JOINT COMMITTEE ON HEALTH AND CHILDREN debate

Impact of Incentivised Early Retirement Scheme on Health Sector: Discussion

Chairman

Our discussion this morning concerns the impact of the incentivised early retirement scheme on the health sector. I welcome the following: the Minister for Health, Deputy James Reilly; and Ministers of State, Deputies Kathleen Lynch and Róisín Shortall; the chief executive of the Health Service Executive, HSE, Mr. Cathal Magee; Ms Laverne McGuinness; and other HSE staff to this meeting. I also welcome Ms Frances Spillane from the Department of Health. As witnesses are aware, in line with its commitment to the troika, the Government is committed to a reduction in size and cost of the public service.

This morning, we have also had news of a decision by An Bord Pleanála regarding the proposed children's hospital, which members of the committee have discussed in private. We are disappointed with the decision of An Bord Pleanála and as a committee we would like to play a role with the Minister and the HSE in the development of the proposed hospital. We respect the independence of An Bord Pleanála but we are disappointed with the decision. Our meeting today is predominantly about the impact of the incentivised early retirement scheme. The Minister may make his opening remarks.

Minister for Health (Deputy James Reilly)

For the purposes of clarity, this is not an incentivised retirement scheme; this is people taking the option to leave before the terms and conditions around their pensions might change at the end of this month. As a consequence, there is a considerable number of people leaving the service.

I thank the Chairman for mentioning the decision by An Bord Pleanála. We are obviously disappointed by it but this is merely a delay and the project is still very much on track in terms of funding and the arrangements around the tighter governance of the three hospitals and the bringing of them together will continue at pace. The Government is fully committed to the project and the additional funding and innovating arrangements around ensuring the funding for the hospital remain in place. We shall now sit down and examine very closely the decision by An Bord Pleanála before making a very rapid determination - with great urgency - to ensure that the children of this country get the best treatment in the best environment for them and their parents.

Chairman

I remind members there is a vote in the Seanad.

Deputy James Reilly

This represents a delay but it is merely that and we will seek to make up the time very quickly. I will appoint a review body, chaired by Mr. Frank Dolphin, to expedite the process and bring a group together to form recommendations very quickly on the next steps. I reassure parents of sick children, and those who are well but who may become sick, that this hospital will be built either at this location or elsewhere. The planning refusal pointed to the value of co-location and we will examine the options.

With the Chairman's permission I will read a short statement on the retirements. It is important that the committee has this opportunity to discuss the issue in detail and there has been much unnecessary anxiety created by hyperbole from certain quarters with regard to contingency plans put in place. I am very pleased to report we have a very complete team looking after this with an assistant secretary of the Department, Ms Frances Spillane, in charge. Ms Laverne McGuinness is the national director in the HSE taking charge of this co-ordination process and there are four regional directors of operation, who are here today too.

Each individual hospital and manager has plans in place and has identified clearly how many people are leaving and are required to be replaced. There are a number of contingencies in place with regard to dealing with this issue, including a mixture of redeployment, changes in work practices and recruitment of new people to replace essential personnel who have left. I have made it clear to this committee and elsewhere that only in exceptional circumstances will somebody who has retired be coming back, and any recruits will be new. They will be people of experience and of a suitable level of qualification. Our aim is to give as many of our newly qualified nurses, doctors, consultants and others a job.

The most recent information available to me indicates that approximately 2,100 individuals will leave the health service during the current month, while approximately 400 had left in January this year. However, it should be noted that these figures are subject to change because of, for example, the time lags involved in collating data at national level. Management at local and regional level has full details of their staff who have already left or will leave by 29 February.

Before I discuss the measures in place to deal with these retirements, I will first put them in context. As the committee is aware, the Government has decided, in line with its commitments to the EU, IMF and ECB, that it must reduce the cost and size of the public service. In this context the Government has determined that health sector employment numbers must be reduced to approximately 102,000 whole-time equivalents, WTE, in 2012. Further reductions will be required over the coming years also. These current departures, therefore, contribute to achieving the required reduction. It is also important to point out that the majority of the retirements during the current period involve staff who have already reached the age at which they can retire. Therefore, they would have retired within the next year or two, even without the effect of the "grace period" arrangements.

The HSE national service plan 2012 acknowledges that there will be an inevitable and unavoidable reduction in services this year because of the scale of the financial and staffing challenge facing the health service. As I said last week in the Dáil, I would obviously prefer to have more funding available for our health services but this is not possible in current circumstances. There is, therefore, a particular onus on all of us working in the health services to be as innovative and flexible as possible to mitigate the impact on services of reduced budgets and staffing.

Indeed, yesterday I was in Drogheda in the morning and in the afternoon I visited Cavan, Connolly Hospital and the Mater hospital. Last weekend, we were in Sligo, Manorhamilton and Galway and we visited Limerick on Saturday. I intend to visit a number of other hospitals before the end of this month. In each of the hospitals I have visited I have seen comprehensive plans in place to deal with the staff who are leaving. I am happy that the staff and the management are co-operating in delivering care in innovative ways which, notwithstanding the retirements, was going to yield much greater improvement in service and allow us to treat more patients more quickly.

The mitigation measures which are in place include the back-filling of certain critical posts. However, the main focus is on reform and achieving greater productivity. The national clinical programmes are already delivering improvements in day-of-surgery admission rates, increases in the proportion of care that can be delivered on a day case basis and other productivity improvements designed to provide a better quality service to patients at less cost. I very much welcome the clinical leadership that is being provided in this regard. I also welcome and acknowledge the improvements in productivity that are being delivered by staff at local level through the Croke Park agreement with regard to, for example, staff redeployment, streamlining of management structures including clinical management roles, changes in skill mix and more cost-effective rosters. However, this is and must continue to be an ongoing process and it is essential that all concerned continue to deliver the level of reform provided for in the agreement. The need for dynamic and proactive management of the impact of reduced budgets and staff will remain and must be pursued vigorously beyond 29 February.

Planning for the impact of the end of the "grace period" began last autumn. The retirement of substantial numbers of staff was predicted and was one of several big factors taken into account when the national service plan was being prepared. Regional service plans have been developed from the national service plan, dealing with the detail of service provision in each of the four regions. Contingency plans have been developed locally for hospital and community services. These plans reflect risk assessments undertaken by each hospital and community services manager and their clinical leaders. The plans have been reviewed in detail at regional and national levels to ensure appropriate contingency measures are in place across all services.

Measures to minimise the impact on front line services include: staff being redeployed across services; consolidation of clinical management roles; reorganisation of services; changes to staff rosters; more appropriate skill-mix; and significant personal flexibility being shown by staff, for example, staff postponing leave or working additional hours for time off in lieu, as distinct from additional pay. During the debate in the Dáil in the last two days, there were many what I consider to be attacks on senior clinicians and consultants, many of whom are working way beyond their contracts and working weekends, including conducting ward rounds and discharging patients at weekends. I welcome that and commend them on it. They are doing that voluntarily, as it were, at present and no service can work on a pro bono basis.

We must get this formalised through the Croke Park agreement. Meetings are starting to take place and I ask that both sides expedite this. The willingness to perform those duties at weekends has improved our situation immeasurably and with the continued development of access to diagnostics at the weekend, we will have what we should have, a seven day service with people getting diagnosed and discharged on a seven day basis, not waiting in bed from Friday until Monday for the result of a test.

It is important to understand that this is a dynamic and ongoing process. Plans will continue to be reviewed and revised, where necessary, based on changing circumstances. In overall terms, the areas of critical risk have been identified and are being addressed, primarily in the acute services and including midwifery, neonatal care, critical and intensive care and also in specific consultant and specialist posts. These are the areas where some staff are being replaced and the senior HSE officials present today will deal with the ongoing planning arrangements in more detail. I am sure members will wish to ask specific questions about their own area and the four regional directors of operations, RDOs, are here today to help in that regard.

In addition, a formal transition team for the health service has recently been put in place to ensure that all necessary measures are in place. The team is chaired by Ms Frances Spillane, assistant secretary in my Department, and includes Ms Laverne McGuinness, national director of integrated services, Dr. Philip Crowley, national director of quality and patient safety, and the four RDOs. It is important to note that Dr. Philip Crowley has been through this to ensure that we have a safe service. I am satisfied that appropriate arrangements are in place at national, regional and service specific levels to proactively manage the impact of staff exits on front line services. The focus is on protecting and maintaining critical front line services such as emergency department, maternity, critical care and neonatal services. The provision of a quality and safe service is at the centre of the contingency planning process.

I wish to reassure people that everything that can be done is being done. We have no reason to expect that we will not have a safe service. Much of the hyperbole and anxiety being created by rash statements with no foundation do little to help patient care or the people who are striving at the front line to provide services to our patients.

Chairman

I thank the Minister for his presentation. I welcome his and the Government's commitment to building the children's hospital. The committee with work with the Minister, the Department and the HSE in any way possible to ensure this hospital is built. Never have we needed one as much and over €33 million of taxpayers' money has already been invested in the project. The Minister will find a collaborative approach to that within this committee. We are disappointed with the decision of An Bord Pleanála but perhaps it offers an opportunity to look at other sites as well.

I welcome Mr. Cathal Magee, chief executive officer of the HSE. I invite him to make his opening remarks.

Mr. Cathal Magee

I thank the committee for the invitation to attend this meeting to discuss matters arising from the impact of retirements under the "grace period" in the HSE up to the end of February 2012. Under the Financial Emergency Measures in the Public Interest (No 2) Act 2009, provision was made regarding the calculation of pension entitlements to ensure that the pay reductions under that Act would be disregarded for staff who left the public service by 31 December 2010. That date was later extended to 29 February 2012. The implementation of the "grace period" retirement scheme is in line with the Government's policy to reduce the numbers working in the public sector and the associated pay bill.

In summary, to date, the total number of staff who have indicated their intention to retire is 4,326or approximately 3,822whole-time equivalents. At the end of January, 2,176 people or just over 50%, have left the health services since the end of September. The balance of circa 2,150 staff will leave during the month of February 2012.

I have set out in the following tables a high level breakdown of the 4,326 notified retirement exits. In the first table of the category analysis, over 1,052, or 24%, are what would be termed early retirements, that is people who are taking up the option of leaving on an actuarially reduced pension entitlement on an early date and that is cost neutral. Some 52% or 2,264 staff have already reached retirement age or are over 60 years, with a certain percentage over 65 years. Some 17% of staff are retiring on other grounds, including permanent ill-health and 6.5%, or 283 staff, mainly in the mental health service, who have the option to retire at age 55 years are taking up that option. In all about 3.3% of the workforce is leaving under this scheme.

In table 2 we set out the regional breakdown of the retirement numbers. In table 3 I have set out the retirement by care group category and perhaps I could set out the percentages across the care groups. Let us look at acute hospitals, even though 1,490 people are leaving from the acute hospitals, it still represents 2.68% of total. Obviously almost 45% to 46% of staff work in acute hospitals. From the disability services it is 2.47% and from care of the elderly, it represents 3.4%. The 586 leaving the mental health services represents 5.64%. That figure is higher because staff in the mental health services have the option to retire at 55 years, increasing the numbers in that category who have the option to retire. In primary care, the figure is 676 which is 3.77% and in the category, "other", the number leaving is 524. Under the heading primary care, we also have a category multicare, a certain number of the category "other" could also be primary care or community services related.

The staff categories have been set out in table 4, with a column for each of the major staff disciplines. Obviously, the number of retirements from nursing at 1,994 is quite significant. In our health services we have 36,000 nurses, which represents 35% of the health service workforce. The uptake of the scheme represents 4.65% of nursing staff and Ms Laverne McGuinness will take us through a more detailed account of the breakdown by the disciplines. In terms of the numbers leaving from the medical and dental service, it represents less than 1.8% of total staff.

As the Minister stated, planning at national, regional and site specific levels has been under way since autumn 2011. The projected numbers retiring were factored into our national service plan 2012, which was published in January and to each of the regional service plans. The service impact of both the grace period retirements and the overall HSE budget reductions of €750 million for 2012 are reflected in both the national and regional service plans. From a budgetary perspective, there is an imperative that the number of staff who work in the health service is reduced, otherwise the budgetary parameters cannot be met. If one looks at the percentage of our spend on pay in the health system, the figure is quite significant, when one eliminates drug costs and the cost of our primary care reimbursement scheme. In our acute service, some 72% of our cost is pay related. Pay, as a percentage of cost in the mental health service is 85%. In disability services it is 80%, so a very significant part of the cost structure of the heath system is pay. If one must face significant budgetary reductions, that can only be delivered by significant reductions in pay costs and pay numbers.

The HSE national service plan for 2012, envisages there will be 3,313 retirements, giving a pay bill reduction of €160 million for 2012. The plan states there will be an unavoidable impact on front-line service delivery in 2012 because of the scale of the financial and resourcing reductions. The challenge facing us is our ability to continue to maximise services to the public through fast tracking new innovative and more efficient ways of deploying our resources. I have set out the steps we have taken to mitigate the service impact of these retirements. We have put in place a number of significant measures which include: seeking extra flexibility and productivity under the Croke Park public service agreement, which is allowing us to reduce and to redeploy staff; consolidate line management resources, including clinical management; engage in change processes; provide for improved staff rostering, changes in skill mix and targeted reductions in reduced absenteeism.

In nursing, some 662 of 1,994 staff leaving nursing will be nurse managers, so obviously this has an impact on nurse management. The second area, would be around innovation and productivity through the national clinical programmes that the Minister has referred to, which are targeted at reducing the average length of stay, improving the day of surgery admission rates, increasing the proportion of day case over inpatient treatment, and more productive use of our operating theatres. There is an investment of €23.4 million allocated in the national plan for these programmes.

There is a clear and pressing need, as outlined in the clinical programmes, to move to models of care, across all our service and care groups, to treat patients at the lowest level of complexity and provide services at the least possible cost. There are 57 consultants retiring from the acute services, but we are proposing to replace almost 48 consultant posts. There is a very significant investment in the clinical leadership of our acute system that must be protected through this phase. Strategic allocations have been included in the national service plan for mental health services at €35 million, with a recruitment target of up to 414 staff and €20 million set out for primary care with an additional €5 million, if we can make the necessary savings in our drugs budget. This additional investment will allow the HSE progress the strategic objective of shifting the balance of services in the community. A figure of €16 million has been allocated for replacement posts and this has targeted critical service posts, where these posts cannot be replaced by redeployment and changes in work practices and where such posts have been identified and agreed as part of our continuous planning process. My colleague, Ms Laverne McGuinness, will take the committee through the detail of that replacement strategy, but out of 4,326 retirements, there will be around 500 replacements, or around 12%. If one takes that figure of 500, together with the proposed 400 staff for mental health services and the provision for recruitment in primary care, up to 1,200 posts will go back into the system. That is subject, obviously, to our financing capability. The HSE key priority at all times will be to maintain critical front-line acute services, including emergency, intensive and critical care, and neonatal and maternity care services. These areas will be the priority for replacement posts.

I would also like to take this opportunity to publicly acknowledge the significant personal flexibility being shown by staff in our health and personal social services at this time, particularly our clinical community, who are taking unprecedented leadership in our system. One of the real positives that has emerged in our health system in the last 12 to 18 months is that our clinicians are beginning to take leadership and management roles. I say clinicians in the broadest sense, not just doctors, but therapists and nursing staff who are beginning to take ownership of the challenges in running the health system and maintaining our services with less resources. They are wrestling with those issues on a daily basis. The level of commitment, the increased productivity and the flexibility that has emerged throughout the health system to meet the resource challenges is impressive and is unprecedented. In our acute system, in the past two years, 2010 and 2011, our costs have reduced by approximately 11% and activity, if one combines day and inpatient activity, is up by 8%. That is an 18% to 19% productivity dividend in our hospital system in the past two years. It has put enormous pressure on the system and that is understood, but it shows that more is being delivered with less. That continues to be a challenge as we move forward and nobody in the health system would understate that challenge. However, it is important to recognise the commitment staff are making on the ground in order to maintain services in difficult circumstances.

We have included in our submission a detailed briefing document which provides all the data at regional level and sometimes for particular settings. We have also circulated a set of summary slides and my colleague, Ms Laverne McGuinness, will be happy to run through them for the committee. The submission provides more insight on the number and type of staff retiring, the contingency planning being put in place, the risk assessment process we have gone through and the review process on replacement posts that we have put in place and the specific measures being taken to mitigate the impact of these retirements.

Chairman

Thank you. I will now call on Ms McGuinness to make her presentation. Members have copies of the presentation documents on their desks.

Ms Laverne McGuinness

I will run through the slides with the committee and will indicate the slide number so that members can keep track of where we are. Slide No. 2 deals with retirement numbers and, to 16 February, the number of retirees is at 4,326. The number of people who have left already, to 16 February, is 2,347, some 54%, and more will have gone since then up to today. It is anticipated that the majority of the retirees will be gone by 28 February. Slide No. 3 also shows the number of retirements by region. In percentage terms, the figures are broadly much the same. In Dublin-mid-Leinster, the percentage is 23%, in the north-east region it is 21%, in the south it is higher, at 28%, and in the west it is 27%.

Slide No. 4 provides some indication of the retirements by care group. Retirements from acute hospitals will come to 1,490. However, over 50% of our workforce are in our acute hospital services so this is relative. Some of the other areas to lose large numbers are the primary care area, where we will lose 676 staff and the mental health and elderly care areas where we will lose 586 and 572 staff respectively. On the right hand of the slide members can see the breakdown with regard to the type of staff leaving. The number of general support staff leaving is 468. One of the higher figures is for our nursing staff, where 1,994 staff are leaving. However, we have 36,000 nurses. Of the 1,994 nursing staff leaving, some 662 are in the nurse manager grades. This data is set out for the committee in our report. In the area of management and administration, approximately 400 staff are leaving.

Slides Nos. 5 and 6 deal with the planning process. The process has been in gestation since the autumn and plans have been made at various levels. Plans have been made locally in each hospital and in each community setting, whether mental health, disability or elderly care. These plans have culminated in regional service plans and a national service plan. We have taken account of the number expected to retire in our service plans and of the pay bill reduction we are required to meet of €160 million. The key areas on which we are focusing are our essential, critical, front line services, such as maternity services, emergency departments, critical care and neonatal care.

The Minister has met the CEOs and the clinicians in the various hospitals as part of the process so as to ascertain the impact of the retirements, the plans being put in place to deal with that impact and the plans being put in place to minimise risk. The major part of the plan is based on redeploying staff and changing the skill mix. Some nurses will be replaced by health care assistants, wards will be consolidated and there will be changes in work practices. Each of the CEOs have signed an assurance stating they are confident significant measures are in place to minimise the risks. The directors of nursing were also involved in that process.

Chairman

When did that take place?

Ms Laverne McGuinness

Individual meetings were held with each of the hospital CEOs or the group CEO over several days in February. We have that information and it is available.

Slide No. 7 indicates a number of national levers we are pushing to the max. One of these is the public service agreement. In terms of the flexibility we are working towards with staff, we are asking for changes in rosters and for staff to redeploy up to a distance of 45 km each way. For example, in the south, over 1,000 staff have been redeployed across the services. In order to minimise the impact on clinical programmes, an additional €23.4 million is being invested this year in these programmes. We are working towards decreasing the average length of stay and increasing productivity with regard to the number of beds we have, albeit we may have some beds left empty.

The national service plan also makes strategic allocations of funding, for example, €35 million extra for mental health, which will cater for approximately 414 posts which will primarily be for our community mental health teams, our child and adolescent psychiatry teams and therapy. Some €20 million is also being provided for primary care and this may increase to €25 million. That investment will go towards therapists and dealing with the gaps in primary care. In addition, some €16 million is available as part of the service plan for targeted recruitment and this will be targeted at areas where there are significant gaps, such as midwifery, neonatal care and emergency departments.

I have a number of slides that give a flavour of what is happening in each region and we have the regional directors of operations, RDOs, here with us and we can go through what is happening in detail if there are questions in that regard. Page 9 of our document indicates what we are doing. We are replacing approximately 524 staff overall nationally, which comes to between 10% and 12% of those leaving in the different regions. For example, based on the meetings we had with the managers and CEOs in the southern region, there are approximately 326 retirees from the hospitals, many of whom have already gone, 54%, and some 57 of these are being replaced. In terms of consultant posts, 14 posts will replace the 19 being lost and in maternity services, 23 posts will replace the 32 being lost and in the nursing area, the services will retain the graduate nurses coming on and the student nurses during the transition period in order to achieve some of the changes in work practices coming about.

Slide No. 9 shows that approximately 17.48 % represents the replacement factor in the southern region across our hospital services. We have also set out on a hospital by hospital basis the number of staff being replaced - 57. In the interest of transparency, we have also set out clearly the number of consultancy posts from which consultants are retiring and the number being replaced, 19 retiring and 14 replacements and this is illustrated on slide No. 10. Slide No. 11 provides the figures for maternity services, a critical area, where a total of 32 people are retiring and 23 replacements being made. In addition, there will also be some students taken off. These slides show the new head counts that will be in place, but there will also be some assistants coming in at these and other grades.

With regard to overall community services throughout the south - apart from the acute hospitals - a significant number of 891 are to retire and 31 of these will be replaced. These figures do not include the new investment about which we spoke that will go to mental health and primary care, but that portion has not yet been divided up between each of the regions. In the significant area of nursing in the community, some 266 nurses will retire, including 21 public health nurses, and some 28 additional nurses will be recruited. We are not necessarily recruiting public health nurses, but are replacing these with registered general nurses. In that way we will unite the skill mix of the public health nurses and the RGNs. We will use the RGNs to cover areas of the public health nurses' work and dedicate the public health nurses to the specific tasks for which they are qualified and needed. Quite a significant number of nurse managers are due to retire, some 662 of the 1994, and we are reorganising nurse manager posts.

We have more detail on Dublin north east in the presentation. Slide No. 13 illustrates that across hospitals and the community area, some 888 people will have left over the period from December to February. Some 357 are retiring from hospitals, with 71 of these being replaced. In the consultancy area, some ten consultants are retiring and some eight will be replaced. In the maternity area, some 21 people are retiring and some 20 critical posts will be replaced. It is important to note that while we say they are to be replaced, there are also interim arrangements in place. Therefore, the posts are currently covered and will be covered by either temporary posts or by staff working additional hours. In the case of consultants, we have locum consultants in place to cover gaps. All the transition plans are based on this premise.

With regard to the hospitals in Dublin-North East, our presentation documents provide a breakdown on a hospital by hospital level of where the replacement posts will be. The replacement rate for the hospitals is 19.88%, as illustrated on slide No. 14. Slide No. 15 shows the detail on the consultancy posts for Dublin-North East. It can be clearly seen that the two posts not to be replaced are in Cavan. If members want more detail in that regard the RDO will be able to provide that. Slide No. 16 indicates that some 21 midwives in the region are retiring and that 20 are being replaced. The other will be reassigned elsewhere. Therefore, there is one-on-one replacement in Dublin-North East in respect of maternity services.

Slide No. 17 shows the data on community and key risk services for Dublin-North East. In general, some 531 will retire and some 109 posts will be replaced. The figures do not take into account the new investment in either our mental health or primary care services. Some 24 public health nurses will retire in this region and some of them will be replaced by RGNs. There is a similar trend of replacement in each of the regions. In the area of mental health, it is intended to maximise the staff available through reconfiguration, particularly where institutional care facilities are closing and care provision is moving to the community. When they have maximised this, some of the critical posts will have to be replaced. We had a particular issue with regard to St. Joseph's intellectual disability services, which is on the site of St. Ita's in Portrane and clinical posts there will need to be replaced in order to have a safe level of service. There is a disproportionate number of therapists leaving from the primary care teams in Cavan and Monaghan and some of these will be replaced.

Slide No. 18 deals with Dublin-mid-Leinster, which will lose 998 staff in total and some 54% of these have already left. Across the hospitals in this region, there will be some 415 retirees and some 83 replacements. In the consultancy area here, there will be 18 retirees from key specialist areas and they all will be replaced. In maternity services, some 31 staff will retire, mainly midwives, and 25 of these will be replaced. Slide No. 19 sets out the numbers leaving and being replaced on a hospital by hospital basis. These plans have been done in conjunction with the CEOs of the hospitals and have been signed off on. With regard to consultant posts for this area, slide No. 20 indicates again that all of these posts will be replaced. Slide No. 21 shows the details for maternity services. A significant number of midwives will retire from Holles Street and there will be six replacements. The master of the hospital has indicated the hospital will reconfigure and convert some overtime and agency posts into wholetime equivalents so that the hospital will be able to deliver safe services. Management is confident of that and has signed off to that effect. The other maternity hospitals will replace retirees almost on a one-on-one basis.

With regard to community services for Dublin-mid-Leinster, which includes all services outside acute services, some 583 will retire and some 50 of these will be replaced. The Central Mental Hospital has been a specific issue, where some seven nurses are retiring, five of whom have already left. However, it is not these seven who have caused the issue, but the cumulative effect of the numbers that have left over the years. However, there is a plan in place to convert overtime money, of which there is a significant spend, into wholetime equivalents or additional headcount and that plan is being progressed. Therefore, additional staff will be recruited for the Central Mental Hospital over and above the seven being lost. With regard to community nursing, some 183 nurses are leaving, including 33 public health nurses. Some 39 nurses will be taken on to replace these posts. We are also reorganising nurse management grades and posts.

In the area of public analysis and laboratory posts, there is specific detail on this area in our report. Quite a number of people are leaving posts across biochemistry and laboratory services. Each of these areas has reorganised to cope with this but some of the key posts must be replaced as not to do so would be risky.

Slide No. 23 relates to the west. In this area some 1,994 staff are leaving in total. Some 392 are retiring from hospitals, with 77 of these being replaced. With regard to consultancy posts, some 11 consultants will retire, eight of whom will be replaced. In the maternity area, some 27 midwives will retire, a high number in Limerick, and 12 will be replaced. In addition, five nurses will move from the Limerick General Hospital to Limerick maternity hospital. Another five agency posts will be converted into wholetime equivalent posts. There are particular risks and challenges as a result of the cumulative impact of the moratorium and reconfiguration across the mid-west hospital group, which includes Ennis, Nenagh, Limerick, St. John's and the orthopaedic hospital. We have set out the number of staff retiring and being replaced. Of the 392 retiring from hospital, some 77 posts are being replaced, which represents a rate of approximately 19.64% in these hospitals.

With regard to consultancy staff, some eight of the 11 consultants retiring from a cohort of 525 consultants will be replaced. In St. John's or Ennis, where there will be either one replacement or none, this is part of the overall reconfiguration plan taken into account by the new CEO of the mid-western region. With regard to maternity services, I would like to draw attention to the figures for the Limerick maternity hospital where new posts are coming into being. In terms of the head count of retirees for Limerick maternity hospital, it is 19 or 16.5 wholetime equivalents. These are being replaced by five new midwives coming in. In addition, some five trained midwives are being reassigned from Limerick Regional Hospital and five wholetime equivalent posts are also being created through the use of overtime and agency funding to address the problem. This means there are 15 midwives replacing those leaving in Limerick. The overall numbers on this are available on Slide No. 26.

Slide No. 27 provides the details on community services. There will be 802 retirements and 46 replacements across the west. There are 318 nurses across the community services and 32 public health nurses from this group will retire. Management services are being reorganised and some of the public health nurses will be replaced with RGNs. The region will also consolidate and amalgamate districts in terms of public health nursing. There were some issues with regard to the community nursing units, specifically the Sacred Heart unit in Casltebar and St. Conlon's in the Limerick region. Casltlebar is recruiting staff and where nine nurses are leaving, these will be replaced by four health care assistants so that the cohort of beds required can remain open. The same applies to St. Conlon's.

The figures in our report represent a point in time and are based on interviews and meetings that took place over February. The figures will have changed slightly as they are dynamic figures. We have put as much detail as we can into our report and have included an appendix which shows where staff are going according to care group. We are satisfied a significant planning process has been under way since the autumn at local and hospital level and across the services. This has been built up into our regional service plans. Regional forums have been held over the past week setting out the service plan and the national service plan, which take account of the €750 million challenge for the HSE as well as the impact of the staff retirements. We expect our comprehensive planning process to mitigate the impact of the staff retirements.

Chairman

I thank Mr. Magee and Ms McGuinness for their presentation and their thorough and in-depth analysis. Undoubtedly, they have demonstrated that staff have shown flexibility and that the key priority is patients. I welcome the comments with regard to the provision of a safe service, where we undoubtedly face a challenge.

Before I call on Deputy Kelleher, I welcome Ms Frances Spillane, Assistant Secretary General, and the regionals directors of operations, Larry O'Reilly, Paul Howard, Dr. Barry White, Stephen Mulvany, Pat Healy, Gerry O'Dwyer, John Hennessy and Ray Mitchell from the HSE and thank them for their work in the regions. I also welcome the Ministers of State, Deputies Róisín Shortall and Kathleen Lynch, to this meeting. I thank them for their work in this area. Deputy Kelleher will have five minutes. I will be strict on time as many members have indicated they wish to speak.

Deputy Billy Kelleher

I will try to keep to questions rather than make a speech. I believe 55 consultants are retiring and 47 or 48 are supposed to be replaced. How long will it take for that recruitment process? Sometimes there can be delayed processes for the recruitment of consultants. Will the recruitment be on an ongoing basis, and have some of these positions been advertised already?

The other issue relates to the 660 nurse managers. They represent a critical component in the management and delivery of front line services. Is there a training programme in place to train up to that level the nurses who are remaining? If we take 660 nurse managers out of the system quite rapidly, we will obviously have a deficiency of corporate experience and knowledge in the delivery of health care itself. Was the Minister's panzer division, the special delivery unit, involved in assessing the impact of the retirements? Was it involved in the discussions with hospital managements on this issue, and on the number of people who should be retained in the short term?

We were accused of hyperbole, but we were just raising genuine concerns and those concerns are expressed in the document read out to us. It stated that particular risks and challenges remain as a result of the cumulative impact of the moratorium and reconfiguration. Where are these risks? Genuine concern was raised by senior consultants in Limerick regarding maternity services. That is continually being raised because there are legitimate concerns by people who are delivering front line maternity services in Limerick. Can we get clarity on this issue? While it might be easy enough to dismiss the views of senior consultants, it is important that we have clarity because the issue is creating great anxiety in the mid-west region, and not only for those who may be using maternity services in the next few weeks. The key front line midwives are raising this issue as well. Why are risks and challenges being mentioned, when hospital risks are not mentioned in any other area?

Deputy Caoimhghín Ó Caoláin

I welcome the delegation. Given the announcement by An Bord Pleanála this morning, it would be unreal if we did not make reference to the decision on the national children's hospital. Whatever concerns we may have had in respect of access and the suitability of the site, one thing that unites us all is that we need a new national children's hospital. Prior to the delegation's arrival, the committee agreed that we would address this in greater depth next week. Is it possible in the intervening period for the Minister to provide us with a briefing note on what the Government may now do in the circumstances? Our critical concern is about resourcing the existing provision of services for children through the existing children's hospital sites. What now can be done for the proposed new children's hospital at the Mater hospital site, given that it can no longer proceed after what has happened?

It is very important to reflect on some of what has been said, particularly by Professor Ronan O'Sullivan, the consultant in paediatric emergency medicine in Our Lady's Children's Hospital in Crumlin. The Minister's speech referred to redirection, moving people about and so on, yet in his article this morning, Professor O'Sullivan states that "Staffing at the front line is so stretched anyway, it is unreasonable to expect people to take on extra responsibility". It is just not within their gift. He also states that the concern which prompted us to keep records of overcrowding has now become a grave concern due to the potential danger to children. Very worryingly, he states that children with infectious diseases, who should be in single isolation rooms, must instead wait for a bed in the less appropriate environment of the general emergency department.

The Minister accused us of hyperbole and of attacking clinicians and consultants during the debate on the Fianna Fáil Private Members' motion on the crisis in the health service over the past two nights. I have not noted such from any Opposition voice. The only attacks I have noted on clinicians and consultants came from the Minister himself, in respect of anyone who dared to speak up. Is there a list containing Dr. Burke in Limerick that will include Professor O'Sullivan and others? It is important that front line clinicians such as consultants and nursing staff speak up so that we fully appreciate the great dangers that are presenting. If the Minister does not listen to us, it is important he listens to them so he can appreciate the overcrowding that is now presenting in emergency departments, and particularly in children's hospitals.

We are now looking at 4,326 retirements, which includes just 1,994 nursing staff. That is a huge number. It is very important that we understand the methodology the Minister and the HSE are employing to create cover. Ms McGuinness read out the replacement numbers. Has the process of recruitment begun for the signalled number of staff across the identified goals? How many of these staff will be permanent? How many are re-recruitments or re-engagements of exiting numbers on the current-----

Chairman

I ask you to conclude Deputy.

Deputy Caoimhghín Ó Caoláin

Please allow me to finish. Around 20% of the total number exiting the HSE are being recruited. Are they permanent recruitments? Are they temporary re-engagements? Are they agency staff temporarily re-employed? There is a huge need to address that across the acute hospital services and in the mental health area as well. We now have a situation in the mental health services where 172 is the deficit between the exit numbers and the signalled re-recruitment.

Deputy Seamus Healy

I welcome the Minister, the Ministers of State and the HSE staff. What we are discussing today needs to be taken in the context of the moratorium, previous retirement schemes and huge reductions in budgets over the past three or four years. Irrespective of what we have heard, the fact is that the health system is creaking under severe pressure, and following this particular exodus, the remaining staff will be under severe pressure. The vast majority are working above and beyond the call of duty.

Slide No.9 deals with hospitals in the south. We have the overall number of those retiring and the number of replacements per hospital, but we do not have the figure of those retiring per hospital. Perhaps somebody can provide us with those figures. How many of the allied health professionals are leaving? How many are being replaced? Page 11 of the document refers to existing panels. It would appear that the only panels in existence are for professionally qualified social workers and team leaders, social care workers and social care leaders, as well as various nursing staff. Are there existing panels, for instance, for occupational therapists or psychologists? What is the current situation with regard to the recruitment of these particular categories? How long does recruitment take, and will they be employed on a full-time and permanent basis?

It is not clear from the documents exactly how many people are retiring in the area of home help and home care assistant services and how many are being replaced. Obviously this is a significant area, given the reduction of about 4.5% in home help hours in the overall budget.

I have received quite a number of inquiries in the past week about the effects of retirement and non-replacement on orthopaedic services and ophthalmology services at Waterford Regional Hospital in particular. For instance, I have heard from a number of people in the past few days that the ophthalmic service, which had four consultant staff, has only two as of last Friday, and it would appear there are no proposals for replacement. The Minister may have a comment on that.

Chairman

I will call on the Minister and Mr. Magee to answer those questions. If the Minister of State, Deputy Shortall, wants to comment she may feel free to do so.

Deputy James Reilly

Deputy Kelleher mentioned the retirement of consultants. We can answer that in more detail, but my understanding is that an average of 100 consultants retire every year, so the 57 retiring at this point do not represent an extraordinary increase. Nonetheless, they must be replaced, as has been pointed out. Where there is no immediate replacement, locums can be used. It takes time to recruit consultants - there is no question about that - but it will not take as long as it used to in the past, which was around 18 months. I mentioned Manorhamilton as one of the places I visited because that is where the central recruiting agency for the HSE is situated. The process of recruitment has begun and there are panels with pre-screened individuals, but obviously there is more to be done. I will ask Mr. Magee and Ms McGuinness to address that in more detail.

The special delivery unit, SDU, was consulted during the course of this process. Many people were involved and much work was done. As I mentioned, because I thought it important to do so, Dr. Philip Crowley was involved also. I will let Ms McGuinness provide more detail in answer to the Deputy's questions about the mid-west.

As the Deputy is aware from the exchanges in the Dáil last night, the Minister of State, Deputy Shortall, read out an e-mail from Dr. Burke in which he stated he was very happy with the way things had been managed, notwithstanding his earlier comments. I have no problem with consultants or nurses speaking out; I encourage it. We want to know where the problems are located. However, I do have problems with people such as Deputy Ó Caoláin, who maintained in the Dáil that there was going to be devastation and that there was no plan. It is clear there is a plan, and a comprehensive one. Rather than creating anxiety, we should all support the plan to ensure we have a safe service and that if there is a problem anywhere - which may happen, as nobody has complete control over the entire system - we can address it quickly because we are made aware of it quickly.

A briefing note on the national paediatric hospital was requested. We have only just got the news within the past few hours, so I think members will allow me a bit of time before I provide a fuller briefing on where we are going to go next. I have already mentioned that Dr. Frank Dolphin will chair a group to address this issue aggressively and with urgency, so we can continue in the process of providing a new hospital. With regard to the comments about Crumlin, the fact that we do not have enough isolation or single rooms is one of the reasons we need to build a new paediatric hospital. No modern hospital would be built with anything other than single rooms, but as we know, we have some hospital stock that is quite old and that needs to be replaced over a period of time. It is a priority for the Government to build a new paediatric hospital, which will itself result in efficiencies. We reckon we could save €25 million a year through efficiencies due to co-location of the three hospitals. The work is ongoing in getting the governance of that hospital right and ensuring greater cohesion among management so that when the day comes to open the hospital we will have, de facto, a single governance and management system.

With regard to replacement, recruitment has commenced, as I said. I have made it clear that it will be rare for people to come back from retirement; it will be new recruits. Of course there may be some dependence on agency staff - I will let Ms McGuinness go into that in more detail - but that is something we are trying to reduce aggressively, because it is not good value for money and it is not best practice because it results in a lack of continuity of care. Deputy Ó Caoláin quoted Professor Ronan O'Sullivan. I will call on Gerry O'Dwyer, the regional director of operations for the area, to reply to that, as he has been in discussions with Professor O'Sullivan since he made those statements.

Mr. Cathal Magee

With regard to Deputy Kelleher's question on nurse managers, as was said, out of 1,994 retiring nurses, 662 are retiring from nurse management roles. In our system, out of the 36,000 nurses we have, 7,900, or about 22%, are nurse management roles. One of the priorities across all our disciplines is a consolidation of line management responsibilities. Given the pressure on service delivery, we are trying to consolidate management roles and amalgamate broader spans of control and broader responsibilities in order to deal with a leaner management structure across all disciplines. This is just an issue of priority in which we must ask where the most value is added. There are substantial numbers in management positions across our health system, and there is a major process of consolidation through the Croke Park agreement.

Deputy Ó Caoláin asked about replacement of nurses. It is not our policy to re-engage staff who are leaving under the terms of this scheme. There is no technical block to it, as was the case under previous schemes, but it would happen only in an exceptional situation and only with the approval of at least the regional director of operations. It is not something we see as a solution unless there is an exceptional risk or an exceptional skill gap. The posts we are replacing, in the main, will be permanent appointments filled by panels. The 500 posts, for which there is €16 million in funding, are permanent appointments, and that is what is the intent.

I will allow the Deputy back in again. I am very fair.

Mr. Pat Healy

On the points made by Deputy Ó Caoláin on Professor O'Sullivan's comments on the radio, I spoke with him yesterday. I and the clinical director, Dr. Colm Costigan, are meeting him within the next week to discuss the issues he raised. It is important to say that the three hospitals work in unison in regard to bed management, theatre utilisation and any surges. Over the past few days there has been a slight surge in respiratory attendances at hospitals. They have been managed and moved as appropriate.

It is also important to note that we do not keep children on trolleys in emergency departments. We move them into cubicles and use rooms adjacent to emergency departments. Over the past 24 hours I spoke with the chief executives of the three hospitals and was assured the area is being constantly monitored. I will also speak to the clinical director this evening. We also hope to involve the clinical programmes in the roll out. Professor Nicholson has been involved and will also meet us.

Deputy Eamonn Maloney

I wish to be associated with the Chairman's words of welcome to the Minister and others.

People referred to the decision of An Bord Pleanála to refuse planning permission for the national paediatric hospital. It is disappointing. Reference was made to the fact it will further delay the project. I am not too surprised at the news. Anyone who looked at the application and noted the limitations of the site would realise that An Bord Pleanála could not have made any other decision.

Various comments have been made about the delays to the project, which I agree with. The delays are regrettable but also regrettable is the fact that almost €30 million of taxpayers' money could have been better spent. I do not want to use the term "wasted." If there had been less political interference in the project from day 1 the hospital would probably have been opened and taxpayers like me might be celebrating the useful use of their money.

I take the Minister on his word that the project will be moved on as quickly as possible. Without being partisan, the best site is at Tallaght Hospital. Had it been-----

Chairman

The Deputy is being parochial.

Deputy Eamonn Maloney

As regards the subject in hand, I was one of the people here in November when some people here were waving around a British tabloid telling us that hospitals were to be closed all over the country, that thousands of people would be sacked and that people would be dying on the byroads of Ireland. This was four months ago. The winter ends in six days and, thankfully, none of this has happened, but all this scaremongering under the guise of debating the subject of health in Ireland serves no purpose whatsoever. This whole debate should be conditional on the fact that the country is in a recession with the resultant lack of money. We would not be having this discussion about people taking early retirement or even considering redundancy if we had our own money, but the case is that someone else is paying, be they the German or British taxpayers, and they want their money back, of course.

I have one question. I am delighted to see the consultants in Ireland's busiest hospital, Tallaght, will all be replaced. When will this happen?

Deputy Denis Naughten

I thank the delegation for the presentations. I have a question for Ms McGuinness. When the complete data are available, could it be possible to supply this committee with a document which has all the blanks filled in to provide an overview of the regions? This would make the work easier for the committee. I ask for a breakdown of information on the retirees who are leaving the acute services in HSE west region.

I ask for clarification of comments made by Ms McGuinness. She stated that replacement posts will be dependent on the hospital meeting its budget. This is the problem with regard to the therapy grades. There is no moratorium on recruitment to the therapy grades but because the PCCCs are not meeting their budgets, the staff are not being recruited and this has caused the crisis in my part of the country, although I am not familiar with the situation elsewhere. Will this be replicated in the acute hospitals?

As regards the reconfiguration at community level, I note the HSE west region is losing a significant number of nursing staff in community care. I presume when Ms McGuinness refers to community care she is referring to PCCC rather than just community. A significant number of public health nurses will be replaced by registered general nurses, RGNs. Can we be assured that the child developmental targets checks will be maintained? These checks identify significant problems at an early stage so that the child is treated. At present, these targets are not being met and if further public health nurses are taken out of the system, how can the system be maintained? The loss of home helps will have a significant impact.

Has any consideration been given to the impact on the hospice service and palliative care? There has been no mention of it in the presentations this morning. I ask for clarification of the impact on the hospice service.

Deputy Robert Dowds

I agree with Deputy Maloney's remarks about the Tallaght hospital site and I hope this will be examined again.

I have two questions and one comment. How flexible is the system if it is shown that insufficient staff are available in a given hospital or health area? I am in favour of the rolling out of primary health care. How will the reduction in staff numbers impact upon this service? How will the development of a primary health care service impact upon the hospital sector? I presume this will result in a decline in the need in certain hospitals if primary health care is rolled out sufficiently.

I commend Ms McGuinness on an interview which she did on RTE about three or four weeks ago. She detailed the figures and she put many people's minds at ease, to the extent that this is possible. I suggest perhaps she should do this more often.

Chairman

As there are six speakers indicating, I ask members to make precise and brief contributions.

Deputy James Reilly

In the interest of time considerations, I will pass over to those who have the answers to the specific questions.

Ms Laverne McGuinness

Deputy Naughten asked whether the replacement of posts will be dependent on budgets. This will not be the case. The €16 million is a dedicated fund so these posts will be permanent posts in the main. They will not be dependent on the budget because they are critical posts which must be replaced. Therapists are not moratorium exempted. Other therapists have gone in the past but these are actually separate so they are ring-fenced.

Deputy Naughten asked specifically about the HSE west region. I am not sure to what missing data he refers. I have figures for the numbers leaving but because of the dynamic nature, there have been changes and my figures are slightly different from those of John Hennessy, who is the RDO. To ensure the Deputy is given the up-to-date information, Mr. Hennessy will provide all the figures for all the hospitals in the west region. These figures are more up to date than those I mentioned in the interview. This is the only reason they have not been provided to the Deputy.

Deputy Denis Naughten

With regard to those giving two weeks' notice, most staff gave one month's notice or in excess of one month.

Ms Laverne McGuinness

This has not had a significant impact. The variant has only been in the region of approximately 109. This is not the total national number who gave two weeks' notice. Some of those applications were made locally and they had not been put into the national system. Only a proportion of that 109 would have given two weeks' notice.

Deputy Róisín Shortall

I wish to respond to the questions about primary care. Deputy Naughten asked about the child developmental tests and the screening programmes. There is no doubt that with regard to the public health nurses and the RGNs, the community nursing service generally is a very important primary care service. It is the safety net for children and for older people and therefore it needs to be a strong service. Provision will be made by means of the €20 million set aside for primary care to fill a number of those posts. There will also be a transfer of work to the RGNs. A significant number of nurses will be brought into the front-line services. It is all to do with flexibility and reconfiguration. I am not satisfied that children's services have been adequate and I know there are gaps. As for the potential for backfilling, account will be taken of where there is an undersupply, as it were, at the moment. We will use that money to rebalance the situation.

I refer to the points raised by Deputy Dowds. The Government is committed to switching activity to primary care level. This will not all be plain sailing by any means but there are very robust plans in place to mitigate the situation to the greatest extent possible, given the kind of funding available. The €20 million for primary care is a recognition of the enhancement of primary care. In addition, the roll-out of the clinical care programmes and, in particular, the chronic disease management programmes which will begin this year with a diabetes management programme, will enable resources to be relocated at primary care level in the community.

Ms Laverne McGuinness

Deputy Maloney asked me whether consultant posts in Tallaght hospital are being advertised. These posts will be replaced as quickly as possible. Temporary and locum consultants are in place. I refer to one consultant in particular who is leaving who has a very specific skill set so we may have to use the retiring consultant for a period of time until such time as a replacement can be found. A very specific skill set is required to provide the service in this case.

Deputy Noel Coonan

I welcome the Ministers, the departmental officials and the HSE delegation. I welcome in particular Mr. John Hennessy, the RDO of the HSE west region. I am delighted he has moved from the backbenches to the front line. Will the Minister and his officials articulate their policy on primary and community care? I had assumed that a pillar of this strategy would be to facilitate people in remaining within their communities for as long as possible. Respite care is an important plank of any such policy. In that context, when will the 22 beds that were closed in the Hospital of the Assumption in Thurles be reopened? This state-of-the-art hospital was opened in 2006 to great fanfare, with the stated policy of the Health Service Executive at the time being that it would serve the people well into the future, in keeping with long-term health service delivery objectives. Now almost half of the accommodation is closed. The Dean Maxwell community nursing unit in Roscrea, meanwhile, has delivered best value for resources in the mid-west, if not nationally. When will the seven beds that are currently closed in that facility be restored? I welcome the fact that St. Conlon's community nursing unit in Nenagh has been saved and had additional staff allocated to it. That is good news.

I recognise that we are in difficult times, but there are important issues which must be addressed. In regard to the budget for the mid-west, will the Minister confirm whether a review has been undertaken? Historically there has been a low budget in the area and €8 million was taken out of community care services last year. The projection for this year was based on the savage cuts implemented in September and October 2011. That €8 million funding shortfall has grown to a deficit of €19 million. Is this problem being addressed or is the mid-west, and north Tipperary in particular, to be the Cinderella of the health system?

Senator John Crown

The Minister has inherited an awful mess of problems and I do not envy him in the scale of the task he is facing. I am sure the news he received the morning was the last thing he needed on top of everything else that is happening. There are issues of which he and I are aware but that some of our colleagues do not necessarily appreciate. I intend to deal briefly with some of them in the time available to me.

The decision to locate the national children's hospital at the Mater site was a controversial one, but there were controversial issues associated with all of the potential sites. I was in favour of the hospital being located in Crumlin but, like many doctors and others who care about the issue, the feeling was that when all the issues had been thrashed out, when the international experts had been consulted, when the reports had been formed and a decision was made, we should just push them to one side and get on with it. Now we are in as bad a position as we can be, having finally overcome the entirely understandable institutional loyalty - I will not use the word "chauvinism" because it sounds a little too judgmental - people had to institutions for which they had an affection and to the development of which they had contributed. Having moved past that and had everybody pointing in one direction, to have this happen is a disaster. I am incandescent with rage over it. The arguments that are being advanced for not putting this much needed national facility in a place where after a tremendously complicated process a decision was made to put it, are based on purely aesthetic grounds.

To put this into context, we have a hospital site which is in front of a prison, alongside two other hospitals and with Dorset Street on its right. No disrespect to that street, where I spent many happy moments during my time in the Mater and elsewhere, but it is not exactly the Champs-Élysées. I am still trying to work out how, when all of the decisions had been reached and all of the expert opinions were taken, a decision which seems to a practical person like me - perhaps I am missing something in my soul - to be an entirely practical one, could be made on purely aesthetic grounds. That is simply wrong.

I am concerned that already this morning we have heard the arguments that this site should never have been chosen, that the hospital should be located in Tallaght, Crumlin or on a greenfield site somewhere. I have no dog in the fight but I ask those who will make the decision to remember that there are few unbiased opinions in this matter. The reality is simple. If one works in Temple Street, one was in favour of it being located at the Mater. A person working in Crumlin would have been in favour of it being located there. Anybody in UCD was in favour of the Mater and those in either of the other two medical schools were in favour of Crumlin and/or Tallaght. That is how it worked.

There are people who appreciate what the Minister will now have to do. The key issue is that we do not become embroiled in another interinstitutional bun fight. A decision must be made quickly. I fear there will be some who will use the failure to secure planning permission to build the national children's hospital as an excuse for not advancing the developments that are needed in the short and intermediate term if we are to avoid the serious service deficiencies we are seeing. We must ensure that hospitals like Crumlin, for instance, which has only one quarter the number of consultants it would have by British standards and one tenth the number by international standards, is able to do the job it has to do. I wish the Minister well in this.

Minister of State at the Department of Health and Children (Deputy Kathleen Lynch)

I thank Deputy Coonan for his questions. I have met staff from the three community units in question. The Deputy is correct in stating they are equally fine facilities which deliver excellent services. There are, however, particular challenges which exist and he will be aware of these. I met the local area manager, Mr. Hennessy, and then re-examined what needed to be done in the area. I am sure Mr. Hennessy will give the Deputy the details he requires. One could not but say that between them, the Dean Maxwell community nursing unit, the Hospital of the Assumption and St. Conlon's community nursing unit provide excellent services. However, we face particular challenges in respect of both older people and the way in which we might continue to deliver the services to which I refer in the future. I accept this is a broad issue but we cannot merely focus on beds within community units. There is a need to ensure that the Department of the Environment, Community and Local Government becomes involved in respect of two areas, namely, supervised living and the provision of smaller housing units that will allow people to remain in their own communities.

The beauty of the three facilities to which the Deputy refers lies in the fact that they are situated within local communities. That is the type of service we must provide to older people. There is no doubt we face challenges and we will be obliged to engage in a serious examination of how we will deliver the service to which I refer in the future.

Deputy Noel Coonan

Five respite beds in the whole of Tipperary and south Offaly-----

Chairman

I will return to the Deputy. I must take the replies from our other guests.

Deputy Noel Coonan

-----does not represent equal delivery of service.

Ms Laverne McGuinness

Deputy McConalogue referred to social workers. A number who operate in some of our special care or high-support services will be replaced. I have in my possession some details regarding the numbers that are leaving. However, there has been a significant investment in social workers during the past two years in the context of the numbers going in. As the Deputy is aware, the national director for children and family services, Mr. Gordon Jeyes, is heading up a review in respect of social work services and the productivity relating thereto.

Mr. John Hennessy

Deputy Naughten raised a number of issues on which I wish to make some comments. I can brief the Deputy on this matter later but in the context of the breakdown regarding the number of staff leaving acute hospitals in the west this month, Letterkenny General Hospital will lose 18 staff, Sligo General Hospital will lose 26, Mayo General Hospital in Castlebar will lose 31, the Galway-Roscommon hospital group will lose 104 and the mid-west acute hospital group will lose 89. There are some backfill arrangements at the end of the contingency process in respect of these developments. For example, seven posts at Letterkenny General Hospital will be backfilled, two will be backfilled at Sligo General Hospital, five will be backfilled at Mayo General Hospital in Castlebar, 22 will be backfilled at the Galway-Roscommon hospital group and 32 will be backfilled at the mid-west acute hospital group. The bulk of these, some 70%, will be nurses. In the units which provide midwifery and obstetric services, the backfill arrangements are almost on a one-to-one basis.

Deputy Naughten also inquired about palliative care. There are no immediate impact issues with regard to palliative care in the west at present in the context of reductions in service associated with staff leaving this month. The policy is to protect palliative care services in any event. We will, therefore, ensure there will not be a service impact in that area.

Deputy Denis Naughten

Is that across the country?

Mr. John Hennessy

It is across the west, certainly.

Deputy Coonan referred to long-stay beds, particularly in the context of the Hospital of the Assumption in Thurles. I agree with him that this is an excellent facility, which opened in 2006. Its current operating capacity is 45 beds but it has capacity for more than 20 further beds. The difficulty here relates to a simple staffing issue. Some 13 additional staff would be required to commission extra beds. We are working hard with local management and conducting a review of beds across the mid-west area to see what capacity we might find - by redeployment - to do that. I expect there will be progress on it in 2012, particularly in the context of respite beds. As the Deputy pointed out, there is a shortage of such beds in north Tipperary. I will keep him informed and advised of progress on that. As already stated, however, I expect some movement on it this year.

Dr. Barry White

I wish to comment on the north west in the context of cardiac catheterisation services. The position at present is that there is strong clinical justification for increasing the volume of cardiac catheterisation interventions performed in the north west. We are fairly comfortable with that. What is not clear, however, is the best way of configuring it between Letterkenny and Sligo and how this potentially relates to hospitals across the Border in Northern Ireland. From a clinical perspective, there is a justification for increased activity. By this I mean that patients who are currently leaving the region to have procedures carried out elsewhere would be able to remain in the region to have them carried out.

Deputy James Reilly

I have had discussions with Mr. Edwin Poots, MLA, the Northern Ireland Minister for Health, Social Services and Public Safety, in respect of cross-Border co-operation on health. This is certainly one of the matters we have discussed. I do not believe there is a large enough volume of people for a 24-7 service in the north west. The nine-to-five service that has been proposed is an alternative but I would like to give consideration to a 24-7 option involving facilities on both sides of the Border. The latter would give people in both jurisdictions the opportunity of having the best service available to them.

Dr. Barry White

What we are talking about is the total volume of activity. Only a small level of that activity is out-of-hours primary percutaneous coronary intervention, PCI. The large bulk of it can be done within hours.

Senator Colm Burke

I thank our guests for their presentation. In the context of the south, some 14 consultants will be replaced and a further 20 will be recruited. That is a total of 34. How many posts have been advertised to date and how many interviews have taken place? How many of the new consultants it is proposed to take on will be in place by 1 September next? One of the difficulties in the past two or three years has been that the number of people applying for consultant posts has decreased from approximately ten per post to in the region of four per post. I understand there have been no applications at all in respect of some posts. In light of the number of staff we must recruit and the timescale involved, how many posts will be filled by 1 September?

Deputy Peter Fitzpatrick

I welcome the Minister, the Ministers of State and Mr. Magee and the other officials from the HSE. Reference was made to the Dublin north-east region and the number of staff retiring and being replaced. In that context, I wish to inquire with regard to two hospitals, namely, Louth County Hospital, Dundalk, and Our Lady of Lourdes Hospital, Drogheda. According to the figures provided by the HSE, 19 staff are retiring and being replaced at the former and a further 19 are retiring and being replaced at the latter. Will our guests confirm that this will be the case? Will they also comment on the HSE's objective to reduce by 50% the overall number of agency staff?

Deputy Regina Doherty

I do not wish to ask any questions, I merely wish to make two brief comments. The absence of any information from the HSE in respect of this matter in the past couple of months has left a vacuum that has been filled by the Opposition's Henny Penny-like exclamations to the effect that the sky is going to fall in. I thank the officials from the HSE not only for the very comprehensive documents and briefing material with which we have been provided but also for the information that was delivered by Ms McGuinness and Mr. Stephen Mulvaney on the airwaves in the past couple of weeks. Ms McGuinness and Mr. Mulvaney are credible and reasonable people and when they deliver the information that is available it is very well received and diminishes the fear factor which has been instilled in certain parts of the populace by particular members of the Opposition. We all know what the latter are saying is not true.

I am genuinely devastated with regard to this morning's announcement in respect of the new national children's hospital, particularly as the reason given is that the building would be a dominant and incongruous structure.

Chairman

The committee will be dealing with that matter next week.

Deputy Regina Doherty

If the Chairman does not mind, I want to place my views on this matter on the record. In light of the fact that An Bord Pleanála has given the go-ahead for hugely dominant and incongruous structures, in the form of 80 foot pylons, to be built across the beautiful landscape of Meath, Cavan, Tyrone and Monaghan, this decision is a joke. I urge the Minister to put this matter to rest. The Minister will note this morning that the argument that surrounded this project a number of years ago has arisen again. He has our full support to get this done and done as quickly as possible.

Chairman

I call Deputy O'Donnell to be followed by Deputy Ó Caoláin and then we will conclude the meeting.

Deputy Kieran O’Donnell

I welcome the witnesses. On a point of clarification, the methodology used to come up with a budget for 2012 appears to take the months of August, September and October 2011 and extrapolate from those the figures for a full 12-month period for 2012. Severe cuts were made in budgets during that period and they are affecting the mid-west region where I am a Deputy representing Limerick city. What was the reason for basing the figure on a three month period? Is that a new departure?

The significance of the cuts is borne out in the figures. In terms of the acute hospital network in the mid-west, there is a cut of 12.9%, whereas within the HSE west area, the cut in respect of Galway is lower at 10.5%. In the non-acute area, there is a cut of the order of €19 million while the average cut in the HSE west budget is approximately 5%, and in the non-acute area that brings it up to in the region of 13.4%. What is the logic for basing this on figures over a three-month period? Have the figures been run for a 12-month period? Why were they based on a three-month period in this case?

Chairman

I call Deputy Ó Caoláin for a brief comment, as he spoke earlier.

Deputy Caoimhghín Ó Caoláin

A number of points arise from the responses I received. As contained in Mr. Magee's figures, €16 million is being provided in regard to targeted recruitment. Will that cover the numbers targeted to be recruited in the course of the time ahead? Is it enough? Is the number involved the ceiling? I have taken the time to go through the document outlining the slides, to which Ms. McGuinness referred. I note the figure of 743. There is not a total in the statistics provided, but 743 of the 4,326 would represent just over 17% replacement. Has a recruitment process begun? What steps have already been taken and has anybody been recruited yet? Given that departures are imminent, many have already left and next week will be the final day for the departures, when will we see replacement staff in situ or will it take a period of time for a recruitment process to make up that number?

In the Minister's preamble in his address to the meeting, he acknowledged that there will be an inevitable and unavoidable reduction in services this year. Does his dynamic contingency plans specify what those reductions will be? Can he share the detail of the inevitable and unavoidable reduction in services with us today? The Minister said in respect of minimising the impact on front line services that staff will postpone leave or work additional hours for time off in lieu, will he accept that is building up a false picture because, ultimately, they will have to get time off, they will expect it and will be entitled to it?

Chairman

Deputy Kelleher can make a very brief comment.

Deputy Billy Kelleher

In the context of the 660 nurse managers who are retiring, I asked earlier if any training programmes will be put in place to support the nursing profession to build up that capacity again?

Chairman

I will take responses from the Minister, followed by Mr. Magee, followed by Ms McGuinness and then we will wrap up the meeting.

Deputy James Reilly

Many of the questions relate to the HSE, which I will pass to my colleagues. One such question was from Deputy Fitzpatrick who sought confirmation of the statistics he gave.

I advise Deputy Doherty that we will expedite that project and we will do so as quickly as possible. Such is the urgency of it that I will leave here shortly to meet the architects to find out what went wrong. Having been through this process, wearing a different hat in a previous life on a number of occasions, I would have expected that there is ongoing consultation. One almost has a sense about a decision before one submits planning. We have to find out where this went wrong. We have to find out what issues we can address on this site, if possible, or elsewhere, if necessary. However, one thing is certain, we will expedite the building of this hospital. Our children deserve it.

Deputy Ó Caoláin asked me about specific details. The plan is very much to minimise the impact and we will keep working towards that. We cannot give him the absolute details at this moment in time. As we become more efficient, as the clinical programmes, which Dr. Barry White has outlined, are transposed across the system, more productivity will be possible and not only in terms of our acute medical assessment units and the admissions that they avoid. Next week we will bring forward a new proposal on care of the elderly, the frail elderly, rehabilitation, transition units, etc., to enable the freeing up of beds currently being occupied by people whose acute treatment is over. When I checked last week, 100 beds in Beaumont Hospital and more than 100 beds in St. James's Hospital were occupied by people who no longer needed to be in hospital but did not have a suitable place to go. That has being addressed in part this week already and I want to thank everybody who sprang into action on Tuesday night in this regard. There was an across-the-system response from clinicians, doctors, nurses, managers, administrators and everybody concerned and it was great to see that the system can now respond. We will refine that response so that the system can respond even more quickly. Many of the people in this room - the four RDOs, Ms Laverne McGuinness, Mr. Cathal Magee and everybody here - and the Department were intimately involved in that, and I want to acknowledge that.

Chairman

The Deputy should take note. I apologise to Ms McGuinness.

Ms Laverne McGuinness

On equipment, a number of the consultant positions have been advertised at this stage. It is important to say that even though the permanent people are not in post, arrangements are in place - be they temporary, locum or agency - to cover the critical areas we have identified throughout the planning process.

In terms of maternity services, which is a crucial area, the new graduates are coming out on 1 March and arrangements are being made. The voluntary hospitals - approximately 50% of hospitals - for example, St. Vincent's, St. James's and Holles St., make their own arrangements. There are direct links with the colleges to take on some of the graduates that emerge. The same is happening across the other regions.

In terms of the other posts on which we rely on the national recruitment service in Manorhamilton to oversee, more than 50% of posts are in progress with it. There are panels in place and appointments will be drawn down from the panels. Local arrangements are also being made in each of the regions.

Mr. Cathal Magee

I will return to Senator Colm Burke's question and ask Mr. Pat Healy to deal with the appointment process. The general point is correct; we are seeing recruitment challenges in the recruitment of specialist consultant posts. It is part of the consideration around how we deal with both the terms and conditions for consultants in future. We must be able to attract the best clinicians into the health system, internationally or from within our system. That is something we must keep under careful review.

We have also seen trends of clinicians moving from public sector employment to private practice, certainly in Dublin. We have been able to fill clinician posts up to now but the trends are that it is proving more challenging, because the public system is very challenging and demanding for clinicians. We must ensure the terms and conditions continue to be attractive in particular for consultants who come from international locations or are returning to this country.

Mr. Pat Healy

Arrangements are already in place to fill all of the 14 replacement posts, the majority of them on a locum basis pending their permanent filling. Some of the new posts that are to be provided are already in place. In Cork, some acute medical physicians have been already appointed. Competitions are currently taking place for other posts. Interest in the positions in Cork has been significant with more than 18 high calibre candidates participating in one interview. That indicates the level of work going on in the city in acute medicine. Right across the south I expect that by September a significant number of the posts on the clinical programme side will be advertised and interviews will have taken place. The filling of some posts may take a little longer but it should happen before the end of the year or early next year depending on the timeframe for when they will start.

Senator Colm Burke

How many of the 34 posts will be filled by 1 September? I am not tying Mr. Healy to the figures; I am looking for a rough idea. Will it be 50%?

Mr. Pat Healy

At least 50% in acute medicine, ED, and the priority areas such as stroke will be appointed by then.

Deputy Róisín Shortall

I wish to respond to a point raised by Deputy Ó Caoláin on the flexibility and potential for back-filling of posts. In the primary care areas the sum of €20 million has been ring-fenced for back-filling those posts, but there is also a facility whereby we can extend that to €25 million if we can achieve savings on the drugs front. The overall budget for primary care, including pharma, is approximately €2.5 billion but €2 billion of that goes on pharma. They are massive costs very much out of line with what is happening internationally and in other European countries. This year legislation is promised on generic substitution and reference pricing, and the agreement with the Irish Pharmaceutical Healthcare Association, IPHA, is up for renegotiation on 1 March. There is already a figure factored into our budgets on significant savings on that front but if we can exceed that and get a better deal from IPHA there is potential for diverting another €5 million into the back-filling of posts at primary care level. We must be serious about rebalancing the overall budget within primary care because far too much of it is being spent on the pharma side - €2 billion out of €2.5 billion is a considerable amount.

Deputy Kathleen Lynch

It cannot be just about reduction in price on the contract the State has with the pharmaceutical industry. It must be equally about the review of prescriptions and the medication prescribed. It is a mixed issue. The amount of money we are spending is incredible.

Mr. Cathal Magee

I reinforce and support what both Ministers have said. Based on the OECD published data in 2009 we spent 17.5% of our total health spend on pharma. In Denmark it is 9%. We are the outlier. In this country drug spend in the past decade since 2001 has grown 9% per year whereas in the UK it has been 2% to 3%. We have a huge challenge in terms of pharmaceutical costs. Much progress has been made in the past year. Savings of €150 million were negotiated last December.

The pharma industry is an important industry in this country. It employs 25,000 and provides a significant amount of inward investment, but we also have a high cost of drugs. We are in the average of a basket of nine countries. We have suggested to the industry that we should be the lowest of the nine countries. The Minister referred to reference pricing. If we are to deliver on our financial objective this year, so that the Minister can release money from the drugs area to spend on replacement of primary care posts, the pharmaceutical industry and IPHA must come to the table and show much greater flexibility on the requirements of the health system if we are to deal with the unprecedented financial challenges. It is a big target area for the significant reductions that are required. I will ask Mr. Hennessy to respond to Deputy O'Donnell.

Mr. John Hennessy

I will respond briefly to Deputy McConalogue's questions on Sligo General Hospital, which is facing a significant challenge in 2012. Its budget allocation represents approximately 7% of its 2011 budget. There is a good understanding of what has contributed to that and it does include the 100 plus consultants posts that went in 2008 and 2009. The national director and I are meeting with Mr. Damien McCallion and his local team in Sligo next week to address the issue. The reason for the budgetary problem arising is almost less relevant than what we can do to address it in the context of the 2012 service plan. It is a significant budgetary challenge in Sligo but it is not unique among the west hospital group.

On Deputy O'Donnell's question on the technicalities of the calculation of budget extractions for the fair deal scheme and child care, a consistent approach was taken based on the run rate in the July to September period, which was consistently done across the country. That had an effect in certain areas which represented a more onerous challenge than others, one of which was the mid west. Donegal was equally hit. We are reviewing that, and if adjustments have to be made to offset onerous impacts, that will be done but it will be done on the basis of an overall examination of the allocations across the west. The objective of that exercise is to ensure the budget allocations that have been made are as fair and equitable as we can make them.

Deputy Kieran O’Donnell

What is the timeframe on that?

Mr. John Hennessy

No more than two to three weeks. I will keep the Deputy advised.

Mr. Stephen Mulvany

I thank Deputy Doherty for her comments. Deputy Fitzpatrick's comments relate to slide 14. Unfortunately, there is a typographical error in that for which I apologise to the committee.

The Louth-Meath Hospital Group covers Navan, Louth County Hospital, Dundalk, and Our Lady of Lourdes Hospital in Drogheda. The figure indicated for Navan is correct at two. Louth County Hospital should be one, not 19, and Drogheda is 16. The total for the group-----

Chairman

Will Mr. Mulvany repeat that?

Mr. Stephen Mulvany

The figure for Navan hospital is correct at two. The Louth County Hospital figure should be one and the figure for Our Lady of Lourdes Hospital in Drogheda is 16. The overall total for the group, therefore, is 19. The reason it is skewed towards Drogheda is because for Louth-Meath, Drogheda is the maternity centre and the paediatric centre and therefore we are replacing midwives and neonatal intensive care nurses. It is also the regional trauma centre for Louth, Meath, Cavan and Monaghan. Apologies to the committee for that typographical error.

Chairman

Aon duine eile? I ask Deputy Coonan to be brief.

Deputy Noel Coonan

Regarding acute services, the Minister announced that Nenagh General Hospital would be an essential part of providing services in the acute sector. The following week a ward closed in Nenagh hospital. What assurances can Mr. Hennessy or Mr. Magee give me that the appropriate staff will be allocated to Nenagh hospital to deliver the services about which they speak?

Mr. John Hennessy

I assure the Deputy that Nenagh hospital is playing and will continue to play a prominent role in the provision of acute services in the mid west. There is a new structure in place, as Deputy Coonan is aware, which involves a regional management team and a chief executive for the hospital group with the express purpose of managing the hospital system as a group of hospitals and not as individual, stand alone sites. That will be to the benefit of Nenagh and will ensure its role as a level 2 hospital facility continues into the future.

Deputy Peter Fitzpatrick

I asked a question about agency staff and the 50% reduction.

Ms Laverne McGuinness

Regarding agency staff, in 2011 we spent €200 million throughout the Health Service Executive on agency staff. In terms of conversion that is approximately 1,500 whole-time equivalents. We explicitly stated in our service plan that we are reducing that this year by 50%, a reduction of €100 million, and the regional service plans have taken account of the effect of that. Part of it will be done by converting some of it into whole-time equivalents where that is appropriate.

In response to Deputy Kelleher, we said that of the 662 nurse managers who are retiring, some of those are being replaced because their roles are critical. If a director of nursing is retiring, therefore, and there is not a director of nursing in three particular units, we are replacing the director of nursing post in specific circumstances. The same would apply in our hospitals also in terms of clinical nurse manager 1 and clinical nurse manager 2 positions. Some of those are included within our replacement process. There is not a specific training programme to deal with this retirement contingency but there is ongoing training in nursing and nursing development. When people in senior positions are on leave the next person in line acts up and therefore ongoing training is going on systematically in the hospitals and throughout the community services.

Chairman

I thank the Minister, Deputy Reilly, and the Ministers of State, Deputy Shortall and Deputy Lynch, along with Mr. Magee and Ms McGuinness from the HSE and Ms Spillane from the Department of Health for attending. In particular I thank the four regional directors of operations, Mr. Gerry O'Dwyer, Mr. Pat Healy, Mr. John Hennessy and Mr. Stephen Mulvany who have briefed not just Oireachtas Members but also members of the Regional Health Forum on the plans they have in place. I thank them for their thorough presentation. I thank the members for their participation. It is important that as politicians of whatever hue or form we recognise that this was a very useful discussion. A total of 3.3% of whole-time equivalent health service personnel are leaving and it is important that we continue to monitor the position post 29 February and 1 March. We should have a review of the process in six months when the witnesses might come before the committee again. I thank them for attending and responding to members' questions.

We will visit the medical card facility in Finglas on Friday week. I thank Mr. Paul Howard from the Department of Health and Mr. M. Mitchell from the HSE for arranging the visit to Finglas. They have been very helpful to us.

I remind members that Mr. Magee and the Minister will come before the committee again on 22 March as part of our quarterly meeting.

The joint committee adjourned at 1.55 p.m. until 1.45 p.m. on Wednesday, 29 February 2012.

JOINT COMMITTEE ON HEALTH AND CHILDREN debate - Thursday, 23 Feb 2012

Impact of Incentivised Early Retirement Scheme on Health Sector: Discussion

Mr. Cathal Magee

Ms Laverne McGuinness

Ms Laverne McGuinness

Mr. Cathal Magee

Ms Laverne McGuinness

Ms Laverne McGuinness

Mr. Cathal Magee

Minister of State at the Department of Health and Children (Deputy Roisin Shortall)

Ms Laverne McGuinness

Ms Laverne McGuinness

Ms Laverne McGuinness

Ms Laverne McGuinness

Mr. Gerry O’Dwyer

Mr. Gerry O’Dwyer

Mr. Pat Healy

Ms Laverne McGuinness

Ms Laverne McGuinness

Ms Laverne McGuinness

Ms Laverne McGuinness

Mr. John Hennessy

Mr. John Hennessy

Dr. Barry White

Dr. Barry White

Mr. Cathal Magee

Mr. Cathal Magee

Mr. Cathal Magee

Mr. Cathal Magee

Ms Laverne McGuinness

Mr. Cathal Magee

Mr. Pat Healy

Mr. Pat Healy

Mr. Cathal Magee

Mr. John Hennessy

Mr. John Hennessy

Mr. Stephen Mulvany

Mr. Stephen Mulvany

Mr. John Hennessy

Ms Laverne McGuinness

JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 23 Feb 2012