and give a positive answer to the question? I do not think there is a large number of women in this category who would voluntarily want to go down this route but there is a significant number. For the cost involved, the Minister should just do so. I ask that he consider that.

I will ask Dr. Henry to comment on some of the RCOG matters. The Deputy and I both know Mr. John Wall well. He is a great individual and a great advocate. I met him most recently three weeks ago and he was also in touch with me yesterday. We set up a new clinical advisory group to look at what is going to be an expansion of the access to medical cards for people with a terminal illness. That is in the budget book. The CEO of the HSE and I agreed that in advance of budget day. From memory - and John Wall asked me this yesterday - they hoped it would have its first meeting on 18 December and I understand that is still the intention. Mr. Wall will be invited to make a presentation. There is an eight-week clock on it so it should be finished by February. I will keep John Wall and the Deputy informed on that. I had a good meeting with Mr. Wall on it.

There is no budget.

It will be dealt with from the primary care reimbursement service, PCRS, budget. I know the Deputy made a pre-budget submission which was generous and set a large sum aside for it. It will not be that large but I am happy to let the consultant applications advisory committee, CAAC, do its work first.

I will not comment on individual cases, although I do not think that the Deputy is asking me to, including that of Ms Kiely other than to say that I have given a commitment to meet her and I will. I will ask Dr. Henry to comment on the broader issue of disclosure, which is important.

Finally, on the broader RCOG issues, I know Stephen, Lorraine and Vicky very, very well. I hold them all in huge regard. Stephen has written me a letter on two issues.

I addressed one this morning and we are considering the other. I will respond to him directly on it. I would feel happier for RCOG to answer those questions in a public forum here next week.

Will the Minister answer those questions after that meeting, though?

Of course, I will, yes.

The Minister cannot stay off the record on this.

I am very clearly on the record that I do have confidence in the RCOG report, that I have thanked the college for it and that I think it is a very robust piece of work. I am not trying to stay off the record on it.

My point on the RCOG report is that approximately 100 colposcopy reviews were done as part of this process which is raising other issues which Dr. Henry might deal with. The Minister's commentary around the review is that it goes to confidence in screening, etc. I am not even going there; that is not my issue. I want to have as much confidence in this as possible, just like everyone else. However, that is not what this is about; this is about the individual women. The three people who brought this up say that they do not have confidence in the process. Let us consider what happened to Lorraine Walsh and Vicky Phelan. Out of 1,051 women, three files were mislabelled and two were those of Vicky Phelan and Lorraine Walsh. A person would win the Euromillions quicker than this. It is incredible that Lorraine Walsh received two reports 24 hours apart saying opposite things and we now know other women received concordant results, despite some of their data slides being unavailable.

We will get answers to those questions next Wednesday morning.

I know but the Minister needs to answer. I have no problem with him doing it next week but he does need to answer.

And he has committed to doing that.

I have been clear that I met RCOG. I asked if it was satisfied about its independence and it said it has never been surer of anything. Its expertise is beyond reproach. It is true that there were errors around wrong letters and so on that it has apologised for. I do not feel as though I have the competency to go beyond that on the methodology the RCOG used. Dr. Henry has significant competencies.

Dr. Colm Henry

Deputy Kelly raised an individual case and he will understand that I would not like to comment on an individual case. On the issues he raised, we know more from Dr. Scally's report and the RCOG report about the original audit where all this began. Dr. Scally described it as well intended and flawed in design and implementation. The focus of the audit by CervicalCheck, like all similar international exercises, was on cytology but it looked at other elements of the screening pathway. The problem was, as we now know, that as Dr. Scally noted, it was "impossible to reach a firm conclusion on the methods employed" in the audit based on his inquiries and "a complete presentation of the audit outcome data was impossible to locate". For that reason, we welcome a more robust, standardised independent review which, we hope, will give greater assurance than one which was well intended but flawed in its design and implementation and which looked primarily at cytology but also other elements of the screening pathway.

What of the request for independent reviews? I did not get an answer on that. What is Dr. Henry's view on that?

Dr. Colm Henry

I understand -----

Can we wait until the RCOG report?

I would like Dr. Henry's opinion on it.

We have to hear from RCOG to see what the issues were.

Deputy O'Connell and Durkan are next, and the Minister is under a little pressure.

I do not need to ask the Minister anything. I seek an answer on the question on Valproate for Dr. Henry. Did Deputy Durkan wish to ask something?

I will take written replies to my questions. I raised the question of drugs treatment. I am not satisfied. There is a greater emphasis now on acceptance and that it is inevitable that people are addicts and that nothing can be done about it. That is a mistake. I ask questions on the number of drug treatment programmes that are offered to addicts or users of drugs and the results among those who were successfully encouraged off drugs, those who were not, and those who were not offered a programme at all.

I also mentioned child mental health services and the lack of maternity cover for speech and language therapists.

The result is a gap in treatment for the child concerned, which is hugely negative. What is being done about that? It is not something that is going to cost €10 million or even €1 million. It is something simple and could make a huge contribution in the context of the treatment of the child.

We will let the Minister go now and ask the officials to answer those questions.

I thank the Minister for his time.

Mr. Jim Breslin

The Deputy is looking for statistical information on the drug treatment programme. I am happy to pull what we have together and provide it to the Deputy by way of written reply, if that is acceptable.

Yes, as long as the emphasis is on what I have been suggesting.

Mr. Jim Breslin

With an emphasis on results, yes.

What about maternity cover for speech and language therapists? The lack of such cover is leaving a very sizeable gap, especially for children who have difficulty communicating or who cannot communicate at all. There is a serious flaw in the system which must be addressed immediately.

Ms Anne O'Connor

We have a very high percentage of females in our workforce across all of our multidisciplinary services, including CAMHS. We try to cover gaps in service but it is not always possible. The provision of maternity cover is a challenge for us. We can often have a lot of staff on maternity leave at the same time. The approach, particularly in CAMHS, is multidisciplinary and we try to move resources around to cover. We do what we can with the resources we have but it is not always possible to cover all maternity leave.

Given what I said earlier, it is necessary to evaluate the situation again to see what can be done. What would it cost to provide cover in order to address the issue? It is not impossible and does not require rocket science. It can be done and it could have a significant impact on the quality of treatment for children and on their families' quality of life.

I thank our guests-----

May I ask a question on valproate?

Of course.

Mention was made of specialist nurses in response to a question posed by Senator Conway-Walsh. I am aware that data has been available on the impact of valproate on foetal development. In terms of where we are now with the existing cohort, it is my understanding that when female patients who have epilepsy talk to their GPs about having a family, they are moved from valproate to levetiracetam or something more suitable to a hospital environment. They get an infusion and come off valproate before starting a family. Is that something that is ad hoc, where the individual GP takes responsibility or is there a programme in place to guide women through this before they become pregnant so they can manage their medication?

Dr. Colm Henry

The Deputy is absolutely right that the best time to make a decision is in advance, before any harm can ensue. In putting together this particular programme, we had to bear in mind that we did not want to alarm people who might, for example, have unstable epilepsy. We did not want them to stop taking their medications abruptly which could cause greater harm. The whole thrust of the programme was to ensure that they got the best and most expert advice, balancing the risks of changing or coming off medication against staying on medication which might harm a developing foetus. The bigger question to which the Deputy refers is access to specialist care and advice. I presume she is not just interested in Valproate but in other anticonvulsant drugs. Working with the epilepsy programme, led by Dr. Colin Doherty, we are developing a specific programme. We have now appointed two out of a planned six specialist nurses for pregnant women who are on anticonvulsant medication so that we can target them early with primary care and afford them the best advice. We want to ensure that their epilepsy remains stable because abrupt withdrawal can be quite harmful. We also want to make sure that they are on the safest possible medication at the safest dose.

I would see a role for community pharmacists here because they are the people who generally sell the folic acid and pregnancy tests and who also dispense medication to patients with long-term illnesses. They are very much aware of patients' history and in well-established community pharmacies, they would have seen girls growing up and going through different phases of treatment.

While I am in favour of specialist nurses, I am of the view that there is a role for community pharmacists here in terms of explaining the science. What is commonly lost in the chat about valproate is the issue of balance, as just described by Dr. Henry. The risk to the woman and to the pregnancy of abruptly stopping medication must be weighed up. If a woman with an unplanned pregnancy who is on valproate turns up at a doctor's surgery, she should be told that just stopping is not the solution. That point is often lost in the argument.

On the RCOG report, Deputy Kelly stated that he is not filled with encouragement. I am of the opposite view, particularly having met representatives from RCOG. I felt that they were full of integrity and that their independence was guaranteed. Perhaps their answers are not the answers that some of us wanted to hear but the answers we got in the private briefing last week gave me some solace. I now feel that the future might be better. There have been constant calls for a reopening of the audit process. To my mind, this all went wrong with the audit. Somebody decided to conduct an audit without considering how to deal with the results and with the fact that real people were involved, either deceased women's families or women who had adverse outcomes. Consideration was not given to the results, the impact of same or the issue of open disclosure, and all of that fed into this crisis for people. It is important that there is some balance here. While I was not necessarily filled with encouragement, I felt confident that the RCOG representatives were independent and were not in the pocket of anyone, as has been suggested.

Dr. Colm Henry

I agree completely. One of the valuable resources for us, in working through the valproate project, was working with community pharmacists who are in a unique position in terms of access to women who are at risk for valproate exposure in pregnancy because such women are known to them. I definitely see a role for them in this programme, which is headed by Dr. Colin Doherty. I will talk to him about how we can use community pharmacists to best effect.

I thank Dr. Henry.

I asked a question earlier and did not get an answer. I asked about troubleshooting when there is obvious overcrowding at accident and emergency departments. Overcrowding is reported to a central location and it should be possible to identify precisely the cause of same. It is no good just saying that it is a sign of the times. If it is a sign of the times and we are not able to meet the requirements that exist, we must address that. We need to know the cause of the overcrowding. Is it because there are not enough doctors, both GPs and hospital doctors? We need to know the cause of the problem. We spend most of our time moaning about it. I spend an inordinate amount of time asking questions about it, as do most Members of the Houses. We must troubleshoot and find out what is causing the backlog in certain places. What is the cause of the snarl up?

Mr. Paul Reid

Ms O'Connell touched on this earlier. We have a service delivery unit, members of which go into accident and emergency departments to ascertain where the choke points exist. They examine whether it is the number of clinicians on duty, staffing levels, nursing numbers or flow-through processes in the hospitals. They have been in place and active all over the country and are particularly engaged in the winter period.

What do they do in terms of dealing with the problem?

Mr. Paul Reid

They come out specifically and work with line managers around the actions that are required at that point in time, as well as over the coming days and weeks, to address the pressure points. Separately, as stated earlier, a review of nine sites is being undertaken. That will look at some of the wider issues across our emergency departments in the context of flow-through. We take full cognisance of the issues in real time. We are also engaging in a wider review of our emergency department processes.

Ms Anne O'Connor

As mentioned earlier, there are daily calls. I have a daily call, where we look at the sites that are in trouble on that day and take immediate action to move people, if possible or to provide extra support. That happens every day throughout the winter period.

We must ensure that all space available in hospitals is utilised.

Ms Anne O'Connor

Yes. There are nine winter action teams throughout the country.

Every day, somebody from the national team dials into their calls. As a result, we have a direct line to the local teams to see what needs to happen.

I thank Ms O'Connor.

Mr. Liam Woods

A question was asked by Senator Maria Byrne about the blood clinic in Dooradoyle. It is a morning clinic. The space is used for another clinic in the afternoon but the phlebotomists go to the emergency department to support venepuncture and other services. It is not that the service is not being provided, it is moved to the emergency department.

I thank Mr. Woods. On behalf of the committee, I thank the Minister for Health, Deputy Harris, the Ministers of State at the Department, Deputies Finian McGrath and Catherine Byrne, and the Secretary General of the Department, Mr. Jim Breslin. From the HSE, I thank the CEO, Mr. Paul Reid, the chief clinical officer, Dr. Colm Henry, Ms Anne O'Connor and Mr. Liam Woods for attending. Is it agreed that we adjourn until Tuesday, 17 December at 5 p.m.? Agreed.

The joint committee adjourned at 1.35 p.m. until 5 p.m. on Tuesday, 17 December 2019.