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Joint Committee on Health debate -
Wednesday, 16 Feb 2022

Oversight of Sláintecare: Discussion

I welcome our witnesses from the Department of Health and the HSE to our meeting to discuss Sláintecare. From the Department of Health, I welcome Mr. Robert Watt, Secretary General; Mr. Muiris O'Connor, assistant secretary; Mr. Bob Patterson, principal officer; Mr. Jack Nagle, principal officer; and Ms Caroline Pigott, principal officer. From the HSE, I welcome Mr. Paul Reid, CEO; Ms Yvonne O'Neill, national director of community operations; Ms Anne O'Connor, chief operations officer; Mr. Liam Woods, national director of acute operations; and Ms Yvonne Goff, national director of change and innovation.

All witnesses are again reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way 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 any of 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 the witnesses comply with any such direction.

I call on Mr. Watt to make his opening remarks.

Mr. Robert Watt

I wish the Chairman and members a good morning. I thank the committee for the invitation to meet it to discuss progress on the implementation of Sláintecare. As the Chair mentioned, I am joined today by my colleagues Mr. Muiris O’Connor, Ms Caroline Pigott, Mr. Jack Nagle and Mr. Bob Patterson.

The Oireachtas all-party Sláintecare report sets out the Sláintecare vision for a universal health and social care system, where everyone has equal access to services based on need, and not ability to pay. I am happy to report today that alongside my colleague and the CEO of the HSE, Mr. Paul Reid; the Minister for Health, Deputy Stephen Donnelly; and the Government, we are making significant progress in delivering on this reform agenda.

Of course, the background to this discussion is the Covid pandemic. This took up much of our management time over the past two years which, unfortunately, slowed down several reforms, but it also demonstrated the benefits of a universal approach and the capacity of the system to change and respond. The Covid response, by necessity, accelerated many positive aspects of the Sláintecare vision. This included fast-tracking service innovation, new pathways of care, new ways of working and changes implemented rapidly in line with the Sláintecare vision and principle. In effect, these changes accelerated the move from a hospital-centric system to one where more services are provided in the community and near a person’s home. With the unprecedented funding support from the Government over the past number of years and again this year, it is now our challenge to galvanise a system to build on these reforms.

The context for healthcare reform is the need, which I believe is generally accepted, to change a system that is not structured around the new and emerging needs of our population. Our population is aging rapidly. By 2028 there will be more people aged over 65 than under 14. We are living longer, thankfully, but many of us will be living with one or more chronic illness. The health service capacity review, which was prepared in 2018, projected that the demand for healthcare to 2031 will grow significantly. For example, it projected increases in demand of 46% for primary care, of 39% for long-term residential care and of 20% for home care. These increases are clearly not sustainable and we need to continue to develop a more efficient integrated healthcare system that can meet these growing patient needs.

There are many aspects of Sláintecare and I would like to focus on a number of aspects today: enhancing public capacity; improving care at primary and community level; encouraging innovation; and the multi-annual waiting list plan.

First, a critical aspect of Sláintecare is to enhance the capacity of the public health system. Significant investment has been made by the Government and this is delivering additional staff, more hospital infrastructure and capacity and unprecedented levels of activity. For 2021, the Government has allocated almost €21 billion to core health spending. This is an extra €6 billion over the original allocation in the budget for 2018, four years ago, and an increase of over 40%. Priority investments include funding to reduce waiting lists, additional staff and more bed capacity. The CEO of the HSE will touch on this in more detail, so I will just be very brief and give some of the highlights. For example, additional critical care, acute and sub-acute beds were fully funded and opened in 2020 and 2021. Staffing in 2020 experienced the largest increase since the foundation of the HSE and 2021 has seen that trend continue with more than 6,000 whole-time equivalent staff members recruited across all service numbers. There are now over 12,500 more staff working in our health service than there were at the beginning of 2020. That is the most rapid increase in staffing numbers over any two-year period since the HSE was established. As colleagues know, a further significant increase in staffing numbers is planned this year. Specifically, there have been improvements in staffing in our acute services, which increased by almost 4,000 in 2020 and by another significant number, 3,690, in 2021.

Second, significant investment has been made to enhance community care capacity and to affect the shift from a hospital-centric model of care to delivering more care in the community. For example, an additional 837 community beds were delivered in 2020-21. To date, 51 healthcare networks, 15 specialist teams for older persons and two chronic disease management teams have been established, as well as national coverage of community intervention teams, which are all targeted at reducing dependence on the current hospital-based model of care. Each community specialist for older people will see between 6,000 and 7,000 people per year, which equates, in total, to over 210,000 patient contacts a year overall. When the chronic disease management teams are fully established, they will have approximately 30,000 patient contacts a year, which represents more than 900,000 contacts a year on a full basis of implementation. Almost 21 million hours of home care support were delivered in 2021, with over 55,000 people in receipt of the service by the end of last year. This is about 2.9 million or 17% more hours compared to 2020, with increased funding maintained for this year. Over 85% of GPs are registered with the GP chronic disease management programme and nearly 220,000 consultations were delivered in 2021. GP direct access to diagnostics, which is another key element of Sláintecare that has been debated and discussed for many years, has resulted in over 138,000 radiology tests being accessed by GPs in the community. I understand that a further 17,000 tests were undertaken last month alone. On the basis of that rate, we will be close to, if not above, 200,000 for the year as a whole. Thanks to the efforts of the HSE, these resources not only enhance community care but avoid unnecessary trips to hospital, thereby freeing up bed capacity for more complex and urgent cases.

Third, we are fostering a culture of innovation through the Sláintecare integration fund. This involves investing in new care pathways, new technologies and new ways of working and eventually shifting care to the left and directly engaging with front-line staff. Specifically, the fund facilitates the testing and evaluation of innovative models of care, with 105 out of 123 projects being mainstreamed through the HSE.

These projects resulted in over 15,000 reduced referrals, more than 18,000 acute beds avoided and over 8,000 patients off waiting lists. More details are included in the Sláintecare implementation report, which the Minister published yesterday evening. It sets out some of the numbers in more detail, as well as some of the significant benefits of these changes.

The National Ambulance Service, NAS, has successfully continued the development and implementation of alternative care pathways, with the aim of hospital avoidance and of an improved use of healthcare resources. The total number of patients treated by the NAS alternative service was over 18,000, with 44.3% being treated at home or in the community.

Various e-solutions and e-changes have been brought about which are improving the overall efficiency of the system, freeing up staff time and reducing the administrative burden. We have just mentioned two of them. Some 14 million prescriptions were transferred electronically in 2021. There was an enormous amount of activity in the community. It enabled a much more efficient administrative management of that issue. Some 333,000 video consultations were delivered based on our estimates. Clearly, now that we see that video consultations can work, they will have a role to play in the future.

A critical objective of Sláintecare is to reduce waiting lists. The short-term waiting list plan, which was published by the Government in October 2021, resulted in a 5.4% reduction in overall waiting lists, which was in line with the target reduction. The 2022 waiting list action plan is being finalised by colleagues in the Department and the HSE and it will be brought to the Government next week. This plan will set out actions to deliver further reductions in waiting lists, address backlogs, stem future growth and lay the foundations for future reform actions. It will set out how and where additional funding will be allocated. As members will know, €350 million has been committed to support this plan. Some €200 million is to support waiting list initiatives and €150 million has been allocated to the National Treatment Purchase Fund, NTPF. This is an increase of €50 million on last year’s allocation. Each year, the number of new additions to waiting lists increases significantly. The challenge is to increase activity, both to reduce the stock of people waiting too long and address the new additions. In 2022, it is estimated that over 1.5 million people will be added to the waiting lists. This reflects normal additions and an acceleration in presentations due to deferrals caused by Covid-19. Under the proposed plan, which it is hoped the Minister and the Government will publish next week, the HSE and the NTPF propose to deliver services to remove many more patients from active waiting lists. We estimate that this will be the largest level of activity ever delivered and that it will result in a significant reduction in these waiting lists. It is hoped that by the end of this year, the number of patients on active waiting lists will be at its lowest point since the beginning of Covid-19.

Reducing waiting lists will also require further capacity enhancements. Ultimately, plans are progressing for new elective hospitals in Cork, Dublin and Galway which will cater for up to 940,000 planned procedures and operations every year. This is a critical short- to medium-term change in the configuration of the system and it will increase capacity to enable us to increase the number of elective procedures. Of course, reducing lists will also require ongoing change and reform in productivity, as well as improvements in pathways and other issues that Mr. Reid and his team will no doubt touch on later. Increasing productivity is a key part of the response to this challenge. In addition, it will require progress on ensuring all patients are treated in public hospitals on the basis of need and not on the basis of their insurance status. This will free up capacity in public hospitals but it will also ensure a more equitable system. Removing private income from public hospitals is a key Government objective and a key objective of Sláintecare. It will require legislation and further discussions with the representative bodies. Members will be aware that talks have been ongoing with representative bodies on the implementation of a Sláintecare contract, which will pave the way for the removal of private care from public hospitals. We look forward to further engagement on those talks.

I will turn now to Sláintecare governance and oversight. A new Sláintecare programme board, which is co-chaired by Mr. Reid and me, has been established to drive the implementation of Sláintecare reforms. The Sláintecare board, which will report directly to the Minister, Deputy Stephen Donnelly, will ensure enhanced co-ordination on delivering key reform priorities. The board has met twice since December. It will meet every second month going forward. Responsibility for the overall project management office has been assigned to the leadership of an assistant secretary, Mr. Derek Tierney.

As this committee is aware, our hospital groups and community healthcare organisations are not aligned geographically, nor do they overlap on management, clinical oversight or budgets. The Sláintecare report identified that regional health areas, RHAs, are essential for the proper and improved integration of health services and for population-based planning in Ireland. The allocation of resources will also enable better oversight and evaluation of costs and health outcome benefits. RHAs will ensure the alignment and integration of hospital and community services at a regional level, based on defined populations and local needs. The Government approved the geographies of the regions in the months preceding the pandemic. The Government decision directed the Department to explore the organisational design, governance frameworks and funding methods via a business case. A memo for the Government decision is being drafted, and the Minister for Health will bring it to the Government in the next few weeks. A detailed implementation plan is being developed by the Department and the HSE, with input from the newly established RHA advisory group. This will cover how RHAs will impact on workforce and HR planning, funding allocations, capital infrastructure and governance lines. Our high-level timeframe is for design detail for this year, with implementation beginning in 2023.

With the unprecedented funding and support of the Government, we now have a real opportunity to build on recent progress, to continue to implement Sláintecare at pace and to continue to translate the Sláintecare report from shared vision to reality. I would like to take this opportunity to again thank all of our colleagues in the Department of Health and in the HSE for their continuing work and dedication in delivering on this agenda for the Minister, for the Government and for the citizens of Ireland. I look forward to working with the committee and to answering any questions.

I now call on Mr. Reid to make his opening remarks.

Mr. Paul Reid

I am pleased to present at the committee today, along with Mr. Watt and his colleagues and our colleagues from the Department of Health. I thank the committee for its invitation to meet with it to discuss the implementation of Sláintecare. I am joined by my colleagues Ms Anne O’Connor, chief operations officer; Ms Yvonne O’Neill, national director of community operations; Mr. Liam Woods, national director of acute operations; and Ms Yvonne Goff, national director of change and innovation. Sláintecare provides us with an unprecedented opportunity to bring about sustained improvements in the quality and capacity of our health system. The reform agenda we are now pursuing has the full support of the HSE board, which will have oversight of our progress in accordance with its statutory governance role. Our primary focus will be to improve access across community and acute services, to increase bed capacity, to address health inequalities and to enhance patient experience. As members will be aware, the HSE corporate plan 2021-24 details a transformation agenda for health and social care. It was developed to align with the Sláintecare objectives.

In quite an organic way, our response to the pandemic has accelerated many service changes that would ordinarily have required lengthy planning processes. I mention, for example, as Mr. Watt has done, e-health, community healthcare and service integration. These innovations are both enduring and system-wide. They were driven largely from the front line, which ensured successful implementation. Models of care were developed in line with one of the principal objectives of the Sláintecare strategy, which is to provide care in a location that meets patients’ and clients’ needs. The pandemic has therefore provided invaluable insights into how we can embed these ways of working. I am keen to ensure we use all that we have learned to the fullest extent. A key example of such progress last year was direct GP access to radiology services, with five external providers seeing just under 140,000 referrals by the end of the year, thereby materially reducing the demand on hospitals.

Between 2019 and 2022, €210 million has been made available through the 2019 GP agreement in support of modernisation initiatives, the e-health agenda and the roll-out of the chronic disease management programme to over 430,000 people. The enhanced community care programme was allocated €240 million for the establishment of 96 community health networks and 30 community specialist teams for older people and for those with chronic diseases to provide integrated services locally. Some 1,400 staff have been recruited, with over 2,000 additional posts to be recruited in 2022. To date, 51 community health networks, 15 community specialist teams for older persons and two chronic disease specialist teams have been established. Separately, the targeted 91 disability network teams are in place. These developments are being delivered collaboratively with voluntary providers to deliver enhanced care across general and specialist services.

Expanded community intervention teams were further developed in 2021, with five additional teams and three enhanced teams, which means that we now have 21 community intervention teams in operation. Immediate measures were also taken to introduce hospital and critical care pressures by permanently increasing surge capacity by 324 additional inpatient beds, along with 42 additional critical care beds. Additional capacity was also contracted from the private hospitals to support demand.

We continue to work with the private sector to rapidly reduce waiting list numbers. A further 314 public community beds and 498 private intermediate care beds were introduced as part of our Covid-19 response. During the pandemic, ambulance services moved away from an emergency medical service to a Sláintecare-aligned model reorientating healthcare from the traditional hospital-centric model by bringing care to patients rather than patients to care. Such developments were planned pre-Covid to manage the impacts of an ageing population, chronic disease and the growth in our population more generally. As a consequence of the pandemic, this was accelerated.

Sláintecare integration fund projects have been established in more than 100 locations nationally with project partners from acute, community and academic settings. Many of these projects have already been mainstreamed - primarily through the enhanced community care fund and the HSE welcomes the €4 million provided to support 29 more projects this year.

Although the HSE delivers approximately 3.3 million outpatient appointments, over 1 million day cases and 82,000 elective discharges each year, demand continues to exceed capacity in many specialties and I fully accept that patients are waiting too long to be seen. During the pandemic, outpatients waiting lists grew by 98,000, or 18%, inpatient-day cases waiting lists grew by 9,000 and endoscopy waiting lists grew by 10,000. Working with the HSE and the NTPF, the Department of Health published a waiting list action plan in October 2021 focused of providing additional procedures through public and private hospitals by the end of 2021 to reduce waiting lists. By the end of December, the outpatient waiting list decreased by 35,000, or 5%, with a 21% reduction in those waiting 18 months or over. There was only a slight decrease in the inpatient-day case waiting list due to the significant effect of the cancellation of elective surgeries due to Covid-19 and emergency department pressures and a decrease of 5,400 in the endoscopy waiting list. A plan to improve waiting lists and achieve Sláintecare access targets is being developed with Department of Health, clinical and managerial colleagues. Essential to the reform of scheduled care is the concurrent redesign of care in the community. We are also aiming to redesign acute care pathways by engaging wherever possible new technologies and innovative service delivery models. Significant progress has been made to modernise and implement over 70 clinical pathways within 16 clinical specialties. A waiting list plan for 2022 is currently in development and the HSE welcomes the additional funding of €200 million, which will be focused on delivering additional capacity to support this work.

The implementation of RHAs using a population health management approach will significantly impact our health system. Working with the Department, we expect to scope out design and development of RHAs and to finalise an implementation plan that is consistent with the Government's decision to establish RHAs. It is anticipated that by the end of the year, corporate and clinical governance frameworks will be completed. Aligned to Sláintecare, RHAs will support population-based service planning and funding.

The scale and challenge of Sláintecare's implementation should not be underestimated and methods of implementation and detailed planning will be important to ensuring our success. Collaboration was paramount in 2021 and it strengthened relationships greatly with healthcare providers right across the public, voluntary and private acute and community settings. This coalition allowed us to meet the relentless demands of the pandemic. Given what our health service has faced in the last 23 months, the almost instinctive alignment of the system to Sláintecare principles demonstrates the commitment of our staff and their belief in this hugely important national strategy. I have no doubt that this spirit of collaboration is the key to unlocking the full potential and the delivery of Sláintecare. I assure the committee that the HSE will devote the whole of its efforts to ensuring that we deliver on Sláintecare. Achieving this would be a fitting reward for the public and also for our healthcare staff, who have given so much over the past two years. I also acknowledge the significant commitment and sacrifices made by our teams over the past two years. Not many organisations could sustain five waves of Covid and a cyberattack.

I thank Mr. Watt and Mr. Reid for their opening statements and acknowledge the exceptional work of all healthcare staff and others in a supportive role during the pandemic. We hope to have these meetings on a regular basis. I hope Mr. Watt, Mr. Reid and their teams can facilitate us on a regular basis. Today's meeting primarily concerns regionalisation and governance but we hope to have meetings on different aspects of the implementation of Sláintecare on a regular basis - if possible, in person.

I compliment all involved in the battle against Covid for the significant sacrifices they made, their commitment to their duty and the overall response of the services to the challenges. No words can convey sufficiently the public's response to their efforts.

I also want the witnesses to transfer that energy, co-ordination, effort and exercise to the next challenge, which is to deliver a fast, efficient and effective health service to the community in line with the objectives of Sláintecare in the shortest time possible. I am anxious for us to move away from the area of a percentage improvement on last year's performance and the performance the previous year in areas like waiting lists, acute services and waiting in general. We have to move away from that because people with a health problem are not happy when they are waiting because they do not know how long they have to wait and in some cases, experience has shown them that it is not a good place to be.

Community healthcare organisation, CHO, 7 is the area encompassing south-west Dublin and Kildare, an area that is densely populated, has significant challenges and is low in the support staff required at all levels. For example, the level to which social workers are deployed in that area is non-existent. There is a crisis there that needs to be dealt with as a matter of urgency. I would also cite issues in Donegal and Kerry that have come to public attention in recent years where there were serious flaws in the system regarding the duty of care towards patients or potential patients. What is likely to happen with regard to those issues?

Mr. Robert Watt

I will certainly communicate the Deputy's comments about staff in the Department back to them and I know Mr. Reid will do likewise with the Deputy's comments about HSE staff. The recognition people receive for what has been an enormous effort over the past two years is very much appreciated and I will relay the Deputy's comments back to them.

I agree with him about the need for us to galvanise much of the spirit, intent and ways of working shown during Covid for the more structural long-term challenges in the system about enhancing capacity, improving clinical outcomes and addressing waiting lists. This is what Mr. Reid and I, along with our teams, are focused on and thankfully, able to focus on mostly full time as Covid is less of a challenge for the health system and society. It is not totally defeated. I know we are not going to talk about it but there are still a lot of people - almost 600 - in hospital with Covid and it is still out there in the community. Thankfully, we are not suffering the more acute phases we have gone through over the past two years.

I agree with the Deputy's comment about waiting lists. My colleagues and I compare changes year on year and if we have an improvement in waiting lists this year, which I hope we do, it is no consolation to somebody who is still waiting too long or is uncertain about when he or she will receive treatment. We hope the Government will decide on the waiting list plan next week. That will set out a variety of actions to buy more private sector capacity, drive more public sector output, change the way we work and so on to increase the overall level of activity. We hope to have the highest level of waiting list-related activity delivered by the HSE, the NTPF and the public and private system this year. Even with that, there will still be a large number of people waiting at the end of the year, some of whom will have been waiting for too long. That represents a challenge. After this year, the challenge for us will be to do even better in 2023 and make further improvements that will involve more resourcing and capacity and different ways of working.

Those different ways of working, which Mr. Reid set out in his presentation, are absolutely critical. One can see some of the enormous benefits and improvements from some of the changes in the deferrals and in people not having to go to hospital and to hospital appointments and so on. I fully agree with the Deputy and that is what we are fully focused on.

Before Mr. Reid joins the discussion, a number of concerns were raised by the co-ordination team previously on the phasing in of Sláintecare. Those concerns resulted in resignations. Have their concerns been fully addressed or are they being addressed?

Mr. Robert Watt

I thank the Deputy for his question. There were a number of high-profile resignations last year and I was at the committee talking about those on a previous occasion. We have hopefully learned lessons from that. We have a different approach now where the key projects under Sláintecare have been delegated to senior leadership nomination in health and in the HSE and they are working together now to implement that. A board has been established under the chairmanship of myself and Mr. Reid and we have pulled that together. Beneath myself, Mr. Reid and that overall board, there is very significant activity every week by the teams pushing ahead. Mr. Reid and I will review the structure in the middle of the year with the Minister, Deputy Stephen Donnelly, to see if it is meeting our needs. Ultimately, it is about-----

Are these concerns being addressed?

Mr. Robert Watt

Yes, I think they have been addressed. We are very committed to having the right structure. Ultimately, it is about focusing priorities on the key projects that can make a difference and driving that change. Some of these projects are very challenging. The RHA project, which I think we will discuss some time this morning, is a very difficult project involving very significant change. Some aspects of the reform agenda are easier to deliver than others. We are making more progress on some than on others. Clearly, we are enhancing public capacity and moving care to the community. Mr. Reid and I touched on that this morning. We are making very significant progress there and less progress in other areas. I am happy that we have addressed some of the concerns that existed and Mr. Reid can give his views on them in a moment. We have a structure that can help us to implement this agenda.

I thank Mr. Watt. I call for Mr. Reid’s response now, please.

Mr. Paul Reid

I thank the Chairman and the Deputy. I will come in behind Mr. Watt on a number of points. I will relay the Deputy’s thanks back to the teams and I thank him for making those comments. They make a difference.

To deal specifically with the general point which the Deputy has made about embracing these issues with the pace and agility that has been demonstrated over the past two years, I share the Deputy’s appetite that we embed that into the future. There are probably three things that I would take from the past two years that we need to consolidate in our ways of working.

The first lesson is a much better understanding of what value is added from the centre of the HSE and what value is added from the services. That is a core principle of Sláintecare. For example, we focused on some of the national issues like the procurement of personal protective equipment, PPE, testing and tracing, and vaccination. We let the services then get on with driving reform because they know best and can do it best on the ground. That is something we have to unleash and embed in a stronger way in the next couple of years. That is one learning.

The second lesson from the past two years relates to decision-making. For far too long, we have taken too long to make decisions on business cases and on PowerPoint. I certainly know, with Mr. Watt, that we are committed to this. We used the principle during the past two years that we will probably get 70% of our decisions right, and I do not just mean from a clinical perspective, but in driving change. We have to learn from the other 30%. What we cannot do is wait for perfection at all times. In the next phase of change we are certainly bringing in the principle that if we are 70% comfortable with something, it is probably good enough to let the system go at it. That is the second principle we want to embed.

The third lesson, which is completely aligned with Sláintecare, pertains to the whole issue of moving services to protect the acute hospital system by increasing the services in our communities. We gave some good examples in our opening statements involving community health networks, community specialist teams, access to diagnostics with GPs, primary care facilities and staffing.

One of my colleagues made a specific comment on CHO 7. He touched on something that is a challenging issue for recruitment. I will give a very brief outline of the scale of this. Over the past two years we have recruited over 35,000 people. We have to recruit 9,500 people every year to stand still as part of the natural churn. We have 132,000 people now in the HSE, which is a net increase of 12,500. As Mr. Watt has said, it is the biggest and most unprecedented increase. On top of that, we have had to add a further 4,000 people who were working on testing and tracing, and vaccination programmes. If one looks at the mix of that, and I will not go through it all here, one will see that for once we have got a very good mix. Across that 12,500 over the past couple of years, some 3,300 have come from the nursing and midwives professions, 2,100 are actual staff nurses and midwives, almost 2,000 are healthcare assistants, 360 are consultants and 2,300 people are working on patient and client care. These are people who are on the front line, perhaps as healthcare assistants or NAS staff. We have difficulties in some areas, which I fully acknowledge to the Deputy, particularly in some of the areas he mentioned like south Kerry and Donegal. It is an issue for us to recruit the specialists we need in those areas. Generally, we are seeing that professional consultants, in particular, want to move to and be based in the big urban centres. There is a quality of life issue that we are trying to promote in our recruitment process and we need to do more work on that.

This is something that Mr. Reid-----

I apologise to the Deputy but he is out of time. I need to move on to the next contributor. Apologies, but we are very much stuck for time this morning. I am asking witnesses to try to keep their-----

What are the time slots, Chairman?

The Deputy had ten minutes.

Ten minutes, Chairman, that is fine. My apologies, Chairman. There are a number of questions there that I will take written answers to.

I thank the Deputy.

On a point of order, Chairman, my understanding was that this meeting was to be about the oversight structures in respect of Sláintecare, specifically regionalisation. Can our guests stick to that agenda, please?

Again, if witnesses are asked questions outside of the remit of it-----

Perhaps members might also adhere to that agenda as this needs to be a productive session.

Okay. I thank the Deputy. I call Deputy Cullinane.

I welcome Mr. Reid and Mr. Watt. I want to keep to the topic of Sláintecare and regionalisation. I will have some questions later on recruitment because the three reasons those who resigned from Sláintecare gave for their resignations were what they saw as a lack of movement or slow progress in regionalisation and the establishment of the RHAs; e-health, ICT and financial infrastructure; and waiting lists.

I will start with regionalisation. Mr. Watt said that lessons had been learned and that a different approach is now being taken in Sláintecare when he was asked about those resignations earlier. Can I read to Mr. Watt an email that he sent to Mr. Reid on 24 September 2021? This is a paragraph from the email:

I agreed with the conclusion that we reached to defer implementation given the pressures we all faced. Having reviewed the papers, I also agree that structural changes need to be kept to a minimum and reflect the reality of your reorganisation [as in Mr. Reid's]. Specifically, all corporate functions, clinical care pathways work, etc would remain the remit of the HSE as they currently are. And there would no vertical reorganisation.

I have to say that my heart sank when I read that because it tells me that first, there is to be no vertical reorganisation and power and control is to be kept in the centre, and that second, if we are not going to see corporate functions, clinical care pathways and so on as real parts of the reform of the RHAs, we are not going to get structures that will work. Can Mr. Watt firstly explain to me very quickly what he meant in that email?

Mr. Robert Watt

I thank the Deputy. I do not have the email in front of me but, from what I recall, the Deputy’s summary sets it out. Sláintecare and the vision set out by it in 2017 said that any structural changes should be kept to a minimum required to deliver on the overall objectives, which are to achieve better geographical alignment between the CHOs and the hospital groups; to ensure integration of care at local and regional level; and to ensure resources are allocated on the basis of population needs in those regions. These are high-level objectives. We are very conscious that we need to keep structural change at a minimum required initially to deliver on the objectives because of the nature of this structural change.

Structural change is very time-consuming and it can be very disruptive. We have a very busy organisation with very busy teams delivering care as we go along.

I will come in again. I have heard what Mr. Watt has said and it does not chime at all with what Sláintecare promised. It does not chime at all with what those who resigned from Sláintecare wanted. It does, however, chime with the reasons they gave for leaving. Mr. Watt cannot say that in making changes there will be no vertical reorganisation and then say we will see substantial reform. He cannot say corporate functions and clinical care pathways, which are central, will remain at the HSE as they currently are. To me, that indicates more of the same, keeping it as it is with superficial changes. That is not what we need.

Mr. Watt spoke earlier about unacceptable wait times, with almost 900,000 people waiting. As he knows, we have elderly people on trolleys, with 1,100 of them on trolleys for over 24 hours in acute hospitals in January. They need a change in healthcare, and it is not just about structures but resources and capacity. When I see that there is no vertical reorganisation and that we will keep things as they are now, it does not tell me we will see the reforms we need.

Mr. Robert Watt

I do not have my email client in front of me and I cannot recall every single word or sentence of what I stated to Mr. Reid. From recollection, I think what I said was well summed up by Mr. Reid earlier. There are national strategies and objectives - things done at a national level - and then things done at a local or regional level. We need to ensure the structures enable the centre to deliver nationally in all the different ways Mr. Reid has touched on. This must be done in order to ensure the regional and local structures enable people to reform, change and deliver, as they know best on the ground how to deliver that care.

I am trying to recall what I meant by the email and maybe it should have been worded better. I meant that initially we are not going to focus on a significant restructuring of the centre or a transfer of responsibilities currently undertaken at a national level or at the centre to the regions. The focus is more on the horizontal integration and change between-----

We have very limited time and I heard what Mr. Watt has said.

Mr. Robert Watt

I am trying to answer the question.

In fairness, I gave Mr. Watt enough time to respond. Basically, this referred to meetings or conversations Mr. Watt had with Mr. Reid. Mr. Watt has said that maybe he could have worded the correspondence better but he indicated that structural changes must be kept to a minimum and reflect the reality of Mr. Reid's reorganisation. He stated that corporate functions and clinical care pathways would remain in the HSE, as they currently are, with no vertical reorganisation. Is that the Minister's view or is it the view of the witnesses?

Mr. Robert Watt

I do not think I share the Deputy's characterisation of the letter. I did not say there would be no change or change was not required; it was quite the opposite. We were having a discussion - a reasonable debate and discussion - that I think people would expect Mr. Reid and I to have about what type of change may be required initially to deliver what we want to see. The point I was making was that I did not see the initial objective as a significant realignment of functions between the centre and regions. That is what I meant by vertical change. The focus was more to be on integration on a regional level, or the horizontal change.

I do not speak for the Minister, Deputy Stephen Donnelly, and the Deputy has plenty of opportunities to ask him questions. The Minister is in favour of delivering RHAs and he has set up an advisory group to advise on this. There are many different questions we must address in how this will be done, how quickly it can be done and the phasing of it. The Minister is well aware of the work that is proceeding. Mr. Muiris O'Connor, my colleague, has indicated the Minister will bringing a memo to the Government-----

I must come back in as I have two more questions.

Mr. Paul Reid

Chairman, may I make a point?

No. I have two other questions and I will come back to Mr. Reid in a moment. We have very limited time and this is my time so I want to put the questions I have prepared. I ask Mr. Watt about the recruitment target within the HSE. There was a target set to recruit 10,000 staff in 2022. In Mr. Watt's view, will we reach that target this year?

Mr. Robert Watt

We have said the minimum target is 5,500, which would be the third-highest recruitment year ever and the stretch target is 10,000, which we all acknowledge will be very difficult to meet, given the recruitment challenge-----

I am asking for Mr. Watt's view. Does he believe that target of 10,000 will be reached this year?

Mr. Robert Watt

I think it is going to be very challenging to reach that target.

It will be very challenging. Is the target of 10,000 and financial resourcing of that going to remain in the HSE service plan?

Mr. Robert Watt

The service plan is based on the 10,000 figure and for the moment that money is allocated to that subhead. As ever in health, if it transpires during the year that we are not in a position and the judgment call is that we cannot meet the target, the Minister can give a direction to Mr. Reid and his team about reallocating that money to ensure it goes to another area.

Okay. I have a question for Mr. Reid. This is a very specific question that requires a "Yes" or "No" answer and an amount. Is there going to be a prior year adjustment of HSE accounts for 2020? If the answer to the question is "Yes", how much will it be?

Mr. Paul Reid

I know the Deputy likes to put "Yes" or "No" questions to me but I have two very brief comments arising from his previous questions. On the prior year adjustment and if there is to be one, we are still working through a process to determine if there is to be one. That is a process we are working through with the Department, the audit and risk committee of the board, the overall board and the Comptroller and Auditor General, should we have to move towards processing that.

Is the answer that Mr. Reid does not know? Is there an estimated amount of what that will be?

Mr. Paul Reid

With respect, I am trying to answer the Deputy's question. On the scale of it, we estimate it will probably be less than €100 million. It is not an increase in funds but a technical adjustment that is ultimately a reduction in funds. It is a technical reduction-----

Will it be greater than €90 million?

Mr. Paul Reid


Will it be greater-----

Mr. Paul Reid


-----than €90 million?

Mr. Paul Reid


It is somewhere between €90 million and €100 million.

Mr. Paul Reid

I cannot-----

Why could Mr. Reid not just have said that then?

Mr. Paul Reid

I am trying to tell the Deputy that it will be less than €100 million from what we judge right now. It is a process that is ongoing. It is an assessment of €1 billion of provisions and accruals for the end of 2020. That is the scale of what we have assessed. We initiated that review jointly with the Department. My judgment right now is it will be less than €100 million and probably greater than €50 million but I cannot be very specific. That process will determine if we need to do it at all.

I will make some brief comments on two other issues that the Deputy might appreciate. On the question of regionalisation, I ask the Deputy not to make too many early judgments based on correspondence between Mr. Watt and me. On the specific question of corporate functions, there is no doubt there will be HR and finance functions in regions and they will need them. They should have them. We were having an exchange about a core principle; there will be some things that would be best held at the centre. Clinical standards and guidance is an element in which we do and will need consistency across regions in future. I urge the Deputy not to make too many judgments because we are still in the design phase of what that might look like. The Deputy will, quite rightly, probe this strongly when we get to a better stage on that.

The recruitment question is topical and there are two points to make. We are targeting to recruit 10,000 people. I have a role as a public servant, which I respect hugely, and I know Mr. Watt has a role as a civil servant and Secretary General, to advise the Minister and the Government if we see a jeopardy at any early stage in the planning process. Based on what we have done for the past two years, we see not just the health recruitment market but the complete recruitment market under significant stress. That is particularly so in the health sector, which has a global market. We have flagged to the Department and the Minister that 5,500 is our likely projection but we will be pulling out all the steps to achieve 10,000. On a positive note, in January we had 675 net recruits, which is a good start.

Will 300 people be recruited in the mental health area this year?

Mr. Paul Reid

That is what we are striving to do. The Deputy knows this is a really difficult market. If we knew the market had the capacity, I would say we could achieve the 10,000 figure. I am being upfront because this is my role as a public servant and the market is not showing that capacity. We are striving to achieve the figures, particularly in the mental health area, because there is a big gap and we want to achieve that target.

We need to move on.

I thank all the witnesses here today. The past two years have been completely unprecedented because of the pandemic. It is probably a time for reflection about how we treat our healthcare staff in hospitals and how public health is delivered. As the pandemic recedes, fault lines are re-emerging in society. The fault lines that have defined this country in the past number of decades have been in public health, especially in hospital waiting lists and so forth.

There is obviously a huge issue in relation to reform and regionalisation of the healthcare system. Most people listening to this will want to hear that, in relation to public health, Sláintecare will deliver for them. In areas such as elective surgery or seeing a psychologist, will it deliver for them? Can the witnesses reassure the public that Sláintecare, in the immediate and long term, will deliver?

Mr. Robert Watt

I thank the Deputy for his comments at the start. As Mr. Reid and I have set out this morning and in the report the Minister published yesterday, Sláintecare is delivering significantly now in terms of reform and the level of activity delivered by the system. It will continue to deliver. However, there are structural problems in relation to the capacity in the public system which create issues around trolleys, and there is a significant structural issue around waiting lists, where public patients have to wait too long for treatments. A key objective of the plan is to address those concerns through a variety of actions and improve the performance of the system. That is what we are doing. Our focus is to continue to improve the performance of the system. Can any of us give guarantees that we will have no waiting lists or people waiting on trolleys? Of course we cannot, given the change in our demography and the change in demand. I am confident that we are delivering and, with the support of the Minister and the Government, will continue to deliver for patients and our citizens.

Mr. Paul Reid

I share the Deputy's concerns around what the public will receive and how it will receive it in the coming years in terms of care. I believe that during Covid the public got a better level of trust and confidence in the health system for a number of reasons. We operated as a more integrated health system than the public experienced many times in the past. All elements of the health system came together, including GPs, pharmacies, statutory hospitals, non-statutory hospitals, private hospitals, the Department and ourselves, working in a more coherent and collaborative manner. That is what the public expect and we need to keep it going. They will judge us on what their experience is. There is no immediate short-term fix but we have to focus on some of the priorities. Waiting lists are one of our priorities. What is probably not publicly understood is that we do over 3.4 million procedures per year; however, we have 800,000 or so on waiting lists. People are waiting far too long.

To give some reassurance, we took from September to December 2021 a joint approach chaired by Mr. Watt and I and our teams looking at all aspects of public health delivery, private capacity, NTPF, reporting, hospital groups and specialties. We asked what was the 80/20, which specialties we could hold straight on and how we could focus on the longest waiters. We will continue that process into the multi-annual waiting list. It is not a short-term fix; it is a multi-annual fix. When I took up my role and I am sure when Mr. Watt took up his role, it was not on the basis of solving this in a year or two or with consideration of the impacts of Covid. We are focusing on what the public expects of us.

I agree that we have seen a glimpse of what could be during the pandemic, where there is no such thing as a two-tier health service. There is one health service that delivers for everybody. The majority of people in this country want to see that service provided for everybody, regardless of income.

What is the composition of the Sláintecare programme board?

Mr. Robert Watt

Mr. Reid and I chair the board and our senior colleagues from the Department of Health and the HSE on the board come in and out of board meetings depending on the topic being discussed. A number of us meet every second month, while others come in and out. Ms Pigott, who is on the call, is involved in convening and Mr. Nagle and others are involved in the planning of it. It is the senior leadership team in the Department of Health and the HSE, supported by colleagues throughout both organisations as necessary.

How many members are on the board?

Mr. Robert Watt

I think it is about a dozen. I can check for the Deputy.

Could Mr. Watt name them?

Mr. Paul Reid

Can I add something briefly? The HSE has the most senior lead national directors on it, who are here with me today. They include chief operations officer, national director of community, national director for change and innovation, and national director for acute hospitals. As Mr. Watt said, based on the item presented on the day, we bring in other key leads.

The core of today's discussion is on governance and structures. I have been involved in reform, restructuring and realignment across my career. It works best where the senior team owns it, is responsible and designs and drives it. That is a model we have, if we get the space and time to make it work.

Is there any member of any of the trade unions in the health service on the board?

Mr. Robert Watt


Mr. Robert Watt

There are other forums where the Department of Health and the HSE engage with representative bodies. There are both formal and informal forums. That is the way we conduct our business. Mr. Reid and I are charged on behalf of the Government to implement this agenda, and we do. We are accountable to the Government and committees, including this one, for delivery of that. When it comes to matters of staff engagement, we have other comprehensive structures in place which enable us to go about our business working with various representative bodies.

I do not want to personalise this but the combined salary of Mr. Reid and Mr. Watt is over €700,000 per year. It is a colossal amount of money which equates to 18 nurses' annual salary. Do they think they are worth that colossal amount while people wait years, in some cases, for the most basic public health?

Mr. Paul Reid

I am happy to answer the question.

I am uncomfortable going down this road. It is supposed to be only on governance, but I will allow the question if the witnesses want to answer.

Mr. Paul Reid

My remuneration package was not designed for or by me. I will let Mr. Watt speak for himself but I went into an open public competition, which I understand was an international competition, and was the successful candidate. That is the process I worked through. It is a significant salary. I take my roles and responsibilities seriously and will work within my contract to the best of my ability to deliver on my responsibilities to the State and public.

I thank Deputy Lahart for letting me in.

Does Mr. Watt want to come in?

Mr. Robert Watt

No, thanks.

Will the committee take my appreciation for the two organisations as read? I have expressed it before so will not take up time. It is not meant to be rude but I want to get into the questions.

My first question is on the Sláintecare implementation board. Mr. Watt can take it first and then Mr. Reid. Cynics could be forgiven for thinking an independent oversight board has been replaced with the chief executive of one organisation and the Secretary General of the Department that would have been subject to the scrutiny of that board. The witnesses have replaced the board with themselves, essentially. We know the way structures work. Mr. Watt and Mr. Reid are the bosses of their organisations, though I know they have the heads of this, that and the other on the board.

I am giving Mr. Watt an opportunity to assuage the justifiable cynicism that they have taken control of this. Mr. Watt referred to this committee. We get just ten minutes each, which is not much time to delve into matters. I will put my hands up and say that I completely lack the professional expertise to delve into this. Who are the oversight critics who provide the critique that the public needs to know that this is working properly?

Mr. Robert Watt

The previous board was an oversight board. The board that Mr. Reid and I have established is an implementation board. We are focusing on driving the implementation. We have adopted an approach based on my experience inside and outside the Civil Service. I have been working for almost 30 years. Although he does not look like it, Mr. Reid has even more experience of change than I have. Based on my experience, this board that we have established, which is an implementation board, provides us with a mechanism to drive these changes. We will review it with the Minister during the year and if it is not working, we will change it. We have tried to allocate responsible officers from both the HSE and the Department of Health to the large projects. They and their teams are driving the change. They are responsible to Mr. Reid and me, as co-chairs of the board. Mr. Reid and I are accountable to the Government for the implementation. We have established that board, which is an implementation board rather than an oversight board.

There have been debates about the extent to which an external challenge will be involved in this. The Minister has set up a regional health areas advisory group, which has a large number of external people. We are open to considering whether some other oversight or external function could help. For the time being, we are happy with the structure and we think it is working. We will review it and if people are concerned about the pace or failings of implementation, then Mr. Reid and I will address that, or the Minister and Government will address it.

Mr. Paul Reid

I fully understand why the committee will ask about oversight. We are public organisations. I will reassure the Deputy about a few points. The HSE has a board that strongly holds it to account on all aspects of performance, change, reform, delivery of our corporate plan and delivery of Sláintecare. That is one strong goal of governance within the HSE, made up of individual experts. The Deputy mentioned the Oireachtas as another avenue. As Mr. Watt said, the regional health areas are independent bodies. I want to make a final point similar to Mr. Watt's. Regarding criticism or scrutiny, the model that we have provides ownership and accountability. As I said earlier, I have been involved in change and reform in the private sector and the not-for-profit sector, central Government, local government, and the health service. The only way I have seen it work effectively is when people who are going to manage or design the change are involved in it and accountable for it. I appreciate that this is a public body and needs oversight, but I think we have strong oversight.

I thank the witnesses. This structure has been up and running for a short period. I ask Mr. Watt for examples of how he believes the structure is working.

Mr. Robert Watt

Hopefully Mr. Reid and I have given a flavour of the progress that we are seeing and a number of different issues. An example of it is the waiting list initiative and the multi-annual plan. We and our colleagues have been working intensively on this plan. Some colleagues who are involved are on this call. Mr. Reid and I give overall guidance, which then goes to the Minister. The waiting list plan is probably the most ambitious plan that we have developed to increase capacity and activity. That is just one example. We are trying to continue to develop a good working relationship between the different teams. From what I am seeing, that is happening, with colleagues working together. They are galvanised and motivated. It provides the teams with an opportunity to work on their projects every day and every week, then to escalate them to Mr. Reid and me, and to the board, if there are issues or blockages. We can then make decisions or provide guidance to try to unblock issues. I hope the Government will publish the multi-annual plan next week or consider it next week and publish when it is ready. That is an example of how we are working. That has been an objective for some time, but we are at a stage now where we have a detailed plan. That is one example. I hope that we can build on that this year and in future.

Mr. Paul Reid

We have not been waiting for new structures to be set up. I appreciate the controversy after resignations. We have not been waiting for new structures to drive the reform agenda and the Sláintecare agenda, because I passionately believe in it. I know I have been challenged about that before. My colleagues here today have led the service changes during Covid. That is the right thing to do. Community specialist intervention teams in the community, GPs having access to diagnostics, community health networks, new roles for the national ambulance service and pathfinders are all Sláintecare plans that have been put into action. That is the demonstration of the organisation's drive. Regarding new structures, we have had a few engagements and two formal meetings, but it is not just about formal meetings, but about what we drive between the meetings.

As we have seen this week, that depends on what happens on the ground, but I think that is for another day. I suppose we can come back to this. I am wondering about Mr. Reid's reach into the depths of the organisation from high up in the structure. That comes to the regional matter. Regarding devolving powers, while I do not want Mr. Reid to answer this because I have a local question, how does he, in Dublin, reach into local areas to ensure oversight and delivery? I do not know how that works. My constituency, Dublin South-West, includes Tallaght University Hospital. Under Sláintecare, disability services have been restructured, with the introduction of the children's disability network teams. In CHO 7, that roll-out has had a rough start, with poor communications with parents and a major shortfall of clinicians. As those waiting lists grow longer, how will Sláintecare address the staffing of these teams? Who will Mr. Reid assign that to?

Mr. Paul Reid

Before I ask Ms O'Connor to answer, I will make a brief point about regional and local levels. Ms O'Connor and Mr. Woods will be in Cork and Kerry tomorrow, at the depths of hospital and community services. We have a role of getting under the bonnet and working closely with services. I ask my colleague, Ms O'Connor, to comment specifically on disability networks.

Ms Anne O'Connor

The Deputy is referring to children's disability services, which have a high level of demand. The roll-out of children's disability networks has not all been smooth. It is a change to how we do our business. There is no doubt about that. Enhanced community care has had the highest allocation of resources, with about 495 posts in that CHO to support some initiatives that we are talking about here, which is higher than anywhere else. We know that there are people who are concerned about how the community networks are being developed. It is a change in how we do our business. In order to meet the needs of as many children as possible and to do it properly, this is absolutely the right way to go. We will continue to communicate at a local level. We have now commenced all networks. It took us longer than envisaged because of Covid and some other reasons, but we now have all children's disability networks in place across the country, and, likewise, we are developing the enhanced community care networks and have 51 of those in place. They will work together to meet the needs of local populations.

The Deputy referred to the reach into the services. Having these networks in place provides a structure that allows us to work with people in their local areas to try to address their local needs, instead of looking at everything through either a bigger regional or national lens. Ultimately, it is about the people working in those areas. There is no doubt that we have a challenge with recruitment to secure sufficient health and social care professionals for those disability teams to be able to deliver all the services that we want to. We remain committed to that and continue to support all the CHOs in their recruitment to continue to drive the implementation of the networks, which are now all in place.

I welcome our visitors. It is important to point out that we are coming to the end of the fifth year of what was supposed to be a ten-year reform programme under Sláintecare. I have to say that when it comes to regionalisation I think the system has stalled, if it is not going backwards. My heart sank when I was listening to the two presentations this morning with regard to regionalisation. Mr. Reid spoke about the senior management team having to own and drive reform. I do not see any evidence of this here. There is no sense of driving a reform programme. I believe what we are seeing is capture of the reform programme. I will support my contention that this is what is happening.

In 2019 the geographical regions were agreed for the regional structure and the map was provided. That was in 2019. They were announced by the then Minister, Deputy Harris, in July 2019. Last year we were told in the strategy and action plan that with the geographical areas agreed, a business plan was being produced and we needed to address the issues of clinical governance, corporate governance and accountability with a population-based approach to service planning and integration of community and acute services. I had been hoping to get an update from the witnesses this morning on these areas and the preparation they are doing on accountability legislation and on a population-based approach to the allocation of resources. However, when I looked at the email Deputy Cullinane referred to earlier, I saw that in one of the paragraphs Mr. Watt spoke about expanding the remit of hospital groups to include community services. A person who makes this statement does not get what Sláintecare is. That is not what Sláintecare is. The hospital groups will no longer apply. These are the regions that have been agreed by the previous two governments. These are the regions Mr. Watt is required to operate to. All of the indications are that he is seeking to rework what government policy was and what was provided for in Sláintecare. What does he mean by expanding the remit of hospital groups to include community services? That has nothing to do with the regionalisation plan as set out in Sláintecare.

Mr. Robert Watt

I thank the Deputy for the question. Maybe the wording of the email could have been better.

I think Mr. Watt said that about another letter.

Mr. Robert Watt

What I understand it to involve is integration at a regional level.

It is the principle of what he is saying about expanding the remit of hospital groups to include community services. We are all concerned about the fact we have a hospital-centric health service. Mr. Watt referred to that earlier. What is he talking about regarding expanding the remit of hospital groups? Will he explain what his understanding is of regionalisation?

Mr. Robert Watt

I think we have spoken this morning about moving away from the hospital-centric system. We have not only talked about it but we have set out in detail the enormous changes that are taking place. This includes the primary care centres that have opened and the community teams that have been put in place.

I ask Mr. Watt to stick to the question I have asked him please. Why would he suggest expanding the remit of hospital groups? What is his thinking on that?

Mr. Robert Watt

I need to be allowed to answer the question.

Mr. Robert Watt

The Deputy has asked the question.

Mr. Robert Watt

The Deputy is allowed to ask a question and I am allowed to answer the question. The Deputy does not get to ask the question and answer it.

Mr. Robert Watt

What I meant by that was-----

I am asking Mr. Watt to answer the specific question I asked.

Mr. Robert Watt

What I meant by that is to have integration. Extending the remit of hospital groups is probably the wrong way to put it. It is establishing a new structure that will encompass the full range of services at a regional level so we do not have this-----

What is your understanding-----

Mr. Robert Watt


Sorry, time is short. What is Mr. Watt's understanding of what would happen to hospital groups in a regional structure?

Mr. Robert Watt

They will be subsumed into the new structure. The new structure will encompass the full range of services across all of the different-----

The structures that have been agreed and the geographical areas are entirely different from the hospital groups. Why would hospital groups arise at all? We should be talking about hospitals and not hospital groups.

Mr. Robert Watt

Sure. That is true. There will have to be an alignment between the existing structures. They will have to be aligned with the new geographies we have set out. The new structures will need to reflect those new geographies. In effect, there will be a new structure and a regional health authority that would subsume the activities of the CHOs and the hospital groups. This new entity will be completely different in terms of how it-----

Mr. Watt is repeating that. There would not be hospital groups.

Mr. Robert Watt

I just said that.

There will be a realignment of hospitals.

Mr. Robert Watt

I think I said the new structure would subsume the hospital groups and would subsume the CHOs into a new entity that would provide care across the full spectrum all the way from community to hospitals.

What Mr. Watt would appear to be talking about is the hospital groups subsuming the CHOs and the community services.

Mr. Robert Watt

No, I think we are looking at new entities here. I understand that the boards of the hospital groups-----

What do you mean you "think"? There are new entities proposed. They have nothing to do with hospital groups. Do you understand what is contained in the Sláintecare recommendations?

Mr. Robert Watt

Absolutely. It is a new entity that would carry out the functions that are carried out by the existing entities, which would be collapsed and would cease. There would be a new entity that would provide integrated care right across the piece. That is my understanding of it. Then we would have-----

Sorry, this is-----

Mr. Robert Watt

Am I going to be allowed to answer any question? Am I not allowed answer any question? That is fine. I have tried to answer the Deputy's question several times.

It is extraordinary that just a few months ago in September, Mr. Watt was talking about expanding the remit of hospital groups to include community services. I can only come to the conclusion that he does not get Sláintecare and that he does not have any understanding of the regionalisation structures that were proposed. They are a central element of the reform programme. We were told last year by Laura Magahy and Tom Keane that one of the main reasons they resigned was because there was no appetite in the Department of Health or the HSE to restructure and devolve power and introduce legal accountability for the provision of services. I cannot help but see now and understand fully the reasons these two people resigned.

I want to ask Mr. Watt in relation to the document-----

Mr. Robert Watt

That is a complete mischaracterisation of my views and what I said. It is a complete mischaracterisation.

I can only come to conclusions based on what I am hearing from Mr. Watt this morning and what I read from him in an email just last September.

Mr. Robert Watt

No, that is not what I said. I am trying to clarify-----

I am going back to the-----

Mr. Robert Watt

I have tried to clarify what I said in the email-----

Mr. Robert Watt

-----and I have tried to clarify my understanding of it and Deputy Shortall has not let me answer any of her questions without interruption. Not on a single occasion.

I can only see what Mr. Watt has written down in black and white. It concerns me greatly because it brings me to the conclusion that he does not understand what regionalisation is-----

Mr. Robert Watt

I totally do not accept that conclusion.

-----or he is seeking to block it.

Mr. Robert Watt

I do not know how Deputy Shortall could infer that conclusion from anything I have said this morning-----

I think most people would come to the same conclusion reading that.

Mr. Robert Watt

-----or indeed what we are delivering, which is more important I think.

Anyway, I want to move on.

In the strategy and action plan for 2021 to 2023 a business plan was to be produced last year. Has that business plan been produced? Does it exist? With regard to an integrated financial management system, we are told the HSE does not have in spite of it being in existence for 17 years. When can we expect to see the business plan for regionalisation? When can we expect to see an integrated financial management system?

Mr. Paul Reid

I am happy to take the latter question or both of them.

I want to ask about the business plan first. I asked Mr. Watt about that.

Mr. Muiris O'Connor

I can speak on the business plan.

Mr. Robert Watt

Yes, perhaps Mr. O'Connor would speak on this.

Mr. Muiris O'Connor

I thank the Deputy and I assure her the senior management teams of the HSE and the Department of Health are very committed to the vision for regional health areas set out in the Sláintecare report and the achievement of comprehensive person-centred integrated care.

Sorry, when will we see the business plan?

Deputy Shortall, you have run out of time.

Mr. Muiris O'Connor

The business plan, as the Deputy will know, was a requirement when-----

Mr. O'Connor is talking over me.

Mr. Muiris O'Connor

-----the Government agreed to the geographies of the six regions in 2019. The Government asked that a business case be presented at the next stage to set out the next steps and the way forward. Notwithstanding the pandemic, work progressed within the Department to do that business case. It sets out the rationale, the objectives and the demand analysis and looked at options for the development of regions and regional healthcare areas. That looked at the number of areas as is versus a HSE local model or a HSE separate model. What we arrived at was-----

Sorry, when will it be completed?

Mr. Muiris O'Connor

It is very near complete. It is being considered by the HSE board in recent months. We are taking input from the Department of Children, Equality, Disability, Integration and Youth because we are conscious that disability policy will move to that Department and in light of our shared commitment to integrated care. The business case is a requirement from us in advance of bringing a memorandum to the Government on an implementation plan. We will have that ready, as Mr. Watt says, within the coming weeks. We are finalising the business case now and that will underpin the Government-approved-----

When will we see the financial management system?

Mr. Paul Reid

If I can touch on something, because the Deputy quoted me also in relation to the regions and commitment to the regions, I will take the integrated financial management and procurement system, IFMS, as well. I will not go back over our commitment, what we have been driving and what is important for the next phase but I want to address the point around our commitment. The Deputy referenced resignations previously. I will not go through all of that. I took this job on the basis of driving Sláintecare, driving reform and making it better for the public. I cannot go back over ten years of what happened but I can go back over the past two years. We need a bit of a reality check. If anybody thinks that in the middle of a global and national pandemic we were having-----

Mr. Paul Reid

Please, Chair, can I make the point?

We have heard all this before. We have heard all these excuses before.

Deputy Shortall, do you want me to cut off the section because you are way over time and you have asked far too many questions to get in within the ten minutes?

There was a specific question about financial management which we were supposed to get an answer to.

Will you allow the witness respond, please?

Mr. Paul Reid

It was suggested that I am not committed to the change. It is important I address my own professionalism and character in this response to demonstrate that I am committed to it. I was making the point that my priority in the past two years - I make no excuse for it - was protecting the public, protecting our patients and protecting our staff-----

Mr. Paul Reid

-----and, as anybody who has been involved in any change management in their lives would say, that was not the time to do probably one of the biggest restructures that the State has ever gone through. I make no apologies. The time was not right to do that.

Specifically, in relation to IFMS, I will make a few points. I cannot talk about 17 years ago. What I can talk about are the past two and a half years. Thanks to the Department, the Minister and the Government, we secured €82 million to deploy an IFMS. It is quite a complex system. It will be rolled out. The design phase has been worked on throughout the last year. We have had issues with the systems integrator that we are in discussions with about termination. We are going to procurement for a further systems integration. However, the process is continuously moving on seamlessly. The reality of it is that approximately 80% of the total spend activity across the entire health sector will be encompassed by 2025. However, at the end of this year we will start loading financial data for the eastern region and Tusla that will go live in 2023. It is a very significant programme involving the massive design of a new IFMS. The Deputy is correct that it is a big loss that we do not have one but we have funding for it. The board is overseeing its deployment.

I need to move on. The next questioner is Senator Conway.

At the outset, I do not think anybody here, from my own perspective anyway, would question Mr. Reid's determination to implement Sláintecare because, ultimately, the HSE is an agent of the Government. The HSE implements Government policy.

The real concern is with the Department of Health. Mr. Watt's performance here this morning - what he has said here and his answers to the questions, certainly regarding the email - is concerning. Clearly, Mr. Watt's understanding of Sláintecare is somewhat at variance with the understanding of Sláintecare that many people here have. My worry relates to the Minister's understanding of Sláintecare because if that is Mr. Watt's understanding of Sláintecare, what is the Minister's understanding of it? That would worry me greatly because the regionalisation of the structures is a key component of Sláintecare. We are five years into what was initially envisaged as a ten-year reform programme. We have had a pandemic and any reasonable person would say that you are talking about an extra two or three years on top of that. I am greatly alarmed by Mr. Watt's answers to the questions but, more particularly, the combative nature of his answers. We will have to reflect on that. I am concerned now that Mr. Watt does not understand Sláintecare in the same way that we understand it.

While all this is going on, there are 96 people on trolleys in University Hospital Limerick, UHL, at present. They are the figures as of today. The bones of €100 million of Government money has been invested in UHL. We are talking about €20 million on a modular unit and another €40 million for a state-of-the-art accident and emergency department. I am wondering what has gone wrong in Limerick. Mr. Reid might be able to shed some light on this. Are there peer review performance comparisons with other accident and emergency departments? How come Limerick accident and emergency department is constantly at the top of the scale when it comes to people on trolleys? Even though tens of millions of euro of Government money have been spent over the past seven or eight years to try to alleviate the problem, we are still in a situation today where nearly 100 people are on trolleys. Is there a problem with the management down there? Does Mr. Reid have concerns with the management of UHL, given that we are in this situation today with 96 people on trolleys?

Mr. Robert Watt

Will I come in and then maybe Mr. Reid will deal with the second part of the question?

First of all, to reassure the Senator and other members, and to add to what Mr. Reid has said, I am absolutely fully committed to this reform agenda and the implementation of Sláintecare. The reason I was happy to be asked to do this job and take on this role was to deliver the change because I believe that the Department of Health, with our colleagues in the HSE and with the Minister, Deputy Stephen Donnelly, and the Government, is making and will continue to make significant changes to bring about a system which can deliver better for citizens. That is my motivation. Nobody, along with Mr. Reid, should be under any illusions. I am fully committed to delivering this and feel that we are making progress and we will continue to do so.

It is not necessarily Mr. Watt's commitment I question. It is his understanding of Sláintecare. Is Mr. Watt on the same page on Sláintecare as Deputy Shortall is and other members of this committee are, and indeed the two previous Governments were? I do not know about this Government. I am not sure. Mr. Watt is the Secretary General of the Department and he speaks in tandem with the Minister. I am now concerned that the Minister does not have the understanding of Sláintecare that the rest of us have.

Mr. Robert Watt

The Minister can speak for himself. I am not here to speak for the Minister but the Minister is absolutely committed to Sláintecare. He is behind the reforms and is leading the Department and leading the team - me and Mr. Reid, and our respective teams - to deliver this, and he is absolutely fully aligned. Of course, as Mr. Muiris O'Connor has said, there are issues relating to how we implement RHAs, and those issues are being debated now and discussed. The Government will receive a memorandum setting out our implementation plan and then we will push ahead with that implementation plan.

In terms of the combative nature of my answers, that is a trait. You love or hate it. There is nothing I can do about it really now. I am probably too old to change.

It is not a very endearing trait.

Mr. Robert Watt

Oh well. Apologies for that, if the Senator does not like it. I cannot do anything about that I am afraid. If people are to question my professionalism and my motivation, I am allowed to defend myself. If people do not like that, I am sorry about that.

I do not, anyway.

Mr. Paul Reid

I thank Senator Conway for his question. In direct response to the Senator's question on Limerick, we have a very good management team led by the CEO in UHL. Unfortunately, she comes under a lot of personal criticism - I am not saying from the Senator.

That is understandable but I have very strong confidence in the CEO of UHL and our clinical team there. They face some real challenges with regard to demographics. The Senator is correct that very significant investment has gone into the hospital. There are approximately 100 extra beds and a new accident and emergency department. However, the hospital is under some real demographic pressures. With regard to capacity, whereas other hospitals, including hospitals on the east coast, have a small number of hospitals to step people down into, there is not similar capacity in Limerick. It is a challenge for us. There is no doubt but that elective hospitals will provide regional capacity in the future. I might ask my colleagues, Mr. Woods and Ms O'Connor, to comment.

Before Mr. Reid does that, I will ask another question. While elective hospitals are an issue, are there specific things he can do in the coming days and weeks to reduce the number of people on trolleys? Is there anything specific that can be done to deal with that? Everyone knows what the problem is but we need immediate solutions as well as medium- and long-term solutions.

Mr. Paul Reid

I will pass over to my colleagues who will recount some of the specific challenges we face at the minute. These largely relate to discharge and particularly the discharge of elderly people. This is a key factor in Limerick. Some 50% of our nursing homes have outbreaks and we cannot discharge to them. We are also using private nursing home capacity for discharge. I will ask my colleagues to give some specifics.

Mr. Liam Woods

The number of people reported to be on trolleys in Limerick this morning is 35 but I believe the Senator is also referring to the surge capacity being used in Limerick, which increases that number. Of course, this is a matter of concern to us, as it is to the group. The group itself is undertaking work to look at the key drivers of that but the emergency department in Limerick has been extremely busy with regard to the volume of attendance and, more so than anywhere else, it has remained so throughout the pandemic. In recent weeks, its level of attendances has really only been exceeded by the Mater. It has that challenge at the front door. Things are happening that can happen in the short term to assist with that. Where there are any delayed transfers of care that can move, we have been seeking to support that movement to create better flow through the hospital. The community has been supporting Dooradoyle, in particular, on that. There are also some front-door initiatives seeking to use more of the pathfinder service, a service provided by the ambulance service, and to use the hospitals in Ennis and Nenagh for step-down to the greatest extent possible. The four new theatres in Croom Orthopaedic Hospital have opened and very good work is being done there on the access to care side, which we have touched on.

Does Mr. Woods see any benefit in upgrading services in Ennis and Nenagh on a temporary basis to try to help with these numbers, even in the short term?

Mr. Liam Woods

The hospitals in Ennis and Nenagh are doing some very good specific work and it would be unfortunate to disrupt it. The key point for us is that patients can flow to Ennis and Nenagh as needed. That is happening. One enabler of that is ambulance transport. We work very closely with the group and the NAS on that. There is already very strong work going on at both sites. I do not necessarily see the benefit in extending the reception of emergency patients into the hospitals in Ennis and Nenagh. Their use for step-down care for patients from Dooradoyle remains very important. It should be remembered that inpatients in the hospital at Dooradoyle tend to have the shortest lengths of stay in the country so it is showing signs of relative efficiency. It is hard to get away from how very busy the front door of that hospital is. There is a capacity challenge. As the Senator has rightly said, there has been significant investment in new capacity. That has been more than consumed by the rise in attendances over the course of the pandemic and up to now.

Ms Anne O'Connor

If I may add to that, with regard to the work that is going on, the Senator mentioned short-term and long-term care. Obviously, enhanced community care is a key enabler for the acute hospital system over time but it is not an immediate quick fix. There are a number of sites. There has been a lot of focus but we have other big model 4 sites that are very challenged, including those in Cork and Galway. They have been consistently challenged over recent weeks and months. This is true across our acute and community services. Ultimately, the solutions to some of the problems in our hospitals do not lie within those hospitals. The solutions are often in the community with regard to hospital avoidance and supported egress. As Mr. Woods said, we have re-enabled a lot of step-down capacity.

My time is up. I thank the witnesses.

I will follow the thread of what the previous speaker has been saying about University Hospital Limerick. Some 96 people are on trolleys there today. On 26 January, the number peaked at 111. Records for trolley numbers are repeatedly broken at UHL. It is an incessant problem that goes on and on.

I will begin with a question to Mr. Reid and Mr. Watt. Who sits on the elective hospitals oversight group that is looking at elective hospitals under Sláintecare? A key recommendation was made to the Government last autumn that there would be three new elective hospitals in Ireland at Dublin, Cork and Galway. For the life of me, I cannot fathom why the mid-west and University Hospital Limerick were omitted from that. Will Mr. Reid and Mr. Watt please detail who is on that oversight group and the logic behind that decision? I can tell them that it was devastating for the mid-west not to be included on that shortlist.

Mr. Robert Watt

I thank the Deputy for the question. On the elective oversight group, Professor Frank Keane is the chair. He is leading a group made up of experts and officials from the Department of Health, the HSE and-----

Will Mr. Watt name the members? I specifically asked who was on it because I need to know that detail today.

Mr. Robert Watt

If the Deputy gives me a second, I can get a list of the names.

I will keep going with my questioning. I would appreciate being given the names in a moment.

Mr. Robert Watt

I will get the list before the meeting is over.

By any metric or logic, I cannot understand why the most pressurised group of hospitals in the country was omitted. This is now progressing. A business case has already been filed for Cork and plans are pending for Galway and Dublin while there is no suggestion of an elective hospital in the most pressurised corner of the country, the mid-west, Clare, Limerick and Tipperary. I will make a proposal to the witnesses. This is something I have been dealing with in the Dáil Chamber as well. We had some warm and positive responses from the Taoiseach just last week. There is a brand new road being built along the border between the counties of Limerick and Clare, the Limerick northern distributor road. It is opening up tracts of land that heretofore were just grazed by cattle. The first phase of that road will be completed in August of this year. The University of Pittsburgh Medical Center, a non-profit private hospital group, is planning to open a 150-bed private hospital along that route. It is perfectly located near the Limerick tunnel, it is accessible to people in Tipperary and, crucially, it is on that border between Clare and Limerick. It is as centred within the region as you can possibly get. If they really want to unburden University Hospital Limerick of its problems through Sláintecare, it is essential that the witnesses look at having a public wing within that new hospital to separate things out at UHL. I ask that this become part of the agenda. There cannot be a shut-door policy on this matter. I want those names. I want our committee to undertake-----

We will get those names after the meeting. We are not going to get them at the meeting. Again-----

I am still talking, Chair. I want the names of those people and I want our committee to undertake a body of work in this regard because a corner of Ireland is being left totally out of this report.

To move on with my questions to Mr. Watt and Mr. Reid, we have all digested this morning's Irish Independent. One of the front-page stories relates to pay in the higher grades of management in the HSE. In spite of everything we have discussed here this morning, how can Sláintecare be delivered when many senior management figures within the HSE are both frustrated and disgruntled because they have been fobbed off by people above them in the management structure for 14 years with regard to having legitimate and approved pay awarded to them? If I follow what the newspaper was saying this morning, in that same time period, Mr. Watt had a pay hike of €81,000. How is it that nothing has been sanctioned for the people in the management levels just below him who have had a pay claim approved, which is now pending? Is that a factor in this not progressing at the speed at which we want it to progress?

Mr. Robert Watt

On the elective hospitals and capacity, we will share with the committee the detailed work that Professor Keane and his group did and facilitate any engagement the members would like to have with Professor Keane, either bilaterally or in this forum. I am very happy to set out their plans with regard to the elective hospitals.

I am happy to engage in whatever format the Deputy and the Chair think is appropriate about the rationale for the location and the proposed structure. Regarding the second question, I have not seen the story in the newspaper so I cannot really comment on it.

I find that hard to believe. If my name was on the front of a national newspaper, I would probably pick up the newspaper and read it first thing in the morning.

Mr. Robert Watt

What does the Deputy find hard to believe?

I find it hard to believe. If a person's name is on the front of a national paper with regard to pay and conditions, I would assume that person would have read it. If Mr. Watt has not read it, then I suggest it is worth reading, because it was certainly a factor when preparing for this meeting. I have had many emails and phone calls from people at various management levels in the HSE and I have a number of questions that I wish to ask Mr. Watt. Mr. Watt and Mr. Reid have repeatedly been made aware that a group of senior management personnel in the HSE and voluntary hospitals have been unjustly picked out for unfair treatment, by the continued withholding of a pay award under report 42 of the review body on higher remuneration, which dates back to 2007. The award was approved by the Government and subsequently sanctioned by the Department of Finance, but it was withheld from this group when all others in local government, An Garda Síochána and across the board received this pay grade. How can the witnesses stand over this injustice when the very same report specifically said that neither the pay of the HSE's chief executive or the Secretary General of the Department of Health merited being any higher than they were then? We saw Mr. Watt get a pay hike of €81,000 when it was said that no more was needed.

Sorry, Deputy.

This happens every week. With the greatest of respect, Deputy Shortall's line of questions was allowed, but the Chair interrupts me every two minutes when I am asking questions.

I am not trying to interrupt the Deputy.

This is the second interruption I have had. I want time added on.

The Deputy will not get time added on. If he continues as is, I will put him out entirely.

I will continue my questions without interruption. This happens every single week.

It does not happen every single week.

It happens every single week. I would like Mr. Watt to answer that question.

Mr. Paul Reid

I am happy to speak. There is a legacy issue, which the Deputy quite rightly referred to as dating to 2007. I was not here then. It is an issue that has been through various industrial relations and pay processes between the Department of Health, the HSE and the Department of Public Expenditure and Reform. It was the subject of various previous pay agreements over past years. It is a legacy issue and it has gone through. There are certain processes and procedures with regard to public service pay which have addressed this. People feel aggrieved but many grades feel aggrieved. I have addressed the matter of my own salary. I was not here previously and cannot compare my salary-----

Even at this very late stage, is Mr. Reid prepared to look at the possibility of impropriety and that the process used to stymie payment was tainted? That has been flagged with both Mr. Reid and Mr. Watt by senior management. Is Mr. Reid willing to look at why this has been stymied and not implemented?

Mr. Paul Reid

Those are the Deputy's words. I am not trying to be disrespectful, but they are the Deputy's words, not mine or what-----

Words or not, is Mr. Reid willing to initiate a process of review?

Mr. Paul Reid

I was addressing the reference that the Deputy made. Those issues are subject to previous discussions and pay claims through all previous pay agreements.

Do Mr. Reid and Mr. Watt accept that the salary increases granted to the posts that they both occupy were in breach of the same financial emergency measures in the public interest legislation that was used to deny payments to other management personnel under report 42?

Mr. Paul Reid

I cannot comment. I can only comment on my own role and pay associated with my own role. It is not related to what it might have been 17 years ago or in 2007. I have answered clearly and tried to be clear about the process for my own pay and appointment.

I am not here to ask about pay. What really concerns me as a politician and as someone who represents taxpayers in my constituency is what the stumbling the blocks in the HSE are when it comes to the delivery of service. One major stumbling block is that we have a huge cohort of disgruntled senior staff who have been waiting for far too long for an award to be made to them, which was approved by the Government. Some people in the organisation are getting pay increases. Others are not. This amounts to dysfunction within management. Within any walk of life, one can be sure that kind of division permeates into all levels. It ensures that the organisation is not going in the direction that it needs to be going in. Many people are following this today. Mr. Reid and Mr. Watt are at the helm of the HSE. They need to give hope that there will be action on this and some internal review arising from today. It is a factor in the HSE coming up short.

Mr. Paul Reid

I have answered the question. It might not be to the Deputy's satisfaction but it has been through various-----

I will have to raise it in the Dáil. It is a major factor. Mr. Reid and Mr. Watt both know what this is about. It needs to be addressed. I will conclude by saying that I think when a Deputy or Senator is in possession of time, if the questions are reasonable and focused on the agenda, we should be allowed to proceed without interruption. We have time to use. It ate up some of my ten minutes today.

We can take it up and discuss it after the meeting.

I thank the Department and HSE. It has been a challenging two years. I thank everyone involved in dealing with the Covid issue and the challenges posed by it. I want to move on to the here and now and where we go from here with regard to healthcare in Ireland over the next five to ten years. One issue that will occur and already exists is with difficulties in recruiting. I am concerned about the disparity in recruitment. For example, since December 2014, the number of people working in the HSE has gone from 103,000 to 131,000, which is a 27% increase. The number working in senior management has increased from 1,185 to 2,154, which is an 81% increase. The number working in home help in 2014 was 3,703. In October 2021, it was 2,352, which is a decrease. The Secretary General referred to the demographic change that is occurring in the sector and said that by 2028, the demands on our healthcare sector and home care will see a dramatic increase. We will go from about 740,000 people over the age of 65 to over 1 million people over the age of 65. How do the witnesses propose to address shortfalls in recruitment and in getting staff? Is a plan in place? What does that plan envisage?

Mr. Robert Watt

I will say something and then Mr. Reid and his team can come in. The numbers the Deputy gave show a significant increase in the numbers employed across different areas of the healthcare system. There was an almost 30% increase in the last number of years, as he said. In the last two years, the number went from 120,000 to 132,000, and there are plans for further increases again this year, of between 5,500 and 10,000. As Mr. Reid mentioned, there are recruitment challenges. There are two aspects of this from our perspective. Mr. Reid and his team can address some of the details. First, we need to become more effective at recruiting internationally. We have made changes regarding the registration of nurses, to double the number of registered nurses coming from overseas this year. Second, we need to provide more training opportunities for our young people and for people within the health system to progress. This is a societal issue. As demographic effects kick in, healthcare will become a bigger concern. We will need to train more of our people to work in the sector and we will need to be attractive to people coming in from overseas. There is a workforce plan for this year. That will evolve into a multi-annual plan to try to address these issues. The Deputy is aware of the areas that we are addressing. Mr. Reid mentioned some of them. We are pushing ahead in all of them. There are more acute problems with recruitment in some areas than others but everybody is focused on trying to do as much as we can to get people in.

Mr. Watt mentioned retaining people. One issue with junior doctors is that if they come in from outside the EU or EEA, they will not get a stamp 4 visa until they have been here for at least five years.

There is a proposal to reduce that to two years. My understanding is that it is now stuck in a logjam between the Department of Justice, the Department of Health and, I believe, the Department of Foreign Affairs. Many junior doctors do not have a stamp 4 and cannot get into any training facility here. For this reason, they do not see any point in staying in Ireland. When will that logjam be resolved?

Mr. Robert Watt

I will come back to the Deputy on the timeframe for that as I do not have it to hand. I am aware that it is being worked through. It is a matter that was identified to the Minister last year and it needs to be fixed and reformed to provide opportunities for doctors to access that training. That is something the Minister has progressed with the Minister for Justice. I will check for the Deputy exactly where we are on that as I am not sure of the exact timeframe or what is causing the blockage. The policy is certainly very progressive. It will help create opportunities for many doctors to stay in Ireland, progress their training and, hopefully, have productive careers in our health system.

The reason I am raising this issue is to do with young people also. Many young qualified nurses and doctors traditionally go abroad after having qualified or having done one or two years here. That has not happened in the past few years. Whether we like it or not, a substantial number of young trained people will leave this country. Are the HSE and the Department of Health planning for this? I have spoken to a number of young people in recent weeks who are planning to move abroad because they have not had the opportunity to travel in the past three or four years to travel. They now want to do so and there will be a shortfall as a result. How are the HSE and the Department planning for that?

Mr. Robert Watt

Just before Mr. Reid comes in again, people are obviously going to leave the country for a whole variety of reasons unrelated to the health system.

Mr. Robert Watt

That could obviously create a challenge for us. I will pass over now to Mr. Reid.

Mr. Paul Reid

The Deputy asked questions on the wider process for recruitment and retention. In the first instance, we put in place a new model over the past two years which devolves a significant level of recruitment to services in order for those services to recruit directly. Second, we have worked with the Public Appointments Service to accelerate the process, particularly in respect of consultants and senior professional medics. That has helped significantly. Third, we have put a new recruitment model in place with a third party provider to operate on a scale well above what we would be able to do because, as I mentioned, recruiting 35,000 people over two years is very significant.

I will ask my colleague to comment on the home help issue the Deputy highlighted, which is a real challenge.

I will make two other final comments, the first of which is on people leaving. I agree with Mr. Watt that people will leave for various reasons. We all know many people who have left, including family members, some of whom have come back and some of whom have not. That is a function of factors and the decisions people make. Specifically for us, I mentioned earlier that we have to recruit 9,500 people every year in order to stand still. When we talk the about 12,500 over two years, we have had to recruit a further 19,000 people just to stand still. There is, therefore, a great deal of churn.

My final comment is not directed specifically at the Deputy but is more general. There can be some awful generalisations made about the health service. I have listened to some commentary over the weekend, not by politicians, that it is an awful place to work, asking who would go to work in it. The health service is actually a very good place to work and is full of highly committed professionals. Some of these general, tired statements that are made at times really hurt us and our staff in respect of retention. The heath service is a good place to work.

Similarly, at senior levels, there is an increasing personalisation of senior roles. I am not talking of my role or that of anyone in particular. The increasing personalisation of public service roles does not do good to get the right people into the public service. I wanted to make a general comment on that because that is about recruitment and retention of the best people.

I will move on to capacity in Cork and the wider Cork-Kerry region. I received a telephone call at 10 o’clock last night from a member of a family whose mother had been in the accident and emergency department of Cork University Hospital, CUH, since Sunday night. After 50 hours, this 92-year-old woman was still in the accident and emergency department. There is, therefore, a significant problem with capacity in Cork.

In fairness to the HSE in the south and south-west region, it presented a plan three years ago. Three years on, a site has still has not been identified. We raised this matter with the Minister last night. My understanding is that there is a report with the Department about that elective hospital. I need to know what kind of timeframe we have for the hospital before this plan moves from the Department of Health to the Department of Public Expenditure and Reform, as the Minister told us it would last night.

Can the proposal be fast-tracked and can the entire project be fast-tracked? When I was Lord Mayor of Cork in 2003 and 2004, we fast-tracked a project to build an extension to Cork City Hall. We invited tenders for design, build, finance and payback over 25 years and got a large extension to city hall build in a very short timeframe. Can we do that with elective hospitals, rather than going through a process that will take four or five years from site identification to getting a hospital physically built?

Mr. Robert Watt

I will comment on the latter point the Deputy made and Mr. Reid may wish to comment on some of the other points he made.

It is certainly our intention to fast-track and build this facility as quickly as possible. The business case is now with us and that goes to the assurance process with the Department of Public Expenditure and Reform. Rather than doing things sequentially, which has been the norm, we are now going to do much of that assurance in parallel to get through it as quickly as possible in order that we can get final approval from the Government. We can then start the detailed design and procurement process. We are doing everything we can to accelerate this.

When we get to the actual procurement and construction stage, I have heard the Deputy’s suggestion and I do not know the details of that, but we are completely open to working with the Department of Public Expenditure and Reform and the HSE team on any options to accelerate this. There is always a challenge in Ireland in respect of building things. It takes a long time for reasons that we are all aware of. Many of those reasons are legitimate but we need to do everything we can to accelerate. We cannot have a situation where we are having this debate in a year’s time, having not started the detailed work. We need to start work and build this hospital as quickly as possible because this is urgently needed.

Even as regards identifying the site, the HSE has a 100-acre site at Sarsfield Court in Glanmire. The hospital could be built block by block there into the future. This is about long-term planning to ensure we are not looking for additional space in three, five or ten years. There is 100 acres of land owned by the HSE that is underutilised. Let us at least identify the site so that we can get on with the job of getting this facility built to deal with the capacity issue in Cork.

Mr. Robert Watt

I fully agree with the Deputy. It is not a question of land or sites but of how quickly we can get this through the process and start building it. That is the bottom line. I agree with the Deputy. This is a priority for the Minister and I know he has met Deputies, Senators and councillors from the area. He is fully committed to it. Hopefully, in the next week or two, we will have some news on where we are in progressing this project.

Can we look at fast-tracking the project to building stage?

Mr. Robert Watt

Various assurance processes that we must go through are set out by the Department of Public Expenditure and Reform. We will fast-track those and deal with them in parallel rather than sequentially. We are doing everything we possibly can to get to a stage where the Government can finally sign off and we can then move to detailed design and procurement. Although I do not know the timeframe, hopefully we will get to the next stage before mid-year and go out for tender to start this process.

Mr. Paul Reid

On the wider question, we have put some teams in place in Cork University Hospital. We are working very closely with local management, looking at flow through the hospital, bed allocations and best use of capacity in the South/South West Hospital Group. As I mentioned, my colleagues will go there tomorrow. I will ask them if they would like to make any comment on the position in Cork at the moment.

Ms Anne O'Connor

Cork has been under huge pressure. We have seen that in recent months in the level of attendance and capacity. Services there have been challenged by the level of demand and, equally, its capacity to discharge from the hospital to community services and home. We have people down there, as Mr. Reid said, working with the site, looking at integrated solutions between the hospital and community services, how it uses capacity and how it can introduce models of care that can have an impact. As I said, the level of demand we are seeing on some sites is quite extraordinary and they have been experiencing a huge surge in recent weeks. Notwithstanding that, we will be in Cork on Friday working with the services to ensure we are doing everything we can nationally to support both the community element in terms of hospital avoidance, the discharge element and the use of all available capacity across the health system.

In 2021, funding was made available for the building of two new theatres. Everyone expected they would be finished by November 2021. It turns out that a contract for the building was not signed until November 2021 and we are now talking about July or August of this year before those two new theatres are built. Can we not deal with the type of delay occurring in the healthcare sector? Why did it take ten months to get from the time money is allocated to getting a contract signed? The tenders were already in by February yet it was November before contracts were signed.

Ms Anne O'Connor

I am not sure of the detail of that.

Mr. Liam Woods

I will come back with details on that. I think the point the Deputy is making is on whether we can accelerate the process. I will come back to him on the specifics of the individual case.

It is that kind of delay where-----

Deputy Burke is out of time.

-----we lose valuable time. We also have problems in that we have consultants who are lucky to get a half day per week in operating space because they cannot get access to operating theatres. That needs to be looked at and that was done by the gynaecology services in Cork where there were 4,500 on the list. They got time in the Mater Private. The consultants went down there and cleared more than 3,000 off the list in a very short timeframe.

I will move on.

I welcome Mr. Reid, Mr. Watt and the teams from the HSE and the Department of Health. Obviously, GPs play a pivotal role in the delivery of Sláintecare. They were before the committee a number of weeks ago and one of the issues they had related to the need for an establishment grant or a tax relief to establish practices. Do Mr. Reid and Mr. Watt believe this and will they lobby for this in their budget negotiations? I refer to Mr. Watt, in particular, with regard to his previous role.

I raised the notification of pension entitlements to staff in a Commencement debate in the Seanad last week. It takes more than a year before staff who are on the verge of retiring or may need to retire early due to burnout are notified of their pension entitlements. It also takes a number of months before the first pension check is received by hardworking front-line staff.

Mr. Robert Watt

I find it very unlikely I will lobby the Department of Finance about tax relief for any group during my time as Secretary General of the Department of Health. There is a very low probability that will happen. However, I have not seen the proposal and will look at it. The way to remunerate GPs is to provide it through the health Vote, which we do and have been doing over the past number of years. Significant resources are available to the GP sector. Are pensions a HSE issue? I am not sure.

If a shortage of GPs is an issue in delivery of Sláintecare, why would Mr. Watt not take on board the issues they raise?

Mr. Robert Watt

I will have a look at the proposal. I have not seen it. The shortage means we need to train more GPs, the numbers of whom have increased. We are now training up to 250 per year. There is a proposal from the general practitioners to increase that to 350. There are issues in particular locations and various proposals about how we can make it more attractive. Mr. Reid alluded earlier to how it is harder to get GPs in particular parts of the country and, when GPs retire and move on, to get the next generation in to replace them. We will certainly have a look at the proposal but, as a general principle, we do not like to lobby the people who pay the bills. Getting them to reduce the tax base is not necessarily what we do in the Department of Health but I will certainly look at the proposal.

Mr. Paul Reid

I will add to what Mr. Watt said on GPs. It is a big issue for us. We are working very closely with the Irish College of General Practitioners, ICGP, on how we will bring through further trainees on the ICGP training programme. Ten years ago, approximately 135 GPs per year were coming through the programme. It is at approximately 235 at present. We want to get that up to 350 by 2028 and we are working very closely on that. We have reassigned the training roles, responsibilities and people across to the ICGP where it fits better, in terms of that programme and training. We are also looking at some non-trainee positions in order that doctors in hospitals can be assigned to trainee positions into general practice to try to get some further relief into it. We are very conscious of the issue and are working closely with the ICGP.

I commit to come back to the Senator with a brief note on the second point. I am not totally familiar with the notification of pension entitlements and delays with them. I have heard some exceptions but I will get a brief note back to the Senator.

A Commencement debate was taken by the Minister of State, Deputy Rabbitte, and she undertook to bring this back to the Department. It is certainly an issue in the Saolta area but across the country, as well.

With regard to delays in the lodging of planning applications for the Galway emergency department, ED, and the whole saga of elective and acute beds in Merlin Park, there is still a huge level of confusion in Galway. This is best exemplified where I have been advocating for childhood orthopaedic theatre and services in Galway. They need a fit-for-purpose, modern facility yet they do not know whether that should be at the University Hospital Galway site or Merlin Park, in conjunction with elective hospitals. The elective hospital will be acute and will not have overnight or acute beds, certainly not in the short term. There is still significant confusion in Galway over progress. When is the ED planning application likely to be lodged? It is long overdue. A temporary ED is being built to facilitate the development of a new ED. Some people in Galway think that is the new ED but it is not. It is a temporary facility. When is the planning permission likely to be lodged?

Mr. Paul Reid

I will ask my colleague, Mr. Woods, to comment. I appreciate the overall frustrations in Galway.

Mr. Liam Woods

I do not have that information in front of me, but I will come back to the Senator shortly in terms of-----

I apologise. There are only a number of us here on the committee. I am here from Galway. A number of Deputies and Senators are here from Limerick. Of course, I will raise an issue from Galway that I have raised before. This frustrates me. It was the same when the Minister appeared here. I was told there was no information and he would have to come back to the committee. One should have that information in preparation for a committee meeting. It is frustrating. I do not normally get annoyed but those are the basics, when one knows who is on the committee.

Mr. Liam Woods

I am very happy to answer the question and I will answer the Senator, shortly. I understand the work is done to do so. I do not want to mislead by giving a wrong answer.

Mr. Paul Reid

I assure the Senator that the preparation we and our teams put in place for coming before the committee is extremely significant. We will be up against approximately five committees over the coming three weeks. We put significant time and focus in and we may not be able to answer all the questions on our feet. The scope of what we were advised today was on the regions and governance. I ask the Senator to appreciate we do not have all the answers to every single question. We have captured most and we will come back on others.

I find it hard to believe that with the full team there, the Department or the HSE do not have information on vital projects such as this. We can talk about delivery of Sláintecare, which is very important, but all projects are vital with regard to delivery of services. Do they not have any information on acute beds in Galway or the saga of a €3 billion to €4 billion hospital in Merlin Park? Can no light be shed on any of that at this meeting? I do not often get an opportunity to address the head of the Department or the HSE.

Mr. Paul Reid

Mr. Watt may have covered the elective hospitals. Mr. O'Connor might want to touch on the process, especially on the business case progressing for the three of them. Does Mr. O'Connor want to make further comment on Galway?

Mr. Muiris O'Connor

I do not have a further comment to offer.

Mr. Robert Watt

We have identified a site for the Galway elective hospital and the business plan is being progressed. We hope to progress this. The timeline is similar to Cork. We are working away on this to get it through the assurance process and we hope to be able to say something more definite in the coming weeks on the Galway and Cork projects.

The delivery of acute beds in Galway goes back to the whole division in Galway, as far as I can see, within the Saolta hospital group over where things should progress and whether our ED should be in Merlin Park.

The people of Galway are caught in that debate. No acute beds were provided under the winter plan, which was highlighted and was unbelievable considering we had the highest number of people on trolleys in an eight-week period. Are there plans for acute beds in Galway in the short or medium term? I know a couple of lines were added to the memo and press release about the elective hospital in relation to future plans for acute beds. As far as I am concerned, that was nothing more than a political fig leaf. Are there short to medium-term plans for acute beds in Galway, either at the University Hospital Galway, UHG, site or Merlin Park?

Ms Anne O'Connor

I will come in on some of the immediate actions that have taken place. In the past week, we opened 26 beds in Merlin Park University Hospital that are step-down beds to support the pressures in Galway University Hospitals, GUH. Those beds opened in that past week as an immediate pressure relief. Senator Kyne is absolutely right; the pressure on Galway has been unbelievably high for many weeks and months throughout the winter period. Any year in which we work with Galway in terms of its winter planning, as we did this year, they are very challenged in identifying a location where they could put extra beds, such as a modular build. We have been working closely with Saolta in that regard.

Galway has been on the top of our priority list for the past three winters. From their perspective, due to the lack of other capacity around them, unlike hospitals in other parts of the country around which there are different types of facilities, they are very challenged and they have not had as much capacity available to them in the private hospitals compared with other parts of the country. They are in a bottleneck. We have been working with them in terms of looking at their existing sites to see if there is capacity to build on the site of UHG, but that would involve them moving other capacity around. Therefore, the UHG site is not a straightforward site, as the Senator is probably aware of. For us, the solution lies in Merlin Park where there is obviously space. The immediate step taken in the past week was the creation of those additional step-down beds.

This comes back to the debate: they cannot find a site because they do not know whether they should look for it in UHG or in Merlin Park. I have said this umpteen times: there is no need for the births, deaths and marriages clinic, which is right beside the hospital, to be there. That service could be delivered elsewhere. That is a prime site for the delivery of acute beds for Galway or other services. That is a matter for the Department and the HSE to investigate and sort out. That is right beside the existing site at UHG.

We need to move on. I call Senator Hoey next.

I have two topics on which to focus, so my contribution will not be too lengthy. Last week, during a discussion we had on the Joint Sub-Committee on Mental Health, a member of the Irish Hospital Consultants Association made an interesting comment that is pertinent to today's discussion. He said that we could publish as many plans and reports on which we ideologically agree, but these reports must come with implementation strategies, and that we need to move to a place where we have a roadmap for implementation as a companion for such plans. Can the Department provide a steer on the implementation of reporting on Sláintecare? For example, in the forestry sector, there is a dashboard that everyone has access to and they can see what targets have been met, such as how many trees have been chopped down and how many saplings have been planted, and how that aligns with the targets that have been set. It is particularly good for public accountability, as well as for public representatives to be able to see what is happening. Could something like that be done? The public wants to know what is happening with Sláintecare. We want to know. We invite witnesses to the committee in order to ask them questions. As to a clear accountability measure, such as a dashboard, are there plans for or a conversation about providing something like that? It would save us from some of the argy-bargy that happens sometimes. It would create a clear and transparent accountability mechanism for Sláintecare which, I believe, the members of the public would like.

I will ask my second question now and I am happy for both of them to be answered together. I refer to the rates of pay that exist and m y party colleague, Deputy Kelly, listed a number of figures in the Dáil Chamber yesterday, such as the 700 vacant consultant posts. We know about the shortage of GPs across the country from reports by Simon Carswell in The Irish Times. One in five GPs are expected to retire by the end of the decade and we need 2,000 more. In 13 GP areas, medical card holders have been without a permanent doctor for a year, and so on and so forth. I need not go into the depth of it. I have a genuine question that is not designed to trip the witnesses up. Considering the current rates of pay, will we ever be in a position to hire enough staff to implement Sláintecare to its fullest? We hear about the core rates of pay and how they are not sufficient to attract to people. If we continue with current rates of pay, will we be able to get to where Sláintecare needs to be or is there a need for a genuine conversation about how that to happen with those rates of pay? My two questions are on implementation and the use of a dashboard system and whether we can reach Sláintecare goals in the context of current rates of pay.

Mr. Robert Watt

I will go first and Mr. Reid or a member of his team may wish to come in afterwards. We produced a report yesterday along the lines of Sláintecare implementation. While it may not have produced in time for the Senator and committee members to go through, it sets out, in effect, what the Senator suggested. Some 228 deliverables have been set out, of which 200 have been categorised as progressed, on track or with minor challenge. That leaves 28 with a significant challenge. We have set out a dashboard or traffic light system. We certainly would welcome any comments on how that reporting could be improved. That is a key part of our accountability and sets out what we have done in 2021. It is a progress report that sets out where we are making progress, as well as where there are challenges and significant challenges. We touched on some of that this morning.

No matter what we produce, there will always be argy-bargy. Argy-bargy should not necessarily be seen as a bad thing. Debate is good and being challenged is good. No matter what we prepare, there will always be contested space in health and other areas of public policy given its importance. We welcome any suggestions the committee may have in terms of improved reporting that would help it with its role in calling us to account.

As for recruitment, which was touched on earlier, a significant amount of recruitment has taken place. There are challenges around that and we are doing a variety of things to address them. There is a wider societal piece about making the health system attractive to people. It is about pay. It is about working conditions. It is about the overall sense of the discussion around health. Mr. Reid touch on this earlier. Working in health provides a fantastic career and fantastic opportunities, and it is much more positive than negative. Of course, there are negatives and, unfortunately, in the public debate, the negatives drown out most of the positives. It is a challenge for Mr. Reid and me, as well as our teams and others, to better communicate the positives of the health system in terms of what has been done, the achievements and the enormous pride people have in their work. We always get a sense of how people are enormously proud of working in the HSE, in other parts of the health system, and in the Department of Health, and how they feel they are making a contribution. I do not believe it is just about pay. It is about a whole variety of issues, including structural issues and making employment as attractive as possible for people.

Mr. Paul Reid

I will add a few brief comments to what Mr. Watt said. I referred to figures on recruitment earlier. It was unprecedented to have recruited 35,000 staff, 12,500 net, in the past two years. What is more important to me is that the mix of staff have been a much better mix than there might have been in the past. They included the recruitment of 3,300 nurses and midwives, of whom more than 2,150 were staff nurses and midwives; almost 2,000 healthcare assistants; and more than 2,300 in patient and client care, including healthcare assistants. The challenges we have, some of which the Senator touched on, include the recruitment of consultants. There has been a 358 net increase in the number of consultants in the past couple of years but that is a massive challenge for us across all the specialties. As I mentioned earlier, there are some geographical areas in which we find it particularly difficult. South Kerry was a clear example of that and, indeed, Donegal can be as well. There are severe challenges in some areas and regions. Highly qualified professional consultants like to be in the big urban centres and urban functions.

I will add one other point to what Mr. Watt said and it is something I passionately believe in.

I talk to a lot of our staff regularly. We would have been able to get out and about much more, but we have webinars and we talk. I passionately believe that our teams like working in the health service. When things go wrong, it is not good. None of us can stand over things that have happened, whether it is in south Kerry or other instances that happened where wrongs or harms occurred. Overall, the Irish health service provides, by equivalent with other health services, a good service in terms of people's longevity and life cycle, cancer treatment and cardiac treatment. It does not always get reported.

I agree with Mr. Watt to the extent that it is a role for me as leader and it is certainly a role for me and my teams, but there is a wider public role in terms of how we draw out many of the clichés about the HSE and the health system. It does hurt the system and it does not make it easier for us. I am not saying that people should not challenge, criticise or have a go at us, but the general commentary does not always reflect the reality of what our teams are committed to in the health service. I am committed to help them as well.

I will not go through what has been said about GPs, but it is a challenge. I went through some of the figures earlier where we are trying to scale up with the ICGP. Everybody is committed this.

I thank Mr. Reid. It is one of those things that we will just have to get to grips with. Not enough money is coming from the Government to employ people to achieve the goal. I accept the comment Mr. Reid made that it is wider than just pay. That is something that we as political representatives have to take very seriously. As an advocate of workers' rights, a fair day's pay for a fair day's work is something that is very important, and perhaps we are just not getting to grips with that.

The forestry dashboard is a hard accountability system, but it is very accessible to the public. The reality is that not all members of the public read reports. Some will read a report but not everyone is going to read it. Such a dashboard is hard accountability based on numbers and figures and something like that would be very useful for members of the public to see where Sláintecare is going because we talk a lot about it and give a lot of time to it. They are all my questions.

Mr. Robert Watt

We will look at that suggestion and see if we can improve on that.

Before I bring in other members, I wish to ask about the Sláintecare programme board, which met once. How often does it propose to meet? The big question is what it will do differently in that regard.

Mr. Watt referred to elective hospitals in his opening statement. What is the earliest date he hopes to see them opening? I would have liked to ask about waiting lists. There was talk of a 5% reduction. Based on that, with 40,000 patients a year, it would take 18 years to deal with it. Could he give a sense in a written reply of how we will reduce the waiting lists and a timescale for it?

Mr. Robert Watt

Regarding oversight, the new board has met twice since December. We have a meeting every second month or more often if needed. As we mentioned earlier, the teams meet every week on the different projects, and on some of the projects they could meet several times a week. There is a lot of activity happening below the teams and issues are escalated to Mr. Reid and me each week but formally then at the board structure. We will see how that evolves over time. We are not wedded to this particular format. We will see. If it works, we will continue; if we think we can improve it, we will make those tweaks.

I do not have a timeline for when the elective hospitals will be delivered and when they will be opened. It is now 2022, so I hope we will get to the stage where we are going out for detailed design and procurement mid-year. It normally takes two to three years after that to get the procurement in and to build. The facilities are not as big as some of the hospitals we have but they are large in terms of their footprint. I will come back to you if I may, Chairman, with a more concrete timeline on that as I do not have it to hand. It will be several years.

Regarding waiting lists, Mr. Reid and I touched on this very briefly today. We are constrained in providing all the detail because the plan is not finalised yet and it has not gone to the Government. It would not be appropriate for us to give all the details before the Taoiseach and Ministers have had an opportunity to consider it. It is a very important decision for the Government, and I hope it will have an opportunity this week to consider it and to debate it formally next week when it meets. The targets do involve significant reductions in waiting lists by the end of this year compared to where we are now, and a very long level of activity, but it will still involve large numbers of people waiting at the end of the year. I hope the number of long waiters will also be reduced. That is a key aspect of the plan as well. The challenge of the waiting lists will take a number of years to address. They are not going to be addressed in one year. In order for us to improve our performance and reduce the number of people waiting, we want to get to a target where people do not have to wait more than 12 weeks, three months, in the main. That is what we get to and it is a challenge to reduce the waiting time to a reasonable level.

So it will be next week.

Mr. Robert Watt

I hope the plan will be published next week, but it is up to the Government. At the next opportunity Mr. Reid and I can discuss the plan in detail with the committee and the methodology and targets we hope to achieve.

Okay. I will take a question each from Deputies Cullinane and Shortall.

We had a discussion earlier on the email that I walked Mr. Watt through. Deputy Shortall referred to the wording as well, which was that over time the HSE will seek to expand the remit of hospital groups to include community services. It goes on to say that there are complexities in this, as the geographies of the CHOs and HGs do not align, which of course they do not. They will only align once we set up new structures geographically, which have already been agreed. Is it the case then from my reading of this, which may be wrong, that the HSE wants to expand the remit of hospital groups to include community services, and probably to align or amalgamate leadership teams across CHOs and hospital groups? What is the timeframe for that?

Why is that being done within the current geographical alignment, as opposed to sticking with what Sláintecare has agreed, which is the six regional health areas? I have expressed concerns already. Concerns were also expressed by people who resigned from Sláintecare on whether this would be satisfactory. What is the timeframe envisaged by the Department for the new regional structures to be in place in full?

Mr. Muiris O'Connor

I can speak to that. In terms of the direction that we are working under, the HSE senior management team, the Department of Health senior management team and the senior management team in the Department of Children, Equality, Disability, Integration and Youth are working under clear direction from Mr. Watt and Mr. Reid to implement the regional health areas consistent with the Sláintecare vision. The commentary on the email is overplayed and is not consistent with the work programme under way.

The frequency of meetings was mentioned. There are meetings every fortnight at least on the implementation of RHAs. The implementation team, consistent with Mr. Reid's and Mr. Watt's overall responsibility for the implementation of Sláintecare, connects their senior management teams on a very deep basis to implement the programme. Our high-level timeline is to have a detailed implementation plan completed at the end of this year to work through 2023 to phase in implementation and, all going well, to introduce the regional health areas from 2024 onwards. Recognising the importance of engagement with this committee, the public and in particular with staff across the health and social care system, in the preparation of a detailed implementation plan our intention would be by the autumn, September or so, to have a comprehensive plan for deep engagement with the committee and all interested parties.

There are a number of work programmes. Mr. Watt and Mr. Reid have spoken to the scale of the reform programme. It is not a caution about the ambition of it, it is a recognition of just how fundamental it is and how important it is to maintain service delivery through the period of implementation. We are setting up work streams now on governance - corporate and clinical; workforce planning, which has featured in this discussion; the opportunity to totally reform and bring greater visibility to the allocation of finances on a population basis; capital infrastructure; and engagement. That is the high-level timeframe. I hope it provides assurance about the senior level engagement on this.

I thank Mr. O'Connor. Deputy Shortall can ask a last quick question.

What time are we finishing?

We are finishing at 1 p.m.

Is it not a three-hour meeting?

That was my understanding.

I want to ask Mr. Watt about a couple of things. Regarding the status of the individual health identifier and electronic health record project, the business case for those was in 2016. Where is that at the moment? When are we going to see a workforce plan?

On change management and reform, I appreciate that Mr. Watt and Mr. Reid have extensive experience of that in other organisations but health sector change management and reform is quite a different kettle of fish. Has Mr. Watt brought in any expertise with regard to this area? Specifically, has he spoken with the expert team from the Centre for Health Policy and Management at Trinity College Dublin, which provided the very strong policy base for the Sláintecare programme?

Mr. Robert Watt

I thank the Deputy. We have brought in some people within the Department of Health and there will be further changes in the period ahead helping us with this change management. They augment the excellent team we have in at the moment. That is something that is happening. I have engaged and met with the team in Trinity College Dublin. We have chatted about the various implementation challenges and what we are trying to do.

Let me come back to the Deputy with a timeframe on the health identifier. I do not have the exact details to hand but we will come back to her on that.

When are we likely we see the workforce plan?

Mr. Robert Watt

Obviously, we have a detailed workforce plan for this year about which Mr. Reid and I have spoken a good bit this morning. That sets out our plans regarding the numbers we hope to recruit across the different areas and specialties. We have a further piece of work being done to look at a more structural medium-term plan. We are getting support from the European Commission and a project of work is available on that. The Deputy might bear with me for one second-----

I am sorry; is Mr. Watt saying the one that he has is only for the current year?

Mr. Paul Reid

I am happy to come in on a couple of points.

Mr. Robert Watt

I thank Mr. Reid; I will just check that detail with the officials.

Mr. Paul Reid

On the Deputy's first question on the individual health identifier and electronic health record project, there is no doubt, and the Sláintecare report calls this out, that the areas that are behind are in terms of e-health. As we have been working through various deployments of both the vaccination and testing and tracing programmes, we have been trying to capture information that will contribute significant data to those projects. They are the ones we are behind on in terms of progress and on which we want to put a particular focus.

Particularly in terms of e-health, we will need to recruit expertise. We do not have sufficient expertise in the HSE in particular. The PwC cyber report that we published did point out some deficiencies in some of our skills, which will be part of our recruitment process to strengthen ourselves in that sector.

Finally, I will make a comment on the change management. The Deputy is correct; I am not from a health background. I have been here for two and a half years. We will need to bring in some external expertise. As I said earlier, this is one of the biggest change management processes in a public service body probably in the history of the State and we need to bring expertise in with us. I have also met the team from the Centre for Health Policy and Management at Trinity College Dublin in my early stages.

On the workforce plan, has the HSE only got one for the current year?

Mr. Robert Watt

I am sorry; I meant to come in on that. We have two aspects. Mr. Reid is correct; one is that as we publish the national service plan we then have a pay and numbers strategy for 2022 and then, separate to all that, we are working with our board on a strategic workforce plan that sets out a multiannual plan to address it. We will be working with the Department on that as well.

How many years is Mr. Watt talking about?

Mr. Robert Watt

It is a multi-year plan. It literally sees us through the duration of a corporate plan, which sets us out to 2024.

I thank the participants very much. This morning was very informative. I hope we can do this on a regular basis to try to keep abreast of the implementation of Sláintecare.

The committee will meet again in public session next Wednesday, 23 February 2022 at 9.30 a.m. I once again thank all our guests this morning.

The joint committee adjourned at 1.05 p.m. until 9.30 a.m. on Wednesday, 23 February 2022.