Vote 38 - Health (Supplementary)

Apologies have been received from Deputies Donnelly and Kelly. This meeting has been convened to consider the Supplementary Estimate for Vote 38 - Health. In that regard, I welcome the Minister of State at the Department of Health with special responsibility for mental health and older people, Deputy Jim Daly, and his officials. I thank the Minister of State for the briefing material, which has been circulated to the members of the committee. Without further ado, I call on him to make his opening statement.

Gabhaim buíochas leis an gCathaoirleach agus na baill den choiste chomh maith. I thank the select committee for the opportunity to bring this Supplementary Estimate for Vote 38 before it. The total additional funding I am seeking for 2018 is €655 million. Of this, €10 million is to compensate for a shortfall in appropriation-in-aid, €20 million is towards capital works and €625 million is towards overspends in current expenditure in various areas of the HSE. I acknowledge that the amount sought is significant, representing as it does 4% of overall health expenditure in 2018.

This year, the anticipated level of overspend by the HSE is linked to the HSE's first charge in 2018 arising from the 2017 deficit, a shortfall in income, winter planning, growth in 2018 activity beyond plan, including the primary care reimbursement service, and additional funding required in the State Claims Agency. Health funding remains a major challenge. Demographic pressures, including a rise in chronic diseases and an ageing population, mean we face challenges into the future. We are implementing our strategic responses to these challenges, while continuing to focus on effective management of resources to ensure that services are delivered in line with the national service plan.

Ensuring the health service is financially sustainable is a key strategic goal of Sláintecare. The significant increases in the health Vote in recent years reflects the Government's commitment to improve access to health and social services for the people of Ireland, through investment across community and hospital services. We need to keep the recovery going and the economy strong in order that we can continue to develop our health infrastructure and the provision of health services into the future.

Next year, the Health Service Executive's national service plan will be framed through the lens of the Sláintecare implementation strategy. The strategy provides the framework within which a system-wide reform programme for the health service will be advanced, and focuses on establishing the building blocks for a significant shift in the way in which health services are delivered in Ireland.

I will now set out the items that make up this year's Supplementary Estimate. On the 2017 first charge of €90 million, the HSE's recorded deficit for 2017 is €139 million. Under the Health Service Executive (Financial Matters) Act 2014, any excess expenditure must be charged to the income and expenditure account the following year and is effectively a first charge on the following year's budget. My Department and the HSE completed a comprehensive review of the anticipated outturn for 2018 and identified a number of once-off savings that will be allocated against the 2017 first charge, with the balance of the funding requirement being met from the Supplementary Estimate.

There has been a significant reduction in the level of private patient income for public hospitals in 2018. Health insurers, as members will be aware, commenced a campaign in 2017 aimed at discouraging members from using their private health insurance to avail of private inpatient services when they are admitted via an emergency department. Instead, they have encouraged their members to consider being treated as a public patient, as is their right provided for under the Health Act 1970. This, inevitably, is leading to a drop in income as more patients are opting to be treated publicly rather than privately.

The allocation for the winter plan of €10 million from the Supplementary Estimate allows for the commencement of a range of measures aimed at alleviating pressure on the acute hospital system during the busy winter period. Timely discharge of patients is vital to ensuring that a ready supply of beds is available to those patients requiring to be admitted through emergency departments. Delayed discharges are a major contributory factor to emergency department overcrowding and adversely affect patient flow throughout the hospital. It is essential that, insofar as is possible, egress meets demand and that hospital and community healthcare organisation, CHO, processes support timely and safe discharge.

Integrated hospital and community plans are the cornerstone of the 2018-19 winter plan, with nine key sites of concern selected based on previous winter performance. Enhanced measures across acute, primary and social care will focus on critical demand pressures on the nine sites during a four-week focus period between 17 December 2018 and 13 January 2019.

With regard to the non-achievement of the €150 million savings target, the value improvement programme included in the national service plan is a single overarching programme with three broad priority themes: improving value within existing services, improving value within non-direct services and strategic value improvement. It is anticipated that none of the targeted savings under the strategic value improvement will be achieved at year end.

Acute hospitals are running at an expenditure level from 2017 which is over their approved funding level. This level of expenditure was to be matched to the approved level of funding through achieving the savings attributable to the service level and corporate value programmes embedded in the division’s hospital budgets. The forecasted underachievement of targets under the corporate value programme by year end is contributing significantly to the estimated overspend. Increasing bed capacity in public acute hospitals continues to be a priority in addressing the causes and challenges of emergency department overcrowding. My Department is undertaking a health service capacity review in line with the Programme for a Partnership Government commitment, the findings of which are due to be published shortly. In the meantime, there continues to be an urgent need for capacity in acute hospitals. On that basis, it is proposed to allocate €5.7 million to acute hospitals to address critical bed capacity deficits in 2018.

Community services incorporates the delivery of primary care, mental health, disability and older persons health and social care services. The main drivers of the overall deficit in community services include emergency placements for people with disabilities, costs associated with HIQA compliance and costs associated with Storm Emma.

Support services incorporates a number of central corporate services including finance, health business services, legal, communications, health system reform, chief information officer and the office of the director general. Expenditure in the area is running ahead of plan for a number of reasons, including the number of large legal cases, professional service costs for the programme for health service improvement and increasing software and professional fees related to support of acute hospital initiatives such as maternity and newborn electronic records.

In 2018, there has been a significant increase in the number of payments made under the treatment abroad and cross-border healthcare schemes. With the trend continuing upwards throughout the year, there is a need for supplementary funding to address this area of growing demand.

The increasing costs of the clinical indemnity scheme are not due exclusively to the increasing numbers of claims but rather to the increasing costs of awards and the high costs associated with catastrophic injury claims. In 2017, significant progress was made on legislation which is expected to lead to a reduction in costs over time. From a health perspective, the most important aspect is the provision for periodic payment orders. Courts will now have the power to award damages by way of periodic payment orders, where appropriate, having regard to the best interests of the plaintiff and all the circumstances of the case. With the enactment of the Mediation Act in October 2017, which provides a wide-ranging statutory framework to promote the resolution of disputes through mediation as an alternative to court proceedings and to reduce the stress for parents and families that often accompanies court proceedings, it is hoped that more families will opt for this route. In addition, €46 million is sought towards the projected deficit in 2018 in the State Claims Agency.

Funding will be provided for a number of GP fees and allowances including €4.85 million towards the cost of providing free cervical check consultations.

The greater than budgeted number of medical cards is driving an increase in the number of items dispensed and it is proposed to allocate €3 million to cover this increased cost. It is proposed to allocate €30 million to cover the continuing increase in high-tech drug costs for treating conditions such as rheumatology, cancer and cystic fibrosis. With regard to long-term illness, €7 million will be allocated to cover the cost of treating long-term illnesses, the most prevalent being diabetes and epilepsy.

Appropriations-in-aid are received by Ireland from the UK in respect of health services provided under EU regulations. The amounts received are based on the Ireland-United Kingdom healthcare reimbursement arrangement. Costs associated with UK pensioners residing in Ireland account for the major portion of the total payment. Historically, each country's pensioner liability was agreed based on the results of sample pensioner surveys undertaken every few years. More recently both administrations have agreed in principle to work towards the introduction of a revised methodology for determining pensioner liability. Trends in demography and migration between the two countries indicate a reduction in the number of pensioners for whom the UK is liable. Initial discussions with the UK indicated that receipts in 2018 might be in the region of €225 million against a provision of €280 million, a difference of €55 million. Detailed discussions have recently finalised and a total payment in 2018 of €270 million has been agreed, leaving only a difference of €10 million.

There is an ambitious programme of capital investment in health reflecting priority accorded to capital spending in the programme for Government position that health capital spending would be a priority. Priority Government projects, most of which are either under way or about to commence, account for a substantial proportion of the health capital allocation in 2018 and the coming years, resulting a high level of commitments. During 2018, extensive measures to actively manage the capital budget have been applied. This has involved balancing as much as practicable the fulfilment of contractual commitments, delivery of projects and managing equipment and infrastructural risk issues, such that capital expenditure remains within profile. Following this extensive engagement and management of issues, capital spending in 2018 remains within profile. The HSE has informed the Department that, with the provision of an additional €20 million in 2018 and the management of the projects' budgets, there will be no overrun in 2018 capital funding.

A significant increase in funding for the health services has been achieved in recent years. As I stated previously, the issue of health funding is a major challenge, not just in Ireland but internationally. Dealing with a growing and ageing population, more acute health and social care requirements, increased demand for new and existing drugs and the increasing costs of health technology will continue to pose a financial challenge into the future.

Sláintecare gives us a new roadmap to support the delivery of high quality care to our citizens. Improving the way services are organised and delivered and reducing costs to maximise the ability of the health service to respond to growing needs, must remain our focus. It is essential that those managing and delivering the service continue to demonstrate good practice by delivering the best healthcare within the significant resources that have been made available by Government for 2019. This additional funding in 2018, combined with the 2019 budget provision, is a practical example of this Government’s commitment to use our economic growth to restore much needed funding to our health service. The above items together with cash projections to year-end involve an Exchequer requirement of €655 million.

I seek the committee’s approval of the Supplementary Estimates for Vote 38.

I thank the Minister of State. Is Deputy O'Reilly ready?

Yes. I am sorry I was not here for the start. I could say I was caught in traffic but I was getting coffee so I might as well be honest. Honesty is the best policy.

The Minister of State is welcome. I thank him for appearing before the committee. We have previously commented on the fact the Minister is not available but in the circumstances, and given the lateness of the time we adjourned last night, I will not go down that road. We thank the Minister of State for being here and for outlining the Supplementary Estimates to us. I have a number of questions which I will run through and ask him to reply to them together.

In the briefing note, we have been given a rough breakdown of the €529 million and how it is spent. I am looking for a more definitive breakdown, specifically of the €220 million that is spent in acute hospitals. How much of that was spent on agency staff? The focus is on the €346 million in savings to be achieved. I have questioned people from the HSE about this previously. Where did the figure of €346 million come from? A formula must been used. How was it calculated? What research went into it? How was that conclusion arrived at? It was unrealistic and it was not reached. It was missed by quite a long shot. Whatever planning went into it was not sufficient. I am also curious to know - the HSE could not give me a definitive answer - where the figure came from. We all heard the tapes of the fellas telling us where they got the figures for banking. I sincerely hope these figures did not come from the same place. Can the Minister of State indicate how the figure was arrived at?

The Irish Fiscal Advisory Council, IFAC, informed us that overruns in health have averaged €500 million per year in current spending terms and that, in 2018, the overrun would be €600 million. Is it not then the case that the health service has been underfunded to the tune of approximately €500 million per year since 2014? We cannot keep having overruns and Supplementary Estimates and get to the end of the year and say we are not being underfunded. One does not need to be a mathematical genius to figure out that if we keep overrunning, we are being underfunded. The IFAC stated that health budgets should be well-founded and credible. It further stated that weak planning and spending controls account for the genesis of many of the problems. I am interested to know how spending €234 million so far this year - or €866,792 per day - on agency staff fits into a well-founded or credible budget. Similarly the council stated health overruns are being masked by unexpected corporation tax and interest.

The council also states that as the top ten companies account for roughly 40% of all corporation tax receipts, unexpected revenue from this source should be deemed to be transient. We cannot rely on this revenue but it seems that we are relying on it. With that in mind, I ask the Minister of State to outline the Department's view on its duty to fund health in a responsible manner. If one ran one's house in this manner, one would find oneself in MABS. This is no way to run a household budget, never mind a massive budget for a very high spending Department.

Immediately after the budget last year I said, as did others, that not enough money was being given to the health service to allow it to even stand still. The budget was inadequate in terms of current service levels. We could talk all day about the inadequacy of current service levels but there was not enough money to even maintain them. Weeks later, the then head of the HSE, Mr. Tony O'Brien, wrote to the Minister and said that the HSE was being under-funded for 2018 to the tune of hundreds of millions of euro and that has turned out to be the case. I am no fortune teller because if I were, I would pick the lotto numbers and leave this House. That said, I could see that the budget was inadequate and I pointed that out at the time. A few months later, it was also pointed out by the director general of the HSE. At what stage in the year did the Department become aware that the health service was under-funded? The Department was not going to take my word for it but Mr. Tony O'Brien wrote to the Department about this. It strikes me as odd that he would have to write such a letter and that the powers that be would not be fully apprised of the position and aware that there was going to be a shortfall. I was not the only person who pointed it out but when I did so, I was dismissed. I was right, however. I will not say it gives me no pleasure to say that because we all love to be right but if I could see it and Mr. Tony O'Brien was flagging it, when did the Department become aware of it? That is material to how we keep finding ourselves in the same position at the end of the year, every year.

I thank Deputy O'Reilly for her questions. She has raised a number of broad issues. I am not sure if we have a figure for agency staff here but I will get it to the Deputy as soon as possible. She asked a very direct question about how much we are still spending on agency staff. I know that there has been some conversion this year on that but I will endeavour to get the exact figure for Deputy O'Reilly.

The Deputy makes a very valid point about the savings figure of €346 million in terms of how it was calculated and the details of that. What I am clearly saying is that the HSE did not achieve the targets set for it in terms of making savings across the three very important areas identified. What is wrong here? Is the issue the HSE's inability to achieve targets or is it that the targets set were unachievable? That is the question the Deputy asks.

I am specifically asking how that figure was arrived at. The HSE did not reach it but it must have been based on something.

It was not plucked out of the sky.

No, it was not plucked out of the sky or anywhere else. There must have been targets. Someone looked at this and came up with a figure of €346 million, as opposed to €350 million, for example. Perhaps I am being cynical but maybe someone suggested a figure of €350 million and someone else decided to make it €346 million in order to seem more credible.

To make it sound more accurate.

Yes, but it has to have come from somewhere.

Indeed, and I am aware that Deputy O'Reilly has asked this question at two previous committee meetings and she still has not been given an answer.

I will undertake to try to assist her in getting an answer. I do not have it here. I do not know where that figure came from but I will go back and ask the HSE to provide an answer to me and will copy the Deputy in on that answer.

On that point, the HSE appeared to put a bit of distance between itself and the Department on that decision. My memory of it is that the executive said it was given this target. Someone should have sat down with the HSE to determine if the target was realistic, which we know now was not the case, and how the HSE was going to reach it. Where was it going to find those savings? It is not acceptable to just give the executive a savings target without figuring out how to help it to achieve it or even if the target is realistic.

Deputy O'Reilly's question is very valid. She wants to know the origins of this figure, the basis for it and how it was calculated. Someone must have seen it as an achievable target, based on some sums. She wants to know what sums or calculations were done to generate this particular figure. I will try to get to the bottom of that for her.

On the wider issue of trying to achieve savings, which ties in with the Deputy's next question as to whether HSE funding is sufficient, there is a constant ebb and flow and tension there. As well as the highs and lows in economic terms, there is also an ebb and flow and tension that is necessary. If we were to give the HSE another €1 billion or €2 billion, it would spend it. In that context, we must try to push back and keep things as tight as we can. It is possibly better to under-fund the executive to some extent because there can be no absolutes. It is a demand led service, which is important to remember. Nobody can-----

The demand is created by sick people.

Yes, but it is a demand led service. Deputy O'Reilly said that she does not have the power to tell fortunes or see the future and nobody on the other side of the House has that power either. We cannot accurately predict how many people will present at accident and emergency departments or primary care facilities, how many people will require surgery and so on. We cannot predict what new drugs will become available in any given year, how many people will require those drugs, whether they represent good value for money, what they will cost and so on. There are lots of unknowns and variables from year to year in any health budget. Ireland is not unique in that regard.

The demand led aspect of this makes it very difficult to quantify the budget required. Something that may not be told as well as some of the other stories in the health service is the fact that there has been a significant increase in the amount of activity within the health service in recent years. A very significant number of procedures have taken place and there have been enormous increases in day case activity and hospital admissions. I know from my area that there has been a significant increase in the activity of child and adolescent mental health services, CAMHS. Approximately 26,000 people are being seen by CAMHS every year, which is a very significant increase. The numbers waiting to be seen are continuing to increase but the full story must be told by pointing to the increased numbers of people who are being seen and treated. That is where we get the real picture. This is relevant to the issue of trolleys too. I feel very strongly that the focus on trolleys is misguided. It is so easy for politicians and those in the media to obsess about trolleys and trolley figures. The real issues are how long people are waiting and delayed discharges. We need to work on the numbers coming out of hospital and what is preventing them from being discharged. For too long, we have been looking at how many people are blocked on the way in to hospital when the real focus should be on those whose discharge is delayed because of a lack of transitional care in the system.

The Deputy's point about reliance on corporation tax belongs to a broader debate involving the Department of Public Expenditure and Reform. The issue is in the news again because there has been another unexpected increase in corporation tax receipts. It is accepted by all Departments and the Government as a whole that corporation tax receipts can go up and down significantly. We have seen that happen and will not be building in a reliance on such receipts. I do not think there is a direct correlation between the funding of the HSE and the amount of corporation tax collected. It just so happens that both are in the news at the moment.

My question was whether the Minister of State thinks this is a responsible way to fund the health service. I would be surprised if the answer to that is "Yes". I do not think it is responsible to fund it this way and nor does the Irish Fiscal Advisory Council, IFAC.

To what is the Deputy referring specifically in terms of responsible funding?

I am referring to funding it from corporation tax receipts and interest. Those sources of funding are not reliable

It is not funded from corporation taxation. It is funded from general taxation. Corporation tax makes up about 18% of the overall tax take. Health requires a much greater spend and is funded from all tax receipts.

IFAC has said that the health overruns are being masked by unexpected increases in corporation tax revenue and interest.

That is a separate point. The council is not saying that the health service is being funded by corporation tax. It is saying that-----

The budget overruns are being masked.

Yes, it is saying that overruns are being masked by increases in corporation tax receipts. In other words, we have the ability to cover those overruns because of bonuses in corporation tax. The health service is not being funded by corporation tax per se. It is being funded by general taxation. The Deputy's question is about our reliance on corporation tax and whether we are over-reliant on this source of income. That is a broader question and one that should be put to the Department of Public Expenditure and Reform.

It is also a question for the Department of Health.

It is not peculiar to the Department of Health.

IFAC made a specific comment about the health budget and overruns, which is what we are here to discuss today. The council was very clear on the matter. I asked the Minister of State if he thinks that is a responsible way to fund the health service and he said that it is not being funded in that way. In actual fact, it is because the overrun is part of the spend now.

Corporation tax is part of the funding mechanism of the health service, but so is income tax, VAT and every other taxation head and subhead. One could argue every one of these is partially funding the overrun in health. The point is moot and it does not hold up to scrutiny.

The Irish Fiscal Advisory Council differs with the Minister of State on that point.

That is fine. It is a healthy attitude if the Irish Fiscal Advisory Council takes exception to anything I say. I have no problem with that.

The IFAC specifically targeted the health service overruns. Trying to pretend that overruns are not part of the spend is nonsense. They are clearly part of the spend but they are being funded from an unreliable source. I asked the Minister of State whether he thought that was responsible. He may think it is responsible, but I do not agree with him.

I am unsure whether this over-and-back format is usual. Is it usual to have cross-examination? If Deputy O'Reilly wants to engage in that, I have no problem with it.

I apologise if I came across as cross-examining. I am trying to get a specific answer.

I do not want to be re-interpreted and I do not want words to be put into my mouth.

I will explain one point. We allow a Deputy ten minutes or so to ask questions and get answers. Perhaps speaking over each other is not going to be beneficial. Please give the Minister of State an opportunity to answer, Deputy O'Reilly, and then submit another question.

Absolutely, Chairman.

I will answer specifically the question about the reliance on corporation tax to fund overruns. Many other taxation sources will fund overruns in health. That is the point I am making. It is not only corporation tax. My opinion on this matter is irrelevant because there are so many other tax heads contributing to the funding.

Deputy O'Reilly asked about the Department approach to running a household budget. This is the point I opened with. It is a demand led service and it is difficult to quantify absolutely. We cannot give too much to the health service. If we do, it will overspend and over-utilise. We must ensure there is tension if we are to get value for money. It is the same with funding any demand led service. We must have checks and balances, and that is difficult. The difficulty is compounded with the highs and lows of economic activity.

The Department gets updates throughout the year from the HSE. It is not at year-end when the Department becomes aware of the overruns. It becomes aware during the year of the pressures and the likely pressures. Many of them are projected and anticipated and efforts are made to avoid them. We cannot be absolutely clear until later in the year. In any event, the Department is engaging with the HSE from the start of the year to see that the executive is on target to meet spending targets. That may answer the Deputy's question. If there are any further questions, she should feel free to ask them.

Does the Deputy have another question?

Yes. The Minister of State mentioned that he would provide me with some figures on agency spending. He mentioned the issue of conversion. When we had Mr. Stephen Mulvany from the HSE before the committee, we asked whether specific targets were set relating to the conversion of agency staff. It appeared this was not the case. I keep going back to the figure of €346 million in savings. Some of the savings relate to conversion from agency, which is highly expensive and a rather inefficient way to run the service. Despite this, the Government is becoming more reliant on agency staff. If there were no targets in place for the conversion of agency staff, then it would seem that no attempt had been made to control it. HSE representatives have said to us that they try to convert from agency. How can this be the case if no targets have been set? Will the Minister of State give me some sense of how much of the €220 million budget was spent on agency staff? Of the €346 million budget, how much was identified for conversion?

The Minister of State remarked on planning and the demand led nature of the service. We have not had a major outbreak of disease. There is nothing happening in the health service that could not have been predicted by looking at Central Statistics Office data. We have an ageing population. It is a good thing that people are living longer and are healthier. There are no major unforeseen challenges. The Minister of State mentioned the storm. That was only a couple of days. There was no major outbreak of disease. There is no reason the Minister of State could not have looked at the CSO figures to enable him to plan ahead.

I do not want to disagree with the Deputy all day but there are several factors that cannot be predicted. These include the outcome of the negotiations of the current general practitioner contract and the associated cost. That is dependent on the outcome of the negotiations. There are negotiations with drug companies as well. There is a major cost in that area. Another factor is whether a decision is taken or otherwise on pay increases. A total of 32% of our staff are nurses. If there was a Government decision taken tomorrow to give a pay increase, the HSE would not know in advance.

Several factors arise that cannot be anticipated simply by looking at the CSO figures. It would be great if we lived in a world where we could identify all these things. One of the major underlying challenges within the health system is the lack of an up-to-date information technology infrastructure to collect, share and analyse data. Our structure is not fit for purpose when it comes to the planning to which the Deputy referred. I imagine we would probably both agree on that.

The Deputy asked about agency staff. I am not the financial officer within the HSE but I will ask the HSE's financial officer to give me a report on agency staff. I will ask specifically that he address the question Deputy O'Reilly has asked about the HSE targets for conversion and how many have been achieved. I suspect the HSE will not have the figures for me until the year end or that we will be unable to get a year-end figure for 2018, but I will ask specifically for that to be given to the Deputy early in the new year based on the year end conversion figures.

I welcome my constituency colleague, the Minister of State, Deputy Daly, before the committee.

We are holding the fort on our own.

We are always holding the fort and I have it for ten minutes now.

I thank the Minister of State for bringing the Minister for Health, Deputy Harris, to west Cork on Monday. I very much welcome the announcements made. I am keen to work with the Minister of State to ensure that what he said would happen will happen. I am keen to put that on the record.

The Minister of State started by saying that health funding remains a major challenge. I appreciate that but there seems to be a major lack of planning, especially with regard to winter cover - for want of a better term. It is obvious that things will happen in the winter and the winter is not only December or Christmas anymore. I find it difficult to get my head around why, year after year – this is my third winter as a Member of the Oireachtas – the Department does not seem to be able to get its act together. I say as much with respect. Will the Minister of State comment on that?

Anyone who is looking for more money needs to ensure we get value for that money. Delayed discharges are a major problem. There is nowhere for discharged patients to go and this needs to be addressed. There is a lack of step-down beds and home care packages. Delayed discharges are at the top of the cake. We need to dig into the matter a little more.

Acute hospitals have exceeded their approved funding level. Will the Minister of State expand on the reason this has happened?

I am keen for the Minister of State to comment on community services, especially in mental health. I am still waiting for an answer to a question about Bantry and the psychiatric unit there.

Did the Deputy not receive an answer to that at the last committee meeting?

No, and I have tried again with a parliamentary question. What is the number of staff in the unit? There is a lack of consultation rooms. Is there a dietitian available?

Cross-border health care is crucial, but the HSE still has to pay. There is a myth that this service is magic and free or else that Great Britain's health service is paying for it. I am keen to highlight that we end up paying for it. Will the Minister of State comment on why it is necessary for people to think they have to go up to the North when we end up paying for it anyway? Why not do it here and make it more comfortable for people, especially those from west Cork who find it difficult to make the journey?

Will the Minister of State comment on the primary care reimbursement scheme? Have staffing levels been increased?

People are still waiting for long periods under CervicalCheck, especially if their first test comes back as unclear.

I know of a few people in the constituency who have had to wait eight months because of an unclear result. I would welcome the Minister of State's comments on that issue.

I thank the Deputy for her comments regarding the visit of the Minister, Deputy Harris, to the constituency and the investments there. Her support for these initiatives is very much appreciated. On winter planning, the Deputy asked the reason we need a winter plan given there is a winter, spring, summer and autumn every year, which is a fair point. Notwithstanding that comment, there is a unique set of challenges that present during winter time and thus an onus on the Health Service Executive to be prepared for the acute peaks and troughs that occur during that time. Challenges can become exacerbated during winter time.

We already know that challenges will present in winter.

Yes, but we do not know the extent of them. A major outbreak of influenza coupled with a storm could have catastrophic implications in terms of people being able to access services, so there is need for forward planning each year. Weather patterns are changing every year and thus the plan has to change.

The weather has been consistently bad for the past five years.

We have experienced severe storms, such as Storm Emma, which we did not experience in previous years. As the Deputy will be aware, it brought services to a standstill although staff made incredible efforts to get to work. I accept the Deputy's point but we must have contingency planning for particularly extreme events, which cannot be quantified year on year.

In regard to the flu vaccine for healthcare staff, there has been renewed effort this year to encourage staff to get this vaccine. We cannot stress enough the importance of healthcare staff getting this vaccination, whether administrative, medical or catering staff. It is very important that people who work in healthcare facilities get the flu vaccination. When I was in New York recently I was told that healthcare staff there who have not had the flu vaccination must wear a mask on site.

Are the masks available free of charge?

Yes, for staff.

They are free of charge but not compulsory.

No, they are not compulsory. A flu epidemic is especially problematic for elderly people in healthcare settings, whether acute hospitals or nursing homes. A nursing home could have to send up to ten of its residents into an accident and emergency department at the height of the Christmas period and during bad weather conditions. Winter planning is important on many levels. It provides an opportunity to reiterate some of the key messages, in particular the importance of the flu vaccine. The Chairman will have heard about herd immunity. The more healthcare staff who are vaccinated, the easier it will be to eliminate the possibility of the flu taking hold in a facility. It is also important that the people who come into contact with them also get vaccinated. These are all issues related to winter planning.

On value for money, we are all agreed that value for money has to be to the fore in terms of all that we do. We cannot just give an additional €20 billion to the health services next year such that all of its needs will be met because that provides no incentive to obtain value for money.

The Deputy also spoke about delayed discharges, home help packages, step-down care and the need for approval of more home care packages. She will be aware that we recently announced 550 intensive home care packages, which are separate and different from one hour home help in the morning or the evening. An intensive home care package facilitates people to leave hospitals. I agree that all of the focus has been on the trolley counts undertaken by the Irish Nurses and Midwives Organisation, INMO, the HSE and so on. Trolley counting is a waste of time. I would have no difficulty with any of my loved ones having to wait in accident and emergency department for two hours for a bed. There is nothing wrong with that. Trolleys may not be comfortable but they are expensive. What is important is that people are treated with dignity and respect. However, if one of my loved ones was left waiting 19 hours for a bed when there were 20 empty beds in the hospital, I would have a difficulty with that. Hospitals should be operating at capacity, within reason. Two hours on a trolley should not be an issue but any longer than that is. The length of time people spend on trolleys is important but I would argue that the focus should be not on the number of people on trolleys but the number of people in our hospitals who should not be there. For a vulnerable older person to remain a day longer in an acute hospital than is necessary is dangerous. Our focus needs to be on that issue rather on the trolley numbers.

On the Bantry hospital issue, I apologise to the Deputy that she did not get the information. I did ask following the last committee meeting that it be sent to her. I will follow up on the matter after this meeting.

I thank the Minister of State.

My apologies for being late, which was caused by multiple issues. I welcome the Minister of State and his officials. On the income shortfall, while I understand the unpredictability of income, it is possible to identify issues based on trends over the past four or five years. To what extent has this been done? Are the same issues arising repeatedly? If so, how are they to be addressed? They are creating unease within the system, particularly for patients who need to access it.

The issue of public hospitals versus private hospitals and the insurance shift was mentioned. Perhaps the Minister of State would elaborate on that issue. It was mentioned that a public hospital receives a fee of €80 per night up to a maximum of €800 but this can drag on and become a larger amount. While this can alleviate the burden on the private sector, it means the public sector is effectively subsidising the private wards. I have no ideological views on this issue but if it is creating a problem in the funding for the public hospitals, then we need to examine it. Now is as good a time as any to deal with this matter once and for all.

On the winter plan, much of what has been said today has been said before. Every winter will test our resources. I agree with the Minister of State's remark that the trolley count is becoming misleading and that the length of time one spends on a trolley is the critical issue. It is better if everybody gets a trolley when they enter the accident and emergency department rather than being left in ambulances or at the doors of the hospitals. The critical issue is the speed at which the patient is dealt with thereafter. This is what we should be seeking to identify in future counts. In the past, elderly people were left on trolleys for lengthy periods, which can cause considerable distress.

Perhaps the Minister of State will give us some idea of the extent to which we are keeping a tab on developments in that situation.

I may ask a further question in a minute. I must get my functions together first.

The Deputy is only getting going.

I have not had coffee yet.

Deputy Durkan asked about private and public. He is aware of the de Buitléir report. There is a wider issue of the use of public and private facilities. On the question of health insurance, though, and as the Deputy will be aware, when people are admitted through an accident and emergency department, they can be admitted into either the public or private system. They have been advised by their private health insurance companies to go through the public door. That is perfectly legal under the Health Act 1970 and they are entitled to do that. It is then an €80 per night charge up to a maximum of €800 for ten nights.

What were the Deputy's other questions?

Bed count and trolley time.

The Deputy is repeating what I have said. He accepts that we should be more focused on the real challenge, that being, what is affecting capacity in our hospital groups and preventing the free movement of people in and out of hospital. The Deputy was articulate in putting his point about the length of time spent on trolleys and that all of us should be damn glad to get onto a trolley straight away provided we are not left waiting, which is too often the case.

The Deputy made particular reference to older people. That is a major challenge for us, as there are 1.4 million presentations to accident and emergency departments in a given year and people aged over 65 years amount to approximately 50% of that figure. I hope I am right about that. I met a group of consultant geriatricians in Cork recently and that was the figure they gave me. Ensuring that older people in particular are not waiting unnecessary lengths of time to access acute healthcare is a challenge for us.

Was there another question?

Yes. The State Claims Agency seems to be increasing its demand as a percentage of the budget. Will the Minister of State shed some light on the various issues covered? Some of them come to mind readily, but to what extent has the Department examined where this is heading? It looks to be heading in a burgeoning direction, for want of a better description, in the sense that it keeps popping up.

As a keen observer of the legislative timetable, the Deputy will be aware that two Acts of note have been enacted in the past year or so. Under one, there are periodic payments so that settlements, especially large ones and compensation awarded in the courts, can be paid out over a period while keeping in mind the wishes of and best outcome for the plaintiffs. It is hoped that that Act will steady the sharp increases.

It is worth noting that the number of claims is not a massive increase. This is as much about the size of the awards made by courts in catastrophic injury cases. There is a separation of powers between the Deputy and me as public representatives and the Judiciary, so we must be careful in discussing this, but it is a matter of fact that the size of the payments is causing the increase as opposed to their volume. Focusing on just their volume would be too narrow a definition.

I have read the briefing notes and am trying to remember. The second Act was the Mediation Act 2017, which was enacted in October 2017. It was an effort to bring about mediation as an alternative to the costly expense and personal trauma of going through court.

Is it operating yet?

From what I recall, it was enacted in October 2017. It is in place and people can avail of it. They are two significant Acts that should contribute towards this issue, but the book of quantum and other issues have to be reviewed periodically as well.

I thank the Minister of State. I will ask him a few questions one at a time to give him an opportunity to answer. What was done differently in 2018 than in 2017 to mitigate the overrun? The 2017 overrun was €200 million. This year, it is €700 million. What was failed to be achieved in 2018? Has there been a change in how the health service plan, which is yet to be published this year, is developed so that the overrun does not continue year on year?

That is a good question and probably gets to the heart of the issue we are discussing today, namely, the difference in planning and implementation between the two years. Separate issues can arise, but demand was the main issue. There was an increase in demand. Our ageing demographic increased pressure on our health services, which has shifted the overrun's dynamic. Demand is increasing at a faster rate than we projected. That is the first difference.

Individual issues arise. For example, we must guesstimate how much our complex appropriations-in-aid payment arrangement with Britain regarding pensioners in Ireland will cost and then negotiate it down. Incidentals arise every year. Storm Emma and so on were of a smaller scale, but other incidentals can be much larger. I referred to a number of headline issues, for example, primary care and high-tech drugs. The largest increase in demand in 2017 was down to pay awards. That arose as the economy recovered and do not arise every year. They came off the back of a recession. Our appropriations-in-aid were small.

As the Chairman will know, we are currently agreeing the service plan with the HSE. There is a keen focus on every aspect of that plan so that we do not perpetuate this cycle of overruns year after year. Even at this preparatory stage, we are trying to monitor expenditure with the HSE stringently so that the service plan can be on target and realistic, but there will always be "Events, dear boy, events" that are unforeseen and detract from the plan. For example, this year saw the CervicalCheck issue. Its cost would not have been that major, but there were cost runs in that of, I believe, €4.6 million for general practitioners. Small payments like that are not massive in the bigger scheme of things, but they take up a lot of attention and many staff are moved onto such issues. We want to try to be readier for such developments next year so that there can be a more consistent and constant focus on the implementation of the service plan month after month and that we are coming in on budget.

The Irish Fiscal Advisory Council maintains that there is weak planning in the HSE and the Department of Health to anticipate expected and unexpected events. At the end of the year, there is an expectation that, if the health service runs over budget by €700 million, it will be met and carried over into the following year in the hope that, in the following year, the budget will come in on target, but it never happens. That is down to weak planning. What can be done to strengthen planning so that we can have an accurate estimate of the cost of the health service?

It is a difficult one to get right. I am not a forensic accountant, which the Chairman appreciates, so I will not be able to answer as definitively as I would like. In 2017, the overrun was much higher than the figure cited. We are taking the €139 million deficit from 2017 this year, but there was a Supplementary Estimate of €200 million on top of that in 2017.

We could decide to provide €300 million for unforeseen developments, but that would be absorbed by and used up in the day-to-day running of the HSE and none of it would be left by the end of the year. It would be a blank cheque and could loosen the checks and balances on value for money. Alternatively, more political decisions could be taken to do this or that or to make pay awards with the €300 million. Providing it in advance is difficult. I am focusing on the macro, headline stuff instead of getting into the details with the Chairman.

That is one step that could be taken. Then we just learn from the previous year and the anomalies that arose and try to use that in projecting as best we can for the year ahead. There is an ebb and flow that will always have to be there and that tension between allowing an envelope, a little headroom, in the fiscal space and at the same time it being gobbled up by some demand-led service.

The point I am making is that if the Department repeatedly does what it did last year and expects a different result, it is probably being over-optimistic. For instance, there was a shortfall of €85 million in income from private insurance companies because they ran a campaign advising patients that they should not be admitted as private patients unless they felt there would be a benefit to them in a public hospital. That is a substantial hole in a budget of €85 million. The Minister of State might speak about that first. How can this hole be filled? Sláintecare speaks of removing private care from public hospitals. There will be a hole of €625 million or €635 million if that were to happen over a period. It is happening at present, however, because insurance companies are adopting a different policy in respect of their policyholders, advising them not to sign that they are private patients when going into public hospitals because they will probably get exactly the same treatment as a public patient. Obviously, this will happen year on year, so how will it be addressed in this year's service plan?

The overarching issue of public versus private and the challenges presented in that regard are, as the Chairman knows, the subject of the de Buitléir report, which the Minister expects by, I think, year end, judging from my last conversation with the Minister on the matter. It is certainly imminent. It will address a number of issues on both sides. There will be positives and negatives to it. It would have been agreed or recognised by Sláintecare as well. There will be a financial implication. How does one adjust for this? First, one must not only project for it, but also try to balance that on the other side of the house. This is why we introduced value improvement processes, VIPs, last year. The Deputy was trying to get to the heart of our identification of that figure. One can try to meet somewhere along the way there, and that will address some of it, but not all of it. Increased funding is probably the main answer to the question of how will we address that shortfall of €635 million as a result, if that is what it comes to be. We will try to mitigate it. I was recently in UCD for an event related to Lean Six Sigma, which is a very impressive initiative taking place in healthcare in association with academia whereby they are trying to identify cost savings. This is an annual and ongoing challenge that we must embrace more and more, to try to do more with less, to lower the level of care. Sending people into accident and emergency departments for everything under the sun is not the answer. We need to try to change our processes and reduce costs by getting people treated at a lower level and so on.

That is the point I am making. We must change the structure-----

Of how we do what we do. Yes.

-----of the health service and reorient it away from everything being sent-----

That is stated in Sláintecare.

Our health service is designed for people to end up in hospital. That is the default position for everything.

The design of our health service should be such that everyone ends up in the community and only goes to hospital in complex cases or acute emergencies. How will this year's service plan start to reorient the service away from the expensive hospital system and towards the less expensive community care system?

There are a number of points to make. First, there is an increased focus on transitional care beds, that is, lower level step-down care. We all know that the cost of keeping someone in an acute setting is anecdotally said to be in the region of €7,000 a week, and in a community setting, a community hospital, about €1,000 a week. This is a matter of opening more transitional care beds. Obviously, we are increasing capacity within the acute system simultaneously. We are renegotiating the contract with the GPs. We hope to have that completed by Christmas. This is ambitious and there is no guarantee it will happen, but we are very confident. A number of different measures will be involved in that which will move towards that Sláintecare ideal of bringing more and more.

One of my hobby horses is telehealth, which I think offers enormous potential for bringing healthcare closer to the person using primary care in that the GP can access consultant guidance and advice and cover there and then from the primary care centre. I am concentrating more on mental health on my side of things with telepsychiatry, whereby we do not have to have a consultant psychiatrist on site at every emergency department, ED, 24 hours a day, seven days a week, 365 days a year. We can have provided by telehealth one person in a hub providing consultant psychiatry to six or seven sites in a 24-hour period.

There are many different strands to this that will be dealt with, and this will be led out by Laura Magahy. There is about €20 million, I think, to drive this forward. I see the argument made on Twitter and such places that we only allocated €20 million for the implementation of Sláintecare this year, but Sláintecare is a policy implementation, a shift in practice and so on. It does not require that kind of massive €2 billion funding straight up. As one lessens the level of complexity and lowers the level of access for people and brings care to them closest to their homes, one can avoid an awful lot of the very expensive, reactive, acute-led medical care that has evolved in the country. Everyone recognises the current system's dysfunctionality. I think everyone understands and accepts the vision of Sláintecare and agrees that it is the way forward. However, there will be many steps along the way to reorienting a ship the size of the HSE, and a number of those will begin in the year ahead.

I am sorry I have had to go in and out of the committee room. I may ask a couple of questions that were asked before. Before I go into the budgetary allocations, the Minister of State raised the issue of telehealth. What regulations is the Department preparing to oversee the roll-out of telehealthcare? We had the Minister for Health before us in recent weeks and, as we know, in an Irish context, there are no such regulations. There have been criticisms from the Care Quality Commission in the UK about some of the dangers of telemedicine such as the development of inappropriate prescribing and the lack of part of the clinical examination that occurs. What regulations are being developed to match the Department's ambition with telemedicine?

I think I had this conversation with the Deputy a long time ago.

He has raised the matter in the Dáil. Telehealth is a very interesting debate. In essence, telehealth does not require a whole lot of additional regulation. Telehealth is just a platform. It is not a new way of doing medicine. It is a screen-to-screen communication tool. At the other end of the screen is a fully regulated doctor or consultant. I refer to the example in my area of consultant psychiatry. I want to deliver consultant psychiatry from a hub in Dublin, or it could be Cork, Limerick or anywhere else, whereby there would be one room with a consultant psychiatrist inside, and instead of having to be physically present in the Limerick, Cork, Tralee or Clonmel ED or any other hospital ED, whether in Naas General Hospital or wherever else, he could cover five or six of these sites from the one hub. What one needs is technology at both ends in order that when my 14 year old son presents at an accident and emergency unit in a state of psychosis at 2 a.m., instead of telling us no consultant psychiatrist is available until 9 a.m., they will turn on a screen in front of him and there will be a consultant psychiatrist who will speak to my son and can assess him, diagnose him, prescribe medication and, if necessary, admit him to an adolescent unit.

Has the Minister of State engaged with the College of Psychiatrists of Ireland about this?

I have indeed, extensively. I have had numerous engagements with the College of Psychiatrists of Ireland and it is very enthusiastic about and supportive of this development. I held a national conference in the National Convention Centre Dublin and brought over clinicians who are doing this in the United States, Australia and so on to speak to the Irish clinicians. The day was deemed to be an unqualified success from the clinicians' point of view because they learned about this new way of doing things and we challenged all the challenges and asked all the questions of the clinicians, the practitioners and the managers of the health service. There were 200 or 300 people there. They questioned all these people and got to the bottom of the matter. There is no need for us to reinvent a wheel that is already moving. I was doing this 20 years ago in education when I was a schoolteacher in Leap in west Cork. We were giving special needs teaching out to islands through technology rather than the special needs teacher having to leave the Leap school, go out to Baltimore and get on a boat or whatever. This is bringing healthcare 20 years on. It is a platform, and I know Deputy Chambers' concern is videoDoc and the prescription-----

No. With respect, if a 14 year old were to present with psychosis, the care provision for them, because of a vacuum surrounding recruitment, should not be a screen. As Minister of State with responsibility for mental health, Deputy Daly's priority should be ensuring the Department fills the recruitment gaps in our hospital system and that we do not replace or dilute proper care provision in our acute hospital system. He mentions not having to have a consultant on site 24-7. They are not there anyway, but we should not dilute proper care provision and proper appointments for something that is not the same. No matter what, face-to-face will beat telemedicine.

We should not have a policy of diluting the quality of care. If one were to ask any 14 year old, he or she would prefer for there to be a team to assess him or her when he or she presents on an acute basis than to be handed a video screen or something like that. While it is fine to develop a process of telemedicine, it is important we do not replace a proper recruitment provision in our acute hospital system. Currently, many children who present at hospitals at, say, 2 a.m. must be admitted to adult beds and they are not seen by paediatric psychiatrists. We should not encourage child and adolescent psychiatrists to work for six hospitals. Rather, we should fill the recruitment gab. It is a failure of Government policy on recruitment, retention and pay. I would not like to see dilution and gaps in recruitment. While it is fine to develop something different, it should not replace proper, direct care, that is, seeing the doctor at the hospital interface.

That was a lengthy and substantial contribution and, therefore, I must respond. I could not disagree more with the Deputy.

It is a fact that there is a worldwide shortage of consultant psychiatrists. We are short 60 of them in Ireland. I cannot make two out of any one consultant, no matter how hard I try. I can try breeding them or cloning them but I cannot make two out of one. All the Government policy, pay and everything else will not make two out of one when there is a worldwide shortage experienced by the United States, Australia and elsewhere. In those places and the rest of the modern world, they have caught up with technology to use it effectively. There are now so many consultant specialties. Time was when there was just a consultant psychiatrist, but now there are consultant psychiatrists for adults and for children, as well as consultant psychiatrists with a specialty in anxiety or in eating disorders for children and for adults, but there are not enough of them because people are presenting in their droves.

Technology is merely a platform. If there is a consultant on that screen, and if that consultant is fully trained, qualified and accredited and so on, the level of service to the child is not being diluted. As a parent, if I went to Cork University Hospital at 2 a.m. tomorrow and was told there was no consultant psychiatrist available until 9 a.m., but if there was a remote consultant psychiatrist who was immediately available, qualified, could speak to the child, assess, diagnose, prescribe and admit if necessary, which would I prefer? Would I prefer my child to be in a state of psychosis in accident and emergency services, with the craziness of it from 2 a.m. until 9 a.m.? I would happily accept the screen psychiatrist.

It has been proven that children with autism are more comfortable using a screen, although I am not suggesting that a screen is superior to face to face. Rather, in a situation where there is a vacuum of 60 consultant psychiatrists in Ireland, I have two options. I can continue to do what I always did but, as the Chairman noted, if we always do what we always did, we will always get what we always got. I can answer parliamentary question after parliamentary question to say we have recruitment and retention challenges. On the other hand, as Minister of State, I can accept my responsibility, step up to the plate and consider a new and alternative way of operating. It does not make sense to have a consultant psychiatrist sitting for 24 hours a day in the accident and emergency department if there are only two presentations for him or her in that period. We have to be real about what we do. This is not to replace human beings.

There is a vacancy in Wexford, where a consultant psychiatrist left his post in a high-profile manner. A consultant from Galway visits Wexford every weekend to deliver clinics for children and adolescents, for which she travels a seven-hour journey in total. I could remove those seven hours in the morning by providing a screen and she would not have to leave Galway because she could assess her patients there with a team which is not remote. When one presents at accident and emergency services, there are doctors, registered general nurses and a whole team of medics. The consultant psychiatrist will be part of that team but will not be physically present, and the input will be via a screen to make more available this precious resource that is not as widely accessible as we would like.

It is the same with the consultant in Galway who requires a full child and adolescent mental health services team. As the Deputy will know, it is a multi-disciplinary team with eight or nine professionals, but they are led by a consultant psychiatrist. When a consultant psychiatrist leaves, we do not want that team to be paralysed. A consultant psychiatrist from another area will be able to use technology, discuss the cases and the caseload, and give advice to the psychologist, the occupational therapist and so on.

I see it as a dilution of the commitment to recruitment and, therefore, we will agree to disagree. I still believe that face-to-face assessment is better for a 14 year old in the circumstances the Minister of State outlined. I am not sure how the full criteria can be met according to international guidelines, in the light of the information and communication technology guidelines, the mini-mental State examination and the whole process of examination. While there might be advances in this regard, and while a platform can be built and it is fine to have a vision, if we are to reflect the Sláintecare vision of healthcare in Ireland, the focus should be on replacing the posts rather than on what the Government is doing, namely, replacing proper recruitment with telepsychiatry.

In his statement, the Minister of State did not mention the elephant in the room, which is the 80% rise in management spending in the HSE in the past five years. In 2012, there were 744 employees at grade VIII but there are now nearly 1,400. What are the Minister of State and the Department doing to address the continuous growth? Every year it seems the first task of the HSE and the Department is to fill the management positions for people at middle and senior levels and there is a merry-go-round of filling the vacant positions. The reality of healthcare in Ireland is one of constant spending and bloating. The front-line workers, whether they be doctors, nurses, healthcare professionals or even secretarial and clerical staff, are the ones at the coalface who are told they must manage and continue as they are if someone leaves. The bloated top, however, continues to grow.

I recognise that Deputy Jim Daly has had responsibility in the Department for only two years but, as a Minister of State, he has a duty of oversight to say "Stop." What is he doing as part of the budgetary allocations to stop the continuous bloating in healthcare organisations, which frustrates everyone on the front line, and the growth in figures? Even at the peak of the recession, people continued to be promoted to more senior positions and their own positions were filled. It continues to become more top heavy. If we are to grapple with difficult budgetary allocations, it needs to happen at all layers and levels, and management is an important issue.

We know from representatives from the HSE appearing before the committee that nobody takes responsibility. There are many managers in many different areas but the buck stops with nobody and they do not meet any of their targets or outcomes every year. For the acute hospital budget, the Department of Public Expenditure and Reform stated that hundreds of millions of euro was allocated but there was no indication of the output or the service-level improvement, and there are more managers managing that budget every year.

What is the Department planning with the HSE to address the continued bloating?

This is a familiar political chestnut that is often thrown around in these fora. I am not a spokesperson for the HSE. I have a responsibility within the Department that oversees the work of the HSE, but the HSE is better able to answer these questions itself. I intend, therefore, to give a broader context.

Politicians like to make the popular point that there are many managers in the HSE, that they are all fat cats with massive salaries who promote themselves and so on. As politicians, we have accountability and responsibility. We demand accountability, and we want answers for tens of thousands of parliamentary questions that are tabled every day. The last Deputy that raised this issue with me on the floor of the Dáil is probably one of the Deputies who table the most parliamentary questions on the HSE. We cannot, however, have it both ways. We cannot expect such accountability, demand we get all the answers and expect a team of those responsible to appear before us on every issue that arises on the 9 o'clock news that night. We submit thousands of parliamentary questions and we make representations in their tens of thousands. Somebody somewhere must deal with them but they are not dealt with by nurses, doctors or front-line staff.

Those issues are the responsibility of HSE management. There was a pause on recruitment to managerial positions within the HSE during the recession unless absolutely necessary.

There was a rise in-----

I did not interrupt the Deputy and I ask that he extend me the same courtesy.

Deputy Jack Chambers should allow the Minister of State to answer the question.

There has been an increase in the rate of recruitment to middle management positions since the recovery from the recession and resources have been made available by central government. During the very difficult years of the recession, the Government of the time did everything it could to continue the recruitment of front-line staff but there was a pause in recruitment to management positions. We are now catching up in that regard. The figures indicate an increase in recruitment. As I stated, the percentage of managers in the HSE is comparable to that in similar organisations internationally and those data are available for anyone who is interested. One should consider the hard data and the broader picture rather than taking populist and opportunistic political cheap shots. I am not unduly concerned on this issue. I am entitled to my opinion. As a Minister of State at the Department, I have no vested interest in protecting the HSE which is well able to answer for itself. However, I am not concerned on this issue.

Front-line staff such as doctors, public health and other nurses and community intervention teams have indicated that they are overburdened by bureaucratic management beyond what is necessary to deliver the service. In fact, the bureaucracy inhibits their delivery of services because the amount of work which they must do to comply with the increasing bureaucracy required takes them away from their patients. There is evidence from front-line staff that the managerial system is overburdensome and is interfering with the delivery of service. It may be a political point but it is also a very practical point being made by front-line staff that there is a profusion of management which is interfering with rather than enhancing the delivery of service.

I have heard that point on numerous occasions from front-line staff, as has any practising politician. I am trying to broaden how we view and narrate this issue. The political side of the issue regards how it is narrated in terms of the organisation being bloated and mangers being overpaid and so on. I accept that HSE management is overly bureaucratic but that is being driven by politicians and the courts. Reference was made to the level of awards. The layers of bureaucracy also result from the demand for accountability, as well as European directives and so on. There is not a culture within the HSE of seeking to create layers of bureaucracy to make life difficult for everybody. Court cases and demands for accountability by the Committee of Public Accounts or through parliamentary questions result in further layers of bureaucracy. We cannot have it both ways. We must accept that those factors are driving the bureaucracy. The parliamentary affairs division of the HSE is responsible for a significant volume of work, while a large number of staff in the Department are dedicated to dealing with queries from Members of the Oireachtas. Do we want that level of accountability or not? These are factors in the debate. I am not putting forward a blanket defence of HSE management but we must accept there is another side to the issue.

I thank the Minister of State. I call Deputy Durkan.

I was in the middle of asking my questions.

I cannot control how long it takes the Deputy to ask his questions. He had the floor for 15 minutes. I am moving to Deputy Durkan. Deputy Jack Chambers can come back in later. The committee can sit until 1.45 p.m.

I served on the largest health board in the country and learned some lessons during that time. As I have stated on many occasions, the HSE is not the appropriate structure to deliver health services in this country. The sooner we return to regionalisation, as proposed in part under Sláintecare, the better. However, there are issues to be addressed.

I do not accept the notion implicit in the comments of the Minister of State that politicians asking too many questions is slowing down the system and costing a lot of money. That is rubbish. It costs no more to answer a question quickly than it does to answer it slowly. In fact, the reverse is the case. To answer it slowly could cost up to ten times as much. People afraid of certain questions being asked are hiding behind claims that the questions cannot be answered.

How does the system work? Is it working? I do not think it is. It should be simple to transfer a seriously ill patient from one hospital to another, but there are major difficulties in that regard. Last summer I became involved in the case of a patient with private health insurance of whom a transfer was sought. I thought the public sector would be delighted to take a patient with private heath insurance and so on, but that was not the case. There was a shortage of beds. The hospital had only a couple of vacant beds and they were reserved for emergencies. The man was in a coma. The hospital staff were asked whether his case would be considered an emergency. We should find out what is slowing down the system and why it is not functioning as it ought. Henry Ford devised a system that was far more efficient than others in operation at the time and produced better goods more quickly, cheaply, and effectively. I do not suggest that we do things on the cheap, but we can do them far better and more quickly, effectively and efficiently than is currently the case.

The National Treatment Purchase Fund is a means of removing patients from the most sensitive areas of our waiting lists. The treatments must be paid for one way or another. If it cannot be done in one system, let us do it in another system, whether that be inside or outside the system or country. There should be an inevitability about treatment being provided. If it cannot be provided within the public system, we should get somebody else to provide it. The waiting lists are not a reflection on the present or previous Government. Lengthy waiting lists have been common for many years. Patients may unnecessarily wait up to ten years in excruciating pain for a hip replacement. They are told to go to their GP and get more painkillers. That is wasting money. The way to use the time effectively is to go to the centre of the issue and deal with it.

I am a little concerned by the issue of the State Claims Agency and the increase in costs to which reference was made. What is the reason for the increasing demand in that regard? Is it a change in culture or is the State exposed to a greater number of claims arising from the delivery or non-delivery of services? I will not go into the issue of unqualified medical personnel who infiltrated the system as that was addressed at a previous meeting. The existence of such issues causes me considerable concern.

On the HSE management issue, I do not state that it is the ideal system or the one I want to see. I am merely contributing another angle in the interests of the debate. Of course, I have no difficulty with people holding the HSE to account and questioning it, but we must be aware of the other sides of the issue. I want the accountability and transparency to continue. The HSE should not be given a blank cheque to employ as many managers as it wishes. I agree with many of the points made by Deputy Durkan but I must put the issue in context and broaden the debate somewhat.

It is not in the interests of winning or losing, or scoring points, or politics, or having to be defensive as a Minister of State. I have no issue with taking challenges head on.

Deputy Durkan talks about the style of management within the HSE and if one considers how the private hospitals are run, some of them are run without the layers of management. I think the Chair wants to make the same point. There is no question that the private hospitals do not have the levels of management that are present in the public hospitals. The efficiency of the private hospitals is probably much more impressive, in many cases, than in the public hospitals. The private hospitals do not face the kind of issues that public hospitals face. They probably do not have the same level of union issues. They do not have issues of public accountability and do not have to come before the Department, or other organisations, or prepare parliamentary questions. They do not have to deal with freedom of information requests and media queries to the same extent that the public hospitals do. There is an element of that. I am just saying that by way of contribution to the debate rather than defending what is happening.

Many people in the Chamber would be vehemently opposed to any further privatisation of health services and their ideological position would be that that is not the way to go. There is a debate all around as to whether public or private is better.

The Deputy asked about the purchasing power the National Treatment Purchase Fund, NTPF, has been given and its increasing power to purchase. As we are aware, much of that is within the system itself. It is identifying where there is capacity and moving funds around a bit.

What was Deputy Durkan's last point?

Why is the system not working smoothly? There was a reference made following an investigation recently about the chain of command. How is the chain of command operating? I do not think it is operating at all and I do not think it has for many years, certainly since the health boards and regionalisation disappeared. There appears to be an amorphous mass somewhere in the centre, a hazy, foggy, no-go area full of pitfalls and traps and all sorts of things where nobody seems to go. The Minister of State is hinting that everybody is afraid of something. What are they afraid of? There would be nothing to be afraid of if the system was working properly. If everything is done in accordance with the rules, fine, although accidents will still happen.

I mentioned the various causes of claims. The size and severity of the claims is one thing, but the reason for the claims is another. I have dealt with a couple of cases recently where there was a clear indication to me that some things that should have been done were not done and patients suffered as a result. There was a reluctance to admit it, even though full disclosure is supposed to be in operation. What does one do? I would have thought that, in such a situation, management would make a tentative offer without prejudice, or whatever the case may be. None of those things happened. Cases go to court and eventually, on the steps of the court, somebody decides to settle. That is not the way to do business.

The first question the Deputy asked was why is the system not running and operating smoothly. I would be a fairly formidable individual if I was able to give the Deputy a succinct, articulate and coherent answer to that.

We believe the Minister of State is fairly formidable so that is why I asked the question.

I thank Deputy Durkan for the vote of confidence in posing the question and thinking I could do it justice.

The Deputy asked whether the issue relates only to an increase in the size of the claims or is the number of claims increasing. I remember, as a backbench Deputy in the last Dáil, tabling parliamentary questions on the issue of the number of claims. I thought, from looking at headlines in the newspapers in 2014 and 2015, that there had been a massive increase in the number but there has not been such an increase. I do not have the latest figures for 2017 and 2018 but, back in 2015 and 2016, there was no massive increase in the amount of claims. There has been a cultural shift towards open disclosure and we are trying to get people in and deal with that legislatively in order that people will admit and own up to their mistakes and acknowledge and inform the victims. The aim of the Mediation Act is to avoid the courts. There are also periodic payments to try to stagger large payments so they are not all done at the same time.

While we need to reduce the amount of claims, there is an increase in the number of procedures taking place in our hospitals. I do not know the quantity of the pro rata increase because I have not seen the figures for 2017 and 2018. I suspect there was a pro rata increase in the amount of claims. I hope not but is it potentially the case.

The establishment of the HSE board will be a positive step towards the oversight of management, holding it to account and ensuring it is not overly bloated. A good, effective board that will challenge the top layer of management of the HSE will be a positive step that will be established in the new year. The four of us here all agree that the levels of management within the HSE need to be challenged, held to account and open to scrutiny.

Can I come back to the pure Estimates again? The overrun in the various regions ranges from €86 million to €118 million. The Minister of State has spoken about the causes of these overruns. It is a demand-led service and there is an unpredictability about various flu epidemics, storms and snowstorms etc. I put it to the Minister of State that there is a predictability to health. For instance, 3,500 people will fall and break a hip every year. It might be 3,400 one year and 3,600 the following year, but there is a predictability about it. There is a predictability about how patients suffering from many chronic illnesses will present to hospital. There is also a predictability about the aging process. We know that 20,000 people per year go over the age of 65. The aging population is increasing. The population over 85 will double in the next number of years. These are all predictable, actuarial events.

They are facts.

Surely the Minister of State can predict the cost of looking after that variability? That is the issue. Each year, the prediction of that variability is off by €600 million or €700 million. We are spending as much money as the average country in the OECD on health but we are getting substantially poorer outcomes. Continuing to do what we are doing, as I said before, is not giving better results. The change that I am trying to get out of the Minister of State, or the idea I am trying to feed him, is that there are efficiencies to be gained by integrating our services. Our services are not integrated and, because of that, there is a lack of efficiency and value for money. Sláintecare is proposing a huge level of integration. The first part is integrating hospital groups and community healthcare organisations into a single budget. That would drive efficiencies in hospital admissions and discharges in transferring care to the community. Can the Minister of State state that this move will take place in the coming year to bring about that change in efficiency? We can keep throwing money at the health system but, if it is inefficient, it will not deliver value for money. The only way to deliver value for money is to have integrated services which, by definition, will bring efficiency. Perhaps the Minister of State might comment on that.

I cannot definitively say that those efficiencies will be brought about in the year ahead. I can definitively say there will be a relentless focus on bringing those efficiencies about. We have a very dysfunctional architecture underpinning our health system and the committee is aware of many of those issues. Integration is key to achieving a more cohesive and coherent health service delivery that works for people.

Someone came to my constituency office a number of weeks ago. They had been in Germany and showed me the new card used there, the equivalent of a driving licence, with a little gold thing in the middle that is the health record for patients. Every interaction a patient has had with the health service since the day he or she was born is recorded on that one little card. We have nothing like that in Ireland. If I go into SouthDoc, then to an accident and emergency department, into acute treatment and back to transitional care, there is shifting of files and paperwork generated and there is a lack of joined-up awareness for prescribing. I can be prescribed the same thing twice or three times. Anomalies arise in the system because of the infrastructure and that is the biggest challenge that I see and I have no monopoly on wisdom on this issue.

My perspective, as the Minister of State at the Department of Health, is to get the IT infrastructure up to scratch and if we can do that, then we can have the integration. It is very difficult to achieve the level of integration desired. Each person has a unique perspective and we want an IT system that will facilitate that. I see that as the single greatest challenge and we must have a relentless focus on trying to get that together. One can achieve so much more with data and information sharing and when everyone can speak to each other from a clinical, medical and management point of view. The information we as parliamentarians seek in order to hold the service to account will be so much more seamless if the IT infrastructure is put in place. That is the single biggest challenge. While I cannot state we will achieve that in the year ahead, there will be a relentless focus on it. We have received €250 million from the European Investment Bank with a view to providing the infrastructure to establish the European electronic health record. That will assist us in taking a significant step towards achieving that but there are many IT challenges in the system.

Currently, integration is ongoing to align the community healthcare organisations, CHOs, and the hospital networks. That will make for improved information gathering, sharing and the provision of health service delivery. Such interaction between CHOs and acute hospitals is crucial to deal with an issue I am very animated about, namely, late discharges. The required level of interaction does not exist currently and never the twain shall meet. They are two separate domains and it is very difficult to try to get them to join up. Thanks to Sláintecare we are very good at recognising and distilling down the key challenges, as well as the optimum ones from which we will get the best results. We must now move Sláintecare along its journey.

Could I get an update on the budgetary allocation for the children's hospital? Has that capital allocation for that changed in the Estimates?

On one level of the Sláintecare implementation strategy, the Minister of State has said there will be a complete split between public and private care, but on another level he has said there will be a problem in terms of a shortfall. There seems to be a perverse incentive whereby public hospitals are reliant on the private income which they are due to lose, but the Government's policy is to remove the private income. What is the weaning phase and the plan for private care in public hospitals under the Sláintecare plan? The Department's position is that there is reliance on private income for public hospitals but then the ambitions for Sláintecare will not be achieved. I would like to hear the thoughts of the Minister of State in that regard.

I respect the fact the Minister of State wants to give a position in terms of management, but instead of saying it is an old political chestnut and an opportunistic comment he should acknowledge there is a problem. The Chairman mentioned it. Everyone working in healthcare gives feedback to us, and I am sure to the Minister of State, that there is an issue. In OECD terms we have one of the highest spends but our level of front-line output is probably below average. We have a mismatch and it is not due to a lack of investment or will on behalf of the Minister of State. We have a lot of people in management that are not managing the budgetary allocation. As Deputy Durkan mentioned, while the Minister of State talks about accountability and transparency, we are not getting accountability from anyone. We cannot even identify who the managers are and how they are matching their targets because there are so many of them. If eight people are responsible for a particular segment of a care pathway or delivery in a particular hospital, they are not accountable. What tends to happen is that people get promoted out of their positions and they are rewarded for not necessarily delivering on their own service plans within the healthcare system. Anyone in the Department, including the Minister of State, needs to build that into the promotion system for managers. I am trying to be constructive. I am not trying to raise an old political chestnut. This is a significant issue and we will never have any progress in Sláintecare if we continue to allow the layers of management to grow. It is not the fault of the Government. The system has been in place for 20 years. All parties have had an input into the Department in those years. I do not lay the blame at the door of the Minister of State but, politically, we need to grapple with it. Hospital groups were created in recent years and there was a change in Government policy to get rid of them and to replace them with a Sláintecare structure. We have spent a number of years layering up hospital groups and now we are transitioning into another structure. I am concerned that we are going to add additional layers because that is always a risk when an organisation transitions. That is the lesson from the HSE. The layers grew when we went from having health boards to the HSE. I hope that we have learnt the lessons from that.

I thank the Deputy. He asked about the children's hospital. As the capital plan has not been agreed yet for this year, I do not have the updated figure or whether there is a projected overrun on the cost of the children's hospital. I will get the information for the Deputy.

The Deputy also asked about the complete split between public and private health care. That is the subject of the de Buitléir report, which is expected to be provided to the Minister imminently. I cannot answer the question definitively as to what we will do to separate public healthcare from private healthcare until we get the report. The details in the report will be used as a roadmap to achieve that end. There will be cost implications that we will have to handle in that regard. I cannot say any more until we get the report.

I am not trying to be provocative. Anybody who knows me knows I am one of the least partisan. When I talk about politics being opportunistic, I talk about myself and my party as much as anybody else. I was not trying to be provocative and I apologise if that is the way it came across. Sometimes, when people talk about the health service, whether it is at the pub counter or outside the church at mass, the blame tends to be laid at the door of the managers. It is a simplistic solution to suggest that if management was addressed that we would have a great health service. The point I was trying to make is that balance is required in the debate, but that does not take from what Deputy Chambers said. My point is halving the number of managers in the morning would not be a silver bullet. I am not sure that we would be much further advanced if that were to happen.

To clarify, we do not intend to change the hospital groups as part of Sláintecare. The Chairman can confirm if I am correct in that regard.

Two weeks ago, the Minister for Health said at the committee that as part of the Sláintecare plan he was not legislating for hospital groups and that they would be changed.

I am not aware of that. Hospital groups were only established four years ago.

That is the problem. My concern is that we have spent four years establishing a system that is now going to be replaced and the Minister is not legislating for that. The Minister told the committee two or three weeks ago that the Department is not progressing legislation on hospital groups to provide for a legislative and administrative framework, and that Sláintecare takes precedence. He said the hospital groups would be replaced with whatever model Sláintecare proposes. That is what the Minister told the committee and that is the basis for my remarks.

My understanding is that the intention would be to better align the existing hospital groups with the ambitions of Sláintecare. That would be accommodated in whatever legislative changes would be made in order to better align the hospital groups. My understanding is that there is not a proposal to abandon the hospital groups or to disregard them but rather to better align them with the community healthcare organisations.

I think the Minister for Health said he is abandoning the legislation that was proposed to underpin the changes.

That might be to take account of the Sláintecare objectives of aligning the hospital groups better with the community healthcare organisations.

Does Deputy Durkan wish to ask a question?

I will return to the Estimates. There has been a substantial increase in the cost of the treatment abroad scheme. Many people are going to Belfast and people are also going to England and other places. Could the Minister of State talk us through that? The National Treatment Purchase Fund is providing services outside the public system for public patients and the treatment abroad scheme is providing services for public patients outside of the jurisdiction. What is the overall cost of the combined schemes for the year 2018?

On the background to the treatment abroad scheme, it is the result of an EU directive which said individual citizens of any member state could avail of healthcare in any other state within the EU. It is a question of awareness.

They were not aware for a long time that they could travel to another EU state, not just Belfast. They could go to Spain in the morning to have their hips done and perhaps avail of better sunshine during their recovery. That is a prospect for people.

People can come to Ireland as well to avail of healthcare. There are different specialties and waiting lists. Some countries have more capacity in their systems for some procedures and limited capacity for others. We have capacity in some areas and lack it in others. We are all aware of the areas where there is a lack of capacity. They are well highlighted.

Irish healthcare is much sought after. I spoke to the head of the police force in Dubai 12 months ago and he wants to do a deal with private healthcare in Ireland for coronary care because the Dubai police force believes the best cardiac care in the world is available in Ireland.

The Belfast issue is primarily the increase because people are availing of it. The Government is still paying for it. It is a capacity issue.

From what budget does the money for the treatment abroad scheme come?

The overall health Vote. It is the same as the acute hospital bill. It is added to that because it is done abroad. People are entitled to it under EU law and we have to do it. Deputy Murphy O'Mahony referred to misunderstandings about it, I think she meant politically, that it does not cost the State. The Government and the taxpayer are still paying for these procedures to be carried out, whether in Belfast or in Dublin. It is a question of capacity. There is more capacity in some of the private hospitals in Belfast to do the procedure.

I will have to get more information on the NTPF.

I asked about the individual or combined costs of the treatment abroad scheme and the NTPF because it is an additional cost to the State outside our public hospital system.

The NTPF was €55 million last year. The budget for the cross-border scheme was €12 million and it was €14 million for the treatment abroad scheme.

Is it possible to get a breakdown of the type of procedures supplied through the treatment abroad scheme and the NTPF?

That would be interesting and helpful and we will certainly get that for the Chairman. There is a correlation between our predictably long waiting lists and where we have capacity. It will be interesting to see what we are delivering and where we are receiving moneys.

Is it possible to get the cost of those procedures through the NTPF and the treatment abroad scheme, for example, the cost of a cataract or a hip replacement?

I presume we can get the standard cost. We can get an average. If, for example, there were 80 procedures and they cost €400,000, we can divide that.

There is a perception that procedures in Ireland are more expensive than elsewhere. If somebody goes for cataract surgery in Belfast, he or she will be reimbursed for the cost of that procedure by the HSE, provided it is less than it would have been here.

Yes. It might be interesting for the committee to have that engagement with the NTPF and the HSE on that issue.

If the Minister of State can get us that information, it might inform our engagement.

I have undertaken to do so and will do so.

When the Minister of State was here three or four weeks ago at the quarterly meeting with the HSE, the interim director, Mr. John Connaghan, referred to an innovation section in the HSE which would consider innovative measures that front-line staff might identify which would lead to efficiencies in the service. For instance, in Scotland front-line staff are asked to identify how efficiencies can be made in their sectors, as opposed to having it come from the top down. Could the Minister of State inquire about that? There are many front-line staff who can identify-----

They see the inefficiencies and would like to be part of the solution.

It works well in Scotland that efficiencies identified on the front line are developed within the sector and perhaps expanded through the wider NHS in Scotland. Staff are trying to be constructive, spotting a niche and developing it.

I will ask Mr. Connaghan to come back to the committee on that. Is the Chairman familiar with the Lean Six Sigma programme with UCD that I referred to earlier? That is along the same lines. I think 2,000 staff have been trained up in achieving efficiencies and working towards that same goal as well.

Senator Burke has spoken repeatedly about a scheme to take blood tests for haemochromatosis in the community as opposed to patients going to hospital. It is substantially cheaper to do it in the GP setting but that never happens.

Deputy O'Reilly mentioned that the €700 million supplementary budget this year for the HSE was undoubtedly made possible by the windfall in corporation tax. If we are to depend on a windfall in corporation tax every year to bail out the health service, sooner or later that windfall will not happen. It is almost like depending on stamp duty, as we did in the boom times, to supply services. We are now depending on corporation tax, which is based on a few American companies operating in Ireland, and if President Donald Trump were to change his policy in the morning, that could substantially change our income from corporation tax. While it goes into the general taxation pool, it almost mirrored the amount required to bail out the health service this year.

Where the money comes from is probably immaterial. The more substantive issue is that we have an overrun in the health service this year of €700 million. Whether it is being funded by a windfall in that regard or is the result of an increase in another tax, it is probably more important that it is there. My fear is that our focus will shift to the source of it when we should have a relentless focus on why there is an overrun of €700 million.

It is not sustainable.

Of course it is not, no matter where it is coming from.

Following the comments on haemochromatosis, Warfarin pilot testing was done in the community. In other countries, that is done in the community. Generally the people on Warfarin are older and are more susceptible to illness. According to the latest figures, people aged over 70 were the main unscheduled presentations in emergency departments. If older people who are susceptible to illness are constantly exposed to the hazards of an acute hospital, it is only natural that they are they will be sicker. There can be efficiencies built in with Warfarin as for haemochromotosis. Giving the flu vaccine in pharmacies worked well. I was among the first tranche of pharmacists doing that eight or nine years ago. The morning after pill has worked and any interventions the Chairman and the Minister of State have made to make it available at the weekend have worked. We have evidence that when initiatives are moved into the community, they can be more efficient in themselves but also reduce burden of disease as well.

A major reason for admissions to nursing homes and hospitals is polypharmacy, incorrect prescriptions and errors. There is an incentive for pharmacists in the UK whereby if they make an intervention in a prescription, for example, bringing 12 meds down to six without interfering with doctor's orders, they get something like £5.

It is not very much, but there is an amount available to make it worth one's while to do the paperwork. That kind of approach has to be considered. Sláintecare is all about moving from acute care to primary care. However, looking at the big picture, what is being done? The money will run out and services will be cut in the future if they are not bedded down into the community with other people taking responsibility for them.

I am particularly concerned about those aged over 70 in the winter months. I do not see any major interventions to try and prevent them from requiring accident and emergency services. There have been proposals, but perhaps the Minister of State could outline the interventions that have been taken. Accident and emergency services are not necessarily the right services for those elderly people.

Most of the statements mentioned by the Deputy have been readily agreed and I concur that the community is the basis of the reform of our healthcare system. Whether seeking efficiencies, better outcomes or an increase in the number of people being treated, the answer lies in community-led services. Interesting initiatives, such as that for pharmacies, provide normal rather than distorted incentives for good, common efficiencies in the prescribing and administration of drugs. There is a significant issue of older people taking too many drugs or taking the wrong drugs. There have been problems with poly-prescribing, where different sources prescribe different drugs for the same issue. We should streamline that, which would lead to better outcomes for older people.

The Deputy asked about initiatives for older people this winter. The winter initiative has older people at its heart. We are trying to provide local clinics and extending GP hours. The Minister has spoken about this regularly in the past couple of weeks. The measures are being taken with a view to helping older and more vulnerable people.

The Deputy mentioned the flu vaccine. I also spoke about it earlier in the debate. We have to make sure more health workers are taking the vaccine to prevent outbreaks. I referenced the fact that in some hospitals in New York, healthcare workers at any level who have not had the flu vaccine have to wear a mask when coming into contact with older people in an acute hospital setting. We are also increasing home care packages. The Deputy will be aware of the announcement that we have added a further 550 intensive care packages. We are also examining the problem of late discharges and will take initiatives in that area, including a public communications policy which will advise people, in particular, older people, that the least safe place to be when one does not have to be there is an acute hospital setting. That is a challenge to normal thinking and is a culture shock to some people, but we must raise awareness of the fact. There are many hospital-acquired infections with which one might come into contact to which older and more vulnerable people can be susceptible. Most of us think that the best and safest place for our loved ones aged over 70 is in a hospital. We are about to start a communications policy advising that it is not; if one does not need to be there, it is the least safe place. We are also taking other initiatives which seek to prevent people from having to go to accident and emergency services. We are working with Nursing Homes Ireland to try to build awareness about nursing homes. Admissions to accident and emergency services should be a last resort and should not be the first option people take, given that it is not the safest place to be unless one absolutely has to be there.

What was the budget for home help hours for 2018?

Some 17 million home help hours were provided in 2018, and I believe the budget was €426 million. I do not have the exact total, but I believe €426 million was the budget. I will clarify that for the Chair.

How much of an increase did that represent on the budget from 2017?

From memory that represented an increase of €26 million from 2017. I do not have the figures in front of me.

Is the Minister of State aware of what the unmet need is?

We costed the unmet need as being in the region of €40 million. That amount would clear the waiting list for home help hours.

Is there an allocation towards that next year?

I expect that there will be some increase but it will not go far towards wiping out the deficit. I have repeatedly made the point that the current allocation model of home help hours is unsustainable. The Chairman, as a politician and a practising doctor, will be aware that we face a number of challenges in the area. We do not have the people to deliver the scheme. We have undertaken to prepare a scheme, which will be underpinned by statute and which will be delivered like the fair deal scheme, where everyone looking for access to it will get it and will be fully funded. However, we also need staff. There is a lot of work going on in the background to ensure we meet the terms and conditions necessary for such a scheme. We also need to reduce reliance on home help as it is in its current form, where it is being delivered eight miles north and south, and provide more options for people so that they can age in a better and more suitable environment, such as supported retirement villages. This would reduce the drain on home help hours massively and provide a much more enhanced level of care for people. The Chairman will be aware that the success of Kilmaley retirment village is one of the motivating drivers.

There is also a retirement village in Kilmihil.

The Chairman will have to invite me to that centre. I have not seen it.

It was started at the same time and is only ten miles away.

I will have to visit it.

The invitation has been issued.

I thank the Chairman.

I hate to ask this question all the time, but we hear about the issue regularly. It is denied by some people within the health services that we pay on par with the highest paying countries in the OECD but we do not receive equivalent service. Is there any way we can identify why that is? We have spoken about inefficiencies and duplications; I believe that is part of our problem.

Like one of the Deputy's earlier questions, there is a rather long and winding answer for this.

The longest way around is often the safest way home.

We have to assess why we are not getting the results we want. The Deputy could read the Sláintecare report, which goes a long way towards answering the question. It identifies the steps towards addressing the problem, and shows how we can spend the same amount but achieve much better outcomes. Essentially we are dealing with an infrastructure which was designed long ago and which is not fit for purpose any more, as I referred to earlier. That is true in respect of the design of the administrative aspect of the HSE and how it was set up initially, and the lack of IT and lack of investment in infrastructure over the years. Capacity is an issue that countries with a similar population do not have. We face severe capacity issues in our acute and community settings, and are trying to reorient services back towards the community from the acute setting in that respect. Sláintecare is probably the best answer to the question the Deputy asked. The reorientation would be provide much better value for our money, and Sláintecare is the ten-year plan we have identified which will make that happen.

I often ask people to consider how far mental health services have come under A Vision for Change, which was also a ten-year plan. In the 1960s, there were 20,000 people in long-stay, inpatient, acute psychiatric beds. Today there are less than 1,000. We have made significant reforms towards community-led service in mental health, and I have no doubt that we can do the same with physical health if we apply the same vigour to it over that ten-year period and embrace Sláintecare, regardless of which politician is occupying a particular chair of office over those ten years.