Quarterly Update on Health Issues: Discussion

I welcome the Minister for Health and Children, Deputy Harney, and the chief executive of the Health Service Executive, Professor Brendan Drumm, for a discussion on important health issues. Before we begin, I advise them that, by virtue of section 17(2)(l) of the Defamation Act 2010, witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or persons or entity by name or in such as way a to make him or her or it identifiable.

I welcome our guests. I am conscious that this is probably the last time Professor Drumm will appear before the committee. Members will have valedictory comments to make, but perhaps they will keep them until the end. We have a number of important issues on the agenda and I want to stick as rigidly as possible to the schedule agreed in advance. The Minister will make an opening statement for approximately five minutes and will be followed by Professor Drumm for a further five. We have agreed that Professor Higgins will provide a synopsis of his paper on reconfiguration issues in the Cork-Kerry region which has been circulated to members. We will take questions on his contribution first.

I am pleased to appear before the joint committee and will try to abide by the Chairman's request that I speak for five minutes.

Every developed economy that wants to provide a quality health service for its population is facing financial challenges. Notwithstanding this and comparing like with like, we needed to reduce the HSE's budget in 2010 by €1 billion from the 2009 figure. This posed a major challenge. Some €650 million of the €1 billion is accounted for by pay reductions for staff, while the balance is accounted for by the reorganisation of services and value for money considerations. It is estimated that the reduction in the cost of pharmaceuticals to the health care system, combined with last year's reforms, will save more than €300 million in a full year.

Health service reform is guided by two factors, the first of which is quality. We have established the Health Information and Quality Authority, HIQA, and the current environment is one in which standards and outcomes govern where and how something happens. I am pleased by the considerable improvement in cancer outcomes. The recently published data for the 2002-06 period show an improvement of 10% in breast cancer outcomes on the data for the previous period, a significant improvement by any standard. The same level of improvement applies to lung, prostate and other cancers. We are in a period when standards and regulation drive health reform.

In addition to HIQA and the setting and enforcement of standards, the patient safety commission and my Department are preparing legislation to introduce in 2012 the licensing and accreditation of health providers, beginning with acute hospitals. This will address a major deficit in the regulatory framework. We have also fundamentally changed the manner in which health professionals are regulated. The Medical Council, the health and social care and the pharmacy professions are regulated in a modern context in which professionals are required to maintain their skills. Competence assurance is a statutory requirement for all doctors in Ireland. The regulatory bodies are governed by a lay majority which inspires public confidence and the confidence of the profession.

Given the resource limitations, it is always a question of deciding on priorities. We must ensure we continue to drive for value for money, not only in the manner in which we provide services, but in where they are provided, be it at hospital or community and primary care level. The HSE's national service plan for this year requires it to provide more hospital services on a day case basis and reduce the number of admissions from accident and emergency units to hospitals by 33,000, which will be done by providing access to diagnostics and so on. The greatest transformation is in the move to primary, continuing and community care, as the majority of health needs can be met at that level.

As members may know, the outcomes of the resource allocation group were published last Friday. The group makes interesting and radical suggestions on how to allocate resources. Sometimes we spend a considerable amount of time debating how we can raise resources. Of more significance is the question of how resources are allocated. I hope to take the group's strong recommendations to the Cabinet for a decision in the autumn. I look forward to engaging with the committee on the report, a fantastic piece of work by an independent group chaired by Professor Frances Ruane.

I will limit my comments at this stage and will be delighted to take questions on specifics later.

Professor Brendan Drumm

A number of questions have been asked, most of which have been responded to in writing, but I will comment on a couple of them.

Medical and GP-only medical cards have proved to be significant issues for the committee. As indicated previously, staff working in the primary care reimbursement service, PCRS, which handles the €2.7 billion spent on demand-led schemes have been implementing plans to accelerate the delivery of services and reduce administrative costs. In the few months since we last appeared before the committee considerable progress has been made. The staff respond to the approximately 850 calls received each day in an average of 13 seconds. As members might have seen in the media recently, we have launched the on-line medical card-GP visit card application service. Applications for full cards made through this facility are being responded to and cards can be issued within 15 days if all of the necessary information is provided. This is a major improvement on the traditional approach, in respect of which there could have been a wait of six to 12 weeks. The public can still make inquiries and apply for cards through their local health offices if they choose to do so. However, nine out of every ten applications are straightforward and the on-line process is suitable. It is interesting that in the system's first three weeks of operation there were more than 3,000 applications, approximately 50% of which were made outside normal hours. This shows the appropriateness of our approach.

The second major issue is that of services for people with intellectual disabilities which has been topical recently. The annual HSE budget for disability services is €1.5 billion, of which approximately 80% goes to disability service providers in the voluntary sector. The recent media coverage of services for people with intellectual disabilities has shone a light on how these services are provided through multiple service providers and the costs involved. During 2009 we introduced new service level agreements with service providers, strengthened our relationship with these organisations and clarified their responsibilities. We will shortly be convening a working group which will, in the light of tightening budgets, examine how these service are delivered and how the many service providers might be able to introduce more streamlined processes to ensure they can maintain and increase front-line services. Approximately 280 organisations are involved. The group needs to examine opportunities for merging organisations, removing duplication of back office functions, reducing management structures and amalgamating and rationalising services relating to transport, estates management and maintenance. These changes are never easy and will create many challenges for the staff and managers working in that large number of organisations. However, such changes have been under way in many parts of the health service in recent years. If we can work constructively with the voluntary sector, the changes will present opportunities to ensure a more efficient use of the resources we are spending on these services.

As the Chairman mentioned, this is the last time I will appear before the committee as CEO of the HSE. I can speak for my colleagues in taking the opportunity to thank members for the way in which they engaged in this process. I say a particular word of thanks to the Chairman, as this is often a difficult environment in which to chair proceedings. Without being patronising, he has dealt with us fairly at all times. This is appreciated. While our exchanges have been challenging, it is important that we be held accountable. I have always asserted that we should try to give as much information as possible at these meetings.

Many health services across the world are facing the same challenges, namely, how does one provide more with less money, a question raised by the Minister. There is widespread acceptance internationally that the hospital dominated model of care, a model on which we were focused a number of years ago, is neither desirable for patients nor sustainable. "Sustainable" is a word I often used when starting out. More and more countries are focused on integrating hospital and community-based services to provide a more seamless journey for patients. This is a significant undertaking for Ireland and every other country, but we are well advanced along the road. Everything we will do now will be about integration. At a practical level, this means that, starting from the point of contact with a GP, therapist, consultant or home carer, all services will be funded as a single service. Prior to this, hospital and community services were always competing interests. A single source budget can make a major difference and is already doing so in parts of the country in which there are integrated services. When integrated services are provided, we find that even the staff are generally much happier in terms of their capacity to work for the good of the patient rather than protecting competing parts of the organisational structure. This could never have been achieved under the old model of providing more hospital beds or putting more people into hospitals.

The focus on integration applies equally to modernising personal social services. Areas such as child care have presented major challenges. There have been many arguments about whether they should even be provided through the health service model. If we do provide for proper integration with proper primary care team structures at the front line, this is an ideal structure in which to provide personal social services.

Today thousands of GPs and HSE staff are providing high quality care for almost 2 million people through primary care teams. During the coming years the range of services they provide will expand. We had to start from somewhere. They will continue to grow and become excellent one-stop shops in communities throughout the country. This could never have been achieved overnight; it will constantly evolve. As part of our programme to improve services for people with mental health difficulties, we are also aligning the provision of community mental health services to a greater extent with primary care teams. This is another major change for those who work in our organisation in terms of how they do their work.

Hospital reconfiguration is always challenging but must take place if we reconfigure services. To be fair, leadership has been shown, not only by clinicians and managers in reshaping services, but also by many political representatives in local areas. It has been very constructive in terms of our capacity. Yes, we have had battles about changes to local services, but politically, people have been constructive in engaging with us, discussing our data and, where possible, helping to explain these to local communities. Thanks to the significant leadership shown by many local clinicians and managers, we are reshaping hospital services. The reconfiguration which includes making it easier for community-based professionals to link directly with hospitals and for hospitals to link directly with community services is improving access, quality and convenience for patients. It is taking us in a direction that a few years ago we would never have thought possible. Two of the more advanced areas are Dublin north-east and the mid-west. In the mid-west, with the reconfiguration of services and the creation of a medical assessment unit in Limerick, we have seen a reduction in the number of acute medical admissions. In fact, the medical assessment unit only admits 16% of the patients it sees. We have also seen the establishment of three community intervention teams as part of that reconfiguration, as well as state-of-the-art cardiac intervention services and intensive care centres.

I give full regard to the development of clinical leadership which has been essential in driving change in the health service — health services across the world constantly struggle without it. People such as Professor Higgins are critical in driving change in health services. Significant change can be achieved, not only by doctors but also by nurses, therapists and others leading change. For the first time ever in this country — certainly for the first time in a long time — we have clinical leadership that can bring about that change. It would have been hard to imagine in 2005 that we would have so many clinicians who are active and willing in driving change and who even appear in public to defend it. The implementation of this change can be an example internationally.

We have had to work in a tightening financial environment and I am glad to say we have been able to reduce costs by €1 billion, while still increasing the services we provide. We are providing care for more people than ever before with less money. The building blocks are in place and the HSE is driving what I hope is unstoppable progress towards a fully integrated system, which is the only way forward. The system must be high performance in terms of quality and safety — in fact, quality, safety and effectiveness tend to go together. Actual performance measurement is now central to what this organisation does. Again, this is a major step forward. It will no longer be a case of providing funding for those who shout the loudest.

While solid progress has been made, it would be naive in the extreme for me to believe we do not still have a long way to go. New work practices must be bedded down in a difficult financial and HR environment. However, there is now a groundswell of support among professionals for our goal of achieving an integrated and predominantly community-based health care system. Coupled with the current roll-out of integrated service areas across the country which will empower local ownership, clinical leadership and decision making to areas the size of one to two counties, the HSE can deliver the high quality and consistent service the public deserves. We must remain focused on the need to build a service that is sustainable and designed, first and foremost, to deliver an optimal service for service users, rather than providers. Equally, we must continually and urgently challenge the rate of progress and the motivation of those who resist progress. Real change requires absolute tenacity and does take time. The quick fix approach can no longer be acceptable. For years we wasted huge resources on maintaining a 1950s model of care which seems at times to be still much loved by some professionals from a bygone era.

Ireland is now much more advanced than most countries in developing an integrated health care system. It will be at least another five years before the integrated model of care is fully embedded. Sticking with the change agenda is the vital challenge. There is no doubt that in another five to ten years another change programme will start because medicine is a dynamic process.

I thank Professor Drumm for his remarks.

Professor John Higgins

I will try to provide a synopsis of my report. I was asked to take up the post of director of reconfiguration in early 2009. It was not a post I had sought and I was reluctant, despite what Professor Drumm said about clinicians stepping forward, to take up the offer, as it was a very public role. There was one key thing, however, that gave me the courage to step forward. When I asked whether I would have access to expertise that would not normally be available, including expertise in business, academia and health, which would allow me to take on the role knowing I would be able to consider some of the challenges afresh and from a different viewpoint in finding solutions to the problems, I was told there was support for that concept and I was introduced to a group which was already in existence. It was a group of individuals who were offering their help and expertise in a way that would be useful to the health system. I expanded its membership to include a broader range of experts, particularly from education and health, and the group's first meeting was in September 2009, at which we worked on the terms of reference and decided to meet five or six times a year.

At the time of our first meeting the management structure in the region was changing fundamentally and it took a number of months for us and the new regional management team to clarify how we would work together. However, we have done this and established the group in consultation with the new regional management team, with the regional director of operations joining the non-executive advisory board. We were able to agree a mechanism for the group to play a non-executive advisory role which would feed into the structural and reconfiguration agenda.

The terms of reference of the group are clearly outlined. I emphasise that this is not a decision-making body. It has not played a role in deciding where services should be provided or what services should be provided in a particular hospital. However, it does allow us, as I said, to draw on its members' experience in areas such as change management, cultural change within large organisations and staff motivation, important components of what we need to achieve within our region.

No member of the group receives any remuneration. The members do not receive any payment for the work they do or the advice they give; they do not even receive travel expenses. From our point of view, the fresh ideas and new thinking that they bring are important. I would emphasise that they are only one part of the consultation process that we have undertaken in HSE south, Cork and Kerry. We have a reconfiguration forum that meets fortnightly that includes all the clinical directors, hospital managers, community services, general practice and the university. We have almost 40 sub-groups with 500 members of staff involved in those sub-groups, including a patient advocate on every group.

The consultation we have undertaken has been unprecedented. I would particularly point to the work that we have done in far west Cork in terms of meeting community groups, not just through the normal streams, but through the Irish Farmers Association, Irish Countrywomen's Association, town fetes, secondary schools and primary schools. We have engaged with the population that we serve. This group is one element in what we are doing. It provides an outside expertise. It is a group with real experience. I put on record my thanks to them for the contribution they have made to date and for giving of their time and expertise in what are difficult times for everyone, and they are all busy persons. I am grateful for the contribution they have made, and I think they will continue to make an important contribution as we go forward.

I welcome the delegation. I was just saying before they came in that I hope no one outside this room gets sick this afternoon because it seems all of the experts are in here.

Despite the fact that most times we meet Professor Drumm it is usually in a confrontational arena, on my own behalf I thank him for the contribution he has made over the past number of years. I am sure there have been times when, like ourselves, he asked himself why he got involved in this at all and, equally, there were times when he had great satisfaction. We appreciate his contribution, although we may not often say so.

I return to the question I have been asking since this process began. When will we see the rehabilitation of HSE south? There is a process in place in terms of how we will provide that, but I will link that to St. Mary's Orthopaedic Hospital. That site was earmarked originally for a rehabilitation structure. It is ideally situation, as Professor Drumm will be aware. There is plenty of space, with 36 acres, and it does not suffer from the confines of other campuses in the city. Are we going to see that? When will it happen? I do not think any other campus in the city is better suited.

In linking that in, one of the matters I put down here for question is orthopaedic services in Cork as they will be delivered. We have already had a meeting with Professor Higgins — everyone on that side will be aware of that — and we made these views clear to him as well. In this particular case, it is not simply a matter of being opposed to change or movement. People are quite genuine when it comes to the moving of the orthopaedic services, which is the heavy cutting and lifting end of surgery, into the South Infirmary-Victoria Hospital. In the South Infirmary-Victoria, there are approximately 60 parking spaces of which 40 are for staff and on any given day there is approximately six available to the public. I inquired, and that is my information. Any time I have ever visited anyone in the hospital I have had to park a half-mile down the road. How are we going to get those who have had the heavy-lifting stuff done — I refer to specialised hips, knees, legs, etc. — and who come out in wheelchairs to get into cars which are half a mile down the road? Is the HSE telling me that it will put in a shuttle service? It is the wrong location for that service and the ideal location is where it is at now. Of course, the HSE would have to put in all the different ancillary services. St. Mary's Orthopaedic Hospital should be about orthopaedics and rehabilitation.

I apologise that I will not be able to stay and I must leave again shortly. I take the opportunity to thank Professor Drumm for his service for the past five years and wish him well in his new role.

I just want to make a few quick comments about what the Minister stated, particularly about the cancer statistics which are very welcome but, of course, unrelated to the cancer strategy as they predate it.

Medical cards, their delivery and the access of people to them, are still a major problem, but no doubt Deputy Connaughton will address that in a more comprehensive fashion. I would ask Professor Drumm why it has taken five years to start rationalising the HSE when, in fairness, he identified problems very early on. Would he agree with many — certainly it is my party's view — that child care should go to an agency other than the HSE?

There are more cancelled operations, there is an increase in the number of delayed discharges, which is up 70%, and there are more people lying on trolleys. On these statistics, the reality for people is not the same as the picture often painted by the HSE management or the Minister. The snail's paced development of primary care, and the fact that there are fewer beds and no corresponding increase in primary care capacity to meet that, is, as far as I can see, a self-defeating circle.

There are specific questions I would like to ask. Lest I forget, the third question I tabled is No. 25, to ask the Minister to provide an overview of savings identified by the Minister for Health and Children, Deputy Harney, on foot of instruction by the Minister for Finance, Deputy Brian Lenihan. I am told that the Department of Health and Children will provide a response to this question but I do not see any said response and I have not received one of which I am aware, nor have my policy research people. The Minister might address that because it seems to be a fairly important question to answer.

I will point out a number of matters. The hospital budget has overrun by €112 million in five months. Can I ask about that, and about the Daughters of Charity and the disability respite situation? Can the Minister assure us that there will be no loss of respite?

When will we see, in the case of cystic fibrosis but also in a general sense, a transplant authority, which is essential?

Could the Minister give us an indication of her views on the termination of the medical card scheme and the new tiered card system recommended in the ESRI report? Specifically, could she tell us whether or not she was aware of this group's recommendationvis-à-vis charges as it was rammed through the House last week without a single contributor from Fianna Fáil or the Greens? This expert group states that this will have a detrimental health impact on those on the medical card scheme.

It is important to note that tomorrow is the fifth anniversary of the co-located hospital announcement as the new fast-track mechanism for extra for the health service, and yet we still have not a sod turned or a brick laid, not to mention a bed. Would the Minister or, more importantly, perhaps Professor Drumm, give us some indication on the plans for a reduction in bed numbers in Merlin Park Hospital, particularly in orthopaedics, etc.? I am sure Deputy Connaughton will be more than happy to expand on that with him.

I refer to the cervical cancer vaccine. When will it be rolled out? I advise the Minister to avoid referring to the pilot project relating to 20 schools as representing the roll-out. When can we expect the screening programme relating to bowel cancer to begin?

Have the plans to involve pharmacists with regard to the flu vaccine been advanced? What is the current position in respect of such plans? Is the Minister in a position to provide an update on maternity hospitals, particularly in the context of the misdiagnoses of miscarriages? When will the relevant report be issued?

Will the Minister confirm whether planning permission has been granted in respect of the project relating to the national children's hospital? How long will it take to complete this project? Is the funding relating to this project available or will its successful completion be dependent on a large proportion of voluntary donations? The position with regard to such donations is clearly uncertain at a time such as this.

I am pleased to see so many Oireachtas colleagues present at this meeting. I hope their presence will finally kill off the rumour that we are on holiday. The work we are engaged in today is important and someone must put that point across.

I wish to be associated with the warm welcome extended to the Minister, Deputy Harney, Professor Drumm and their teams. In the event that we do not have time to do so at the conclusion of proceedings, I pay tribute to Professor Drumm. I hope the praise he is going to receive today will not upset him. The offering of such praise probably represents a departure from the norm. Professor Drumm has always attended meetings of the committee and engaged with members. I am aware, from personal experience, that when something has been asked of him, he has generally delivered.

I welcome Professor Drumm's reference to the Chairman, Deputy Ó Fearghaíl. We have wanted to state for some time that the Chairman has been particularly fair to us. We have been afraid to comment on this matter in the event that we might get him into trouble. I say "Well done" to the Chairman.

Deputy Kathleen Lynch referred to Cork on a number of occasions so I presume that means I can refer to Dublin and, in particular, Tallaght, where I live. I put down a number of questions for today in respect of the future delivery of children's services in the Dublin region, the need to restore confidence in Tallaght Hospital and the question of primary care in the Tallaght area. I appreciate the replies I have been given in that regard.

Deputy Reilly already referred to the future delivery of children's services. It is clear that Tallaght Hospital is an important element in the strategy in this regard. I will continue to seek guarantees that if the project at Eccles St. proceeds, funding for the urgent care centre in Tallaght will be front-loaded. That is extremely important.

I challenge the view expressed in respect of overnight beds. This remains an issue in Dublin and the surrounding region. As this is the last occasion on which Professor Drumm will come before the committee, I ask that he comment on this matter of which he has some experience. The need for overnight beds at the new facility in Tallaght remains compelling, particularly in the context of the proposal to move the maternity unit in the Coombe Hospital to Tallaght. Will Professor Drumm and the Minister comment on the up-to-date position on the subject of maternity services moving to Tallaght?

The four Deputies who represent Dublin South-West recently had the opportunity, through the good offices of the chief executive of Tallaght Hospital, to meet the master of the Coombe Hospital. The latter came across as extremely enthusiastic and excited with regard to the prospect of the transfer of services. I am seeking guarantees in this regard, particularly in view of the massive young population in Tallaght and the need for maternity services there and in the overall catchment area. It is important that we continue to exert pressure in respect of this matter.

In recent times, Tallaght garnered much publicity in respect of doctors' letters and X-rays. I do not intent to rub it in but these were issues of concern. GPs and patients in the catchment area were extremely unhappy about this matter. When will Dr. Maurice Hayes's report be forthcoming? The four Deputies who represent the constituency had the opportunity to meet Dr. Hayes and were extremely impressed with regard to the work he is doing.

I was disappointed by the bad news that emerged in recent days to the effect that Professor Kevin Conlon will not remain as CEO of Tallaght Hospital. He is the fifth CEO to work at Tallaght Hospital since it opened 12 years ago. He has made real progress in the past six months. In all the meetings we have had with him, he referred to the future and was very enthusiastic about developments at the hospital. It must be remembered that the hospital does not cater only for Tallaght. Its catchment area stretches all the way to Carnew, on County Wicklow's border with County Wexford. I lament the fact that Professor Conlon is leaving his position and I take this opportunity to pay tribute to him. Has the HSE interacted with the board of Tallaght Hospital in respect of what will happen next? I hope the board will be encouraged to advertise publicly for the position to find someone who will, in conjunction with the HSE and the Department of Health and Children, work to maintain the progress that has been made at the hospital.

Earlier today, the committee met representatives from the Irish Dental Association to discuss the dental treatment services scheme and dental care for medical card holders. I do not intend to ambush our guests in respect of this matter and I am sure they have seen the relevant documents. One of the statements made at this morning's session was to the effect that the HSE's actions in respect of this issue have caused chaos, confusion and hardship to patients and that the Irish Dental Association believes this suffering was entirely avoidable. Will our guests comment on that matter?

Speakers referred to the Irish Pharmacy Union, IPU. I do not want to rake over the coals relating to past issues, I am merely seeking confirmation that relations between the HSE and the IPU are now good and that both are now working satisfactorily on behalf of communities.

Along with Deputy Neville and Senators Prendergast and Mary White, who are present, I am a member of the Sub-Committee on the High Level of Suicide in Irish Society. I am sure the three members to whom I refer may mention this but it is important that our guests, in the context of their remit, should continue to stress that suicide prevention remains a core principle and that it should continue to be examined by the sub-committee to which I refer.

I wish Professor Drumm well. Perhaps he will pass on to his successor the news that the joint committee looks forward to meeting him. We hope Professor Drumm's successor will be just as helpful as he has been.

At least eight other members are offering. In such circumstances I ask that members confine themselves to contributions of two to three minutes each, if possible.

I thank Professor Drumm for his past co-operation and wish him well in the future.

I echo Deputy O'Connor's comments on suicide. Last year, the number of suicides increased by 25%. Recently published figures indicated a rise from 424 in 2008 to 527 last year. We are aware that the real figure is much higher but I do not wish to engage in an argument on that matter. As I stated in the Dáil in recent times, research indicates that in times of recession the incidence of suicide, attempted suicide and self-harm tends to increase. As a result, there is a need to allocate further resources to try to limit the pain experienced by those who commit suicide and their families. The level of self-harm increased by 5% last year, while the number of attempted suicides also rose.

There have been cutbacks in respect of this area. However, I put it to our guests that it is a special area in respect of which a response must be made. A new need exists in this area as a result of our changed circumstances. I have stated on numerous occasions — and I wish to avoid being overly repetitive — that predictions relating to an increase in the number of suicides last year as a result of the recession have been realised. I put it to our guests that there is a case for not reducing the resources relating to suicide prevention. All of the NGOs which operate in this area have been subjected to considerable cutbacks and an argument also exists for not reducing their resources further.

The independent monitoring group recently published its report on psychiatric services in the context of the implementation of the recommendations in A Vision for Change. It is not acceptable that little substantial progress was made in 2009 in implementing the strategy. These are not my words; I am paraphrasing the report. The group especially raised the lack of clarity around a new assistant director for mental health, the lack of authority around this post and the emerging clinical management administrative structure of the HSE, which is totally unacceptable. The new assistant director of mental health is a top class person. I have known him for some time and the committee has met him. There is enormous potential in giving him the opportunity to do what I believe he has the ability, will and energy to do.

The monitoring group expressed frustration and confusion about the constantly changing management structures in the mental health service. It stated that it is difficult for the newly appointed executive clinical directors to carry out their tasks when there is an absence of clarity about their precise role and their relationship with the clinical directors and the management structures of the HSE. It is another damning indictment that the group found an absence of mental health leadership. It criticised the revenue allocation for A Vision for Change in 2009, which was not delivered as promised. It states, "Without this, it is difficult to see how the HSE and the Government can achieve their objective to implement A Vision for Change in full". It criticises the continuing drop in relative expenditure on mental health. In 2009, expenditure was 5.3% of total health funding, which reflected a continued relative increase in recent years. This is the tone of the full report on the delivery of A Vision for Change. I also understand 1,000 staff have been lost across mental health services in the past 18 months. This was stated by the president of the College of Psychiatry of Ireland, Dr. Justin Brophy, at a recent conference. Perhaps the Minister will deal with those two issues.

Representatives of the Irish Dental Association, IDA, appeared before the committee earlier. I ask the officials to read the transcript. They gave us a full report on the circumstances. I read into the record some of the examples of what is happening. A 17-year old girl who requires five fillings prior to commencing orthodontic treatment at Cork Dental Hospital and who was advised by to get the fillings done first was refused. A 72-year old woman needs three fillings replaced. She has Parkinson's disease and tends to fracture her fillings, thus the need to redo these fillings. It was stated as a clinical necessity but it was refused by the HSE.

There has been a change in the cost and procedures to obtain visas for non-consultant hospital doctors. Will Dr. Drumm clarify this?

I welcome the Minister and the HSE officials. I pay tribute, in particular, to Professor Drumm and wish him well in the future. We have had robust exchanges from time to time but he has grown used to that. I will be robust shortly again but I will begin with a nice question. What advice will he give his successor?

I refer to an issue I raised on a number of occasions in recent weeks, which is the reopening of respite services for people with intellectual disabilities in the mid-west. I received an e-mail from the Minister for State, Deputy Moloney, last Thursday, in which he stated, "The Brothers of Charity at yesterday's meeting with Minister Harney and myself indicated that they would work with the HSE to ensure this happens." That is, the reopening of the respite house. I understand the HSE has not engaged with the Brothers of Charity in the mid-west on the basis that officials will not meet its representatives until they say they will reopen the respite house. We all want the house open but everyone at least needs to sit down and talk. If I am wrong about this, please correct me but my understanding is the HSE has laid down this prerequisite to meeting with the Brothers of Charity locally. That house needs to be opened. The two parties need to sit down, identify where the money is coming from and then address the other issues. That is my priority at this meeting. A total of 63 families in the mid-west will not have respite care for four weeks and that needs to be resolved this week. Will the Minister and Professor Drumm ensure that the obstacles are overcome and the two organisations sit down together and sort this out immediately?

There are other issues, one of which is equality in all the regions. Is the moratorium being applied on the same basis in each of the regions with regard to funding for intellectual disability? The moratorium alone has cost the mid-west more than €500,000 and I am not sure it is the same in other regions.

I welcome the report on resources published last week. Will the Croke Park deal help? Will she give an indication of how the measures agreed in the deal will facilitate changing the system and the move towards primary community care and so on? I appreciate that is a broad question but I would like to her to give an outline. The report indicated that we have more than enough private beds in our system and, therefore, why she is going ahead with collocation? It will be five years tomorrow since this policy was announced and not a sod has been turned, as Deputy Reilly said. What is the point? Why is the Minister doing it, especially given that more than 1,000 public beds will be closed this year? We need public, not private, beds. Question No. 18 on page 13 of the report on national issues deals with the extent of bed closures, ward closures and theatre closures in hospitals across the State. We did not get a specific answer on that and the reason given was the HSE could not gather the information. However, is updated information available now?

On the dental issue, the committee was informed earlier that €59.3 million of the €63 million allocated for the scheme has been spent. Is that accurate? If so, how will the medical card dental service be maintained for the rest of the year? The IDA representatives also made the point that 270,000 more people are entitled to participate in the scheme than in 2008, yet dentists are being asked to participate on the basis of the amount allocated in 2008. How can that be done?

Is there any news on the paediatric physiotherapist for the mid-west? The Minister kindly gave me an answer on that but she did not state when the person would be appointed. What is the position on the sun bed legislation? I refer to resources for cancer centres. A problem in Galway was highlighted earlier this week and there have been shortcomings in meeting the indicated timeframes for the various elements of the cancer service.

Legal issues have to be addressed regarding thalidomide sufferers but will the Minister meet the groups representing them to address the issues? HSE officials have visited people's houses but they need to meet the Minister as a group to clarify the issues. They deserve and need the full support of the State and need it to engage fully with them in terms of the issues they have raised.

I have two other questions. One concerns the dignity of patients, in the context of the victims of Dr. Michael Shine, and the other relates to the survivors of symphysiotomy. This committee supports both groups in terms of the need for an inquiry. What progress has been made in that regard?

Finally, I asked about the sexual assault treatment units and why the Limerick statistics were not included and received a written response. There is a sexual assault unit in Limerick, but it is not funded nationally and perhaps that is why it is not included in the statistics. The statistics should be included if we are to have valid statistics for the whole country. I ask that this be addressed.

I welcome the delegation and wish to be associated with the good wishes to Professor Drumm. I wish him well on whatever path he takes now and perhaps our paths may cross again.

I know it is dangerous to lavish praise on somebody, but when I heard Professor John Higgins speak earlier about the non-executive advisory board and reconfiguration in Cork and Kerry, I wondered why we in the north east do not have a Professor John Higgins. If we had that level of engagement and buy-in from all the stakeholders, many of the troubles we have had could have been avoided. His experience teaches us that open, honest and transparent engagement with all the stakeholders works. People respected his clinical experience and bought in to his proposals. He continues to engage and what is being developed will not be anà la carte approach where people can pick the bits they like and leave out the bits they do not like. If only we had an approach like that in my constituency, things might be a little different.

I have a number of questions. I feel passionately about the issues raised by the Irish Motor Neurone Disease Association, members of which spoke to this committee. This small group of people does not face a good outcome, but its members have significant concerns with regard to the treatment and assistance they will require. Can some consideration be given to providing medical cards for these people to enable them obtain the treatment and assistance they deserve?

Representatives of the Irish Dental Association spoke at our meeting this morning. Can we have some clarification with regard to the consultation and engagement that took place with the HSE, officials from the Department and the dentists? It seems to me there was a complete breakdown in communication. This morning, the members of the association indicated they were willing to engage and consult. That offer must be accepted because it appears from listening to them that problems exist in the system. The only way these problems will be solved is if people sit down together and thrash out the issues and try to come to some kind of agreement.

I have said previously that when people gain access to the system, they find treatment is excellent. However, access to the system remains a very significant problem. I will not personalise the issue, but will give an example from my constituency. A constituent of mine who was diagnosed with stomach cancer six weeks ago contacted me because six weeks on this person has got no further than the diagnosis. With each week that passes this person's condition gets worse and a major operation is required. However, the latest news is that there is no bed available either this week or next week. We talk about prioritising people who need urgent treatment. As far as I am concerned, this person is a priority, but yet this person must wait. It is unacceptable that this person must wait so long for treatment while knowing what is growing inside this person's body. I mentioned this to Dr. O'Hanlon earlier and understand that when he was in practice, that would not have happened. He and any other GP would knock down doors to ensure this person got attention. Where are we failing now. Does the problem occur when patients move on from their GP to the next stage? There is a logjam that must be sorted out. The treatment and outcome for such patients is more perilous than if they receive treatment six or eight weeks earlier when their condition is diagnosed.

I am also concerned about the recent position regarding day services for elderly people. The one day a week or a fortnight that many elderly people get in local units is very important from both a medical and social point of view. However, the rumour is that day services will be cut, because this is an easy cut to make. The thinking seems to be that two days a week can be cut off, leaving just a three-day service. This certainly does not prioritise older people. Many of these people live in rural isolation and depend on the service as it is the only day in the week that they get to meet and speak with other people. I mention in particular the Darley day care centre in Cootehill and St. Mary's Hospital in Castleblayney. The people who attend these centres fear their service will be affected. I have said time and again that we must be proactive and inform people of what is happening rather than let rumours take hold. That puts us on the defensive. If we learned nothing else over recent years, we should have learned that the HSE needs to be actively involved in consultation with people in order to stave off the rumour mill. I know we cannot deal with every rumour, but the HSE must be more proactive. There was a complete breakdown in communication between it and the Darley day centre in Cootehill. Service users were told one thing, while service providers seem to have been given different information, thereby creating a dilemma. My interest in this is not in buildings or facilities, but in ensuring the excellent service that is being provided to people continues, because it has a positive effect on their daily lives.

I would like to comment on the situation in Monaghan and the ongoing challenges we face there. I am concerned by the removal of an emergency ambulance from Monaghan to Castleblayney to deal with some of the difficulties arising from the reconfiguration in Louth. This will affect the people who live in north Monaghan where the service was working well. My concern is that the removal of the ambulance will create a dilution of the service. Monaghan hospital is providing a good rehabilitation and step-down service and is full most of the time. However, there is room for enhancement of the services it offers. I would like to see more patients coming back from other hospitals to their home county for rehabilitation. In the context of rehabilitation, perhaps we should consider a centre of excellence in Monaghan hospital. We have the expertise, the space and the capacity. This is something that should be considered as it would relieve pressure in other areas.

A CT scanner is now in place in Monaghan hospital. I have seen it in its room. Now we need to see it up and running. It will help reduce waiting lists for people waiting for vital scans. There is no point in having such a beautiful new machine in a newly decorated room if we do not have the radiologists required. We need this problem sorted so as to get the scanner working as quickly as possible.

I must ask members to stick to just three minutes if possible.

I thank Professor Brendan Drumm for his work with this committee in recent years. I have some questions for Professor Higgins on his advisory group. Were advisory groups available to other reconfiguration programmes throughout the country or was it just to Cork? I am puzzled because reconfiguration is the big buzz word at the moment in all areas of the health services. There have been marches in support of hospitals and people are very concerned. Does the group have a secretary, are minutes recorded and is the group subject to freedom of information? Would it be possible to read the minutes? I am interested to know what sort of an input they have. There is also an issue that information may be advantageous to them from the perspective of having a distinct advantage with a discussion about where services may or may not be based. I ask for clarification of those points.

The moratorium on recruitment of staff and the fact that 120 public health nurses positions are vacant is causing untold hardship in the delivery of primary care. When the Minister was in the Seanad she did not answer any of the questions because of certain actions. Will it be possible to lift the moratorium on recruitment of public health nurses because their role and the work they carry out cannot be replicated? It is vital that the timeframe for child development testing and other functions is maintained or else important pointers will be missed.

Will the Minister comment on the maternity services at South Tipperary General Hospital and the 40% increase in deliveries? Will she comment also on the progress of the review of the decision to close St. Michael's psychiatric unit? I refer to my question about the statement from Mr. John O'Dwyer, the coroner, that nursing homes were transferring patients to hospital when they were near to death. The Minister responded that she had written to Professor Drumm in March to ask the hospitals to include in the protocol an identification to HIQA of any concerns they may have with regard to inappropriate admission or referral trends identified from particular nursing homes. Has there been any response? Would a breach of regulations or standards mean that HIQA could de-register offending nursing homes? What are the legal implications for those patients in homes availing of the fair deal scheme? Could this be a protracted process?

A review of ambulance services was to be carried out. Since 2007 I have been raising the issue of the pre-election promise to provide an ambulance service based in Carrick-on-Suir in County Tipperary. I was expecting that question to be answered on many occasions but as yet it has not been answered. Is it possible to give an answer to this question?

I thank Professor Drumm for his commitment and dedication to improving the health service over the past five years. I wish him a healthy, happy and successful future, wherever that may be. I commend Professor John Higgins. It is very refreshing to see the local leadership he is giving in the southern area. I agree with the Minister in her highlighting of the resource allocation and how it is spent. In my view, far and away the biggest challenge facing us all is how we are going to provide the level of health service we have whatever about an improved health service in the future. I recently met a consultant from London who was prescribing a drug, costing £250,000 per year, for a rare form of cancer. Fortunately, it is a rare form of cancer but this is an example of the challenge we will face. I would like to see our committee addressing the challenges because it does not matter who is in government, the challenges will be the same. It would be interesting for the committee to spend more time addressing how we ensure we can continue to provide the current level of service as well as improving it in the future.

I wish to ask the Minister and Professor Drumm about value for money, comparative analysis between different hospitals and different disciplines and the unit cost of procedures. Is there a variation nationally? What is being done to ensure best practice?

I have two questions arising out of Professor Higgins's contribution. I refer to the role of general practitioners and their relationship with consultants. In my day, they stayed very separate, there was clear demarcation and the consultant, by definition, was a consultant. There was integration in so far as there was tremendous communication between consultants and GPs. It appears to me now that there is not the same level of consultation between them about communications in regard to patients. I highlight the case referred to by my colleague, Deputy Margaret Conlon. The issue of GPs working in hospitals is another issue. It would appear to me there is a very good case for having GPs in accident and emergency departments for a variety of reasons. First, there is a scarcity of non-consultant hospital doctors. Second, there is no continuity and it is more difficult at times of the year such as 1 July and 1 January. Third, GPs have experience.

My other question is whether there is a place for health economics in the undergraduate curriculum. The medical profession in one way or another is responsible for the vast majority of spending in the health services. From what Professor Higgins has said about business experts being brought into the health service, is there a case for having health economics as part of the undergraduate course all the way though university training? This would enable doctors to be better equipped to make important decisions on priority and how money is spent. In my view, this is the real challenge for the future.

My final question is to the Minister and relates to the status of this report of the expert group on resource allocation. What is the next step?

I welcome the Minister and Professor Drumm and his team. I wish Professor Drumm the very best. He is probably going back to the other side now to see what has happened while he was here for a few years. Deputy Jan O'Sullivan asked what advice he would give to his successor. My advice is to tell him to keep away from politicians and, in particular, Opposition politicians.

We will remind the Deputy of that in a year or two.

The Deputy should not start bragging too soon. Is Professor Higgins involved in the reconfiguration in the south east? I know he is involved in Cork and Kerry. Is the model in the Kerry and Cork situation the same for the south east? There is some disquiet in our area in the four hospitals involved, three outside of Ardkeen hospital. This report was expected on 1 February and then it was May and then June and now we have been told it might not be ready for another few months. I ask for an update on the situation.

I welcome the report which shows the health system will achieve €1 billion in savings next year and this is to be commended. I note €650 million will be saved on payroll costs and €350 million on services. Will this mean redundancies or will this €650 million be saved through the moratorium on recruitment? I am delighted to see this kind of money being saved. I just wonder why this was not done long ago. This saving was achieved in the space of one year and there is still talk of an integrated and better service through the roll-out of primary care. How did it take us so long to reach this point? Are the services in place for the roll-out of the primary care programme? I accept that we have made much progress in recent years. It is an ambitious target to reduce the number of people accessing accident and emergency services by 33,000 in the next year. It would be commendable if that target could be reached. If that were the case we would have better health services.

There is a big take-up on the fair deal scheme. Is finance available for the scheme for this year, next year and the following year? It is my understanding that the scheme is working a treat and there is much demand for it.

I too am concerned about cutbacks to the hours of those involved in the home care service, especially in rural areas where carers and home help are so important in terms of keeping people at home and out of the hospital system. Cutting back that service would only result in a short-term gain and a long-term loss.

Like everyone else I wish Professor Drumm well. He had a terrible job but he always approached it with a great degree of honesty. One cannot ask more of anyone than that. I assume history will show that to be the case. He is leaving behind many problems. I do not know who will be able to solve them but that is what we all, collectively, must try to do.

We had a robust discussion on medical cards on two occasions. In fairness, despite the many shortcomings, in my view as a politician it is easier to get through to Finglas than was previously the case. I assume if I can manage to contact the centre then so can many others. I thank those concerned for the work that has been done. However, I have two concerns. I tabled a question in the context of the meeting on when all the applications will go directly to Finglas. The question was not answered, it was side-stepped, but I received a detailed reply of two to three pages on other aspects of the system.

On page 4, number 9, there is a gem; it says that 84% of callers now choose to speak directly to a person. To whom does the Health Service Executive believe they would like to talk? The reason for that is to get over the Goddamn answering machine. As people get older the one thing they despise is to be told to press button one or other option up to ten between research and whatever else, one's date of birth and possibly the name of one's dog by the end of the call. All kinds of useless information is demanded. All a person of a certain age ringing the centre wants is to speak to someone who knows what he or she is talking about who can deal with him or her in an efficient, affable way. From what I can see, it appears that is the road the Health Service Executive is going down. If that is the case then it is the first major step in solving a significant problem.

To return to the issue with which Professor Higgins is concerned, I do not know anything about what he is doing in the Health Service Executive south area but I like what I hear. It was not done in the case of medical cards. Someone decided that the system would be centralised and the problems were allowed to flow afterwards. If the engagement that subsequently took place was carried out prior to the decision and if the HSE could foresee the most common problems, especially as people get older, we would not have got into the current mess. I do not wish to hear from any evaluation officer in the next couple of years that in order to achieve efficiencies there would be a return to the use of answering machines rather than employing a person. I hope I do not hear that in my time in Leinster House because it would signal a return to the old problems. That approach simply will not work.

What is the status between the local offices and the centre in Finglas? Is the work to rule ongoing or is it over now? I would like an indication of the problem areas. I deal with queries all the time, as I am sure do many of my colleagues. It appears that if there are no problems with an application it will be dealt with relatively quickly. The problem arises when something incomplete is spotted on an application and things drag on for months. I know an 83 year old who is now in a nursing home whose medical card has gone over the review date. In spite of everyone's best efforts it took two months for the centre in Finglas to write back to get additional information and even when the information was supplied the man still did not receive his medical card. One can imagine the problems that caused in a nursing home in so far as the visiting doctor and chemist are concerned. That is only one of many cases of which I am aware. The matter is a serious one and whatever else the Health Service Executive has done it has not righted that wrong yet.

A significant problem exists in Galway at the moment where many are concerned about services being removed from Merlin Park Hospital and put into University College Hospital Galway, UCHG. There is a need for a Professor Higgins to handle such issues. Can one imagine how people in Portiuncula Hospital in Ballinasloe feel when they were always told that the centre of excellence was UCHG and that the big operations would be carried out there and the smaller operations that can be done efficiently by smaller hospitals would be carried out in places such as Ballinasloe and Merlin Park? All of a sudden we find that a fairly big chunk of the hospital at Merlin Park is being put into UCHG where one could not swing a cat. The Minister knows that. The hospital is packed. We are delighted we have a centre of excellence in UCHG but the way matters are being handled makes those in smaller hospitals in the adjoining area fear that the same fate awaits them as happened to Merlin Park Hospital, namely, that all the services will be centralised.

I am at a disadvantage sitting down. I would prefer to stand because I feel so passionate and annoyed about the three issues to which I wish to draw attention. Every time one mentions the latest CSO statistics about the 25% increase in suicide in 2009 compared to 2008, people's brains switch off. There is no question that suicide does not register with people, those in the media or the Department because if it did, they would do something about it. Since 2007 the National Suicide Research Foundation has indicated a continuous increase in the number of people deliberately self-harming. We have a crisis in terms of suicide and deliberate self-harm. A total of 80% of those who died last year due to suicide were men. The increase can be attributed to the personal stress caused by socioeconomic circumstances. Stress affects one's marriage and every other area of life.

The State should run an awareness programme on suicide to let people know there is help and that they do not have to keep their problems to themselves. The Department and the Minister must do something about it. I produced a document, entitled What We Can Do About Suicide In The New Ireland, and find it very frustrating that nothing is happening in this regard. Last week's tremendous Civil Partnership and Certain Rights and Obligations of Cohabitants Bill 2009 will help people who are discriminated against because of their sexual orientation. While we have made considerable progress in that regard, I want to shout about the issue of suicide because everyone switches off when one mentions it. We need a national campaign such as the one to lower the number of road deaths. We all know of the tragedy in Donegal the night before last. That said, there has been a focus on road safety. Thirty times more money is spent on road safety than on suicide and self-harm prevention.

Consider my other policy document, A New Approach to Ageing and Ageism. On the issue of ageism against older women, I have raised with the Minister many times the fact that women over 64 do not get free breast screening, despite the fact that one is seven times more likely to get breast cancer if one is 65. Associate professor of gerontology, Des O'Neill, advised me on this when I was doing my research. There are simple steps I would take if I were in the Department of Health and Children or if I were more important politically.

With regard to thalidomide, let me quote a letter I wrote to theIrish Examiner:

There is [universal] support, in the Seanad and Dáil, for the campaign of the thalidomide survivors, but this support must now be met with action. The survivors are owed an apology, appropriate compensation and access to the legal documents of the time.

The survivors did not get adequate support as children and they remain in need today.

This is an issue that can and must be put right. I know the wrong done cannot be undone, but justice can and must be achieved.

I want to speak specifically on the reconfiguration process in so far as it relates to Mallow General Hospital. I will be brief because I realise there are many questions to be answered today. I raised this issue on the Adjournment last week and was given an undertaking by the Minister for Community, Equality and Gaeltacht Affairs, Deputy Carey, that officials would be in touch with me to organise a meeting to discuss the acute services and the reconfiguration process as it pertains to Mallow General Hospital.

I am concerned about the document that is being discussed internally. It relates to ceilings of care, certain protocols and modelling systems that may be put in place by the HSE. As a member of the Mallow General Hospital action committee and a representative of the people of Cork East, I believe this will have an adverse effect on the ability of the hospital to deliver acute services.

Professor John Higgins states the reconfiguration process is about change management. We are all in favour of the change that is necessary. We were given undertakings that there would be no change to acute medical services and that they would be increased. We were told there may be changes with regard to the delivery of accident and emergency services and acute surgical services. The document I put into the public domain last week clearly contradicted that. Trust has broken down. We bought into a process with Professor Higgins whereby we accepted there would be ongoing negotiations with people such as the group I represent. When the document came into my possession last week, it threw that process out the window. Trust must be regained because it has been lost under Professor Higgins and the HSE with regard to the reconfiguration process.

Some members may feel the advisory group comprises a wonderful approach that espouses lateral thinking. However, when a secret advisory group is put in place and people who have bought into the reconfiguration process and who are trying to manage change, such as the people I represent, are not being consulted on that process or the internal document, it makes a mockery of the whole process. I seek a meeting with the head of the HSE and the people who are in charge of reconfiguration at national and local levels. That is all I want.

I am not a member but want to put a few points on record. I wish Professor Drumm all the best in the future. While I may not always have agreed with him or been as nice as I will be today, I will be as straight as I can with him and wish him well. I wish well Mr. Magee who is to take up Mr. Drumm's position. His will be no easy task.

My main reason for being present is to bring to the attention of the Minister, once again, the outstanding case of Mr. Neary and the 35 people who still have not been dealt with. This is not a political issue but an all-party issue that Members want addressed as quickly as possible.

We must reconsider how we deal with the issue of suicide, as raised by Deputy Dan Neville and Senator Mary White. The suicide rate in west Cavan and Leitrim was very serious earlier this year. There is a need for a full and frank debate on it in the Dáil.

I thank my constituency colleague, Deputy Conlon, for raising the issue of the cancer sufferer. Unfortunately, it is not the only case in the area. Professor Drumm, his personnel and the Minister must treat this seriously because we do not have sufficient hospital beds to deal with patients in time. This is very serious.

In another case, the treatment of an individual who had the same health problem I had was postponed for a number of days. Consequently, he passed away for want of a pacemaker. Addressing problems such as this simply cannot be postponed.

With regard to services for the elderly and others, l reiterate what Deputy Conlon said about the Darley day care centre and St. Mary's Hospital. They have provided a tremendous service and should not be the victims of cutbacks. Day care services are very important.

Drumlin House in Cootehill was mentioned on the radio yesterday morning. It deals with young people with mental disabilities. The manager is having serious problems because of cutbacks.

The idea of having integrated hospital and community services sounds great but unless the services are delivered on the ground, they will not work. There are many cases of people being sent home from the rehabilitation centre in Dún Laoghaire without receiving the follow-up treatment they were promised. This is not acceptable and must be dealt with.

We have heard a lot about the reconfiguration of hospitals. In Cavan-Monaghan we have experience of it. We were promised we would lose no service until an equivalent or better one was put in its place, but this did not occur. As for the Cork issue, members should ensure this does not happen in their area because the result of removing services before alternates are in place is nothing short of a disaster and, unfortunately, we have ample proof of that.

I also wish Professor Brendan Drumm well in whatever he does in the future and hope he returns to his primary profession, in which he has great expertise. I refer to the eighth question on bed closures and note that substantial bed closures have taken place throughout the State, including the Mater Hospital. Even day services have been cut in counties Cavan and Monaghan. As this matter has been referred to, I will not elaborate on it but 29 working days have been lost in the Cavan and Monaghan area alone. As for the management of some of these changes, communication in respect of the closure of the accident and emergency service and acute beds in Louth County Hospital was simply non-existent at that time. A leaflet was delivered to people's homes seven days later to explain the closure of the accident and emergency service but it did not deal comprehensively with the issue.

The ambulance service, which obviously is connected and related because it has been transferred from Monaghan to Castleblayney, is to cover both north County Louth and north County Monaghan. I suggest this is an impossibility, given the experience following an incident that happened at a football match at Knockbridge, County Louth, which is just a few miles outside Dundalk. It took one hour for an ambulance to arrive at the scene of the incident. Clearly, that does not constitute an emergency service and, clearly, there are substantial gaps in this regard. While I could spend a substantially longer time addressing the issue of north County Louth, I do not wish to limit discussion to it because much broader issues exist.

The figures provided to members regarding home help appear to indicate an improvement in the service. However, they bear no resemblance to reality as reflected in the representations my colleagues and I receive on this issue. It appears that for every ten minutes' additional time to be given out, ten minutes must be cut from somewhere else. This is the message I have received from local managers and it reflects my experience. The witnesses know as well as do I that society has changed. Population shifts in recent years mean that children do not live as close to their parents as used to be the case and substantial differences arise in this regard. I note the draft guidelines have recommended 7.5 hours per week. They envisage taking ten minutes to get an old person up in the morning, 15 minutes to get him or her showered and ten minutes to get breakfast for him or her. Anyone who believes this to be possible should spend a single morning with a provider of home help and then they would see what the outworking of such times would be.

As for symphysiotomy, I note the Institute of Obstetricians and Gynaecologists is preparing a report and I seek an indication as to when it may be available. I do not place much weight on the report because it constitutes self-policing and self-reporting, which are the worst of bad practices right across the board. While the issue of symphysiotomy must be dealt with, this is not the way to do it. Nevertheless, the witnesses should advise members as to when the report will be complete.

Finally, I refer to Loughloe House in Athlone. This is an institution about which HIQA made 37 recommendations, none of which included closure. I repeat that closure was not suggested at all and although 34 of the aforementioned recommendations have been implemented, it appears as though closure of that house will proceed. I ask the Minister the reason for this. What is the agenda in this regard? While I have an opinion as to what is the agenda——

Does the Deputy refer to Loughloe House?

Yes. It is about privatising the service. I certainly would welcome the Minister's honest reflection on what is the real agenda in this regard.

While I have strong views about the health service, I will not take up people's time this afternoon and it is important to allow the witnesses time to respond. However, I welcome any forum such as this, in which there is some level of accountability in respect of the HSE, because there is none in the Dáil. Nevertheless, I appreciate the comments made by Professor Drumm in his scripted contribution at the outset in which he stated that he welcomed appearing at this forum. I acknowledge that I also consider it to be useful and it is a pity that its time is so tight.

While the Chairman has been lenient in respect of time, I will try to keep within two minutes. I congratulate Professor Drumm on the work he has done to date and wish him well in the future. I will try not to repeat comments made by other members and note that the roll-out of the primary care teams nationwide is the most important matter being undertaken by the Minister at present. As a politician, I would like to be kept up to date with the progress of this process and all politicians nationwide should be kept up to date in this regard. I concur with the points well made by Deputy Connaughton relating to care versus efficiency of service or the most technically important way of doing things. Care in the health service is what most people seek. For example, in the course of the debate between St. Luke's Hospital and St. James's Hospital, the interesting point was made that St. Luke's Hospital is an institution that was put together with love, care and attention. As it now is moving to a highly efficient institution, St. James's Hospital, I hope its caring aspect will not be lost and one must ensure as much is done as can be done.

One area that other members have not discussed is health promotion and preventative health measures. This is an issue that gets missed out on a lot in this sort of discussion. Although one is always talking about fixing people who are not well, it is important to try to ensure people stay as healthy as possible. Consequently, matters such as health promotion, health education and preventative health should never be allowed to fall off the health agenda because the last thing anyone wants is for people to be obliged to enter hospitals when it is unnecessary to so do. Environmental health is another subject into which it is important to put effort. I certainly would welcome the roll-out of the national environmental health action plan. It has not been rolled out and I seek an update as to progress on this issue. As all members are aware, the next budget is approaching and everyone wishes to ensure those who are most vulnerable are not harmed, in so far as possible. As for front-line services, a debate on respite care has been ongoing in my native county of Galway but it is incumbent on all members to try to protect front-line services as the primary issue pertaining to health care in the budget.

The matters covered have been broad and in the relatively short time remaining, it will be virtually impossible to address them all. Perhaps the witnesses could revert to the joint committee in writing on a number of the particular issues. On a personal level, I support the comments made by Deputy Jan O'Sullivan and Senator Mary White regarding the survivors of thalidomide. Those members who have engaged with the very small number of people affected realise they are fundamentally unhappy with the manner in which the issue has been dealt with by the State Claims Agency. I suspect there may be very little between what is on offer and what will satisfy many of those concerned. I ask the Minister to find a way in which to engage on this issue as a matter of some urgency.

The issue of medical cards for those with motor neurone disease has arisen before the joint committee a number of times. It has heard a presentation from the Irish Motor Neurone Disease Association and members are highly conscious that a Member of the Oireachtas suffers from that condition. One matter that was of particular concern to members arose when they heard from the association that some people who had discretionary cards awarded to them subsequently would be subject to a review of that card. Reviewing a medical card that was offered on a discretionary basis to someone who is not going to get better appears to be putting people under unnecessary pressure. I again note this matter pertains to an extremely limited cohort of people and appeal to the Minister to find a way, if possible, to deal with it.

The issue of dental treatment arose on foot of two presentations to the joint committee before lunch today. I commend the Minister and Professor Drumm on their attempts to achieve economies and to reduce costs. They have been highly effective in what they have done in the pharmacy sphere. This also must be done with regard to dental services. However, I do not know how this can be done without engagement and if what members were told today is correct — and I believe that all members accepted what they heard — such engagement has not taken place. It would be preferable to have such engagement first and then decision-making afterwards, rather then having a unilateral decision on the part of the HSE to be followed by a level of engagement. It seems reasonable that if the allocation was set at the 2008 level of €63 million, it should be possible to function fairly effectively. Today, however, we have heard about a plethora of people who cannot receive a service because of the way in which the system operates.

That 280 organisations are working in the disability field is mind-boggling. There must be rationalisation. Each of us has an affinity with some of these organisations and we recognise the value of their work. Cutting front-line services and making the most vulnerable suffer the most when economies must be achieved is something that would have been done in a bygone age and is not acceptable. There must be engagement with service providers which in my constituency have taken cuts and been told to live with them. There has not been the necessary level of engagement.

Deputy Conlon referred to a problem with patient care for cancer sufferers. Like other committee members, I have recently been dealing with young people suffering from eating disorders. As I told my wife a few evenings ago, I hope nothing will happen to any of our children, but I would prefer if they were diagnosed with a well known illness rather than an eating disorder. If one has leukaemia or diabetes, at least there is a treatment path to follow, but there is no such path for those who are unfortunate enough to suffer from life-threatening eating disorders. The battle in which parents and sufferers must engage is often beyond their capacity, given the stresses involved. We need to do something in this respect.

In terms of primary care services, the committee supports wholeheartedly the work the Minister, Professor Drumm and the HSE are doing. It is the way to go, as the redirection of funding and resources towards primary care services is vital. Our report late last year or early this year did not belong to any one individual. There was total ownership by the committee and everyone bought into all of its recommendations. As a Government Member, I was disappointed by recent comments about the report's proposal on incentivisation. Our proposal to incentivise the delivery of primary care centres was based on our belief that, if one was to exploit the full potential of the primary care strategy and achieve the optimum benefit for patients, one would need to bring the health professionals together in a single centre. This could only occur in the current economic climate if there was some form of incentivisation. It is fundamentally wrong to compare incentivisation for primary medical care facilities which benefits society in its entirety with the faults in the incentives provided to build house and apartments. There is no comparison between the two. Having travelled the country to view centres engaging with health professionals, we are convinced there needs to be some form of incentivisation. We proposed to limit the incentivatisation to one health professional per primary care centre but also to prevent the corporatisation of primary care services, something that is under way. Will Professor Drumm assure the committee it is not the HSE's policy to co-operate in the corporatisation of primary health care provision?

It would be a good idea if Mr. Patrick Burke responded to the queries on the medical card since he is our national expert.

The issues raised fall into a number of categories, the broadest of which is resources. We will always operate with limited resources, even during the good times. The challenges we face are faced by every government in the European Union. Last week I attended a Council of Ministers meeting. My colleagues, be they from countries which have health systems funded through taxes such as ours and that of the United Kingdom or that use a different method, are all facing considerable challenges. Among these challenges are the ones raised by Deputy O'Hanlon.

I have been asked how we can afford to provide patients with access to new innovations in medicine which can often be expensive, while maintaining current services. The only way we can meet this significant challenge is by being innovative in the way we provide services and, as Senator Ó Brolcháin mentioned, placing greater emphasis on health as opposed to sickness. We will shortly be tabling proposals on alcohol to the Government, given the problems it causes society. Some 80% of health funding is spent on treating chronic illnesses; therefore, the question is how can we prevent them, identify chronically ill patients and manage them more appropriately. Recently I met many groups with new innovations in monitoring patients at home through central nurse-led stations. Intel is working with St. James's Hospital and others on innovative tools to allow elderly people to be monitored in home settings on a daily, weekly or bi-weekly basis or whatever is appropriate. This is the future, particularly for an ageing society.

I intend to bring the findings of the resource allocation group's report to the Government in the autumn for decision. The strong emphasis in the report is on the procurement of services and the separation of the providers of services from their procurers. The report is neutral as to where services should be procured, provided they are of a high quality. It recommends mainstreaming the National Treatment Purchase Fund, NTPF, which has a good track record in procuring hospital services and, more recently, nursing home services. According to our estimates, we have enough money for the fair deal scheme and its application process has speeded up to just two weeks in many parts of the country, although the period remains somewhat longer elsewhere. We hope to have the timeframe reduced.

I will address the issues raised about Dr. Shine, Dr. Neary, symphysiotomy and thalidomide together. Regarding Dr. Neary, the redress scheme body was chaired by Judge Maureen Harding Clarke who made the report and the Government accepted her recommendation on the close-off date. It was anex gratia payment and there is no question of reopening the scheme. I only want to be honest. I understand one or two cases were not dealt with because they were outside the terms of the scheme but were dealt with confidentially by the State Claims Agency.

I recently asked Judge Thomas Smith to examine the issues concerning Dr. Shine's victims and report to me. He is due to report in the next couple of weeks. He started the report in January and engaged with the representatives of Dr. Shine's victims, Dignity for Patients. When I have the report to hand, I will meet the group again and give it a copy of the report.

An independent report on symphysiotomy practices is under way and everyone conducting the inquiry is from outside Ireland. We asked the Institute of Obstetricians and Gynaecologists to conduct it, but the independent inquiry team is being led by Professor James Dornan from the United Kingdom and comprises people from Scotland and so on. We hope to have the report to hand in the latter half of this year. A case being appealed to the Supreme Court may determine the law also.

Regarding thalidomide, there is a great deal of misunderstanding about the role of the State Claims Agency which was not asked to negotiate with the victims of thalidomide, rather it was asked to make an independent assessment for the Government. Many Governments have been in place since the 1970s when the first settlement was made, but this is the first to reopen the issue. The State Claims Agency's main recommendation and the main request of anyone I have met is that services appropriate to the victims' needs be provided. We have accepted this recommendation. Dr. Paul O'Connell, a rheumatologist at Beaumont Hospital, is involved, while Carmel Buckley, a HSE nurse, will act as co-ordinator for the group. Dr. O'Connell's intention is to assess everyone individually and make recommendations on each person's need requirements. Our commitment as a Government is to meet those requirements.

Another issue the group has raised with me is access to documentation. I remain open to giving the maximum access. I have not seen the documentation but we have asked somebody to assemble it, and that is where it remains. I hope that work can be concluded imminently; in fact, it may be close to being concluded. I see no reason for withholding any documentation from this group and I would not want to see documentation withheld from any group. Why would I? A legal issue has been raised and I am awaiting the Attorney General's opinion on that. I hope to correspond with the group shortly.

When does the Minister think the documents may be released?

I am awaiting the outcome of the trawl that was done to assemble them. That is my understanding. I hope to have a report on that imminently. This matter was on the Adjournment today in the Seanad, where we were dealing with it.

I share the view that there has unfortunately been an increase in suicide rates, particularly among men, and not just young men. I attended the funeral of a 50-year-old friend in the past two weeks. There is no doubt the rates of suicide and self-harm show a major correlation with increasing pressure due to unemployment, financial difficulties, family stress and so on. The Minister of State, Deputy John Moloney, has been active in this regard. I accept that we need to provide more resources, although I am not certain it is just a question of resources. We hear about many instances in which people will not come forward for any service, whether because of the stigma attached to mental illness or the way we deal with mental illness. I recently attended a good conference with Professor Drumm in Kerry at which a service user made the point that when one is in the service, everything one does is related to therapy — that is, art therapy, dance therapy and so on. We need to get rid of the therapy perspective and have a much more normalised service. I thought that person made a great deal of sense. The same man may have appeared before the committee on a number of occasions.

With regard to the stigma attached to mental illness, a major campaign is under way, led by the Minister of State, Deputy Moloney. One of the things I had not realised, for example, is that a person applying for a visa to visit the United States must state whether he or she has ever been mentally ill. There is major stigma associated with mental illness and that feeds into the problem of reluctance among people, particularly men, to come forward for services. It is a journey we have begun in terms of trying to make services more appropriate. That is why primary care is so important.

Senator Prendergast asked me about the psychiatric unit in Clonmel. Everyone in the House signs up to great plans such as A Vision for Change, but when it comes to implementing them on the ground it is a case of "Not for me." The reality is that in Clonmel one is five times more likely to be admitted to an in-patient bed than should be the case. The number of beds there is totally inappropriate to the needs of the area. The €10 million under A Vision for Change will be spent on this area to move from a hospital model to a community-based model, to which we have all signed up. The same applies to long-term care.

My question was not about St. Luke's. It was about the acute psychiatric unit in the general hospital, which is to relocate to Kilkenny.

That is correct.

There was no consultation with local stakeholders and no option appraisal document. There is no difficulty with the implementation of A Vision for Change with regard to St. Luke's——

I am sorry; that is what A Vision for Change is. There is to be a single service between the two hospitals. However, we will differ on that. We have had this debate before and I know the Senator has engaged with the Minister of State in this regard. I do not know whether Professor Drumm is in a position to comment. The €10 million plan for community-based facilities in Clonmel is proceeding, and the quicker the better. This issue is arising around the country as we move towards a community service model. People want community services but they also want to protect what they have. The whole notion is to switch care from hospitals to the community and have a much smaller number of acute psychiatric beds in a small number of hospitals around the country.

It was just that there was no clarity about how the decision was arrived at. There was no problem with A Vision for Change and closing St. Luke's. It is the acute unit in the general hospital that is the problem. There was no review of how the decision was arrived at and announced by Mr. Pat Healy.

With regard to long-term care, HIQA produced a report on Loughloe House, and a number of the recommendations can be implemented, but some cannot be implemented without a new build, which is difficult in the current environment. What concerns patients and their families is the quality of service. It is possible to have a high-quality service in the region — although I accept some people will have to move outside Athlone, which is unfortunate — but the reality is that it is not possible to make that building fit for purpose. Many of our longer-stay facilities, unfortunately, are old workhouses — although I know this is not one of them — and they are just not fit for purpose. The sooner we can have people housed in appropriate accommodation, the better.

When we move on to the licensing of hospitals, we will have the same issues. When it comes to enforcing standards, we all know what the consequences are. Private sector nursing homes have closed too. That will be the future. If facilities in the public or private sector cannot meet the standards we expect for older people, we must either have them refurbished to meet those standards——

In that case they have been met, as the Minister knows. Thirty-four out of 37 recommendations have been implemented.

No, they have not, actually. I had this discussion only last week with representatives from the area.

The great benefit of the Croke Park deal is that it will allow us to move staff from hospitals to the community. We do not have budgets for additionality and sometimes when we want to do something new or different it is a question of obtaining additional resources to make that happen, which leads to a great deal of duplication. One of the main things we need to do in the public health service is to move staff from hospital environments to provide services in a community setting. The agreement facilitates that. It also provides for flexibility and longer working days, and it gives health managers — whether at local or national level — the capacity to drive the kind of change that is necessary.

I see great examples of people driving change. A minor injuries unit of the Mater Hospital opened in Smithfield recently and staff transferred from the hospital to Smithfield. There were no industrial relations issues and it was handled superbly. On some days the staff work in the Smithfield centre and on others they work in the emergency department of the hospital. That sort of flexibility represents the future. Every time one wants to make a change, one is not facing massive industrial relations issues and that is good for patients.

I will let Professor Drumm deal with the issue of dental services. I know the committee is always convinced by groups that come before it, but we also need to use our critical faculties and challenge things when people come before us. Dental services here are very expensive even compared to those across the Border. That is a fact. I am open to consultation. Everybody keeps telling me they are open to consultation but they must accept that we have a limited amount of money. I consulted the Irish Dental Association at a meeting which was, I think, attended by Mr. Burke.

We should not confuse the issue of consultation with that of money. Money is restricted, as it is in virtually every health system across the world for whatever reason. We have capped the money at 2008 levels; I do not think that is unreasonable in the current environment. We are already €10 million ahead of where we were last year at the end of June. I expect to hear that everybody is closing down all over the place; we heard this last year about pharmacies, but there are more pharmacies now than there were this time last year. We need to be more challenging in our discussions. If people are interested in coming to the table on the basis of the budget that is there and having a discussion about how we allocate that budget, I am certainly up for it and I believe the HSE is also.

What did they say about a circular being issued before the criteria were decided upon?

I will let Mr. Burke deal with the circular and whether there was consultation. Sometimes people confuse consultation with agreement.

The circular was sent out before there was any consultation.

We will deal with Mr. Burke in a minute. We will let the Minister continue.

We have a new two-year visa for junior doctors that will exempt them from the requirement for a work permit to work in our system. That was agreed recently with the Department of Justice and Law Reform and the Department of Foreign Affairs.

Last week, along with Deputy Moloney, I met representatives of the Brothers of Charity and we had a good discussion about respite care in Limerick. There is a budget of €25 million. I do not accept that within a budget of that size there would be an issue with €150,000 for respite care. The organisation has properties in the region that I understand will not be used. We had a fruitful discussion and I expect that service to be restored as quickly as possible. I had a letter from Brother Alfred today and I understand the organisation is engaging with the HSE in Limerick — at least, that is what was stated in the letter I received this morning.

Everybody would share members' views about people caring for disabled children at home. We have 5,000 respite places and 42 organisations working in this area. Of these, 40 do not seem to have an issue, while two do. The HSE is working with both of these. We all need to apply innovative solutions. Those who work in the public sector have had their wages cut this year and the same cut was applied to voluntary organisations because they are generally on a par with people who work in the public health service.

Senator White asked about older women and BreastCheck. I look forward to the roll-out of the screening programme for older women. I am advised that while the incidence of disease is higher for older women, the number of fatalities is lower, but that is not to say we should not do it. I would like to see it happen. The next priority is colorectal screening, which will begin on 1 January 2012.

When will the Minister be able to roll it out?

It is a question of resources and it will always be a question of resource priority.

It is about human rights for older women.

Yes, but we have never had a screening programme involving men and the colorectal one——

I am not disregarding that.

On sunbed legislation, the heads of a Bill were cleared by the Government and it will be published later this year. I have dealt with most of the issues.

I want to bring in Professor John Higgins.

I want to ask a very important question. I would like to ask the Minister, on behalf of the Irish Thalidomide Association, if she will meet it as soon as possible.

I met its representative two hours ago.

That is on the margins.

Of course I will meet it.

It really wants to engage with the Minister and to share with her how it feels, from a human point of view.

I understand that but I do not give any false impression of this meeting. The Government has made a decision based on the report. We have to deal with the legal files and other issues, which should be dealt with shortly. I will be very happy to meet the group. I have huge personal sympathy——

When does the Minister think she will be able to meet it?

It would be better if I met it when the decision on the legal matters is made, which will be shortly.

I will bring in Professor Higgins.

Before that, on a point of order I asked many questions which the Minister has not addressed. I had to leave the meeting but I have been back in time to hear her answers and she has not touched on the hospital budget overrun, she has not mentioned the transplant authority, she gave us no answer on her knowledge of the ESRI report on the attitude to prescription charges, she made no comment on collocated hospitals, she told us nothing about Merlin park in Galway and its proposed closure, the cervical cancer vaccine——

We cannot rehearse them all again because——

Can I just——

I would not like to end the season on a contrary note——

That would not be like you.

——in particular given it is Professor Drumm's last week. There is very little point in us asking questions if the Chairman allows the Minister not to answer them and move on because of time constraints.

The Chairman said if questions were not dealt with the Minister had the option to correspond with us, something with which I am comfortable.

A major issue such as collocated hospitals requires an answer here.

Does the Minister wish to take some questions?

I am sure that Deputy Reilly does not like repeating himself and neither do I. Most of the issues were dealt with in the Dáil recently but I will go through them. I received the report from the resource allocation group on Thursday. I dealt with the transplant authority during the recent debate on cystic fibrosis. The HSE is preparing to set up a unit and is currently recruiting the clinical lead for the transplantation programme. On cystic fibrosis, Mr. de Fraine is here from the HSE and is the person responsible for the cystic fibrosis project at St. Vincent's. The offer to the new contractor is optimistic and it has 30 days from last week to respond.

On collocation, I will repeat what I said in the Dáil. We are in a very different environment, as far as banking and construction are concerned. The HSE recently received the application for the Limerick project which clearly has to be evaluated.

While the Minister may not have received the finished report from ESRI until Thursday, does she expect us to believe that she did not know any of its contents prior to that time?

The Deputy can believe me or not but I did not know the recommendation was in it until Thursday night and that is the truth.

Thank you, Minister. We will deal with the reconfiguration issues.

Professor John Higgins

The Chairman asked for a synopsis but I may have veered a little from my text. I want to ensure the text is in the Official Report.

Yes, it has been circulated to members here.

Professor John Higgins

It is a considered response. I understand I was asked to address four items. Deputy Lynch asked about rehabilitation in our region. It was the first priority identified by reconfiguration. Funding was put in place to appoint a locum consultant, who is the first consultant rehabilitation specialist outside Dublin. That post is linked to the national rehabilitation hospital, in keeping with the national strategy document on rehabilitation. That post has been progressed to become a permanent post and will set a model for how rehabilitation is provided nationally outside Dublin because until now the only specialist services have been in Dublin.

The location of the rehabilitation unit which will follow from that appointment is part of what we are working on in terms of reconfiguration. I wish to make a specific point relevant to rehabilitation and the question of the orthopaedic hospital, that is, that there is a general recommendation coming from all the subgroups from within the groups we have set up that individual specialties cannot be provided in the future in isolation from a broad base service that gives a broader repertoire of support. That applies to the orthopaedic hospital. It cannot exist in isolation. There is no back-up for general medicine or anaesthetics when one has an isolated set-up such as that.

That will be going too.

Professor John Higgins

I will finish my point. Likewise, with rehabilitation the subgroup has recommended that it would be better located where there is backup. One can extend that argument — I will not comment on Cappagh. In the South Infirmary-Victoria Hospital we are now aggregating specialties that are complementary, that overlap and together will provide a significant surgical resource which can be supported by anaesthetics and general medicine and can also deliver efficiencies in terms of throughput and treat more patients. We have more than 4,000 patients on waiting lists for orthopaedics in Cork and Kerry. It is a very important service that we have prioritised.

With regard to Senator Prendergast's point, we have minutes of the board meetings which have already been made available to the councillors on the health forum and to anyone who has sought them. It would be reasonable for us to put them up in advance on the website rather than having people seek them, and I am happy to do so.

In terms of non disclosure and conflicts I again emphasis that the group is not in the executive line and has no decision making authority, and that is the context in which we will examine the issues of confidentiality and non-disclosure. It is something on which we will seek further advice.

I was grateful for the flattery about what we have been doing but I was also grateful to Deputy Sherlock for bringing reality to the situation. It is not plain sailing in Cork and Kerry, no more than anywhere else. Deputy Sherlock indicated with some passion his views on Mallow hospital. In this regard I want to absolutely clear. Mallow hospital currently uses approximately 3% to 4% of the hospital budget in Cork and Kerry. However, it sees a significant number, about 2,000, of selected patients with general medical disorders. I must be clear about the document to which Deputy Sherlock referred. It is a draft proposal from a group examining the treatment of patients with acute medical problems nationally. It is a clinician-led group.

The group came to Mallow two weeks ago and met GPs, physicians, anaesthesiologists, surgeons and us under reconfiguration. We gave it a joint agreed response to its proposals. It is part of the answer I would give to Deputy O'Hanlon. The GPs in north Cork were represented in the presentation we made on our proposals to the national group and its draft document. I will make a general point. If we have a clinician-led national agenda there must be room for draft documents. We have to consider proposals. We welcomed the fact that the group came to Mallow and heard a joined-up, agreed response from all of us and it was taken aback that so many parts of the health system in north Cork could make an agreed proposal.

With regard to the services currently in place there is no proposal to remove services until an alternative is in place. That was a commitment we gave and it stands. Mallow is part of six hospitals. They need to function as one hospital system in Cork and Kerry, and we have made clear that we will not withdraw services until alternates are in place. I want to be crystal clear. The population we service in north Cork is important to us, just as in west Cork, the city and Kerry.

The last point to which I return is Deputy O'Hanlon's point about the role of general practice and its relationship with consultants. It is a key component in what we are doing to try to re-establish what was in the past a very close working relationship between general practitioners and the specialists to whom they referred patients. There is work to be done to re-establish the closeness that is now very often only seen in small hospitals. I accept that as a challenge and we are working on it. We have almost 40 working sub-groups, all of which have at least one general practitioner, feeding in a general practice perspective to the reform and the reconfiguration of the hospital system.

We were asked if general practitioners work in hospitals. In certain instances, they do. I wish they worked more, not just in the hospital but particularly in the rural areas where we provide pre-hospital emergency services. A significant number of general practitioners have expertise and training and an interest in being part of the emergency response, and we want to maintain that. If there is a gap between general practitioners and the services provided in a hospital, patients can fall into the gap. That is why we must try to develop national treatment programmes or guidelines — call them what you will — that cross those divides.

On health economics, I was the chair of the curriculum committee in UCC medical school for the past two years. It is one of the areas where we have brought some content into the programme. The president of the American Medical Association visited Ireland twice in the past two years. He is at the end of his career. He made the point that no country can afford to provide all the treatments that are now available to each and every person, but he challenged us, as medics, at the Irish Medical Organisation annual conference to not run away from contributing to the decisions that would have to be made once one accepts that universal rule. In other words, we are placed to make some hard decisions and we, as medics, should not run away from that.

Does Professor Drumm want to address some of the questions?

Professor Brendan Drumm

The Minister has addressed quite a few. Deputy Reilly raised the issue of rationalisation of the HSE. Essentially, the HSE has 4,000 fewer persons doing the same work. It has added developments that Government added in the past five years but it has 4,000 fewer workers than in 2005. It has also operated without a redundancy programme of any kind. There is not a mechanism other than natural movement and retirement of persons in that situation. There is no quick-fix to reducing numbers of staff.

He asked if child care should be under a separate agency. That is a Government policy issue. I mentioned in my opening remarks that it is a considerable broad remit, but if it can be provided, no doubt the primary care team structure, which Deputy Reilly is as aware of as I am, ultimately, is a good mechanism through which some of these services can be provided locally.

I have just been given the accident and emergency figures. We will always have people on trolleys between zero and six hours. Unfortunately, now people are quoting zero. It would be a strange hospital that would not have people on trolleys between zero and six hours, and it would be totally wrong. Such a hospital does not exist anywhere in the world and, certainly should not exist.

Yesterday, the following hospitals had nobody on trolleys beyond six hours: Mullingar, Portlaoise, Tullamore, St. James's, Beaumont, Cavan, Our Lady of Lourdes, Clonmel, Kilkenny, Waterford, Wexford, Cork, Kerry, the South Infirmary, Dooradoyle regional, Letterkenny, Portiuncula, Roscommon and Sligo. If anybody wants to look back at the figures for 2005 and claim that they have not improved, I am happy for anybody to look at that independently and to look at the figures at any stage.

He referred to the snail's pace delivery of primary care. We all would have liked to have seen it delivered instantly. It is a massive change programme.

Nine years, since 2001.

Professor Brendan Drumm

In 2005, we took on ten primary care teams over which nothing had happened for quite a while. We have now moved to a situation where, essentially, we have 1,000 general practitioners signed up to work in teams and doing that. That is a fairly massive change. The world has faced the challenge of bringing general practitioners into primary care team structures. We now have 60 teams building or built, which cover more than 600,000 people in terms of capital infrastructure. There is an intent. All that we need going forward were oversubscribed with persons who wanted to be in primary care centres. We have more than 600,000 people now covered by what is built or being built, contracted and under way.

Professor Brendan Drumm

We have come a long way. The hospital budget overrun of €112 million is much lower than that at the same time in previous years. We are confident about our budgetary situation. In fact, the Vote is not over spent. At this stage of the year our major challenge on hospital budget is in the west. That means the matter must be taken on board because the rest of the country will not bail out the west again. We had considerable problems with that previously and there is a significant degree of unhappiness in terms of how other parts of the country have had previously to move funds there at the end of the year to fund overruns that have not occurred elsewhere. That will be greatly improved upon now that we have an excellent regional director of operations there. We have also appointed a clinician as the manager of the Galway group of hospitals. That is a massive step forward for the west. It is the first time that has been done.

The west of waste.

The west is awake.

Professor Brendan Drumm

That will be a big step forward.

Can we let Professor Drumm finish?

Professor Brendan Drumm

Deputies O'Connor and Reilly raised the issue of the children's hospital. It is the priority set by Government in the capital plan. In terms of the issue of the expense of it, obviously, it is significant. Obviously, that has come down in the present environment but it is still a significant build. For anybody who spent any time walking around either Temple Street Hospital, or, to a lesser degree, Crumlin Hospital, there is no doubt that if this project did not go ahead, one would need overnight, on the demands of Amnesty or another body, to spend at least €200 million on Temple Street and at least €100 million to €150 million on Crumlin and end up with a totally unsatisfactory outcome. In any eventuality, the best option here would be to keep going and there is a significant commitment by the Minister and the Government to that.

Has planning permission been got?

Professor Brendan Drumm

The plan has just been submitted.

It has not been got yet.

Professor Brendan Drumm

The design brief has just been submitted, which is in line with the development board's time lines. Its time lines are being followed.

Deputy O'Connor raised the issue of Tallaght. There certainly is no plan at this point to have overnight beds. There is a commitment to building the ambulatory centre. There will be overnight beds in terms of the new maternity hospital for children because for newborns there will be a neonatal intensive care unit as part of that. On the difficulty delivering on that, Deputy O'Connor is correct that Dr. Chris Fitzpatrick has provided significant clinical leadership in this area. We hope we can find a way to release the funds, between the existing Coombe site and other savings through the joint merger of shared services with Tallaght, so that this can be advanced. It would be a significant step forward. Clinical leadership will be vital in this regard.

Many members referred to suicide prevention. As the Minister stated, any funding which can be found must be invested in this area. Again, however, that is regularly the limitation.

Deputy Neville referred to the independent monitoring group on A Vision for Change. We must accept that every such group has a strong view — in the context of its specific area of competence — and that is to be respected. It is unfortunate that, in the context of the staff who are involved with implementing A Vision for Change, perhaps more focus was not placed on a balanced view of what is actually being done. On the capital side: construction on the Letterkenny acute medical unit has commenced; the residential unit at Ballinasloe will be completed at the end of the year; construction on the Clonmel residential unit is due to commence; construction has already commenced on St. Mary's in Mullingar; work is almost complete on child and adolescent units in Cork and Galway; construction has commenced on the Cherry Orchard child adolescent unit; work is just about to commence at Grangegorman; a contractor for project relating to the acute unit at Beaumont Hospital will be appointed before the end of the year; construction has commenced on the project at St. John's Hospital, Enniscorthy; construction on the Limerick acute mental health unit should commence by quarter four; and the design process for the new acute units at University College Hospital, Galway, and Cork University Hospital has commenced. It is hoped those will all proceed on foot of the sale of lands. A great deal of work is being carried out and we wish progress in respect of these projects was much faster.

With regard to the relationship between the HSE and executive clinical directors, Dr. Justin Brophy is very involved in leading out that process at the postgraduate forum. The appointment of executive clinical directors in mental health is a positive development and I hope that fact will be recognised.

On Deputy Jan O'Sullivan's point, I would be the last man to give advice——

Perhaps we will pass on that one.

Professor Brendan Drumm

Yes, I will refrain from commenting. Perhaps Ms McGuinness will comment on the issue of intellectual disability services in the mid-west.

Ms Laverne McGuinness

The question in that regard was whether there has been any engagement or correspondence in respect of such services in the mid-west. The answer is that there has been. The Deputy is correct in so far as recent engagement had not taken place. They were seeking a commitment that the respite service would be restored. I understand that, as of today, conversations are taking place in that regard. We hope that respite services will be restored immediately because the budget is sufficient to deliver on that. Effectiveness and efficiencies can be achieved in other areas. It is just two services in the country which are stating that they do not have adequate funding to provide——

I was informed that two meetings were cancelled by the HSE because the representatives of the Brothers of Charity would not provide a commitment in advance of those meetings that they would reopen the services. Those involved must come together and make a decision on opening them.

Ms Laverne McGuinness

I have a copy of correspondence exchanged between the HSE's local manager and the Brothers of Charity in advance of this and not just yesterday or the day before. The Deputy is correct that local HSE representatives did not want to meet the Brothers of Charity until they gave a commitment to restore respite services.

Has the position changed? There is no point is setting up a stand-off. Those involved must negotiate.

Ms Laverne McGuinness

Throughout the rest of the country, that is being done. Commitments have been given that they will restore respite services. Discussions are taking place today.

Limerick is the only facility that has been closed. The remainder have not been closed.

Ms Laverne McGuinness

Yes. Discussions are ongoing. I spoke directly to the manager involved and I will discuss the matter with the Deputy after this meeting.

Will Ms McGuinness direct those involved to meet and engage in discussions?

Ms Laverne McGuinness


Mr. Patrick Burke

I will deal with the issue of medical cards, specifically in the context of the issue of motor neurone disease. On the previous occasion on which we came before the committee, representatives of the Irish Medical Organisation, IMO, were also present. It would be fair to state that we were not on the same page in the context of where we then stood. The IMO outlined approximately 17 different issues relating to governance, and so on, which they wanted to be addressed or dealt with before we proceeded further with the roll-out. In the interim, we have engaged in quite a number of useful meetings with the IMO and have agreed a plan to be implemented in conjunction with GPs during the next three to four months.

We are responsible for issuing and reviewing cards. Between GP-visit and ordinary medical cards, there are approximately 1.6 million cards in circulation. So the centre is not always aware of whether someone has special needs. However, GPs are aware of the needs of their patients. We have agreed with them that they will identify such people and ensure that their cases are fast-tracked. In instances where reviews are necessary, the process will be simplified. In the past two weeks we have altered the review process relating to those over 70 and this will now take the form of a simple self-assessment. This will be on the basis that their means will not change. Quite a number of things have happened, even in the past two months.

There is a balance to be struck between working through the review process and issuing cards. Such cards are not issued from slot machines. This year alone we have issued more than 80,000 new medical cards. We have a multichannel approach. As the CEO pointed out, we have launched a new on-line application. In the past three weeks we received 3,500 applications and more than half of these were submitted outside business hours. That is 30% of applicants during the past three weeks.

We also faced a particular challenge in respect telephone calls. We received approximately 6,000 such calls per day and quite a number of these were made by irate clients and customers who rang on several occasions. Our first challenge was to deal with this and we put in place a triage system, which contains a number of layers and which directs people in respect of how they might obtain information relating to their applications. Slowly but surely, we are making progress. The figure for telephone calls currently stands at 80% and we intend to increase this to 100% in the coming weeks. If an individual wishes to discuss a matter with an operator, he or she will — as is the case at present — be dealt with in 13 seconds.

We are of the view that we have dealt with the issues relating to telephone calls and access. In the coming three months, and in conjunction with the IMO, we will have addressed all of the outstanding issues and will be in a position to move forward.

What is the position with regard to local offices? Are disputes at such offices ongoing?

Mr. Patrick Burke

No, there are no disputes. There is a public service agreement in place which provides that the centralisation of medical cards is a key project. We are moving forward with that project. However, we want to address the various governance issues that have been identified and we will do so within two to three months. When they have been addressed, we will deliver the benefits of centralisation nationally.

Can people who experience difficulties still visit their local offices?

Mr. Patrick Burke

Absolutely. That was one of the commitments we gave at the previous meeting, when it was stated that the local offices would act as guardian angels.

Well done on that. What is the position with regard to dental treatment for emergency cases?

Mr. Patrick Burke

When the budget for 2010 was announced in 2009 consultation took place with the Irish Dental Association. At the relevant meeting, the representatives from the Irish Dental Association were privy to and had copies of our correspondence to the Secretary General in which we set out how we intended to move forward. I confirmed that in the past two weeks with the CEO of the association.

I received a direction from the Secretary General to put in place arrangements to manage the scheme within budget and I immediately began to consult principal dental surgeons. I engaged with them on several occasions in January, February and March. On 1 April, I copied a draft of the circular, which we issued four weeks later, to the principal dental surgeons. On 2 April, I received a sign-off in writing to the effect that I had addressed all of their concerns. That circular was issued on 26 April. On that date, I contacted the CEO of the Irish Dental Association to state that I wanted to meet him, within days, to put together teams to work through the implementation process. I also confirmed to him that we intended to review the operation of the new arrangements on a quarterly basis and that we would take cognisance of any feedback the association or others wished to offer in this regard.

In the interim, I have offered, in writing, to meet the principal dental surgeons without either preconditions or prejudice. However, they have a number of preconditions, the basis of which is that there should be no change, that supplementary funding should be provided or that the money should be taken from elsewhere in the HSE's budget. These are not things that are acceptable for any meeting. I do not know the status of this submission to the committee but I know the status of three affidavits I have sworn to the High Court. Everything I said over the past few minutes is contained in them and much more, particularly the exhibits I talked about and the terms of the circular being signed off on 2 April. For someone to say was there was no consultation, in light of all that, is pushing it out. It might be no harm for the committee to have copies of the affidavits because there is useful information in them.

It is difficult for the committee to do its business if any group comes before us and makes categorical statements, irrespective of the fact that we outline to witnesses at the commencement of meetings that they have privilege. Now that we are telling them they have absolute privilege, one would hope that no group would abuse that by putting information into the public arena that is at variance with the facts. That is something to which the committee will have to return.

As a committee, we also need to use our own rationale. We have to be able to make a judgment call ourselves.

We make judgment calls on the facts.

But these are not facts. The facts have proven to be different. The Deputy is always willing to believe the other side.

Perhaps this is a matter for us to discuss in private. I thank Mr. Burke for his clarification.

Mr. Patrick Burke

The HSE is quite willing at any time to meet the IDA to discuss the implementation of the new arrangements. We are mandated to deliver a service within the 2008 budget. Fees have dropped since 2008 and we believe we can deliver the same level of service as in 2008. We have on the record several times indicated our willingness to meet the IDA without preconditions to work through the implementation and to provide clarification. There are certain temporal clarifications that one cannot put into a policy that deals with a €63 million allocation for a scheme in two pages. Over the years, policy statements issue and there is always ongoing dialogue and meetings with groups.

Earlier I said I find myself at a disadvantage when a group appears before the committee and makes a statement but nobody is present from the other side, as Deputy Reilly described, to help us with the information. Perhaps it is something we need to consider.

People in the deputation were employed by the HSE.

But we did not hear anything back.

They were not representing the HSE.

Is it fair to say there was consultation in advance of issuing the circular?

Mr. Patrick Burke

Yes, the lead representatives of the people referred to by the Deputy signed off in writing that the circular that issued, a draft of which they had on 1 April, did not change between that and 26 April. It is an exhibit to the affidavit, which says I had met all of their major concerns.

We have heard both sides and it is up to us to make up our own minds. I have made mine up.


Ms Laverne McGuinness

Anybody who was there was present in his or her capacity in the union rather than as staff of the HSE.

I am aware of that.

I made a reasonable point and the committee needs to examine it again.

We do but it would be preferable if the dental body and the HSE had the engagement suggested by Deputy O'Hanlon earlier and resolved the matter.

Can Mr. Burke address the motor neurone issue?

Mr. Patrick Burke

Over the next three months, the arrangements we have put in place to deal with the 17 issues raised, including for individuals with special needs who may get a letter from the HSE saying their card will be reviewed in three months, are that we will make the GP aware of that in advance. We have other more constructive proposals which have been received well by the IMO. The organisation must give us feedback on the specifics but the position is we are moving down the correct road.

We will move to concluding remarks but it would be a pity if Mr. de Freine did not have an opportunity to comment on St. Vincent's Hospital.

Mr. Paul de Freine

I will quickly summarise the position on the new ward block. The plan is to provide a ward block containing 100 inpatient beds plus a dedicated day unit for patients with cystic fibrosis, CF, and other ancillary accommodation. The recently completed ambulatory block in the hospital provides accommodation that is also for the use of CF patients.

Will the 100 beds be specifically for CF patients?

Mr. Paul de Freine

That decision is to be made by the management board.

What is anticipated?

Mr. Paul de Freine

As I understand it, there is a ten-bedded unit for the day treatment of CF patients and there is a proposal to have one of the five 20-bedded wards given to the use of CF patients but all the beds with the 100-bed complement are to be designed to the same standards. Four beds per ward will be isolation beds, which will provide an even higher standard of accommodation.

Are these all in separate rooms?

Mr. Paul de Freine

Absolutely. They are replacement beds to replace existing beds that do not meet current standards within the hospital.

With regard to the 120 vacant posts for public health nurses, will the moratorium be lifted to help the people being affected by it?

Before we proceed with concluding remarks, will Professor Drumm address any outstanding issues?

Professor Brendan Drumm

The NCHD issue is not all about recruitment and immigration. Ireland produced 318 Irish medical graduates in 2004-05. We will produce 430 EU graduates next year, 542 the following year and the intake last year, which will emerge in four years, was 651. Ireland's problem with medical graduates going forward will not be a shortage. This is the most massive increase in intake.

With regard to general practice and corporatisation, if anything, it needs to go in the opposite direction because Ireland will have so many of its own doctors looking for work that——

Yes, but will they be working for themselves, the HSE or a corporate body?

Professor Brendan Drumm

We will work with any process or incentivisation the Government decides to put in place to get the centres built.

I refer to a number of outstanding issues, which can be addressed in writing, relating to the ambulance service in the north east and home help service. Can I get an assurance that will happen?

We will get a written response.

Is the orthopaedic-stroke unit in Merlin Park Hospital closing or not? It is a matter of grave concern and I would like an answer before the meeting concludes. That is not unreasonable. I also asked about influenza vaccines being administered by pharmacists but that was not addressed by the Minister or Professor Drumm. I also sought a maternity hospital update and asked about the misdiagnosis scandal and that was not addressed either.

There are outstanding issues relating to small groups of individuals who have been seriously affected by our health service and who still seek resolution of their issue. They include the thalidomide group, the symphysiotomy group and the victims of Dr. Shine, Dignity for Patients. I also refer to the gross unfairness meted out to patients who suffered at the hands of Dr. Neary. Purely on age grounds, they will not be compensated, even though they had some of the most serious injuries and insults inflicted on them. We will have to look at that again.

We did not touch on the issue of discretionary cards for the terminally ill. There was a time when these were nearly automatically provided. Now, people are being put through the wringer to get them and often have passed away by the time they do. On a more positive note, both the committee and I visited the primary care centre in Mitchelstown. This is the way forward. Professor Higgins has moved his entire ante-natal care practice there, including obstetrics. The centre is an excellent model that should be pursued elsewhere. The Minister talks about the national treatment purchase fund, NTPF, in glowing terms. Last year some €90 million was spent treating 28,000 patients, most of whom did not require major surgery, whereas the North of Ireland cleared a list of 57,000 patients for £36 million.

I must mention Loughloe House, which I visited with Senator McFadden. The quality of service there, as adjudged by the people who use it, was excellent. The HIQA had reservations about management and staffing levels there, which are matters for the HSE. However, we have been told the facility is not fit for purpose. Is it true it is to be modified to turn it into a mental health facility? When will a decision be made with regard to the move of the Central Mental Hospital to Portrane and the sale of its land? Will the Minister respond in writing to me with regard to when the decision will be made on that? What moneys will be raised from the sale of lands this year?

Did Professor Drumm say we would have a huge psychiatric unit at Beaumont? Planning permission for that has been compromised by the proposal for a new co-located hospital there, so how can it go ahead if that is the case? Perhaps this is an admission by the Minister that we will get a psychiatric unit for real patients rather than pie in the sky. I would welcome that.

The Deputy should visit the site. He needs to go out and to look at the hospital.

The co-located hospital impinges on the same site. Therefore, unless the Minister applied for further planning permission, the original planning permission was compromised. That I know.

Professor Drumm mentioned shorter waiting times of from nought to six hours around the country, but we believe what we see. We walk into hospitals like Beaumont and see patients lying on trolleys for two, three or four days. I can attest to that. The same is true for Drogheda. He also alluded to 1,000 GPs being part of teams. These are virtual teams, but we want to see real additional services through new primary care units, as promised nine years ago.

I am delighted Mr. Burke has made some changes with regard to the over-70s. This will make their lot easier in terms of their concerns about their medical cards.

I thank the members of the delegation for their responses. My main bone of contention is the respite services. Am I correct in my understanding that Ms McGuinness will ensure a meeting will be held between the HSE and the Brothers of Charity in Limerick to resolve the issue? Will she assure me they will sit down and discuss the issue, without preconditions?

Ms Laverne McGuinness

I spoke to the managers yesterday, but have not had any conversation with the brothers yet.

That is welcome. I hope the centre will be open before the end of the week.

I am speaking on behalf of the Labour Party. Senator Prendergast raised the issue of the moratorium on the recruitment of public health nurses. We need enough nurses to ensure the service can be delivered. I am aware, for example, that developmental tests have been delayed because public health nurses have been so busy, partly because of the administration of the H1N1 vaccine. Cervical screening is another issue. I urge the Minister and the HSE to be conscious of these issues. Senator Prendergast is also concerned about south Tipperary maternity services.

The Chairman made a strong defence of the committee's report on primary care and raised the issue of corporatisation. Our concern is that developers or people with money will build these centres and hire them out to GPs. That is not what we have in mind. We feel that people working in the service, whether as private or public health practitioners, should have control of these facilities. That is my understanding of the Chair's concern with regard to corporate control, although perhaps I should let him fight his own battles. However, he is fighting the battle on behalf of the committee, which had strong feelings on this issue, right across the political spectrum. I also welcome the progress made with regard to medical cards because we took on this issue in the committee and took a cross-party position on it.

I am concerned about the mention made by the Minister of registration of hospitals before the end of the year. I am pleased this will happen, but have a concern. It is very easy for private hospitals to cherry-pick their patients and the issues with which they will deal. Therefore, it will probably be easy for them to satisfy registration requirements, because they will only do what is profitable and what they can do within the rules. However, public hospitals must, whether they like it or not, deal with everybody who comes in the door. I am aware the Minister does not like the word "resource", but can we have a commitment that a public hospital that has a statutory duty to look after everybody in the community will not be disadvantaged in comparison to private hospitals? Will she assure us that private hospitals will not just be allowed to do all the nice bits while public hospitals are left with tougher and sicker patients? We need to consider the situation before we end up in a position where we in the Opposition are told that we are not standing up for a quality service. We want the public health service to be raised to the quality required in order to ensure public hospitals can be registered.

Once again, I thank Professor Drumm for his assistance and wish him the best of luck.

Does the Minister wish to respond?

I am not in a position to break the moratorium. The health service must, as part of the public service, meet the numbers required. There is no ban on recruitment in a particular group. It is a question of reducing numbers overall, but where there are priorities, the HSE is in a position to address them within the overall numbers, including particular types of nurses.

The flu vaccine is mainly administered by GPs. I favour pharmacists being involved and last week launched an initiative for Boots where, under the patient group directive and beginning this coming winter, it will provide the flu vaccine. It will be a matter for patients or the HSE, if it wants to procure services, to decide whether to use pharmacists, based on quality and price. With regard to the National Treatment Purchase Fund, Deputy Reilly will be aware that the Comptroller and Auditor General has looked at its cost base. Comparing like with like, the NPTF compares very favourably with HIPE. Deputy Reilly compared NTPF costs with costs in Northern Ireland. With regard to out-of-hours treatment, we pay €108 million for such treatment for 1.6 million people, whereas in Northern Ireland, treatment for the same number of people costs only £18 million. Unfortunately, we do not compare favourably with Northern Ireland across many headings in the health area. We need to reduce our cost base and get it much closer to the kind of costs they have in Northern Ireland.

No reduction in charges for five years.

I have not received any support from Deputy Reilly when I have been reducing costs.

We do our best and support the Minister when it is appropriate.

Even in the Deputy's favourite health system, dental care is restricted. Everybody understands that money is limited and we must use the money we have to deliver the best possible care we can.

On licensing and accreditation, we hope the draft standards will be published by the HIQA this summer and that we will have the heads of the Bill later this year. We are talking 2012 for the system. We could not begin it now because hospitals and other facilities need time to prepare. It will not happen next year. We are working towards a timeframe of 2012, but will publish the draft heads for consultation. The HIQA will publish the draft standards this summer.

I think I have dealt with most of the issues raised, although I am aware Deputy Reilly thinks I never deal with his.

What about the Merlin Park issue?

Professor Drumm will deal with that. I would like to pay personal tribute to Professor Drumm as this is his last meeting here. He has been a breath of fresh air in the public health system. Unlike many people who ran the health service in the past, he did not complain about resources. He was driven by quality and the new clinical leadership that has emerged owes a lot to him. We see the evidence of that in Professor Higgins. I wish we had a Professor Higgins everywhere in the country. Perhaps it is his Northern Ireland blood that gives him the stamina for the job. He is doing a terrific job. In fairness, there are also many other excellent people in the service throughout the country. Great clinical leadership has emerged and we all owe a great deal of gratitude to Professor Drumm for the outstanding public service he has given in reforming the health services over the past five years.

Well done.

Professor Brendan Drumm

My colleague, Ms Laverne McGuinness, will deal with the question about Merlin Park.

Ms Laverne McGuinness

Merlin Park hospital is part of the Galway university hospital. We have spoken about budgets. Merlin Park and University College Hospital are the hospitals with most over-expenditure in the country at this stage. As part of the rationalisation to ensure they come back to budget this year, a number of services are being amalgamated. It is intended that orthopaedic services will be one of the services that could be rationalised at UCH rather than in Merlin Park, in a measure of effectiveness and efficiencies. Discussions have taken place with clinicians. A range of other measures will happen over a number of sites, including Portiuncula and Roscommon, as we move forward, in order to bring Galway back in line with the rest of the country.

Will the stroke unit be moved out?

Ms Laverne McGuinness

I am not sure about the stroke unit. I will have to come back to the Deputy on that question.

Professor Brendan Drumm

There have been many comments about clinical leadership. The north east made the first start when there was very little clinical leadership anywhere. It is very important for me to acknowledge the difficulty of that situation. However, Dr. Colm Quigley, former president of the Irish Medical Council, came to the north east from the south east and Ms Eilís McGovern, the current president of the Royal College of Surgeons in Ireland, did tremendous work on clinical leadership. Little by little it became possible for locally-based people to take up the mantle. I refer to James Hayes in Cavan and Cavan-Monaghan has been less problematic in recent times. I wish to acknowledge the tremendous work of Dr. Dominic Ó Brannagáin in the Louth-Meath area. I am sure Deputy Reilly will allow me say this about accident and emergency departments. I acknowledge some of them have had chronic problems but the vast majority have done very well. Drogheda, in particular, had huge problems. I do not think any hospital in the country has been criticised more than Our Lady of Lourdes Hospital, Drogheda, over the years. There are many reasons for this. However, in the past couple of months, there have been no patients waiting on trolleys. This is due to the tremendous efforts of staff. I wish to acknowledge this effort on behalf of the HSE. Clinical leadership has been the cause of this turnaround.

I thank the committee members for their comments.

On behalf of the members I thank Professor Drumm for his five years of service. At that time he took on what looked like being probably the most challenging position in the Irish public service. That took courage and it probably took more courage to stay with the position over the past five years. It has been very turbulent. I think history will record that he led the service through significant positive change and the nation owes him a large debt of gratitude. His successor will have big shoes to fill. We wish him well but we wish Professor Drumm success in whatever course he decides to follow. I thank him for his courtesy over the years.

The joint committee adjourned at 5.35 p.m. until 3 p.m. on Tuesday, 27 July 2010.