Update on Health Issues: Department of Health and Health Service Executive

I remind members, witnesses and those in the gallery to ensure their mobile phones are switched off, as it interferes with the broadcasting of the meeting. I welcome the Minister for Health, Deputy Leo Varadkar, the Minister of State with responsibility for primary care, social care and mental health, Deputy Kathleen Lynch, and Dr. Tony Holohan, Ms Tracey Conroy, Mr. Tony O'Brien, Ms Laverne McGuinness, Mr. Pat Healy, Mr. Liam Woods, Ms Anne O'Connor and Dr. Áine Carroll from the Department of Health and the HSE. The witnesses are all very welcome. This is the quarterly meeting of the Joint Committee on Health and Children to discuss local and national issues. Written questions have been submitted in advance by members, and responses to these questions have been circulated.

I advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

The committee will hear the Minister first, and then Mr. O'Brien and the Minister of State, Deputy Lynch, will make opening statements. Party spokespersons will have seven minutes each and members will be given four minutes each in rotation. I invite the Minister to make his opening remarks.

I thank the Cathaoirleach and members of the committee for the invitation to attend. I am joined by Minister of State, Deputy Kathleen Lynch, Dr. Tony Holohan, chief medical officer, Ms Tracey Conroy, assistant secretary in my Department, Mr. Tony O’Brien, director general of the HSE, and members of his leadership team. Members will recall that at the start of the year, the Minister of State and I set out our work programme for 2015. It contained 25 actions under five major themes. I will touch on each of them briefly and record some of the progress being made.

The first theme is Healthy Ireland. We need to improve our health as individuals and as a nation. This is the best way to ensure we live long and healthy lives and the most effective way to prevent illness and reduce health costs in the long term.

The legislation brought forward by the Minister, Deputy James Reilly, on plain packaging on tobacco was signed into law by the President on 10 March and my Department is currently drafting regulations on the prescribed aspects of the Act. It is, as members know, subject to legal challenge.

The general scheme of the public health (alcohol) Bill was approved by Government on 10 February. I intend to publish it before the summer recess. As it has already been subject of a dedicated committee meeting, I will not say any more on it today. Provisions under the Public Health (Sunbeds) Act 2014 requiring health information, warning signs, prohibitions on certain marketing practices, health claims, notification requirements, fee and fixed penalty notices were commenced in February and March. This will discourage younger people in particular from using sunbeds, while imposing stricter regulation on providers. It will reduce skin cancer prevalence and save lives.

Recent statistics reveal that 61% of Irish adults and one in four primary school children are now overweight or obese. My Department held a major stakeholder consultation at the end of April on what we need to do collectively to address the challenge of overweight and obesity. The consultation brought together key stakeholders to prioritise the actions which Government and other sectors need to take over the next ten years to tackle overweight and obesity. A new obesity policy and action plan will be finalised this year and brought to Government for approval. While some comments and reports on the matter in recent weeks were sensationalised and not evidence-based, which serves no good, it is a real personal and public health issue and needs to be taken as seriously in the future as tobacco in the recent past and alcohol now.

The second theme is patient outcomes and patient safety. As members know, I have taken a personal interest in emergency department overcrowding. Overcrowding in our hospitals has eased since January and is trending downwards. Progress is being made but it still remains higher than at this point last year. Similarly, the number of delayed discharges has fallen from a peak of 850, but remains at about 680. At the beginning of April the Government approved additional funds of €74 million to reduce delayed discharges by providing €44 million to the fair deal scheme resulting in an additional 1,600 places, and €30 million to provide an extra 250 convalescent and rehabilitation beds in community and district hospitals. The implementation of these measures has now begun but will take about eight weeks to fully implement.

As of 30 April there were 575 people on the fair deal waiting list with an average wait time of four weeks from the date of approval, down from 11 weeks at the start of the year. More than half of the additional community and district hospital beds are now open. The emergency department task force report needs to be fully implemented and I will personally drive this. There will always be surges in demand, and all health services have patients on trolleys from time to time, but trolley waits of nine, 12 and 24 hours represent a real patient safety risk and need to be reduced considerably. I have mandated the HSE to ensure than nobody is waiting more than 18 months for a surgical procedure or outpatient appointment by July, and no more than 15 months by the end of the year. I know that may not seem very ambitious, and it is not, but within current resources it is realistic and achievable in all but a small number of sub-specialties. While the numbers on waiting lists are likely to continue to rise as demand rises, I want to make sure that those who are waiting are not waiting as long.

On patient safety, we are continuing to develop and monitor the implementation of the national clinical effectiveness guidelines, of which there are six to date with a further two currently in development, namely, the national paediatric early warning system and the clinical handover for acute services, and we are continuing to develop better implementation of HIQA recommendations. The HSE's joint open disclosure policy with the State Claims Agency is now being used in 47 acute hospitals and five PCCC areas, up from 15 hospitals and one PCCC area in 2013.

The third theme is universal health. Agreement was reached with the IMO in April on GP care without fees for the under-sixes and over-70s and on the introduction of an asthma cycle of care for children and a diabetes cycle of care for medical card or GP visit card holders who have type 2 diabetes. This represents the first step in the phased introduction of a universal GP service and will benefit over 300,000 senior citizens and children this summer. On universal health insurance, I firmly believe that we need to make health insurance more affordable before we can make it universal. At the end of 2014 I announced a number of actions to achieve this. These include a reduction in risk equalisation stamp duty, a reduction in the HIA levy, no further diminution of tax relief, discounts for young adults and, last month, the introduction of lifetime community rating. As a result some premiums have been reduced, others frozen and new affordable products are on offer. The number of people with health insurance is rising again and initial indications suggest that a very large number of people signed up in the past few weeks to beat the LCR deadline. I have learned this morning, in fact, that 74,000 additional people signed up in the past few weeks and the figure for the year so far is 80,000.

The fourth theme is reform, including greater investment in IT, which saw a 30% increase in budget this year to €55 million in capital. Key IT projects include e-referral, so that GPs can make referrals to hospitals online; electronic patient records, a move from paper to electronic records which we hope will be fully in place by the end of the decade, so that the moment a person gets into the back of an ambulance a paramedic can access their medical records on an i-Pad; and the issuing of the first individual health identifiers later this year - a sort of PPS number for health. I would encourage the committee to invite Mr. Richard Corbridge, chief information officer for the HSE, to come in to brief you on these very exciting plans.

The fifth theme is investment in modern infrastructure and facilities. The most important of these is the new children's hospital, the biggest single health infrastructure project ever in the history of the State. The planning application for the hospital will be lodged this summer and, subject to An Bord Pleanála’s decision, we could have planning permission by Christmas or early in the new year with construction commencing soon after. I visited Great Ormond Street Hospital in London this week and I can assure the committee that the new children's hospital we have planned will be more modern and have more beds and operating theatres than any children's hospital in the United Kingdom.

On the overall financial position of the health service, the latest figures from the HSE demonstrate the significant challenge facing us as a result of the changing demographics in Ireland. Over the next few years, the population aged 65 and over will increase by approximately 20,000 per year, placing increased pressure on our acute hospital, community, and social care sectors. We will continue to work to develop safe quality services for patients, while at the same time looking for ways to reduce costs. While it is difficult at this stage to draw conclusions as to the year-end position based on data from January and February, due to a number of factors including the exceptionally high level of delayed discharges during these two months, the new measures recommended by the ED task force and agreed by Government, along with the ongoing reform of practices and processes in hospitals, are beginning to show results. Current expenditure projections are preliminary in nature, and my Department and the HSE are working together to understand the deficit to date and the likely full year impact of this variance and emerging and known funding pressures. The HSE is moving to reduce overspending and is working closely with the Department to mitigate the projected deficit to the greatest degree possible. Mr. Tony O'Brien will speak on this further if members wish.

I want to turn now to maternity services and, in particular, to the recently published HIQA report on Portlaoise hospital. Many aspects of the HIQA report disturb me, as I am sure they do committee members. I am ashamed at the manner in which patients were treated without respect, care and compassion when they most needed it by members of my own profession and other professions. Many did not receive the quality of care we should expect from a modern health service in the developed world. Patients and their families were treated dreadfully and at times inhumanely. As I have said previously, it is not all about resources and we should challenge those who seek to make resources the excuse for all failings. If we allow it to be an excuse it will always be the default excuse. That in itself is a threat to patient safety. It costs nothing to care. Honesty costs nothing - and in fact it probably saves money - and neither does compassion. Adherence to professional standards and being properly trained and accredited to do one's job should be a given. Too often, it is not.

The report highlights the urgent need to embed a patient safety culture right throughout the health service. I intend that this should not just be another report. It should be a watershed report. Patient safety, outcomes and quality must never come second to institutional, corporate, staff or local political interests. Decisions made on resource allocation and service location must be made on the basis of what is best for patients in terms of safety or outcomes, not financial savings or votes. Having met some former patients and there families last night, I am more convinced than ever that a patient advocacy service should be established and it will be fully independent of the Health Service Executive.

All mistakes are not medical negligence and mistakes and misjudgments will always happen - that is the nature of medicine. All complaints will not be valid or upheld. But we need to move to a new culture when complaints are welcomed and seen as a tool to guide us in improving services and patient satisfaction. Too often and for too long the health service has been defensive in dealing with complaints and fails to deal with them in a timely manner and therefore adds insult to injury and hurt on hurt. An independent patient advocacy service will be crucial in supporting patients and changing that culture. I accept the HIQA report in full and thank the investigation team for its work. The four recommendations made to my Department will be implemented. The HSE has confirmed that it too will implement the four recommendations made to it. I expect the HSE to implement an action plan to address the findings of the report without delay, and certainly by the end of the year.

Improvements have been, and will continue to be made at Portlaoise hospital, which I had the opportunity to visit yesterday. New management and governance structures, both clinical and operational, are in place, including a new hospital manager and a director of midwifery for the first time, as well as an on-site risk manager.

Appointments have been made to key posts of concern in both the maternity and general services. This includes additional consultants in anaesthetics, surgery, emergency medicine, paediatrics and obstetrics. Sixteen additional midwives have been appointed and approval has been given for further midwifery posts to include shift leaders and posts in diabetics and ultra-sonography. An ambulance by-pass protocol is in place for serious paediatric and trauma cases. For the record, it is important to point out that since the Government came to office the number of midwives employed in the public health service has increased from 1,100 to 1,400 and the number of consultant obstetricians is at an all-time high. It is certainly nowhere near where it needs to be and it is not up to international standards but it does show that during a period of cutbacks the Government did prioritise front-line services in particular in this area.

Structural change has begun, with Portlaoise hospital now forming part of the Dublin-Midlands hospital group. Governance of the maternity service will transfer to the Coombe in line with a memorandum of understanding agreed already. At the end of April, I appointed a steering group chaired by Ms Sylda Langford, former director general of the Office of the Minister for Children and Youth Affairs, to prepare a new maternity strategy for Ireland. In doing so, I am implementing one of the recommendations of the HIQA report into the care of Ms Savita Halappanavar.

The new maternity strategy will put the needs of mothers, babies and their families at its centre. The focus will be on maximising patient safety, quality of care, and clinical outcomes as well as the desirability of greater patient choice, the move towards more services in the community, and a renewed focus on prevention and well-being. I have asked the group to report to me by the end of the year. As committee members are aware, ten years ago cancer care in Ireland was below standard and fragmented, and we did not collect data properly. Today, it is well organised and survival rates are improving all the time. I want to adopt the same programmatic approach that was adopted to cancer to women's and infant health in the next decade.

There are a number of other initiatives and developments on which I would be happy to update the committee but I know my time is limited and committee members will also want to hear from the director general and to ask questions, so I will conclude at this point. I will be happy to respond to queries that arise.

I thank the Minister and call Mr. Tony O'Brien, director general of the HSE.

Mr. Tony O'Brien

I thank the committee for the invitation to attend. I am joined by a number of my colleagues: Ms Laverne McGuinness, deputy director general, Mr. Liam Woods, national director of the acute hospital division, Dr. Áine Carroll, national director of clinical strategy and programmes, Mr. Pat Healy, national director of the social care division, and Ms Anne O’Connor, national director of the mental health division.

The committee requested information and replies on a number of specific issues prior to this meeting and members will have received a written response to each of them. In my opening remarks I would like to update the committee on a number of issues. The first relates to the HIQA report concerning the Midland Regional Hospital, Portlaoise, MRHP.

The HSE on Friday last received the final report of the investigation into the quality, safety and standards of services provided by the HSE to patients at the Midland Regional Hospital, Portlaoise. The HSE welcomes the conclusion of the HIQA investigation, accepts all of the recommendations of this report and acknowledges that their implementation will contribute to improving the quality and standard of services delivered in Portlaoise hospital and similar hospitals. The HSE has already taken objective steps to improve the quality and safety of services in Portlaoise over the past two years. These important steps are included within many of the HIQA recommendations. As a consequence of the measures taken, the HSE is confident that MRHP provides a safe level of service to its patients in the midlands today, although there are undoubtedly questions of sustainability to be addressed.

The HSE has already acknowledged that there have been failings at Portlaoise over the years. The HSE has in the past apologised for these failures and the suffering and distress that they caused to the families concerned, and I reiterate that apology once again today. Last year in the context of some of the very distressing reports, I wrote to every health service staff member about this and that letter is appended to the printed version of my statement.

The hospital in Portlaoise provides extremely important services to the midland counties and is a very busy hospital today. For example, it is expected that there will be approximately 1,900 births in its maternity unit this year. I am also very conscious of the potential of negative publicity surrounding this report to undermine the confidence of some of the patients who use the hospital's services. Any negative publicity is also likely to impact on the hard working and dedicated staff who have been putting their hearts and souls into their work in the hospital in very trying circumstances, where demand for services is increasing and resources continue to remain limited. I wish to emphasise that any failings relating to the past either have now been or are being rectified and that Portlaoise hospital is now on a path to being an excellent hospital as part of a wider group. Significant improvements have been, and continue to be, implemented in both maternity and general services at the hospital, which is overseen by a joint steering group comprised of representatives from Portlaoise and other hospitals in the Dublin-Midlands hospital group, including the recently appointed chief executive officer of the group, Dr. Susan O'Reilly.

An important improvement is the introduction of an expanded and new management and governance structure, both clinical and operational, for the maternity unit and the general hospital. This new structure allows for strengthened management at local level and clearer reporting relationships within the Dublin-Midlands hospital group. Central to these new arrangements is the formalisation of existing pathways between the maternity unit and the Coombe Women and Infants University Hospital. In this regard a clinical director for integration has been appointed. Furthermore, existing relationships between Portlaoise and Tullamore, Tallaght, Naas and St. James's hospitals are being further developed and strengthened particularly in the areas of emergency medicine, ICU, surgery and bed capacity.

An area of concern, raised in a number of reports over the recent past, has been in relation to staffing levels. The staffing moratorium across the public service over the past five years has impeded a full resolution of this situation up to recent times, as a consequence of a much reduced health budget arising from the financial emergency. A considerable number of staff have been, and continue to be, appointed to key posts of concern in both the maternity and general services. This includes a number of additional consultant posts in anaesthetics, surgery, emergency medicine, paediatrics, obstetrics, and physician posts. In relation to midwifery posts, 16 additional midwives have been appointed and are in place. Approval has been given for further midwifery posts to include shift leaders in delivery, and posts in diabetics and ultra-sonography. Additional general nursing posts are also in progress. A full review has been conducted of the structures and processes of quality, safety and risk in both the maternity unit and the general hospital. Following this review a significant number of improvements have taken place.

The appointment of quality and patient safety, QPS, managers for both the maternity unit and the general hospital will considerably strengthen the QPS function. The management of complaints has also been examined and improved. Following the national patient safety culture survey, conducted by the quality improvement division of the HSE in 2013 and 2014, a report of the results from the Midland Regional Hospital, Portlaoise has been produced and disseminated to all relevant parties. Among the many other improvements in Portlaoise hospital, patients, following triage in the emergency department, are now under the care and accountability of a named consultant at all times. Portlaoise hospital has also fully implemented the national open disclosure policy, the national consent policy and national bereavement care guidelines.

Additionally, the maternity unit has implemented the national early warning score, NEWS, and the Irish maternity early warning score, IMEWS. Furthermore, all midwifery staff in the maternity unit have received training in cardiotocograph, CTG, and additional online training facilities have been introduced. In light of this report I have taken the decision to bring in an external investigator in accordance with our disciplinary procedure to look at issues of concern. Many issues were escalated but they did not always find their way to the right decision making levels and that must be investigated in accordance with fair procedures Many of the issues which arise in Portlaoise hospital are not just about resources or the quality of clinical care but about the human and compassionate care that was or was not provided. Accordingly, a separate examination will examine this matter. The names of the investigators and terms of reference will be published shortly.

It is important, starting in the maternity unit in Portlaoise hospital and the wider hospital and other maternity hospitals, that we have a thorough programme of empowering nursing and midwifery leadership and interdisciplinary leaders to drive compassion in care. Following the lead of the NHS in England and Scotland, respectively, we intend to implement the Florence Nightingale Foundation’s leading for compassion programme and the caring behaviours assurance system, CBAS, programme throughout the health service.

Turning to the national service plan, members are aware that each month performance against our national service plan targets and deliverables is monitored and measured. The latest published performance report shows that in February 2015 there were 185,688 emergency attendances for the first two months of the year. While the average daily attendance is up 5%, or 177 per day on January, the overall attendances are 2.1% less than the same period for 2014. The number of delayed discharges has fallen from a peak of 850 on 4 January to 705 at the end of February. Additional funding of €74 million, provided by the Government, has assisted in alleviating pressures in acute hospitals by providing additional nursing home placements.

The two most recent delayed discharge reports of 28 April and 5 May 2015 recorded fewer than 700 delayed discharges for the first time since September 2014 and the trajectory is now downwards.

The national plan prioritises a reduction in waiting times for hospital care with a focus on those waiting the longest so that nobody will wait longer than 18 months at the end of June or 15 months by year end. In February, 98% of adults were seen within this timeframe for an inpatient or day case procedure and 82% of patient were waiting less than 52 weeks for an outpatient appointment. Plans are being finalised to ensure the June target of no patient waiting longer than 18 months is achieved.

With regard to emergency ambulances, the percentage calls responded to within eight minutes and 59 seconds by ECHO reached 78% and by DELTA reached 65% during the month. A total of 82% of referrals accepted by child and adolescent mental health teams were offered a first appointment within 12 weeks against a target of 78%. A total of 13,407 people were in receipt of a home care package during February, which is 10.5% more than the same time last year. In mental health services, difficulty in filling staff vacancies remains a significant challenge to providing timely and appropriate care. A number of recruitment campaigns are under way to address this.

In primary care, work is progressing on improving access to primary services through the extension of GP care free at the point of delivery to all children under six and all adults over 70. Contracts have now been issued to GPs for signing following agreement with the IMO on the details, and public registrations are due to commence from June 2015. This service enhancement due to commence from July will provide GP access, wellness health checks and asthma care for children, and care for patients with type 2 diabetes in primary care in accordance with the models of best practice for the management of chronic medical conditions.

The investigation into Áras Attracta and the disciplinary procedure is progressing on schedule, having received clearance from An Garda Síochána to recommence its work. The aim is to have the investigation work completed by the end of May or early June, with findings and a final report completed by the end of July. Dr. Kevin McCoy's assurance review is progressing well, having met residents, family members, staff and management. In addition to recommending specific plans for each centre in Áras Attracta, the output from the review team will help to inform our system-wide programme of improvement. A new governance structure is being implemented, with a new director of service post advertised. Under the leadership of the new director, three discrete centres will operate in the campus, each centre specialising on the particular needs of service users. A residents' council is being established as part of the national volunteer advocacy programme.

The new policy “Safeguarding Vulnerable Persons at Risk of Abuse” is being fully implemented with nine safeguarding and protection teams being established, one per community health care organisation. The recruitment of 20 additional social work posts has commenced. The quality improvement enablement teams are in place and are focused on supporting our centres, in transferring HIQA standards into good practice in front-line services. The initial phase has prioritised HSE residential centres, with the team visiting more than 50 centres delivering services to 448 people, representing almost 25% of HSE residential services. In addition, a confidential recipient, Leigh Gath, has been appointed, who is independent in her functions with the authority to examine concerns and to hear of issues and complaints in a totally confidential manner.

There have been recent media reports on the accessibility of mental health services for children and adolescents. The HSE is committed to ensuring that all aspects of child and adolescent mental health service, CAMHS, are delivered in a consistent and timely fashion regardless of where in the country the service is accessed . A number of measures have been put in place to improve access to and quality of these specialist services. These include a CAMHS service improvement project established to review and improve, where necessary, performance relating to both inpatient and community CAMHS.

I am also pleased to advise the committee that seven new suicide prevention officers have been recruited and they will take up duty shortly. It is also anticipated that additional suicide prevention resource officers will be recruited later this year through the 2015 mental health development funding.

Despite the progress being made in our mental health services I am particularly concerned at the significant challenges posed by the recruitment of nursing and medical grades, which are now impacting on service delivery. The mental health division is working closely with HR and the national recruitment service to progress overseas recruitment initiatives to address this issue.

Primary percutaneous coronary intervention, PPCI, commonly known as coronary angioplasty or simply angioplasty, is a non-surgical procedure used to treat the stenotic, or narrowed, coronary arteries of the heart found in coronary heart disease. In November, the acute hospitals division of the HSE requested the national clinical programme for acute coronary syndrome, ACS, programme to review the current configuration of PPCI services in Dublin, having regard to the requirement to deliver safe, sustainable services on the designated sites. The model of care produced by the ACS programme was informed by advice from the principals involved in centres in the UK and other European countries. The programme was also informed by models of care from the United States and Australia. Experience at national and international level highlights the importance of having sustainable rotas of clinical staff to support the 24-7 requirements of this service.

Based on this comprehensive review, the HSE took the decision to consolidate the service in Dublin into two centres, which reflects the international trend towards the consolidation of such specialised services on a smaller number of sites to allow for the concentration of volume and expertise. Since 17 April there are two 24-7 PPCI centres for Dublin, located in the Mater hospital and St. James’s Hospital. These centres now accept all ambulance transfers of Dublin patients with ST elevation myocardial infarction, STEMI.

In the wider context of percutaneous coronary intervention, PCI services, a review of these services is under way and will be completed shortly. Once complete, PCI capacity nationally, including Waterford, will be examined. This review will look at the further provision of PCI services nationally in the best interest of patients and on evidence on the volume of clinical need, the quality and safety of the service that can be provided, the ability to staff it safely and the resources available.

This concludes my opening statement and together with my colleagues we will endeavour to answer any questions the committee may have.

I remind members that on Tuesday we will have a specific stand-alone meeting with the HSE on the HIQA report into the hospital in Portlaoise and I ask them to be conscious of this in their responses to Mr. O'Brien and the Minister, Deputy Varadkar.

I welcome the Minister, the Minister of State, the director general of the HSE and others. We accept we will have a meeting next week with the HSE to discuss the findings of the Portlaoise report, but it is important while the Minister and the director general of the HSE are before us to raise some points which are of huge concern about the report and any interpretation to be put on it.

Why we have the report in the first place makes for very sad and debilitating reading. When we see the testimony and listen to the families involved, the huge resistance put up by the HSE to engaging with them even on finding out basic and general information and trying to elicit the truth seems to be the culture and normal practice. To speak about freedom of information in general, this is extending throughout many Departments. I will make the political point that it is getting more and more difficult for citizens, be they Members of the Opposition or anybody else, to get information from the State. We must be very honest. We speak about open disclosure in the context of medicine and clinical decisions, but there must be open disclosure across the full remit of the State. In this context the HSE has much to do.

The service priorities for the 2015 service plan include improved quality and patient safety, with a focus on service user experience, the development of a culture of learning and improvement, patient, service users and staff engagement, medication management, health care associated infections, serious incidents and reportable offence, complaints and compliments, implementing quality patient safety and an enablement programme. We can only hope that on foot of the report into Portlaoise and its recommendations that we will act upon the opening statement of the HSE's service plan.

I read the letter Mr. O'Brien sent to all members of staff of the HSE after the "Prime Time" report. It calls for people to engage with patients, more openness and asking the staff in general to make the best efforts possible. It mentions an apparently unfeeling bureaucracy and excessive defensiveness in a way which appears only to serve self-interest. Much of this is explained. It was important to send the letter to the staff after the "Prime Time" report.

However, when I read the report it appears that even the person signed the letter on behalf of the HSE, Mr. O'Brien, did not even act on the recommendations of the CMO.

The HIQA report stated:

In his report, the Department of Health’s Chief Medical Officer said two previous HSE reviews published in 2008 into breast cancer misdiagnosis cases at Portlaoise Hospital should have provided a very strong case for ‘external oversight and support to Portlaoise Hospital as it dealt with the legacy of those issues’...

Six previous investigations into hospital care in Ireland have been carried out by the Authority [that is HIQA] between 2007 and 2013. These have made a number of important findings and recommendations which were intended to be used by all healthcare services to inform and improve practice. Had the relevance of these investigation findings been reviewed in the context of Portlaoise Hospital and the aligned recommendations been subsequently implemented, the Authority is of the opinion this could have vastly reduced the identified risks in the services being provided to patients.

We have had the Tania McCabe tragedy in Our Lady of Lourdes Hospital, we have had the Savita Halappanavar case, and we have had the investigations into Mallow and Ennis hospitals. There seems to be no ability for the organisation to take the best practice from within the system. More important, when recommendations are made, there seems to be a complete inability to follow through on those.

This is an issue for the Minister as well. Representatives of HIQA appeared before the committee yesterday. They made the point that the regulator should not be the body overseeing the implementation of the recommendations. Equally the organisation that is requested to implement the recommendations should not also be overseeing it.

Without being overly hostile to the HSE, any reading of this Portlaoise report would seem to indicate that almost nothing has been learned from the previous seven reports and, if it has, it has not been implemented. In the context of a patient safety advocacy group, we should consider establishing some form of commission to oversee the implementation of recommendations of a regulator.

The report also states: "At the time of reporting in May 2015 – some 13 months after the publication of this recommendation by the Chief Medical Officer – these arrangements were still not in place." Those arrangements were that in the interim Portlaoise hospital would continue:

to operate in the absence of formal systems enabling clinical cooperation and communication between it and some of the larger training hospitals that are to be involved in the group. The Chief Medical Officer’s report made a specific recommendation about ensuring the networking of senior clinical leadership between the larger Coombe Women and Infants University Hospital in Dublin and the maternity unit within the smaller Portlaoise Hospital.

I find it extraordinary that that had not been fully implemented in the context of the Chief Medical Officer's report that was published 13 months ago.

We can go into further detail on this in Tuesday, but I really need an explanation of this one. Page 12 of the report states:

The pivotal appointment of a director of midwifery to a maternity department located within a general hospital is unique to Portlaoise Hospital. This role has had a very positive influence in terms of assessing and improving the standard of midwifery care, enhancing multidisciplinary working relationships, improving staff morale and re-energising a patient-centred approach to care.

As with much of this report the next word is "however":

However, at the time of writing, a senior obstetric lead had not been appointed to the Maternity Department to provide independent senior experienced obstetric clinical leadership. This is despite a direct request by the Authority [that is, HIQA, again] to the Director General [that is, Mr. O'Brien] of the HSE in September 2014 to do so because of the investigation team’s concerns about the absence of adequate clinical leadership within the maternity unit and the failure to progress the development of a clinical network with the Coombe Women and Infants University Hospital.

I know that a memorandum of understanding has since been signed with the Coombe hospital. However, I find it extraordinary that more effort was not made.

The Minister's contribution did not really refer to the major crisis that is facing us with outpatient waiting lists. Some 412,000 people are waiting for an outpatient appointment and it is getting worse. At some stage the Minister will have to accept they cannot do it themselves. It will be necessary to re-engage the National Treatment Purchase Fund and admit that the system is not working. We need to engage with the private sector at least to allow patients a chance of being seen and getting treatment in a reasonable time.

May I come back again later?

The Deputy can indeed. I call Deputy Ó Caoláin, who has up to seven minutes.

As Deputy Kelleher has said, I am conscious that we will have a dedicated opportunity on Tuesday to address with the HSE the matters arising from the Midland Regional Hospital report. Last week the Minister announced the appointment of a steering group to help prepare a national maternity strategy. Yesterday, speaking to the media in Portlaoise, he speculated on the closure of a number of smaller so-called maternity units. It is very premature to talk in those terms when any number of measures that would warrant consideration should be examined before such a serious step would even be contemplated. I would have liked to have heard him acknowledge the inadequate staffing provision leading to an impossible situation for many who provide excellent maternity services across our 19 maternity units. We need to recognise that there were 33 unfilled vacancies at Portlaoise hospital. The recruitment to fill these positions is only now being seriously addressed. It is very premature and I am very concerned because it only fuels the upset and confusion. The director general spoke about negative publicity. Again, suggesting more closures is a negative step. It is not dealing with the problem at all. Women do not want to be displaced and herded into factory production in over-centralised settings which clearly lack the compassion, care, time and attention they deserve in these situations. The overwhelming number of them are not sick; they are having a child.

The director general said that the HSE received the final report of the investigation into Portlaoise hospital on Friday. What differences were there between the final report and the report that gave rise to his very strong intervention that went so far as to threaten legal action to injunct the publication of that draft report? What was the difference between the draft report and the final one, when apparently, from what the director general has said and the Minister has indicated, the HSE is accepting all the recommendations that directly impact on the HSE? What was the difference? What gave rise to his first reaction and his more accepting stance to the report in its final presentation?

I will not continue to address the Portlaoise report at this point, knowing that we have the debate on Tuesday. I do not want the issues I had highlighted for quarterly address to be completely lost.

They merited it and I would like to refer to it. The first concerned question No. 9, in which I raised the issue of vulnerable adults and their safe care in a variety of settings. We are talking about aged and vulnerable adults who are unable to articulate and represent themselves. Áras Attracta might be a backdrop to the question, although I am not specifically or solely addressing that setting. The Minister's reply states that under the policy, that is, the safeguarding of vulnerable persons at risk of abuse national policy procedures, all service providers are required to have a publicly stated no-tolerance approach to abuse. What does "no tolerance" mean? Could the Minister translate that for me? Despite all the public attention and the exposé on national television, I am not convinced that this issue has been satisfactorily addressed. The fears and concerns still remain.

I note that at the end of the subsequent paragraph the Minister states that in cases of suspected sexual abuse, An Garda Síochána would always be notified. Why would the Garda not always be notified in cases of physical abuse and assault? Why does the answer refer specifically only to cases of suspected sexual abuse? Would cases of suspected or actual physical abuse and assault not always be notified to the Garda? If this has not been the case, will the Minister give us an assurance that it is now and always will be in the future? Abuse of an elderly person or a vulnerable adult should always carry both criminal and civil penalties and strong legislation is required in this area. Elderly persons and dependent adults are a disadvantaged section of society. I have such adults in my immediate family and I am sure many others in this room can identify and empathise with this critically important situation. I want to see the very best guarantees enshrined in legislation. I do not ever again want to wake up to new revelations of elder abuse or the abuse of dependent adults.

My question No. 10 concerns the vaccine for meningitis B. We have seen examples of the impact of meningitis, and meningitis B accounts for the majority of cases in Ireland. We have the highest incidence of meningococcal disease in Europe and there was a significant increase of up to 25% in cases in 2013. Children under five are the highest risk age group. I am very concerned about the response to my question, which states that the introduction of any new vaccine into the primary childhood immunisation schedule will be considered in the context of recommendations from the national immunisation advisory committee, NIAC, the outcome of cost-effectiveness analysis, the conclusions of the review of the HSE vaccination services currently being carried out, and resource availability. This is not an answer. The issue is not being actively and seriously considered. I am anxious to know if it will be revisited. Is it the case that only parents who can afford to buy the vaccine will be able to protect their children from meningococcal disease?

My question No. 11 raises access to emergency dental general anaesthetic services in Dublin city. Those services were withdrawn last year, yet the Minister's answer states that a protocol is now in place requiring this service remain under regular review. Heaven protect us all. What is being done to ensure a public service of a high standard is in place which children who are dependent on the public service and require an anaesthetic for extractions will be able to access? The service was in place in St. James's Hospital until it ceased last year. The consequences are very serious for the families who are directly impacted.

In the absence of Deputy Healy I call Senator van Turnhout.

I concur with my colleagues, Deputies Kelleher and Ó Caoláin, on the Midland Regional Hospital report. As we will have dedicated time for this as a committee, I would now like to focus on some of the questions I raised, which are of critical importance.

My question No. 14 concerns the children and adolescent mental health service, CAMHS. I raised this because of a report produced in March 2015 by Dr. Helen Buckley, chair of the national review panel on children who died in the care of the State. The report was about 26 vulnerable children and stated that three out of four teenage girls who died by suicide were known to our child protection services and, for lengthy periods before their deaths, were on waiting lists for psychological services. According to the individual reports on the circumstances surrounding 12 of the deaths, at one point before taking her life, one of the girls, called Jennifer in the report, had been on a waiting list for psychological services for two years. Her mother had tried to access mental health services the week before she died. This happened last year. It is not something historical. Another case concerns a teenage girl, named Zoe in the report, who had been in and out of State care in childhood. Her case with the social work department had been closed months before she died by suicide.

I am hearing more and more that there is an urgency to close cases rather than being absolutely assured that the child is getting the services she or he needs. Dr. Helen Buckley states that mental health difficulty is very prevalent among people and their parents. Referring to waiting lists, she states that two years is the treatment time she is seeing in the cases she is looking at. She further states that young people in critical conditions are often receiving very limited treatment. This is echoed by the child care law reporting project led by Dr. Carol Coulter and her team, which gives us an insight into child care proceedings in the courts. This project reports on very recent cases and the characteristics and demographics mirror all those interplaying factors identified by Dr. Buckley.

I am frustrated by the lack of urgency within our mental health services. We know from the Royal College of Surgeons in Ireland that by age 13, one in three young people is likely to have experienced some type of mental disorder. By the age of 24 that has increased to one in two. How we deal with it at that age frames how we deal with it for life. Getting it right at that age is critical for our lives. When I talk to community-based organisations on the ground, they say the pathways for getting to the services are extremely difficult. For example, I was talking to a person in Tallaght who told me that although Jigsaw and Headstrong employ a consultant psychiatrist, they cannot refer directly to CAMHS but have to refer the young person to a GP who can then refer them on. It does not make sense when they have a consultant psychiatrist who specialises in the field. They say to me they do not have a waiting list because they do not tolerate a policy of any waiting list. For someone who is experiencing severe mental health issues, even 12 weeks seems a long time in that critical phase.

I could make the same speech on this issue as I made four years ago. From talking to the organisations on the ground, I do not know where it is going, particularly in respect of services outside the 9 a.m. to 5 p.m. period. What are youth workers to do and how can they get help for a young person? The issue needs more attention.

On question No. 12 regarding the hospice friendly hospitals programme, I am surprised there is no mention of the HSE palliative care co-ordinators. This was in the joint committee's report on end-of-life care. We had a really good engagement with the HSE on that report and I am surprised it has not been mentioned. Perhaps we could have more detail on that.

I was very disappointed by the answer to question No. 13 and I believe a more detailed answer will come. It gives the impression that things are happening but, sadly, they are not. We only have seven months left in four-year policy programme to get to our implementation plan. The programme has been there for four years and we have seven months left but we still do not have the implementation plan. This is about stroke survivors and rehabilitation care. It is totally unacceptable that we do not have that yet. I agree that health service funding can be part of the problem but much of what is required could be delivered through reorganisation. We must do much more about this, as we have seen a deterioration in service in the lifetime of this Government rather than an improvement. This area needs extra focus but I will await a further answer.

I ask the Minister about the children's hospital. I welcome his statement and his visit to Great Ormond Street Hospital. In the media there is a very strong focus on the geographical location but this committee's understanding, having visited the site, is there is an idea of satellites, consistency of services and outreach. It has not really been conveyed to the public. Has there been a decision on the maternity hospital, as it is important to consider the site and the services in play? I repeat my welcome for free GP care for those under six; it is a prevention and early intervention step, and it is a very positive move to a rights-based approach to health care. I want to see all children getting the health care they need when they need it. The health checks have been required for a long time. I hope we can get to the children who are in abusive cases or neglected much earlier in life. That is a critical issue.

I also welcome the HSE statement on alcohol-related harm. A policy is being developed where there will be no interaction with the drinks industry, which is welcome. I hope the Departments of Health and Education and Science, as well as other Departments and the Child and Family Agency, will follow suit with a similar statement.

The Minister of State, Deputy Lynch, must go to the Chamber to speak on the national dementia strategy so I ask her to briefly address her questions.

I will be brief as I do not have time to answer the questions as put. With regard to vulnerable adults, Mr Pat Healy is here and he might take up that matter. I must go as the statements on the national dementia strategy will shortly be taken in the Dáil. I hope to get back here. We are in negotiations about a range of vaccines and I know Deputy Conway has also put down a question on that. As the negotiations are ongoing, we should allow them to happen. That should not take forever.

There was mention of the child and adolescent mental health service, CAMHS, and I share those concerns. We must remember that CAMHS is for people who are acutely unwell and outside of that, we should be able to take a deeper look at the waiting list - we have been doing that - to see where exactly people can be dealt with. Perhaps it could be at the very early stages, as was suggested, so that people do not necessarily have to go to CAMHS. We have much difficulty with recruitment. I spoke to the director this morning and we have not been very successful in the recruitment process. She can fill in the committee on that as well. We are very conscious of the need for pathways to be clearer and access to be more immediate. There is a programme being worked on because we can do much better. When there are glaring gaps like we have had with personnel within the service, it is very difficult to deliver on our very high expectation. We have reduced waiting times and are getting on top for the first time with bed allocation and inappropriate placement. We have far more information on that now, which we did not have before. I must go but I will do my best to return.

I will ask the Minister to respond to the opening statements and questions. I remind members that eight people have indicated and I will take them in groups of three.

I will address the policy questions and leave the various service areas to the directors, as they have the most up-to-date and comprehensive knowledge about them. Deputy Kelleher asked about the oversight implementation and recommendations. It is a very pertinent question. One of the specific eight recommendations made in the HIQA Portlaoise report is that the Department would set up a steering group to oversee the implementation of the recommendations of that report. I can commit that it will be done; there is a commitment led by the Department to oversee the implementation of all eight recommendations in the report. This applies not just to the recommendations made to the Department but also those made to the HSE.

What is particularly helpful and strong about this report is the fact there are eight recommendations. They are specific, measurable, achievable and realistic. They can be time-bound. What can be difficult with other reports, not just from HIQA but from other bodies in the past, is that there may be 70 or 200 recommendations that are not very specific or time-bound. Sometimes they are not achievable. That would put anybody in a very difficult position as it is arguable as to whether they could ever be implemented. HIQA have set down a good marker by having eight very clear and doable recommendations that we can implement. The truth is that, on occasion, sometimes HIQA has made recommendations that cannot be done. With respect to ambulances, it specifically made a recommendation that would be in contravention of European law, and we would have to tender the ambulance to do what it recommends. That is obviously not something we intend to do. Sometimes the recommendations cannot be achieved because of financial limitations, and that is particularly the case with accident and emergency departments. We are building a new accident and emergency department every year in Ireland because we can only afford to do that. I wish we could build 20 new departments but we cannot. That is the reason we are certainly behind on some of those recommendations regarding the emergency department in Tallaght that could be applied across the country.

There may also be problems with recruitment and sometimes it is hard to recruit people in filling certain posts, no matter how hard we try. The fact that recommendations are not necessarily implemented does not mean they are being ignored. Sometimes we are still working at trying to implement them. We need to move to an approach of "comply and explain" with HIQA recommendations. I have asked the Department to go through and audit all recommendations made over the past number of years and have a rolling programme of checking every couple of months where we are in implementing them.

Will the steering group have an independent chairperson outside the Department?

We have not yet decided. My plan is for it to be chaired by a Department official but I am open to views on that. There should be independent input, particularly a patient representation.

I touched on the outpatient appointment issue. There are 412,000 people now waiting for their first appointment with a consultant, although there could be a fair bit of double counting. We will let the committee know about that. It is always important with waiting list figures to drill down and 170,000 of those people are waiting less than 12 weeks. In some cases they are waiting a few days. That refers to anybody, in effect, who has been referred by their GP to a consultant. It is not the case that they are all waiting inordinate lengths of time. The figures may be confusing. With the surgical area, the number of people waiting less than three months for a procedure is going up, for example, but the number of people waiting a long time is going up. People are being seen quickly by efficient services that are turning people over quickly, leading to improvement, but particular sub-specialties have lists that are getting longer. When I speak with people on waiting lists, they are not all that interested in whether they are number 100,000 or 106 on the list but rather how long they will have to wait. That is why the focus is not so much on getting the numbers down, as every time a new service is established, there is a new waiting list for it. There are waiting lists now in areas that did not exist two years ago.

My focus is on reducing waiting times so that people do not have to wait too long to see somebody. That is why we have set these maximum tolerable limits - which should not be tolerable, but unfortunately, they are - of 18 months by June and 15 month by December. I agree that we will need some help from the private sector and potentially even overseas in order to address some of those targets. That will be expensive but it needs to be done. It can be done through the National Treatment Purchase Fund, NTPF, which was used to eliminate the long waits for urgent colonoscopy procedures at the end of last year. I have no problem doing that again if the budget is available to do so. However, it does not necessarily have to be done by the NTPF in the old way as it can also be done directly by hospitals and groups which are already using the private sector to pick up some of their work.

For example, I refer to the very long waiting list for scoliosis operations for children which I find personally to be extremely worrying. That is why we have allocated an extra €1 million this year for this procedure. We have had to use the Blackrock Clinic as well as Cappagh to deal with some of those cases. However, there are limitations in that there are only so many theatres and so many surgeons. We are putting a whole new theatre into Crumlin hospital even though it will be out of use in three years. A constraining factor is the theatre space and the number of consultants who are trained to do the operations and this has caused us serious trouble. We may need to send some cases overseas for these operations.

There is a bigger picture with regard to waiting times for appointments. We need to reduce the number of referrals because, quite frankly, too many people are being referred to specialists. The best way we can reduce referrals is to support GPs, have more referrals to generalists, build up primary care in particular and also have GPs taking a special interest in areas such as dermatology and ENT. They can be trained up to deal with these areas of medicine. This would allow for inter-practice referrals as is the case in other countries. The e-referral system will mean better referrals. It is really disheartening to hear of patients who wait a year to see a consultant and the consultant tells them he did not need to see them. Better quality referrals using e-referrals, photograph referrals and video conferencing can all help.

We need proper adherence to chronological order and that is not always being done. It is supposed to be urgent cases first and then all routine cases in order but that does not happen. We need better IT systems in particular to ensure this does not happen. We need to change the ratio of reviews to new patients. At the moment in any clinic there is approximately one new patient for every three seen, or one to about 2.6 patients. If that ratio is changed slightly, there would not be a need for more clinics. More new patients would be seen and instead of a review every six months, it would be done every seven months or patients could be discharged back to their GP. A slight change in the ratio with existing resources could actually transform the waiting list. However, making that happen in every hospital and clinic in the country is very difficult, in particular when one is working from headquarters. We need more consultants in many areas, in particular in some of the specialties such as dermatology, ENT, orthopaedics and others. If it was a case of just having more consultants, the problem would have been solved a long time ago. We have more consultants than ever in the health service. However, it is a bigger piece that needs to be addressed; it has never been addressed properly and we are doing our best in that regard.

Deputy Ó Caoláin asked about the closure of maternity units and he said it was premature to be discussing that issue. It is probably premature to be talking about it and I accept that criticism. However, I wish to make it clear that it is not ruled out in that it is part of what needs to be considered. It is important to underline that this is not just a question of staffing; adequate patient numbers are required. For example, if a unit has 2,000 births a year, that is three or four births a day. When that one in a thousand case arrives, that unit probably has not seen such a case before and it is not sure what to do. The nature of specialisation is that smaller centres can give more personal care but bigger centres are more used to dealing with those rare cases, those one in a thousand cases or those one in ten thousand cases. Sometimes these cases can be picked up in advance and referred to the specialist centre but sometimes they are not picked up and that is the inherent nature of a smaller unit when it comes to a specialist service. The same applies to emergency departments, to cancer treatment in the past and to many other conditions.

If I were to explain it very simply, 20 years ago medicine was very safe, very simple and it was not very effective. Now it is very effective, very complex and potentially dangerous. A person having a heart attack 20 years ago would have gone to the local hospital where they would probably not have been able to do very much for the person and any doctor could do it. Now it is totally different. For example, a particular type of heart attack, a STEMI, means a patient is taken by ambulance to a specialist centre where a specialist does primary PCI or else the patient is taken by helicopter in some cases. If it is not that type of heart attack, the patient goes to a different centre which specialises in thrombolycis, a treatment that cannot be done in every hospital and never was or could be done in every hospital. That is why there has to be a lot of changes. Our job as politicians is to explain to people why the best care is not necessarily the nearest care and that it might be better to travel an hour or two to the right place rather than to have local care that is not up to standard.

Another aspect to remember is that staff can become de-skilled, and this issue was raised in the HIQA report on surgery in Portlaoise. If the surgeons are not doing complex surgery every day, they will not be as good at it. It is the case that one will be better at something one does every day rather than what one does only once a week. That is often the problem with smaller centres; it is often not lack of staff but rather lack of patients with those particular conditions and needs.

It must be borne in mind that even where there are staffing issues, the recruitment of skilled professionals is very difficult. There is an international shortage of doctors, consultants, midwives and specialist nurses. As a result they generally want to work in big centres attached to universities and centres of research. There is a struggle to recruit to peripheral centres and this applies not only in Ireland. It is not just a question of money; there are many reasons. It will come to the point where we must ask if it is desirable that we are only keeping services open by staffing them with locums and agency workers who work for a week or two. These are the questions we need to tackle as a country. This was the situation with regard to cancer and it will be the case in other areas.

On the question of maternity models, the strategy group will examine this in the round. In my view there is a lot more space for midwife-led care and midwife-led units and a lot more space for the domino system which means mothers go home early from hospital. There is more room for home births, within reason, if these can be done safely. Therefore, there would be fewer hospital-based births and as the birth rate falls, we would need fewer hospital units. It will not be possible to have the two systems. More midwife-led care, birthing centres, community care and home births, along with fewer births overall, will mean we will hardly need the same number of maternity units. That is just common sense and we need to be upfront about that.

On the question about vaccines, no country in Europe as yet vaccinates its entire population or child population for meningitis B. The UK will be the first country to do so later this year. It is under consideration as part of the service plan for 2016 but it is not under consideration on its own in that other vaccines are available to be considered. I refer to HPV for boys and men. The rotovirus vaccine is not given in Ireland but it is given in other countries. We must also consider the BCG vaccine because it has now been recommended by the experts that we no longer vaccinate everyone for TB and that only high-risk groups are vaccinated. We will look at all the vaccines rather than one at a time in order to develop a package for the service plan for 2016.

Senator van Turnhout spoke about the satellite centres and I agree with her. The planning permission for the children's hospital satellite centres in Blanchardstown and Tallaght will be submitted at the same time, which is this summer. If planning permission is granted, they will be open in 2017, so the satellite centres in Blanchardstown and Tallaght will be open before the main hospital opens. There will be a national network so every paediatric ward in the country will be linked into the children's hospital using the same IT system. The satellite centres will be ambulatory. For example, the Blanchardstown centre is a big three-storey building with a walk-in emergency department, outpatient department and other facilities. The Tallaght centre will be similar. In general, people will bring their children to these centres if a child has a bad chest or an injury and they will not go to the main campus because that will be the specialist centre, by and large.

There are four stand-alone maternity hospitals, Holles Street, the Coombe, the Rotunda and St. Munchin's in Limerick. The plan is to co-locate these hospitals with adult hospitals. This can only be done one hospital at a time and Holles Street will be the first. The planning application to move to the campus of St. Vincent's hospital will be submitted this summer. The hospital will be on the campus but it will be separate from St. Vincent's hospital. A decision remains to be made on where the Coombe, the Rotunda and St. Munchin's will go but that decision will be made in a matter of weeks. The locations are obvious but we have to ensure that the decisions stand up, are supported by data and are not based on any political considerations. We cannot have any allegations that decisions were taken on that basis.

Mr. Tony O'Brien

I will ask my colleagues to respond on certain questions. I will ask Mr. Liam Woods to comment on outpatient care and waiting lists generally.

Mr. Pat Healy will speak on the safeguarding policy and community rehabilitation, Ms Anne O'Connor on mental health services and Ms Laverne McGuinness on dental services and palliative care. In response to the questions on maternity services and Deputy Ó Caoláin’s concern about the nature of care in large maternity units, approximately 40% of the babies born last year were born in large maternity units. The three Dublin units are not associated with an absence of compassionate care. They are associated with very high standards of care. There should not be a suggestion that if there were to be a centralisation into larger units, it would be equated with a downgrading of the level of compassion and care. That correlation does not exist at all.

In response to Deputy Kelleher, who reminded me of the commitments made in the 2014 service plan, the quality and patient safety enablement programme identified has been established. It intends to ensure there are differential focuses on quality improvement on the one hand and quality assurance and verification on the other. That is having a significant impact on the system which all those who interact with it have recognised. He also mentioned the issue of health care acquired infections. When the latest performance assurance report is published shortly it will show for example that in Clostridium difficile, C. diff, we have the lowest recorded incidence at 2.1. There are areas where progress is being made.

The Deputy asked specifically about the response to the publication of the Chief Medical Officer’s report last February. On the day of its publication a new manager and a new director of midwifery were installed in the maternity services in Portlaoise. They are judged in the HIQA report to have made a very significant impact on the improvements that have occurred there, so much so, that, although it was described as a slightly innovative approach, HIQA has recommended the approach in general hospitals that have maternity services and that having a separate director of midwifery should be replicated. That is a sign of confidence that initiative went through. Two obstetricians have been appointed. The Irish maternity early warning system, IMEWS, has been implemented on site. In regard to the Dublin Mid-Leinster hospital group, in order to bring the strongest managerial focus I could to the group, I moved one of the most senior leaders in the HSE, Dr. Susan O’Reilly, who was brought to this country to head the national cancer control programme, into that group, specifically to ensure it had the type of managerial and clinical leadership focus required to address the issues there. That is also bearing considerable fruit.

The institution of a serious reportable events recommendation that the chief medical officer included in his report was implemented by my direction throughout the system from that day forward and it has since evolved, has been strengthened and is being audited. There has been a significant response. None of that of course is intended by me to take away from the fact that there were prior events from which there was insufficient learning and Deputy Kelleher referred to one of them. The letter to staff I issued was a reflection of my reaction to the particular unbelievable experiences of patients, their families and bereaved parents in terms of how they were responded to at their time of greatest need. It was intended to send a clear signal, which it did, that we can all, each of the 100,000 in the health service, do better than that.

Deputy Ó Caoláin asked me in particular about my position on the HIQA report. In terms of anything that went before, I had not seen, because it is not the practice that one would see, the recommendations of the HIQA report as part of a draft sent for fact checking and verification. That is not how it is done. Any comments I made about the report were not about the recommendations because I had not seen them. I was briefed verbally on those recommendations this day last week and received them when I received the full copy. I had and have absolutely no hesitation in agreeing with, supporting and committing to the implementation of the recommendations because I believe they will contribute to an improvement.

The issue I raised previously with HIQA was characterised here as threatening to injunct it, which I did not do. I did raise the prospect of a judicial review in circumstances where I had been asked to provide feedback on a draft report, without sufficient information to enable me to do so. I had on five occasions attempted to reach an engagement with those involved in order to overcome an impasse. Ultimately, at my appeal, the Department of Health was able to facilitate an engagement where we overcame some of those issues, appropriate time was allowed and a comprehensive submission made to the HSE. As to the extent of change, I do not think this is the time for that discussion. At the moment it is appropriate to focus on the report itself. My acceptance of the recommendation does not mean that I agree with every line in the report but that is not for now.

Would Mr. O’Brien agree that it also looks particularly bad when two State agencies are involved in a public dispute over a very sensitive matter?

Mr. Tony O'Brien

I think it is very unfortunate that one of the agencies chose to put it into the public domain. That was not me.

Yesterday that agency told us in response to a question I asked that there was no interchange, that it was the HSE’s fault. I am not interested in who did what but to those looking from the outside-----

Mr. Tony O'Brien

I agree that it is not ideal. All I can say is that I attempted on five occasions in direct dialogue to secure the information, the time and an engagement to enable the matters to be concluded. That was acceded to once I asked the Department for assistance and once it was acceded to we were in a position to make a comprehensive submission, which we did and which enabled us to complete our part of that process. I believe it was very important. I found it extraordinary that as the head of the regulated body I was not being afforded the courtesy of the information I needed to respond to its request for a submission.

Yesterday there were 42 patients on trolleys in Our Lady of Lourdes Hospital in Drogheda, which was the second highest number in the country. What plans are in place to reduce that number? I know the Minister is monitoring the trolley situation daily but it is a real problem.

Mr. Tony O'Brien

There were some questions my colleagues were going to respond to. Mr. Liam Woods was going to speak on waiting lists.

Mr. Liam Woods

The Minister has made the point that the new to return ratio is very important. There are just over 900,000 new appointments for outpatients every year and approximately 3.2 million total appointments. Managing that number and getting it right is very important. The length of wait is impacting on the new to return ratio. There are some things we may be able to do to work on that.

On the inpatient day case side we are 94% compliant with the 18-month target the Minister set, based on the expected work to be completed. That includes in-sourcing within the public sector that hospitals will help one another complete their workloads and extra clinics being run within hospitals, and some outsourcing. We are already in dialogue with the private sector on those issues. We are also progressing well on outpatients. The point made about the latest data showing just under 400,000 total outpatients is of concern. We are progressing well toward the conclusion of the 18 month target. At the moment we are getting near 60% and are working on that. There are some specialties where there will be a residual challenge within the last 6%, relating to areas such as scoliosis and sleep apnoea. We are looking for further options in the private market to address those.

Mr. Pat Healy

Regarding the vulnerable adults policy, Deputy Ó Caoláin correctly identified that the elder abuse policy had been in place and working well for some years. Child protection arrangements are also in place. Much has been done to develop this front, but there was a lacuna, in that vulnerable or disabled adults who were not elderly were not covered. Following the establishment of the social care division, one of our first actions was to develop a safeguarding policy, which was published last December and is being rolled out.

The reference to a no-tolerance policy relates to the need for a change in culture. There is a basic expectation that staff at all levels, be they in residential centres or communities, would engage compassionately and appropriately in terms of the care and support provided to the people with whom they engage. However, we have learned and continue to learn that this is not always the case. The no-tolerance policy is meant to drive home to providers and staff across the sector as well as to the public that there is an intention to change. We are not just supporting this with the implementation of the safeguarding policy, which will see safeguarding teams across the nine community health care organisations. Twenty additional social workers are being recruited for these teams, as are some of the principal social workers who will head them up, with the others already in post. We will also support the no-tolerance policy through a six-step change programme and a volunteer advocacy programme, under which we will have residential counsels in our residential centres. The idea is to open up our centres so that people can come in from the outside and there can be a general sense of engagement.

There is a dedicated team for the quality improvement programme. As the director general stated, the team has visited 50 of our centres, representing 25% of the HSE's services. We have prioritised our services because they tend to be found in large congregated settings. The roll-out of the programme is significant and there have been two national summits attended by the Minister and others, including all of the stakeholders. The summits have provided the HSE and the national task force an opportunity to report on progress and others with an opportunity to feed into that process. More summits are planned for the summer and autumn. We will continue reporting.

Regarding community rehabilitation, my colleagues, Mr. John Hennessy, the national director for primary care, and Dr. Áine Carroll, and I wrote a more comprehensive answer that did not find its way to this meeting. We will send it to Senator van Turnhout and engage directly with her on the matter.

Mr. Tony O'Brien

Ms O'Connor will answer the question on mental health issues.

Ms Anne O'Connor

The Senator raised valid concerns about the child and adolescent mental health services, CAMHS. The report into child deaths raises a number of issues in terms of psychological services, not all of which are provided by the mental health services. The first early intervention piece is access to psychology at primary care level. We are working with the primary care division to examine this matter.

Notwithstanding that, there are a number of challenges for the specialist services. The service improvement project is under way to improve access to and quality of CAMHS. We have waiting lists, with a number of areas challenged in terms of children waiting for longer than 12 months. We are addressing this issue with those areas. However, a number of factors have an impact, for example, our capacity to recruit. In terms of staffing, more than 50% of our CAMHS teams are working with less than 50% of what A Vision for Change recommended. We are significantly challenged in terms of recruiting consultant psychiatrists. Only in the past week have we heard that, of the three CAMHS and three mental health of intellectual disability, MHID, service posts advertised by the Public Appointments Service, PAS, not a single application was received. This is concerning because we have services with no CAMHS consultants. We must try to address this issue.

The CAMHS validation exercise has told us that approximately 20% of children referred to CAMHS and on waiting lists could be seen by primary care. We have legacy issues to address in terms of how things work in areas. For example, to access services, they come through CAMHS, which is unnecessary. There are children sitting on waiting lists for educational assessments who do not need CAMHS. We are trying to unpick all of this and to determine where children and young people need to be seen.

A specific point to make about the children referenced in those reports and the at-risk young people who are in the care of the State is that we are seeking to develop a CAMHS forensic team from the 2015 development funding. We are awaiting approval. We are working closely with Tusla. A small number of children have complex cases and take up a great deal of Tusla and the mental health service's time.

They must be seen so often.

Ms Anne O'Connor

Absolutely. We want to take a targeted approach to those young people while working with Tusla. We are hopeful that this will make a difference. We are also working with the justice system.

A number of initiatives are under way as part of the improvement project, including to address the Senator's points about on-call liaisons for CAMHS so that, when a young person presents at an emergency department, he or she can be assessed by a child and adolescent psychiatrist. These initiatives are in train and I hope that the response the committee received set some of them out for it.

Ms Laverne McGuinness

Deputy Ó Caoláin asked about children's dental services, particularly in terms of the use of general anaesthetics in Dublin. That service was provided in St. James's Hospital until last year when the accommodation was no longer suitable under health and safety standards. There is a short to medium-term solution, but the medium to long-term solution is for the new service to be provided in the new children's hospital. The children who need it currently have been provided a private service, with up to 300 children having been referred. The plan is to re-examine the location at St. James's Hospital with a view to upgrading it so that the facility can be re-opened for general anaesthetic services for children.

We will get Senator van Turnhout more comprehensive information on the palliative care co-ordination as it relates to the hospice-friendly hospitals.

Mr. Tony O'Brien

I will clarify. In fairness to our colleagues at St. James's Hospital, it was a facility on the hospital's campus rather than part of the hospital itself. It was a HSE facility.

Take 2 for Deputy Fitzpatrick. My apologies.

I thank the Chairman. Yesterday, there were 42 patients on trolleys in Our Lady of Lourdes Hospital, Drogheda. It was the second highest number in the country. What plans are in place to reduce these numbers? The Minister monitors the trolley situation on a daily basis, but the problem in Our Lady of Lourdes Hospital is serious.

At the beginning of April, the Minister's Department approved additional funding of €74 million to reduce delays in discharges. That was welcome. Some €44 million was provided for the fair deal scheme, which the Minister stated would result in an additional 1,600 places, and €30 million was allocated to provide 250 rehabilitative beds in community and district hospitals. I welcome the decrease in the fair deal waiting list from 11 weeks to an average of four weeks. I am pleased to see that County Louth's two hospitals - Our Lady of Lourdes and Louth County Hospital - are working closely together, sharing facilities and opening up roads to help alleviate the problem at the former. We must see some kind of improvement in the trolley situation at Drogheda. I have spoken to patients and doctors. All reports are that the services and staff are good, but that they need more beds.

I am delighted that the issue of obesity will be addressed in the same stance as tobacco and alcohol. "Obesity" is the medical term used to describe the state of being overweight and in bad health. Obesity is a timebomb that is ready to explode. Nearly two thirds of us are obese or overweight. It is putting our children at risk. We lack self-awareness of body size. It is costing us millions of euro and increasing the risk of cancers, including bowel, kidney, womb and breast to name but a few. It is causing heart and diabetes problems, damaging our joints and increasing the likelihood of developing varicose veins. It gives one a sense of being unattractive and reduces one's self-confidence. I plead with the Minister to intervene in the obesity issue. I am the committee's rapporteur on obesity. We will do anything to help.

The situation is getting out of control. Ireland's is one of the worst in Europe, perhaps even in the world. This is an important issue. In fairness to the Minister, he has done a fantastic job since entering office. I like that he is open, honest and says things like he sees them. The situation is very serious. For the past four or five years, all I have seen is people promising, promising and promising. Deputy Varadkar is the type of Minister who does not make false promises. I ask him for a full commitment to help combat obesity.

I thank the Minister and Mr. O'Brien for their presentations. I will touch on the Portlaoise report briefly. There are 19 maternity units around the country. Is information available on the perinatal mortality rate for all 19 units?

It is important to reassure people. There are 19 units and there are people working who are concerned and it is important that the information is put out there. The second issue raised in the Portlaoise report was that the State Claims Agency was aware of concerns at Portlaoise hospital, but there seems to have been no mechanism between the agency and the Department to ensure there was a response to those growing concerns. Is there now a mechanism in place should a situation arise in another hospital facing a large number of claims? What are we doing where one agency knows there is a problem, but another is not reacting? Is there a mechanism to allow the former to go directly to the Department?

The second issue I raise relates to the Cork-Kerry area. I have been made aware in the last few days that there was an agreement that 30 vacancies in relation to public health nurses and community nurses would be filled. I have also been made aware in the last two days that this has been put back and long-fingered. Can that be clarified? It may not be possible to do so today, but I ask it be done. We need these people out there in the community. They do very good work, but there are more than 30 vacancies in the Cork-Kerry region which have been open for some time notwithstanding the agreement that they be filled.

The third issue is the response to my fifth question, which was on junior doctors. I have been raising this issue for four years, but we have not made a huge amount of progress. The response to my question states that there are 2,943 doctors on structured training programmes. While they may be on structured training programmes, they are not on contracts as such. A number of junior doctors are still moving around on training programmes and six month contracts and are on emergency tax every six months. We seem to have made no progress in the last four years in real terms. I also raise the issue concerning junior doctors in Cork University Hospital of the absence of Internet access in the doctors' residence. The library access is insufficient for them. They are studying and training and providing a service, but we cannot provide a simple service to them notwithstanding that we want them to stay in the country. We are not making a great deal of progress. We need these people. We need good people to stay here but we are not putting the incentives in place. We have now had two reports from MacCraith and another lot of reports is being put on a shelf to be dealt with at some stage in the future. We are not making enough progress. Now is the time to start dealing with this issue so that when someone is on a five-year programme, he or she has a contract and does not go onto emergency tax. It should not be a case of six-month contracts. It is something with which we need to deal if we want to make serious progress on the retention of very good people in the State.

I want to say something on Portlaoise hospital. I listened to media reports this morning on what I understand was a long and emotive meeting last night between the Minister and the families. One comment struck me which was that the Minister heard from families whose cases date back to the 1980s. That is alarming. The Minister stated in his opening remarks that to care costs nothing. I am not trying to pre-empt anything, but it sounds to me that there is an appalling culture in the hospital. It is as we have seen in all of the exposés of recent months, be it child care services or Áras Attracta. A culture emerges and is somehow approved by a failure to speak up. If we do anything as a Government, we must break that kind of culture that starts to embed itself in organisations and places where often vulnerable people - and pregnant women are very vulnerable - go as a place of safety. It is alarming in that regard to think that we are talking about cases dating back over 30 years. I will leave it there as we are to have another meeting on Tuesday to discuss this.

I was interested in Mr. O'Brien's opening remarks on PPCI services. There is an ongoing PPCI national capacity study, which includes Waterford. We are told it is due to be completed shortly. How long more are we going to have to wait on this? If Mr. O'Brien could provide us with a timeline, I would greatly appreciate it. As he understands, the lack of a 24-7 cardiology service at University Hospital Waterford is of huge concern, not just to people in Waterford but throughout the south east due to our geography and issues of proximity to other PPCI centres.

I am very disappointed in the reply to my question on academic appointments for University Hospital Waterford. The response states that the Higgins report does not indicate the introduction of these posts at the hospital. However, I have a press release from the HSE's website dated 16 May 2014 in which the former Minister, Deputy James Reilly, in renaming the hospital in the presence of Ambrose McLoughlin, the then Secretary General, and, I understand, the President of UCC, Dr. Michael Murphy, stated that five academic posts would be provided at University Hospital Waterford. We have heard from other colleagues about the importance of ensuring that our junior hospital doctors and trainee medical students have all they need to ensure they are trained and get the utmost from their placements and internships in our hospitals. Frankly, I am beginning to think University Hospital Waterford was just a name change. It means nothing unless we get our academic posts that were agreed on and promised by Ambrose McLoughlin, Deputy Reilly and the President of UCC.

My last question is on speech and language services. It has come to my attention from encounters with a great many people that when children reach age six, their access to speech and language therapy changes. If the child is lucky enough to be a member of an early years service, he or she has access. Once the child turns six, however, he or she reverts to the community care service. The numbers are alarming given how few speech and language therapists we have in Waterford in comparison to neighbouring areas like Carlow-Kilkenny and Wexford. That is despite the fact that we have the highest number of patients waiting to be seen by therapists. In Carlow-Kilkenny, there are 11.7 therapists who are working with 907 people. In Waterford, we have 9.8 whole-time equivalents but 2,361 people, often young people, who are waiting to be seen. In Wexford, there are 18 posts with only 2,246 people. It is a huge disparity. What is happening in that regard? Children are coming through the early intervention teams and by the time they get to school, they regress because the services are no longer there. It is not something we can stand over.

I want to pick up on what Deputy Ciara Conway said about speech and language therapy. I have asked on a number of occasions over the years for the Minister for Health to look at this and deliver a service through our national primary school network. What is happening is that parents get appointments which they cancel or fail to turn up for and the child may not be seen again for six months. If the therapist arrived at the school, the principal will be there and can ensure the child gets the therapy. It would be a huge improvement for children.

I congratulate the Minister on the scheme he has launched to bring nurses home.

I have been asked to raise as issue that is causing major worry in Dún Laoghaire. One nursing home had to close last week because it could not find qualified nurses. Nursing homes recruit nurses from abroad, but when they gain experience, hospitals take them on. The nursing home in question is back at square one, having to recruit more nurses. Nursing homes have identified a solution to the problem - fast-tracking registration. It takes a long time - I have been 12 months - for nurses from abroad to get onto the Nursing and Midwifery Board of Ireland, NMBI, register and obtain their PIN from An Bord Altranais, the Irish nursing board. It would help if that process was fast-tracked.

I am delighted with the Minister's proposed action plan to tackle obesity. Perhaps he might have a word with the Minister for Finance about introducing a sugar tax, with the revenue raised to be ringfenced to treat people with diabetes and other problems associated with obesity.

The treatment of junior doctors is disgraceful. These highly educated qualified doctors must attend for interview every six months and have to move around the country. Senator Colm Burke raised the issue of their being put on emergency tax. They are treated with disdain. As they have to move around the country, they cannot make any family decision. I do not know of any other group of qualified professionals who are treated as badly as junior doctors.

I know that I have the opportunity to talk about the Midlands Regional Hospital in Portlaoise, but looking at it from a clinician's perspective, it looks like the basic interchange between two entities, with one administrative organisation criticising the other for what its perceives as an inadequate administrative response. I do not think that is a high priority. The problem is not unique to Portlaoise; it is emblematic of a set of broader problems in the health service which require fundamental structural change. I know that I sound like a broken record, but a big chunk of the problem is due to the number of specialists involved. I am grateful for the detailed answer to my question. According to the numbers, we have probably the lowest number of career level obstetricians per head of population of any country in the western world. Some 10% of obstetrician jobs, according to the figures provided today, are occupied by locums. This understates the disproportionate distribution of the problem. I suspect there are very few locums in the three Dublin hospitals and in the hospitals in Cork, Limerick and Galway. I could be wrong, but I suspect that in smaller units there is a disproportionate utilisation of locum services. No matter how well trained locums are, it is not as satisfactory an arrangement as having somebody who is providing for continuity of care throughout the entire course and trajectory of a pregnancy and in the provision of after care. Those who go on to have a number of children may want to have a consultant who is aware of their obstetrical problems from prior pregnancies. It is not a good arrangement.

The Minister comes very close to identifying the problem when he states it appears to him that some units are so unattractive to Irish graduates who are training, by and large, in international centres of excellence that they cannot recruit them to work and that as a result the jobs are being filled by locums, which is leading to the conclusion that perhaps the units might not be viable. I would like the Minister to think of an alternative explanation because there is one. The basic currency, for want of a better word, that determines the viability of an obstetrical unit is the number of births. The question is whether there are units which deal with an insufficient number of births that it is not possible to have sufficient obstetric, paediatric, midwifery and ICU resources to provide modern 21st century care and, if so, whether these units should be closed down. It is that simple. If that is the logic of what the Minister is saying, I would absolutely support him in gutting the number of units in the country and closing them down. However, it is not true. There were approximately 2,000 births in Portlaoise last year, or about six every day, which is enough to support a well staffed unit with enough obstetricians to provide attractive jobs for those who want to come back from the leading centres of excellence and with their own paediatric special care baby unit and on-site 24 hour intensivist paediatrician. This is not a remote part of rural British Columbia where people are spread over thousands of miles. This is a concentrated area in which there is a large number of births and which should have its own proper modern obstetric service. If we cannot attract good people to it, it is not because there are not enough births but because we have made a decision that the unit will not be adequately staffed.

I asked a question about medical schools and I am a little less happy with the quality of the answer I have been given. I am very interested in knowing how many are actually employed full time by medical schools working as academics at consultant level in the clinical specialties of internal medicine. The figures I have been given are not reflective of this but reflect people who have health service jobs because their job is based in a teaching hospital and have a degree of entitlement as "academics". The numbers I have been given do not add up. I will not go into all of the details today, but I believe the number of doctors employed in medical schools as full-time academics with dominant clinical academic components to their jobs is very small. We need to get to the bottom of this issue. It is hard to justify giving priority to reforming the medical school sector when there is no major constituency for this reform. Therefore, it is hard for politicians to see it as a high priority at a time when people have to wait for two years on a waiting list and deaf children sit at the back of the class and are not able to have their ears tested for six months at a time. We have six medical schools; we have twice as many per head of population as the European average and three times as many per head of population as in the United States, with an entirely inadequate level of staff. I have to be careful about how I say this, but I suspect that a very rigorous scrutiny by external agencies of the education service provided in these medical schools might result in greater urgency to fix them.

I am very grateful to Mr. O'Brien for clarifying the issues in respect of percutaneous transluminal coronary intervention. He needs to know a little about the hospital group idea. A hospital group is a good idea if we get the reforms right; however, it is not if we do not. It appears to have been ignored in the way services are being organised in Dublin. The Mater hospital and St. Vincent's University Hospital made a proposal to form one hospital group, with one university and one medical school. The very large cohort of cardiologists in the two hospitals who are very good and very experienced decided that they wanted to be seen as one entity for transluminal coronary interventions. They would work a 24 hour, seven day a week and weekend rota, but they were turned down. They are a little confused and cannot quite understand the reason for this. For hospitals which have not traditionally worked well together, becoming involved in hospital groups involves a certain degree of compromise. They believe this compromise is not being rewarded in dealing with the specifics of this issue and that it is not laid out as logically as it should be.

I wish to raise a number of issues. Will the Minister and the director general of the HSE set out what they see as the short-term and medium to long-term future of the accident and emergency unit in Navan hospital? It seems that there are mixed messages. One day it is proposed that the unit will remain open and the next that it be turned into a minor injuries unit. We know what the overall plan is. A related question is whether a regional hospital for the north east is on the agenda of the Government and the HSE.

The Department of Health and the HSE have responsibility for the provision of SNAs in preschools in County Meath. Funding is an issue in this respect and the usual fight to retain funding was partially successful. What was said to one of the parents involved was that if the HSE continued to fund SNAs in preschools in County Meath, a child who was sick or dying would have to be turned down for a home care package. This immediately brought to mind what the HSE had stated openly that somebody else would have to lose out because of the allocation of resources to a person who needed Soliris.

The parents who heard this were very upset and it has caused consternation. They certainly do not want to see one child being pitted against another. I thought it was a terrible way to deal with matters. There are resource allocation issues but this was not a new funding stream; it was a continuation of a previous funding stream in an era where we were told the cutbacks had ended.

I would also appreciate a comment from the Minister on lifetime community rating and age related penalties and how they interact with the provision of universal health insurance. There seems to be confusion about this and the Department is saying this will not apply in the event of universal health insurance. Does this policy, which is seen as necessary to prop up the current system, indicate that universal health insurance is less likely?

Did the Senator see the reply to his other question?

I have a single question for the Minister. At a time of unprecedented public concern about suicide rates, the Reach Out national suicide prevention strategy seems to have expired. In March 2014, this committee was told that a new policy framework would be in place by November 2014. We are now into the fifth month of 2015 which makes the framework strategy seven months late. Could the Minister give the committee an update on the progress of this?

I thank the Chairman and the Minister and his very large team from the health services for coming here this morning. We had a very interesting session with HIQA yesterday. I come to this from a personal point of view because I have met the families in Portlaoise. After the "Prime Time Investigates" broadcast, I brought Roisin and Mark Molloy to meet members of the health committee in January 2014. At the time I was eight months pregnant. When I had my baby, I had precisely the same experience as the Molloys - a very difficult labour with the baby's heart rate dropping. I was under the care of Professor Mick Foley and an amazing team in Holles Street, but all that went through my mind during that experience was, "Thank God I am in Holles Street". When things went seriously wrong, the staff, the care and the attention to detail saved my baby's life. If the families in Portlaoise had received the level of care I did, their babies would also be alive. That is a stark reality which I find deeply upsetting. I take the Minister at his word and hope this will not be another report which sits on a shelf. There have been so many reports over recent years relating to the health service and maternity services that it is difficult to have the confidence that anything will be different on this occasion.

The perinatal mortality statistics are completely inaccurate. Dr. Tony Holohan's report made that finding last year. Could the Minister let the committee know what precise plans are in place to make the reporting of baby deaths in maternity services mandatory and will there be criminal liability for hospitals and individuals who do not report? A voluntary system does not work. I note that the policy on open disclosure is now being rolled out through a substantial number of hospitals, but it is still a voluntary process. What does the Minister envisage for the mandatory nature of that? What will the sanctions be for those who do not participate fully and openly in the process and when will the legislation appear?

It is cause for concern that many of these issues were raised by parents directly with senior individuals within the HSE throughout 2012. There was no real satisfactory response. What is the role of the national incident management team? It expressed concern internally in November and December 2012 and that was not acted upon. Letters were written by parents, and in particular by Mark and Roisin Molloy, to Mr. Tony O'Brien, the director general of the HSE. These received vague responses and nothing was done until after the "Prime Time" documentary. It is frustrating that those responsible for the care of citizens can abdicate responsibility until the scandal is unearthed on an RTE programme. There is public humiliation of the services and then people own up and express remorse. The committee discussed this scandal with HIQA. Failures were identified locally, regionally and nationally. Four members of staff at a hospital are to be referred for disciplinary sanction, but who is responsible at regional and national level? Is Mr. O'Brien responsible? Does he intend to fall on his sword and be answerable for what has happened? Repeated letters and requests for meetings by the families were ignored until the "Prime Time Investigates" documentary. Somebody has to answer, at a national level, for a dysfunctional and negligent system which encourages cover-up rather than transparency.

I will ask the director general to speak about the information sharing between the HSE and the State Claims Agency which is important. I will ask the chief medical officer to discuss the plans for open disclosure and the decision made between mandatory and protected disclosure. He will also expand on the issue of figures for perinatal mortality rates, which unfortunately give false reassurance.

Based on figures from the Irish Nurses and Midwives Organisation, there were 42 patients on trolleys yesterday morning or 35 based on the SDU figures. As the nurses' union's own website confirms, their figures include people who are not on trolleys - people in beds, in day wards or surgical wards - patients who may not be in the right ward but are certainly not on a trolley. Nonetheless, 35 based on our figures is still unacceptable. By 8 p.m. last night, that figure was down to 16, of whom only eight had been on a trolley for more than nine hours, so it does change during the day, and that is the nature of an emergency department.

Beds have been opened in Moorehall nursing home and patients from the Louth hospitals have been moved there. Navan and Dundalk have been used also to relieve Drogheda. There are the additional fair deal places, but even where there is funding for fair deal, the shortage of nursing homes in the Louth-Meath area is a problem. We need more nursing homes built, but that will not be done quickly. They are also getting additional home care packages which allows more patients to go home. In June or July 2015, a new modular ward will provide an additional 20 beds for Our Lady of Lourdes Hospital, Drogheda. In a logical world, if there are 35 patients on trolleys in the morning and 16 by the evening, an extra 20 beds should mean it will be down to 15 in the morning and none in the evening. That is not going to happen and it is a concern that one can add more and more bed capacity to a hospital and it does not bring down the numbers on trolleys - there are so many other dynamics. Admission rates vary and in some hospitals one is twice as likely to be admitted as in others, even though they are similar hospitals. The duration of a hospital stay can vary between hospitals. Often, when there are no people waiting on trolleys, there is less pressure to get tests done quickly or to discharge patients quickly. People may be brought in unnecessarily on some occasions. I have been there - I have been a doctor in the hospital where we were encouraged to admit everyone and also in the hospital where we were discouraged from admitting unnecessarily. There are many factors and I do not agree with Deputy Fitzpatrick's suggestion that we just need more beds.

If it was just down to that, the problem would have been solved a long time ago. We have started a programme in Tallaght called the Irish hospital redesign programme which applies management techniques such as lean six sigma to hospitals. The programme is starting to work in Tallaght and if it proves successful, Drogheda might be one of the sites to which we will extend it next. It is all about patient pathways and making better use of what we already have before we add an extra 1,000 beds because if the beds are not used correctly they will never be enough.

I have to prioritise the public health (alcohol) Bill 2015 but we intend to prepare a new action plan on obesity by the end of the year. Two weeks ago we had a good discussion on this issue in Farmleigh with Professor Donal O'Shea and staff from McKinsey who carried out international research, among others. The message I took from the discussion is that no single action will work. The list is topped by issues like portion size reformulation but taxes are far down it. We will require a cross-sectoral action plan which includes policies on physical education and snacks in schools. Health policy will clearly be a major element, however. Children who are signed up for GP care for under six year olds will receive two obesity checks per year. It will be important that we put in place referral systems so that something can be done if obesity is identified. We will need to introduce legislation on calory posting, marketing and product placement. The jury is still out on the sugar tax, however. Mexico has introduced such a tax and several other countries are completing research into whether it works. If it works, we should introduce it but if it does not there are more efficient ways to raise revenue.

Deputy Conway asked about the meeting I attended last night. As this was a private meeting and I assured people of confidentiality, I will not recount anything that they might have said. I commend those who attended on their courage and strength and thank them for sharing their experiences with me, the Chief Medical Officer, the new CEO of the hospital group and my departmental officials so that we might learn from them. It was a valuable exercise for that reason. Some of the issues raised were specific to Portlaoise and they are being addressed. However, other issues were more systemic. If we were to go back 20 years to meet 100 patients who had bad experiences in Waterford or Blanchardstown hospital, the discussion might have been very similar because people have bad experiences in all hospitals, including tertiary referral and national specialist centres. Much of the discussion concerned the quality of care received but equally there was concern about the way people were treated afterwards, both in terms of how professionals communicated with them initially and how their complaints were dealt with by management subsequently. This is why I think an independent patient advocacy service would make a huge difference. Somebody would be available to listen to patients, take their side and guide them through a difficult process laden with unnecessary officialdom, medical jargon and defensiveness. That could drive a change of culture in our health service to make it more focused on patient experience. This is something I want to achieve in the next couple of months.

Deputy Conway also asked about the five additional academic posts in University Hospital Waterford. The Department is keen to support linkages between the hospital groups and their academic partners and careful consideration is being given to any service implications that might arise from these posts in the context of the strategic plan currently being prepared by the south and south west hospital group. The cost of the five posts is €1.4 million per year. That amount of money would allow us to staff the new Waterford hospice for the best part of a year.

Do that first.

The planning permission is in and the money is available in the capital plan. These are the kinds of decisions that have to be made in the health service. We are always trying to choose between one child and the other but if a commitment is made, it should be honoured as soon as it can be funded. An issue also remains outstanding in respect of academic contracts, however.

I will ask Mr. O'Brien to address the issue of speech and language therapy. Deputy Mitchell O'Connor's suggestion that we should assign speech and language therapists to schools should be seriously considered.

The chief nursing officer's office is engaging with Nursing Homes Ireland to develop solutions on the shortage of nurses. When it comes to nursing, everyone is poaching from each other. The hospitals poach from the nursing homes and I even hear advertisements from Beacon Hospital offering hello money to nurses if they come to work for it. That is a general symptom of the shortage of nurses in the country. I will be investing considerable effort into the UK recruitment campaign in the coming months, as well as developing a package of measures to encourage this year's graduate class to stay here. It is a good thing that people go overseas for a year or two to get experience but we want more to stay this year than was the case last year.

Senator Crown is correct that 2,000 births per year is an adequate volume to provide safe care in low to moderate risk pregnancies. Some units are below that threshold. However, it is not an adequate figure for tertiary or national specialty units. Recruitment remains a struggle for smaller units. The solution for Portlaoise is to put it under the governance of the Coombe, which allows joint appointments to be made. I am not sure if a joint appointment has been made yet but we have given approval for two joint appointments in obstetrics and two joint appointments in paediatrics. As the Coombe is only an hour away from Portlaoise by road, they are feasible as a joint appointment. NCHDs will also rotate between the two hospitals, which means that if somebody has a two-year post in the Coombe, he or she might spend six months of it in Portlaoise. The Coombe has been very helpful in this regard and I thank the master of the Coombe, Dr. Sharon Sheehan, and the board of the hospital for taking this on. If it is successful, it might become a model for other smaller units.

I do not want to dwell on the primary percutaneous coronary intervention issue but I understand that St. Vincent's proposed to work together with the Mater to provide a 24-7 hour rota between the two sites. The ambulance service had a problem with this aspect of the proposal in particular because of the risk that confusion would arise as to where patients should be brought on a particular day of the week. This is why the decision was made to operate from two sites in the greater Dublin area, St. James's and the Mater.

There are no plans at present to end 24-7 emergency department services from Navan hospital but the hospital groups will need to develop strategic plans for reconfigured services in the future. A regional hospital in the north east only makes sense if the five existing hospitals are closed or downgraded. That would be a politically difficult and controversial decision but it would also be questionable given that we are investing considerable resources into Our Lady of Lourdes Hospital. One would wonder if it is a good idea to build a regional hospital in Navan if it means downgrading or closing Our Lady of Lourdes. There is no funding in the budget for such a proposal but it has not been ruled out as a possibility in the future.

The number of people with health insurance increased by 80,000 so far this year, including 76,000 who signed up in the past few weeks. We have received the results of the HIA's initial work on universal health insurance but I do not yet have a report from the ESRI, although I am due to receive it shortly. Regardless of whether universal health insurance is in place, loadings can still apply. One could argue, on the one hand, that as universal health insurance is compulsory there should be no loadings or, on the other, loadings can be applied to those who did not have health insurance for a period of time before its introduction in order to reward those who have already paid into the system.

Is that different from what the Department argued previously?

It is different because we could approach it from either perspective. That decision remains to be made. Senator Gilroy asked about the suicide strategy. The strategy is being led by the Minister of State, Deputy Kathleen Lynch. It has been considered by the Cabinet sub-committee and we intend to bring it to Cabinet in the next week or two, following which the Minister of State will publish it at a time of her choosing.

I ask Mr. O'Brien to address the specific questions on Portlaoise. Deputy Creighton said that she found it difficult to have confidence in reports which end up being left on the shelf. I understand her scepticism about the potential for HIQA reports making any difference.

However, they do make a difference. The report on cancer misdiagnosis has made a major difference and totally changed cancer diagnosis. We have reduced the number of centres from 30 to eight and are achieving much better, and constantly improving, outcomes. The reports on the nursing homes, particularly on Leas Cross made a difference. While standards in our nursing homes are far from perfect, they are much better than they were five or six years ago when we were hearing horror stories about nursing homes all the time. We are hearing about the disability care homes only now because HIQA regulations started in 2013. These problems did not begin in 2013. The problems in our care homes and the way residents have been treated must have been going on for decades. The difference now is that HIQA goes in, produces and publishes reports and the system is forced to act. It will result in a major improvement in the quality and standards in the coming years.

The hygiene reports make a major difference. MRSA rates are at their lowest ever recorded, although this is not just down to HIQA hygiene reports. The report on the ambulance service is making a difference and is the reason there is an extra €5 million for ambulances this year, there are three new ambulance bases and we are centralising control in Tallaght, which will be fully up and running within months. While I understand the scepticism due to the failure to implement some recommendations, which happens, let us not ignore the enormous amount of work being done by those who are implementing recommendations in ambulance services, hygiene, hospital acquired infections and nursing homes. It has made an enormous difference, and it should be recognised. Although it was not the Deputy's intention, we should not discount or denigrate all the work done by those people who have taken HIQA recommendations on board and made a significant difference for patients.

Dr. Tony Holohan

We have provisional perinatal mortality data for 2014, which we got from the national perinatal reporting system. Deputy Creighton mentioned the work we did last year on perinatal statistics. We have discovered that perinatal outcomes and deaths are reported through four mechanisms, namely, the national perinatal reporting system, which was with the Central Statistics Office and has moved to the HSE; the HSE's National Perinatal Epidemiology Centre, which was recently established following the Lourdes inquiry and which is based in Cork; the CSO, which reports on statistics; and the General Register Office, GRO. Not surprisingly, with four different systems, we get four different answers, for reasons that are complex but explicable. They relate to the variations between the systems, how they get their data and the mandatory nature of the reporting.

Among the recommendations we made as a consequence of some of the analysis we did last year was to make mandatory the notification of early neonatal deaths, which was not a requirement under the Civil Registration Act. The Department of Social Protection amended the Act in 2014 as a consequence of this piece of work, and a set of regulations is to be commenced to bring the provision into force. There is a recommendation on standardising a single, common definition of perinatal death. If we end up with different reporting systems each producing what appears to be a different answer to the same question, it undermines public confidence in our collective ability to describe. The one outstanding one remains for the HSE regarding the bringing together of the national perinatal reporting system and the NPEC which use different processes and methods and have different answers on perinatal mortality levels.

I would like to strike a note of caution regarding the interpretation of perinatal mortality statistics. The statistics have a value, which is reassuring, especially at national level, where they show that we stand up well in comparison with other countries, notwithstanding what I said about the variations between the reporting methods. When one examines smaller units and hospital level data, the numbers on which it is based are much smaller and the variation between centres is not picked up in a way that will show statistical significance. This can lead to an over-reliance on clinical staff and undue reassurance being taken from a rate when there were many other issues that might have suggested there were problems that were not being taken into account. I encountered this in Portlaoise.

The perinatal mortality rate should be seen as an alarm, not a description of a standard of care. It tells us we should look further. A perinatal mortality rate which is reassuring in the context of a series of so-called never events and a rise in adverse events, etc. is like saying the fire alarm is not ringing and ignoring the evidence that there is a fire. Undue reliance on perinatal mortality statistics can lead to a situation in which people are not as open as they might be to the possibility that things are not as reassuring as the perinatal mortality rates might suggest. This is why we made a recommendation around so-called patient safety statements in order that on a monthly basis some of the kinds of information about which I have spoken, including increases in adverse incidents, staff numbers, increased numbers of births, which happened in Portlaoise, and a range of other information, can be examined as means of quickly identifying safety problems rather than relying, particularly at the small unit level, on data that are produced only once a year in arrears.

I raise it because of all the coverage of Galway, Ballinasloe, Portlaoise and Cavan. It would be helpful if people had access to information that is reasonably positive about most units throughout the country. This is a problem about which patients and staff are concerned. The coverage is very negative, although there is some positive information from the units.

Dr. Tony Holohan

We have the information and I am very happy to provide it. I am simply striking a note of caution around its interpretation, not by the Senator but by others who use it.

I accept that.

Dr. Tony Holohan

As the Minister mentioned, an open disclosure policy has been developed between the State Claims Agency and the HSE, and Mr. O’Brien might say something further about its implementation. It is a very good policy, and stands up to the standard of policies around open disclosure to be found anywhere. The question that arises is the extent to which any additional benefit arises from mandating open disclosure. Our expectations should be that, through the open disclosure policies, staff will always deal in an appropriate way with patients and be honest and open when things go wrong. Patient safety depends on creating the kind of environment in which professionals will be honest and open with patients in the first instance when things go wrong, explain it to them and deal with them appropriately. It does not always happen. Part of this is creating an environment in which health professionals can feel supported in participating in a range of activities that can improve quality and patient safety, including clinical audit, other quality assurance arrangements, adverse event reporting and open disclosure. We intend to build into our health information Bill, which is part of our set of proposals, when it is published shortly, protections from access to this kind of information through freedom of information and data protection that will give health professionals an assurance that if they participate honestly and openly in these processes, the information will not be used against them in freedom of information. It is about creating the sense of a culture which is not about imposing requirements on professionals and mandating them to do things but giving them a sense that they are supported in doing the right thing, which in this case is being set out in the open disclosure policy in the HSE.

Mr. Tony O'Brien

I ask Mr. Woods to comment on the acute sector issues, especially the timeline on the PPCI process.

Mr. Liam Woods

I note Senator Crown’s comments on PPCI. The decision was based on a substantial review and clinical input through the clinical programme in the area. The co-operation between the Mater and St. Vincent's, which are members of the group, is bearing fruit, as it can in other areas. In this instance, the decision was made, based on clinical input and wide consultation, to locate the service in Dublin in St. James's and the Mater. Some decisions will arise, particularly around the Dublin area, that are potentially above group level in terms of organisation of service. As the clinical programmes proceed and we make further health care decisions, the groups will require guidance as part of their preparation of their strategic plans, which were referred to earlier, which will be above group level.

On a point of information, as the position may have been misrepresented, the Mater hospital and St. Vincent's hospital currently provide daytime services for everyone except STEMI patients. It was proposed that consultants at the two hospitals do a joint rota at the Mater hospital site only in the evenings and on weekends. Consultants did not reject providing the service on two separate sites but on the Mater hospital site only.

When will a decision be made on the national PPCI programme?

Mr. Liam Woods

I will revert to Deputy Conway on that issue as I will need to discuss it with members of the clinical programme.

Mr. Pat Healy

I assure Deputy Conway that the need for additional speech and language therapy in the Waterford area has been clearly recognised. We are trying to develop an integrated approach which takes account of school services, voluntary service provision and the service provided by the Health Service Executive. These are the progressing disability services for children and young people aged from birth to 18 years. The governance for this programme has been introduced following extensive consultation over the past year. Additional posts will be provided in the current year. This year, the south east will receive a proportion of the 120 additional posts to which I referred because the programme is ready to proceed. While we have not yet settled on an exact number, Waterford will receive additional posts in the current year. We are working jointly with the Department of Education and Skills and making progress across the disability and primary care areas.

One of the challenges, particularly in the area of disability, has been the tendency among special schools or classes which have access to services to hold the service for the children to whom it is being provided. This leaves others waiting for a service. What we are trying to do in the progressing disability service is to have an agreed position, protocols and so forth across schools and the health, primary care and disability services. Children will then be referred on an agreed basis and will receive a service on the basis of need, rather than having to depend on the service available to their school. A proper referral pathway will be provided. This service will require additional resources. It is a positive development that 80 posts were provided in 2014. Waterford and the south east will secure some of the 120 additional posts to be created this year.

When will they come on stream?

Mr. Pat Healy

We will make an announcement in the next couple of weeks and the posts will be in place in the second half of this year.

Mr. Tony O'Brien

We will provide Senator Colm Burke with a written response to his question on counties Cork and Kerry. Based on information we have received by text, as it were, we believe the Senator's understanding of the matter to be incorrect. We are currently replacing vacant nurse posts in that region and the current number of nurses is the same as last year. Increased throughput in our national recruitment service means the time required to replace such posts has been reduced. We will provide the Senator with a written response as the information I have provided is based on a response to a brief inquiry we made.

My understanding is that it is now the norm to provide non-consultant hospital doctors with contracts of 12 months' duration. Six-month contracts are now the exception.

We will examine the issue the Senator raises concerning emergency tax. However, I would not expect emergency tax to apply when a person moves from one payroll to another. I will raise the issue with payroll staff.

Employees can move employer every two weeks if they like, provided they have a certificate of tax-free allowances.

People are experiencing problems in this regard.

Mr. Tony O'Brien

We will investigate the matter. I was not aware of the issue regarding Internet access for non-consultant hospital doctors in Cork University Hospital. We will ask the hospital to investigate as it seems odd in these times that people would not have Internet access. We will find out what the story is in this regard.

If Senator Byrne provides us with details of the specific case he raised, we will be pleased to inquire into the matter.

To respond to Senator Crown's general point on the number of specialist consultant obstetricians, there is clearly an issue in this regard as the number is very low. There is no doubt that any long-term solution will have to involve a step change on that issue.

Deputy Creighton asked a number of specific questions. As we were effectively stood down from the detailed discussion on the Midland Regional Hospital, Portlaoise, by communication from the joint committee yesterday and the scheduling of a meeting next week, I do not have in my possession all the detail that would enable me to give the Deputy a comprehensive answer. However, I will be happy to do so on Tuesday when our team will include individuals who will be able to speak directly to the operation of the national incident management team and its role in this matter.

As Deputy Creighton missed the start of the meeting, she may not be aware that the joint committee will meet representatives of the Health Service Executive next Tuesday afternoon.

I am aware of that.

Mr. Tony O'Brien

If it is okay with members, that is how I propose to proceed.

Is Deputy Creighton satisfied with Mr. O'Brien's proposal?

I am sure the point I made regarding accountability could be answered now.

Mr. Tony O'Brien

I can give a partial answer. Deputy Creighton is correct that information entered the public domain indicating that four health professionals are subject to referral to their respective health regulators. In my opening remarks, I also made reference to the commencement or initiation of formal investigations in accordance with the HSE disciplinary procedure. This will examine two distinct issues, the first of which is what could be broadly described as the administrative side of the process, namely, the escalation of issues and the response thereto. The second relates to issues of care, which will be pursued in accordance with the disciplinary process. This is separate from any referral that may have been made either by an employer or a patient to a health professional regulatory body.

With regard to the more specific questions the Deputy asked, I will be able to respond to them next Tuesday when I have detailed information with me.

I will be back on Tuesday.

Perhaps Mr. Woods will address the issue raised regarding the financial position.

Mr. Tony O'Brien

The data in the performance assurance report, PAR, for February indicate that we are in a challenging financial position, principally in two areas, namely, the acute sector and the social care sector. The acute sector experienced particular pressures in January and February - these continue to some extent - versus objectives around cost containment which would have seen us converting more agency cost into permanent cost. This pressure coincided with the time when we needed to retain a degree of agency employment to cope with particular demand. In the social care sector, costs are being generated by regulatory compliance, although they are not exclusively in that area. At this stage in the year, it is too early for me to speculate as to where we will land later in the year. However, we will do so in due course.

Outside of these factors, there are pressures in demand-led schemes. Although the economic recovery is leading to some reduction in the numbers of people needing ordinary medical cards, the number of discretionary medical cards has increased and the costs of drugs and so forth are an ongoing pressure. It is far from being a challenge-free year financially and in fact this year will be very difficult for the health service financially.

I sincerely thank the Minister for Health, Deputy Leo Varadkar, the Minister of State, Deputy Kathleen Lynch, Dr. Tony Holohan, Ms Tracey Conroy, Mr. Tony O'Brien, Ms Laverne McGuinness, Mr. Pat Healy, Mr. Liam Woods, Ms Anne O'Connor and Dr. Áine Carroll. I also thank Mr. Ray Mitchell for co-ordinating the committee's engagement with the Health Service Executive and for his courtesy. I remind members that we will meet officials from the Health Service Executive on Tuesday next.

The joint committee adjourned at 12.20 p.m. until 11.30 a.m. on Tuesday, 19 May 2015.