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Joint Committee on Health debate -
Wednesday, 6 Apr 2022

Oversight of Sláintecare: Discussion (Resumed)

Today the committee will meet representatives from the Department of Health and the HSE to discuss the Sláintecare progress report 2021. From the Department of Health, I welcome Mr. Robert Watt, Secretary General, Mr. Muiris O'Connor, assistant secretary, Mr. Bob Patterson, principal officer, and Mr. Jack Nagle, principal officer. From the HSE, I welcome Mr. Paul Reid, chief executive officer, Ms Anne O'Connor, chief operations officer, Mr. Robert Kidd, assistant national director for acute operations, Ms Yvonne Goff, national director for change and innovation, and Ms Yvonne O'Neill, national director for community operations. They are all very welcome to the meeting this morning.

On a point of order, yesterday the Department or the HSE published on its website the business case for the regional health areas and set out three options. The business case was not sent to committee members. I have seen it but to do so someone would have had to have known about it or looked for it. Given that we are here to discuss regional health areas, many committee members will not have seen the business case that sets out the three options the Minister had and the option he went with. It is unfortunate it was not sent to the committee.

I will note that. It is unfortunate.

Mr. Robert Watt

I understand the report was sent to the committee at lunchtime yesterday. If I am mistaken on that, I will come back.

We can check that.

These are obviously important documents that we need to have. We cannot have a discussion in the absence of the business case that has been published. Could we make arrangements to circulate a copy?

Mr. Muiris O'Connor

I understand the document on the website was sent from Mr. Watt's office to the committee.

There has been some mix-up but we will circulate them straight away.

The witnesses are all very welcome to our meeting. All members and witnesses are reminded of the long-standing parliamentary practice to the effect that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction. I call Mr. Watt to make his opening remarks.

Mr. Robert Watt

I thank the committee for the invitation to discuss progress with the implementation of reform. I am joined by my colleagues, Mr. Muiris O'Connor, Mr. Jack Nagle and Ms Muriel Farrell. Ms Farrell is an addition to the team and not on the original list the committee received.

We are here today to discuss the Sláintecare progress report for 2021, published by the Department in February. The report sets out progress made against the priorities and actions detailed in the Sláintecare Implementation Strategy and Action Plan 2021-2023. The provision of healthcare radically changed during the pandemic, as we are all aware. As outlined in the end-of-year progress report, significant reform and innovation were delivered throughout our health and social services. The voices of patients highlighted throughout the report reveal the reality of Sláintecare in people’s everyday lives and the outstanding work being done throughout the system to adapt and provide integrated services that put patients first.

I will update the committee on some recent developments this year, specifically on what has been delivered by the Department and the HSE in terms of reform since we last came before the committee in early February. In late February, the Minister for Health launched the 2022 action plan on waiting lists following engagement between the Department, the HSE and the National Treatment Purchase Fund, NTPF. The plan contains 45 actions to reduce and reform waiting lists across four main areas of work. These are delivering capacity, reforming scheduled care, enabling scheduled care reform and addressing community care access and waiting lists. Implementation of the plan is governed by a waiting list task force. This meets regularly and is chaired by me and the CEO of the HSE, Mr. Reid. It is an extension of the approach and structure that we used for the short-term waiting list action plan that ran from September to December last year, and which saw a 5.4% reduction in waiting lists.

Projections for this year suggest that more than 1.5 million patients will be added to active waiting lists for acute scheduled care this year as post-pandemic pent-up demand for health services is released. Through the plan, €350 million has been allocated to the HSE and the NTPF to deliver services to remove more than 1.7 million people from active acute scheduled waiting lists. This will result in a projected reduction in waiting lists of 18%. It is hoped that by the end of 2022, based on implementation of the plans and the progress we would like to see, the number of patients on waiting lists will be at its lowest level in five years. The plan will also make progress towards the achievement of intermediate waiting time targets as set out in the service plan.

Significant reforms are being progressed in tandem with delivering this extra activity. These include modernising care pathways to bring care closer to the community, reduce the pressure on our hospital system and greatly enhance the availability and analysis of data and information.

Progress is largely on track despite the recent surge in both emergency department, ED, attendance and Covid cases. No doubt, what has happened will undoubtedly have had an impact on delivery over the past three to four weeks in particular. As the number of Covid cases comes down and the pressure on the hospital system eases, however, we will hopefully be able to continue to accelerate our progress on waiting lists.

Significant progress has been made with the regional health areas, RHAs, project since I was last before the committee. The Government approved the geographies of the regions in the months preceding the pandemic and directed the Department to explore the organisational design, governance frameworks and funding methods for RHAs via a detailed business case. Substantial work was undertaken by the Department in partnership with the HSE, and with input from the RHA advisory group, in the development of the business case, which was published yesterday. Also yesterday, the Government approved the implementation of RHAs, another important landmark in the reform and modernisation of our health services, as envisioned under Sláintecare. RHAs will provide for the alignment and integration of hospital and community healthcare services at a regional level, based on defined populations and their local needs. This is key to delivering on the Sláintecare vision of an integrated health and social care service.

The allocation of resources by RHAs will also enable better accountability, oversight and evaluation of costs and health outcomes at a regional level. A team of officials including representatives from the Department of Health, the HSE and the Department of Children Equality, Disability, Integration and Youth is on track to produce a detailed implementation plan by the end of this year. I am happy to engage with this committee, and other committees as necessary, to input into that plan. The plan will cover how RHAs will impact on workforce and HR planning, funding allocation, capital infrastructure and governance lines.

Work has started on the development of a population-based approach to service planning and resource allocation. Planning our services in this way will improve our ability to equitably allocate our workforce and capital resources. As part of the Estimates process for 2024, a population-based resource allocation, PBRA, funding model will be used to allocate funding by RHA. A shadow budget cycle is planned for 2023.

In conclusion, the Department will continue to engage with the public and a broad range of stakeholder to increase understanding of how Sláintecare is building a better, more equal health system for all. I am happy to answer any questions from committee.

Mr. Paul Reid

I thank the committee for the invitation to meet to discuss progress with the implementation of Sláintecare. The Chair has already introduced my colleagues so I will not do so again. Members will recall that I previously provided updates on the main elements of Sláintecare progress at the February meeting. As members will be aware, in addition to the mid-year report, an end-of-year progress report for 2021 has also been developed and we are close to finalising with the Department the Sláintecare action plan for 2022.

I would like to focus on the following aspects of Sláintecare progress today: the multi-annual waiting list plan; Regional Health Areas; enhancing community care programme; and the Sláintecare integration fund.

On multi-annual waiting lists, a critical objective of Sláintecare is to reduce waiting lists. Since the last update provided, the 2022 waiting list action plan was launched on 25 February. The plan allocates €350 million to the HSE and NTPF and details 45 actions to reduce and reform waiting lists. The immediate focus of the plan is on the delivery of activity to reduce active waiting lists for acute scheduled care by 18% this year, which would bring the number of people waiting to their lowest point in five years. In addition, the 2022 plan focuses on 15 high-volume inpatient and day-case procedures, including cataracts and hip and knee replacements, so that every person waiting over six months for one of these procedures, and who is clinically ready, will receive an offer of treatment.

The 2022 plan also lays the foundations for longer-term reforms in areas such as patient care pathways, key service reforms and data and information. This is the first year of a multi-annual programme of reform to achieve the Sláintecare targets whereby no person waits more than ten weeks for their first outpatient appointment and 12 weeks for their inpatient or day-case procedure. Consistent with this, each hospital group has been set a target that by December 2022, 98% of all patients on our waiting lists will wait less than 18 months for their first outpatient appointment and 12 months for their procedure.

Of course, it is important to note that there continues to be challenges in the area of scheduled care, as Mr. Watt noted in his opening statement, with the most recent surge in both ED attendance and Covid cases. We will continue to work closely with hospitals to ensure appropriate supports and plans are in place to deliver the 2022 waiting-time targets. We are also working closely with CHOs to tackle long community waiting lists. I will continue to brief members on progress in relation to these key areas.

Since the February update, we have continued to work with Departmental colleagues to take forward planning for the introduction of RHAs. The focus of this planning work has included detailing the vision and objectives for RHAs, and the identification and scoping of key implementation work streams. At this time, the work streams identified as part of the wider work programme are as follows: programme co-ordination; corporate and clinical governance and accountability; population-based resource allocation; finance; digital and capital infrastructure; people and development; and change, communications and culture.

In early March, a workshop was held involving the senior management teams from the HSE and the Departments of Health and Children, Equality, Disability, Integration and Youth to provide an update on the position with RHAs and to consider, scope and refine the key implementation work streams. Similar workshops are being arranged in the coming weeks for CHOs and hospital groups. The HSE board will also be playing a lead role in overseeing the RHA agenda as it progresses. A detailed implementation plan is being developed by the Department and the HSE with input from the RHA advisory group. This will be finalised in 2022. Transition to RHAs will take place during 2023 and, by quarter 1 of 2024, the expectation is that RHAs will be fully operational.

The developments under the enhanced community care programme, ECCP, continue at pace with 51 community health networks, 15 community specialist teams for older persons and four community specialist teams for chronic disease management now established. Some 21 community intervention teams are now operational, with national coverage secured. The GP diagnostics programme has facilitated 139,000 scans of various modalities in 2021 with a further 38,000 provided to the end of February 2022. Crucially, key leadership roles have been and are being recruited which include 84 network managers, 82 assistant directors of public health nursing, 35 GP leads, 52 operational leads for community specialist teams and 54 consultants. An individual population health profile has also been created for each of the 96 community health networks, containing standardised data on the demographics and health status of each community health network.

Members will recall that budget 2019 provided €20 million for the establishment of a ring-fenced Sláintecare integration fund to support service delivery which focuses on prevention, community care and integration of care across all health and social care settings. This fund supported 123 projects and over 100 projects have now been mainstreamed into the healthcare system. Overall, these projects have resulted in over 15,000 reduced referrals to scheduled care, more than 19,000 acute inpatient bed days avoided, and more than 8,000 patients removed from waiting lists.

My commitment, and that of my colleagues and members of the HSE board, to Sláintecare reform is clear. This was demonstrated over the past couple of years whereby, despite major challenges caused by the pandemic and the cyberattack, significant Sláintecare reform and innovation was delivered across our health and social services as outlined in the mid-year and end-of-year progress reports. I look forward to the publication of the Sláintecare action plan 2022 so that we can continue to report on and monitor progress of the reform programme. As we progress and report on Sláintecare initiatives, we are hopeful that we will build trust and confidence in the Sláintecare programme of reform itself so that it is seen s delivering upon promised reform and improvements to Ireland’s health and social care services.

Go raibh maith agat.

On a point of order, can we get clarification on the business case document?

There is a difficulty. We have not officially received it.

Mr. Muiris O'Connor

My understanding is that an email went from our offices to the clerk yesterday with links attached. They are on our website.

But we were not aware of it. That is the problem. Could Mr. O'Connor check about that email now, please?

Mr. Muiris O'Connor

We have had confirmation in the past ten minutes that it went yesterday.

There is clearly a problem. The clerk is saying that they have not received it. Can we move forward on the basis that we will try to clarify that within the meeting?

Mr. Muiris O'Connor

We will clarify within the meeting, yes.

The only problem with that, and I do not want to hold the meeting up, but we have a very short time available. We have an hour and a half in total for the meeting, and we each have six minutes. We cannot spend our six minutes getting clarity on something that should have been sent to us.

Mr. Muiris O'Connor

We made sure that the members had maximum time with the document subsequent to the Government approval of it yesterday.

We cannot really resolve the matter here.

I know. Let us move on. I accept that.

The point has been made. There is clearly a difference between what the clerk is saying and what others have stated. There is some problem. We did not receive the document; officially anyway. I will move on.

To assist with the business of the meeting, maybe Mr. Watt could give us a brief account of the three options considered and the reason one, in particular, was selected. It would mean we would not have to spend time drawing it out.

Mr. Robert Watt

Absolutely. Does the Deputy have a copy of the paper? Deputy Cullinane does. The three options are keeping things as they are, establishing the model on an administrative basis, and establishing the model on a legislative basis. I shall go through the differences between the options. I will try to proceed quickly. Option 1 would effect no change in the current structure, with its nine CHOs and the hospital groups. That is obviously not where we want to get to with Sláintecare. Option 2 would involve what we call a HSE local model, with RHAs set up administratively within the HSE structure. There would be six RHAs geographically aligned, involving integrated subdivisions of the HSE that replace the nine CHOs and six hospital groups. The model would provide regional management authority and accountability and one population-based budget per region. Critically, the RHAs would not have separate boards, and they would not have legal status on their own. They would be set up administratively and the legal entity would continue to be the HSE, which would remain the employer. There would be a strong HSE centre regarding the reforms Mr. Reid has set out.

The third model, which we call the separation model, entails six legally separate RHAs with a contractual relationship with the HSE. We hope that it, too, would provide regional management authority and accountability and one population-based budget per region. However, each RHA would have its own board. Each RHA would be an employer, not the HSE. The structure of the HSE centre would be broadly the same.

The difference between the two options that require change is that one would involve establishment on an administrative basis while the other would involve establishment on a legal basis. Our preference would be to set up the system on an administrative basis. We would ascertain how that would work, set up the structures and deliver on the policy objectives. If legislative underpinning were required later, it could be achieved; however, to make progress on this within the timeframe, which would entail implementation and significant progress next year, we believe the administrative model is the best way to go. Again, we have an open mind on it. If legal powers were required, we might have to amend the existing legislation. However, we do not envisage a full RHA Bill at this stage. It could become necessary when we see how the model develops.

What is the case for selecting option 2?

Mr. Robert Watt

It is on the basis we believe we can achieve the objectives — geographical alignment, integrated care, a budget per region, and improved accountability and governance — on an administrative basis.

Did the Cabinet sign off on option 2?

Mr. Robert Watt

The Cabinet signed off on-----

Mr. Muiris O'Connor

As the direction of travel.

Mr. Robert Watt

As the direction of travel, but we have been asked to develop a detailed plan. There is much work involved in this, as members can appreciate.

We should proceed to our questions now.

Has the Cabinet signed off on an administrative approach as opposed to a legal approach?

Mr. Muiris O'Connor

It entails a HSE local model for the time being. This is a working title. The approach is to pursue the development of a strong national health and social care service consistent with Sláintecare and organise coherently at regional level. The three options that Mr. Watt spoke about were assessed in a multi-criteria analysis against objectives explicitly set out in the Sláintecare report. In this regard, I refer to clarity on corporate and clinical governance, population-based funding and the facility to ensure integrated service delivery. Value for money and the feasibility of change were also assessed.

Can I ask what Mr. O'Connor is reading from?

Mr. Muiris O'Connor


I really need to move on. We are down to five minutes.

I know, but-----

We have not been told anything about this.

What we have been told by the parliamentary representative is that there were IT problems in the Department yesterday. The information was stuck in drafts and did not arrive. These things happen.

Does the time start now?

Hold on; give us a break. Members will have five minutes each. If I can, I will allow the main spokespersons back in.

When I asked at the start, it was seven minutes. Is it now five?

I have a question for Mr. Reid. We had an address from the Ukrainian President this morning. Could Mr. Reid provide the committee with an update on the HSE's response to the crisis in Ukraine, particularly in respect of providing trauma support for the people affected? I presume that is acceptable.

We are supposed to be dealing with the Sláintecare progress report.

With respect, I highlighted this at a private meeting yesterday.

Could we get a report from the Department?

Mr. Robert Watt

We can certainly provide a report.

A report would be great. It is an important matter of public interest.

Following on from our discussion on administrative and legal options, I am seriously concerned about accountability and proper governance. If we are to develop the model on an administrative basis, the effective framework for proper accountability, governance and oversight will not be in place. How does Mr. Watt envisage ensuring that senior management in the six RHAs will have proper oversight?

Mr. Robert Watt

People can have different views on this. I do not have a dogmatic view and am happy to have a debate about it. The detail on accountability, governance and oversight will have to be worked out. I envisage that the leadership of each RHA will be accountable for delivering services in its region and budgeting. I imagine that each would be accountable to the CEO of the HSE and the board. The relationship of accountability depends on the type of contract, the key performance indicators that are set and how each body is called to account. These questions have to be worked out in the design, but they are fundamental. Can we achieve what we want to achieve with this model? I believe we can. Will people have different views? I am sure they will. Can we debate them over the coming months? Absolutely. I will be happy to hear people's views. I have outlined what I believe will be proposed. From my experience, it is about having the right people, the correct targets and a clear governance arrangement such that staff know to whom they are accountable.

Mr. Paul Reid

I have a few comments on accountability for now and as we move to new organisational structures. We know in the HSE that we need to strengthen accountability. This is usually raised when things go wrong. We know we have weaknesses in this area. I have brought several papers to our board over the past couple of years. Right now, we are engaged in working through these matters. This will feed into the new structures.

In very simple terms, there are a few strands to trying to strengthen accountability. The first involves having clearly defined organisational roles and responsibilities. There should be no vagueness regarding who is responsible for what. The second involves the very clear delegation of responsibility in legislation, with people accountable in this regard. The third involves the regulation. These are all strands that we are working on. Many of the professional grades in the health system are regulated but some are not, which means strengthening these.

Two issues arise over performance management. The first is that we are not strong enough in performance management in the current system, which means our performance management will have to be strengthened. The second concerns discipline. Discipline involves a very complicated process within the health service. It is quite dated, in some cases dating back to 1970s legislation. These are strands that we regard as being part of accountability, for now and for the framework. Simply putting in six RHAs on their own will not suffice. That is a process we are involved in right now.

There is concern, especially in rural areas, that in adopting a population-based approach, there could be discrimination against parts of rural areas. Could Mr. Watt elaborate on where he is coming from regarding that approach?

Mr. Robert Watt

The Sláintecare proposal, which we support and are working towards, is that allocations will be made on a regional basis and based on the population needs in the region. As the Senator is aware, the budget is currently allocated based on considerations such as older persons, disability and so on. Our hope for 2023 is to have, in addition to the existing budget, a shadow budget to set out what it would look like in terms of allocations to each of the regions on a per capita basis and then see how that works. Ultimately, there are benefits to the objective and general principle of saying there is a population of 700,000 or 800,000 in an area and we are going to allocate €3 billion, €3.5 billion or whatever the figure is to it and having a person accountable for providing services in that area. When we do the shadow budget for 2023, it will be interesting to see how it will look per head of population and per region and the extent to which that-----


Mr. Robert Watt

I do not know the answer to that.

I do not think any of us does. It is something we need to consider.

Finally, I wish to raise a matter that is in the public interest. There is significant concern regarding the appointment of Dr. Tony Holohan, the Chief Medical Officer, CMO, to a position in Trinity College Dublin. Did Mr. Watt sign off on that? Did the Department engage with Trinity College or was it the other way around? A secondment is usually temporary. Will a temporary CMO be appointed? How did the secondment come about? Who signed off on it?

Does Mr. Watt wish to respond? I know it does not fall under the topic for the meeting but it is an issue people are talking about.

Mr. Robert Watt

Dr. Holohan is going to take up a new role in Trinity College Dublin. We will be appointing a new CMO in the coming months based on an open competition through the Top-Level Appointments Committee process. Dr. Holohan is moving to this new role. Obviously, he is hoping to contribute significantly in terms of public health policy and preparedness and all the things we believe we need to do as a country. He is going to contribute to that. I am not really here to talk about that today. The Taoiseach and the Minister have answered questions on it already.

Mr. Watt did not answer my question on whether the Department will be advertising for a permanent CMO or a temporary CMO.

Mr. Robert Watt

We will be appointing a permanent CMO.

In that case, the secondment of Dr. Holohan from the Department is permanent.

Mr. Robert Watt

Dr. Holohan is going to Trinity College. As regards the arrangements, the plan is that a new CMO will be appointed on a permanent basis.

Dr. Holohan will not be returning to the Department of Health.

Mr. Robert Watt

He will not be returning to the Department as CMO. He is going to Trinity College. The expectation is that he will-----

Is the secondment open-ended or for a set period of time?

Mr. Robert Watt

Dr. Holohan is moving to a new role in Trinity College. It is a contract of indefinite duration is the way-----

The Department of Health will be funding this for the next 20 years, assuming Dr. Holohan stays there for 20 years. That is highly inappropriate. Is Mr. Watt satisfied it is appropriate?

Does Mr. Watt wish to provide the committee with a note on this issue? I do not think any reply he gives now will satisfy members.

Mr. Robert Watt

We will come back to the committee on the details.

Is that okay with members?

Mr. Muiris O'Connor

I just want to acknowledge that the Chairman was correct regarding the email. We just found out we had IT trouble and the email did not issue as we intended.

That is unfortunate but these things happen.

Mr. Muiris O'Connor

We wanted to give the committee maximum time with the report.

We might return to that issue in the next round.

May I make a quick point on the secondment? It is an important issue. Mr. Watt has given clarity that the CMO has permanently stepped down from his position and will take up a position in Trinity College Dublin. All present support that. It will be really good for Trinity College and for the State. If he will still be paid by the Department of Health, however, that can be a problem. A secondment implies that one will return to one's post. Dr. Holohan will not be returning to his post. That does raise questions that have to be answered. The Department will have to answer those questions because somebody in the Department signed off on this. Obviously, the Government signed off on it. It is unsatisfactory.

I will move on to the issue of regional health areas. I refer to option 2, the HSE-local model, referred to in the business case. What is being proposed is that the RHAs will not have a board. Is that correct? Yes. What is being proposed is that there will be no legal change. As Mr. Watt stated, there may not be even a need for legislation. This will be an administrative change. Is that correct?

Mr. Robert Watt

Yes, that is the-----

The HSE will remain the employer and there will be a strong HSE centre. Is that not correct? The business case goes on to state that HSE centre will provide all corporate functions. Is that correct? It states that "RHAs are divisions within HSE Centre". In other words, HSE centre will provide central procurement, central finance control, central HR functions and ICT support. When the Minister was going into Cabinet he was asked what was his vision for this and he stated that we will have a leaner HSE at the centre. Option 3 is the one that refers to having a leaner HSE centre but the Government has not gone for that option. It says it in the business case. Option 2, which is the one the Government has gone for, refers to a strong HSE centre. We have not gone for a leaner HSE centre. There is not even going to be a legal underpinning for these RHAs. They will not have any powers or responsibilities in respect of corporate functions. We know that Mr. Reid has for many years made a case for the strong HSE centre to remain. Has he won out here? That question is for Mr. Watt.

Mr. Robert Watt

I do not think the two models are fundamentally different when it comes to the role of the centre. We are talking about a centre that provides those basic functions. Ultimately, the difference between them is whether the RHAs are set up as a legal identity and have their own board. Obviously, that would change how they relate to the centre. I have an open mind on this and am happy for people to have different views and debate it. If there is a HR function, a procurement function or an IT function at the centre within the HSE, is it appropriate for that function to stay? I think it is because what are being provided are common type of services that do not differ-----

We are very short on time. I am genuinely enthusiastic about the establishment of regional health areas.

Mr. Robert Watt

So am I.

The realignment of healthcare, acute care and primary care is really important but it is not going to work and we are not going to usher in a new level of accountability and change in healthcare by things pretty much staying the way they are. We are going to have a geographical and administrative alignment but the RHAs will not have a board, there is no legal underpinning, the HSE will remain the employer and all corporate functions will remain at the centre of the HSE. These RHAs will be a division of the HSE at the centre. The HSE will control procurement, finance and all other corporate functions. That is not reform. It is not what was envisaged in Sláintecare. We have been hearing for some time about a pushback from within the HSE in respect of the type of reforms the vast majority of Oireachtas Members want. From my perspective, option 3 is the best model because it would establish regional authorities and regional health areas that would have their own board and would be legal entities. The business case states that these RHAs "cannot enter into contracts in their own right". They cannot even enter into contracts unless they get permission from the centre. This is not reform.

Mr. Robert Watt

It is consistent with Sláintecare reform. I read the business case and it is consistent with such reform. It is really about the focus on that horizontal piece, as we have discussed previously. It is about integration of services at the regional level. That is the main objective of this. Ultimately, it is to improve accountability for delivery of those services on an integrated basis across the hospital and community systems and primary care. Do I believe that establishing boards or reorganising the centre of the HSE in a more fundamental way is essential to deliver of Sláintecare? I do not, but I am happy to engage in that conversation at-----

I have a final point, if I may. I can fully understand now why Ms Magahy left her post. From my perspective, the pushback has won and we are not getting the leaner HSE and regional health areas we were promised. That is not a good day for healthcare, accountability, transparency or the delivery of better healthcare. It is really disappointing.

Mr. Robert Watt

I do not accept that------

I know Mr. Watt does not, but I am giving my opinion.

Mr. Robert Watt

-----at all. The Deputy is entitled to his opinion but it is not a fair characterisation of the-----

It is my characterisation.

Mr. Paul Reid

I just want to make a few comments for the record. The Deputy suggested I have made a case for a strong centre and pushback. That might sound reasonable but it is not factually correct. I have been on record very publicly in saying throughout Covid that we have had significant learnings from Covid about where the centre added value and where it did not add value. I have said we should have a model that I describe as tight and loose, that is, where some issues are at the centre but there is a loose system to let people go and activate, make decisions and innovate. That model is recommended in the model presented to the Government.

The role of the centre, in my view, should be to give value for money, to add value not destroy value and, equally, to promote patient safety and clinical guidelines throughout the six regions. That is what the role of the centre should be and that is based on good practice-----

What Mr. Reid proposed would involve weak RHAs and a strong HSE centre. That is what he proposed. He has always said that. He can give me his opinion and that is fair enough. I am giving my opinion based on what I can see in front of me with my own eyes. There are three options, one of which would set up legal entities, devolve more responsibilities to the regional health areas and create a leaner HSE centre, while another will create a strong HSE centre, with fewer functions and responsibilities given to RHAs. The latter is the one the Government went with and Mr. Reid recommended, but it is not the one, in my view, that Sláintecare had proposed.

Mr. Paul Reid

It is fine that that is the Deputy's opinion and I fully respect that, but it is not factually correct to say that is what I have said. It is not factually correct that the Deputy would represent that I have made a strong pushback or that I would make the case for a bigger, stronger centre. I have never done that.

Mr. Reid has done so, however, by recommending the second option, unless he did not do that. Did he recommend that option?

Mr. Paul Reid

I fully support the-----

Absolutely. Mr. Reid did recommend it. For me, that option is going for a weaker RHA model and a stronger HSE centre, by definition.

Mr. Paul Reid

That is a fair debate-----

That is the Deputy's interpretation only.

Mr. Paul Reid

------but what is not fair is the Deputy characterising what I said as making the case for a big, strong centre and pushback. The Deputy can check the record.

Deputy Colm Burke took the Chair.

Mr. Watt used the term "contract of indefinite duration" in respect of Dr. Tony Holohan. I would like him to send me a note on the contract of indefinite duration he indicated Dr. Holohan will have. Is that okay? Will he send me a note to support what he said earlier?

Mr. Robert Watt

Yes, I will send the Deputy a note on what the position is.

I thank Mr. Watt. I have to say, this session has been really disappointing. The carry-on is unbelievable and very disrespectful to the 12 months of work that was put into developing the Sláintecare plan. More important, it is very disrespectful to the millions of people who look to us, as Members, and to our guests, as civil servants, to run a decent public health service to which they can get timely access.

This would be funny if it were not such a serious issue. Mr. Watt stated the Department is going to take this approach initially and then see how it works out. What on earth is that about? Mr. Reid talked about a "tight and loose" system. Before we come to that, will Mr. Watt outline the status of the selection of the second option? Who has selected it and what is the status of it?

Mr. Robert Watt

This related to options we put to the Government, and we said the second option was the direction of travel. As part of the Government decision and as part of the deliberation of this, we have been charged with establishing all the details of this, which-----

Was a decision taken by the Cabinet to go with the second option?

Mr. Robert Watt

A decision was taken that this would be the direction of travel-----

I do not know what that means. What does it mean? Our guests had been working on this for a long time.

Mr. Robert Watt

In effect, it was the option that found favour-----

Was the option endorsed by the Cabinet?

Mr. Robert Watt

Yes, it was.

It was a Cabinet decision, therefore, that the second option should be chosen. Is that correct?

Mr. Muiris O'Connor

The business case found we would achieve most of the Sláintecare objectives by adopting regions internally within a national health and social care structure-----

I apologise but I am not talking about the business case.

Mr. Muiris O'Connor

It is not a weak interpretation of Sláintecare. The accountabilities, the population-based funding and the integration of care at local level-----

We have heard all that.

Mr. Muiris O'Connor

-----is paramount in our thinking.

Will Mr. Watt clarify whether a Cabinet decision was taken to endorse the second option?

Mr. Robert Watt

Yes, that is my understanding of the position.

I thank Mr. Watt. When the Sláintecare implementation office was stood down, everybody's fear was that we would end up with departmental capture of Sláintecare, and it is clear that is exactly what has happened. There are no grounds for anybody to think things are going to be done any way differently as a result of this. It is just more of the same from the HSE. The problem with the HSE, in terms of a delivery model, is that it is top heavy. It is highly centralised and there is a lack of accountability throughout the health service. There is no line of sight of the massive budgets the HSE gets every year and there is a sense of a black hole within the organisation. What we wanted was a leaner centre, with power, decision-making and accountability devolved to the regions, but what we are getting is a more centralised organisation. At the moment, there is a certain degree of independence for the hospitals and the hospital groups, or for the voluntary ones at least, but if they are to be combined and integrated with the community services, does that mean the HSE centre will now have even wider responsibility and greater control? That is the way I foresee it working.

In case we ever needed an example of what does not work in terms of the centralised nature of the HSE, it is to be found in HR, as anyone working within the health service will attest. It is impossible to recruit a nurse or a doctor because there is this big rigmarole whereby a business case has to be made to the centre, where it is considered, gets lost and comes back down at some point. This is simply not going to work. In light of the fact we did not have the business case and of the fact there is clearly serious concern about our guests' direction of travel, will they give a commitment that they will come back before the committee, after the Easter break, for another session in order that we can properly discuss this? We cannot let this go the way it is going. It is failing the people.

Mr. Paul Reid

I might clarify my perspective on a couple of issues, including when I referred to the concept of "tight and loose". I have worked in change management throughout my career. I have worked in centralisation and decentralisation, in nationalisation and decentralisation, in every kind of model and in very large organisations. There is a concept of "tight and loose", whereby the issues that need to be controlled centrally are kept “tight”, which for me, in this case, relate to patient safety and clinical consistency, while the "loose" refers to devolvement and creating that empowered culture of innovation. It is not a derogatory process at all; rather, it is about reinforcement. One lesson we have learned in the HSE throughout Covid has related to being less in control at the centre and letting the CHOs and the acute hospital systems work together, and that is what has worked-----

That is not what the business case is about. Again, it is black and white.

Will Mr. Watt reply while the Deputy’s time remains?

Mr. Robert Watt

I am very happy to engage with the committee on this and I would be very happy to return to talk about it at a later meeting, and to engage with and hear people's views. As I said earlier, there is a very clear commitment to regional entities, local decision-making, integrated services, geographical spread and a single budget. They are the core principles and I do not think anybody disputes that.

As for the details of how this is phased in over time, I will be very happy to engage with the committee. We have been asked by the Government to develop a detailed plan and to engage with different stakeholders, and we are very happy to do that. I am very happy also to be convinced of an alternative. Everybody wants to get to the same destination, as Mr. Reid articulated.

The Minister for Health signed off on this plan, as we now know.

At our next meeting, we need to decide about bringing Mr. Reid and Mr. Watt back in-----

I would argue the Minister for Health as well-----

I want to ask one last question.

In fairness, there are other people who want to come in as well, so perhaps the Deputy could come in at the end.

Just one thing. Mr. Reid talked about delegating in law. What does he mean by that?

Mr. Paul Reid

I believe it was Deputy Cullinane who spoke of some things, such as not being able to procure. That is legislated for in terms of procurement rules. They can procure locally and continue to do so.

Okay, we will come back.

I am next on the list to ask questions. I will be very brief.

My first question relates to Sláintecare and the implementation of it at a regional level. On the replacement of the independent chair for the consultant contract negotiations, that person retired back in December because they were appointed at High Court. A new chair has not been appointed. We now have a scenario where there are 838 permanent consultant posts vacant. There is a major concern in places like Donegal, Sligo, Mayo and Kerry, where one in four consultant posts is vacant, but are now it at one in two because they cannot get replacements. What is the problem in appointing a new chair? When will it happen?

Mr. Robert Watt

We had a chair who, as the Acting Chair said, was appointed to the High Court. Those talks with the representative bodies did not reach a conclusion and were put in abeyance in December. Since then we have been working with them and the Government-----

There was to be a chair of this independent group. There was to be a chair and the person who retired offered to compile a report to the new person appointed. We are four months down the road-----

Mr. Robert Watt

We have not given any commitment about a new chair, so we do not-----

Is Mr. Watt saying there will not be a chair appointed?

Mr. Robert Watt

We would like the talks to recommence-----

This is not what was said to the medical organisations. This is the first that they heard that a new chair will not be appointed. Will a chair be appointed or not?

Mr. Robert Watt

No, a new chair may not be appointed. We want to engage in the talks and how we engage in them-----

We have moved to a situation in four major medical facilities, namely, Donegal, Sligo, Mayo and Kerry, where they cannot get applicants for jobs. Many of the consultant posts are now one in two. What is Mr. Watt's answer for dealing with that issue? We were talking about Sláintecare in the context of having access to services, no matter what part of the country someone is in. However, people cannot access services and waiting lists are building up

Mr. Robert Watt

As the Acting Chair is aware, the recruitment of consultants is taking place. We have increased the number of consultant roles that are vacant. We would like to accelerate that recruitment and engage more----

But it is not happening. There are no applicants for many of the positions now advertised.

Mr. Robert Watt

In the context of some positions, there are a small number-----

No. There are no applicants in respect of a large number of position.

Mr. Robert Watt

But there-----

A contract is on offer.

What I am saying is that there is no-----

Mr. Robert Watt

The existing contract is on offer.

However, it is not working. There was an independent chair. Now Mr. Watt is telling us he will not appoint an independent chair to deal with this issue.

Mr. Robert Watt

This is an industrial relations. IR, issue. This is an issue of us engaging again with the representative bodies. That process has been ongoing.

It has been four months since the chair. This is the first they have heard that a chair will not be appointed.

Mr. Robert Watt

The process ended in December. We have been engaging with them about a new process and aspects of-----

When we have 838 vacant positions, why does it take four months to talk about a new process, without even talking about-----

Mr. Robert Watt

There is not a consensus around the contract and where we go between the Government side and the representative bodies.

What do we do in the meantime, when we have no consultants, we cannot get surgery done and we cannot get people seen? We will push them all into the major centres like Galway, Limerick, Cork and Dublin.

Mr. Robert Watt

We would like, and the Government said this clearly, to offer a new contract that hopefully will make the consultant posts more attractive, increasing the number of applicants and the number of people who can be taken-----

Mr. Robert Watt

-----but we are not there yet, unfortunately, with the representative bodies.

Can we set a target date so that we will have some progress made on this matter?

Mr. Robert Watt

No, I am not in a position to set a target date.

Is Mr. Watt quite happy to leave 838 posts vacant?

Mr. Robert Watt

That is not what I said.

They are not being filled.

Mr. Robert Watt

There are two separate things here. There is the recruitment of positions-----

Mr. Robert Watt

-----which can be recruited under the existing contract.

However, it is not working.

Mr. Robert Watt

There are many reasons why we cannot fill posts. Attractiveness of the contract is absolutely one of them, but there are other reasons as well, such as the pool applicants, the attractiveness of posts and so on-----

Mr. Robert Watt

-----but they are not exactly the same.

I want to ask one further question on the comment from Mr. Reid about the appointment of 82 assistant directors of public health nursing. That was in his statement earlier. I have the figures for public health nurses. In December 2014 there were 1,450 and in October 2021 there were 1,543. We are now literally going to appoint 82 assistant directors, which is one for every new nurse appointed in six years. Of all the areas of healthcare there is a 27% increase, for example, of doctors, nurses and management, across all systems in the HSE, except public health nursing, which has only increased by 4% in six years. To give an example from Cork city, an elderly gentleman, 80 years of age, was discharged from hospital more than six weeks ago and requires ongoing care. However, a public health nurse has still not called to him. In fairness to her, she is out sick, but there is no one there to step into her shoes. How can Mr. Reid justify appointing 82 assistant directors when we have appointed no additional public health nurses in six years?

Mr. Paul Reid

I will make some comments very briefly on the recruitment of consultants. We have recruited 360 consultants in the past two years, which is the highest level of consultant recruitment we have done in a long period of time. I fully acknowledge the issues that are there; they impact us on recruitment. However, I would just like to say that the past two years has been the highest level of recruitment we have had in many years.

Second, on public health nursing, we hugely value the role of public health nursing. This is part of the model of community health networks and having multidisciplinary integrated teams in the community across a range of network. Part of that is recruiting public health nurses and not just nursing managers. I do not have the full breakdown, but-----

It is a 4% increase in six years.

Mr. Paul Reid

Our total nursing recruitment since January 2020 was about 3,600, of which there are some-----

It is only 4%. I have the figure and there has only been a 4% increase in six years, whereas in every other area it has been 27%.

Ms Anne O'Connor

In terms of the public health nursing and certainly enhanced community care, the structure is one of the challenges we have had. There would be assistant director at a network level who would work as a key team lead for nursing rather than having many individuals. Particularly, we have the integrated care programmes and they would actually co-ordinate activities. That, in effect, would be more attractive for people too - having a structure in each network. It is about developing that structure and having a network where nurses can work within teams with healthcare assistants and other professionals, and the assistant directors will be key to that.

I just want to begin where we left off on 16 February. I had a line of questioning that Mr. Watt and Mr. Reid said on the day they were not too familiar with. On 16 February, the Irish Independent ran a major story to the effect that there were serious morale problems within the HSE because there were people in the very top echelons who had high pay hikes. The paper referenced Mr. Watt's €81,000 pay hike. However, people in middle and senior management grades had not had that. It was seen as being a barrier. How were people to progress Sláintecare when morale was low? At the day, Mr. Watt and Mr. Reid said they had not read the article and did not have the awareness. I ask them both what are the barriers to have the sanctioned pay increases for the management tiers below them? What are the barriers to having that implemented and paid to them? Is that a morale factor in terms of delivering Sláintecare on the ground?

Mr. Paul Reid

I am happy to comment.

I presume Mr. Reid has read the article between February and now.

Mr. Paul Reid

Just to be clear, I did not say last time that I had not read the article. I had. I did not say I had not read it. I can correct the record.

Mr. Reid and Mr. Watt both said they had no awareness of it that day.

Mr. Paul Reid

No, I did not.

I have the minutes here on my screen.

Mr. Paul Reid

The Deputy can check again. Just very briefly, the article refers to Report No. 42, I believe it is referenced as, which goes back to 2007.

This is still a live issue but it is over a long period of time. I have two responses to the questions. First, in terms of the motivation or morale of managers, I have never seen in any organisation the response I have seen from the health service, from managers at senior levels and at all levels, over the past two years in response to Covid-19. While morale is challenged on many different issues, it has not been a factor in terms of management's response over the past two years. Managers at senior level have worked seven days a week, 18 hours a day throughout Covid-19. I want to recognise and thank them for that.

Specifically related to Report No. 42, it is a process which has to be dealt with under the pay bargaining arrangements. We have communicated that to the people involved. I appreciate it is a legacy issue. We are under clear structures in terms of where pay discussions have to take place and in this case, they have to take place in the context of the Building Momentum pay deal.

I would also like Mr. Watt to answer that.

Mr. Robert Watt

I have nothing to add. As Mr. Reid said, there is an IR process and it is a legacy issue but I understand it is being worked through.

Does Mr. Watt believe it is a barrier? If someone has for many years had a pay increase approved and it has not been paid, surely that is a barrier to delivery and affects and impacts on morale?

Mr. Robert Watt

I believe Mr. Reid has touched on the morale question.

I am asking for Mr. Watt's view on it.

Mr. Robert Watt

Mr. Reid mentioned the issue of managers in the HSE and their contribution over the past two years, which has been phenomenal. As I said, there is an IR process and that process has to do its thing.

It is a major factor and I think it needs to be drilled down into by this committee. In the days after I asked that question of hospital groups, I heard many people in management positions, both current and retired, say that this is a major barrier to Sláintecare delivery. Not everything is about how many beds, what trolley capacity and what acute capacity hospitals have. Sometimes a helmsman or helmswoman is needed. If there are morale issues on which those at the helm are supposed to be leading - there are major morale issues that have not been addressed here - then surely that is a factor? We have not gone into that properly today.

There is a lack of clarity in regard to the Government’s arrangements that replaced the Sláintecare implementation advisory council, which was shut down following the resignations of Professor Keane and Ms Magahy in September 2021. The oversight role has effectively been taken out. This is not good corporate governance and it is not in line with best practice. The HSE and the Department of Health overall do not have the best track record when it comes to corporate governance. For example, the HSE was left without an independent board for several years and places on the board comprised, inter alia, senior officials of the Department of Health. It was also chaired by the Secretary General.

We have very little time.

There is a line of questioning I want to pursue.

There are four other speakers and we have 20 minutes.

My time is up then. I did not even get to ask a question.

Mr. Robert Watt

I think the Deputy is asking about the structures of the Sláintecare board. Mr. Reid and I chair that, with the senior teams. As I say, ultimately the extent of progress has to be judged by the delivery of actions and that is the focus. We have published a report, which we have not got to yet, that sets out significant progress. Since this was published and since the last time we met the committee, we published on two significant issues. We have spoken about the RHAs already, on which there are different views, which is good, important, welcome and the way it should be. We also published the waiting list plan, which is a very significant plan on the waiting lists. They were two outstanding issues, on which we were behind.

I am happy to be challenged in six months or a year's time and asked what I have done on this reform agenda. I am happy to be judged on the basis of what we have achieved. This report shows significant achievement in the context of an incredibly challenging time for the health service during the pandemic. I think we have shown great progress. Even in the past few months, we have made progress. Let us see in a year or 18 months' time. If the committee is not convinced that we have made progress, I think it would be legitimate to say that these governance structures are not working, the personnel are not working or whatever, and we should try something different. I am very happy to-----

We will move on to Deputy Kenny.

Mr. Paul Reid

If I may make a point on the board to which Deputy Crowe referred, we now have a board of the HSE which holds us, at senior management level, quite strongly to account. It is a process I value hugely. Before that, if there was not a board, that was a Government decision. It was not a HSE decision.

I want to thank both of the witnesses for answering the questions I did not ask because I did not get to ask any questions. I know the Chairman has a difficult job. With respect to Deputy Shortall, I took it when she had a three or four-minute-----

We have 20 minutes remaining. The next speaker is Deputy Kenny.

We will get there in three month's time again.

The question I want to ask today is on the progress made on Sláintecare and where we are going with the concept of Sláintecare. The vast majority of people in this country want to see a different health system, one that is not inherently unequal as regards public healthcare. What people want is less bureaucracy, more delivery and radical reform. They want public healthcare at their time of need and they want it delivered in a very good fashion. I presume that is what Sláintecare is about, namely, universal healthcare. That is the concept of Sláintecare. Does Mr. Watt believe in that concept and ending the two-tier health system? All the indications in recent years have been that what is being delivered is Sláintecare-lite at best and, at worst, that constant obstacles to reform are being put in place. We need radical reform in our public health service. Does Mr. Watt believe in the concept of Sláintecare?

Mr. Robert Watt

I thank the Deputy for the question. I agree with the objective absolutely, that is, to build a public health system which addresses the two-tier issue and provides the type of healthcare that people want. I absolutely agree with the Deputy and fully support that. Overall, I have set out, as Mr. Reid and our team have previously, our commitment to this. The Deputy and his colleagues will have to judge that on the basis of our delivery. I am happy to be accountable for our delivery and to focus on the things in the report and the discussions we have had, which are the meat of what we are trying to do in the Department of Health and the HSE.

I would argue that there is very significant change, reform and delivery already. Mr. Reid alluded to some of the stuff in regard to community care and the radical changes taking place in terms of what is called "the shift to the left" in the community. There is much more to be done around recruitment and systems, and the RHAs will help in that regard. Overall, however, I am fully supportive of this and I would not have taken on this job or sought it if I was not committed to the reform. Making the health system better for everybody in terms of waiting lists and access to care is what motivates me and my team. I know it is the same for Mr. Reid and his team. That is what motivates us. I am fully committed to this and look forward to driving the change.

Deputy Cullinane mentioned earlier the enthusiasm and excitement for the changes. We are in the same space. My colleagues here are devoting their careers to health and to making this happen. I absolutely and fully support it.

Does Mr. Watt think Sláintecare is on target in relation to the progress envisaged?

Mr. Robert Watt

It is fair to say that it is on target in some respects and clearly not on target in other respects. That is clearly the case. This year, we are going to make significant reform and take further steps on some of the key items. I do not think we will be satisfied about reform in all aspects. Many positive things have happened and are happening in delivering more and better care to people but we need to do better. We are not satisfied. It is fair to say it is mixed and we need to do better this year. This is an important year for the programme.

In regard to private healthcare, there was a report in the weekend newspapers in regard to Larry Goodman's consolidation of three private hospitals. A consolidation of private healthcare does not sit well with anybody who wants to see universal healthcare.

Where does it fit in, in relation to individuals and vested interests in terms of overall public or private healthcare? Where do private individuals making profits out of healthcare sit in the context of the Sláintecare concept? I do not think the two of them fit together. They are antagonistic to each other, even though a lot of people in this country have to turn to private healthcare. Some 50% of people have private health insurance but I do not think it is compatible with Sláintecare.

Mr. Robert Watt

We have a private healthcare system and 45% of the population have private insurance. If we can build a public health system that can meet the needs of the population, I hope over time that people will see the benefits are not there for private insurance as they have thought historically. Ultimately, there is a private system in place. It has been a key part of our system for a long time now and there are entanglements between the private and public system which we have to address and Sláintecare sets out how are going to do that. I think there will always be a private sector. We need to look on it in some ways as something that the public system can access. During the pandemic we have accessed capacity in the private system and through various initiatives we are buying more. That is fine, as long as it is seen as a complement to the public system rather than a substitute for it. We need a public health system that people have confidence in and that delivers for people.

Would he see-----

I am sorry, but the time is up. Could Mr. Reid comment?

Mr. Paul Reid

I will come back on two points, the last one first in terms of public and private. Like everybody, we have all grown up with the public system and as CEO of the HSE, I am absolutely committed to making the public system better, and uniform and consistent. That is why we come to work every day. We do have to be realistic and just say where we are right now. We have to use the capacity that is there in the private system as well, and contract for it. Last week, almost 2,000 bed days were contracted from the private system. That is just a function of where we are at right now, but it is getting people seen at a time when emergency departments in hospitals are under constraints. Could I make two general points briefly on the first set of questions?

Mr. Paul Reid

Like Mr. Watt, I restate all of our commitments to reform. Something that is often missed is the level of reform that happened during Covid. Sometimes we might create the impression that everything was on hold. Pre-Covid, we did not have the number of community intervention teams that we have now. Before Covid, we did not have the chronic disease management teams at the level we have in the community now. We did not have access to diagnostics for 140,000 people by GPs outside of the hospital system, but we do now. We did not have a very different role for the National Ambulance Service, and for treating people at home and enhanced primary care. Likewise, we did not have a universal health service, which we had for vaccination and testing and tracing. We may be part of creating the impression that everything was put on hold, but it was not. I have seen more reform accelerated in the past two years than in the previous five or six years. Some credit must be given to our teams.

Could we move on to Senator Black?

I thank the witnesses very much for their presentations today. In response to Deputy Gino Kenny's question about being on target, Mr. Watt said some parts are on target and others are not. Could he say a little bit more about which parts he thinks are on target and which parts are not?

Mr. Robert Watt

I do not know if the committee wants me to go into too much detail. There are 228 deliverables and 200 of them are on track or are progressed on the basis of the report and 28 deliverables are progressing with significant challenges. We have spoken about some of them, such as waiting lists, removing private care from public hospitals, and Sláintecare in the context of what the Acting Chairman asked about. The areas where there has been significant improvement is the increase in public capacity; the number of beds; the number of people that work in the public system; the streamlining of care pathways that has been talked about and I mentioned the waiting lists. Another critical area is the recruitment for the enhanced community care programme and the different teams that we set up such as the community health networks, the community intervention teams, the chronic disease management teams and the disease programme for older people. From what I see, and from what I am told about every day, this is starting to have an enormous impact in terms of the system. I do not wish to downplay the other issues, because colleagues are working hard on all of them, so it is not fair to say that they are less important but that shift to the left is the biggest change that is happening, which is starting to have an enormous impact now on the health system. Based on the plans that Mr. Reid set out in detail in his opening remarks, by the end of the year we will have further advanced these teams. There has been enormous change, as well as the increase in the public health capacity. It is not as obvious at the moment because we have 1,400 people with Covid and, with the separation of beds, that is having an impact on the reality of the capacity, but if we could get to a post-Covid phase, the initial staff and beds could make a difference in terms of addressing the waiting lists and preparing for next winter where we will clearly have challenges again. I am sorry, as that is a long-winded way of answering Senator Black's question. There are plenty of positives there, but of course there are issues that we need to address.

I thank Mr. Watt. It is good to see the roll-out of the chronic disease management teams, with more than 85% of GPs on board, which is vital to making essential care accessible to people all over the country. However, I worry that fewer than 12% of GPs have opted to provide abortion care to patients. Can lessons from the implementation of Sláintecare be used to try to expand coverage for reproductive healthcare? I would welcome Mr. Watt's thoughts on the matter.

Mr. Robert Watt

There is a review of the operation of the Act, which is ongoing. As part of that review, we are looking at the availability of services across the country. We are looking at the experience of people and the providers and trying to understand exactly the extent to which the system is delivering on the legislation that was passed to give effect to the services following the passing of the referendum. The issue raised by the Senator is part of the ongoing review. I am happy to share the results of that during the year as the work progresses. We have a team set up and there are many different strands to the ongoing review. The lack of availability of services in certain parts of the country is a real concern and it is something the Minister is very keen to focus on and address. That will be part of the review.

I have one final question, because I am aware that I do not have much time. This committee has been engaged with local campaigners who are trying to prevent the closure of the Owenacurra mental health facility. They have highlighted the sparse provision of mental healthcare facilities in east Cork relative to other areas. The report mentions the development of regional health areas to better co-ordinate care. Will these bodies have a role in addressing regional inequalities in service provision?

Mr. Paul Reid

I am happy to take two aspects of the question. In terms of the future, the regions will have devolved responsibilities for mental health services and disability services. There will be some central guidance in terms of standards and clinical governance, but a lot more devolvement at a very high level. As Deputy Shortall stated earlier, it will be worked out on population-based budgets, based on demographics, by looking at the health population in certain regions and allocating budgets on that basis. That is a core principle of the Sláintecare devolvement.

Specifically, on the Owenacurra mental health facility, we are still working with the families involved. It was 11 families, but I think it is down to nine families now that we are still working with in terms of alternative placements.

Will they be placed in-----

I am sorry, but the time is up. In fact, the clock was not put on when Senator Black started, so she got about six minutes and I have two other speakers who wish to ask questions.

I will be as brief as I can. I welcome the team and thank them for their presentations. Mr. Watt talked in his presentation about the population-based approach to service planning and resource allocation. I come from the west, which is part of area F, the region that covers Connacht and Donegal. It is the largest geographical area. Is it purely going to be based on population or will it be based on disadvantage and demographics? It is a large geographical rural area that has a number of services that are spread out and that will require a higher level of investment vis-à-vis the population, if that makes sense.

Mr. Robert Watt

It will be interesting. This is work we are doing now based on the allocation of budgets for this year and next year. What does that actually look like on a per capita basis on the different prospective regions we set out? I do not know the answer to that question. Is broadly the same per capita? You imagine it is since the types of service are broadly the same but there might be differences. In the main, geographically dispersed services cost more so will they cost more? Are they costing more now? I guess they are. Will that be reflected in the allocations? I just do not know. That will be interesting to see. When we move this forward, the question arises as to where we are now and how we allocate budgets into the future. We talk about it on a per capita basis but it involves reflecting the characteristics of each region from a demographic perspective in terms of the demographic profile and how it differs across different regions. Issues around the spatial dimensions of population will also be factors. They must be factored in but I do not know the answer to the question because we have not seen the numbers. It will be interesting to see - we are doing the work this year - exactly what it looks like based on the budget for 2022 and the shadow budget for next year. We do not know the answer to the question but we would be interested in seeing what the numbers actually say.

I am presuming this only involves current budgets, not capital budgets. Capital budgets are in the capital plan are based on need, not per capita. I presume there is no impact there. Certainly in the west, we already have three major projects that are part of the NDP, namely, the new emergency department in University Hospital Galway, the elective hospital at Merlin Park and a cancer care centre for the west. According to the presentation from Professor Michael Kerin last week to Members from the west of Ireland, the west already has the worst cancer outcomes vis-à-vis the rest of the country, which he put down to the lack of investment and the lack of a cancer care centre for the region. I would be concerned to ensure that what Mr. Watt is talking about here does not impact on capital budgets. That capital budget is reflected in what is in the NDP and in respect of need.

Mr. Robert Watt

It will not impact on the capital budget but I presume that since the plan is to ensure that there is a certain level of service in each region, which is comparable across the country, over time the extent to which the quality is the same across the country must be taken into account. As we have our existing capital plans set out in the NDP that are being implemented, it will not affect us directly. Over time, it will affect us as we look across the different regions and see that each region has the type of infrastructure and services it wants. Obviously, infrastructure provision is a key part of that.

If I heard correctly earlier, there will be no boards that are accountable in these areas. What is the thinking behind that in terms of local accountability by having a chair that is accountable on a regional and local basis in a huge geographic area, for example, area F - Connacht and Donegal? Would it not be beneficial to the area in terms of accountability if there was a board? It would be more easily accessible and more easily accountable and could provide information on what is and is not happening in a local area.

Mr. Robert Watt

No, we think a board would be further duplication and is not necessary. There is already a board in the HSE. The CEO is accountable to the board and in turn, the chair and board are accountable to the Minister. Mr. Reid touched on how delegation works and how you manage it but, ultimately, the CEO and head of each region would be accountable to the CEO of the HSE, its board and in turn to the Minister, the Oireachtas and the whole range of accountability mechanisms in place. We do not believe the overall performance would be helped by establishing boards at a regional level.

I want to be one of many to offer my congratulations to the HSE, the Minister's office, everybody involved and those present here today for the work done with regard to Covid. It proves what could and should be done at all times. I believe the next phase is how to superimpose that on the health service and deliverance generally. I have not yet heard that confirmation. To what extent does the superimposition of Sláintecare on the health service manifest itself insofar as the patients are concerned? I hear about what we propose to do by the end of the year but we must have some information to go on as to what has been done and what has been put in place regarding, for example, the hundreds of thousands of patients on waiting lists.

Mr. Robert Watt

We see that this reform programme is improving outcomes for patients. It is improving the number of people being treated and the quality of care they are getting. We need to demonstrate this over the period ahead and we need to demonstrate it in things that matter to people in terms of how long they are waiting, the quality of the care they receive, the performance of emergency departments and their overall satisfaction with the system, which is high but needs to get better.

That is a good answer. If I was sitting on that side of the table, I would consider that to be a very good answer - one that is sufficient to make the committee walk away and say "that's been answered". It has not been answered. In respect of referrals to other jurisdictions etc., to which I am not opposed, has the Department evaluated the extent to which the number of patients on various waiting lists all over the country were being referred this time last year and how many are being referred today?

Mr. Robert Watt

Colleagues in front of me can correct me if I am wrong but about 80,000 people are waiting for day case or inpatient procedures, while around 620,000 or 630,000 people are waiting for outpatient consultations. That is not very different to the numbers this time last year. It is around the same. Every year, about 1.5 million people are expected to come on to the list for outpatient consultations and inpatient procedures. The figure for overall waiting list-related activity this year is projected to be 1.7 million. As the Deputy mentioned earlier, that has been affected by Covid. Things have not improved dramatically over the past year for all the reasons we have spoken about but with the dip in the number of Covid cases and, hopefully, pressure on hospitals easing, we hope we can get back to full electives. With the different measures we put in place, we hope that at the end of the year, the lists will be 18% lower than they were at the beginning of the year.

How can we claim that we are on the road to introducing Sláintecare and that Sláintecare will make an impact on delivery? How do we quantify that when we do not see the results?

Mr. Robert Watt

We will see it in terms of overall activity - emergency department and acute avoidance, reductions in waiting lists and improvements in satisfaction.

We do not see a reduction in waiting lists. The purpose of the exercise has been to introduce Sláintecare as quickly as possible. A number of key people engaged in that have resigned and have been replaced, will be replaced or will not be replaced. We do not know. Tell us all about it. This is a committee of the Houses and it needs to know. When we see public commentary in the newspapers and on television, radio and elsewhere, we do not know the answers to the questions simply because the answers have not been made available to us and every time we ask the questions, we are stonewalled.

The idea was that over time, every moment would be utilised to ensure that Sláintecare was inducted into and became a central part of the HSE's delivery of services. This is not the case. We have been told again that we can wait for another year and we will be evaluate it in a year's time. "No" is the answer to that. It is too late then. We have had this exercise before many times. It is now time to deliver on the issue by superimposing the template of Sláintecare on the HSE's plans and co-ordinating them.

Why is that co-ordination not in place?

Mr. Paul Reid

I will give the Deputy a few examples. He is absolutely correct. The ultimate measure of this is, and should be, what is the public's experience when they come for their care. We should always remind ourselves of that in any reform, one must come from the customers' side, in our case, the patients' side.

I will give the Deputy some specific examples of how we believe the situation has improved. Waiting lists are an issue that is still far too big. I gave some examples earlier. Thankfully, more older persons are receiving care in their homes because of increased hours. It is not as many as we would like but more people are receiving this care. More people are getting their chronic disease and illness managed away from an acute hospital setting. More people, including some 140,000 last year, are going to their GP and getting access to diagnostics without having to be referred to an emergency department. We have put in place more beds. It has been impacted by Covid. Through our National Ambulance Service and various reforms, people have been treated outside of emergency departments. It should not be the default to bring them to an emergency department. We have more multidisciplinary teams caring for people in the community.

On the waiting lists, there are four key strands to our plan to make this better. We had a focused short-term plan in December that reduced the waiting list by 5% in a short period. The first strand is to increase our capacity in the public system, for which we have the investment to do that; second, to utilise the private capacity in the meantime; third, to provide extra funding for the NTPF for certain procedures; and as important is the radical reform of how we deliver care across a range of specialties. We are looking at 37 specialties to see if patient needs can be addressed without having to go to a senior consultant. Are there other roles and responsibilities whereby people can come forward for their care and get it? I reassure the Deputy that will be the ultimate difference from the patients' experience - by radically changing how we are delivering the care.

Does Mr. Watt wish to come in?

Mr. Robert Watt

I do not. I hope we have answered the questions. I think Mr. Reid has answered the Deputy's questions.

The Chairman can ask another question if he wants. I lost time at the beginning.

I am sorry about that. We are ten minutes over time. I thank everyone for coming in. The committee will get back to the witnesses soon with a proposal for them to come back before the committee to go through the issues that were not dealt with this morning, and some of the issues raised about which some members were not happy with the responses they received. I thank all guests here.

I also take on board what Deputy Durkan said about the past two years being a difficult time, and there still are many challenges in healthcare when dealing with Covid and all the other challenges that are present. Again, I thank everyone for their contributions.

We received a message from the Chief Medical Officer that, unfortunately, he was not aware of our request for him to come before the committee. I think there was a communications error. He is available to come in and he will try to come before us tomorrow. The clerk to the committee will come back to us in the coming hours.

Is a time set for that?

The time has not yet been proposed. It will be at a time that will facilitate him and members, and allow members to ask questions of him.

The joint committee adjourned at 12.44 p.m. until 9.30 a. m. on Wednesday, 27 April 2022.