Quarterly Update on Health Issues: Discussion with Minister for Health and Children and HSE

I welcome the Minister for Health and Children, Deputy Mary Harney, and Mr. Cathal Magee, CEO, Health Service Executive and their officials. We can extend a special welcome to Mr. Cathal Magee because he is with us for the first time and, as a committee, we all wish him well with the onerous responsibilities he has taken on board.

Mr. Cathal Magee

Thank you, Chairman.

I wish to advise that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. If witnesses are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him or her identifiable. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given, and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise, comment on or make charges against any person or entity by name or in such as way as to make him or her identifiable. I ask everyone present to make sure their mobile telephones are turned off.

We will follow the agreed and now standard timetable, with opening statements from the Minister and Mr. Magee of about five minutes duration, after which we will ask the party spokespersons for their comments and then to the general membership of the committee.

I welcome the Minister once again and ask her to start proceedings.

I thank the Chairman. It is a great pleasure to be here at the Joint Committee on Health and Children for one of our quarterly meetings. I am pleased to be joined for the first time by the new chief executive officer of the HSE, Cathal Magee, and his team. I will make a few short opening remarks because I know the committee members are often more interested in the question-and-answer session.

There has never been a more important time to have an overall perspective of health in Ireland. I was presenting health awards yesterday and one of the winners had a project entitled Balance Matters. Balance does matter. In terms of the health of our population, Ireland is among the top 10% of countries in the world. Our health is better than that of 5 billion other people. Between 1996 and 2008 we added four years to the average life expectancy, the fastest growth in the OECD. We have also seen major improvements in infant mortality, with the rate halved since 1990, to 3.1 deaths per thousand. That puts us in a better position than the US, Canada, Germany, the UK, the Netherlands and many other countries.

There have been major improvements in hospital-acquired infection rates over the last four years. The winner of the health awards yesterday was Wexford General Hospital, which improved its infection rate from 9% in 2007 to 4.4% in 2009, not by using additional resources but by applying innovation and change and taking a focused approach. I would like to single out the hospital in this regard as it was an outstanding achievement.

Our cancer outcomes have shown major improvements. For example, the survival rate from breast cancer has risen from 74.2% to 80.6%, representing an additional six women out of 100 who would not otherwise have survived, while the survival rate for prostate cancer has risen from 77.6% to 87.2%. There have been significant improvements in the outcomes for all cancers. With the establishment of the cancer control programme that has been in operation for the last number of years in eight designated centres around the country, with a focus on multi-disciplinary care and higher patient volumes, we will see further dramatic improvements over the years ahead.

I am sure much of the focus of the committee will be on the four-year plan and the fact that the public health sector will see a reduction of more than €1.4 billion in spending over the next four years, which be front-loaded next year with a cut of almost €750 million. Since 2001, spending on health has more than doubled. The fastest increase in public spending in Ireland since 2000 has been on health, at 186%, and the second fastest in social welfare, at about 160%. Members will see that documented in the plan. We have seen a major increase in the amount of public money devoted to health and, contrary to the perception of some, the proportion of money spent on health from the public purse has increased quite dramatically over the same period, from 71% to 77%. In the 1990s the proportion was 71.5%, and by 2008 this had risen to 76.9%, although it was higher in 2000. We are spending about 12% of our national income on health. In terms of US dollars and purchasing power parity, this represents $3,793 per capita as against an OECD average of $3,010. Thus, in terms of spending, we are at the top end.

The focus now is on reducing cost, as it has been for the last number of years. Next year we must take more than €740 million from the cost of funding ourselves, in the context of an ageing population and all the resulting pressures on the health system. Yet we must continue with reform. It is not a question of putting reform on hold simply because the resources have been reduced. There has never been a more important time to continue with the reform programme, not just in the area of cancer services but also in day-case activity in our hospitals and community-based services. The eligibility of our citizens for health care based on ability to pay must also be reformed.

The resource allocation group recently recommended a new way of allocating resources. Sometimes we concentrate on how the money is raised, but this is not the relevant issue. There is a finite amount of money and the issue is how to allocate it, whether it is raised from private health insurance, taxation, social insurance, or a combination of these. The resource allocation group made a number of key recommendations, one of which was on the funding of hospitals. It recommended that we move to what is called prospective funding, and we hope to begin this next year. That is one of the things I will be asking the HSE to do in the context of improving its service plan, beginning with orthopaedic procedures, which would be the easiest place to start the prospective payment system.

As members are aware, in recent years we have moved into the provision of home supports for older and dependent people, including home care packages, and we have further to go in this regard. The fair deal scheme is strongly supported by older people and their families. Almost 13,000 people have now availed of the scheme, which provides equity for those in public and private nursing homes. Everybody has a standardised assessment of need and everybody's means are assessed on the same basis so that, depending on their means, they get the same level of support. This has, for the first time, brought equity to the provision of long-term care for older people. Heretofore, those in public nursing homes had 90% of their care costs met by the Exchequer, while for those in private nursing homes only 40% of the care cost was met. This was inequitable and highly unfair to older people and their families. We have heard horrific stories of children and other family members having to remortgage houses or take out large loans in order to pay for their relatives' care. The point has been made to me that this support, which is fair and well received by older people and their families, is not available on the same basis outside the residential setting and that we should apply something similar to home care packages. In the context of the plan, we have committed to expanding the fair deal scheme into community settings based on the notion of having a tiered level of support along the lines of the recommendations from the resource allocation group.

In view of the projected reduction of €745 million in the HSE's budget, the emphasis in the plan for next year must be on those that supply goods and services to the HSE. The HSE procures approximately €5 billion worth of goods and services on an annual basis and I expect to see the bulk of the reduction coming from that source, and also from reductions in staff as a result of the incentivised early exit packages. It is too early to say how many people will leave the HSE because those who have applied have until the end of November to finalise their applications or withdraw from the process. However, this scheme, together with the retirement of 1,500 people next year, will reduce the HSE's pay bill. The HSE also spends about €1 billion on non-core pay, including agency, on-call and overtime workers. Central to the Croke Park agreement is the development of a working environment that is more flexible, progressive and modern, with a strong emphasis on redeployment, longer working days, five-over-seven-day working and so on. I hope the central features of that agreement, which allow for us to introduce modern practices within the public health system, will reduce that bill of €1 billion and help with the funding issues faced by the HSE not just next year but over the next four years.

I thank the Minister. I call on Mr. Magee.

Mr. Cathal Magee

I thank the Chairman. I introduce my colleagues, Ms Laverne McGuinness, director with responsibility for integrated services and Dr. Barry White, director of quality and clinical care. I am joined also by Mr. Brian Gilroy who has direct responsibility for reconfiguration and Mr. Martin Rogan, assistant director with responsibility for mental health.

Prior to this meeting the committee requested information and replies on a wide range of issues and members will have received written replies to all these questions. Accordingly, in my opening statement, I shall comment briefly on three areas, namely, our service activity levels in 2010, our financial outlook for the current year and our service and financial plans for 2011. The 2011 service plan was framed in the context of a reduction in the overall financial resources available to the HSE. Despite the reduced funding the HSE committed to deliver the same level of service as was provided in 2009 and is achieving this target for the year to date, as of 31 October. This includes delivering services to more than 1.2 million in-patient and day cases.

I wish to highlight some key performance outcomes, as of 31 October. At the end of September our day case activity was 6.7% ahead of the 2010 plan and 9.7% ahead of our activity at the end of September 2009. Our in-patient activity was 8.4% ahead of 2010, and 1.2% reduced on our activity of 2009 which is in line with the direction to reduce the level of in-patient care and to migrate to a higher level of day case activity.

Our emergency admissions, at 275,000, are 11.2% higher than our target, an increase of 0.7% on emergency admissions for the same period last year. More than 2.6 million people have attended our outpatient services so far this year, 3.2% ahead of the 2010 plan and 5.2% ahead of 2009. More than 9,600 home care packages were delivered to people, representing an increase of 0.5% for 2010 and 9% more than at this time last year. In home help hours we are 5.3% behind our 2010 target of 12 million home help hours, down 6% on the home help hours delivered at the end of September 2009. There are 5,600 children in care, 92% of whom are allocated social workers, an improvement on the figure of 86% this time last year. It is fair to say, therefore, that even though there has been a significant reduction in available resources and funding the level of activity in our health system increased significantly in 2010 as compared to 2009.

In terms of financial outlook we are on target to achieve a break-even against the revenue budget for 2010. The mix is somewhat different but this follows significant cost restructuring during the course of the year. There is a substantial shortfall in the health levy collection which may require a Supplementary Estimate. It should be noted that the health levy collections, although attributed to the HSE Vote, are not under the direct control of the HSE. With regard to the capital programme, with the exception of ICT capital and a shortfall in the disposal of mental health lands, the HSE expects to complete its capital programme for 2010.

Deputy Kathleen Lynch: Will Mr. Magee please repeat the last sentence?

Mr. Cathal Magee

With the exception of the spend on ICT, namely, information and communications technology, and the shortfall in the funding that was to be created through the sale of mental health property and lands, which is behind plan, we expect to complete the capital or building programme the end of the year. Mr. Brian Gilroy, who is director with responsibility for our estates and capital programme can add to this at a later stage.

We will come back to that later. Mr. Magee should continue.

Mr. Cathal Magee

We are currently in the process of developing our national service plan for 2011 which will be the first year of the HSE corporate plan cycle. We anticipate that 2011 will be an extremely challenging year, given the funding decisions announced yesterday. In quarter 1 we will begin work on the three-year multiannual corporate plan and obviously will need to align that plan with the Government's announced four year plan and funding estimates. There is benefit at least in that we have clarity on both the capital and the funding sides regarding potential financial scenarios over the coming four years. In addition, the moratorium on recruitment will impact on our capacity to achieve certain service objectives being developed for our 2011 plan. Within the overall manpower resource constraints we are seeking further flexibility in key areas of recruitment to maintain our service levels. Mental health services are one example of where this approach has allowed some flexibility in our response as we remain within the financial parameters. We may need further such flexibility. Other flexibility was found in regard to the recruitment of additional social workers which is currently under way.

In regard to the HSE's financial plan for 2011, our key area focus will be to drive out costs that do not have a direct impact on services, minimising the impact on services, and to optimise our collection of income to offset the impact of these funding reductions. As the Minister stated, specific area focus will include targeting significant reductions in our non-pay expenditure, in particular, across our general supplier base. This includes reducing costs in areas such as medical and surgical supplies, utilities, legal services, transport, travel, a whole range of office expenses and equipment and all other supplies. Discussions are under way already with a significant number of suppliers as part of our major supplier engagement. There will be a particular focus on the cost of drugs. We spent more than €2.2 billion on drugs and although much progress has been made in the area of generic drugs we are focusing in particular on the cost of patent drugs. Discussions are under way with our clinicians and with the industry with a view to achieving significant reductions in expenditure in this area in 2011.

Improving our performance in income generation and collection in private patient billing will also be a key priority in 2011. On pay, an important element of the cost reduction programme will be our incentivised exit schemes which are currently under way. The purpose of this programme is to achieve a permanent reduction in the numbers of management, administration and support staff with effect from 1 January 2011. We have received 3,775 applications for both schemes but it is important to point out that applicants have the option to withdraw by the end of this month. Given the tight timelines for application and the uncertainty in the economy we can expect withdrawals from this number.

In a table in my opening statement I set out the analysis of the applications across each region, splitting them between management, administration and general support. I also outlined the breakdown of the impact in terms of applications from our senior management grades, in particular, of three senior grades, namely, assistant national director, general manager and Grade eight staff. Members will see that the level of applications represents very significant percentage reductions on the manpower levels in these areas. Accelerated exit programmes obviously involve a degree of risk in terms of their immediate impact on both administrative functions and services, as gaps emerge when managers and staff depart in various locations. However, it is important to balance such risks with the imperative to reduce pay roll costs in 2011, quickly and effectively. A series of contingency plans is being drawn up with a view to dealing with the gaps that will appear when significant numbers of staff exit at the end of December 2010. There will be a need to simplify and streamline our management and administrative structures, particularly to reduce the number of hierarchical levels in the system. We will work closely with staff and representative bodies under the Croke Park agreement to meet and deliver on this challenge. We will need a more flexible, innovative and solutions-driven administrative and management culture, with greater levels of output based productivity to ensure we can continue to deliver high quality support services.

I commend the staff working in our health and social care services for their commitment and contribution, and particularly for their efforts to deliver the service plan targets in a difficult environment. Yesterday we held our achievement awards in the Mansion House and it is great to see the level of commitment from staff to the improvement of services despite the funding constraints in the system.

We will stick to the protocol of five minutes for questions from spokespersons and four minutes from others. That way everyone can participate.

I welcome the Minister and her team from the Department and the HSE. I apologise for missing the Minister's opening remarks but I was caught on the radio.

There are good things here that I welcome, particularly the opening up of the GMS list to allow GPs to set up in practice when they have the necessary qualifications. There is a manpower crisis and that is an important way of removing a barrier. I also welcome the charging of the full costs of private beds to insurers in the public system.

What about Letterkenny General Hospital? It is a regional hospital but it is classed by the Department as a local hospital, causing a loss of €2 million that could provide vital services, including cardiology and stenting, preventing the necessity for people to travel to Dublin to have stents put in. Other services could also be put in place.

The major question relates to the €440 million in savings. Where is the split between procurement and demand-led schemes? There is no breakdown between the two and the schemes in question are not named. I presume we are talking about the GMS medical card scheme, the drugs scheme and the long-term illness scheme. I would like, however, a specific answer that breaks the areas down. A reduction in the number of in-patient beds was mentioned but could we have the specific number and the remaining number in the system?

It would be appropriate at this point to mention collocation. It was supposed to give us additional capacity but it has not delivered anything. Could we get confirmation that the scheme is now null and void and will deliver anything in any meaningful way in the near future?

I have met Mr. Magee before and I wish him well in the difficult job he has taken on.

The reduction in staff by 6,000 between 2010 and 2014 was mentioned. I wish Mr. Magee every success in his new job, it is an unenviable task but essential to the future of the health service. Does that reduction include the 3,000 who have already applied, not withstanding the fact that some could withdraw their applications? Are we only looking for another 3,000 in the next four years? That does not sound very ambitious and will not save as much money as we need to save.

There is language about medical card patients that suggests there could be cuts to access to GPs and-or medication. Will the Minister outline her plans for these vulnerable people?

I have a letter from the hospital in Navan. Are we going to consider that today or is that for another day?

If the Deputy wishes, he can cover it but he must do it within the five minute timeframe.

What are the plans for Navan Hospital in light of recent reports that there will be a ten man surgical team to cover the three hospitals in the north-east, between Our Lady of Lourdes Hospital, Navan Hospital and Louth General Hospital? I am given to understand there are five non-consultant hospital doctors needed in Beaumont Hospital in the accident and emergency ward and that there are no NCHDs for the anaesthetic service in Navan Hospital, with the resulting service implications. What is the Minister doing about the pending non-consultant hospital doctor crisis we face?

The Minister has put aside €450 million for the funding for the national children's hospital, €50 million from the HSE and €400 million from the Department. Is that included in the Estimates or must it be borrowed? If it must be borrowed, no one is lending to us at present so is it realistic?

Is the funding for the cystic fibrosis unit at St. Vincent's Hospital in place and will that project go ahead on schedule after all the delays we have seen? Given that we have such high unemployment, is there a provisional sum set aside for more medical cards for those who find themselves unemployed?

I welcome the Minister and her team and Mr. Magee and his team and wish Mr. Magee well in his difficult but hopefully productive post.

I thank Mr. Magee for the breakdown of the various areas under the voluntary and early retirement schemes and the four year plan. It is welcome that many of them are in the grades we want to lose, assistant national directors, general managers and grade eights. I am concerned, however, about the geographical distribution. HSE west has a large number and that area is already finding it difficult to provide front line services in the current situation. Will particular regions be assisted or will they lose more because more people applied? How will it be spread out fairly in terms of the delivery of frontline services?

I welcome the proposals to collect the actual costs from private patients in public hospitals. It was highlighted that HSE west had not collected all of the money owed by private insurers. Has that money now been collected and will it help with service delivery? What are the plans to ensure money is collected from private health insurers in a timely fashion?

Dr. Reilly asked about the breakdown of the figures on page 126 of the four year plan. I am concerned about the demand-led schemes. Will there be less money for fair deal, for medical card schemes and for home helps? Vote 39 for child care and youth services covers organisations like the Brothers of Charity who deliver a service to people with disabilities and other vulnerable groups. Will those groups be given enough money to run their services? I wish to highlight a local organisation, Headway, in Limerick which is providing a tremendous service. I visited its clients who are very concerned that its funding might be cut back. The service is vital for those living with brain injury.

Will the Minister and her colleagues consider getting rid of the moratorium on recruitment because it is having a detrimental effect on service, particularly nurses and other allied professionals? We met with the Irish Nurses and Midwives Association who told us that 850 nurses are due to retire in 2011. The mental health nurses service has lost a huge number of nurses. Given that 2,100 posts are gone already through the moratorium on recruitment and that more than 3,300 people have made application for the two schemes, that takes us over the 5,000 staff number identified in the Croke Park agreement. In terms of front line services it is important to look at the moratorium on recruitment - I would like to see it gone.

There are two issues about which I am very concerned because I think there is a privatisation of services due to the moratorium on recruitment. The HSE has invited submissions from interested parties for the provision of recruitment services for short-term temporary agency placements in categories like nurses, locum doctors, health and social care assistants, allied health professionals, NCHDs etc. Effectively, this is privatising the administration of employment in the Health Service Executive. I know why it is being done - it is because it is not allowed recruit people.

An article in the Irish Medical Times of 19 November states that the HSE is setting up a framework agreement with external companies for the provision of a managed service for community nursing units because of the current staff embargo. This is essentially privatising what should be done within the HSE. We in the Labour Party are very much against that approach. Perhaps the Minister will respond to that issue.

I am also concerned about mental health. A delegation from the mental health sector has requested, by letter to the Minister dated 22 October, a meeting with the Minister and the HSE. Will the Minister and the HSE meet the delegation? Will the Minister clarify the discrepancy between the HSE's stated spending on mental health care in its annual service plan circa €700 million and the Department's figure of €977 million? Mr. Martin Rogan, who is present, brought to our attention the fact that spending on mental health is down to 5.3% of the budget. That needs to be protected and we need to ensure there is no further erosion of the mental health budget. I am concerned that children and adolescents will not end up in adult wards. That is a particular problem in Limerick.

I ask the Deputy to conclude as soon as possible.

In the Mid-Western Regional Hospital in Limerick, I am aware the Crystal Care unit is going ahead and I welcome it but there is scope for the accident and emergency department on the ground floor of that building. I ask the Minister to consider funding that. On the issue of home help hours I have tabled a written parliamentary question. I am concerned that Mr. Magee has said the number of hours is not up to the level expected. Finally, four months have elapsed since the thalidomide group was told it could get the redacted report on individual cases etc. Will the Minister give the group that documentation?

A vote has been called in the House. I suggest we suspend pending the completion of the vote.

May I make a few comments as the Joint Committee on Foreign Affairs is meeting at 11 a.m.?

I compliment the Minister on the work she has been doing. Very often the debate is about individual incidents and we lose sight of the excellent work that has been done, to which she referred. I welcome the chief executive officer of the Health Service Executive, Mr. Cathal Magee, and wish him a successful and pleasant time with the HSE. The figures he read out for the service activity levels are very impressive. Why are the figures going up for hospital activity? It appears to me that there is a communications problem between consultants and non-consultant hospital doctors within the hospitals and also a serious communications problem between the GPs and the consultants and the NCHDs which, if addressed, would certainly improve the figures because I believe more patients should be seen outside.

I am impressed with the statement that one of the key areas of focus has been to drive out cost that does not have a direct impact on services. Is there any comparative analysis between similar disciplines in different hospitals around the country with a view to finding best practice in the interests of quality and level of service and also of cost efficiency?

Finally, in regard to the different areas where the HSE sees an opportunity to reduce costs, I note the inclusion of transport. Apart from the acute ambulance service, all other transport should be integrated under some new arrangement such as a voluntary funded transport and there is an opportunity now to do that.

I thank Deputy O'Hanlon.

Sitting suspended at 10.45 a.m. and resumed at 11.03 a.m.

We will resume proceedings. We heard Deputy O'Hanlon's contribution and the next contributor is Deputy Kathleen Lynch.

I welcome the Minister and Mr. Magee. Given that they are both here, I am inclined to ask the question: "Who is looking after the shop?", but that is beside the point. I have asked that question many times.

I have three questions but I would like to refer briefly to a matter, about which Deputy O'Sullivan spoke, the moratorium on recruitment. As my party's spokesperson on equality, I believe that women, given that most nurses are female and that there are also a few female doctors, should be exempt from the moratorium because it is women who have babies. It is not as if that applies equally to both genders. I am serious about this; I am not being flippant. A moratorium on recruitment weighs more heavily on women than it does on men because women are not replaced when they go on maternity leave. That issue might be examined for the future.

I have three questions, one of which concerns a local service. I refer to the waiting time for an assessment for and the fitting of a hearing aid in the audiology service in Cork city. A reply I received states that the average waiting time is 39 weeks following referral, the waiting time for a hearing assessment is between one and 24 months and that no one is waiting longer than between one and four months for the fitting of a hearing aid. I am always reluctant to say that figures are wrong but I do not believe those figures are correct. My experience is that the waiting times are much longer than those given that reply. I am not sure whether that comes down to having a mechanism to get people onto the list and have an assessment done. I dealt with the case of a gentleman in his eighties last year, who was concerned about the fact that his hearing was not what it should be and who was being cared for by his elderly wife, and it took about 12 months for his case to be dealt with. It may be that people in their later years are not considered a priority and, while there is definitely an improvement in the service, the waiting time involved needs to be examined. It is essential this service is provided as poor hearing can result in accidents which would involve greater expense.

I have raised regularly the provision of a podiatry service for people with diabetes. The provision of such a service needs to be specifically addressed. There were 56 amputations in Cork last year, 30 of which were directly related to diabetes and there is the follow-on cost from that. It is reckoned that nationally it costs about €239 million to treat preventable diabetic foot disease. We all know that prevention in such cases can have a huge impact. We need to consider this group as a specific category and provide for them. The Diabetes Federation of Ireland is concerned about this and I am aware that the authorities are engaged in discussions with it, but such a service could be provided quickly and it would have an immediate impact.

I wish to raise the issue of vaccine trials. We, as a committee, took a specific interest in the files gathered on vaccine trials on children, most of whom were in State care, in Bessborough Mother and Baby Home in Cork and other institutions, including St. Patrick's Mother and Baby Home in Dublin. We all know where they were. It appears from the Minister's reply that information was gathered and that on foot of a High Court case all those files had to be returned to the organisations that gave them because they were the property of those organisations such as GlaxoSmithKline and others that held the files in the first place. Clearly, there is information on this and we will have to speak about this later because we gave a commitment that we would request a formal investigation into this. Were those files returned with the proviso that nothing would happen to them and that they would be kept safely? The Department now knows where those files are and to whom they relate. Have the children involved in those trials - now adults - who sought their files been informed that they are there and are available?

I must ask the Deputy to conclude.

I will conclude on this point. Will the Minister ask those agencies to make those files available to those adults - on whom these trials were carried out as children - who would like to see their files? Will the Minister make that promise today?

I call Deputy O'Connor.

I would like to be associated with the welcome extended to the Minister and, in particular, to Mr. Magee on his first appearance before this committee. I look forward to working with him and I wish him well.

There is a good deal of business to be dealt with by the committee but perhaps the Chairman will allow me to talk briefly about Tallaght. It is where I live and those present will have to forgive me, if I am parochial.

We are not surprised.

If I am parochial for once, I am sure the Minister will understand.

Think about the national interest.

As the Minister knows, Tallaght is the national interest because Tallaght Hospital is a national issue. I will confine my remarks to that. There has been much talk recently about the publication of the so-called Tallaght review report by Dr. Maurice Hayes. I pay tribute to him and his team for the manner in which they carried out that business. It is important that I get guarantees from the Minister and from the HSE that serious attention will be paid to all the recommendations in that report. Ultimately, it is about restoring public confidence in Tallaght Hospital in a serious and positive way.

There are a number of recommendations which I hope will be dealt with in that manner. I am particularly keen that the recommendations regarding the relationship with general practitioners are dealt with. The general practitioners in the Tallaght Hospital catchment area should be capable of accessing services on behalf of the community and there are clearly gaps in that regard. With regard to the management of the hospital, I have been saying for some time that there should be a local perspective on the hospital board, and I am not referring to myself or Dr. Tom O'Dowd who are former members of the board. I am not criticising anybody on the board but I hope the restructuring of the board will include a credible local community representative. The general practitioners in the catchment area should be also strongly represented.

There is also the issue of the radiology service, which I raised in my questions. The report from Dr. Hayes clearly identifies the gaps in that regard. Action is required. Recently, I brought to the attention of the Minister and the HSE the difficulty many people are having with X-rays. One cannot get a CT scan in Tallaght without waiting for approximately 13 months. There are many other examples, some of which were highlighted by Deputy Reilly recently. As is the case with any other hospital, people should be able to go to Tallaght Hospital and get a simple X-ray without having to wait forever. I hope account will be taken of these issues.

Another issue I have raised is the provision of a primary care centre for the area close to Tallaght Hospital. This clearly links into what is happening in that hospital. There has been much discussion in recent years about the need for an out-of-hours general practitioner service attached to the hospital. I hope that, too, will receive attention.

It is not all negative. One must talk about the positive, look forward to the future and hope the further development of services at Tallaght Hospital will progress. I feel strongly about the move of maternity services at the Coombe Hospital to Tallaght. I am aware the Minister sometimes walks the streets of Tallaght and she is always welcome, but the jury is still out with regard to the issue of the new children's hospital. I will continue to press the Minister and the management of the HSE on the urgent care centre which clearly must be developed in Tallaght Hospital if the main hospital is built on the Mater Hospital site.

I welcome the Minister and Mr. Magee. This is the first time I have had an opportunity to raise issues as a member of the committee. Hopefully, it will not be a long relationship but a productive one for as long as we are on this side of the House.

Chairman, I put down a number of questions but I also have questions about the issues that have been raised this morning. With regard to budgeting and Mr. Magee's presentation on the applications that have been received under the new early retirement scheme, I note there are 582 applications from management and administration in the HSE west. This will have a dramatic impact at corporate level in HSE west. Of course, we were at the wrong end of the scale until now. There were more than 800 corporate staff, which was a huge drain on financial resources. Now that there will be a dramatic reduction in the number of those staff, will it have an impact on front-line services or will the money be absorbed back into the national pool? The previous level of corporate staff in the west put huge pressure on front-line services. That could be seen in the acute hospitals throughout the west and the crisis we have had with them this year. Can the HSE give a commitment that some of the funds being released can be put back into the front-line services so we do not see the same stark, dramatic issues arising next year that were experienced this year?

The plan published yesterday by the Government stated that emergency services will continue to be available on a 24 hour, seven day week basis and in her written response to some of the questions, the Minister again reiterated the aim of protecting front-line services, particularly emergency services. Can she explain the situation that will pertain from 1 January at Roscommon County Hospital and Sligo General Hospital due to the lack of front-line and nursing staff? The accident and emergency services of both hospitals are under threat because Roscommon County Hospital does not have theatre nurses and a similar situation has arisen at Sligo General Hospital. Will the moratorium be lifted? As Deputy Kathleen Lynch said earlier, maternity leave is a huge issue with regard to hospital staffing because women who are on maternity leave have not been replaced. This is causing a crisis in some hospitals. Will the moratorium be lifted with regard to key front-line staff or will we continue to have the farcical situation whereby the position is not filled and locum or agency staff are brought in to keep a service going, which is costing the health service far more?

On the recruitment issue, could somebody elaborate on what is happening with the NCHD crisis? What progress has been made in dealing with the current crazy situation with regard to visas to this country? It has changed. What factual progress has there been in that regard? The Department has been in negotiations with the Department of Justice and Law Reform for almost eight months on the issue.

What is the exact position with regard to the reconfiguration of hospital services in Galway and Roscommon? We are being told more complex cases will be transferred to Galway University Hospital and less complex work will be transferred to the smaller Portiuncla and Roscommon hospitals. However, it appears from the information we are getting now that it will be transferred only on a temporary basis pending the establishment of a new elective hospital at Merlin Park. We are saying, therefore, that less complex work will be brought to smaller hospitals but it is only a temporary little arrangement to get over the hump and once services are cut, they can then be moved out again in the future.

The Deputy's time is up.

With regard to disability services, I sought assurances on the impact of possible cuts to the disability services but there is no reassurance in the response given by the Minister. Would it not make more sense to publish the review on the efficiency and effectiveness of the disability services in advance of the budget?

I thank the Minister for her comments and I welcome the new chief executive officer of the HSE, Mr. Magee. It is nice to see somebody with some local knowledge in that position and I wish him the best in his new role.

I welcome the information regarding the HPV vaccination programme. It is wonderful that almost 47,000 girls have been vaccinated since September. That is to be commended. I see that the second dose is under way from mid-November. I also want to thank the witnesses for the detailed response concerning the Darley day care centre for older people in Cootehill. There has been much consultation about this and it is ongoing. Local people will be happy with the level of engagement that has taken place.

Since joining this committee I have, like others, had to be a bit parochial. Today will not be any different, so the Chairman will have to indulge me. I will direct my questions directly to Dr. Barry White. I am very interested in seeing the development of the acute medicine programme as it relates to Monaghan Hospital. That hospital has had a large investment but it could be doing an awful lot more. There is a big potential for development there. We could set up an MAU quickly for low-risk patients who do not need acute intervention, but do need medical assessment. We could also have some inpatient beds for low risk people. I am talking from personal experience in this regard. During the summer, I witnessed this when my mother-in-law was ill. She had to go to Cavan for an i/v, which does not make sense. There should be such a facility in Monaghan for such people who do not need acute care, but who require good medical care. It would save money to do so because Cavan and Drogheda hospitals are bursting at the seams. We could make better use of the resources we have.

We have a rehabilitation unit with 13 beds and 13 step-down beds, but the latter beds could be relocated. All the rehabilitation should be carried out in Monaghan Hospital, which should be a centre of excellence for rehabilitation. It would not cost a large investment and it is the right thing to do for the patients' benefit. People have told me that the medical assessment unit in Cavan is under huge pressure because of the large volume of inappropriate referrals. If necessary, that information needs to be communicated between the hospital and GPs.

In recent years Monaghan Hospital has been held up, not as a shining example, but as an example to the rest of the country that their fate could be similar. We now have an opportunity to be a leading light in the delivery of these services. I am not interested in a watered down or easily removed version. All the stakeholders, including consultants and GPs, think this is the way to go. There has been some engagement and I will be seeking more. The Lisdarne unit in Cavan would be well able to accommodate some of the step-down beds, as would St. Mary's Hospital in Castleblayney where there is capacity.

The Deputy should conclude.

I am almost finished. We now have a CT scanner in place, which is working two and a half days per week. I would like to see its operation extended further to clear waiting lists. We have a major potential and are rightly placed to have greater cross-Border co-operation on services, particularly with the opening of a new hospital in Enniskillen. I look forward to hearing Dr. White's response.

I, too, extend a warm welcome to all the people here. I join with other speakers who have referred to the recruitment moratorium. Some 1,500 graduate nurses are leaving to work for the NHS in England. Their individual training has cost approximately €96,000. In the meantime we are paying agency prices for nurses, which simply does not make sense on a cost basis or for the loss of our intelligent, well-educated, young workforce. More than 40% of nurses are over 50 years of age, and the other age groups are disproportionately absent for very good reasons.

In addition, only two specialist psychiatric nurses have been assigned to primary care teams in the entire country. That is not a good way to do business. The decision to close St. Michael's unit in Clonmel was announced last January. The closure date is now deemed to take place by June 2011. How much money has been realised by the sale of HSE-owned property? The figure was €50 million, but I see in today's response that it is now €20 million.

There is a proposal for a day hospital and community mental health team headquarters for the Clonmel sector, but what is its status? There is supposed to be a 40-bed community nursing unit in Clonmel, but where will it be located? A ten-bed high support hospital is also proposed, but where is it to be situated and when will it be operational? Are staffing requirements in place for the crisis house in South Tipperary? Where will the two residential units be situated and when will they open?

The proposed 5% cut appears to apply to the HSE west. Can we assume that there will be a 5% cut in mental health budgets for the entire country next year? Some 5.6% of the gross health budget has already been cut, so I do not think it could take another 5% cut given all we hear about mental health service requirements at the moment.

The Minister gave Deputy Mattie McGrath an undertaking that there will be no changes to acute hospital services in South Tipperary for 12 to 18 months.

According to Deputy Mattie McGrath.

Can the Minister confirm if she made that commitment to Deputy Mattie McGrath? I would like an answer to that question, please. I asked the Minister to provide a list of all advisory committees, consultative bodies and non-medical management consultants that have an input into, or are referred to by, the HSE at regional or national level. I note that for the past six months, some €3.8 million has been paid for consultancies. The previous CEO had, over six months, a personalised consultancy for €90,314. Can the Minister clarify what that was for?

Reference is made to radiographer advisory services to the MER unit. I do not know what the MER unit is, although I could guess. Some €13,100 was paid in that respect, but I wonder what it applied to. Colgan Associates Management Services were paid €3,812, but I wonder what services they were reviewing.

The Senator's time has elapsed.

If I do not get an opportunity to finish asking these questions, may I submit them in writing?

If the Senator has one or two more questions, perhaps she can put them quickly.

DKM Economic Consultants were implementing a new system for cold laboratory services. Does "cold laboratory" mean non-emergency services? There was a cost of €48,400 for that.

In addition, there was a cost for examining and reporting on new build, patient transfer ambulances on behalf of the HSE. What does that mean?

The management consultancies for the north Cork GP review committee, section 55 inquiry and trust-in-care reviews for the Clare mental health committee were undertaken at a cost of €28,490. I wondered what those reviews were.

I have a few more questions but I am aware that time is short.

If the Senator could submit any other questions in writing, we can ask for the matters to be addressed.

I thank the Chairman for that, but I would like the witnesses to answer my oral questions today.

I welcome the Minister and Mr. Cathal Magee. Mr. Magee has vast experience and has dealt with many challenges. I am confident that while this is a challenge, it is also a major personal opportunity for him and for everyone in Ireland also. I will try to proceed as speedily as I can. On many occasions, I have raised the issue of having a 24-hour helpline. I received the following response from the Department in this regard:

The Samaritans provide a 24 hours per day, 365 days per year service to people in emotional distress. This is a confidential non-judgmental emotional support service for people experiencing feelings of distress or despair, including those which lead to suicide.

Links have been established between the significant increase in suicides and self-harm and the economic recession and the sharp increase in unemployment, which has become a national issue. Therefore, it is a key priority to establish a 24-7 national suicide helpline for people in a suicidal crisis. The Samaritans is a listening service and does not conduct a proactive approachvis-à-vis people in a suicidal crisis. In this regard, a national suicide helpline would be complementary to the Samaritans. As I have said many times at this committee and in the Seanad, more people die by suicide than by road traffic accidents and it has still not hit the radar politically, so we must keep hammering away.

I am delighted to say that Dr. Tony Holohan has, in response to Professor Kevin Malone's plea at a meeting we had some months ago, kindly agreed to set up a meeting. Dr. Holohan will chair the meeting and will bring together all the key gatekeepers involved in suicide. The Chairman will remember Professor Malone said that we need an audit of where, and how many, suicides are occurring. To provide a proper service, one needs to know what is going on. We do not know that yet. I take this opportunity to thank Dr. Holohan for agreeing to that meeting.

Two days ago the second annual child and adolescent mental health report was launched. This report shows that the majority of children and adolescents - 68% - must wait more than three months to be seen for assessment and 17% must wait more than one year. We have raised that at this committee also. This is particularly worrying because Irish adolescents have a high risk of deliberate self-harm, as evidenced by the national registry of deliberate self-harm. This gap in the child and adolescent mental health services needs to be addressed as an urgent priority.

At a meeting we had with the National Treatment Purchase Fund and Mr. Pat O'Byrne, I raised the issue of how his organisation could help to reduce the waiting list for children. I am happy to state that during the break this morning, Mr. Martin Rogan, assistant national director, mental health, HSE, has kindly offered to meet me and the chief executive of the National Treatment Purchase Fund. I very much appreciate that. When I spoke to Mr. Pat O'Byrne after that meeting, he was quite enthusiastic.

As I have said before, international evidence proves that even the smallest amount of psychiatric support and help can prevent a child or an adult self-harming or dying by suicide. We must speed up the process. We cannot have children on this waiting list.

Will the Senator conclude?

The other issue-----

The Senator will have to be very brief.

I will be as quick as I can.

I am the Fianna Fáil spokesperson in the Seanad for children and older people and that is why I am hammering away at issues concerning them. It is wrong that there is a cut-off of 64 years of age for breast cancer screening. I am not casting aspersions on any man here but the majority of the decision-makers and policy-makers when that decision was made were men. A woman over the age of 64 is seven times more likely to get breast cancer.

I draw the Minister's attention to the thalidomide cases. I spoke to her approximately two weeks ago at our parliamentary party meeting about documents being made available. Apparently, no documents have as yet been given to the group.

Will the Senator conclude?

This is a very important national issue for thalidomide survivors and I am spokesperson for children in the Seanad. I have no other opportunity to raise it if I cannot do so here with the Minister.

Yes, but I cannot give the Senator more time than I give to other members.

I am not asking for more time. I must fight for my space.

Yes, and the Senator is doing very well.

We need to address this issue, even if the money is not currently available. We should acknowledge it and apologise for the fact babies were born with thalidomide at a time when the drug had been banned in other countries. Even an apology would go a long way.

I thank Senator Mary White.

I apologise-----

The Senator is okay. She took advantage of my gentle nature.

The Chairman certainly has a gentle nature.

I welcome the Minister and the chief executive of the HSE who takes up his post at an extraordinarily challenging time for the health service. That was very from his initial report to us. The combination of funding problems, staffing changes, the gaps in staff in areas where we need them and the excess staff in other areas is extremely challenging. The key question, about which all of us are concerned and which we present in different ways, is the impact on front line services due to the current funding difficulties. Many administrative changes need to be made, we must get more money from the drug companies or elsewhere and cut costs, about which I will ask. The important question which needs to be addressed is given what was outlined here and what is in the four year plan with €700 million identified, where will the axe fall and how will the HSE protect front line services? It is a big question but we would like to hear Mr. Magee's views on it.

In that regard, I ask about the impact of 56% of general managers and 42% of assistant national directors leaving. We can say the scheme is welcome but what will be the impact on services? What sort of response does Mr. Magee expect to get in terms of moving staff and dealing with whatever gaps must be filled because of the uptake of the scheme? We do not know the final cost yet. I do not know whether Mr. Magee can give us an indication of what the savings will be if all these people avail of the scheme and of what the salaries of general managers and assistant national directors are. Perhaps he will address that because key questions arise from it.

I refer to the drug companies and reducing the cost of generic drugs. How much pressure is the HSE putting on the drug companies and the pharmaceutical industry, which is a very important industry here? Everybody has anecdotal evidence of drugs being much cheaper in other countries. What is happening here? Does the HSE expect to make savings? What negotiations are taking place with the drug companies? Is any resolution expected because I note in the savings targeted for next year, that area is identified?

Some very good points have been made in regard to the impact of the moratorium. Can Mr. Magee give us an indication of the number of vacancies currently? How many staff have left front line services and how many vacancies are there which have not been filled because of the moratorium? We know about the psychiatric nurses and the impact on mental health services but what is the impact on other areas? This committee needs to monitor the gaps caused by the moratorium on an ongoing basis. A number of my colleagues made the point about the impact the moratorium is having at local level.

I refer to the Supplementary Estimate because of the health levy being down. What does Mr. Magee expect it to be? Perhaps the Minister could answer that. It was stated that there is a substantial shortfall in health levy collections which may require a Supplementary Estimate. Is there any indication of the amount?

Emergency admissions are 11.2% higher than the target. That is quite a disturbing increase in emergency admissions. Is there any data on this? Are more people being admitted because of drug and alcohol problems, or is it people not being able to afford to go to general practitioners or pay for their medication and, therefore, we are seeing this increasing activity which must be putting quite a bit of pressure on the emergency services?

The Senator's four minutes are up.

I will not repeat the mental health questions that have been asked by Deputy O'Sullivan but they are important. I make a special plea - we see it in the report published today - for those between the ages of 16 and 34 who are vulnerable to mental health problems and where the service levels are very low at present.

In the current climate, is the Minister confident about the €110 million shortfall in funding for the children's hospital? Has she any indication that the shortfall will be filled by voluntary contributions or where will that funding come from?

I support the call on BreastCheck. If the Minister cannot increase the age of women who are eligible for BreastCheck at present, the very least she must do is provide an information campaign to women emphasising that they should not stop having mammograms at that age because they continue to be vulnerable. There is a false sense of security in women once they stop getting the reminders. It is a superb service and it needs to be extended. They have done it in Northern Ireland. The European Commission is recommending it be extended to those aged 73. It is a critical issue. Obviously, there is a funding problem in that regard but it is extremely important that it is dealt with.

My final question on mental health is to do with the money that will not now be available from the sale of lands. How will that be dealt with in terms of the mental health budget for next year?

I must ask the five remaining speakers to stick to four minutes. Otherwise, we will have had many interesting questions but no time for the answers, which are also important.

I welcome the Minister and wish Mr. Magee well in his tenure with the HSE in the years ahead. These are challenging times and I wish him the very best.

I want to ask about the report on reconfiguration for the south east which was due nearly 12 months ago. We were first promised it in February of last year. It has not been published. There is something of a vacuum created in the south east where there are four hospitals. We do not know what the future holds and there is much concern. As late as yesterday I received a notice of a motion from Waterford City Council asking what has happened to the report. Will the Minister outline when the report will be published?

My second question relates to community nursing homes for the elderly and inspections by HIQA. There are three or four of these in my county of Kilkenny and they are concerned about the strict inspections by HIQA. They maintain that most patients, especially in the community nursing homes, are self-sufficient, are not bed-ridden and do not need a care nurse during the night because they are able to get themselves out of bed. The argument is that the same strict procedures should not be used in these community nursing homes as are used in public nursing homes where patients are bed-ridden. I ask that HIQA would go easier on these homes because they feel they will be closed down if the rules and procedures are applied to them too strictly.

My next question relates to a more local matter. Kilcreene hospital is the orthopaedic hospital in Kilkenny. This year, in the middle of summer, two wards were closed down and the number of procedures fell from 20 a week to ten. Will that be redressed and will those wards be re-opened?

I am also told by the staff in that hospital that if it was used, they could carry out procedures for the National Treatment Purchase Fund at much less cost than in private hospitals. With all the cutbacks, I wonder could that hospital be utilised more? I am told that it can carry out knee and hip operations for €4,000 or €5,000 less than in private hospitals. The Minister told us previously that only a percentage of the National Treatment Purchase Fund cases can be sent to public hospitals. Can that be changed? Why is that the case? If the Minister can get treatment for patients at a reduced price using well qualified staff, why not use that public hospital facility and keep the patients away from private hospitals?

My last question is about the pay of local doctors? In 2007 and 2008, before the recession hit, I was aware of doctors who were charging €45 per person for a visit and today they are charging €65. Why is that allowed? Everyone has taken a pay cut in the past two years. We ourselves have take a 20% or 25% cut. It is a scandal that a doctor who two or three years ago was charging €45 is charging €60 or €65 in present circumstances and something should be done about it. If doctors themselves do not lower their price, we should introduce a provision to force them to do so. A charge of €60 or €65 per person for a visit is too high and something should be done about it.

I thank Mr. Magee and his team, and the Minister, for attending.

There are just three issues to which I wish to make brief reference. The first relates to my parliamentary question to the CEO of the HSE on legal costs and expenses in the child care area. I am most dissatisfied with the reply and wish to receive a more comprehensive one on the matter. It is totally unacceptable that the reply states that the information I sought is not currently available. I cannot accept that information is not readily available on the legal fees the HSE expends by way of public money in the child care area. The reply stated that there was a grand total of €21.3 million spent on solicitors' fees in the past three years. It is less than satisfactory that this figure does not include counsel fees. In terms of the tendering for legal services, I want to know the manner in which the HSE engages in the process. I am concerned at the distribution of legal services, the manner in which the tendering process operates and the few legal firms which are involved in the tendering or invitation process. I will come back to this matter in the House if I do not get the level of detail that I require.

My second point relates to my own hospital at Portlaoise and the failure of the HSE to comment publicly on a reconfiguration of services that involves a most serious downgrading of the delivery of health care services in the south midlands area. I want to know about the rigidity of the delivery of services in what was the old Midland Health Board area incorporating the hospitals of Mullingar, Tullamore and Portlaoise. These rigidities must change. I want to see positive relations forged between hospitals like Portlaoise and the Dublin hospitals because I believe it will result in a greater service delivery for those who require it.

I refer briefly to a really important point made by Deputy O'Hanlon earlier, namely, the total lack of co-ordination between the Department of Health and Children, the HSE and the Department of Transport. Reconfiguration of hospitals is happening and people do not have a real difficulty with the principle, but there must be a close relationship between the Department of Health and Children and the Department of Transport. We in the midlands will not have proper care service delivery in the hospital configuration unless a rapid ambulance service is available up and down the spine of the country, through Longford, Westmeath, Offaly and Laois, which will involve road development in the area of health care delivery.

My third point is on child care. I would ask Mr. Magee and, in particular, Ms McGuinness, why the HSE continues to fail to put children first, and why it continues to stand over an organisation where there is a culture of fear and cover-up, where there is chronic and continued systemic failure in the management and delivery of services as outlined in the PA Consulting report and others, and where there is a total absence of accountability. The way the HSE is designed - it is here that the Minister has a role to play in the context of policy - actually fosters and encourages a complete lack of accountability. The recruitment embargo is having a devastating effect on child care and protection services. I invite the Minister to rebut my view that the delivery of social care and child protection services through the HSE must be brought to an immediate end because that organisation does not have the capacity to deliver such a service in the area of child protection.

I also welcome the Minister and Mr. Magee. I wish the latter every success in his tenure as CEO of the HSE.

The first point I wish to raise relates to the savings of €746 million within the health service. I am seeking greater detail in this regard, particularly in respect of the approach to community support for older people. It is proposed to make some €440 million in savings in respect of demand-led schemes. I am particularly interested in how this will affect the home help service and home care packages. Does the Minister envisage that the approach taken in this regard will be somewhat similar to that which is taken in respect of the fair deal? Will she provide further details in respect of this matter?

A high proportion of the savings to be made relate to the area of payroll. I welcome the fact that such a high number of people have applied to take early redundancy. I also welcome the fact that such a high proportion of those who applied are at management level. There is as much of a need to streamline matters at this level as there is to reduce the number of people in the lower administrative grades. However, I am concerned that some 893 applications for early redundancy have been made by staff in the western region. When compared with the number of applications from staff in Dublin, mid-Leinster and the north east, that represents a high proportion of the overall total. I am concerned with regard to how this will impact on services in the west.

If Fianna Fáil remains in government after the election, the HSE will still be in existence. However, if those in opposition come to power and in light of the various proposals they have put forward in respect of the executive, it is obvious that many more staff will be laid off. I was interested to hear comments from Opposition parties regarding how the health service will be rolled out after the election. It is certainly not clear from their plans how that roll-out will work, particularly in the context of even further reductions in staff numbers. This is a critical issue for people in the west. Have all of the applications made by staff in the region been accepted or is the HSE expecting some people to withdraw their applications? Perhaps Mr. Magee might provide additional information in that regard.

Reference was made to how the service plan is being rolled out and to the level of service that was provided in 2010 compared with that which obtained in 2009. There are two matters to which I wish to draw attention in this regard. It is stated in the service plan for 2010 that the same number of home help hours would be provided in the current year as in 2009. In County Mayo there has been a 10% reduction in home help hours. Is it in order for HSE management in a particular county to reduce the number of home help hours by such an amount - thereby making significant savings - without referring to the executive at national level or to the Department of Health and Children? I understand that the change to which I refer could not have been brought about in the absence of consultation.

What has happened in County Mayo is not in accordance with the service plan. I am particularly concerned with regard to this matter because a review has been carried out in the county and all the evidence indicates that the number of home help hours have been slashed to a significant degree. I have the relevant figures in my possession, I can give a copy of them to the Minister and I can certainly forward them to Mr. Magee if he is interested. Mr. Magee stated that in national terms the HSE is 5.3% behind 2010 target for the provision of home help hours. As already stated, the number of hours being provided in County Mayo is down by 10%, which is not acceptable.

The second matter to which I wish to refer in this regard is accident and emergency services. I am concerned about the position both locally and nationally in this regard. At previous meetings to discuss the quarterly update on health issues during the past two years, I have raised the issue of cancer patients. When cancer patients who already have track records with hospitals and who need to be admitted in the early hours of the morning as a result of particular medical problems arising, they must first be admitted to accident and emergency departments. This is despite the fact that their files are already with the hospitals in question. That is completely unacceptable.

When I raised this matter with the Professor Tom Keane, then head of cancer services, some two years ago, he wrote to University College Hospital Galway in respect of it. I am sure he did the same in respect of other hospitals throughout the country. I received a number of lovely letters from management at University College Hospital Galway stating that they were going to consider the matter and revise the way in which things were done. As of now, however, no changes have been made. In my view, this is giving rise to grave inefficiencies regarding the delivery of accident and emergency services. I am sure it would be possible to deal with the 275,000 emergency admissions to which Mr. Magee referred in a much more streamlined way if the matter to which I refer was resolved. We have been discussing this issue long enough and prompt action is now required. People, many of whom are terminally ill, are being left on trolleys for eight to 12 hours. If we want to improve the health service, action must be taken in this regard.

I agree with Senator Mary White regarding the provision of BreastCheck services to people over the age of 65 who are already in the system. I have mentioned this matter to the Minister in the past. Providing a service to those to whom I refer would prove cost-effective because one in nine women over the age of 65 are liable to contract cancer. It is important that this service be made available to women who are already in the system. I wish to raise a number of other matters but I will leave them until later in the meeting.

I thank the Chairman for allowing me to contribute. I am not a member of the committee but like everyone else here, I have a major interest in issues relating to health. I welcome the representatives from the HSE. Apart from the challenges the organisation faces in the context of service provision, it also faces a challenge to become more loved by the people and to equal the NHS in Britain with regard to the respect and affection in which it is held. I would not like the HSE to be replaced by foreign insurance companies, as Fine Gael proposes, because there would be no accountability whatsoever.

Deputy Charles Flanagan stated that no one has a problem with reconfiguration. I suggest that he makes that point at the various rallies throughout the country which will be addressed by members of Fine Gael.


Deputy Thomas Byrne should not worry about us. He should be more concerned about the electorate sorting his party out.

The Deputy is a gurrier and he has never been anything else.


That is why we are here discussing these matters. This is Fianna Fáil's legacy.

Order please. It might be advisable if Deputy Thomas Byrne proceeded to ask questions and did not seek to excite other members.

Those in opposition cannot back up what they have proposed.

What we have been left with is Deputy Flynn's party's legacy.

The Chairman should protect Deputy Thomas Byrne.

I am being well protected.

One might even state that the Deputy has been cosseted.

Those opposite believe they will have it handy but they did not even contradict what I said.

Deputy Thomas Byrne should proceed to ask his questions.

I wish to seek a clear answer from the Minister for Health and Children. Why were elective and emergency surgery services removed from Our Lady's Hospital in Navan so suddenly a number of months ago? A clear answer is required in respect of this matter, particularly in light of the confusion that has arisen. Rumours to the effect that elective surgery services will recommence at the hospital began circulating earlier in the week. Are these rumours true? Are there any documents available which indicate why the decision to remove these services from Our Lady's Hospital in September was taken? If there are, would it be possible for them to be made available to the committee and to the Members of the Oireachtas who represent the county?

I am also not a member of the committee and I thank the Chairman for allowing me to contribute. I welcome the Minister and the new chief executive. I wish the latter well.

Deputy Thomas Byrne, the other Oireachtas Members who represent County Meath and I were all extremely concerned with regard to the withdrawal, without any consultation, of elective and emergency surgery services from Our Lady's Hospital in Navan. When the original decision was taken, the six Oireachtas Members who represent the two constituencies in County Meath had a good, constructive meeting with representatives from the HSE. The Minister for Transport, Deputy Dempsey, Deputies Thomas Byrne and Wallace and I then had a meeting with the consultants at Our Lady's Hospital in Navan. The latter completely rejected some of the points that were put to us at our earlier meeting with the representatives from the HSE. Will the Minister and Mr. Magee indicate who is telling the truth?

Has the HSE taken into consideration the cost - in terms of lives and money - of transporting patients from hospital to hospital in order to obtain beds for them? I am aware of a case where a patient was driven by ambulance from Navan to Beaumont. The individual in question was assessed but because there was no bed available, had to be put back into the ambulance and driven to Drogheda. A further assessment took place there and the person was again loaded into the ambulance and sent back to Navan. I am sure other Oireachtas Members who represent the constituencies in County Meath have heard similar stories. That is a desperate waste of money. Such behaviour is not fair to patients or their families. Perhaps the Minister and Mr. Magee will clarify the position in this regard.

Why are hospital beds in the north east being closed when services are already stretched to breaking point? The community in County Meath not only depends on the hospital for its medical needs but also on the 2,000 jobs it provides. A reduction in service will mean fewer jobs in the area.

Primary care centres were due to be built in different locations. I have spoken to GPs and developers who were going to construct them but it is not possible for them to do so without tax breaks. I raised this with the Minister for Finance. I am sure it is not a great time to give anybody tax breaks but they would be valuable to GPs and those who would like to construct the centres.

We have been successful in securing the location of a regional hospital in Navan. While it will not be built overnight, could the Minister indicate when it will be constructed?

I would like to add to the comprehensive range of issues raised by members. I congratulate the Minister, Mr. Magee and their teams on the positive presentations they made. I am conscious of the huge cohort of staff working in the health service who need to have their contribution recognised and who need to be motivated and encouraged. Greater outputs are being achieved with fewer resources. If we could hear more in the media about the achievements in the health service, it would serve as an encouragement to the many wonderful people working in the service to continue to do better and deliver better outputs.

A number of members referred to the cystic fibrosis unit. It has been bedevilled by delays. It is a critical legacy issue and the unit needs to be put in place.

Deputy Kathleen Lynch and Senator Mary White referred to the thalidomide issue, which could be resolved, as there are reasonable people on both sides. We should be able to bring it to a quick conclusion.

Representatives of the Jack and Jill Foundation appeared before the committee and they are lobbying all Members of the Oireachtas. I ask both the Minister and Mr. Magee to please do something to support this organisation, which is providing a service that would not otherwise exist for terminally ill children.

Deputy Brady mentioned the primary care programme. Deputy Reilly and others have been party to the production of a report supported by the committee. In good times it might have been possible to deliver state-of-the-art primary health care centres through the private sector with some State funding. They will not happen now without State support. We will not get the network of centres we need which, in turn, would take the pressure off hospitals, achieve good value for money and provide better care ultimately for the patient.

I refer to the outsourcing of diagnostics and procedures such as CT and MRI scans. Many people are supportive of using the private sector where top class medical equipment is not fully utilised. Can we not contract that through the National Treatment Purchase Fund to reduce the waiting times for scans?

Reference was made to the moratorium and members are interested in the number of places that remain unfilled. It is my understanding that the Minister has protected front-line services and, despite the moratorium, recruitment has continued in essential service areas.

Will she comment on that? Both the Minister and Mr. Magee have 25 minutes each. If he has to leave, will he first address some of the issues? Is that okay with the Minister?

Yes. Many issues raised fall into the patient safety agenda and it would be appropriate if Dr. White, the clinical lead, dealt with them.

I do not mind who leads off in dealing with the responses. We have 50 minutes to get as many answers and as much clarity as possible.

Mr. Cathal Magee

I will begin with Deputy Reilly's questions. I refer to the issue of staff strength and the numbers published in the national plan yesterday in terms of head count projections over the four-year period. My understanding is that the 6,000, which is 1,500 multiplied by four, is additional to the numbers that will exit the service under the current programme, which will be completed on 31 December 2010. I have been saying that the 1,500 is based on natural wastage and posts not being filled. With the impact of the voluntary exit programme for both administrative management, and support staff, we expect the normal turnover rates will be impacted and, therefore, it will be quite difficult to meet the current projection of 1,500 leaving through natural wastage or normal attrition. Arising out of the report published yesterday, we still have work to do with the Department to understand exactly the reconciliations of those numbers. My understanding is-----

Over what period will 1,500 leave?

Mr. Cathal Magee

Annually over four years. That is in addition to the numbers who will exit now.

Navan hospital was mentioned and I will ask Dr. White to cover that in a comprehensive way and to answer questions asked by a number of members.

Dr. Barry White

I have been director of haemophilia services for the past ten years and I have had to implement the Lindsay tribunal report into what was one of the most serious episodes of patient harm in the history of the State, which was the infection of patients with haemophilia with HIV and hepatitis C. I have plenty of experience in the area of living with risk in that context and in areas of health care risk. I take issues that arise regarding patient safety particularly seriously and that is what the issue around Navan hospital relates to.

Over the past number of years, there have been a number of reports into Navan hospital and surgery in the region. There is a report from Teamwork which involved surgeons outside the country. There is a report from Capita, which is not published and which also involved surgeons from outside the country. There is a report by HIQA into Ennis hospital, which has implications for hospitals of similar size, such as Navan. All the reports recommended the removal of emergency surgery from Navan from a patient safety perspective.

The second piece of work worth mentioning is that over the past year since I took up this role we established a programme around acute medicine and acute hospital services. This is a ground-up programme involving clinicians and patient organisations in terms of defining how services should be optimally delivered. In that context, the issue of the roles of hospitals has come up but that document has not formally issued. One of the steps due to take place over the next months is an engagement with Oireachtas Members as part of the consultation process. However, questions have been raised about Roscommon and Monaghan hospitals and the document strongly supports the role of local hospitals in the context of both their benefits, cost effectiveness and the benefit of providing services locally and at as low a level of complexity as is required for optimum patient care.

It is worth noting that many of the areas of growth in health care over the next number of years will be in the areas of ambulatory care, day surgery, including up to 23-hour surgery, rehabilitation and respite care. In order for their health services to work, those smaller hospitals will have to grow their activity as opposed to reducing activity. In that context, Navan hospital is an appropriate location for laparoscopic surgery, which is elective surgery. During the summer, safety concerns arose in the context of delivery of surgery in that area. The provision of laparoscopic and elective surgery in Navan hospital can proceed when those issues have been resolved satisfactorily. A process in this regard is under way. In health care, as in any other area, the fact a safety concern arises does not mean that it will be proven to be a safety concern. If a concern or flag has arisen, it needs to be assessed. The outcome of that process will determine what actions need to be taken to ensure patient safety. The review of the cases in question arose from expert surgeons reviewing cases.

To answer the specific question on Navan hospital and to respond to Deputy Reilly's comments about the future role of the hospital, I think it would be an appropriate location for elective surgery, but not emergency surgery. It would also be an appropriate location for a range of additional services in the areas of ambulatory care, diagnostics and selected inpatient medical cases.

If it is a good place for elective surgery, why is that not taking place currently? Why was elective surgery stopped suddenly at the beginning of September? What are the specific safety issues?

Why is the capital report not published?

We will deal with those matters and then move on.

With respect, I have questions on the same issue. Why was action taken suddenly after four years? The first report suggested this move and raised the problems four years ago. Why is this suddenly being addressed four years later? The RCSI "letter", as opposed to report - I do not think there has been a report - raised concerns about emergency surgery, but did not mention elective surgery. Therefore, why was elective surgery cancelled if the issue concerned emergency surgery? Many allegations have been made about reports to the Medical Council. Can Dr. White tell us how many complaints were made, how many were considered vexatious and dropped by the council, how many were vindicated and how many remain in process?

To clarify a point for this committee, laparoscopic surgery is only a small part of elective surgery. Many other surgical procedures take place apart from laparoscopy, as I am sure Dr. White will agree.

May I ask a brief supplementary question?

I apologise I was not here for the earlier contribution. I take this opportunity to welcome Mr. Cathal Magee to his position and to wish him well in his new responsibilities.

Acute medical services have been removed from Navan hospital and transferred to Drogheda without notice. Two months ago, without notice, trauma ambulance services were removed from Navan hospital and people can no longer be stabilised in Navan. All elective surgery in Navan hospital has been cancelled until further notice and the psychiatric service is signalled to go next, in 2012. The medical ward lies empty and local GPs have said that patients' lives are in danger. What engagement has there been on this and what level of consultation or listening is taking place given the seriousness of what is involved? It is no wonder so many people are so deeply angered by what has happened at Our Lady's Hospital, Navan. It is unforgivable.

Thank you. We will deal with those questions now and then must move on to the other issues.

Dr. Barry White

I will ask Mr. Magee to deal with the question on the capital report.

Mr. Cathal Magee

The committee has requested that we make the capital report available. Dr. White and I and the HSE would be keen to co-operate with the committee in that respect, but in view of the potential litigation, we have been advised there are problems with doing that. I am happy to discuss the issue with the Chairman and if we are required by the committee to provide it, we will give the matter further consideration. However, there are genuine legal considerations arising out of the litigation and I would like to appraise the Chairman of those considerations and talk them through before we respond further.

Mr. Magee used the word "potential". Has any litigation been initiated or is it just a potential case? Is there a case currently?

Mr. Cathal Magee

Yes, there is.

Is the committee going to request the report?

It has already requested the report.

Mr. Magee has invited a further request for the report.

Our request stands. The committee wishes to have the report.

I understand Mr. Magee is offering the committee a private conversation about why the HSE cannot provide it.

Mr. Cathal Magee

That is correct. I wanted to stress that we would like to be as transparent and as open as possible.

We also are governed by Standing Orders and I must remind members of Standing Order 57(3) to the effect that a matter shall not be raised in such an overt manner that it appears to be an attempt by the Dáil to encroach on the functions of the courts or a judicial tribunal. We do not wish to do that, but we do wish to see the report, if that will not be in any way prejudicial. Let us proceed.

Mr. Cathal Magee

On the question of Letterkenny, we support the classification. That is an issue with the Department, which will impact on the manner of charging for private patient income. We have been in discussions with the Department on that issue.

A number of Deputies raised questions on the comparative analysis of the impact of the take-up of the redundancy scheme, particularly with regard to different parts of the region. The numbers, particularly in the west, are proportionate. The take-up, in terms of applications, for Dublin-mid-Leinster is approximately 23%, Dublin north east, 24%, and the west, 21%. The west is quite a big region and over 4,138 people are involved in that cohort. The take-up in the south is 26%. Therefore, the figure for the west is not disproportionate. Corporate services are different in the different parts of the country. Our big challenge will be to ensure that there is no impact on front-line services arising from this programme. There are risks and there will be difficulties. The first couple of months of 2011 will present transition problems. The staff involved are not front-line staff, but they are staff who provide support to front-line staff. As I said in my opening remarks, we need to restructure our administrative and management levels. We need to simplify our management structures and to get more efficiency and productivity from our administrative systems. That is the challenge for management in the first six months of 2011. It will be very challenging, but we are confident that we can execute the plan.

The question of agency work was raised and we will look at that and other pay costs. Deputy O'Sullivan asked about the procurement process and the recruitment of agency staff. This matter relates to the attempt by the HSE to centralise and co-ordinate the procurement of agency services, which are currently fragmented throughout the country and involve excessive costs and margins. We are trying to create a competitive structure. However, agency work will continue to be part of the health service system, but the costs are prohibitive and we need significant efficiencies.

Agency work has become too big a part of it.

Mr. Cathal Magee

With regard to the impact of the moratorium, we agree there are inflexibilities with the way in which the moratorium operates, which can impact on the provision of front-line services this year and may impact further next year. We are in discussions with the Department and with the Minister about further flexibilities with regard to agencies. There is no doubt that agency staff are in part substituting for posts that are unfilled as a result of the moratorium. This is not satisfactory in the long term. We need to review the scale of the agency workforce in the system and how more full-time recruits can be substituted, in nursing, for example. These are all very valid considerations because the current system has cost considerations and quality impacts and it leads to a lack of consistency in the care patterns in acute and residential care settings. The members have made a number of fair points and we will be addressing those issues.

Deputy O'Hanlon asked about a comparative analysis. Dr. White's work on acute medicine and the clinical transformation programmes will help to bring focus to the comparative analysis of how our various acute settings are performing both in terms of care pathways, length of stay and efficiency. If we could bring best practice in each of our acute settings and transfer it to every part of the health system, we would make a significant improvement in the quality of health care being provided. This is the first step before considering international benchmarks. If we could bring every area of our service up to best practice level internally, that would be a significant step forward and Deputy O'Hanlon's point is a fair one.

I will ask my colleague to deal with Deputy Kathleen Lynch's questions about audiology services.

I asked Dr. White a number of questions but he deferred to Mr. Magee on the question about the legal issue. However, there is still the question of the sudden action after four years and the fact that the RCSI letter did not refer to elective surgery and other issues. On a point of clarification, has Mr. Magee finished answering my questions because he did not address the issue of beds?

No, he has not finished answering the Deputy's questions.

Dr. Barry White

To deal with some of the specific questions about the separation of emergency and laparoscopic surgery, the concern about the safety of laparoscopic surgery was raised. The recommendation was made that it should be stopped. Once this form of surgery is stopped then emergency surgery should not be provided because an appendicectomy would then be an open operation whereas it should be a laparoscopic procedure. The reason the emergency surgery had to follow and be precipitated was because laparoscopic surgery was stopped. I agree with the Deputy that the ending of emergency surgery had been recommended for a number of years beforehand.

Why non-elective surgery then?

Dr. Barry White

Minor surgery which is not under general anaesthetic is still occurring in the location.

There are other surgeries such as hernia repairs and cholecystectomy which do not necessarily require laparoscopic surgery.

Dr. Barry White

Surgical procedures can be performed laparascopically which is a minimally invasive procedure. It is a keyhole procedure and is associated with a lower complication rate. Those surgical procedures need the option of being either done laparoscopically or open, and one may convert from laparoscopic to an open procedure in a case but one certainly needs to offer patients the opportunity of hernia repairs or cholecystectomies. I do not think one can separate out and provide a service for laparoscopic only and for open procedure on separate occasions. I am sure Deputy Reilly will agree that the first pass will generally be laparoscopic.

The cases were reviewed by a surgical review team who reviewed surgical activity in the site. It was identified in summer and the recommendation of those surgeons was that laparoscopic surgery should stop with immediate effect and this is the reason such action was taken. The reason emergency surgery followed was because they could not provide emergency surgery unless they were performing laparoscopic appendectomy.

A number of statements have been made with regard to this matter. I wish to emphasise that the decision was based on an issue of concern for patient safety. It was not something we sought to do nor did we seek to rapidly reconfigure. It did not suit the configuration of surgical services at that time. The action was based entirely on concerns for patient safety.

I invite Ms McGuinness to deal with some issues.

Ms Laverne McGuinness

Deputy Kathleen Lynch asked about audiology services. A review is being carried out by Professor Bamford. This review commenced in the south and it is now a national review. The results of this review will be published. In addition, we are putting in place a number of developments. Two senior audiologists are being appointed in child care services and they will begin work in November. As regards the adult service, one of the senior audiologists is participating in a continuing professional development course to allow the conduct of digital hearing testing. A neonatal screening programme is commencing in 2011.

Deputy O' Sullivan asked a number of questions about the home help service. The home help hours are behind by 5% at this time and we are over in regard to home care packages. This will balance out towards the end of the year because home help is being retained until the winter months. A review has been carried out to ensure the appropriate people were in receipt of the appropriate level of home help hours. A standardised assessment of the arrangements was undertaken. We will be very close to our target of 12 million by the end of the year. I refer in particular to the west region which is behind in its home help hours by 9.5% and its home care packages are over by 4.9%. The west region is aware that its home help hours must be recalibrated between now and the end of the year. Meetings have been held with the assistant national director-----

Is that 40,000 hours behind? They do 75,000 hours in the last two months of the year but that is physically impossible.

Ms Laverne McGuinness

I will explain to the Deputy that some of the home care packages in the west contain elements of home help hours so that has to be recalibrated back to home help. It is a case of coding.

Is it out of order for the implementation of a policy decision to reduce the home help hours by 10%? Is that going against the service plan?

Ms Laverne McGuinness

Yes, we are required to deliver the service plan. There should not be a reduction of such magnitude at a local level as it will impact on the delivery and they are aware of this. Those arrangements have been put in place with the assistant national director for older persons and with the west region and discussions have been under way to recalibrate and rebalance between home care and home help. They cannot take a decision which will have such an effect on the level of service.

I have a brief question about the audiology service. Did the review decide that hearing tests could be delivered in the same way as eye tests are delivered, in other words, a walk-in shop which is approved by the HSE?

Ms Laverne McGuinness

That was not part of the review which is now complete. We are replacing the objective audiology testing. It is being updated to ensure that we do not have as many false positive results as in the past. Many of the recommendations will be very useful for providing national audiology services in the future.

I am conscious of time constraints and I suggest that questions be grouped and that local questions could be dealt with by way of written responses. I suggest we deal now with the more general issues.

Mr. Cathal Magee

I will ask Dr. White to deal with the issue of diabetes which is a very important issue.

Dr. Barry White

I agree with Deputy Kathleen Lynch's statements that foot care is not at the optimum level in the system and the improvement of foot care services would also significantly improve quality of patient morbidity and be cost effective. We have developed a diabetes programme of work involving a multidisciplinary team of clinicians. Retinopathy screening and foot care are the two top priorities identified as being absolutely essential to progress. We are very committed to it and I would agree with the Deputy that something needs to be done about it and that it can be a highly cost effective intervention. The development of a national foot care programme for diabetes is at an advanced stage of planning and I strongly believe it is something we need to implement.

Would Mr. White envisage some action being taken on it early in the new year, within the next six months or within the next 12 months?

Mr. Barry White

Obviously the service plan and the agreement on funding need to be worked out. However, for me it would be a major clinical priority and would need to be actioned within, probably, six months. That would be a reasonable objective.

Mr. Cathal Magee

I will ask my colleague, Mr. Brian Gilroy, to deal with a range of questions that came up regarding capital facilities development and investment.

Mr. Brian Gilroy

The mental health facilities land sales featured in a number of questions. There seems to be a misunderstanding of what has happened in the course of the year. Last year we planned to sell €50 million worth of land and use that to reinvest in mental health estate. Due to the nature of the market we will have achieved by this year approximately €20 million worth of sales, approximately €10 million of which we will have in cash by 31 December. However, that has not prevented us implementing the programme. So there is no capital investment in the mental health programme that has not started. Some have been delayed owing to planning issues, etc. This year alone we are now in almost €90 million worth of contractual arrangements on the A Vision for Change programme. This year we will have cashed €30 million against it and the future commitments that go with it. We expect to add Grangegorman and Beaumont to that list fairly shortly. So there is no delay in the programme.

We were able to continue with the programme because we are absorbing the costs into the rest of the capital envelope and because in comparison with the start of the year, we have continued to see a fall in tendered prices. So the savings that have been achieved in the tender prices are now accommodating the mental health programme. I wish to reassure members that none of the individual local programmes is under threat of being removed and we are sticking with the building programme. At the end of the programme we will not have spent €400 million because we will have got the infrastructure we said we would get for considerably less in the current environment. I want to set the record straight on that.

Is Mr. Gilroy saying that the money from any land sold went back into the mental health budget? I believe a response to a parliamentary question about lands sold in Ballinasloe indicated that the money did not go back to the mental health budget. Perhaps Mr. Gilroy can explain that.

Mr. Brian Gilroy

No money goes back to the mental health budget. All the money goes back to the Exchequer.

However, it is meant to be ring-fenced.

Mr. Brian Gilroy

All that has been sold this year has yielded €10 million. By 31 December we will have €10 million worth of cash in. We will have spent more than €30 million. So more than the amount that has been achieved from the land sales is being spent on mental health.

That is very clear. I thank Mr. Gilroy.

On the signalled programme of works, when is it intended to progress the proposed new admissions unit for the Cavan-Monaghan psychiatric services, I believe in the grounds of Cavan General Hospital?

Mr. Brian Gilroy

I do not have the exact date in front of me, but it is true that it will be progressed next year. It is in line with the programme we published in March. We had a series of projects that would happen this year, next year and the following year. My recollection of that one is that it will be in the middle of next year. There has been no impact on that programme. No projects have been cancelled and none is being delayed. For example, a planning issue has set back developments in Grangegorman by a month or two and a similar situation exists with Beaumont.

The national paediatric hospital funding is in place and remains in our envelope. There were questions about the shortfall in funding. By the time we get to construction contracts, I do not believe that shortfall will be as large because the projections still have contingency and inflation figures. If the construction environment remains as it is, more savings that can be achieved will close that gap further. Many of the areas of spend in that part of the envelope are "nice to have" rather than "need to have". The core funding in there at the moment of €450 million will deliver everything that children will touch in the hospital. The other pieces we are talking about would be research facilities and other types of facilities. So the core funding is there and we do not see the project as being under any threat. Even following yesterday's announcement of the four-year recovery plan, the funding for the hospital is still there.

Speaking in the Seanad, the Minister recently told us there was a shortfall of €110 million and also €90 million.

Mr. Brian Gilroy


The €110 million was going to be raised from charitable donations and the €90 million was going to be raised through parking, coffee shops and other facilities. Is Mr. Gilroy now saying he does not expect there will be a €200 million shortfall?

Mr. Brian Gilroy

We hope to be in the market in the second quarter of next year. If construction prices remain as they are, the overall costs will have reduced without any change in the scope, because we still have contingencies for the possibility of construction prices rising. If they do not rise, that gap closes further.

Assuming they do not rise, what does Mr. Gilroy estimate the shortfall might be? If it was €200 million a week ago, can he be serious?

Mr. Brian Gilroy

If we see construction prices continuing as they are, another €30 million or €40 million could come off the overall bill.

I thank Mr. Gilroy.

This is the first time I have heard there are bits of it we could do without. For example, Mr. Gilroy mentioned the research facilities.

We can get a note from Mr. Gilroy on that.

Mr. Brian Gilroy

I can give a comprehensive note on it.

We had understood there was a shortfall of more than €100 million.

We will get an advice note and we can proceed with the other questions.

Mr. Brian Gilroy

The accident and emergency unit in Limerick is being actively reviewed for inclusion in the critical care block and we are working with the staff locally on that issue. To cover another national issue, it looks like we are about to conclude negotiations on the primary care centre in Tallaght and we will see one advance in the centre.

The reply I got suggests the end of 2011. I take it Mr. Gilroy is somewhat more optimistic than that.

Mr. Brian Gilroy

We will conclude negotiations and then it will require fit-out, etc. It could be that time before it opens.

However, it will progress.

Mr. Brian Gilroy

We would be in contract and that is what we expect to see happen.

Mr. Brian Gilroy

I believe Deputy Charles Flanagan asked about the legal tendering process. We are dealing with 11 different health boards and various different hospitals throughout the system. The difficulty in providing a more detailed answer for the Deputy was the cost coding used down through the years is different in each of the health boards. So although we were able to extract solicitor fees, we could not easily extract counsel fees because a counsel fee would be included with a settlement. We have not even been able to do this for our own national tender. One bill would be received and it would be costed to a particular centre. That is the difficulty in providing a subdivision; it would require going back into every single office, pulling out the paper invoices and dividing it to provide a more detailed response. I assure the Deputy we are hoping to bring to our board a proposal following a national tendering process on the legal issue. If that is approved in December we could report back to the committee and I believe many of the issues the Deputy has raised and the concerns he has will be addressed in the new process we will be adopting. However, I would prefer that to have been examined by our own board first.

Can I communicate directly with somebody because I am not happy with the process?

Mr. Brian Gilroy

I would be happy to meet the Deputy on the matter. We are still seeing progress in primary care centres and while there have been delays in some parts of the country, many of those delays are down to the funding institutions being used as opposed to any other issues. As recently as last month I met representatives of Bank of Ireland who stated they would happily fund more of these if people approached the bank about them. We have also had discussions with a private equity firm from London which is on the brink of investing €100 million in primary care centre projects. While I appreciate some projects are not progressing, in many cases that is down to the funding institutions being used or the legacy of some of the promoters with regard to their financial status.

The cystic fibrosis unit in St. Vincent's Hospital is under contract and construction is under way. The only issue of delay related to adhering to public procurement. We went with the timescales we outlined.

The preferred bidder we selected had to post bonds and prove its ability to finance the scheme. It failed to do so within the specified period of time, so we moved on to the next bidder. The contract has now been placed with the next bidder.

I thank Mr. Gilroy and congratulate him on the work he is doing. Has Mr. Magee said everything he wishes to say?

Mr. Cathal Magee

I ask my colleague, Mr. Martin Rogan, who is the HSE's director of mental health, to respond to the questions that were asked about the recently published report on child and adolescent psychiatry.

Mr. Martin Rogan

The second report on child and adolescent psychiatry was published on Tuesday of this week. Significant progress has been made in this area. The number of children waiting for these services has decreased. The length of time they have to wait has also reduced significantly. Some 49% of children are seen by a mental health professional within a month of referral. Some 67% of them are seen within three months. Emergency presentations of children who may be at risk of self-harm are dealt with immediately, without any waiting time. Significant progress has been made in that area.

A member of the committee asked about the treatment of children in adult units. We operate 42 approved adult centres. We are pleased to say that in 40 of those units, no child under the age of 16 has been treated since July 2009. We will open two brand new units in the next few weeks, one at Merlin Park in Galway and one at Bessborough in Cork. These world-class facilities will meet the needs of young people with mental health problems. A great deal of progress has been made in this regard.

I wish to reiterate what Mr. Gilroy said about mental health capital programmes. I have worked in this area for almost 30 years. In any given year, we normally have one large mental health capital project. This year, we have 16 such projects. As a result of the substantial progress that has been made in this respect, the quality and calibre of the facilities we use will be greatly enhanced.

Primary care services represent an important part of the primary care sector. Approximately 90% of mental health issues present in primary care. Many of them do not progress beyond primary care. Approximately 10% of them are referred on to secondary services. At present, there are 14 mental health professionals working in primary care teams nationally. There has been an improvement in this area.

We have developed a programme in conjunction with our colleagues at Dublin City University. We are now in the second cohort of the programme, which relates to team-based approaches to mental health in primary care. The aim of the programme is to increase the skill set, competence and confidence of workers in the primary care sector as they try to recognise and address mental health issues. We are very encouraged. We are undertaking a survey at the moment. We have had over 150 returns from primary care and community mental health teams. There are good protocols in place. Although we would like to improve on it, it is looking very promising at the moment.

There is no doubt that the area of self-harm and suicide is of grave concern. Last year, some 527 people completed suicide, which represented an increase of 24% on previous years. There are approximately 12,000 presentations of this nature in emergency departments each year. Research has suggested that a further 60,000 people do not present for treatment in these circumstances.

Helplines are very valuable for people in distress. The moment of crisis often arrives in the middle of the night, when some other services are not available. We are working with a number of non-governmental organisations and helpline providers. During the year to 30 September last, the Samaritans received over 310,000 calls, which represented an increase of 10%. We have developed a number of initiatives to deal with this area of concern. We are working on self-harm supports with our colleagues in the HSE and the NGO sector.

I asked a question about the mental health budget.

Mr. Martin Rogan

In relation to-----

We will take a couple of supplementary questions together.

I would like an answer to my initial question about the mental health budget.

I asked a question about the 5% budget cut. I also asked where and when a support hostel for the Clonmel area will be provided. I acknowledge and admit that Clonmel is not the centre of the universe.

It is for the Senator.

This an important matter for people with mental health difficulties in south and north Tipperary. It has been announced that the existing services will close by 30 June next, even though community services are not in place. It is perfectly reasonable to ask this question and to expect an answer.

I referred earlier to the 2009-10 annual report on mental health services for children and adolescents. I will mention some of the statistics in the report. At the end of September 2010, some 2,370 children and adolescents were waiting to be seen. I gave the percentages earlier. These are the actual figures. Some 1,611 children have been waiting for more than three months. Some 402 children have been waiting for a year. These children and adolescents are actual human beings. They have been waiting for up to a year because they do not have the money to pay for these services. It is a very serious issue.

Let us hear from Mr. Rogan on these important matters.

I reiterate that the Samaritans provide a listening service. They do not take a proactive approach to people who are in a suicidal crisis. We need a proper national suicide helpline that can take a proactive approach.

Mr. Martin Rogan

The most recent report on waiting times for child and adolescent services is the second such report. The previous report and audit was done in March 2007. At one stage, approximately 3,600 children were waiting for these services. That figure has now been reduced to 2,700, which is a significant improvement. I agree with the well-made point that the distress of young people also affects their families. Emergency presentations are seen on a clinically prioritised basis. Significant progress has been made in reducing the waiting list and we intend to reduce it further. Our 55 child and adolescent teams are working very hard on that topic.

I asked whether the blackspots around the country where there is no service have been addressed.

Mr. Martin Rogan

Services for young people are provided throughout the Twenty-six Counties. I have spoken to Senator Prendergast about St. Michael's unit in Clonmel on a number of occasions. It currently offers inpatient services to patients from north and south Tipperary. Patients in north Tipperary will migrate back into the mid-western service. One of our senior managers has been assigned to oversee that process. One of my own staff members has been actively involved in planning that.

Additional community developments are taking place in the Tipperary area. For example, a 40-bed adapted community nursing unit is being developed on the existing campus. The accommodation provided to service users and staff at the new facility will be far superior to that currently offered. We can correspond directly with the committee to provide details of where buildings will be provided under a number of capital programmes. We are working with our colleagues in estates to provide crisis houses and other support options to patients in south Tipperary.

It seems that the expected outcome of the sale of HSE lands has not been realised. In our area, we were very rich because we had so many lands in our ownership. They were red-circled. When the Minister of State, Deputy Moloney, was the Chairman of this committee, he was part of that process. Is it the case that the plans to close the services that are currently provided will stop right here and now? We do not have the follow-on services that are needed. The status of night superintendents will be reduced from January. It will be a matter for the nursing officer. The potential closure date will be between March and June 2011. It is not good enough for those patients.

Mr. Martin Rogan

As Mr. Gilroy has said, our estates programme has underwritten the value of the mental health commitments we have already made. Reference is often made to ring fencing. The concern with a ring fence is that one can be ring-fenced in or ring-fenced out. If we were wholly dependent on the sale of assets, that would be a serious concern. Our estates colleagues have actually expanded the envelope to ensure all the mental health commitments can be delivered. We are confident that the programmes to which we are committed will be delivered.

We were asked earlier about the apparent difference between the Department's figure for mental health expenditure and the HSE's expenditure in this area. I think the comparison that was made was between a 2009 figure and a 2010 figure. We use a number of sub-categories that are not used by the Department. Some of the non-care group categories are telescoped into the mental health spend.

We do not tend to use high-end technologies in the mental health area. Most of what we do is very labour-intensive. Over 80% of our expenditure are in the staff arena. There has been a significant decrease in expenditure as a result of last year's salary reductions and staff losses. A number of members have mentioned the moratorium, which accounts for much of the reduction.

Can Mr. Rogan comment on the fact that in certain parts of the country, parents are routinely told that there is a one-year or two-year waiting list? When does he envisage that this practice will change?

Mr. Martin Rogan

We have concerns in this regard. It has been suggested that there are inordinate delays in some parts of the country. A detailed report on our website demonstrates that less than 10% of children have to wait less than 12 months for this service. We are aware that some applications are enhanced, for example by including psychiatric opinions, in order to access educational supports like special needs assistance. That has introduced some delays to the process. There have been radical improvements in children's mental health services, for example in community-based and inpatient acute care.

A psychiatrist from Scotland was appointed to investigate the reason Limerick is receiving many more admissions. Is the investigation almost completed?

Mr. Martin Rogan

The work to which the Senator refers was commissioned by the Mental Health Commission. Dr. Sally Bonnar from Dundee has conducted this work and her initial report has been submitted to the Mental Health Commission. We are actively working with the commission.

Before I ask the Minister to respond, I ask Mr. Magee to make some concluding remarks.

Mr. Cathal Magee

On the general questions on the service plan, arising out of the publication of the funding scenario for next year, we will work through the development of the service plan from now until the end of December. No decisions have been made on service configuration, either in terms of inpatient beds or how we will execute the full delivery of the required savings of €750 million. We will try to minimise to the greatest extent possible the impact the funding reductions will have on the range of services available; seek to develop flexibility regarding the operation and management of the moratorium, which has a direct service impact; and focus on making significant efficiencies and cost reductions in overheads, procurement and drugs. We are already in negotiation with the drugs industry to try to achieve significant reductions in expenditure for next year. These measures will be taken with a view to producing a service plan to be submitted to the Minister at the end of the year. The plan will seek to provide for the best service possible within the resources available. Patient services will be the last port of call for impact.

I ask the Minister to address any pertinent issues raised.

The HSE has addressed many of the questions. While I would be pleased if the HSE were able to brief the joint committee on the Capita report on Navan Hospital, it must also be careful in that regard. I have had an opportunity to read the report, which is very stark and specific. Placing information of this nature in the public domain would allow us to have a more informed debate on the relevant issues, rather than the current misinformed debate. This applies to Members across the House. I do not believe anyone in my position would jeopardise patient safety when such strong evidence is available.

Deputy Reilly referred to the reclassification of Letterkenny Hospital. Classification is based on the complexity and acuity level. However, the complexity and acuity level of Letterkenny Hospital does not correspond to the classification in question. Nevertheless, I have some sympathy with the hospital in this respect and the matter is being reviewed. I understand a value for money report is about to published on these issues. When I visited Letterkenny last year I found the hospital to be well run. I know Mr. Magee would love us to reclassify the hospital because it would mean more money for him. We must bear in mind a range of issues.

The question on opening up the general medical service, GMS, is timely. The GMS has not been opened up because of an agreement between the Irish Medical Organisation and the health authorities which was reached when the GMS was established. Approximately 500 doctors who are appropriately qualified do not have access to the GMS list. Not only does this deny GMS patients the opportunity to have a wider choice, but it denies highly trained and educated doctors the opportunity to bid for State activity. While I accept the HSE will have to decide supports for doctors in the GMS scheme based on volumes of patients, there is no reason a qualified doctor should not have access to GMS patients. Opening up the scheme would enhance innovation in the provision of GMS services.

I was asked a number of questions about demand-led schemes. There appears to be a misunderstanding that the fair deal is a demand-led scheme. That is not the case. The demand-led schemes are the medical card, drug payment and long-term illness schemes. I do not envisage that the number of medical cards will be reduced in 2011. We are about to go to Government with proposals for long overdue legislation on eligibility, which will reflect the suggestions made by the resource allocation group. A tiered level of benefits is what is needed in future to ensure we use the finite resources available to us in the fairest manner possible. We do not envisage that the reductions in funding next year will affect medical cards.

Funding will increase for the fair deal scheme, disability services and mental health services, specifically suicide prevention given the substantial increase in the number of suicides in 2009 compared with 2008. I am sure the incidence of suicide will be higher again in 2010. We need to enhance our efforts in the area of suicide prevention. Earlier this week, I met Mr. Day from the National Office for Suicide Prevention and Mr. Rogan and others who are keen to ensure the Department allocates all funding through one channel and uses the resources available to us in the most cost effective manner possible.

Home helps and home care packages are a priority and we must continue to roll them out. Notwithstanding the immense financial constraints facing us, we must continue with the change programme which is not an option but a priority. This will mean switching resources from areas of lesser priority to areas of greater priority.

In Ireland we are obsessed with the number of beds when the key issue should be activity. When I was a child I spent a week in hospital having my tonsils removed. Thankfully, such long stays are no longer necessary. In 2008, the HSE and the Department embraced the British Association of Day Surgery, which has 25 procedures in its basket that are done on a day case basis. Ireland has adopted 24 of these procedures, the 25th being abortion which is not performed here.

Last Saturday morning, I attended a good conference which addressed these issues. The target for day case procedures we have established is 75%. The figures vary significantly among hospitals, however. For example, Tallaght Hospital is the best performer in the area of hernia repair, with 85% of such procedures done on a day case basis in the hospital. The figure for Mayo hospital, on the other hand, is only 16% and the average length of stay in the hospital for the 138 patients who had the procedure performed was three days. Some 99% of varicose vein procedures are performed as day cases in Loughlinstown hospital, whereas the figure for the Mercy Hospital in Cork is 57%. Day cases should account for 95% of all cataract procedures and while the Mater, Waterford, Sligo and Letterkenny hospitals are achieving rates of approximately 90% for these procedures, the figure for St. Vincent's Hospital is only 42%.

Mr. Magee pointed out that if all hospitals were operating at best-in-class levels, we could do much more with the resources available. There are also significant variations in the system for same day admission for surgery. For example, in Wexford hospital and Naas hospital the figures for day admission for surgery stand at 81% and 73%, respectively, whereas the figure for Tallaght Hospital has fallen from 32% to 15%.

Serious issues related to the operation of Tallaght Hospital were highlighted in a report done by Dr. Maurice Hayes. Cultural, managerial and other issues at the hospital are being addressed by Mr. Magee and the HSE team as well as the board of the hospital. Mr. William McKee who for many years ran health services in Northern Ireland very successfully is assisting the hospital in improving its operations from a range of perspectives.

I am aware of a concern expressed by Deputy O'Connor, who is not present, that there should be local representation on the board of Tallaght Hospital. The manner in which the board was put together is not a model for the future. We need to learn lessons for the new children's hospital because we have merged three hospitals and, as Senator Fitzgerald will be aware, Tallaght Hospital consists of the Meath Foundation, Adelaide Foundation and Harcourt Street Foundation. This tells us all we need to know about the failure to achieve the appropriate mix in the hospital. We need to learn lessons from this failure. The board of the hospital has appointed a smaller board to act as a management board. I support this decision. The HSE will work with the hospital on the recommendations of the Hayes report.

On staffing, we cannot break the moratorium because we have a major issue with financing. While I salute the lobbying of committee members by the Irish Nurses and Midwives Organisation, notwithstanding reductions in staff, the Irish health system continues to have a high proportion of nurses relative to other European countries. The figure here is almost twice as high as the figure in France. Issues arise regarding the deployment of nurses. Under the Croke Park agreement, we want to redeploy staff from areas where they may be surplus to requirements to areas where they are necessary. We have had some good examples of such redeployment this year.

Nurses must also be empowered and for this reason we provided that they may prescribe medication and X-rays and carry out forensic examinations. Nurses could do many more of the tasks currently carried out by junior doctors and are willing to do so. We need to embrace this agenda and achieve a better skill mix.

The issue of visas for junior doctors was resolved in June. The chief medical officer might talk about the issues that arose in regard to junior doctors, in particular in so far as accident and emergency and other services are concerned.

Deputy O'Sullivan mentioned the different figures. There are two sets of accounts, namely, the Vote accounts and the income and expenditure accounts. I am not an accountant. I will ask Mr. Woods to clarify later why there is a difference. As I understand it, it is do to with accounting rather than anything else. There are different ways of calculating the expenditure.

Notwithstanding the moratorium, permission was given to the Health Service Executive to recruit 100 psychiatric nurses. The Health Service Executive is currently recruiting social workers, therapists and consultants. There are exceptions to the moratorium but until we get the flexibility of the Croke Park agreement embedded in the system we must be careful before we start a massive recruitment campaign which would not make sense at the moment.

On thalidomide, we have agreed that all the documentation will be given to the association. I am sorry it is taking so long. It is like a discovery process, which is a very slow process. I have spoken to the Secretary General. We have greatly reduced the overtime bill in the Department of Health and Children for obvious reasons. If we were to speed up the process it would require putting in resources by way of overtime. The Secretary General will do his best to have that documentation provided as quickly as possible. I would like to see that happen.

Could the Minister put a time on that please?

Mr. Michael Scanlan

I will not promise something today that I cannot deliver. I will go back and check with the Department between now and the end of the year on what I can achieve and I will let the Senator know.

With all due respect, this is going on for months. It is very unbusinesslike.

It is not actually. To be fair-----

We will ask the Secretary General to correspond with us as soon as possible on the matter.

He should give us a date. It is dragging on.

He is not in a position to give us a date today.

Is it not just a case of photocopying documents and redacting names and information that are not supposed to be public?

I will stop the members as it is contrary to the proper committee procedures-----

We have to speak. People are waiting.

-----to put questions to the Secretary General on the situation.

I am sorry. We will put them to the Minister.

We will put the questions to the Minister. I am sure the Minister will arrange to provide the information.

That is very odd.

The Secretary General talks to the Minister all the time.

I am sure he is advising the Minister.

In this era of accountability we need to let Secretaries General speak for themselves occasionally.

I do not make the rules but I will implement them.

No other country but Ireland would allow this to go on for so long.

Senator White should not put her hand up in that manner when she is talking about that sort of thing.

I am advised by the Secretary General that it is a question of going through a multiplicity of files. They are not all in the one place. It is not a question of just putting material on a photocopier and sending it off. A big search is going on to find all the documentation. It is not in one place. The Secretary General will revert to the committee as soon as possible.

Thank you, Minister.

Deputy Naughten asked that the value for money report on the disability service would be published. That is not ready yet. However, there is another policy review which will be ready shortly which we will publish. Among the recommendations it is making is for a more customised service such as perhaps providing respite care at home, moving towards individualised support rather than block grants to institutions to provide services. It would be very useful if we could have that published as quickly as possible.

Deputy Lynch inquired about the moratorium on women and pregnancy. Our only midwife, Senator Prendergast, referred to the fact that women have the babies "for the moment". Notwithstanding the wonderful developments in the health system I am not aware of-----

These things might change.

-----any emerging research that sees that changing in the foreseeable future.

Thanks be to God.

Approximately 6,000 people in the Health Service Executive avail of maternity leave. It is a very young workforce. In general, those people are replaced but there are exceptions where they may not be for particular reasons. They are not affected by the moratorium but there may be isolated incidents where they are not always replaced.

I was asked about my letter to Deputy Mattie McGrath. I am very happy to let the committee have a copy of the letter. I said in the letter that Professor Turner was examining maternity services. He will not report for another 18 months to two years. In the event of maternity services going to Waterford it would need capital investments so there will be no change in that in the foreseeable future. Clearly, the current financial situation will impact on acute hospitals across the country. I am not in a position to say at this stage how it will impact on a hospital such as the one in Clonmel. I have not seen the service plan of the Health Service Executive. In fairness, it could not supply the service plan until it knew the position. Everyone will be affected by the reduction in resources. That is why, as the chief executive said, we need greater flexibility, more innovation and thinking outside the box.

In reply to Deputy Aylward's question on HIQA, we are always very good at calling for regulation and then when it happens and we do not like it. We are the first to say "Hands off, here." It is a bit like our local facilities. We see the consequences of a failure to enforce regulation in the banking system and what that has done to the country and individuals. A failure to regulate in the health area can have fatal consequences for older people, as we saw. It was never the intention to include what is called the "welfare homes" because that is not a nursing care model. It is more a retirement model, as it were. We are reviewing the legislation to exclude them.

That is the issue I raised. We all want regulation. We understand the need for it. However, I wish to know whether the same strong regulation will apply as applied in the past.

To be honest when the regulations were introduced that was not brought to our attention. We were aware of the existence of "welfare homes" but we were not aware that they would be brought in under the regulation because of the way they are classified. We are addressing the issue.

Will they be excluded?

They will be. We have started a review. I had a good meeting with people the other day.

That is good enough.

The officials in my Department are beginning that review and they will consult on the matter.

I was asked why doctors charge between €60 and €65. Perhaps Deputy Reilly might answer that rather than me.

When I am Minister I will answer it.

I suspect that much of it has to do with Deputy Reilly's previous activities.

Hardly. The increases occurred in the past two years. I have not been doing that job for five years.

In my area a doctor who lives three miles away from me in one direction charges €45 while another doctor who lives in the other direction charges €65.

I suggest Deputy Aylward goes to the doctor who charges €45 and if the other one sees his patients moving-----

The doctor charging €45 cannot deal with all the patients. That is the problem.

We need more doctors. When the 500 new doctors come in I hope we will see an improvement.

Could we regulate the price?

We do not regulate prices here but if we were to, it would not be a matter for me, it would be a matter for the Minister for Enterprise, Trade and Innovation as it relates to price control and regulation. We have long since gone away from that.

Senator Fitzgerald asked about the fair deal scheme. There will be additional resources for the fair deal scheme. We have sufficient money this year to meet the demand. We want to continue with that. The Health Service Executive is working hard to process and approve all the applications by the end of this year.

We have taken approximately €250 million from our drugs costs in the past 18 months. There is a host of factors as to why drugs are more expensive here. In terms of the supply chain we reduced the retail margin from 50% to 20% but in Germany it is 3%. The distribution margins are another factor. We must look at all the elements of cost. We intend to do that. I hope all the people who supply the Health Service Executive with goods and services will respond to the economic difficulties the country faces and the huge pressure that confronts the health service. If we cannot get reductions in the cost of goods and services then patient care will be affected. I appeal to everyone to respond to the current situation. I am optimistic that will be the case.

What about breast cancer services?

I would love to see BreastCheck extended. I have already spoken to Ms Susan O'Reilly, the new head of the cancer control programme. I know she would like to do that too. It is clearly an issue of affordability. The two screening programmes we have at the moment are for women, CervicalCheck and BreastCheck. Next year we will start the first screening programme on colorectal cancer. That will include men. The strong advice available to me and the Health Service Executive is that it is the next area we should roll out. We will make provision for additional resources for cancer as well in the context of the Estimates for next year and the four year plan. It would be a good way to start if we could find an affordable way of doing it for the women who are currently in the system. I would like to see whether we could advance that. I cannot give any promise today because we are under many financial pressures and it is an issue of affordability at this point.

It is about the human rights of older women.

Those affected by colorectal cancer also have human rights.

A woman is seven times more likely to get breast cancer.

Only one speaker at a time should speak.

I am going through the questions one at a time. If there is something I have not answered I am more than happy to return to it.

We will quickly go to the spokespersons for concluding comments. Members who are not spokespersons may ask a brief supplementary question now.

The 5% cut will not apply across the board. We do not intend to apply it to mental health and disability services because they are priorities and affect the most marginalised. In the approval process for the service plan, we had discussions with the CEO and chairman of the HSE on this matter. We hope there will be less of an impact on those services in particular. I am very keen to ensure respite services will be protected in the funding allocation process. There was considerable controversy last year when organisations announced they would turn off respite care. That would not be acceptable. Respite services will have to be protected in the mechanism by which funding is rolled out by the HSE. That is the only way people can support those with a disability in a home environment. Without that, it would be impossible.

If there are questions I have not answered, I ask the members to revert to me.

I ask every member to mention his or her issue of concern.

Mine is the issue of cancer patients having to go through accident and emergency departments.

What about the extension of BreastCheck? Could the HSE liaise with the Marie Keating Foundation, for example? Could there be some work done in this regard?

With regard to the national treatment purchase scheme, I understand only 10% of patients can be directed towards public hospitals. Why is this and why must 90% be directed towards private concerns, given that there is a facility and staff in Kilkenny that could carry the relevant procedures. The staff are paid by the HSE and the ward that was closed could be opened. Why can this not be achieved?

I referred to vaccine trials.

I ask the Minister to respond, after which we will proceed to the wrap-up.

With regard to vaccine trials, the legal advice as a result of the litigation in the courts is such that the information cannot be made available to anyone. I am not free to make it available. We no longer have the information; it had to be returned. I do not see the position on this changing. The matter went all the way to the Supreme Court.

Were the people to whom the files were being returned told they should keep them safely because people are looking for them?

The Supreme Court found that giving that information over with a view to the commission carrying out an inquiry wasultra vires. The Supreme Court is the highest court in the land. That situation will not change and I do not believe anybody will be able to address that.

Consider the question on the National Treatment Purchase Fund. We pay our consultants and we block grant our hospitals. Clearly, if we were to move to a higher level of activity in our public hospitals, it would have to be on the basis that the input cost rather than the staff cost, which is already paid for by the taxpayer, would pertain to the procedure in question. I will be happy to examine that.

Even though the procedure can be carried out for one third less money.

That is not true.

That is what I have been told.

The National Treatment Purchase Fund has been the subject of three inquiries on the part of the Comptroller and Auditor General. There is a bit of an obsession with it. Bearing in mind case-mix activities, procedures are sometimes much cheaper but, generally, the prices are around the average.

In the spirit of innovation and given the financial constraints we are under, we must examine all the options. As I stated, the resource allocation group recommended prospective buying from hospitals for activities, particularly elective procedures. We hope to begin that process this year. The National Treatment Purchase Fund will have a role in that.

We are running seriously over time.

I am told the average cost of a procedure in the private hospitals is €12,000 to €14,000 whereas it can be done in those to which I refer for €7,000 to €8,000.

I will consider that and revert to the Deputy.

I asked about the transportation of cancer patients.

That issue should not arise. I will allow Dr. Barry White to address it.

Dr. Barry White

Patients ought to go directly to the ward. That happens in a number of hospitals, including the one in which I work. The standardisation of this practice across the system is a component of what we are trying to do in respect of acute medical admissions. They include cancer patients.

With regard to the hospitals in question, we will follow up on the question and have Dr. O'Reilly, the director of the national cancer control programme, revert to the Deputy. Deputy Flynn is correct in her point on increased efficiency.

It has been promised for two years but it still has not happened.

I call on Deputy Reilly to make concluding remarks.

A number of questions were not answered and I will take the Chairman's direction in regard to them. I would like them addressed before I make my concluding remarks.

Could the Deputy include them in his concluding remarks?

So long as they are answered.

We will ask for them to be answered.

I asked how many beds would go and how many would be left in the system.

Mr. Cathal Magee


We will listen to all Deputy Reilly's remarks and then hear the answers. Otherwise we will be here all day.

I asked about funding for the national paediatric hospital. Is it in the kitty or must it be borrowed? The answer I received on the national paediatric hospital suggested the specifications pertaining to a greenfield site would be such that the cost would end up very much the same. Are the specifications available for inspection by anyone who so desires? It would be appreciated if they were made available.

With regard to the medical card scheme, is there funding to accommodate the increase anticipated on foot of the high level of unemployment? I was concerned about changes with regard to medical card services. Are there plans to change the services available under the medical card scheme in respect of savings and procurement?

HIQA is very welcome and does identify problems. Unfortunately, there is a history of the Department and HSE using its reports to shut services down instead of addressing the issues raised therein. I refer in particular to Loughloe House, in respect of which ten problems were identified, eight of which related to management and staff. These are HSE issues.

The Minister referred to savings that could be made in respect of drugs and the drugs reference pricing legislation, which is far from being ready. A month's supply of hydrocortisone tablets, which have been available for decades, used to cost 96 cent but the cost has now risen to €22. That is before the chemist adds a mark-up. This is the case because there are no longer multiple producers; a single licence has been given to an individual, presumably because not enough money was being made in the past. This is an outrageous rip-off of patients and the public purse and it must be addressed. I hope the Minister will give us some comfort in this regard.

With regard to the Croke Park agreement, when will the 8 a.m. to 8 p.m. day start, and when will we begin to make savings?

On the home help issue, Mr. Magee stated we are 5% below this year's target. Is that on top of the 6% drop last year? Is it cumulative or 5% down overall? When I was in Donegal, I noted 105,000 hours had been removed from patients or clients. There are people who had home help with none now and they are very upset.

With regard to HPV vaccination, the figure of 47,000 is very welcome. What was the target population? Was it 60,000, 65,000 or 64,000? What is the percentage being obtained given the completion of the first round?

The non-consultant hospital doctor issue has not been addressed. I did not hear a full explanation of how we will address the problem of a shortage of non-consultant hospital doctors this January. This is to be the case in the accident and emergency department in Beaumont and will be the case in respect of anaesthetics, for example, elsewhere.

Nobody would preside over unsafe practice and I, as a doctor, certainly will not. However, notwithstanding what Dr. White said, my information is that there were four laparoscopic procedures reviewed out of 200. The review has never been made available to the surgeons concerned. Only 200 out of 1,800 elective surgical cases last year in Navan involved laparoscopy. While the Minister has had the benefit of looking at a report and is shocked by it, I have not had that benefit. Natural justice dictates that those who stand accused should be afforded an opportunity to see what they are accused of so they can defend themselves.

On the issue of day procedures, everyone wants to see a shorter hospital stay. However, that is not feasible if one does not have community supports in place such that when people leave hospital they will continue their recovery in a safe fashion. Where one attempts to have a shorter hospital bed stay without such support in place, one ends up with readmissions and worse outcomes.

I thank the delegates for their replies, one or two of which I want to address. The Minister stated she does not envisage a reduction in the number of medical cards in 2011 but that there will be plans to tier the benefit thereafter. That is a distortion of what was proposed by the Minister's expert group. It sought to expand access to primary care through the medical card system. Will the Minister clarify if she is examining reducing access for people with medical cards?

I welcome the Minister's assurance that the 5% cut will not apply to mental health and disability services. Will those who deliver section 38 services, such as Headway and the Brothers of Charity, have their 5% allocation cut or will their funding be protected?

Will the Minister respond to Mr. Magee's request for flexibility in implementing the recruitment moratorium? Ensuring the proper complements of staff will be important in protecting front-line services.

Is the Minister going ahead with the reference pricing for drugs Bill? Has HSE west collected all moneys it is owed by the health insurers? Will a better collection system be in place next year?

Senator Prendergast submitted a freedom of information request in February about the closure of St. Michael's acute psychiatric unit in South Tipperary General Hospital but still has not received a response.

With regard to hydrocortisone, I understand production was transferred by Merck Sharp & Dohme to Auden McKenzie. Merck Sharp & Dohme was prepared to supply it to the Irish market at 80 cent per 10 mg tablet. Unfortunately, under the new licensing arrangement, Auden McKenzie now supplies the UK market at a price of €46 per 10 mg tablet. Such issues arise with monopoly providers of medicines. It is regrettable to see such an enormous price increase for patients and public health services.

We do not envisage taking medical cards off people. We are also factoring in increases because of rising levels of unemployment. The resource allocation group recommended a greater emphasis on primary care with four different categories of support. There would be those at the bottom, for whom everything is paid, and as one went up, some people would make some sort of a contribution. This is a large transformation which will take some time.

The eligibility criterion for a medical card is based on disposable income. The case has been made, which I believe is valid, that health requirements should also be factored into the criteria. Some may not have a health requirement to see their general practitioner very often while others have particular illnesses which may require more frequent use. A medical dimension should be factored into how medical cards are allocated.

There has been an 18% take-up of the hepatitis B vaccine. Regarding funding for the national children's hospital, all moneys spent on health are borrowed. That is no reason, however, for not proceeding with vital infrastructure projects.

This week we are waiting on more borrowing.

It is capital borrowing. Although there have been large reductions in the Health Service Executive's expenditure, the capital programme is preserved. Of the €1.6 billion reduction over the lifetime of the plan, there is a reduction of €13 million in capital expenditure which is nothing. Given what Mr. Brian Gilroy said about the new tendering outcomes, this is a healthy state of affairs. Essential ICT, primary care and hospital infrastructure will be provided for.

The current children's hospitals at Temple Street and Crumlin are not fit for purpose. The original plan was to build a new hospital for both which would have been more expensive, never mind not having the best clinical outcomes. I can give Deputy Reilly the details on the costing and clinical outcomes for the alternative site. All involved in the process, McKinsey, RKW Healthcare Strategists, Dr. Ronnie Pollock and Mr. Boden, strongly endorsed the current approach. The Bristol inquiry in the UK also stated that quality outcomes must come before access issues.

The children's hospital will be a key piece of infrastructure that will be protected in the four year recovery plan and hopefully, will go to construction in the third quarter of 2011.

Mr. Seán McGrath

There are over 4,600 NCHDs in the system, of which 3,750 are in training posts, a number of them are in contracts of definite duration in small to medium-sized hospitals and 300 in service positions. We are hoping to rotate these 300 service posts in January. Normally the majority of training posts are rotated in July.

We have advertised in the system for junior doctors, with particular emphasis on services posts in small to medium-sized hospitals. We are coming under pressure at Beaumont, Letterkenny, Limerick and other hospitals, particularly in accident and emergency, anaesthetics and surgical specialties.

Many of the service posts used to be six-month rotations. We are reconfiguring the employment contracts for these service posts and rotating them through a training institution, such as Beaumont. This will create more attractive posts. Traditionally, they would not have had a training element in them. A significant training element will be built into them now, particularly in competency development, and they will be certified by the appropriate postgraduate medical training body.

We have advertised two-year posts for accident and emergency in Donegal. Over the next week, further advertisements will be issued for other two-year posts in speciality areas. They will be rebranded in a way that makes the post more attractive.

It is about contingency plans at local level. There are more advanced nurse practitioners. We need to ensure we use the skills mix in the system. Local areas are building these into their systems with clinical managers and clinicians. The second week in January is our focus for this rotation; the largest rotation will be next July.

The eight-to-eight roster is an integral part of the Croke Park agreement. It already exists for nurses, consultants and junior doctors. We have put in place engagement with diagnostics and laboratories to have eight-to-eight rosters in place. We are working through the rosters with the small, medium and large-sized institutions and hope to have them in place on 1 January 2011.

Mr. Cathal Magee

On the home help scheme, the 5% and 6% figures are the same. The 2010 service plan was somewhat behind the 2009 outturn. It is the same number and is not cumulative.

No decisions have been taken around capacity planning for hospital beds next year. This will be done over the next three to four weeks based on funding decisions.

As regards income in HSE west, we have made some progress. A better process is in place between now and the end of the year to maximise the income collection from private patient billing. I still believe there are inadequacies in the system and that we will have a lot of work to focus on next year in changing the process so that we can collect the income we are due. We are in discussion both with the Department and some of the insurers to try and tighten up the effectiveness of the process because of the significant gaps in our system.

Does Ms McGuinness want to say something about Loughloe House?

Ms Laverne McGuinness

The fabric of that building has long been inadequate, because of its flat roof, etc., and the level of investment required to render it appropriate was far in excess of what the building itself was worth. It was always intended to move the patients to a new centre at some time.

Is the building now being kept for a mental health facility?

Ms Laverne McGuinness

It is not suitable for the long-term care of older persons. There are six places left to be moved at this point.

Mr. Cathal Magee

As regards the Jack and Jill Foundation, I am arranging to meet its representatives over the next period to discuss the issues and see what we can do.

That is very good.

Will the Minister say when the report on the reconfiguration facilities will be issued?

I am not sure, so I shall ask Mr. Magee.

Mr. Cathal Magee

No date has been set for the publication of the report, as has been outlined in the answer to the written question. A group is in place. As the Deputy may have seen, we recently had the Cork-Kerry working group publish its report. No date has been set, but we are keen that the group there should engage and come up with conclusive recommendations.

What is the delay? We were promised last February that it would be issued, then in May and again during the summer. Is there a reason for this?

Mr. Cathal Magee

As was evident in the south region, we are engaged in extensive consultation, trying to build consensus and commitment both within the acute areas and communities to create understanding as regards the proper way forward, and that takes time. It is important to give that time to it so that we can have an output that has the support of the communities and the individual acute areas.

The outcome of the publication of the integrated acute network configuration in Cork this week, with the support of the voluntary health system, the statutory agencies and the various individual hospital units, sets a benchmark as regards how the management of change may be achieved in what is a very controversial and difficult area. The example now being set in Cork and Kerry is a model in terms of process, and we should like to see that replicated in the south east, a solution that everybody can support.

Very briefly, Deputy Reilly.

I am not clear whether the Minister is confirming to us that there will be no reduction in services for medical card holders in terms of access. There are no plans to change what people are entitled to in that regard.

Yes, that is correct.

I thank everyone for their patience and for the elaborate manner in which the questions have been dealt with. I wish you well in your work. I believe I speak for all the members in saying we hope to be back here in some shape or form for the next quarterly meeting.

The joint committee adjourned at 1.35 p.m. until 2.15 p.m. on Tuesday, 30 November 2010.