Update on Sláintecare

I welcome the witnesses to our meeting. They are all presenting remotely and will provide an update on the implementation of Sláintecare. They are Ms Laura Magahy, executive director, Sláintecare, who is joined by Ms Ciara Mellett, Ms Caroline Pigott and Ms Grainne Healy, and from the HSE we have Mr. Dean Sullivan, chief strategy officer.

Before we begin I must read out the usual note on privilege. It is a standard procedure and I apologise for delaying the meeting. Before we hear the witnesses' opening statements, I need to point out that there is uncertainty if parliamentary privilege applies to witnesses giving evidence from a location outside the parliamentary precincts of Leinster House. I ask our guests to note that the constitutional protection afforded to witnesses presenting in person in Leinster House may not extend to those presenting remotely. No clear guidance can be given on whether, or the extent to which, the evidence given is covered by absolute privilege of a statutory nature. Therefore, if a witness is directed by the Chair to cease giving evidence on a particular matter, he or she must respect that direction.

The witnesses' presentations have already been circulated to members of the committee. They will have ten minutes in total to make their submission. We are working to a two-hour window for a meeting. I look forward to the witnesses' submission.

Ms Laura Magahy

I thank the Chairman. Can everyone hear me?

Loud and clear.

Ms Laura Magahy

I thank the members for the opportunity to meet with them. I have met some of them in person. I have not met others but it is a pleasure and a privilege to meet with all the members.

I will put up our opening statement on the screen.

This is the technical part of the meeting.

Ms Laura Magahy

Can the Chairman and the members see that?

Ms Laura Magahy

I want to introduce myself and my colleague, Dean Sullivan, who we work with closely in the HSE. Ciara Mellett is the new head of Healthy Ireland, which is a key part of Sláintecare. Caroline Pigott is our head of resources in the Sláintecare office and Grainne Healy is our head of citizen engagement. If the members have any particular questions on those areas they can address them to those colleagues.

As most of the members know, the Sláintecare report emanated from the all-party Committee on the Future of Healthcare. It is a ten-year healthcare reform. We translated that into an implementation strategy, an action plan and, this year, a joint action programme. We are taking a programmatic approach to the implementation of this vast and exciting programme.

The key principles are delivering the right care in the right place at the right time and given by the right team; promoting health and well-being and preventing illness; bringing the majority of care into the community; creating an integrated system of care that is provided on the basis of need and not ability to pay; and moving from long waiting times to a timely service, with accountability and performance at the heart of it. Fundamentally, it is about trying to deliver a health service that has the capability and capacity to manage changing needs. This will be done through a population-based planning approach with clear pathways between GPs, community and social care services and hospitals and empowerment of front-line staff, with one budget per region. It was a decision by Government last year that we would be moving to this regional implementation. Fundamentally, it is about many parts of the system working together in terms of community healthcare workers, occupational health, dental services, GPs etc. and all of the HSE colleagues across the system.

We are in year two of implementation. Our job in the implementation office, which is based in the Department of Health, is to ensure that all parts of the system are following the strategy, to work collaboratively and to report on progress. This year, it is also about learning the lessons from Covid-19.

I will not go through them but we have a variety of implementation work streams. It is a vast programme with many moving cogs that all need to work together, and there is a strategy behind that. Fundamental to it, and it was very much addressed in the budget, is the capacity and access programme, which is about making sure we have enough access so that people can hit the Sláintecare target waiting times for inpatient, outpatient, diagnostics, emergency department, ED, and community care and that we have enough human and infrastructural capacity after reforms in line with the health capacity review. These are divided into three big pillars. One is about healthy living, which is our Healthy Ireland programme. Another is about enhanced community care, which I will talk about, and the other is about hospital productivity improvements.

Regarding progress to date on healthy living, we have our Healthy Ireland strategy, which rolls out the obesity policy, physical health and sexual health strategies and a focus on prevention and citizen engagement. We have many initiatives with partners across the country to roll that out, including with Healthy Cities and Counties, the Healthy Ireland charter network, the warmth and well-being scheme and the Making Every Contact Count initiative through GPs.

Interestingly, in the budget for next year we have a new area-based health and well-being initiative in disadvantaged areas with a ring-fenced additional €20 million for Healthy Ireland this year, which we very much welcome.

In terms of enhanced community care, the focus is on rolling out community healthcare networks with a basis of population for 50,000 in a group. There will be 96 of those across the country,with chronic disease and older persons specialist hubs, integrated care, GPs, community and hospitals. This will be enabled through healthcare pathways, and I would be very interested in elaborating on that if we get the opportunity to do so. The approach is to help these mini-communities of approximately 50,000 across the country.

The impact of this community care initiative will be to move patients with ambulatory-care-sensitive conditions from hospitals into the community. The funding in yesterday's budget and through last year is very welcome and will mean these 96 area-based services can be rolled out and we can start to give the care in the community that is absolutely needed. The provision will be based around the older persons and chronic disease service model, moving between the hospital, community and GPs and making sure we can treat people and keep them living well at home as long as possible.

Throughout this year we have had some very interesting innovation funds, with 122 different projects all around the country represented by the little red dots members can see on the screen. These projects are about encouraging innovation, shifting care to the community and scaling and sharing examples of best practice and processes for chronic disease management. There are some lovely examples of this happening throughout the country and fantastic learnings coming through from these projects, which will be scaled into next year. I have set out the details of the different projects in my opening statement but I will not go through them now. Fundamentally, they are about providing services for people and making sure they get the right care in the right place.

In terms of hospital productivity, we are looking at streamlining ways of working. There have been great innovations such as the ambulance service's hear and treat initiative, pathways to treat people outside of hospital, virtual clinics and trauma centres and hospital avoidance measures. An example is the virtual clinics for heart failure which have moved outpatient department treatment into the community. This has meant fewer people going to hospital, with 90% of treatment now being delivered in the community. We are making great progress on our elective hospitals development project and hope to have a business case ready before the end of the year. The oversight group is being chaired by Professor Frank Keane.

Regarding the implementation status, we have had, through 2020, a quarter of the funding needed for community services. That allocation is massively augmented in the budget for 2021. Our e-health priorities are agreed and capital funded, we have a business case for elective hospitals and there are innovative care re-design initiatives addressing waiting lists. We were very pleased that the programme for Government reaffirmed the commitment to Sláintecare and we are very grateful for the support of this committee in keeping an all-party focus on its implementation.

I do not have time to go through the many learnings from Covid. Many things were fast-tracked during the pandemic, particularly e-health and new ways of working. People showed they could adapt and were up for a change and looking for new ways of doing things. We see this in the use of e-health video consultations, the deployment of the individual health identifier, the attend anywhere booking system and Healthlink, which gathers information back to GPs. We have a superb programme of e-health initiatives which is now fully funded in the budget and we will be able to implement it with speed over the next two years. Huge progress was made on the individual health identifier initiative this year. Everybody in the country now has an identifier and we are moving towards a shared care record in the coming years.

Our priorities for 2020 to 2023 are, first, to keep people well at home or near home, out of hospital and living independent lives. That will be worked on through a series of initiatives which I do not have time to go through today but are based around health pathways, enhanced community funding, scaling integration funds and implementing related projects. Our second priority is to achieve the waiting list targets through implementing the capacity and access programme, devising a multi-annual waiting list plan and commissioning the ambulatory elective centres. The third priority is around standing back and looking at things from the perspective of a citizen care master plan, working towards universal eligibility and multi-annual funding.

The budget has provided a huge investment in Sláintecare, amounting to approximately €1.34 billion. It will provide permanent funding for initiatives that have sometimes only had part-time funding. It is a really welcome initiative. The challenges and implementation risks for our implementation office are around ensuring there is a co-ordination of effort moving in the direction in which Sláintecare was set by the Oireachtas committee. The recruitment at scale is going to be a big issue. A huge investment in people is required in terms of getting the right personnel in place. The ongoing Covid impact on non-Covid services is something we all must live with and adapt to over time.

I thank the Chairman and members for the opportunity to discuss these matters with the committee. I am very happy to continue the discussion.

Chairman

Thank you very much, Ms Magahy. I now invite Mr. Sullivan, Sláintecare's chief strategy and planning officer, to make his presentation.

Mr. Dean Sullivan

Thank you, Chairman. As Ms Magahy said, we are delighted to have this opportunity to engage with the committee and meet the new members. As the committee is aware, during 2020, the Irish health services faced unprecedented pressures as a result of the Covid-19 pandemic. Following NPHET's decision on 27 March regarding the required public health measures, many non-urgent healthcare services were reduced or suspended altogether. In recent months, the HSE has focused on restoring those services as far as possible, which involves delivering care in very different ways and in different settings and maximising opportunities fro technology.

Many of the service changes made this year in the context of Covid-19 align fully with the vision and direction of travel set out in Sláintecare but there remains much to do if we are to effect the complete transformation of healthcare services in Ireland that is required. The OECD's recent country profile for 2019 noted that, in comparison with other countries, Ireland has made good progress on life expectancy but some members of our community still experience worse outcomes than others. We consume too much alcohol and do not maintain healthy weights. Access to services is an issue and we have a lower proportion per head of population of practising doctors than elsewhere. We must seek to achieve better outcomes for everybody, recognising that where we are falling behind, we need to address that and focusing our efforts on reversing those trends and accelerating the digitisation of our health service.

A key principle of Sláintecare, as Ms Magahy outlined, is the right of patients to timely access to all healthcare and social care services according to clinical need. In addition to the recent impact of Covid-19, there were already increasing pressures for a number of years on our scheduled and unscheduled care services as a result of population growth, increasing instances of chronic disease and an aging population. As well as needing the right people and the right infrastructure, including buildings, equipment and technology, to deliver the right services, we need to recalibrate and remodel how we deliver those services. Consistent with Sláintecare, we are seeking to shift the delivery of care from the hospital setting to community settings, with a greater emphasis on prevention and supporting the population to remain healthy and well. Our aim is to sustainably address long waiting times for scheduled care services and in emergency departments, rather than just putting in short-term fixes, particularly for older people and those with more complex needs. In that context, it is crucial that we reduce bed occupancy levels in hospitals and reduce our reliance on community residential models of care by expanding our primary and community care services. We must enable our aging population to maintain their independence and live in the community by delivering care as close as possible to patients' homes.

While we anticipate that the continued management of Covid-19 and the restarting and delivery of core services will be a primary focus for us over the next 12 to 18 months, the wider transformation of services for the long term must occur in parallel in order to ensure we emerge stronger from the pandemic and build on the positive changes we have seen within the service in the past year. The implementation of the recommendations of the 2018 health service capacity review has been agreed by both the Department and the HSE as a starting point for developing our capacity across community and acute services, while also reducing bed demand and improving the health of the population. The capacity review identifies the need for significant increases in capacity across a range of community and acute services. Consistent with that, we have made investments in a range of community and acute services, including additional home support hours and enhanced home support packages. As Ms Magahy said, progress on the community health networks and community specialist teams will very much accelerate in the next year. There will be a focus on ramping up the availability of diagnostics to GPs in the community and other settings and increasing the number of community, step-down and acute beds. The very welcome investment in yesterday's budget for the health service will allow further significant increases in capacity during 2021.

Working closely with Ms Magahy and other departmental colleagues, the implementation of Sláintecare will continue to feature very prominently in the work of the HSE in all our planning processes and also in our operational decision making. It is clear that we will be living with Covid-19 and its impacts for some time to come. Our experience in recent months demonstrates that we are capable of driving positive change and innovating in response to unprecedented challenges. We are living in extraordinary times where, despite the challenges the pandemic presents, there are nonetheless huge opportunities for us to make real changes happen for patients.

Chairman

Thank you, Mr. Sullivan. We will now begin the first round of questions and answers, starting with Senator Kyne.

Senator Seán Kyne

I think the witnesses for their presentations. They have provided us with a lot of information on what is a very important area.

We had a presentation last week from mental health groups, specifically Mental Health Ireland and Jigsaw. The representatives spoke about the percentage of the budget going to mental health and we also heard about the percentage going to GP and primary care services. Everybody's percentage cannot increase because, otherwise, that for some area of the health sector would have to drop. Where are we out of step, comparatively, with our EU counterparts in the context of health spending and how can it be reprofiled?

There was mention of community healthcare networks. How do these compare with the primary care settings? I presume they would be part of that. We have seen the rolling out of many impressive buildings and there is always a question regarding buy-in from GPs. We have the infrastructure in many parts but not the buy-in from GPs.

There are areas in my county and close to Galway city, for example, that would not be covered by Westdoc. This can have an impact on recruitment of GPs. The system could break down if the recruitment is not there. If we are looking to invest, should we start by ensuring that there is adequate cover for Westdoc and other regional services?

I am interested in the issue of chronic illness. Heart failure in a community setting is very often overlooked, especially in comparison with cancer, but it is responsible for one in every two hospital admissions relating to people over 65. This is heart failure as opposed to heart attacks, although the difference may not be understood by everybody in the country. Do community voluntary charity organisations feature to the fullest extent in all of this? For example, Croí in the west of Ireland undertakes really excellent work with people on a holistic approach to health. Could more be done in this regard?

Mr. O'Sullivan mentioned the long waits for scheduled care services and accident and emergency departments. We will speak at some stage about capital plans. There are areas with new accident and emergency departments, such as Limerick and Kilkenny, while areas like Galway, based on the current timeline, could be four or five years waiting for a new accident and emergency department to open. Will these infrastructural deficits have an impact on the implementation of Sláintecare? Is the timeline too long and will this have an impact?

Ms Laura Magahy

I thank the Senator and will take his questions in order. The reprofiling of health spending is very interesting. The Economic and Social Research Institute, ESRI, has just finished a benchmarking exercise in respect of where Ireland sits in the international context. It was quite difficult to do because we include disabilities, mental health and other definitions in our spending, whereas other jurisdictions do not.

I take the Senator's point on mental health and I am very happy to say we advanced significant funding to Jigsaw during the pandemic. Jigsaw is represented on our Sláintecare implementation advisory council. We are very aware of the work it is doing.

The Senator asked about community healthcare networks and how they link with primary care settings. The community healthcare networks are really interesting from a population planning perspective. They will be able to predict the needs of a population of an average of 50,000 people and adjust the services needed for the population. The primary care centre's role is critical in that.

The Senator asked about GP buy-in. We have a very engaged working arrangement with GPs and we meet every three weeks. We have agreed a programme of work with them that also includes looking at future strategies for GPs, especially in the terms of the topics raised by the Senator, including recruitment in a rural setting. That is a major issue for GPs. We have also agreed to fund the benchmarking and monitoring of the chronic disease management that GPs will be doing. They have kindly agreed to work in close partnership with us in healthcare pathways, which is a very interesting system. I will ask Ms Mellett to elaborate on that if we have time.

The Senator asked about relief for GPs in the context of Westdoc. We have a very interesting initiative happening this year with advance triage and this is being funded by the National Ambulance Service. If people are anxious during the night they can phone up and be directed either to a service that is local or in a hospital, with the goal being to have this staffed by GPs. We look forward to working with the ambulance service in rolling that out, as it is a very exciting initiative.

The Senator mentioned Croí, which we have funded. The work it has done on heart failure is one of the projects we have been delighted to fund. The Senator is absolutely right that this is fantastic work. It is something we will look at in terms of scaling. The example I gave during the presentation was a remote heart failure clinic that is being run by Kilkenny and St. Vincent's hospitals. There are slots available for GPs to phone in and get a senior consultant's advice on whether a patient is doing well. It is a case of not bringing in people as an outpatient but having the expertise available on tap. The new ways of working we have been able to explore during the year are exactly what the Senator inquired about.

I will ask Dr. Healy to speak about community and voluntary organisations, which are a key part of our engagement. We have been very fortunate to have the support of the community and voluntary sector in the work we are advocating. Is it possible for my colleagues to speak about health pathways and the community and voluntary piece?

Yes, although the difficulty is that we are working in slots of ten minutes. Other questions were asked of Mr. O'Sullivan and I am not sure when he can answer them.

Ms Laura Magahy

They will be quick.

They can come in for a minute or two but I need to look at the clock. The lesson for members is that if they ask seven questions, we will not be able to get the answers from everybody.

Ms Ciara Mellett

I can give some information on the integrated care pathways. These are a means of documenting the current approach to a particular condition, set of symptoms or patient cohort. They are agreed by relevant health professionals and adopted to local circumstances. The initial focus for implementation is around the interface across primary care, community care and social care with the acute sector.

With regard to benefits, this is really about building integration between primary care and secondary care. It allows clinicians to drive service improvements. In countries where a similar approach has been implemented, they have found that not only does it help to identify the current approach but it also helps to identify gaps where services could be improved so people can work together. It allows a greater level of standardised care. This is not a one-size-fits-all approach, it is quite the opposite. A minimum standard is agreed on the basis of the resources available in each region or area. That results in a reduced variability of care, providing a better patient experience through more timely and consistent care.

The key purpose is to support GPs and others providing care in the community in order to provide more care away from the hospital setting. It gives information to GPs in order to support them in making more decisions when the patient is sitting in front of them in the general practice. I will not go into too much detail but I should say GPs are very strongly in favour of this approach and we are working with a broad range of stakeholders to try to implement this approach with our colleagues in the HSE.

Dr. Gráinne Healy

The involvement of the community team in the voluntary sector is very significant for the delivery of Sláintecare right across the board. We have seen real evidence of this with the 122 integration fund projects that have been in the process of being rolled out for over a year.

That involves local community groups such as those mentioned by the Senator. Croí was a good example. We have also been working with local mental health services and vulnerable groups that have their own representation, such as LGBT Ireland which works with LGBT people and the needs they have. Such organisations may offer care for older people or those with particular vulnerabilities. Having partnerships between medical professionals and voluntary groups is very important. It is particularly important to move towards the delivery of care as close to home as possible and in the community in order to reduce the footfall into acute settings. We have found that many people prefer to be cared for at home or with their local community supporting them. It is an important delivery. Many of the 102 projects involve really interesting new pathways for care that are delivering the right care in the right place for those people.

Mr. Dean Sullivan

I do not have much time, so I will be brief. To build on what the previous speakers said around networks and so on, as well as to reassure members regarding general practitioner, GP, buy-in and so on, there were extensive discussions with GPs and other staff groups as part of the 2019 agreement to secure their buy-in through the relevant unions. The discussions involved taking that agreement forward and the development of the networks. As my colleagues have stated, voluntary groups are an integral part of the local network arrangement. The whole point of what we are trying to get towards with populations of 50,000 is that we can do things more locally and join things up in a much more straightforward manner than one can nationally or regionally. This initiative is very positive in that space.

The Senator asked about infrastructure and whether it is limiting step in this context. Obviously, there will always be more demands for capital and resources in general than there are resources available, but I assure members that we have robust prioritisation processes in place to ensure that all the capital resources we have are directed to maximum value, such as investing in additional equipment or new buildings or tidying up existing buildings and so on. There is a process to address issues that arise. The Senator mentioned the issue of front door capacity. For a combination of reasons, that issue would receive a high rating in any prioritisation process. It would be daft for us, given the budget outcome yesterday around some of the revenue funding and so on, to have everything lined up in terms of an ability to put additional capacity on the ground but then find that we did not have the kit for staff to use or a safe, modern and appropriate building for them to work in. We work very hard to ensure the revenue and capital sides of the house are very closely aligned. One of the reasons the service planning process we will conclude in the coming weeks is being taken forward in parallel with the capital planning process is to ensure the two join up.

I welcome the witnesses and thank Ms Magahy and Mr. Sullivan for their opening statements. I have very distinct questions, some of which will involve looking for figures, if our guests have them. My first set of questions is for Mr. Sullivan. The implementation strategy document refers to introducing additional acute hospital capacity of 2,600 beds, including new elective facilities. I presume those are additional beds above the health service capacity review and national development plan. What was the baseline figure to which those 2,600 beds would be additional?

Mr. Dean Sullivan

The starting point for the 2018 PA Consulting capacity review was the level of capacity in the system as of 2016. The 2,600 capacity referred to by the Deputy as an increase was the increase forecast to be required between 2016 and 2031 to-----

I understand that. That is the 2,600 increase, but on what figure-----

Mr. Dean Sullivan

It was from a starting point of just over 12,700.

The starting point was 12,700. How many acute beds are there in the system now? Does Mr. Sullivan have the up-to-date figure in that regard?

Mr. Dean Sullivan

I do. For clarity, the baseline was 12,700. As of the end of last year, that baseline had increased to 13,200 inpatient, day case and adult critical care beds.

I am asking about acute beds. How many acute beds are there in the system?

Mr. Dean Sullivan

That is what I was saying. At the end of 2019, there were 13,241 permanently and recurrently funded acute beds in the system. Obviously, there are a number of temporarily funded beds, especially in the context of Covid, which can confuse matters a little. In terms of the budget announcement yesterday and the additional capacity that has been put in place on the ground through this year, we should have funding to allow us to increase that figure of 13,240 to just under 14,500 by the end of 2021.

The number of beds will increase to 14,500.

Mr. Dean Sullivan

It will increase to 14,490-odd, to be precise.

That refers to permanent funded beds.

Mr. Dean Sullivan

Yes. That is a crucial point as not all beds are the same. The number relates to beds for which we have a recurrent funding stream. That is the only point of sanity in terms of Ms Magahy and me being able to track progress against the 2018 capacity review. It set a baseline in respect of permanently funded beds and, as such, the only way in which we can monitor progress is on the basis of additional permanently funded beds.

I refer to wait times. The target set in Sláintecare was that access to a hospital consultant should take no more than 12 weeks. Figures recently released by the National Treatment Purchase Fund indicate that the number of people waiting to see a consultant had risen again, to 612,283. The number of people waiting for 12 months or more is 249,959, up from 243,000. Has Covid altered or readjusted the timeframes and targets relating to reducing wait times? If the number of people waiting to see a hospital consultant and the number of people waiting more than 12 months have gone up, are the targets relating to reducing the wait time to 12 weeks now under review again, given that Covid has interrupted several core acute services?

Mr. Dean Sullivan

That is a good point. The Sláintecare targets are that it should take ten weeks to go from GP referral to being seen in outpatients and 12 weeks thereafter to receive definitive treatment. It should take ten days for a diagnostic test if that is required. As the Deputy indicated, Covid has had a material impact, in some cases of more than 50%, on levels of capacity and activity. That is why in the winter and pandemic plans we sought to secure extra resources to help close the gap in terms of lost capacity. We have been successful in that regard, which is fantastic. At this time, it is inevitable that there will be an impact in terms of the timeline for bringing in the Sláintecare targets. It would be a big ask in terms of treatment, those waiting for inpatient or day case care and so on, to even hope that those targets would be reached. The total number of outpatients has increased from just under 570,000 in September 2019 to 613,000 now. Total inpatient and day cases increased from 68,000 to 76,000.

We had been making some progress on the inpatient day case treatment times prior to the onset of Covid but the gains in that progress have been lost in the context of Covid. In summary, the point the Deputy is making is right because, first, there are more patients waiting now and, second, for the foreseeable future it will be hard to deliver something close to the levels of activity that were delivered pre-Covid. It will affect the timeline for introducing the Sláintecare waiting times. However, through a combination of additional capacity and transformation in how we deliver services, we are still committed to delivering on those targets. They are crucial to the confidence that the public and the public's representatives have in the service. It is very important. Many people are waiting in pain and distress. It is a key priority for the HSE right up to the board of the organisation.

I have a question about elective hospitals. The programme for Government commitment did not identify the number of hospitals, but we know Sláintecare supported three elective hospitals in different parts of the country and there is a high-level team examining it. What timeframe are we facing to get to a point where we can start to see concrete proposals? Business plans are being examined, but as regards moving from a business plan to having the capital funding in place or at least an application for capital funding, what realistic timeframe are we facing? What was the intended timeframe for having these elective hospitals built and open, or was there any timeframe in the plan?

Ms Laura Magahy

Electives are a key part of addressing waiting lists. A great deal of work has been done under Frank Keane's chairmanship and by colleagues across the Department of Health and the HSE to look at the terms of reference and the things we need to do to develop the capacity over a ten-year horizon of need, quicker higher access, to drive down the waiting lists and reduce the cancellations. We will have the business case done by the end of the year. The capital funding is in place, so then it is a matter of implementing. The decision we are looking at is how these can be done as quickly as possible. Is there a way we can do what has been done in Tallaght, for example, which is to adapt an existing set of buildings to get four ambulatory elective theatres? They will be opening by the end of the year. That is a highly significant initiative which will, after one year, address 5% of the waiting lists and hit those Sláintecare targets. We are examining if we can deliver them not in the normal five- or ten-year building programme timeframe, but something much more lively and alert in order that people can get day surgery procedures as quickly as possible.

The national development plan commits to having centres in Dublin, Cork and Galway. We have looked at, and finished, the question of what provision is needed for the entire country. There is no point in just looking at what is needed in Galway, when those who live outside Galway are not provided for. We stood back completely and took a countrywide look at the elective procedures that are needed and defined them under ten different specialties. Now, we are in the middle of saying what this translates to in a spatial brief. We are assessing what is the quickest way of getting these implemented, whether it is through direct build, adapting existing infrastructure or whether there is a quicker way of doing it. We have calls out through various channels to get to that answer as quickly as possible. We cannot wait ten years for these elective centres.

I thank the team for the presentation. I have a series of short questions. Regarding the slogan of the right care in the right place at the right time, when will we see the first children in the new national children's hospital?

Ms Laura Magahy

I will ask Dean Sullivan to answer that.

Mr. Dean Sullivan

Thanks, Laura. As members will be aware-----

A short answer would be good.

Mr. Dean Sullivan

Pardon?

It was a short question. A short answer would be good.

Mr. Dean Sullivan

I will try to give a short answer. The target opening date for the satellite centres is 2021 and for the new children's hospital is 2023. However, it has been reported reasonably well in the public domain that there have been some challenges in the timeline linked to Covid and, indeed, some issues that existed before Covid. We are currently reviewing that timeline. For the moment, the target timeline is 2023, until it is decided to be something different, but there are significant challenges associated with that.

What is Mr. Sullivan's best guesstimate?

Ms Laura Magahy

Do not do it, Dean.

Mr. Dean Sullivan

If I were to give my best guesstimate, I would say that the 2023 date is very challenging. Given that the Chairman warned us at the start about privilege and so forth in calling in online, it is probably best to leave it at that, if that is okay.

I thank Mr. Sullivan. Regarding breast cancer screening and other types of screening, how has that been impacted and how is it being addressed?

Who are you going to ask?

Whoever wishes to take it.

Mr. Dean Sullivan

I am happy to kick off on that. Clearly, a number of key services were impacted in March and April at the time of the first wave of Covid. It has been a priority for the organisation to get those services back up and good progress is being made on that. In terms of the detail of the exact position now with that specific service across the country, I will be happy to get a written update. As has been said, it is a key priority for the organisation.

Perhaps we can follow up on a written update. Regarding Sláintecare and the organic nature of it - this question is for Ms Magahy - 50 or 60 years ago we had an institutional setting, particularly for matters such as mental health, if that is not a misnomer. Then the emphasis was to move it - it continues to be to move it - into the community. However, Deputies and Senators, as constituency representatives, have known that there was significant pressure on the provision of community care in the home and in other community settings. What has been learned with regard to Sláintecare? For example, if this is not the only pandemic we ever experience in our lifetimes, what has the team learned about trying to deliver continuous care to people in their homes in a safe way? How much is the inability to deliver it safely due to the provision of items such as adequate PPE? Specifically, things like respite care would be a priority for a small number of parents in the constituency as they are under so much pressure. The numbers relating to the provision of respite care are significantly reduced, which means the parents of adult children or children with special needs are the ones who have probably carried the greatest burden outside of front-line staff during the pandemic due to their inability to access this. What stops them accessing it? It seems that the provision of proper PPE would be one part of it.

There are two parts to that question. It is my last question in this five minutes so the witnesses have time to respond to it. What lessons have there been regarding the provision of community health, be it is people's homes or in other community settings? What is stopping the provision of proper respite and other community care in facilities funded by the HSE but perhaps run by other organisations?

Ms Laura Magahy

I will start and then ask Dean Sullivan to contribute on operational questions. It might be the case that we need to follow up. People with children with disabilities have been badly impacted by Covid. Day services have not been available and people coming into the home were restricted in the earlier days.

It is a significant issue that needs to be thought about carefully from a policy perspective if this pandemic continues.

Some lessons to be learned might be around the importance of having broadband in every home. When services were being delivered in a different way, such as physiotherapy, we have learned from some of our integration funds that people who were able to respond to a programme of activity online were helped by it, although it did not suit everybody. As people began to learn to live with the disease, it became possible for people to visit other people in the home. That does not counteract the social side and it does not counteract children missing going to school, meeting their comrades and the rhythm of every day. If the thinking is that this will go on for much longer, the model of care for people with disabilities needs to be thought about. This also applies to older people who would be used to going to day service settings, people with Alzheimer's disease and those caring for people with Alzheimer's disease, etc. It is a significant burden for people who are caring for loved ones. I can follow up or ask Mr. Sullivan to follow up with his colleagues on other initiatives, but those are the things we have learned.

Mr. Dean Sullivan

The point about access to day services for people with disabilities is well made. Trying to return them to closer to pre-Covid levels was specifically referenced in the budget, which is welcome. The more general point about lessons learned, whether relating to PPE, preparing for a pandemic or whatever else, is that there are ongoing processes in the HSE and working with departmental colleagues to ensure that we capture all the learning, both the good and the bad, so that we can reflect on what we might do differently in future to prepare for future waves of this pandemic or indeed for future pandemics. On some of the more specific points the Deputy made, if it is all right, we will secure a more detailed update from operational colleagues as Ms Magahy suggested.

There is a good book by Ida Milne on the Spanish flu in Ireland. There was a surge in November and a further surge the following March, then, thankfully, the flu disappeared. It looks like we are in the middle of a second surge and that it will be with us for a year and a half. What have we learned about respite and other matters that we might have been frightened to do at the start? Can PPE cover that? Can a child who has special needs, whose parents were used to that child being taken into a residential setting once or twice in a year, be provided with respite care? I know it is still restricted and am wondering what is stopping that, given that hospitals are still open. If the witnesses cannot answer, that is fine, and they can send details afterwards. Have visitations to people's homes returned to levels they were at?

Mr. Dean Sullivan

If it is all right, we will get a written update on those matters, because Ms Magahy and I would only be able to give a high-level response at this stage.

I welcome all our guests. I think Deputy Durkan and I are the only two who were on the Committee on the Future of Healthcare, which addressed Sláintecare. I cast my mind back to those cross-party deliberations over an 11 month period with 14 Deputies. The issue that came up most frequently during those deliberations was the fact that the organisation of the HSE is disjointed and incoherent. At a time when we are supposed to have integrated care and integrated budgets, the HSE had seven hospital groups, nine community health organisations and God knows how many mental health teams and other structures. There was no coherence whatsoever. Members unanimously, as well as the vast majority of people who came in to give evidence, identified this as a key problem in how we deliver services. There are hospitals doing one thing and community services doing another, and never the twain shall meet.

There was a strong recommendation from that committee that we needed to co-ordinate all of that and restructure it with a regional structure so that we would have a number of regional organisations, perhaps six, that would include hospitals, community and all other health and social care services. There would be a single budget for each of those regions and a single management structure so that decisions could be taken on the spending of money in the best place. If it was more economical and effective to spend money on community services rather than expensive hospital services, then that money could be redirected, and there would be coherence and value for money. That was taken up, it was in the final report and it was accepted by Government, but I gather it has now been put on hold. That is really disappointing because that was a key recommendation. Unless we get that kind of coherence about the structure, the budget and the management accountability for the delivery of services and the spending of money on a regional basis, we are just going to continue with the HSE being amorphous, with nobody knowing who is in charge or where accountability lies. Is it the case that that has been put on hold and, if so, why? When are we likely to get back to implementing that key Sláintecare recommendation?

My second question relates to elective hospitals and Ms Magahy has responded to this to some extent. In the witnesses' consideration of that, are they considering the potential purchase of a private hospital, as happened in Edinburgh, to kickstart the shift to elective-only hospitals? I know the witnesses are in touch with Cappagh National Orthopaedic Hospital. There is plenty of space there and potential to develop it as an elective orthopaedic hospital. Is that on the cards?

My last question relates to the two key objectives of Sláintecare. One was to shift activity away from hospitals to the community so there would be better health outcomes and value for money. The other was to remove cost as an obstacle to people accessing care, because we are the only country in Europe where people have to pay the full amount to see a general practitioner, physiotherapist or such. Is there any funding in yesterday's budget to remove cost? It seems to have slipped down the agenda. We have not heard anything about better, cheaper access to GP care, community care or medicines. Can we expect anything out of the budget in that regard? Affordability is an important element of Sláintecare.

Ms Laura Magahy

The Deputy's first question was about the regions. That is and has been a critical part of Sláintecare's implementation. The rationalisation, population-based focus, clear governance over a defined population, the empowerment of front-line staff, equitable access to services, the budget being distributed on an equitable basis for a population, and a clear regional governance framework are key parts of Sláintecare. It is in the programme for Government. The reality of what has happened is that we had a joint working group which Mr. Sullivan and I co-chaired. We had worked out a high level programmatic approach for the implementation, which was concluded in February of this year, then Covid hit. It was put on ice at that time and needs to be reconsidered in consultation with the HSE, its board and chief executive, and with the Department. It is in the programme for Government and we consider it as a key part of Sláintecare.

There was a Government decision on the geography of the regions and a commitment to come back with a business case that clearly outlines the rationale, costs and risks in ruling out these regions. That is the next concrete step that needs to be considered and the timing of that needs to be considered too.

There is no timeline on decisions. Is that the case?

Ms Laura Magahy

It is an active discussion but we consider it a key part of the implementation of Sláintecare.

Ms Laura Magahy

I thank the Deputy for the question. The next question concerned electives. All options for speedy delivery are on the table. Following a procurement process, we have engaged a commercial company to examine if there is interest and availability among existing hospitals. There is also potential with hospital buildings that are to be vacated. An example would be the current site of the National Children's Hospital if and when it moves to its new site, as well as other properties in the ownership of the HSE which become available. We have also been having conversations with the Land Development Agency, LDA, regarding what it might have available.

At a strategic level, an elective hospital would be a key regenerator of different areas in that it would bring many people to those areas. The Government would have that kind of perspective. We are trawling far and wide and our minds are open. It will be dependent on how big these centres will be. That detailed exercise is under way.

What is the timeline for decisions to be made in that regard?

Ms Laura Magahy

It is before Christmas. The way the system works is that it is necessary to do a strategic business case, looking at the different options, going through the rationale, the costing, the benefits and how large they are, etc. That strategic business case will be submitted to the Government before Christmas.

I thank Ms Magahy.

Ms Laura Magahy

We are actively engaged in that exercise and it is progressing well. On the shift to the community, perhaps the Deputy will refresh my memory and repeat the question.

I referred to removal of cost as a barrier to accessing care.

Ms Laura Magahy

It would not have been clear from the budget yesterday but I have the detail here. The more detailed announcement on the details of health spending was at noon today, so we are all missing that now. Regarding GPs, there will be access to 136,000 additional diagnostic tests in 2021 and the medical card eligibility will be extended to those aged over 70 years, with 56,000 people benefiting from that measure. From November 2020, there will be a reduction in prescription charges for those aged over 70 by 50 cent to €1 per item, and by 50 cent to €1.50 per item for those aged under 70. That will benefit about 1.5 million people who have medical card eligibility. It is heading close to the original recommendations the Deputy and her colleagues made in their report to the Oireachtas, so that is good.

Moving to the drug payment scheme, there is a reduction in the threshold, from €124 to €114 per month, which will benefit the approximately 1.38 million people who are registered on the scheme. We are not there fully, but we are getting there in respect of costs being removed as a barrier. What is really important for the next stage, within the context of community healthcare networks, is that we will be able to plan and look at how people move between hospitals and the community. The eligibility roadmap must be looked at in that context. There are some oddities in that regard, for example, someone with a medical card will be entitled to services in primary care, whereas people without a medical card might be referred to an outpatient waiting list. We need to streamline existing eligibility and ensure the kinks are ironed out of that system. The next stage will be to ensure that everybody has fair access to services.

I ask the witnesses to provide a written reply to the remaining questions, as we need to move to our next block of questions.

I thank our guests for appearing before the committee. I was not part of the Sláintecare report endeavour because Senators were not permitted to be a part of the process. Even though there are two Houses of the Oireachtas, Senators were not allowed to be part of-----

The Seanad was not sitting when the committee was set up.

There was a Seanad during the term, with respect to Deputy Shortall. I know significant representations were made for Senators to be a part of-----

I ask the Senator to ask his questions. I allowed him to contribute because he indicated he needed to leave soon.

That is fine, but that point had to be made. My question concerns the funding of section 39 organisations, which step in to provide supports that the State should be providing. An array of criteria is applied to that area. Some section 39 organisations get up to 95% funding, while others do not receive that amount of funding even though they may be providing as many, if not more, services. I am thinking of organisations such as the National Council for the Blind Ireland, NCBI, which gets 70% funding from the State and then must rely on fundraising for the other 30% of its income. Other section 39 organisations, however, are funded up to 90% or 95% by the State. Are there any plans to review the criteria for funding section 39 organisations? Has there been any audit of value for money in this area and whether value for money is being achieved?

An additional €4 billion was allocated to health in the budget, and we are all trying to work out the detail of what that means. It is a significant increase. Since I have been in the Oireachtas, we have been used to additional funding allocations to health of €1 billion or €2 billion in most years. Do the witnesses believe we are getting value for money now? I ask because I think most people do not believe we are. Are there any plans to-----

Two and a half minutes are left for the witnesses to respond.

I will stop there then but I think we need to review the timeframes.

We are working to a two-hour timeframe. I let the Senator in because he indicated he wanted to contribute and I thought he had to leave. The witnesses have about two minutes to respond. If they cannot respond in that time, I ask them to reply to the committee and Senator Conway in written form.

Ms Laura Magahy

I ask Mr. Sullivan to take the questions regarding the section 39 organisations and I will address the question on value for money. A robust process is in place once the service plan is agreed with the HSE, which is the major supplier of services to the State. That is an oversight process between the HSE and the Department of Health. The service plan lists what has to be done each year for the money the section 39 organisations receive.

The people in the health service work extremely hard. With regard to value for money, they have proven themselves adaptable and agile in response to something as immense as the impact of the coronavirus. A robust system is still in place for oversight. It will always be possible to get better value for money. Having the ability to look at things on a regional and population basis would assist in doing that because that is not as clear now. I say that because as people move between community services and hospital, their care journey is paid for by different parts of the system. Some parts might be paid through the GP, some through community services and some through hospital services. It is not always possible, therefore, to see what the total journey of care is for people who move between the settings. There are, however, very robust systems within the HSE. That is particularly the case regarding activity-based funding in the hospitals, but it is less robust in community settings at the moment. That is something the e-health programme is designed to address in more detail.

Mr. Dean Sullivan

Building on what Ms Magahy said, securing value for money with the significant resources given to the HSE each year is a key priority for the organisation. I will not repeat the points made by Ms Magahy but I will address one particular issue. One of the key issues for us is to have robust, comparable data and information on relative performance. We have made huge strides in that area in recent months in strengthening our understanding of that process and where the opportunities lie, particularly on the acute side of the house but less so on the community side because of some of the data deficits that exist. Maximising value for the taxpayer from the resources we are given remains a priority for us in the future.

The vast majority of agreements with section 39 organisations are typically made between the relevant section 39 organisation and a community healthcare organisation or, in exceptional cases, a hospital group.

The expectation would be that that is where the discussions are happening with regard to levels of service and appropriate funding for those. There are historical anomalies which have led to particular levels of funding being awarded, but the bulk of discussions, insight, understanding and changes to the pattern and volume of services happens very much at that level.

May I ask specifically if there are any plans to review the criteria relating to section 39 companies and funding? There are historical issues with many of the companies involved, which are either being overfunded or underfunded. Are there plans to review the entire system and develop a more modern and appropriate means of funding?

Mr. Dean Sullivan

That has been an ongoing process. It would be most straightforward for us to respond to the Senator's question in writing. There are a lot of subtleties around the issue that I would prefer to capture in writing.

I would appreciate that.

I have two questions regarding service redesign that I will address to Ms Magahy and another on capital funding. One of the things that struck me from the briefing note was in respect of the national clinical lead for trauma services. In 2019, work was done in that area and staff were appointed. Particular work was done in Dublin hospitals regarding their submission to become trauma centres. An implementation group was also set up to oversee that. With the proviso that the ambulance service and how it operates is always a hot topic in Dublin, can the committee get a progress update on the work being done in Dublin hospitals?

The second issue is that there is a huge amount of work involved in the implementation of Sláintecare, which is not only about the move to primary care but also the treatment of chronic illnesses in the long term for citizens. The latter is a major concern and has a massive impact on people's quality of life. An issue that has been raised with me by a few groups, and by the Asthma Society of Ireland in particular, is the creation of registers. The Asthma Society of Ireland has reported that some of its members who attend medical services encounter difficulties in being recognised as having the condition they have. This is also relevant in the context of people with diabetes and epilepsy. There do not seem to be programmes for registers in Ireland, although they are quite prevalent in other EU countries, even those that operate under the constraints of GDPR, which I am sure is a concern when it comes to data collection. I would like to understand if the creation of such registers has been considered.

Finally, we have talked about capital funding today. This is a very important issue and I hope that the budget which has just been announced will help in that area. We have talked a great deal about elective procedures and the possibility of accessing capacity in private hospitals. My question concerns the community care side and relates to a much smaller-scale aspect of capital funding, particularly in the context of disadvantaged communities. I refer to the Healthy Ireland programmes and those lifestyle and well-being benefit programmes that are listed in the briefing note. I would like to understand what the decision-making process is regarding capital funding as it relates to those programmes. Are we trying to find bricks-and-mortar facilities to house those important community programmes that relate to illness prevention and, if so, where are we with that work?

Ms Laura Magahy

Mr. Sullivan can perhaps answer the question relating to the work done in trauma because he has been very involved with it.

Mr. Dean Sullivan

I am happy to answer that. The Department completed a trauma review a few years ago, the report relating to which contained 40 recommendations. Three or four of the recommendations related to work in the east of the country, as mentioned by the Deputy. We established a trauma implementation group approximately a year and a half ago and it has responsibility to make recommendations regarding the location of the major trauma centre and the trauma units within the Dublin area, the appointment of a national clinical lead, the taking forward of the by-pass protocols and the costing of the implementation of the trauma review as a whole. We made good progress in all aspects, with the implementation of more trauma by-pass protocols, the appointment of the national clinical lead, Mr. Keith Synnott, who has been in post for several months, and recommendations made and discussions ongoing with the Department in respect of the major trauma centre and trauma unit issue. In general, good progress has been made regarding all of these aspects and in discussion with the Department. We are now finalising the plan for the wider implementation of the trauma strategy and not just in respect of the issues relating to the east. Across the piece, good progress has been made.

To follow up, is there a timeline for completion of the implementation in the Dublin area?

Mr. Dean Sullivan

We have a timeline for progressing implementation in the Dublin area, but not for completion at this stage. I am hopeful of making substantial progress on that during 2021. The final completion of it might take two or three years, given that it will require much reconfiguration on different sites in terms of ensuring that the major trauma centre has access on site to all the various specialties that are required in a national trauma centre. I am hopeful of making good progress on it in 2021.

Ms Laura Magahy

I will answer the Deputy's other questions and will also supplement Mr. Sullivan's response.

There is €147 million of funding in the budget for implementing the national strategies and expert reviews. That includes the implementation of the trauma centre system and investment in the national ambulance service, which will be linked to it. That is good, because the work can now progress with some money behind it.

The Deputy mentioned the creation of registers. I am pleased to say that one of the innovation projects that we have funded is to create a register for diabetes, which we have not had before. It is being compiled at the moment. In the context of registers for other conditions, it is interesting that the Deputy referenced the Asthma Society of Ireland because it is represented on the Sláintecare advisory council. In discussion with the Asthma Society of Ireland and others, it is recognised that sometimes people have many chronic illnesses. For example, they may not just have asthma but also heart failure issues or diabetes. I am told that the difficulty in creating individual registers is the issue of people being on multiple registers. With the roll-out of the individual health identifier, however, that can be streamlined. There will not be a need for individual registers for individual conditions; there will be an individual health identifier, so the condition can be linked to the person, which is better than just having a register. With the agreement with the GPs and in the context of their management of chronic disease, which is paid for, we will be beginning the data collection process with them. The opportunity to roll out this chronic disease register is part of that work and has already been agreed.

The issue of Healthy Ireland is interesting because it is clearly operating, physically, through primary care centres through the Making Every Contact Count initiative. However, it is also operating at a wider level through local authorities. Almost every local authority now has a Healthy Ireland co-ordinator and plan. As recently as yesterday we were talking with the local authorities about a resilience campaign relating to mental and physical health, which will be coming on stream before the end of the year. In the context of the area-based disadvantage approach to Healthy Ireland whereby certain people are particularly disadvantaged, there is specific funding in place for a very exciting programme that can be implemented and rolled out next year.

There are now 135 primary care centres operational around the country. Many of them are top of the range, new infrastructure and will house the more than 2,000 primary care staff who will be recruited next year. There are great opportunities to link health and well-being. In terms of prevention it is about keeping people well in the community through primary care centres and GPs and avoiding hospital through chronic disease management in the community.

I thank the witnesses for their contributions in what is a very difficult time for everybody. My question is short but the answer may be long. What do Ms Magahy and Mr. Sullivan say to the charge that Sláintecare is largely aspirational, ambiguous on the issue of private healthcare, too technocratic and resistant to reform and that in the ten-year implementation programme universal healthcare will not be achieved? I acknowledge that the question is quite broad. It is my understanding that Sláintecare aims to achieve universal healthcare and to dismantle the two-tier healthcare system we have currently. Some people will level the aforementioned charges at Sláintecare and I am interested to hear what the witnesses have to say in response.

Ms Laura Magahy

I thank the Deputy for that great question and I am sure it is one that was widely debated when the Oireachtas committee was formulating its report. There is an absolute commitment to a universal health system and to separating public and private care. The objective of Sláintecare is to build and reinforce the public infrastructure, including staffing levels, and that is where the majority of today's funding is going. Sláintecare does not say, interestingly, that there should be no private care but that there should be a separation of public from private. In looking at how that would take place, the de Buitléir report last year recommended a series of steps. Critical to implementation is a new public-only consultant contract which will come into play from January next year. In public hospitals consultants can only provide public care and no private work will be permitted. That will separate the public and the private and make the differentiation between the systems much clearer. If a patient is in the public system, he or she will get care in public hospitals by publicly funded staff. That is a very important initiative. There are 300 consultant posts funded at €250,000 each in the budget that was announced yesterday and they will be rolling out next year.

There will always be some resistance to reform but what we have seen is that people are very willing to come on board with the principles of Sláintecare. They were obviously very well considered when they were written because they are things to which people can sign up and the principles of Sláintecare are understood by everybody. The delivery of them will be nuanced, depending on people's perspective. We have certainly found, and Covid has demonstrated in spades, that when people see the bigger picture and see where they fit within it, they are willing to go with it and are pleased to do so. They like that leadership and vision. I would say that has held and that the budget, to be honest, is a lever of change. The budget today will ensure that this aspect of Sláintecare is implemented at speed over the next year.

Mr. Dean Sullivan

To build on what Ms Magahy said, Sláintecare is actually quite specific on issues such as expectations around waiting times in emergency departments in hospitals of four hours and waiting times for scheduled care services, as we discussed earlier. It states very clearly that people should wait no longer than ten weeks for an outpatient appointment, 12 weeks for treatment and ten days for diagnostics. It is also very clear about the expectation of and need for universal access to healthcare that is free at the point of use. It is also very clear about the direction of travel in terms of delivering care as close as possible to the patient's home and about trying to support people to live healthy lives at home as independently as possible. There is nothing in there that any of us here or among the population at large could argue with but the challenge is giving life to that. We have made reasonable progress over the first couple of years, as Ms Magahy has described, and I hope that progress really accelerates in the next 12 to 18 months. In that context, the budget is a very welcome step in the right direction in terms of supporting the pace of change. We are in reasonable shape going forward and Sláintecare is quite clear about the things that it needs to be clear about.

Where would the witnesses like to see Sláintecare in five years, given that it is a ten-year plan?

Ms Laura Magahy

I want to see it done in five years. In fact, I want to see it done in four or three years. We are only two years into it. The report was written in 2017 and it took that length of time before our office was established and implementation systems agreed with the HSE and other colleagues. We are up and running now but I do not think it should take ten years to implement Sláintecare. We are well on the road towards doing that and every year that goes by we are advancing towards it. As I said earlier, the budget is a lever of change but it is not the only lever. We still need structures to support the changes and critically, we need e-health and the people to support them. Quite honestly, one of the biggest challenges will be recruiting the numbers of staff envisaged, which will be funded by the budget. As we know, it takes years to train professional staff and unless they are in the pipeline, we will not have them ready to switch on. That is going to be one of our biggest challenges. Now that we have money, we must make sure that we are able to recruit people and put them into the right place. We must also ensure that the systems are joined up and supported by e-health and that the structures are in place to support the changes required.

I thank the witnesses for being here. I have one question with two parts. Like Deputy Kenny's question, I am dealing with high-level or blue sky thinking. Obviously Covid-19 has had an impact on every part of our lives but particularly in the health sector. The witnesses have already alluded to this but how will the Covid-19 crisis affect the Sláintecare plan? Ms Magahy said that she wants to see this done in a couple of years but we do not have an endpoint for the realisation of Sláintecare. When the National Health Service was set up, people in Britain were told it would be done by a certain date and that was the end of it. When one does not have an endpoint, it is a little bit easier to extend and move things around. What impact will Covid-19 have on our Sláintecare implementation plans? Is that a bit like asking how long is a piece of string?

I am interested in two issues in particular, one of which is weariness among those working in the sector and the other is change management. A key element of this is buy-in from those who are going to be rolling it out. Weariness and burnout are pervasive and get into people's core. This is an issue for healthcare workers most of the time but Covid-19 has exacerbated it. Is the office engaging in strategic planning on how to deal with weariness and burnout in the sector? If the people rolling out the programme are not able to do it because they are exhausted, that will knock Sláintecare on the head. Is there long-term planning around the knock-on effects of Covid-19? Those effects will be society wide and include issues with people's physical and mental health, undiagnosed illnesses as well as delayed diagnoses. We have a shocked system and a shocked population. We do not yet know what the long-term implications will be but we know that people are missing out on diagnoses and so forth.

How does Ms Magahy see that impacting upon those timelines? As she said, she is optimistic about getting it done within a few years but there has been a big shock to the system. What plans are there to try to deal with that?

Ms Laura Magahy

That is a great series of questions and it is blue sky thinking. The Senator is correct, in that even when Sláintecare is done, it will require continuous improvement on an ongoing basis because nothing is ever finished. If we can manage to put in place the structures, systems, staffing, training and e-health, then the architecture of Sláintecare will be complete and it can continue iterating and improving thereafter.

The Senator is correct to say that there must be burnout in the system after Covid-19. It has been an incredible onslaught for people working in the system, both those working on the front line and those managing the pandemic. Colleagues in the HSE and the Department have been at the forefront of this in recent months and have been working unbelievable hours to try to deal with something they had not expected and do not fully understand, as nobody does. They have shown incredible resilience in doing so. I must say that people need hope that a better system is coming, that it is funded, that there is a plan for it and that they can see that things will get better. An indication of the need to fund that is that there is money in the budget for well-being for staff, and a particular programme of activity will be implemented in this area by the HSE. Therefore, there is recognition that there is an issue in terms of burnout and people being worried, as well as a programme being implemented in that respect.

The Senator also raised the issue of the wider societal impact of Covid-19, and the unknowns that exist. Some very good planning has been done through the clinical care programmes within the HSE and the Department in trying to anticipate and put in place specialist hubs in the community for people who have been impacted by Covid-19, particularly in the areas of respiratory and mental health. This will entail putting place more mental health supports for young people, older people and the staff of the health services and systems. Therefore, a good bit of anticipatory work has been done and has been factored into the community healthcare planning. When we started, we talked about community healthcare networks linking with primary care teams and specialist hubs for older people but now, there are also specialist hubs that will be focusing on the downstream effects of Covid. We do not know what will happen until we have a vaccine and things get better next year at some point, but people need hope that the system is going to change and that they will be a part of that. It is a recognition of all the work that people have put in.

I am going to call Senator Black next as I am conscious that the Fine Gael group has gone way over its allotted time. There will be time for others to speak.

I have a specific question relating to alcohol harm in this country. There is no doubt that Ireland has one of the highest levels of alcohol-related harm in Europe. If one looks at the evidence, three people a day die from an alcohol-related issue. Alcohol problems in Ireland are rated third, following heart disease and cancer. Alcohol is a factor in half of all suicides each day and 1,500 hospital beds are taken up with alcohol-related problems. Moreover, it costs the Exchequer €1.5 billion. We now know that breast cancer is related to moderate drinking among women and it is also a known cause of seven types of cancer. With regard to Sláintecare, will there be a comprehensive treatment strategy with fully resourced systems and services to arrest the rate of premature deaths and to reduce the impact of alcohol-related harm throughout Irish society? That is not even taking into consideration the impact on families of alcohol harm with regard to mental health, stress and anxiety. I work at the coalface on this issue with families and I see its impact every day. I believe that if we can get to the families and provide services to them in respect of interventions, we can break the cycle of addiction. What comprehensive treatment strategy is in Sláintecare with regard to alcohol harm?

Ms Laura Magahy

It is a key part of the Healthy Ireland pillar. Healthy Ireland is about prevention and self-care and the three big-ticket items under that pillar are obesity, smoking and alcohol prevention. There are comprehensive plans in place that are rolled out through NGOs, local authorities, the HSE and GPs. There is recognition that alcohol causes huge harm and has a knock-on effect on ongoing care, not to mention the devastation it causes to families. There is both recognition and funding in the budget to deal with the issue. I do not have the figure to hand but I can get it for the Senator later.

That would be great.

I wish to return to the issue of elective hospitals. While Ms Magahy has answered some questions on this issue already, I am a little confused because the committee got the same answers to questions on this issue 12 months ago. If one takes Cork as an example, a number of sites are clearly suitable for the development of a new elective hospital, one being in Sarsfield Court, which has more than 100 acres and is owned by the HSE. My understanding from Ms Magahy's comments this morning is that while a proposal will be made to the Government by the end of the year, that proposal will not identify the preferred site of development. I am confused about timelines in this regard because if the plan does not identify the site, we will spend another six to 12 months identifying a site, another two years trying to get planning permission and a further three years building the hospital. I am confused that although there is an area in which no new hospital bed has been provided in the past 30 years and which has experienced a huge growth in population, we seem to be pushing paper around without any clear answers. Four weeks ago, I asked the Minister for an update in writing. What Ms Magahy has presented to us today is not in writing. I would like it put in writing that a proposal will be made to the Government by the end of the year and that I do not have to ask the same questions in February 2021.

The second issue I wish to raise concerns community healthcare. In the past four years, as I understand the figures, there has been a 17% increase in the number of nurse managers and nurses within the hospital system. At the same time, the number of public health nurses has only increased by 3.5%. What are the plans to increase the level of qualified people at ground level within the community? I have seen no evidence of the increase in numbers in the professions that we require to provide healthcare within the community.

Ms Laura Magahy

First, I wish to reassure the Deputy that we are on the case in respect of elective hospitals and want to get the work done quickly. The goal is to have sites selected. We are aware of what is happening in Cork and have had submissions and discussions in this regard. The issue is finding the optimal location and the fastest way to get the work done, not just for Cork but also for Galway and Dublin, and to make sure the hospitals are sized correctly. We know about the sites but we want to make sure they have the right size, and that is the exercise we are completing at the moment. We can certainly update the Deputy in writing.

On the issue of community healthcare, I will make two observations. First of all, there is a significant boost in terms of community workers in the budget. There is a total of €425 million there for enhanced community and social care services.

Deputy Colm Burke's point about public health nurses is well made and they will be included in the configuration of that.

What increase has there been in the number of public health nurses employed in the past two years? My understanding is that an additional 60 nurses have been employed across the country.

Ms Laura Magahy

It is definitely more than that.

Could I have the figures?

Ms Laura Magahy

I will come back to Deputy Burke with the figures.

The figure I have is from the middle of 2019. Between December 2014 and the middle of 2019 there was an additional 60 nurses, which is an increase of approximately 3.5%, whereas in the hospital service there was an increase of 17% between nurse managers and nurses working on the front line. That is 17% compared with 3.5%. That does not fit when we are talking about community care.

Ms Laura Magahy

I will come back to the Deputy with the absolute figures. Is he talking simply about public health nurses or general nurses?

I am talking about public health nurses, because the issue now is that we want more people to stay at home and not to be in nursing homes. We need to make sure that we have a sufficient number of professionals to be able to deal with the new challenges posed by the number of people requiring care in the home. I have been involved in a case already that was covered by one of the national newspapers where a lady was getting an appalling level of care, yet her apartment was less than 100 yd from the base of the public health nurse.

Ms Laura Magahy

I can come back to the Deputy on that or perhaps Mr. Sullivan would like to comment if that is okay.

I am not blaming the public health nurse. It is about not having sufficient numbers.

Mr. Dean Sullivan

We can certainly come back on that as it is an operational issue. We can also give more definitive numbers on the number of nurses. I know that in this year alone we have offered 47 new nurse training places and, as Ms Magahy has indicated, the progress that we have made and expect to make around networks and specialist teams will result in a step-change increase in all aspects of the community workforce of nursing, health and social care professionals, in particular, but also other staff as well. I am happy to come back with more specific numbers on that, but there has been demonstrable progress during 2020 and that will accelerate in 2021.

It would be better to take the operational issue that was raised offline. To reassure the Deputy, of the 47 who have been offered places, 14 of those have already taken up posts.

Mr. Sullivan said 47 training positions have been provided. Is that a sufficient number going into training in view of the new challenges we have? The elderly population will increase from approximately 640,000 to more than 1 million in the next nine years. Therefore, we need to have a lot more people providing care at the community level.

Ms Laura Magahy

I might give a supplementary response if that is okay. Two issues have been raised. First, nursing staff are a key part of the workforce and while they are the biggest part of the workforce they are not the only part of the workforce, so there have been increases in other professions as well that provide valuable services in the community.

A second point, which I suggest to Mr. Sullivan that we might factor into the figures, is that there has been some very interesting work on what is called the community virtual ward where nurses are employed by the hospital but they provide services in the community. They follow patients out of the hospital and make sure that they are okay for two weeks after they leave hospital and the service is provided in the community. We need to give the committee a much broader picture of what is happening in terms of services involving nursing and other professionals who are giving these invaluable supports to people. We are completely on the same page with Deputy Burke. This is an essential part of keeping people well and at home and independent.

I thank Ms Magahy.

I apologise, as I have just come in from the transport committee. I listened to most of the contributions on a headset but I did not hear the entire debate. I have a number of questions for the witnesses and I value their answers more than what I will say.

I live very close to a primary care centre and I have some very small children at home. Developmental checks are crucial in the first and second years of a child's life. They identify if a child has failed to attain any of the benchmarks that are set and they can highlight a future difficulty a child may have, in terms of intellectual or physical disabilities. As Covid has ravaged its way through the health and economy of the country, how up to date are we with developmental checks? Are they happening when they need to happen and are we following up on them? I ask Mr. Sullivan to respond.

Mr. Dean Sullivan

I am happy to take that question. If I can, I will come back with a more detailed and substantive response but, as one might expect, I am aware that there has been an impact on those checks as a result of Covid. I am also aware there has been an ongoing corporate planning process within the HSE over the past year, and the importance of the checks came through consistently. I will give some specific numbers in terms of where we were, where we are now, and how quickly we are trying to get back to the previous position on that key issue.

I read in the press during the week that 90% of all medical needs are currently being met at GP level because people are reluctant to go to hospital because of the fears around Covid. Could any developmental checks be devolved to GP level, rather than the public health nurse, so that we could ensure some cases are followed up more quickly?

Mr. Dean Sullivan

Those issues are being explored. A particular set of skills is required to carry out those tests and I am not sure devolving them to a GP practice would be the solution, but all opportunities are being explored. The service provided needs to be right. It is probably best that I would come back with a more substantive response highlighting the gap in the service as a result of Covid and what we are doing to try to bridge the gap and manage the risk associated with that, given the importance of early checks on children's development.

I thank Mr. Sullivan. Could I ask Ms Magahy a follow-up question to what the previous speaker mentioned regarding nurses? Is there any detailed analysis from this year of the payroll cost of agency nurses versus those directly on the HSE payroll? It seems to me or to anyone who visits a hospital that if one gets into a detailed conversation with nurses, one still encounters a lot of agency nurses and yet the need for hospitals to be staffed to a high level has not gone away. If anything, it has increased significantly since the arrival of Covid. Is there any cost of agency nurses versus nurses on the HSE payroll and is there a strategy to get more nurses onto the HSE payroll so that the cost of agency nurses is diminished?

Ms Laura Magahy

"Yes" and "Yes" is the short answer. An analysis has been carried out by the HSE of its budget. The barrier to full-time recruitment is the knowledge that ongoing funding would be required for the posts. Going back to the detail of today's budget, there is a commitment to many thousands of ongoing posts on a permanent basis, which should obviate the need for agency staff in a significant way. It is good news that we are now able to recruit more permanent staff and to invest in the public system.

When we hear about beds being funded, we are talking about the staff. It is the staff who are being funded, not the beds. The beds come from the capital plan. The issue is the staffing of those beds. As we are aware, in intensive care units, ICUs, a five-time ratio is needed in order to provide full-time care for a patient. That is a massive investment in nursing staff and in other healthcare professionals in hospitals and in the community. Whether it is community beds, hospital beds, ICU beds, residential beds or neurorehabilitation beds, the big cost is not the beds, it is the staff. What is in the budget today will allow us to plan on a multi-year basis and not just fund things on a temporary basis. Traditionally, when we fund services for winter, which is a bizarre concept anyway, we have been turning services on and then turning them off. One cannot hire people on that basis because they cannot commit and hospitals cannot commit to the training and the ongoing service. When full-time funding is given for these positions it will reduce the need for agency staff and will put in place the permanent workforce that is needed.

Okay. I will ask about the mid-west as I am a Deputy in County Clare. Over the past two years we have consistently seen that the trolley numbers in University Hospital Limerick have been at their worst. I have always believed a solution might lie in beefing up the neighbouring hospitals in the region, in Ennis and Nenagh.

Are there specific measures in the winter plan and yesterday's budget for between now and next spring to alleviate the perennial problem at UHL and share some of that burden and capacity across Ennis, Nenagh and St. John's Hospital in Limerick? I ask Ms Magahy to address that.

Ms Laura Magahy

I will pass the parcel to Mr. Sullivan, who might be closer to that matter. If he cannot answer, we can come back to the Deputy with the detail that is needed.

Mr. Dean Sullivan

My understanding is that there are plans to expand bed capacity within Limerick over the coming months through a modular capital build, which will get that additional capacity on the ground much more quickly than would otherwise have been the case. More generally, as we have said a few times today and I mentioned in response to Deputy Cullinane's question about beds, there will be a very significant step change increase in beds across the system, including Limerick, with an increase of over 1,000 permanently funded beds over the next 12 to 18 months.

Does Deputy Durkan want to come in with a quick question?

I will come in with several quick questions. Having waited this long, I will try to exert what little influence I have. We need to change the system a little. Committee meetings are long and drawn out and this room is extraordinarily cold. I am freezing to death down here, but perhaps it is only this part of the room.

I will take written answers to the following questions. St. John of God's services are being discontinued from next year. What preparations are being made for the replacement? When will know exactly what it is and will it be sufficient to meet the requirements? Those requirements are growing as opposed to otherwise.

What stage are we at with cervical cancer screening and bringing that up to date with the results of tests and continuous screening? To what degree are patients continually informed, do they have to wait or are they asked to wait longer?

There are huge gaps in the system relating to child mental health. That is worrying. I have never seen it so bad. Are there imminent signs of putting a system in place that responds adequately to the level of demand in respect of child mental health at the present time?

For children with special needs, such as those with autism, are there any plans to ensure continuity of services and various therapies and that there is not a tail-off? At the moment, if a therapist goes on maternity leave there is no service for the child, which is a huge break and setback to the treatment level because the patient or child then regresses. That is not fair to the child.

The progress made towards the targets set has been raised by a number of speakers already. Is the progress to date in line with, ahead of, or below expectations?

The Chairman will be pleased that this is my final question. I was one of the people who pressed strongly for a new regional board system when Sláintecare was under discussion. The new board of the hospital has now been set up. How is it interacting with the regions and services generally, nationally, and throughout the regions? Is it interacting sufficiently? Are there any weaknesses and has the progress to date been indicative of a movement towards responses to the issues about which practitioners on the ground have been complaining? I thank the Chairman. I will take written replies to all those questions.

That is great. If the witnesses do not mind, I ask them to send written replies to the Deputy.

I will take them as one reply or separately. It is up to the witnesses.

We have a few minutes left. I want to ask about the same issue Deputy Durkan raised regarding children with special needs. Mr. Sullivan spoke about recalibrating and remodelling how we deliver services. During Covid, many of the hospitals and services we bought in such as Citywest were not being used and people said that was a missed opportunity to deal with some of the waiting lists. Have we learned from mistakes that were made in the past? Mr. Sullivan said in his submission that 98% of Sláintecare projects were on track in June 2019. It is now October 2020, so after seven months of Covid, what level of disruption does he estimate has been caused to that timeline?

As Deputies and Senators, we hear about the delayed diagnosis issue all the time. For orthodontics or children with braces, the delays are years in some cases. For ophthalmics, eyesight issues, or cataracts, people have to travel to the North in many cases. In some cases they wait years or possibly worry about going blind. Deputy Durkan also talked about kids with special needs waiting. In CHO 7, which covers both our constituencies, children are waiting up to two years, or even two and a half, to get an assessment. They then might have to wait another two and a half years to get speech and language therapy and so on. We are talking in terms of 12 weeks to get into the system. People at home want to know what is being done to fix the services that are clearly broken the areas we have outlined in those questions. I do not know if the witnesses have time to answer as we only have a few minutes. Perhaps they can come back to us.

I apologise to the witnesses who did not get in and have waited patiently here throughout the session. It is just the system under which we are operating. My colleagues are probably upset that they did not get enough time either but I really appreciate the witnesses' input here today. I invite them to sum up in the minute or two we have left.

Ms Laura Magahy

I might kick off, if that is okay. On the disability assessment of need, there were a huge number of people waiting for it. I am very familiar with this matter because we were able to forward €8.7 million to clear those backlogs just three weeks ago. We are awaiting details from each of the CHOs around the country on how they are going to clear those backlogs in a matter of months. That funding is there for them to take up. It is a significant amount of funding which is supposed to clear that whole backlog. That is very good and means there will be a new disability network manager system where children will be referred in to get treatment directly in the disability networks. Those people are now in place and they will be able to do their work with a clean sheet and without a backlog of people waiting. That is very positive.

I know time is short and I just wanted to say how much we welcome the opportunity to meet everybody. The ongoing support of the committee is important to us, and I would have made the same point to the previous committee's Chairman. We see Sláintecare as neutral territory which everybody has signed up to and wants to happen. We are trying to steer that along and make sure it happens but it is important to us that we have the support of all Members of both Houses. We appreciate the opportunity to come and talk to the committee whenever it wants and we can provide any updates it wants. My phone line is open so I ask the committee to please get in contact if it needs any details. We appreciate and need the committee's support.

I thank Ms Magahy. Does Mr. Sullivan want to say a final word?

Mr. Dean Sullivan

I thank the Chair for the opportunity to have the final word. We need to reflect the realities of Covid-19 and that has undoubtedly pushed out some of the timelines. Ms Magahy and I are joined in our commitment to transforming how and where services are delivered. It is clear from today's discussion and more generally, including the support announced in the budget, albeit the detail of that will have to be worked through, that we are all trying to get to a different place with the service. Committee members have described some particular issues and risks around disabilities and so on. We are just fixing small problems and that is not where I would like to be. I would like to be in a position where we have fixed everything and outstanding issues would be the exceptions, as opposed to facing challenges in waiting times across a range of areas.

I echo what Ms Magahy has said. As she said, she is keen and happy to appear before the committee on any occasion, as am I, and as are colleagues within the HSE as we continue on the journey we are on. Let us hope that we get through Covid-19 by the back-end of next year. We should try to make some progress on transformation during that year and lay the foundations for what will be a very different health and social care system for the State in the future.

I thank the witnesses for their helpful engagement.

The joint committee adjourned at 1.30 p.m. until 11.30 a.m. on Wednesday, 21 October 2020.