Implementation of Sláintecare: Discussion

Apologies have been received from Senator Annie Hoey and Deputy Cathal Crowe. There is one piece of housekeeping to deal with before I bring in the witnesses. I refer to the draft minutes of the private meeting of 28 September and of the public meeting of 29 September. Are the draft minutes agreed? Agreed.

I welcome the Minister for Health, Deputy Stephen Donnelly, and the Secretary General of the Department of Health, Mr. Robert Watt, to the meeting. Today, the committee will engage with them on the implementation of Sláintecare. I also welcome Mr. Bob Patterson, principal officer, Sláintecare programme implementation office, Department of Health.

Members now have the option of being physically present in the committee room or may join the meeting remotely from Leinster House. Members and all in attendance are asked to exercise personal responsibility in respect of protecting themselves and others from the risk of contracting Covid-19. They are strongly advised to practice good hand hygiene and leave at least one vacant seat between them and others attending. They should also maintain an appropriate level of social distance during and after the meeting. Masks, preferably of medical grade, should be worn at all times during the meeting, except when speaking, and I ask for the members' full co-operation in this regard.

All witnesses are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person or entity either by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

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

I invite the Minister for Health to make his opening remarks.

It is great to be back in person at committee and it is another mark, please God, of things returning to a post-Covid world.

I thank the Chairman and members of the committee for the opportunity to meet them this morning concerning the future of Sláintecare. I am joined by the Secretary General of the Department of Health, Mr. Robert Watt.

Members of the committee and others will have been concerned about the resignations of Ms Laura Magahy, as executive director, Professor Tom Keane and other members of the Sláintecare implementation advisory council. I regret their resignations. I pay tribute to their determination to implement the vision of a universal, single-tier health and social care system.

In the first instance, I would like to assure everyone, and those who may be watching today, of my absolute commitment and the commitment of the Government to universal healthcare. That commitment is absolute and unwavering.

Universal healthcare has never been achieved in Ireland and we are still far from it today. Changing that, making universal healthcare a reality, is one of the defining projects of our time. Our goal is clear. It is timely and affordable access to consistently high-quality care for everyone. Sláintecare matters because it provides a pathway for this. Doing it requires very significant funding and we have made a very substantial investment. Investment of more than €1.2 billion in budget 2021 has allowed us to increase capacity, which is fundamental to improving access to care.

I pay tribute to my officials and those working in the HSE for the significant progress and reform that has been delivered in spite of the pandemic and cyberattack. I will not be able to list all of those achievements today but the increase across various areas is substantial.

We have delivered record increases in hospital bed capacity. We have already added around 850 permanent beds to the hospital system this year. That is the equivalent of about two medium-sized hospitals and more will be added between now and the end of the year. In fact, we will have added more permanent beds to the system this year than have been added in any single year in decades.

Some €52 million was also provided this year to increase critical care capacity. We have delivered a record increase in critical care beds. We had 255 critical care beds at the beginning of last year. We now have 296 critical care beds and more will be delivered in the coming months. We plan to have 321 critical care beds in place by the end of this year or very early in 2022. That represents an increase of 66 beds or 25% in total critical care capacity in just two years. To put that in perspective, we delivered an average of six critical care beds per year between 2017 and 2019. We will have gone from an average of six beds a year to 66 beds in just two years. Our plans are ambitious and I have already brought a plan to Cabinet, which has been agreed by Cabinet, aimed at increasing critical care beds to 446 over time. Critically, this will exceed the recommendation of the 2018 health service capacity review.

We have 6,000 more staff working in the health service than we did last summer. That includes almost 1,400 more nurses and midwives, and 1,200 health and social care professionals.

I am bringing proposals to Cabinet in respect of three elective hospitals in Cork, Dublin and Galway. Very significant work has been done on this by the Sláintecare office.

I would like to talk about new patient pathways and care closer to the home. Various initiatives and reforms are ensuring that people receive care closer to their home. Some €25 million was allocated to the GP access to diagnostics initiative this year. It enables GPs to refer patients directly to access diagnostics, including X-rays, MRIs, computed tomography, CT, scans and many more. These are in a community-based setting. I am delighted to be able to share with the committee that we estimate that through this new initiative, which was a core recommendation in Sláintecare, we estimate that about 140,000 additional scans will be carried out by the end of this year. That is very positive.

There has been a dramatic reduction in waiting lists for funding approvals for home care. Thanks to a large increase in funding there are no waiting lists at all for home care packages in some areas thus ensuring that we deliver on our objective to keep people well at home and out of hospital.

I am excited by what we are seeing in respect of the redesign of care pathways and the incredible impact that skilled advanced nurse practitioners are having. Many patients who would otherwise have had to wait for traditional hospital appointments or to attend emergency departments can be treated in the community using these new pathways to care. I will give an example. A pilot service to manage people living with heart failure, provided by specialist nurses in County Donegal, saw waiting times for new patient referrals drop from 18 months to between two and six weeks. The current target, which is to have 2% of the nursing and midwifery workforce, approximately 800 people, working as advanced nurse practitioners or advanced midwifery practitioners, will be reached. I want that to be scaled up and have asked my Department to revert with a plan to that effect. This area has great untapped potential for our healthcare system. It fundamentally redesigns the model of care, bringing specialist care much closer to the patient and keeping it out of the hospital, wherever possible.

One aspect of universal healthcare that gets less attention than access is quality. There is, understandably, a great deal of focus on access in our country because of the completely unacceptable waiting lists. We will come to that but one of the core components of universal healthcare is a consistently high quality of care. The reality in Ireland is that it can be hard to access parts of the public health system but, when one does, the quality of that care is often excellent. That may not be the case in some cases. There are also parts of the system where the care is good but needs to get better. If we are serious about universal healthcare, we have to be serious about a consistently high quality of care. One of the main routes to this is via our clinical strategies in maternity care, cancer care, trauma, mental health and many more. This year, I allocated funding to ensure these strategies were, for the first time, fully funded. I am delighted to be able to share with the committee that a lot of progress is being made on behalf of patients. I encourage the committee to consider allocating some of its time to invite the clinical leads in these areas in to discuss this progress with them. We have had some productive debates in the Dáil and the Seanad on issue such as maternity care and cancer care. Serious improvements and progress are being made now that the strategies are being funded. It would be great to be able to hear from the clinical leads on that.

As the committee will be aware, the Government approved the Sláintecare implementation strategy and action plan for the period from 2021 to 2023. The Sláintecare programme implementation office prepared a report on progress in the first six months of the strategy. That progress report indicated that, of the 112 deliverables, 109 were on track or on track with minor issues. That means that, even while dealing with the worst public health crisis in 100 years, more than 97% of the Sláintecare projects have been progressing well. The report identified three of the 112 projects, specifically the waiting list, ehealth and regional health areas projects, as facing a significant challenge. Action on these has undoubtedly been severely hampered by the pandemic and the cyberattack, as was clearly stated in the report produced by the Sláintecare office.

Tackling waiting lists is my number one priority. They were terrible before Covid and have worsened substantially since. People are living in pain. The long waits that many of our citizens face to access care are causing immense distress. I am setting up a task force that will tackle waiting lists and funding it appropriately. It will follow the vaccine task force model that has worked so well and will learn from it.

Substantial work has been undertaken over the past several months in progressing regional health areas. Research into international best practice has been completed. Policy options have been drafted. Consultation with stakeholders including patients, clinicians, policymakers, hospital groups and officials in community healthcare organisations, CHOs, has taken place. More is planned in the coming weeks. I am establishing an advisory group on this. We must ensure we arrive at a structure that is owned and respected by those working in our health service.

Our public health system is not where we need it to be when it comes to ehealth. Our healthcare workers are often working on old, antiquated systems, but significant progress was made during the pandemic. A great deal of additional work is required in this area.

In recent weeks, there has been debate about governance structures for Sláintecare. We are making some changes. A new programme board co-chaired by my Secretary General and the chief executive of the HSE, and comprising other members of our senior teams, will be established. This new board will ensure that the drive for universal healthcare is fully embedded in both the Department of Health and the HSE. The board will report to me and the Cabinet committee on health will meet to discuss progress as appropriate.

It has been stated as part of the recent debate on Sláintecare that change is impossible. Not only is change possible, but it is happening at an unprecedented rate. It is being led by people working across the healthcare family, women and men who are rightly proud of their efforts. Many healthcare workers have been galvanised by what our health service has achieved during Covid, with one of the most successful vaccine roll-outs anywhere in the world. There will always be people who will only focus on the negative and what they believe cannot be done. Eight months ago, we were lambasted by some for saying we wanted at least 70% of our adult population to have been offered a vaccine by the end of September. Our health service proved them wrong. We are ambitious. Change and reform is always challenging, but we are up for that challenge. Access to high quality healthcare when it is needed cannot and must not be a privilege for those who can afford it. It must be available to every girl and boy, every woman and man. That is what universal healthcare means. That is what must be delivered. That is our absolute focus.

I thank the Minister very much for his presentation. I also thank him and his Department for all the work they have done over the past 20 months in dealing with the Covid pandemic. I will return to a number of issues he touched on. The first is the resignations. There is a view that Ms Laura Magahy and Professor Tom Keane, although less so in respect of Professor Geraldine McCarthy who resigned as head of the group in Cork, were forced to resign because they felt that what they wanted to deliver in respect of Sláintecare was not going to be delivered, that there was resistance in the Minister's Department to their planned approach to what was agreed on an all-party basis with regard to Sláintecare and that sufficient progress was not being made. That is the view out there. The Minister barely touched on these people leaving their roles in his statement. Will he clarify some of the issues surrounding their leaving and the progress we can make without them? They have great experience and their leaving is a very significant loss.

I reiterate that I regret the resignations. Both Professor Keane and Ms Magahy added a great deal. As we are all aware, there has been public commentary as to whether change was happening, whether progress was being made and whether there is resistance to change. The first thing I would look at is the progress report from the Sláintecare implementation team. We have to look at the evidence. The evidence that change is happening is overwhelming. The Sláintecare project is defined by the Sláintecare team on the basis of 112 projects.

They resigned so they obviously felt that progress was not being made, or would not be made, on the further steps that needed to be taken to implement Sláintecare. They did leave so they obviously felt frustrated. The Minister needs to clarify whether he was aware of that frustration and whether any action was taken to deal with that issue.

Neither Professor Keane nor Ms Magahy raised any frustrations with me. The first I was aware of any such concerns was when their resignations happened. If I may, I want to finish my point on the substance of the issue. If we are asking whether there was resistance to change, the question we must ask is whether change was and is happening. The report I have from the executive director states that not only is change happening but, in the case of more than 97% of the projects, they are either on track or on track with minor issues. The next question we must ask is how substantial the progress has been on the three remaining issues, because those issues matter a great deal. What I see on e-health is that Ireland is a laggard, but substantial innovation happened during the Covid period. We now have telemedicine and e-prescribing, which we were told could not be done. We have unique patient identifiers for the first time because of the vaccine programme. Much more needs to happen on e-health but substantial progress was made.

I want to go back to the previous point. The Minister may not have been aware of the frustration felt by Professor Keane and Ms Magahy but were officials in his Department aware of it? This situation did not happen overnight. It was obviously an ongoing issue and Professor Keane and Ms Magahy came to the conclusion there was no point in staying on.

That may well be true. What I can tell the Deputy is that neither of them raised the issues with me nor sought a meeting with me to express-----

The Minister has not clarified whether they raised their concerns with people in the Department.

I cannot speak for what other people may know. I can tell the Deputy that the issues were not raised with me.

If officials in his Department were aware of the frustration of the two individuals in question, would they not have advised the Minister that their resignations were likely?

I received no such advice.

I want to move on to the issues relating to the proposals for the three elective hospitals in Cork, Galway and Dublin. It appears to me that what is proposed is very much watered down from the original. In the case of Cork, in particular, the existing hospital is an old building, originally built in 1751, with very little capacity to extend or renovate it. Now there is talk of its being a day care facility. If it is a day-only hospital, it will not be able to carry out serious operations, such as hip or knee procedures. This means that large numbers of people will be excluded from availing of that facility, including anyone with underlying conditions such as diabetes. It is going to be a very restricted facility. We are now four or five years on from when this hospital was originally proposed and a site for it has not even been identified. Where are we at with the proposal for elective hospitals, including site identification? Even if a site were identified tomorrow, it will be necessary to go through a planning process. We are at least four to five years down the road from anything being delivered.

Will the Deputy clarify what he would like me to address?

The proposal regarding elective hospitals has been watered down. Is that the right way to go when we have a huge increase in population in the Cork-Kerry region and there has been no increase in hospital beds in real terms? The talk now is only of a day care facility. How can that be justified?

First, I am absolutely determined to get moving on these hospitals. A great deal of work has been done and I am bringing a memorandum to Government on it. I entirely share the Deputy's determination that we get these hospitals-----

Will the Minister bring the memorandum to Government this week, next week, next month or next year? We need clarification on the timeframe because a site has not even been identified for the hospital in Cork.

I will present the memorandum tomorrow. The position the Deputy has laid out is one of the core discussions. The very strong recommendation from the Sláintecare programme office and the team that has done the work is that these hospitals should be day case facilities. There is a contrary, and very reasonable, view being expressed by some in the clinical community that they should offer inpatient care as well. We are looking at both options at the moment.

Does the Minister accept there is a shortage of beds in the Cork region? In fact, many patients are going to Dublin because there is not capacity in Cork to treat them and the current facilities cannot be further developed. When the next census results are available, they are likely to show a population increase for the Cork-Kerry region from 410,000 to 600,000, without there being any increase in healthcare facilities. Does the Minister accept that a day facility is not the way forward?

The most important thing is that we get moving and stop talking about what may happen in the future. I think we are both agreed on that. Do we need more operating theatres, outpatient facilities and day case facilities? Yes, we do. The question the Deputy is asking is whether, as well as that, we need more inpatient beds. The answer is that we certainly do, and they must be provided. The question then is whether they should be provided as part of what is meant to be an elective-only centre. The view from the Sláintecare team is there is a risk that if patients are in inpatient beds, this could potentially stop the flow through the operating theatres. For example, there is a new unit in Tallaght University Hospital, the Reeves Centre-----

The Minister may not be aware of the situation with the current facilities in Cork. One of the hospitals has a 25-bed unit that is not suitable for modern medicine. Is the Minister saying this should continues for the next 20 years?

I want to be clear that I absolutely have not said anything like that. I would not like what I am saying to be misrepresented. I am saying we need more operating theatres, outpatient facilities and day case facilities and, on the Deputy's point, we certainly need more inpatient beds. We are completely aligned on that. The only question is where one puts those inpatient beds. Should they be put with an elective hospital - the recommendation from the Sláintecare team is that they should not be - or should they be put with the current model 4 hospitals, which deliver more complex care?

I have a question regarding the National Treatment Purchase Fund, NTPF. There is a major concern that patients are being referred out for assessment, after which they are referred for another period of time to another list. The proposal is that when people are referred under the NTPF, it should be not only for assessment but that whatever procedure is required should also be carried out. Is that being considered as part of efforts to deal with getting people off the waiting lists from start to finish?

Yes, it is. The stark reality we are faced with right now is that we have a huge number of men, women and children waiting for care. What I want, and I am sure we all agreed on this, is a single-tier public health system that can handle capacity for the entire country. While we are building that capacity up, we will have to use all the capacity we have on the island in the best way possible to get care for people who are waiting for it. As part of that, we are looking at the mandate of the NTPF in terms of how it operates.

At the moment, however, it is a two-scale process that is not making any progress.

We need to move on. The next speaker is Deputy Cullinane.

I welcome the Minister and Mr. Watt. My first set of questions is for the latter. He did not make an opening statement but he is here to field and take questions. How long has he has been in role as Secretary General?

Mr. Robert Watt

It has been nine months.

The Minister made reference to regionalisation and the substantial progress that has been made in that regard. He also talked about policy options that were brought forward by the former executive director and others involved in the implementation of Sláintecare. Was there any disagreement between Mr. Watt, and his officials, and Ms Magahy regarding the policy options for regionalisation?

Mr. Robert Watt

There was no disagreement on the policy options. Those options are set out in a paper, which I understand the Minister intends to publish.

Did Mr. Watt have meetings with Ms Magahy specifically on those policy options?

Mr. Robert Watt

I certainly did.

Was there any disagreement on them, any pushback against any proposals or any favoured options put forward by Ms Magahy?

Mr. Robert Watt

There was no settled view within the Department in terms of-----

Were there differences of opinion?

Mr. Robert Watt

No.

Were Mr. Watt and Ms Magahy on exactly the same page in terms of what regionalisation would look like?

Mr. Robert Watt

In terms of the options, the team that was advising on the regional health authorities, RHAs, was going through a multi-criterion analysis. That analysis is not complete.

A clear view has not been offered yet by the team on which of the options we would recommend to the Minister and the Government. There was of course-----

Is the Department in favour of the decentralisation to six regional areas and more power being devolved power to those regional areas?

Mr. Robert Watt

Am I personally in favour of it?

Mr. Robert Watt

I would give my advice to the Minister and the Minister would bring his-----

Mr. Watt is here today to answer for himself.

Mr. Robert Watt

I am in favour of it as the current misalignment between the hospitals groups and the CHOs is not working for us. We need to have an integrated approach at regional level in order to drive the integration of care which is completely critical and which everybody speaks of as such and is a key part of-----

I accept that but can Mr. Watt understand the position from our perspective? We are sitting here today and we have the Minister and the Secretary General of the Department in. We have had six resignations associated with Sláintecare, including the former executive director, the chairperson of the board, and the two of the most senior people tasked with responsibility for delivering Sláintecare. We have also had a number of other resignations from the advisory committee, and, as I said earlier, the chairman of the South/South West Hospital Group. In fairness, there is a standing invitation to most of those individuals to come before this committee also.

Yet, we are led to believe that the Minister had no idea that there were any problems with Sláintecare or these individuals' views on Sláintecare and that there was no difference or disagreement between Mr. Watt, the Department of Health, and any of these individuals, and that is seems they have resigned for no reason whatsoever. It is hard to comprehend that there was no sense of disagreement that would have led to those resignations because we have received some glimpse of some of what they have said, particularly from Professor Keane and we want to hear from the others.

From where I am sitting, can Mr. Watt understand how difficult it is for me to comprehend how we have these resignations on the one hand but there is nothing to see here from Mr. Watt and from the Minister on the other hand?

Mr. Robert Watt

I have not said that there is nothing to see here. The Deputy asked me a question on regional health areas, RHAs, and was there a disagreement between myself and officials in the Department and I answered that there was a disagreement on policy. There may have been issues on implementation and on how quickly we would do it and whether it was appropriate for us to push ahead. We all-----

We will come to that then. It is implementation. What did those-----

Mr. Robert Watt

Can I just-----

I ask Mr. Watt to wait one second as he mentioned implementation. I must point out that this is the members time. Mr. Watt is appearing before the committee-----

Mr. Robert Watt

I am answering the question.

Yes, and I am putting another question to him as I have heard that answer. Mr. Watt talks about timeframes. He is saying that there is no disagreement on the policy direction that was proposed by Ms Magahy and my understanding is that her council wanted this done over two years. Is Mr. Watt saying that there was a disagreement or different opinions on how long it would take to get there and arrive at the final destination?

Mr. Robert Watt

No, there was no disagreement on the final destination because ultimately that depends on whatever policy decision the Minister accepts and brings to the Government on the actual implementation of the RHAs. The timeframe on the implementation is a function ultimately of the policy that is arrived at. Clearly, there were views and discussions with ourselves and the HSE about implementing structural change in the middle of the worst public health crisis for 100 years. Sláintecare itself states very clearly that we need to be completely sure that any structural changes are kept to a minimum, that we do not interrupt the provision or enhancement of services and that we are completely sure that any structural changes that we bring about are completely necessary and will improve the functioning of the system.

Our time is very short and we have that answer and I thank Mr.Watt.

Mr. Robert Watt

There are many different aspects to this. I would not have recommended to the Minister or the Government that we engage in functional change, whether it is horizontal or vertical organisational change of an organisation like the HSE, in the middle of the worst health crisis in 100 years. Perhaps there are others who would have advised the Minister differently. Good luck to them. That is fair enough and that is their own view and we are all entitled to our views. I would not have recommended that, however, because it would have been a mistake and overly risky. The attention-----

I have heard that answer. With respect to Mr. Watt, he cannot talk down the clock when we have ten minutes and we have heard that time and again.

Mr. Robert Watt

I have got plenty of time, Deputy, and I can stay here for as long as the Deputy wishes.

We have heard already that there was some pushback on the timeframe to deliver because of the Covid-19 pandemic. My understanding of what the Sláintecare Implementation Advisory Council, SIAC, was proposing was into the future as opposed to what was happening during the Covid-19 pandemic. We will talk to the SIAC members whenever they appear before us.

I want to turn to the Minister because this has been very difficult and it has damaged Sláintecare and, more importantly, people’s perception that we will see changes in healthcare after having seen these resignations. We now have this new structure that is being put in place, the programme board. The patient advocates have been removed from it, as far as I can see. I see that Róisín Molloy is no longer going to be on that new structure nor will Brendan Courtney. There is a perception again that these people would not necessarily have had a critical eye but certainly would have had a constructive view of this, and perhaps sometimes an alternative view to Mr. Watt or Mr. Paul Reid, and that these people are no longer on that board. This structure will actually be headed up by Mr. Reid and by Mr. Watt. Is that actually the best way to proceed with the delivery of Sláintecare?

I thank the Deputy for the question. We are talking about two different sets. One was an advisory group and the other is an implementation group. SIAC, the Sláintecare Implementation Advisory Council, had a three-year term and was due to finish up on 24 October. This group did not report into me but reported into the director of Sláintecare and I was not aware of any further meetings being scheduled. Perhaps there was an intention to schedule more meetings but to the best of my knowledge I was not aware of any further meetings that were scheduled. That group was essentially finishing its agreed term in the next few weeks, in any event.

I am doing two things. I am setting up a new advisory group to advise specifically on regionalisation. Regionalisation had been identified by a great number of people-----

Can I stop the Minister there, please, because that is part of the problem? We now have this narrow focus on regionalisation. I accept that the Minister is saying that this will focus on regionalisation. The Minister said in his opening statement that we are a long way away from universal healthcare. We certainly are. We can talk about 97% delivery of some elements of Sláintecare but we are a long way away from moving private healthcare from public hospitals, from universal GP care, and from reducing waiting lists which have gone in the wrong direction.

I will put a number of quick questions to the Minister and he or Mr. Watt can provide some quick answers. Even in the presentation given by the Minister, he talks about €1.2 billion that was allocated to health last year, which it was. I ask Mr. Watt how much of that €1.2 billion will be unspent this year?

Mr. Robert Watt

Deputy Cullinane knows the answer to that question as we met a couple of weeks ago and I told him what it was.

I am asking Mr. Watt today what the answer to that question is.

Mr. Robert Watt

That answer has not changed since I spoke with the Deputy the last time. The figure is about €350 million.

Some €350 million will go unspent. The Minister statement then talks about 1,147 additional beds. How many of those acute beds will not come on stream this year?

Mr. Robert Watt

There will be almost 1,000 acute beds this year.

How many beds will not come on stream of those funded beds?

Mr. Robert Watt

Between the end of last year and the end of next year there will be 1,200 additional beds.

How many of those 1,147 beds will not come on stream? It is a simple answer.

Mr. Robert Watt

Let us focus on the positives here, please, Deputy-----

I am asking Mr. Watt a question and he does not get to answer the question he wants to.

Mr. Robert Watt

These are real beds and real patients are in those beds.

Mr. Watt must answer the questions that are being put to him. This is a reasonable question. Of the 1,147 additional beds that were funded last year, how many of them will not come on stream this year? Some 200 is the figure, is it not?

Mr. Robert Watt

Yes, approximately 150 of them will come on stream-----

It is a bit more than that. Why could Mr. Watt not just have answered that?

Mr. Robert Watt

-----next year.

Of the €150 million that was provided for enhanced community services, am I right in saying that half of that figure will go unspent?

Mr. Robert Watt

There is a challenge, as the Deputy is aware-----

I am asking will half the figure go unspent?

Mr. Robert Watt

-----in recruiting necessary people. Many of the people who would work or propose to work in those services were involved in other activities such as the test and tracing systems, and so on. They will be reallocated, hopefully, when we get successfully through this phase of the pandemic. There has been slow recruitment and lower spending in some areas because of the challenges that the system faced because of Covid-19.

I want to make a comment very quickly, if I may, Cathaoirleach, as I have just 30 seconds remaining for me to speak. I have to tell the Minister that I do not have confidence that we are going to see any rapid reforms in Sláintecare and I am not at all comforted by anything that he has said today as to why any of these very good people have resigned. I do not have confidence that we will see any big changes in the next number of years in the big challenges in healthcare such as removing private practice from public hospitals under this Government.

I have talked about the €1.2 billion and the beds that were promised. The Minister talked about 14,700 staff last year where only about 7,500 of those will be recruited. People see promises on the one hand but do not see delivery on the other hand. At the root of all of that, which is why I welcome that there will be a focus on waiting lists, are real people, as the Minister knows. We have talked about such people who are in pain, children with scoliosis and who are one of the 900,000 people. The mind actually boggles at the number of people who are on waiting lists and yet we are not seeing the resources and the capacity go into the system. Even what the Minister says he did and funded last year has not been delivered upon and it is very frustrating.

Chairman, can I come back briefly on that, as an important statement has been made?

I understand that we all have to come in here and do what we have to do but I want to be clear about how important universal care is, and we are all agreed that it is important. It is one of the most important projects in our Republic.

Let us deliver it then.

When the Deputy says he cannot see any progress-----

I see some progress.

Can I respond? What the Deputy said was that he does not see the progress. I reiterate this for people who are watching because I would hate people to think there is no progress on one of the most important projects in our republic. This year, we will have added more beds to the public system than any year on record. This year, we will have hired more people into the public system than any year on record. This year, we will have added more critical care capacity to the public system than any year on record. This year, we will have funded GP access to diagnostics at a level that has never been achieved before. Some 97% of the projects that we have all agreed are critical to reform are on track, or on track with minor issues. I appreciate the Deputy's job is to keep the pressure on me; that is what he is doing and I respect that. However, let us make sure that the public know that there is a vast amount of progress. We must almost always push for more but let us make sure that the public and the people working in our system and who depend on our system know there are levels of progress being made in the system now that are the most on record. I want to put that on the record.

I thank the Minister and the Secretary General. Context is everything. I have always tried to be non-partisan on this and I will continue in that vein. In a non-partisan way, there are two or three issues that strike me about this. First, the Minister is just a year and a half in the job, so much of the narrative around Sláintecare would have preceded his time in office. Second, Mr. Watt is barely a wet week in the job and the consequences have landed on his table. Third, as Mr. Watt said, we are hopefully emerging from a global pandemic. That is the context. To be honest, and I do not mean to be trite about it, part of me wondered about what all this excitement is about Sláintecare right now, given what we have been going through and given what the health system has had to cope with and deal with, and what all the HSE staff and healthcare workers have had to do. That is my objective overview of it.

When a Minister says he is putting the chief executive of the HSE, who, for a period, nationalised a load of private hospitals to deal with the pandemic and, so, has just garnered a load of experience in the provision of universal public healthcare in a particular context, and then the Minister also says that, with the Secretary General of his Department, these two individuals are going to take charge of the implementation of Sláintecare under his political direction, that is about a big a statement as it gets in regard to the commitment of a Government to a particular policy initiative that emerged from an all-party Oireachtas report. I imagine that a Government, regardless of what political hue it is in the future, would do well to follow that.

I have one caveat. The Minister is bringing everything back to the centre, and I see the necessity for that in the circumstances. How does he propose to withstand the accusation that the regional structure is the way to go when he is bringing everything back to the centre?

I thank the Deputy for genuinely acknowledging that the changes we are making are exactly to that end. I am appointing the head of the Department and the head of the HSE to this role. They report to me and I will report in to the Cabinet, so this is being managed at the most senior level, with clear lines of direction and accountability on that.

With regard to the regional health organisations, essentially, what we are talking about is merging community and acute care. That was the point. A lot of work was then done on how that might be achieved and the six regions were arrived at after a long consultation period. Some people agree with those regions and some people do not agree with those regions, and that is quite normal.

A reorganisation of our healthcare system is probably the highest risk element of our reform programme. Tackling the waiting lists, adding capacity, changing the models of care, and increasing advanced nursed practitioners and GP access to diagnostics are important but they do not pose a systemic risk, even if they do not work as well as one might want them to. A reorganisation of a system as complex and critical as our healthcare system is a high-risk endeavour. That is why the Sláintecare report itself said it should be done with minimal change.

If we are going to embark on what I believe is the highest risk part of Sláintecare - it is one of the enablers but it is high risk - it must have the oversight and the leadership from the Government, me, the Department, Mr. Watt and the HSE and Paul Reid. However, if it is going to work, the change has to be owned by the people in the system itself. A mistake would be for a group in the centre to come up with a detailed design and then announce it and say, “This is the new change and this is what is going to happen”. International evidence shows that is resisted by the people who we need to be part of that change. Therefore, while the policy direction will be owned at the most senior level at the centre, if we are going to get this right and do it successfully, it has to involve people right around the system, in the CHOs, hospital groups, hospitals and throughout the system. Essentially, there will be wide consultation and involvement in this process.

Does Mr. Watt wish to add to that?

Mr. Robert Watt

I thank the Deputy. I agree that context is the first casualty of political debate now, it would seem. The context for all this is critical and everyone knows that the pressures the system has been under for the past while have certainly impacted on our ability to do other things. Since I took over this role only nine months ago, I have spent 90%-plus of my time in regard to policies on Covid, vaccination policy, test and trace, hotel quarantining and all the different aspects the Department has been grappling with. That is the reality of it. We are now hopeful, given where the disease is, that we will be able to focus on all the other non-Covid aspects of health and public health that we have to do.

I will not add too much to what the Minister said on this question of centralisation. The CEO of the HSE has reorganised the centre, and he did that a few months ago. There is an interesting debate about what functions should remain at a central, national level, with national standards, policies, procurement policies, IT, HR and all of that, and what then should be delivered at a local level. I am pretty convinced, having read a lot of the research on this internationally and in Ireland, that we need to align CHOs and hospital groups. We need to integrate them to have organisations at a regional level that can deliver the integration of care that we talk about.

The demographic challenge the country faces, because of the number of people aged over 85 and the number of people over 60, is the wider context for this debate. There is a massive increase in the demand for our services and it is only going to go one direction, thankfully, as our citizens are living longer. As we know, as they live longer, they will have more conditions and they will rely more on the health system. We cannot meet current needs, let alone future needs, with this structure, and we need to have much more of the service provided at primary level and community level. The change that is proposed in regard to the regional health areas, RHAs, is critical to deliver that.

The final element, which is very important, is in terms of the allocation of budgets. We allocate budgets based on "acute", "primary" and so on. We need to start allocating budgets over time on the basis of the population needs of people in particular geographics, so that we look at what are the needs of a population - not what are the needs of the acute system or the community system, but the needs of the population - and allocate on that basis.

They are the critical elements. We need to make decisions over the next few months and the Minister will have to decide, with his Government colleagues, exactly what implementation plan to embrace in regard to the RHAs. We are committed to doing it and the HSE is committed to doing it, and we will push ahead strongly over the period ahead to do it. It is a fundamental reform. I agree, having read once again the implementation report on Sláintecare, that this is a fundamental aspect we have to deliver to achieve the overall objectives.

The implementation board will be co-chaired by Mr. Watt and the chief executive of the HSE.

Mr. Robert Watt

I do not wish to discuss in detail. I have known Laura Magahy for a long time and we have worked together intensively during the recent period. I do not want to get into reasons. People resign for a variety of reasons.

I did not ask any of that.

Mr. Robert Watt

I know the Deputy did not. The key lesson I draw from it ultimately is that I do not think the structure set up was the correct structure. Ms Magahy may speak with the committee or she may not. She may make comment on this. The office was set up in a particular way as an adjunct to the Department, with Mr. Patterson and his colleagues working away. I am sure Mr. Patterson and his colleagues would accept this. What we need in the Department of Health - this is what we are doing now because we are reorganising the Department - is to ensure that Sláintecare is embraced by the entire management team. Ultimately, Ms Magahy felt that the office was not set up properly and that it was not going to deliver properly unless we embedded the philosophy, culture and the projects across the Department. That is the key lesson for me from what has happened. We need to look at our delivery structure and learn from it. Ms Magahy suggested how we would do this in the future. I accept that and that is what we will now do.

When does that start?

Mr. Robert Watt

Starting now. We are reorganising the Department and we will devolve responsibility for the main projects to a senior leadership team in the Department so that it is fully embedded in the work of the Department.

I ask Mr. Watt to expand what he has said about reorganising the Department.

Mr. Robert Watt

Before the Covid pandemic, there were plans to look at the structure of the Department. Many changes took place and many people were reallocated from functions. Many functions were put in abeyance as staff were reallocated to deal with Covid. Approximately 150 or 200 staff were affectively on Covid activities. Most people are now moving off those and they will be reallocated. As part of that, we are restructuring. We are setting out a change in the overall priorities and based on those priorities we will look at the structure and we will reallocate the resources to reflect both the strategy and the structure.

Is Mr. Watt saying that Sláintecare will now effectively be part of the oxygen in the Department of Health?

Mr. Robert Watt

Yes.

I thank Mr. Watt.

The main reason the Minister is here today is to discuss the recent resignations. Professor Tom Keane and Ms Laura Magahy have significant reputations for reform and change management. They were good choices at the time. What is the Minister's understanding of why those two senior people resigned?

I agree with what the Secretary General has just said. His analysis feels right to me.

With all due respect, I am asking the Minister about his understanding of the reasons those two people resigned.

I understand that.

I do not want that description; I have heard that.

The Secretary General has just given a detailed one. I would agree with that.

No. I am asking the Minister why he thinks those two people resigned.

I understand that.

Can he tell us that?

I can repeat what Mr. Watt said if the Deputy likes.

No, I would prefer if he did not. I would prefer if he would answer the question.

I am answering the questions.

Why does the Minister think they resigned?

I have the same view. I think ultimately, as Mr. Watt has said, Ms Magahy was frustrated. I think probably the structure of the Sláintecare team needed to be changed and that is exactly what we are doing. As to why Professor Keane resigned, he referenced a resistance to change. As the Deputy will be aware, in his letter to the council that he chaired, he felt the environment was such that change was impossible.

What is the Minister's understanding of what he meant by that?

To be honest, I am somewhat puzzled by that. What I see right across the system is change.

Is the Minister saying he does not understand why those two people resigned?

No, I have just told the Deputy why Ms Magahy may have resigned.

Does the Minister thinks she was looking for a structure such as the one the Department is proposing now?

Really, that is a question for Ms Magahy. The Deputy asked me why I thought she resigned.

I am asking the Minister what his understanding of the situation is.

I have given the Deputy my understanding of the situation.

It seems to indicate that he does not have an understanding of why they resigned.

The Deputy may say that if she wants. She asked me what my understanding was; I have told her what my understanding is.

Professor Keane has been through this before with the cancer programme and is highly respected. He said he would not hang around if there was not political support for Sláintecare. What is the Minister's understanding of why he decided to resign?

The reasons he gave me and the reasons that he wrote to me referenced an environment in which change was impossible and a resistance to change. They are-----

Does the Minister think that was a justified assessment of the Department and the HSE - the health system?

Based on the report I got from the executive director about a week or two prior to this-----

Does the Minister think that view of the resistance to change, as expressed by Professor Keane, was justified?

Based on the report I got from the executive director-----

I am just asking if the Minister thought it was justified. He may answer "Yes" or "No".

With respect, the Deputy may ask whatever questions she wants, but she must allow me to answer the questions.

I do not want the Minister repeating what he said already. Does he think it was justified or not?

I will answer the question if the Deputy will allow me to answer the question.

I am under pressure for time. He may answer "Yes" or "No".

May I answer the question?

I thank the Deputy. In answer to the question as to whether change is possible, we need to look at the evidence.

I did not ask the Minister that question.

Okay, I would like to move on. The big recommendation of the Committee on the Future of Healthcare was that the Sláintecare office would not be located within the Department of Health. Lessons were learned from the experience with the cancer strategy. The big fear was that there would be departmental capture of the Sláintecare plan. If the Department of Health and the HSE were capable of reform, we would have seen it long ago. However, the concern was that it would be captured. Hearing what is now proposed as a replacement structure, I cannot help coming to the conclusion that this is a hostile takeover of Sláintecare. I ask the Minister to be a bit more precise on what exactly he is proposing. I ask him to outline the new governance structure for the implementation of Sláintecare now as he referenced in his statement. Who will be in charge of the implementation of Sláintecare? Where will the independent oversight come from?

I might just pick up on one comment the Deputy made. I appreciate that we are tight for time.

I would prefer if he just answered the questions, please. I asked three questions there and I would like the Minister to answer those.

Fine. As we laid out in the opening statement, the Secretary General and the chief executive of the HSE will co-chair a board. They will have their senior teams on that. The accountability and responsibility for the major projects will be shared across the Department. As we were discussing earlier, that had not happened previously.

What is the exact structure for implementing Sláintecare?

I am sorry, Deputy.

Sláintecare is a reform programme. It appears that the organisations that need to be reformed are the HSE and the Department of Health to facilitate Sláintecare. The Minister is appointing the two senior people from those two organisations and embedding it in the Department. What is that about? It sounds like it is a continuation of this concern about the attempt to suffocate Sláintecare.

Where is the open governance of that? Where is the oversight?

I am not sure what the Deputy means by open governance and oversight.

Who will drive reform?

Myself, the Secretary General and the chief executive of the HSE.

Okay, but we have not had reform from either of those two officials.

The Deputy keeps saying this and I have to push back. She keeps saying that the Department and the HSE are incapable of reform and that there has been no reform.

What I am saying is-----

I will finish on this.

-----that we need somebody driving that reform programme for it to happen. There were two senior people there, working on this for the past few years. They have come to the conclusion that there is serious resistance within the Department of Health and the HSE to the kind of reform and particularly the kind of accountability that was envisaged by Sláintecare.

However, more than 97% of the Sláintecare projects are on track.

I am talking about the key issues, that is, the devolution of power and the introduction of legal accountability for clinical outcomes. That is what I am talking about. In the Sláintecare programme, a requirement was established for six pieces of legislation. One of those has been introduced, which reinstated the HSE board. It was crazy that this had to happen in the first place. Two of the others concern legislation on the accountability of the Minister for Health, all staff, and in particular, the accountability of senior management in terms of the spending of budgets and also, critically, clinical outcomes.

I have looked at the legislative programme. There is no indication that any work is being done on those pieces of legislation, which are regarded, and were regarded by the all-party committee, as essential to achieving the kind of reform required, that is, the devolution of power and the introduction of legal accountability for people within the health service. Can the Minister provide a reason for no progress being made in that regard?

I cannot speak to the period before I came into office-----

But the Minister has been there long enough to know.

-----but I can tell the Deputy that in the year and a half that we have been in office, as the Secretary General has said, the vast majority of our time, attention, focus and resource has been on the pandemic. Hopefully, we are coming out of that period now. Now, we are seeing a reorganisation in terms of the most senior leadership team for universal healthcare, a waiting list plan, the elective hospitals progressing and lots more.

Okay, but no progress has been made on legislation for accountability.

I do not think I have heard the Minister use the term "accountability" at all in respect of what is required in terms of reform. Does the Minister accept the view, and the very strong view expressed by the all-party committee, and indeed, probably the number one priority shared by everybody on that committee, that the absolute priority must be the restructuring of the HSE and the introduction of accountability for service, budgets and clinical outcomes at local level? What is the Minister's view on that priority, which was set by the committee?

My view is that the absolute priority is getting people access to high-quality care. That is the priority-----

I asked the Minister about accountability.

I am answering the question.

I asked him for his view on the importance of accountability, as set out in the structures proposed by the Sláintecare plan.

I am trying to answer that question. I am making the point that the absolute priority is that people get access to care and----

-----as part of that, there has to be accountability. One of the huge gaps that I have seen in the system, and it is a conversation that we are having with the HSE, is a lack of data. We can have all the legal structures and legislation we want-----

That is what regionalisation is about.

-----but without the data, we cannot hold anyone to account. One of the things we are-----

That is exactly part of the regionalisation plan-----

If I could finish, Chair.

There is integration, budgets on the basis of population profile and accountability for clinical outcomes.

The first step, and I would hope that we would agree on this, is that we have to have the information, because without the information we cannot hold anybody to account. One of the things that we are doing right now-----

On the basis of----

Please, Deputy Shortall.

----is we are pushing ahead and putting systems in place to be able to gather and track that information.

On the basis of what the Minister has outlined in his statement regarding giving responsibility to the Department and the HSE for their own reform, embedding Sláintecare in the Department, I think the Minister is absolutely going against the intention of Sláintecare and the democratic decision of the Dáil in terms of progressing this proposal prioritising the issue of regionalisation and accountability. The Minister is going directly against the expressed wishes of the Dáil in that respect.

Moving on. I call Deputy Hourigan.

I wish to follow up with some questions on regionalisation, but before I do, I am hoping that I can get some clarity on a few points. In the Minister's statement, he spoke about the regional health areas and the advisory group. We have just discussed this new implementation body with the CEO of the HSE and the Department. Is that the advisory group, or is it a separate body?

They are separate. There are two groups. One is an advisory group, which is being set up specifically to advise on regionalisation.

Who will sit on that advisory group, who will chair it and how will it operate?

The names for the advisory group---

I refer to its formation. I do not need the actual names. Who will be part of that group?

We want to see representation from the front lines. In order to get the reorganisation right, it has to be something that works for our clinical and non-clinical teams working on the front lines. One of the things that the advisory group is going to be able to do is provide feedback into the Department and to me as to how the proposals would work for those working on the front lines across the healthcare system.

Can I take it from that that the group will contain a range of stakeholders and representatives from nursing and particular disciplines, and patient stakeholders?

We have not finalised it, but it will be a small group.

Does the Minister have an idea of who will chair the group?

I have views on it, but nothing that I can share just yet.

In terms of the discussions that have been ongoing, one of the observations is that perhaps there is a feeling that Sláintecare Implementation Advisory Council was peripheral. Is there a danger with this advisory group that it will continue to be peripheral to the process?

No, I do not think so. We are looking for very serious individuals to provide very serious advice on what is one of the cornerstones of the reform programme.

In fairness to Ms Magahy, she does seem to have recognised that good progress has been made in many areas in respect of Sláintecare. However, I would like some clarity on one issue. We understand that there was a pause in reform with the pandemic. Perhaps this is a question for Mr. Watt. Did the Department officially recommend or advise that there would be a pause to Sláintecare? Was an end date given for that pause or was a timeframe provided for it? It was said that everyone was in agreement that it should be implemented within a two-year timeframe and, therefore, the pandemic meant that there was a pause. What timeframe was given for that pause?

Mr. Robert Watt

There was not a pause. Sláintecare has continued to be delivered as outlined in the progress report that Mr. Patterson and the team have just published, which sets out progress on the other aspects that are not included in the report. There is ongoing reform in terms of how services are provided for patients. There is reform in relation to ehealth. Eprescribing is a very significant change which has brought about big benefits in terms of clinical practices, critical pathways and GP services. That is ongoing.

Mr. Robert Watt

To an extent, the pandemic forced the necessary change in places. There was a dynamic for change. The pandemic ensured that barriers were kicked down and so on and things were done. Paul Reid and his team----

Mr. Watt said that the pandemic required----

Mr. Robert Watt

On the issue of RHAs in terms of structural change, there was a view, which I shared and I recommended to the Minister, that we would not engage in functional reorganisation of the HSE during the pandemic and that we would get to it-----

What does that mean in terms of a timeframe? The pandemic is going to reverberate through our health system for many years to come. Was SIAC advised of a particular timeframe for that? Did Mr. Watt have a timeframe in mind? Is there a timeframe within the Department in respect of when it is considered that it is time to get everything back on track again?

Mr. Robert Watt

We are working on what the policy advice will be to the Minister in terms of the exact structure of the RHAs. Obviously, there are different views on that.

Was any advice given on the impact of the pandemic in terms of a timeframe?

Mr. Robert Watt

Not explicitly. The view, regarding RHAs, was that we would not push ahead with that structural change during the pandemic, but now Paul Reid and I are discussing that. We will have recommendations with the Minister soon, which he will no doubt bring to Government in respect of that. That will include a plan for implementation and timelines. I do not have timelines at this stage.

From SIAC's perspective, would it be reasonable to say that this is an indefinite pause and we do not know when the end date of the pause will be?

Mr. Robert Watt

No. It is an indefinite pause in that we have not, at this stage, set out the clear direction of travel in terms of the policy or the timeframe from that, but we hope to do that over the next few months.

A timeframe was not set out then, but were requirements set out, for example, regarding infections or cases having to be under a certain limit?

Mr. Robert Watt

No.

I recognise that progress has been made. However, while work is ongoing on specific Sláintecare projects, without regionalisation, it is a bit like designing the best practice of a one-off item or perhaps designing a luxury room without the structure of the building around it.

Will Mr. Watt give us further information on what the Department imagines the implementation of the regionalisation will be? When will we start to see the full devolution of budgets to regional structures?

Mr. Robert Watt

We do not have a timeframe for that. We are setting the budget for 2022 now. The Minister for Public Expenditure and Reform will set out the 2022 allocation to our Minister next week, so the devolution will not happen next year. We are hopeful that we will have put in place a process for 2023 onwards. I do not have the details at this stage, but over the next month or two, we will have them. I agree with what Deputy Shortall said about the importance of this reform having a regional focus that enables the integration to take place, ensures that budgets are allocated based on need at regional level and provides better accountability at regional level for outcomes for citizens. That is the philosophy that I subscribe to and that is the way to go. We will give our views on how to push ahead with this to the Minister shortly.

There is no institutional resistance to this in the Department of Health or the HSE. There was a healthy debate about the timeframe. My experience as a long-time civil servant is that healthy debate between officials and, God help us, even between officials and Ministers is a good thing. That there can be differences of opinion, which there are, is not a bad thing. The worst thing is to have differences but not to air them and not to have a frank discussion.

Mr. Robert Watt

I will make an important point. Mr. Patterson and I not agreeing on something, which happens quite often, is not necessarily a problem. That is healthy. We do not all have the same views; we have different views, but we ultimately get to what we think is the best view, which we then give to the Minister, and the Minister and his colleagues decide what to do.

I will put the same question to the Minister and Mr. Watt. What do they feel are the major barriers to regionalisation?

Mr. Robert Watt

Recently, the major barrier has been the bandwidth of the senior team in the HSE. Structural and functional change is time consuming. I have been involved in many reforms across the public service. I do not know Professor Keane at all, but I have great time for Ms Magahy. She is a great person and I know Professor Keane by reputation, but they are not the only people who work in the health system who have experience of reform. Mr. Paul Reid is one of the most impressive public servants this country has ever produced. His record of delivery over the past 12 months has been phenomenal. We will refocus and we will set out what we are hoping to do, and we will be able to deliver these changes over time.

Although I will ask the same question of the Minister, that sounds like there is a capacity issue with people’s workload. Given that we are now hearing that the head of the HSE and the head of the Department will be responsible for implementation, that is something of a worry.

What would the Minister consider is the most significant-----

Mr. Robert Watt

May I say something on that? Mr. Reid and myself are accountable to the Government and this committee and we are legally responsible for the allocation of budgets and spending public money on delivering this change, which is what we are going to do. I have been involved in many reform programmes across the Civil Service in particular. My experience is that they need to be driven by the people who are heading the organisations, with the political direction of the relevant Minister and the Taoiseach. That is the best way to get progress.

Now that we are in a different phase of Covid, it is my professional view – members may disagree with me on this if they wish – that what the Minister is proposing in terms of Mr. Reid and me being charged with this responsibility is the most effective way for us to deliver the programme of change. I am fully committed to doing that. It is not as it has been characterised, that is, reform being suffocated. The Department of Health wants to deliver this because the Department knows – colleagues say it to me every day – that the current system is not delivering for our citizens. It is not a case of people being hostile to or suffocating reform; quite the opposite. With the HSE, people in the Department are the ones who are driving the change and reform. We are dissatisfied with ehealth and we want to do more, and we are dissatisfied with waiting lists and the changes in that regard. The people in the Department are as dissatisfied as the Minister or anyone else. The characterisation is not fair. Officials in the Department are fully focused and driven. That is why public servants want to work in the Department of Health. That is what motivates them. They are not just motivated to stay in the Department. If they wanted easier jobs, there are plenty of them across the Civil Service.

I thank Mr. Watt.

Next is Deputy Kenny, who I note is in the precincts of Leinster House. I recognise the building behind him.

I am in the Department of Agriculture, Food and the Marine, to be precise.

I thank the witnesses for appearing before us. Everyone will agree that the past number of weeks have been bad for the concept of universal healthcare, that is, Sláintecare. Regardless of whether that is down to internal or external factors, members of the advisory committee have asked serious questions of the future of Sláintecare. In light of that and the perception it has raised, many people - or some people, depending on their objectivity – believe that there is institutional resistance to reform, be that resistance political or in the HSE, the Department or other bodies. Some of the wording in the resignations of Professor McCarthy, Professor Keane and Ms Magahy is damning of the Sláintecare process and some people will perceive that there is institutional resistance. Would the witnesses like to comment on this perception?

To which of us is the Deputy putting the question?

Mr. Robert Watt

I thank the Deputy for the question. To those who say there is institutional resistance, I am available to talk to anyone and I would ask him or her to tell me two things – the issue the Department is resisting, be it a policy issue or aspect of Sláintecare, and who is resisting. Is it me, Mr. Reid or someone else? I am not accusing the Deputy of making general comments, as he is reflecting what people are saying, but making general comments that there is resistance to change or reform in an organisation is too easy. There is something in it of people having watched too much "Yes Minister", with civil servants going around unwilling to make changes and only looking after their own interests. That is 40 years old, to say the least. I do not listen to radio, but I have been told that people have said on radio that there is not only resistance, but "brutal resistance", which apparently is an even greater form of resistance than normal resistance. If people have evidence of that brutal resistance or resistance, they need to tell me. They can email me, text me or even organise a meeting and I will listen to their evidence of the specific issue they are referring to and which officer is involved. Is Mr. Patterson resisting the change? Maybe he is, so let me know. I do not know. Is someone else resisting the change? Tell me who-----

May I just ask about-----

Mr. Robert Watt

-----instead of pretending that there is some vast conspiracy of shadowy figures. That is all nonsense. If people have evidence, let them come to me and I will talk to them about it.

I will quote a sentence from the end of Professor McCarthy’s resignation letter. She wrote: "However, recent information and my own experiences tell me we are no nearer to the required reform than we were six years ago." That is not fabricated. It is coming from someone who was spearheading Sláintecare. It must be taken seriously if a person who has been leading the charge is saying this.

We have to take any such resignation seriously. Ms Magahy is a serious person, Professor Keane is a serious person, and I take their resignations seriously. The Deputy will have seen substantial new proposals from me, the Department and the HSE on the governance of Sláintecare. I am appointing the Secretary General of the Department and the chief executive of the HSE to its implementation. That is the level of senior leadership that we will have. That board will report directly to me and I will report directly to the Cabinet.

The Deputy rightly said that damage had been done. That is true.

There is a perception among some that change is not happening. We heard a member of the committee say already today that the Department and the HSE are incapable of change. All I would say is that we, as parliamentarians, need to be very clear as to the evidence. Is there resistance to change? In my experience, people do not resist change; they resist loss. People from any walk of life or in any organisation, be it the HSE, the Oireachtas, Microsoft or whatever, will resist perceived loss. That is why we have to get the reorganisation right. If it is perceived as something whereby people lose out, they will resist that change. It is human nature. We all resist loss. It is why it is so important that the reorganisation is done right.

Doing a reorganisation of a healthcare system is a bit like trying to upgrade a Boeing 747 mid-flight. We do not get to shut down the operating theatres and tell the doctors and nurses to go home for two weeks. We do not get to shut the maternity hospitals. Everything has to keep running. All the patients have to be seen. No machine gets turned off and nobody gets to go home. While they are still doing their jobs under immense pressure, we have to rewire the system in an important way. That only works when the men and women who work in the system are brought into the change.

This is the point I was trying to make earlier. When any of us make statements saying there is no change or progress, and that these people - whoever they are - are incapable of reform, it is incumbent on us as parliamentarians to look at the evidence. The evidence we have is unambiguous. The Sláintecare office handed me a progress report stating that 97% of our projects were on track or on track with minor issues. Think about that - not 60% or 70% but 97%. I do not understand how an organisation can be 97% on track and at the same time incapable of reform. I think we would all agree with this.

I spend much time out in the healthcare system talking to our front-line workers. I believe I speak for us all when I say that what they have done over the last 18 months is magnificent. It is extraordinary. They are exhausted. Many of them are traumatised but they have lived change every single day. They are passionate about change and about the people they serve. When I talk to people right across our system, be it in the Department of Health, the HSE or our front-line workers, I see people who are passionate about universal healthcare and who have probably implemented more change over the last 18 months than any organisation any of us can see. Is it perfect? No. Does everything work perfectly the way we want it to work? No. Will we get pockets of resistance to certain ideas? Absolutely we will, as we will get anyway. Ultimately, this is a system that wants to and is capable of reform. We in government are deadly serious about reforming it to ensure 100% universal healthcare.

Given the Minister's statement today, I do not disbelieve there is change. Nobody listening to today's events and previous events will doubt there is change. How fast that is going is the question. We all want universal healthcare. We want a system that ends the two-tier health system.

What is the current position on reform with regard to private healthcare in public hospitals? It is one of the concepts of change in Sláintecare. For most people, that is counter-intuitive to what universal healthcare actually means. Is there resistance from private medicine to decoupling that from our public hospitals? As I said, most people hearing about that concept of private healthcare in public hospitals would say that if the Government does not start with that, then we have a problem.

I thank the Deputy. Removing private care from our public hospitals is absolutely essential. We are in the middle of negotiations with regard to a public-only contract. I cannot get into the detail of that, obviously, because the negotiations are ongoing. The policy goal, however, is that public patients are treated in public hospitals and that is it. It is very important.

To address the Deputy's question on resistance, the doctors in our system have dedicated their lives to our patients. They want to be able to treat as many people as possible as quickly as possible with the best available technology and medical science. That is what motivates them. That is why they went to medical school and why they work 60, 70 and 80 hours per week. We need to make sure, therefore, that the change is positive and works and that we move forward together.

Mr. Robert Watt

To add to what the Minister said, I absolutely agree with the proposal that we need to remove private practice from public hospitals. I do not believe the current system works. It leads to elements of dysfunctionality and it needs to end.

It has been heartening to hear so many consultants over the last few weeks giving their vocal support for Sláintecare and saying that we should not cherry-pick Sláintecare. That means those consultants are in favour of removing private practice from public hospitals given their very clear support for Sláintecare in all its manifestations. Given those comments, we look forward to reaching agreement on making the changes we need to make.

Is there a timeframe, particularly for that concept of removing private healthcare from public healthcare?

Mr. Robert Watt

There are negotiations going on now with the consultant bodies. It is not, therefore, appropriate for us to comment on that. There is, however, a timeframe for the end of this month to conclude those negotiations. Negotiations on that contract and aspects of it will be a really important element of the reform to ensure that all patients in public hospitals are treated on the basis of need and not their insurance status. By the end of the month, hopefully, we will have agreement for a roadmap to move forward on this. That is one aspect of it. There are other parts of it but that is a very important aspect.

I thank Deputy Kenny. We will move on to Senator Kyne.

I welcome the Minister, Deputy Donnelly, and the Secretary General, Mr. Watt. I acknowledge the tremendous success of the vaccination roll-out and programme and its uptake around the country. Everybody can be rightly proud of the team within the HSE and Department of Health.

I also welcome and acknowledge the success of the heart health diagnostic pilot whereby GPs can refer their patients with suspected heart failure directly to the primary care teams for tests and diagnostics. That is healthcare in action and working. I will mention one bit of testimony from a friend of mine whose mother was referred by a GP for an ultrasound to a facility in Santry connected to Beaumont Hospital. She was in and out in 15 minutes. Again, that is public healthcare working correctly and properly. It is important to put that on the record.

I welcome the plans for the elective units in Galway, Dublin and Cork. I understand and welcome that the Minister is bringing that proposal to Cabinet tomorrow. I am sure he will not want to go into too much detail about what is in it and I understand that. As Deputy Colm Burke mentioned, the facilities planned are day-only beds. This is not what the Saolta University Health Care Group has indicated is needed. It has made that clear. We have been led to believe, for example, that knee and hip operations would be carried out in these new elective facilities, which I do not think is feasible in a day-only facility. Perhaps we could get some clarity on that. Is there a commitment to overnight beds in the national development plan, NDP, for University Hospital Galway, either in the elective centres or elsewhere over the course of the plan?

I thank the Senator very much for his kind comments on the vaccine programme and other aspects of reform. I am bringing a memo to Government tomorrow. The Senator will appreciate that I cannot discuss the details of that. What I can say, though, is that I fully acknowledge there is a need for more inpatient beds in Galway. The capacity in Galway needs to be increased. A very ambitious plan is in place, on which the Senator and I have been corresponding, in terms of an emergency department block and additional facilities that would be part of that block. There is an ongoing discussion about whether those inpatient beds are best deployed to a model 4 hospital or an elective-only hospital. That is a live debate.

I cannot say too much before I discuss it at Cabinet tomorrow. However, I can wholeheartedly support the core assurance I think the Senator is looking for, that being that more inpatient beds are required.

That is good to hear. In response to the Sláintecare proposals published earlier in the year, the Saolta University Health Care Group has indicated it believes the proposals must go further. After the options appraisal there is an ongoing debate in Galway in relation to Merlin Park versus University Hospital Galway. There a plans for a full move to Merlin Park, a partial one, and so on. That has muddied the water to a degree. I would rather there was a focus simply on healthcare in Galway and what is best, rather than have this competition, if you like, between certain elements in Saolta.

The Minister and his officials will be aware there was no mention of the ED on the list of projects on pages 141-142 of the NDP, much to my surprise and that of many people in the Saolta University Health Care Group. I am not sure if that was an oversight or whatever else. I put on record that I do not believe that means the project will not go ahead, or at least I hope it does not mean that, I should say. Maybe Mr. Watt, from his experience at the Department of Public Expenditure and Reform, will be able to say whether that Department will argue that because the ED is not listed on pages 141 -142 of the NDP it therefore is not a priority. That would be a concern. It is three years since the Minister's predecessor came to UHG and was promised by the Saolta University Health Care Group that planning permission for a new ED would be lodged by Christmas of that year. I appreciate the specification has changed but that is still not lodged. The facilities are inadequate. Former Taoiseach, Enda Kenny, said, I would say back in 2015, that they were not fit for purpose back. The Taoiseach, when leader of the Opposition putting questions to him agreed, following a visit, that they were not fit for purpose. Everybody agrees they are not fit for purpose but there is such a delay on delivery. There is a delay even on lodging the planning application. We do not even know how that will go. I presume it will be positive because it is so needed. God behold anyone who objects to something as vital as that for Galway. This is so needed. Nurses are absolutely frustrated. They have done so much Trojan work during the pandemic. They are now decanting to temporary accommodation which will be open between April and July, as I understand it.

What is the update on the ED? I believe the Minister is committed to this but I would like to hear it from him. Will he commit to an emergency department on the grounds of UHG for the people of Galway and the west?

We are committed. The Senator's analysis of it not being in the NDP is correct. That absolutely does not mean it will not proceed. Not every project is listed in the plan nor could it be. I am very aware of the need for the facilities in Galway. The Senator has raised many issues around planning permission. As he will be aware, it is a multi-stage process which must be gone through. I will get back to the Senator with a detailed note on exactly where all those pieces are.

Okay. I have raised it before. I am hearing dates and I have heard dates before. I heard dates of February 2019, May 2019, then it was delayed for the options appraisal, then it was going to September 2020, and here we are in October 2021 and there is now talk of 2022. I have not been given a specific month, nor would I believe one at this stage because I have heard so many different dates. I ask the Minister to come back to me on that with urgency. There is frustration, as I said, from the front-line workers in relation to a project everybody, including at the most senior level of the Taoiseach and former Taoiseach, and the Minister and his predecessors, accepts is absolutely required. Ms Laura Magahy appeared before the committee at our last meeting. She talked about a more ambitious plan locally in Galway. This comes back to the whole argument over what is needed. The Minister has pointed to the fact that more inpatient beds are needed. I would welcome an update, following tomorrow's Cabinet meeting, for Galway elected representatives on what exactly is planned with respect to inpatient facilities and where they are going to be located, if they do happen and whether they would be provided in Merlin Park, as the Saolta University Health Care Group desires, or in UHG. I look forward to such an update. As a final point on that, the Minister mentioned in his opening statement that 850 permanent beds have been provided to the hospital system this year. Will he supply details on the location of all those? Is there a small number of them in every hospital or a large number in certain facilities? He might be able to provide that detail to us if he does not have it now.

Turning to Mr. Watt, he will know the expression "poacher turned gamekeeper", although perhaps in his case it is gamekeeper turned poacher, because he is now fighting for extra resources whereas in his previous role he may have been pushing back against Departments being given extra resources. That might be an unfair categorisation but he can respond. Is his primary role about securing additional funding for healthcare in this budget and all budgets, or is it about reform, saving us from waste, although that might be unfair, and improving efficiency within the healthcare system? How does Mr. Watt see his role? I ask because we have seen increases in budget every year. There have been many successes and where there is capital expenditure and increases in staff, these are obviously visible and have an important role. At the same time, given Mr. Watt's previous experience where does he see his role as Secretary General now?

Mr. Robert Watt

I thank the Senator. We will come back to him on the beds. We have a table here but it would not be a very efficient way to read something into the record. We will provide the table. There are changes across all the regions with respect to increased capacities. We will send that on to him and he will see the details on that.

My job is to run the Department of Health and to deliver for the Minister and deliver the reforms for the Department and for the system. That is my job. Making the Department work as effectively as possible will enable us to deliver on the reform agenda, on the various policy initiatives and the legislative programme for the Minister. My job is to manage the Department to deliver on the Minister's and the Government's agenda. An aspect of that involves fighting with the Department of Public Expenditure and Reform - and they are very reasonable people in that Department - about money. Despite the general sense, officials in that Department want to have a well-funded, efficient health system that meets the needs of citizens. People in the Department of Public Expenditure and Reform are also humans, despite what some people would suggest. They are part of this community as well and they rely on the public health system in the same way as anybody else. There is always a bit of adversarial cut and thrust around budgets but, ultimately, the Minister for Public Expenditure and Reform, Deputy Micheal McGrath, and the Minister, Deputy Donnelly, have the same objective in mind, that is, to fund the health system to meet the needs of citizens of Ireland, so that is what we are about. My job is to work with the Minister on that.

Mr. Robert Watt

The budget increase for 2021 was very unusual but it is the largest core increase in spending ever. I have no doubt the Minister, Deputy Michael McGrath, will be making announcements but I am not going to pre-empt the budget. In my experience Ministers prefer to announce the budget themselves, which makes sense. Next Tuesday, the Minister, Deputy Michael McGrath, will be announcing plans for 2022. It is not agreed yet of course but I am hopeful there will be another significant investment in the health system.

On top of the initial resources we have spoken about, which are absolutely critical, we must reform the structures and the system to get more out of those resources, and everybody accepts that. We must ensure more of our citizens are treated closer to home in the community by community teams and GP teams. We need to keep people out of hospital and when people get into hospital we must get them out quickly. More and more treatment must take place outside the acute system. That is not only better for patients but it is also a more efficient way of providing that care. A key part of our role is not only to argue for and get more resources but to drive efficiency and change across the system.

There are many issues here with the drugs budget, for example. We are negotiating with the pharmaceutical companies in the context of the drugs budget as we need to get savings on drugs. It is very expensive and going up all the time. We cannot meet the need that is out there. There is the use of existing facilities. Can we get more out of the diagnostic machines we have? Can we get more out of the operating theatres? Can we look at changes in work practices to drive efficiencies? Thus there is a whole agenda which we are committed to, as is the HSE. We are committed to it because no matter how successful the Minister is at extracting money from the Department of Public Expenditure and Reform, those resources are finite and are never going to meet the needs we identified, so we must ensure we are maxing out all the time. That is an ongoing challenge for us. It is the challenge we face in the Department but it is a challenge every healthcare system in the developed world is now facing. We have a demographic change which is absolutely profound and is going to have profound implications for our society. It would be useful, Chairman, to talk about that at some future date when we can get into the detail of it. Respectfully, it is a much more important issue than people resigning from councils or whatever. How are we going to deal with the enormous changes that are going to be brought about by the fact that, thankfully, our citizens are living longer? The number of people now over 85 years of age and indeed over 65 years of age will have a profound effect on the health system.

Those are the big challenges we face and that is what we are focusing on.

I thank the Minister, the Department and the HSE for all their work in the very difficult year and a half that we have all had. They have been very committed to everything that has been happening. I do not doubt the commitment of and the great work the Minister, the Department and the HSE are doing with regard to Sláintecare and a better healthcare system. I just want to go back a little bit to the cross-party Oireachtas committee on Sláintecare. One of the top priorities of that committee, and many of the witnesses who came in, was reform of the HSE and the devolution of power. Do the Minister or Mr. Watt think that there may be a conflict of interest with the Department and the HSE stepping into that role?

I understand the premise of the Senator's question and it is a very fair one. We are tasking the centre with reducing its authority or its executive bandwidth, so whether that is a direct conflict is a very reasonable question. Regardless of whether there is a conflict, when embarking on a programme of reform and organisational redesign of this scale the only people who can lead it are the senior leadership teams in the organisations. They are the only people who can lead. No one else can do that job other than the senior teams in those organisations themselves. If you give it to somebody else it will fail because the organisations will not own it. They will not have created it and they will resist it. There is consistent evidence of that in large-scale change all over the world. It has to be led at the most senior levels politically, which is me reporting to the Cabinet, as well as at an official level, which is Mr. Watt, and at an operational level, which is Mr. Reid. That is the leadership team. Mr. Reid and Mr. Watt are going to co-chair a very senior group of people who will report to me and then I am accountable to the Oireachtas, to this committee and to Cabinet. The first thing needed for success is absolute commitment at the most senior level. Given that, the Senator's question, which is how we ensure that happens, very much comes into play. Part of what we have to do is tap into the fact that everyone involved is dedicating every minute of every day to universal healthcare. Everybody has bought into that. All of us have bought into that. If people have bought into this, the argument has to make sense. If it makes sense, and if people can see that this is better for patients, clinicians and workers, then it will happen.

The concept in management terms is subsidiarity, that is, pushing out decision-making as far from the centre as possible. We have just seen an incredibly successful model of that with the vaccine programme. Right at the centre we had a task force that reported to me, we had very senior leadership from the Department and the HSE and we had a very clear goal, which is critical for these programmes as well. You have to be absolutely clear about where you are going and what it is you are trying to achieve and then the operational model is to push out the local solutions locally. For example, I was in vaccine centres in universities, in GAA clubs, in hotels and in all sorts of facilities. Every single person running those vaccine centres had to optimise locally but with all the support they needed from the centre. Another area that gets less attention but which was even more random is testing and tracing. I went to a testing and tracing centre in an old fire station. We had testing and tracing on the site of a county GAA stadium and in all sorts of different places. Again, that worked because our front-line workers were trusted to do the job that they know how to do and they got the support they needed from the centre. That is essentially the philosophy. I have bought into that, the Department has bought into it and the HSE has bought into it. The Senator's question, which is really important and is one we are going to have to keep asking ourselves repeatedly, is whether we, the HSE or the Department are resisting this concept of subsidiarity. We need to make sure we are not. The way to deal with that is through a very clear goal and everyone passionately wanting to get there. I am also establishing an advisory group specifically on this area so we will have a group of people who are outside of the direct implementation who will be able to feed back into the Department and to me as to whether they think we are getting that right.

I have no doubt about the commitment and dedication of the Department and the HSE to everything they do, as well as the experience they have. It comes back to the Sláintecare cross-party Oireachtas group and the recommendation that was given around the reform of the HSE and the devolution of power. Is that a recommendation that will not be taken on board? I am only asking about the cross-party Oireachtas committee and that recommendation. Does the Minister think that recommendation will now not be taken on board?

It is absolutely being taken on board. In terms of operational principles for regionalisation, it is exactly what we need to do. I passionately believe that the only way we will get the level of performance and change we need, on behalf of patients, is to empower our front-line workers to do the job they know how to do. I will give a very quick example of where it goes wrong and what we need to change. I was talking to an emergency medicine consultant before I was in office who told me that they were trying to set up a triage room in their emergency department, which is an absolutely basic operational procedure for emergency medicine. She told me that it took five years to get it in place. At the time her colleagues told her she was wasting her time and that she would be exhausted by the end of it. They got it after five years but she said to me it was the last time they were going to embark on that kind of local reform programme. That is a case of the system being stuck and buried in red tape and failing on behalf of patients. What we have to do is trust our front-line staff, our clinicians and our front-line management teams as well. In fairness, there are many parts of the system that are already doing this. We have to trust them to do the right thing in their local environment.

However, the flip side to that is that we need to know how it is going. One of the big problems we have in the system right now is that we do not know. We do not know, for example, how many procedures are being run per operating theatre in each hospital. We do not know how many scans are being run per diagnostic suite. We are not able to compare and contrast one hospital with another and say that it looks like hospital A is getting an awful lot more for the capacity it has than hospital B, for example.

There is wonderful change happening. I will give an example just from last week. I was in one of our model 4 hospitals and they brought me to the ophthalmology suite where they do cataracts. They have basically applied engineering principles and lean process design to get the patients moving through quicker. Believe it or not, they are going from an average of four and a half cataract procedures per session to 15. No one in the centre, be it politically, in the Department or in Dr. Steevens' Hospital can solve those local problems and spot those local opportunities. The only people who can do that are the people working in the community or in acute settings. We have to make sure they are free to do it but at the same time we need to be able to hold them to account and make sure that reform, change and improvement are happening.

The Irish Platform for Patient Organisations, Science and Industry has concerns over the ehealth agenda and its progress under Sláintecare. Could the Minister speak to the developments and the strategy that the Department is implementing to advance ehealth? Does the Department intend to evaluate and review that current strategy?

Ehealth is an area in which we are very far behind internationally. I believe Ireland is a laggard in e-health. We have invested a significant amount this year, but in fairness to those leading on that strategy, we got hit with the cyberattack and the extent of the damage that the cyberattack caused probably is not fully understood. It caused absolute chaos in the system. The very people - and they are excellent - who were going to be pushing on the ehealth agenda ended up having to respond to the cyberattack. Therefore, I think we are behind.

However, a digital transformation team within the HSE is examining innovation. We must also recognise that, during the pandemic, important changes were made. We were told that telemedicine could not be done; now it is being done right across the system. It is being embraced within the system and by patients. For years, we were told that technically, it was not possible to move to eprescribing. I am told that it was done in approximately three weeks under the intense pressure of the pandemic. Through the vaccine programme we now have unique patient identifiers, something we have never had before. There are exciting pilots going on in terms of diagnostics and sensors being used in people's homes to monitor chronic diseases they may have. They are being monitored in the community by public health nurses or specialists. Therefore, a lot of innovation is happening, but there is a vast amount of work required to bring Ireland up to the level that we need to be at. Mr. Watt and I are having ongoing discussions about how we begin to push that, and have a clear and ambitious strategy and implement that.

I welcome the Minister and Mr. Watt to the meeting. Much has been said about Ms Magahy and Professor Keane, their departures and the reason for them, and so on. Has Mr. Watt had any discussions with Ms Magahy or Professor Keane since they left on why they left?

Mr. Robert Watt

I have had discussions with Ms Magahy, but not with Professor Keane.

Did Mr. Watt learn anything from the discussions with Ms Magahy?

Mr. Robert Watt

I did. What we are trying to do is to learn the lessons from what succeeded and what has not succeeded and to ensure that we are better able to deliver the reform into the future. That is what the focus is on now. It is about learning the lessons of what has and has not worked.

Has the Minister learned anything from his discussions with them?

I have spoken with both Ms Magahy on several occasions and Professor Keane. Ms Magahy and Professor Keane are serious individuals with a lot of experience. I very much regret their resignations. I would have liked if the issues had been flagged earlier, and perhaps we could have proceeded differently. However, the situation is as we find it.

In terms of Ms Magahy, as Mr. Watt has said, what was expressed to me were two issues. The first was a frustration with resistance to change and, second, that the structure was not working. There is a team within the Department trying its best. Mr. Patterson and the team are working incredibly hard to own something as ambitious as universal healthcare. Ms Magahy was frustrated with that structure. We are making changes to that structure. Let us be very clear: we are talking about universal healthcare and what I would argue is the most important programme of change and progress in our society and republic. That is how I view it. Something that big and ambitious has to be owned right across the Department and the HSE.

With regard to Professor Keane, his letter was sent to SIAC and is available. He is a serious individual with a lot of experience. He has brought a lot to the table and it has been very valuable to have him in. He, too, expressed frustration with a resistance to change, and stated that the environment was such that change was not possible.

People also need to be realistic. We are just emerging from a major medical emergency in the pandemic. That was always going to interfere with change and progress. If it did not, there would be something wrong. We would have the greatest health system in the world if it did not.

In terms of universal healthcare, the term "universal" worries me. I want universal healthcare for those on low and middle incomes, not necessarily for people who can afford it. I certainly do not share the view on that concept and understanding of universal healthcare. The wealthy in society should continue to pay for medical treatment.

I would like to raise an issue local to the mid-west, of which I am sure the Minister will be aware. A 60-bed modular unit opened in the past few years to deal with the emergency department issue in the University Hospital Limerick, UHL, yet, in the past couple of days, there were reports of 82 patients waiting on trolleys. Can he understand the bemusement and the lack of understanding of the people of the mid-west at the situation wherein a 60-bed modular unit has been provided, yet 82 people have been waiting on trolleys? Can he provide some kind of explanation and understanding to the people of the mid-west as to why that is happening and when it will be resolved? When will we be in a situation where we will not see those type of numbers on trolleys in Limerick?

First, the 60-bed unit was critical but not enough. That is part of the issue. We launched an ambitious winter plan last year. There was only around a 12% reduction in attendances, but there was a 60% reduction in the number of those on trolleys. The trolley numbers were the lowest since the records were first collected, I believe, in 2013. Therefore, it worked well. There were some things going in our favour, such as the absence of seasonal flu, but we had other things going against us such as the global pandemic.

The reason it worked was we implemented solutions for the whole patient flow. First, we kept people out of the emergency department wherever possible. Second, if they did need to come to emergency departments, they were streamed into minor injuries, medical assessment or surgical assessment units or what we would all understand as the normal emergency department. Third, if they could be discharged quickly and supported at home, we did that; and, fourth, if they did need to be admitted, for example, to be stabilised for 24 hours, we ensured a home care package was available to get them out of the hospital and supported at home as quickly as possible. This approach worked. We are looking at a similar approach this year.

The good news is that last year's plan was a €600 million winter plan and we locked the vast majority money into the base. The staff, home care hours, diagnostics and beds that we added for the winter plan are still there for this winter. That said, I share the Senator's concerns, because this is going to be a tough winter.

The concern is that in the past week or two, there have been reports of 82 people waiting on trolleys and the winter has not even begun yet. What is going to happen in November, December and January, when the flu peak usually happens post-Christmas and early into the new year? If there are 82 people on trolleys now, what way is it going to be in January?

We are doing everything we can to that end. I very much share the Senator's concern. We will allocate home care hours, staff, beds, diagnostics, frailty intervention teams and much more. However, he is correct to point out that the system is under a lot of pressure. What we are seeing in Limerick and other areas is people coming in who may be sicker than normal, and who, because of the pandemic, have perhaps waited or have not had the care during the year they would normally get. They are less resilient at the moment and their average length of stay is longer. That is what the emergency medicine professionals are telling me. Therefore, it is a real concern and we need a comprehensive package in place on that.

I have a final question on an issue that I have spoken to the Minister about previously. It concerns the appointment of eye clinic liaison officers to hospital groups. HE quite rightly mentioned a hospital that has turned around the number of cataract operations it performs per hour from 4.5 per hour to 15 per hour, which is fantastic.

However, for people who are diagnosed with post-operative sight loss, there is no link between healthcare professionals and step-down services. The eye clinic liaison officer is that link. It has worked well in the children's hospital group in Dublin. If it was rolled out across the country, it would reduce the amount of time that medical professionals have to spend explaining to people what they needed to do in terms of step-down services. It would ease a significant blockage and give people access to much better step-down supports. I hope there will be eye clinic liaison officer funding in the budget next week and that the Minister will give a commitment to that at this meeting.

The Senator will appreciate that, if I were to give any commitment ahead of the budget, I would have the Minister for Public Expenditure and Reform on the phone to me explaining how things were.

I will have to leave all of the detail of the budget until budget day. The Senator has advocated for this service previously. He and I have spoken about it in the Seanad. It is something that we are examining closely.

I thank the Minister.

I wish to associate myself with Mr. Watt's comments on Mr. Reid. He stated that Mr. Reid was one of the most impressive public servants this country had ever seen. I wholeheartedly agree. I have experience of Mr. Reid from his time with Fingal County Council. While we were sorry to lose him, it was to the benefit of the country. I am aware of his deep commitment to public service and the public healthcare system. His capabilities and those of the Minister and Mr. Watt have been shown in how we are world leaders with our vaccination roll-out. It is a great source of pride for this country and we can hold our heads high. I commend the witnesses and their teams on their excellent work in that regard.

I have a couple of questions. Perhaps they have been touched on. When the witnesses were making their contributions, I was delayed at another meeting, so I apologise if they have answered them. Did Ms Magahy or Professor Keane ever alert the Minister to the fact that matters were so serious in their eyes that they were going to tender their resignations? Was he given any advance notice of their decisions?

Regarding Professor Keane, no. He and I were at a SIAC meeting. When I took office, I met SIAC to thank its members for their work. I am open to correction if I have this wrong, as I am going from memory, but the next communication I had was the resignation letter.

Ms Magahy and I worked approximately four offices away from each other. We worked on many issues together. We had great ambitions, and still have great ambitions, together from Healthy Ireland to advanced nurse practitioners, from elective hospitals to waiting lists. It was Ms Magahy whom I asked to put together all of the work for the multi-annual waiting list plan. She did an excellent job. She led the work on the electives. She and I spoke regularly. Through our meetings, did she raise frustrations about this or that not moving fasting enough? Undoubtedly. Regarding her resignation, though, the first I was aware that it had escalated for her to that level was when she came to tell me she was resigning.

The Minister had no idea that either of them was thinking about resigning over these issues until they gave in resignation letters.

Did they ever seek a meeting with the Minister to express and discuss their deep concerns? Clearly, they had deep concerns.

Not to the best of my knowledge. I do not recall any such request. Maybe a request was made that came through the office and was not escalated to me, so I cannot categorically say "No", but I can say that I am not aware of any such request.

The Minister did not speak with either Professor Keane or Ms Magahy regarding their concerns or the fact that their concerns were so grave that they were going to resign.

No, not in terms of resignation. As I said, though, Ms Magahy and I are colleagues. We have worked closely together over the past year and a half on any number of important issues. I have no doubt that she would have shared frustrations with me and I would have shared frustrations with her. As Mr. Watt mentioned, debate, teasing matters out and expressing our frustrations with things that are or are not happening is normal enough. I want to be fair to Ms Magahy, as it is of course the case that she raised frustrations-----

But the Minister was shocked when they resigned.

I was really disappointed. They both added a great deal of value. Professor Keane chaired an advisory group that reported to Ms Magahy and Ms Magahy led on the electives. I asked her to lead on the waiting list plan, where she did excellent work. She led on the 112 projects, including Healthy Ireland. Recently, she and I had an exciting meeting about something we will launch after the budget, funded for this year, around tackling health inequalities in the community. She and I were doing a great deal of work together and I was very sorry to see her go. However, it is important to say that we all move on from jobs. She has added extraordinary value and has done her country a great service in the work she did in that office.

Did the Minister ever prevent Ms Magahy or Professor Keane from meeting SIAC?

No. I have no role in that relationship at all.

Does the Minister know why they did not meet the council?

I believe they met ten times over three years.

Does the Minister know why their impending resignations were not raised or why a specific meeting was not held?

No. The council members were informed in writing. There may well have been private conversations and phone calls. I know that there was not a further meeting of the group where Ms Magahy or Professor Keane attended, but they may have spoken privately to council members.

There was not an official meeting.

I will move on to another topic, namely, the use of the Irish language within the HSE. I have spoken to the Minister and Mr. Watt about this a couple of times and written to them both. Have they put together a system to ensure that inaccurate Irish will not be used in anything emanating from the Department of Health and the HSE from here on out? I am referring to mistakes in Covid certificates and the Covid regulations and apps not being immediately available in Irish.

The Senator has moved away from the scope of today's meeting.

A number of colleagues moved away from its scope, and this is something that I have raised previously. I just want to flag these issues. I only have three and a half minutes left.

I have no problem with it and if the officials do not mind responding, it is fine, but we are moving away from the scope and-----

It is something that I have flagged with both of them.

-----I am obliged as Chair to revert to the witnesses.

Mr. Robert Watt

There was an issue. I am aware of a mistake-----

Mr. Robert Watt

Several issues. Obviously, we regret that. I will not make excuses for it. Things were done within a truncated timeframe. Perhaps I will revert to the Senator. She has written to me about it-----

Mr. Robert Watt

-----and I believe I responded during the summer, but I will revert to her. I am not over the detail of the matter, but we regret that those mistakes were made. Let me revert to the Senator.

Maybe I could meet Mr. Watt at some stage to discuss the issues. The point I am trying to make is that, from here on out, Irish needs to be at the centre of any new development from its creation on rather than an afterthought and incorrect. This created significant problems. I would be more than happy to meet him to discuss the matter.

I apologise for cutting the Senator off.

I welcome our witnesses and thank them for their contributions. It has been mentioned that Ms Magahy was allegedly frustrated. I am a little frustrated myself. Having listened to the debate so far, I believe I know why senior people have resigned.

When Laura Magahy indicated to the Minister that she was about to resign, did he ask her to reconsider?

It was not that she indicated she was about to resign; she informed me that she had resigned.

Did the Minister ask her if she would be willing to reconsider, given the important job she was doing?

I did not ask her that, no.

Reference has been made to resistance to regionalisation. Who was resisting?

It is unclear who was resisting, but I am more than happy to acknowledge my part in the pausing of regionalisation. I was asked by the HSE, given the unprecedented pressures due to Covid, if we could pause the implementation of regionalisation and I agreed to that. My view was, and is, that we needed an absolutely focused HSE over the past 18 months. To the HSE's credit, it has-----

On what basis was it assumed that regionalisation was a threat to the smooth running of the operation that has had to take place during Covid?

That is certainly my view and, I believe, a view Paul Reid and the Secretary General would have-----

Did Paul Reid indicate that?

He asked for regionalisation to be paused during the pandemic, yes.

Early or later on in the pandemic? In the beginning?

I can try to find an exact date. From memory, it was reasonably early on in my tenure that the request was put to me, and I agreed with it.

Apparently, resistance to regionalisation is a major issue. Where are the resisters now? Have they taken up other positions? Have they been sent to Coventry or are they still within the system, continuing their resistance?

I am not sure who they may be. I would be happy to be told and to have that conversation with them. While we have paused the implementation, Bob Patterson and his team in the Sláintecare programme office have been doing significant work on detailed design, consultation and so forth in the background. Now, as we are transitioning out of the Covid phase, it is hoped, our intention is to push ahead.

Is the Minister suggesting that the resistance is diminishing or are the pockets of resistance still there? Why has there been resistance to regionalisation, given that it was an integral part of Sláintecare?

I am unaware where these provocateurs are. Certainly, I have not seen any resistance. I have discussed this directly with the chair of the HSE, Ciarán Devane, Paul Reid and the management team in the Department of Health. No one has ever put it to me that regionalisation is something we should not do. What they did put to me - and I fully agree with them - was that it is something we should not do during the pandemic.

It was the considered opinion of all, including the Minister, that during the pandemic regionalisation was a potential threat or hazard.

I do not know if all were of that opinion, but the Secretary General, the chief executive, the chair of the board and I were. We viewed, and I still view, embarking on a whole-scale restructuring of the health system in the middle of a pandemic as a very foolish and very high-risk thing to do.

Did Minister make an announcement to that effect at the time?

I do not recall if I did.

Did the Secretary General make an announcement to that effect?

At the time there was an acting Secretary General in place, and he may have, but I do not recall any such announcement.

Did Laura Magahy meet with all the principal officers involved on whom she depended in the course of her job and the task she was given?

I would need a bit more-----

Ms Magahy addressed a meeting of our committee two or three months ago and indicated that she had not met certain people or they had not met with her.

I am sorry but I cannot add anything to that.

Could anybody add to it such as the Secretary General?

Mr. Robert Watt

I do not recall the reference. Obviously, a number of people would have reported to Ms Magahy in her role. Our principal officers in the Department would have reported to her and Ms Magahy would meet colleagues, principal officers in the Department, every day. I do not know if that is-----

Has anybody avoided reporting to her?

Mr. Robert Watt

Civil servants do not really have a choice. If you are a principal officer, you have to report to the person-----

That is what I thought. I will continue for a minute on the resistance from within, which, I think, the Minister referred to as well. That is ominous. We need to know more about that than what we have been told. If there is resistance from within and the resistance has not gone away, or we have not been told where it has been sent - and, in reply to a previous question, the people resisting have not gone to Coventry and are, therefore, still there - can I take it that the pausing of the process may have been seen by some as a means to stall the process and reverse it? Is that true?

The Deputy is asking me to speculate. It is a pretty reasonable question but not one I can answer. I do not know what others may have thought of the matter. All I can tell the Deputy is that the decision was taken for operational reasons to manage risk. I believe that it was absolutely the right decision and that the results of that are seen in how the HSE has responded with the vaccination programme, testing and tracing and everything else that has gone on over the past 18 months. Is it possible that people thought as the Deputy has suggested? I guess it is, yes. Maybe they did, but I do not recall anyone expressing such a view to me.

What level of resistance exists to the realignment of the CHOs with the hospital groups?

I have not encountered any resistance. I am not saying there is not any - there may well be some - but, if there is, it has not come across my desk. The reality is that plans were advanced, implementation was paused for the reasons we have discussed, and the detailed planning continued and continues now. I have set up an advisory committee to provide those of us involved with an external view. I have set up the most senior team possible in terms of the ongoing implementation towards universal healthcare, of which regionalisation is one part.

Mr. Watt mentioned again exchanges within the system. Could they be regarded as robust exchanges? As a result of such exchanges, did it become clear that difficulties were arising that should have been averted? I am willing to take an answer from anyone.

Mr. Robert Watt

I do not think there are differences regarding the policy on the RHAs. There were differences regarding the pace of implementation during the pandemic. I think that was the issue.

Everything comes back to the pace of the organisation during the pandemic, yet it was felt that Sláintecare was an integral and important part of the reorganisation of the health services. It would be normal to presume that any slowdown in the progress in that area would lead to difficulties, and it obviously did.

Arising from the frank exchanges, did it become obvious that some members of the implementation group were getting disenchanted and were disillusioned?

The implementation group is a wide group of stakeholders. If we are talking about creating a single management structure for the patient pathway from the home through to the acute, from cradle to grave as it were, there are many stakeholders. There is the Sláintecare programme team, which has been doing much of the policy work. There are myself and the Cabinet, senior officials in the Department and senior officials in the HSE. There are many different people involved in this, but certainly all the conversations I had in the Department, politically, with the HSE and, indeed, on the front lines are for a very strong buy-in to integrated care, which is what this is all about. The problem has been that, for example, the community does not have funding for a home care package so somebody has to stay in hospital, which is bad for the patient and bad for the hospital.

My last question is simple and straightforward. Can the Minister give a firm undertaking now that it is intended to proceed with the implementation of the Sláintecare plan forthwith, that it will not be further impeded and that there will be no changes to the original intention of the Sláintecare plan in terms of the delivery of services?

I can, and I will. First, if I may, I will refute the premise of the question slightly. There is an implication that progress is not being made, that there is no commitment and that the commitment is-----

There is more than an implication. There is an indication from a number of senior stakeholders in the system, to such an extent that they resigned. Obviously, they resigned due to disappointment, whether it related to frank exchanges, pockets of resistance or whatever. That is a fact. I asked the question about where the resisters were now, and nobody knows where they are. They could still be buried in the system and could continue to obstruct and frustrate progress on Sláintecare into the future. I do not know. However, the Minister can direct. He is going to form a new board now and, presumably, that board will take directions from him. It is time to let the committee and the stakeholders know exactly what will happen in the future. Will there be changes? Are some of the proposals set out in Sláintecare going to be reversed?

Let me be very clear about this. The sole focus of this Government, the Department of Health and the HSE in healthcare is universal healthcare. That is it. There are three elements to universal healthcare. One is affordability, and we are moving on that. We are also moving on access and clinical quality. That is what defines universal healthcare. If we were meeting now and half of the Sláintecare projects were not being implemented, if beds were not being added to the system, if GP diagnostics was not being rolled out, if advanced nurse practitioners were not being ramped up and if real activity was not happening, I would absolutely say this committee should be pushing and saying that it needs a commitment that things are going to get better. I am saying there is an absolute commitment. As I said previously, I believe this is the single most important project for our country. I am totally committed to it, and I am in charge politically of its implementation. We have a 97% rate of implementation from the Sláintecare office. Across the board we have added record levels of additional capacity this year. We are moving on affordability and record investment in clinical quality. That shows a Government that is absolutely committed, is investing and is delivering. That is the starting point.

On top of that, am I making additional changes to go further and faster? Yes, I am. I am appointing the most senior team possible to ongoing implementation. That team reports directly to me and I report directly to the Oireachtas, this committee and the Cabinet on that. I hope that we will have a very favourable budget package that will focus on our priorities with regard to capacity, reform, women's health, access and clinical quality. I am absolutely committed and, yes, I have made some very significant additions to the work that is already taking place to ensure we move as quickly as we can towards the goal of universal healthcare.

I thank the Minister.

A couple of other members wish to come in for a second time. Regarding what we are hearing this morning, there are two narratives. There is the narrative of those who resigned that there was resistance. The Minister and the Secretary General are saying that we are on track, with 97% progress and so forth. People were asked about where the resistance is coming from and the Minister and his officials are saying that there was no resistance or that if there was, they are not aware of it. That is the conundrum for this committee. I presume that if we can get some of the people who resigned before the committee, we will get a better sense of what was happening. The only real answer we got this morning was that any cause of delay was basically down to Covid-19, and that if there was a resistance at all it is down to Covid-19. Am I correct in that summary so far? The Minister is not aware of where the resisters are. Are they in the HSE or in the Department of Health?

I am conscious that when one has the great privilege of being a Minister people probably do not share their resistance with one. They tend to say "Yes". Now, they may go off and not do everything that one would like to see done-----

That would never happen.

-----but I am very cognisant of the fact that I am in an unusual position. Whatever resistance there may be, it typically would not be aired in front a Minister. Let us be clear about that. Would there have been and is there resistance within the system to large-scale programmes of reform, including this? Of course, there will be. If we were engaged in large-scale reform in the Oireachtas, there would be resistance. There also would be resistance in companies. People resist loss or perceived loss. When the ambition for reform is as big as ours is for the healthcare system, of course there will be people worried, scared or threatened by that and who do not agree with it. I want to be clear. I am not suggesting for a moment that every single person across the health system is lined up, shoulder to shoulder, reading through the committee report and saying, "This is how I am going to do it". That is not how it works. Of course, there will be resistance. Do the Sláintecare team and the director, Mr. Patterson, encounter resistance to change within the system? I bet they do. Of course, they do. Anybody who is trying to drive large systemic change comes up against resistance.

We can take that as a given in any ambitious programme of reform. The question that is most important for me is: is whatever resistance may be there slowing us down and is it making us fail on behalf of men, women and children in this country?. To answer that question, I have to return to the Sláintecare progress report I get. It says 97% were on track or on track with minor issues.

That was in the report I got. When I ask that question, of course there will be resistance. However, is the change happening because ultimately that is all that matters? The answer l have is the score of 97%. If any of us, in any aspect of life, was handed a progress report with a 97% figure, we would be able to see a lot of change happening. There are areas where more needs to be done. We have talked about ehealth, for example. We are laggards in ehealth and have to do more on that. We have talked about regionalisation at length here. My view is that it was paused for the right reasons, and we are now moving on that again. The third project in the report was waiting lists. We have an ambitious plan of work on waiting lists. That is what is happening.

As I said to Deputy Durkan earlier, if I had come here today to account to the Oireachtas, with Mr. Watt, as the Accounting Officer, and the Oireachtas said to us that it had allocated us €1.2 billion, but we had not added the beds, the people, or the diagnostics, we would be having a different conversation. However, that is not the case. As Deputy Cullinane pointed out, the money has not all been spent, and we all understand why that is.

I was handed a report from my project team giving a 97% score. At the same time, the HSE has reported back to me about record numbers on beds, staff, diagnostics, and on all of these areas. Therefore, while we can all say this bit or that bit has not been done, I think in the round, we have to accept the overwhelming evidence that not only is change happening and progress is being made, it is being made at measurable record levels. That is my sense, although I do not want to give the impression that I have come in to say that there is no resistance anywhere. Of course, there will be resistance, as there is always resistance to big, ambitious change. However, it is not slowing us down. I would argue that we are going faster than ever.

Is the Minister is saying today that the Sláintecare Implementation Advisory Council, SIAC, has run its course? The Minister has not asked the members to stay on, so it has clearly run its course. The advisory committee for the implementation of Sláintecare has run its course. Is that what the Minister is saying?

That is what I am saying. By its own terms of reference it was coming to an end. I want to acknowledge that some members of the group sought an extension. We will have a more focused version of the advisory committee. We will have a smaller group. It will be focused on the issue on which we have spent most of our time today, which is regionalisation. That group will be important in giving a perspective from a group of people who are not at the centre of implementing that change.

The Minister is talking about some of the issues with Sláintecare, such as the waiting lists. We are talking about 900,000 people on a waiting list. Part of the difficulty in dealing with that will be that Minister will have to buy in private elements. Sláintecare was supposed to be moving towards a one-tier rather than a two-tier system. The difficulty is that most people who are looking for medical supports or to get into the system see that if they try to get an MRI, for instance, there is a long waiting list. Their only other option, then, is to go the private route for their MRI. We are still at that level.

We will be bringing in BreastCheck shortly given the month that is in it and so on. At one time, if a woman had her breast removed, she could have reconstructive surgery within six months. Now there is a waiting list of two years. The delays are occurring right across the health service. A lot of that is down to Covid-19 and I accept all that.

The implementation committee said it had to resign because of resistance and so on. People are not seeing the roll-out of services.

The Minister said that Ireland is a laggard in relation to the ehealth and that we have old and antiquated systems. Is there any movement on the individual health identifiers, IHI? I imagine that should be standard practice across the service, if we are talking about tackling lists. It is all the more challenging if we have multiple people on them. How many of the individual systems are still running on the operating system, OS, which is out of support and is vulnerable to cyberattack? The Minister might come back to the committee another day in relation to that, as part of this report.

The biggest challenge we face are waiting lists which are getting longer. The Minister started off this morning by saying that he is being ambitious, and he mentioned the increase in number of ICU beds. Yet, a report from the HSE, going back to 2009, talked about a goal of 579 ICU beds. There are currently only 321 beds. We were talking about that years ago. Covid-19 has shown the weaknesses in our system. Clearly, one of those weaknesses is the number of ICU beds. The additional numbers of beds are, of course, welcome.

While I will not speak on the behalf of other members of the committee, we are all concerned about why there have been so many resignations from the high-level advisory committee, because the members feel as though there is a resistance to change. I do not get a sense from the questions that were posed to the Minister this morning, or from the answers that we received, that we are any nearer to finding out who those resistors are, what they are resisting, and what is the reason for the pushback.

I wish the Minister well with his new implementation committee. Will he use those people who have that experience as part of the new advisory committee moving forward?

I can come back to Chair on those questions. However, the answer to his last question is "yes".

The Minister might revert with the answers to the other questions. I call Deputy Cullinane.

The Chair may cut me off after ten minutes. I believe there are ten minutes each for myself and Deputy Shortall.

This been a long meeting. We started the meeting by trying to get answers as to why these people resigned, because these are key people. Second, we wanted to get answers as to whether we were on the right track in relation to healthcare reform. Leaving testy exchanges and differences opinion we might have in the committee aside, many people looking in at this committee, or even people who are not looking in because they are working in healthcare, or are one of the 900,000 people who are on a waiting list, might see the healthcare service as not working for them. They feel that the healthcare service does not work for them and that their experience with it is not a good one. If they get into the health system, it is a great experience, but it is getting in that is the problem. They are concerned about what we are going to do, what our next steps will be, and what big changes we will see in healthcare. That is the starting point for me. Far too many people do not see the public health service working for them. This is why the Oireachtas made a commitment to create a single-tier health service for universal healthcare. One of the first things the Minister said in his opening remarks was that we are a long way away from universal healthcare, which we are.

My commitment is to work with everybody, including those Government and people in the system, to make universal healthcare happen. However, when people resign from the programme that is designed to bring those changes on the scale that they have been resigning, and when these people are in senior positions, it calls into question in public's mind, at least, whether or not there is something more fundamentally wrong. If one listens to what the Minister and Mr. Watt have said today, there is to some degree an air of bewilderment and puzzlement as to why these people resigned. The Minister has given us his view as to why they resigned.

If I am reading this right, the Minister said that given that progress was made, there was an air of puzzlement or bewilderment as to why Ms Magahy and Professor Keane, in particular, stepped away from their positions. Would that be a fair assessment of the Minister’s view?

I thank the Deputy. I was surprised and I was genuinely disappointed. Of course, frustrations have been discussed.

We are all involved in something important, big and difficult, namely the move to universal healthcare. Ms Magahy has added tremendously to that process so, yes, I was surprised. What I have been able to share today, in the context of why any of us does anything, was what was shared with me. There may have been other reasons, but I can only share what was shared with me.

The question then is why was the Minister surprised.

I will go through some of the quotes on the public record from some of these individuals. It is more important than ever now for us to hear from these people. A standing invitation has been issued to many of the people to whom we have referred. We will have to revisit this issue next week. Returning to some of the things said on the public record, however, let us start with Laura Magahy. She was quoted saying that there had been "“slow progress in three key areas requiring dedicated, focused, reform effort: [regionalisation]; ehealth; and waiting lists". Does the Minister share Ms Magahy's concern in that regard? Does he agree that there has been slow progress in those areas?

I agree that there has been very slow progress on ehealth and that we have paused regionalisation for the reasons we discussed today. On waiting lists, those were too big before the arrival of Covid-19, they are much bigger now and we have a serious and funded plan in place until the end of this year in that regard. We are seeking funding through the budget process for next year.

The Minister broadly agrees with the thrust of what she said about the slow progress.

It must be put in context-----

That is fine. I will move on to Tom Keane. He said, "the requirements for implementing this unprecedented programme [as in Sláintecare] for change are seriously lacking". Would the Minister agree with that?

It is difficult for me to agree with that when I have been handed a report by the executive director which states that we are 97% on track.

Anthony O'Connor, in talking about the Sláintecare Implementation Advisory Council, SIAC, said that previously its advice, whether solicited or unsolicited, had at least always been received, albeit with varying degrees of enthusiasm. He continued by saying that it was clear that, "our advice is no longer required, valued or respected". He has now gone, as have several other people. Would the Minister agree with his views on this issue?

The relationship SIAC had was with the executive director. Therefore, it is not for me to comment on how that relationship was.

He is also, though, expressing frustration in respect of advice being taken and implemented. Turning to Ms Roísín Molloy, one of the patient advocates, she expressed concern that the Government will implement a "diluted version" of Sláintecare. She continued by saying, "I need to know how the people that convinced me to stay, through expressing so much conviction and belief in the delivery of Sláintecare, could somehow, in a short space of time, walk away. What obstacles led them to this position?”. Would the Minister agree with her analysis?

I think she was posing a question, if I am hearing that correctly.

She expressed concern that a "diluted version" of Sláintecare would be implemented.

Again, 112 projects are identified as Sláintecare projects and the latest report I have states that 97% of those are on track or are on track with minor issues.

I come then to Liam Doran. He was one of the people on the advisory council. He is gone now, but he said that he was "not surprised but disappointed" regarding the new group now being set up. He went on to say that ultimately the council had been "set up to monitor and comment on the ongoing implementation of the totality of this Sláintecare report" and that "Members of the council [...] view progress as impossible because of the lack of governance and accountability and commitment". Mr. Doran continued by saying that "we now have a Minister", and I assume that he is talking about Deputy Donnelly-----

-----"who has decided to dispense with our services and set up a group which has a one item agenda [...] which is not the totality of Sláintecare and that of itself is disappointing as well". Does the Minister agree with Mr. Doran's analysis?

I find it impossible to square a statement that refers to change as impossible with an evidence base that gives us a score of 97% on progress.

It would seem then that what we have today is a situation where Laura Magahy, Tom Keane, Anthony O'Connor, Roísín Molloy and Liam Doran are all wrong. Yet what we are hearing from the Minister and from Mr. Watt, and I said this earlier, is that there is nothing to see here in respect of the fundamental concerns expressed by the people to whom I have referred.

I turn to one element of the reforms, universal GP care. This will be relevant to Mr. Watt as well because I am sure that he oversees the responses to parliamentary questions. I submitted a parliamentary question seeking information on the cost of this reform and how it will be done. The response stated: "Such a calculation would require a complex and detailed modelling exercise to account for a range of demographic changes, future projections of service demands and variation in the number of GPs and allowances that could be paid". It was also stated that "It is not possible to give an estimate of the cost of extending GP care". I will put myself in the Minister's position and ask how anyone can reasonably provide answers here if that modelling has not been done. How can the Minister give us any confidence that we are going to deliver universal GP care in the timeframe that was agreed? How can the delivery of universal GP access be guaranteed if the Department has not done the modelling in respect of demographic changes, the increase in demand which might arise as a consequence and the additional number of GPs that will be needed? How is that telling me that the Department and the HSE are serious about the provision of universal GP care? I ask that question in the context of being the leading Opposition spokesperson on health and not even being able to get a cost and an estimated timeframe concerning how long it would take to do that because, as the answer to my parliamentary question stated, the requisite modelling has not been done.

All I can tell the Deputy is that I am going to proceed with increasing universal access to GP care. I have costings, at least on a marginal level, as to how to proceed with that endeavour.

We provided and legislated for access in this regard for all children aged up to 12. We are still far away from that, however, let alone anything else. I have one last point. I ask the Minister to hold the line on public-only contracts for consultants. That is the core of this issue for me. We need a centralised referral system and an integrated waiting list management system. There are things that can be done and the Minister will get the support of the Opposition if he makes the right changes. I fundamentally believe that if we do not make those changes, then we are always going to have a two-tier system where people are treated unfairly.

I thank the Deputy. I call Deputy Shortall.

Ms Laura Magahy publicly announced her resignation on Tuesday, 7 September. As well as heading the Sláintecare implementation office, she was deputy secretary of the Department. When did Ms Magahy inform Mr. Watt of her intention of resigning?

Mr. Robert Watt

I think it was the previous week.

Does Mr. Watt remember what day it was? It was the week before.

Mr. Robert Watt

It was the week before.

Mr. Robert Watt

Ms Magahy said that she was going to move on. I said that was fine and we had a chat about that and then we chatted the next day as well. I said that I would speak with the Minister, but she said that she wanted to talk to the Minister herself. The Minister then met Ms Magahy the following Monday, or whatever. Therefore, it was the week before.

Mr. Watt said that was fine. Did he tell the Minister?

Mr. Robert Watt

No.

Mr. Watt did not inform the Minister that the deputy secretary in his Department had decided to resign?

Mr. Robert Watt

Ms Magahy wanted to speak with the Minister herself and I respected that.

That was a strange decision to come to. It was big news, with big implications.

Mr. Robert Watt

I do not think that it was a strange decision, but if the Deputy wants to-----

The implications of that decision are huge. I would have thought that since Mr. Watt works in the same building as the Minister that there would have been an obligation on him to inform the Minister of that news.

Mr. Robert Watt

No, there is not an obligation.

Mr. Robert Watt

I informed the HR manager in the Department. We spoke about it and the details of notice periods and so on. I would have spoken to the Minister, but Ms Magahy explicitly expressed a preference to speak to the Minister herself, so I said that was fine.

Mr. Watt told the HR manager but he did not tell the Minister.

Mr. Robert Watt

Yes, absolutely.

The Minister has made much of the fact that there were serious pressures on the health service last year, and many this year too, in fairness, in respect of the impact of Covid-19. That is a reasonable thing to say about last year, even though the people who were charged with doing the detailed planning for regionalisation were different people. They were not involved in the response to Covid-19 at all. Whatever about last year, then, on 12 May this year the Minister launched the Sláintecare Strategy and Action Plan 2021-2023.

What was contained in that plan was that progress would be made on the development of the business case and submission to Government in quarter 2 this year, there would be detailed scoping of the process for the regionalisation plan in quarter 3 and quarter 4 would involve commencing implementation of RHAs and change management programme in line with the Government decision. In May 2021, the Minister announced that the Government had decided to go ahead with regionalisation and set out a clear timescale for quarter 4 this year, which we are now into. The Government was to commence implementation. What happened between May and now?

Those various activities have happened. I might ask Mr. Patterson to give the Deputy the detail on the design and consultation that have been going in accordance with those-----

I am not talking about the consultation. The Minister committed in May to implementing regionalisation programme in the final quarter of this year.

What happened? Are he on track with that? Has it been held up? What is the situation?

I believe we are on track. Quarters 2 and 3 were around the detailed work consultation. Mr. Patterson can give the Deputy the details regarding the work. An awful lot of work has been done in the background. Quarter 4 is the start of implementation.

It was not really consultation because there had been a lot of consultation. In quarter 2, it was about finalising the business case while in quarter 3, it was the detailed change process. What is the position now in respect of the timeline set out by the Minister in May?

I would say we are on track.

Have the implementation of regionalisation started?

That is exactly what we are discussing now. I appointed two groups - the implementation group in terms of Sláintecare, which includes regionalisation, and the advisory group on regionalisation.

There is a difference between setting up an advisory group and implementing something. The Minister committed in May that he would implement the regionalisation plan in the final quarter of this year. We are into that. What has happened?

We are at the start of that quarter. I have set up two important groups. One is the advisory group that is specifically focused on the implementation of regionalisation while the other is the most senior level management group for the full implementation of universal healthcare, including regionalisation.

That sounds very much as if the Minister is reopening the whole question. We were supposed to be on track, he announced that we were on track and now it seems we are not. There are certainly grounds for understanding why all the people who have resigned were saying the same thing. The fact that we are not on track regarding what the Minister set out as the regionalisation plan would give credence to the concerns expressed by various people involved. What happened at the meeting with the representative group from the advisory council last Wednesday that resulted in Professor Anthony O'Connor tendering his resignation immediately afterwards?

Mr. Robert Watt

We had a meeting. I agreed to meet representatives of the group and we had a discussion. They set out their views on Sláintecare and reform, Paul Reid and I set out our views and we had an exchange of views.

Did Mr. Watt have any contact with Professor O'Connor subsequent to that meeting?

Mr. Robert Watt

I did.

Would he like to tell us the purpose of that?

Mr. Robert Watt

No. It was a private conversation with Professor O'Connor and I will leave it at that.

Was it prior to his announcement of his resignation?

Mr. Robert Watt

It was after his resignation.

Mr. Watt contacted him after his resignation. Other people involved in that meeting included one particular patient advocate. A lot of thought went into the make-up of that advisory group, which represented people across the board and the different interests in health. This morning, the Minister tells us that he is setting up various groups. They seem to be mainly staff groups, which is fine. There should be provision for staff involvement in this. Where is the voice of the patient in all of this? At least two people, if not more, were chosen for the advisory council as patient advocates. Where does the Minister see the voice of the patient being brought into all of this?

When it comes to reorganisation and regionalisation, the group I have set up will give me, the Department and those implementing it a view from front-line clinicians. That is the purpose of this group.

Would it not be more relevant or as relevant to get the view of patients and patient advocates?

That is a fair point and one to reflect on.

Did the Minister not consider that?

I wanted the group because I wanted to hear from the front line. When we are doing the reorganisation, people working in the organisation must buy into it for it to work.

But, clearly, patients are on the front line and are experiencing the sharp end of a healthcare system that cannot cater for need if someone is a public patient and where people are forced to fork out for expensive health insurance. Surely the patient's voice and the public's voice should be heard but the Minister has made no provision for that.

This group was specifically set up to hear from the front line but I certainly share the Deputy's view. It was my amendment to the establishment of the HSE board that looked to include patient voices and indeed front-line clinical voices as well so I agree fully with the principle. However, it is not the purpose of this advisory group.

That is an extraordinary oversight given the scale of the challenges facing the health service.

Regarding elective-only hospitals, this was a clear recommendation of the Sláintecare group. We had learned from the experience in Scotland where the Scottish Government took over one private hospital and was building a second to be elective-only hospitals so that we could make quick progress through the waiting lists. What happened to that proposal? It has now been downgraded to three day hospitals rather than fully functioning elective hospitals.

The strong recommendation from Laura Magahy and the Sláintecare team was that we have day case, outpatient and diagnostics but that we do not have inpatient. When I discussed this with the Sláintecare team because the local clinicians have a different view and want inpatient beds, the rationale I was given was that these elective hospitals are about seeing as many patients as possible. The problem with emergency departments is that it throws all that off-----

I know. We made the recommendation.

So the view was that the inpatient capacity could essentially do the same thing. A surgeon arrives for his or her list on a Monday morning and all the patients are there. However, they need beds at the far side of the operating theatre but because there is a finite number of inpatient beds, they are not there and the list has to be cancelled.

That was the whole intention. It related to excessively long waiting lists for procedures such as hip and knee operations, which predominantly require inpatient care.

The recommendation and rationale from the Sláintecare team was that in excess of 60% of procedures could be done through day cases and that in doing that and pulling all of that work out of the model four hospitals freed up beds and operating theatres for more complex work. No final decisions have been made. It is an ongoing debate and I am receiving strong views from two different groups. One is the Sláintecare team, which is saying it should be day case only, while the other is the clinical community and now the Deputy today, who are saying it should be inpatient as well.

Sláintecare recommended that there be an independent implementation office with its own budget.

There would also be a high level oversight group. Regarding the proposals the Minister is announcing today, is an oversight group proposed or is it all being left in-house?

Is the Deputy asking if there will be an external oversight group?

What would that look like?

It was a recommendation of the all-party committee that an oversight group be established to report on progress such that reporting would not be left to only the implementation office.

It is an interesting question. The reporting to date has been done by the director and by the implementation team. They have done a pretty good and thorough job in terms of implementation.

I am not looking at setting up another external group that would then report on the work being done by the board, if that is the question.

The intention was that group would report to the Taoiseach's office. We are back again to that mistake that was made in locating Sláintecare in the Department of Health. If the Minister had followed the recommendation from the all-party committee, we would not be in this position.

Having spent a year and half in government and seeing how it works, and what works well and what does not, if we had followed that recommendation, which the previous Government did not follow, Sláintecare would not be happening; we would not be at a 97% score. The Department of the Taoiseach cannot implement universal healthcare.

Nobody is suggesting that.

If the Deputy is asking whether there is a direct line of accountability, the answer is "Yes".

It is about the oversight, muscle and ability to clear blockages.

The part of this that is important is accountability. Is there a direct line of accountability? The answer is "Yes". This board reports to me. I provide the oversight and I report to Cabinet and Cabinet provides the oversight.

It is not transparent. That is the problem with it.

I thank Mr. Patterson, Mr. Watt and the Minister for attending for what has been a lengthy meeting. I am told that the March for Maternity protesters have asked to meet them. I do not know if they have time to do that. The protesters are gathering outside the gates of Leinster House today.

They have asked specifically to meet the Minister. I think that at some point that request should be accepted by him in whatever form he can.

I appreciate the Minister, Mr. Patterson and Mr. Watt being here today and I thank them for answering our questions. I thank everybody for their helpful contributions.

The joint committee adjourned at 12.33 p.m. until 9.30 a.m. on Wednesday, 13 October 2021.