Vote 38 - Health (Further Revised)

I welcome the Minister for Health, Deputy Simon Harris, the Secretary General of the Department of Health, Mr. Jim Breslin, and the Assistant Secretary at the Department, Mr. Colm Desmond. The purpose of today's meeting is to consider the further Revised Estimates for the Department of Health for 2019, Vote 38, which were referred by the Dáil to the Select Committee on Health on 20 February 2019.

I invite the Minister to make his opening statement.

I am delighted to be back at a meeting of the select committee and I very much look forward to taking the opportunity to address it on the Revised Estimates for my Department for 2019, Vote 38. The committee wishes to consider the Revised Estimate on a programme by programme basis but, as the Chairman will be well aware, the health Vote, unlike other Votes, is not configured along programme lines. My Department continues to work towards the development of programme budgeting and changing the structure of the health Vote to reflect this.

I welcome the fact that the committee wishes to focus in particular on the financial allocations for implementation of the provisions of the Sláintecare report and capital allocations for hospitals. In that context, 2019 has the highest investment ever in our services. It is also the first year that the Health Service Executive's national service plan is framed through the lens of the Sláintecare implementation strategy. The strategy provides the framework within which a system-wide reform programme for the health system will be advanced and focuses on establishing the building blocks for a significant shift in the way in which health services are delivered. It is a matter of considering what more can be done in the community. The idea of everything having to be channelled through the hospital structure no longer applies.

The national service plan sets out further details on how the totality of health service resources, including the significant additional provision being made available by the Government, will be used to advance Sláintecare objectives in 2019. In addition, the welcome increases in the health capital budget over the period to 2021 will allow progress on key developments such as the new national children's hospital, which I am sure we will discuss, the national forensic mental hospital and continued improvements in radiation oncology infrastructure in Dublin, Cork and Galway. This becomes all the more pressing in light of the National Cancer Registry of Ireland's report of this week. The programme of development of new and refurbished primary care units and community nursing units throughout the country will continue to be rolled out. Additional funding over the period will be utilised to deliver additional acute and residential care beds and progress work on key Sláintecare projects.

The gross provision for the health Vote in 2018 was €15.977 billion, comprising €15.464 billion in current expenditure and €513 million in capital expenditure. This represents the gross funding position for both the Department of Health and the HSE and includes additional finding of €645 million granted by means of a Supplementary Estimate. The additional gross funding requirement comprises €20 million towards capital works and €625 million towards current over-expenditure, which we have discussed before.

In framing the 2019 budget, the Oireachtas allocated significant further additional Exchequer funding for the health sector. In 2019, gross health funding is €17.032 billion, comprising €16.365 billion in current expenditure and €667 million in capital. This represents an increase of €901 million on the 2018 current expenditure budget and €154 million on capital expenditure and recognises our commitment to providing a health service that seeks to improve the health and well-being of the people. It is no surprise to any member of this committee or anybody in the country that the issue of health funding is a major policy challenge, not just in Ireland but also internationally. Despite welcome increases over recent years, the need for effective financial management remains crucial as the health service deals with a larger and older population, with more acute health and social care requirements, increased demand for new and existing drugs and the rising costs of health technology. The costs associated with these service pressures will increasingly need to be managed not solely through annual increased Exchequer allocations but also through doing things better, reforming our health service and improved efficiencies, productivity and value from within the funding base. Demographic pressures, including a rise in chronic diseases and ageing populations – an increase in life expectancy is good - are major challenges to health funding internationally. The additional funding secured over recent years provides a substantial basis for the health service to maximise the level and quality of service delivery while also implementing the Sláintecare programme.

I now wish to address a number of issues that I understand the committee, in its letter to me, identified as being of specific interest. On the new children's hospital, members will be aware that the independent comprehensive review of the escalation in cost of the hospital, the contributory factors and associated responsibilities has been completed, was discussed by the Government yesterday and has now been published. I very clearly welcome the report's finding that the Government decision in December 2018 to continue with this project, based on the advice available at the time, was the correct decision. It states that any alternative course of action would have resulted in significant delay, further increased costs and the possibility that the hospital would not be built. I received much advice and was subject to many political charges from around these Houses after the cost escalation became clear and I was told I should retender the project, pause it or move it. The report by PwC, an independent financial auditor, indicates the appropriate decision was to proceed with the project.

The report addresses in detail the flow of information on the cost escalation and confirms the information already in the public domain regarding communications with my Department. It is important that all the documentation that PwC had access to aligns with the published documents that I made available to the committee previously.

The report points out significant areas of weakness that need to be addressed and strengthened to support the project to successful completion, as well as significant lessons for capital projects in general. Now we are back in an era of investing in capital projects there will be many big projects, not only in the area of health. While it is important that we retain the experience and expertise gained over the last number of years by those involved in progressing the new children’s hospital project to this stage, based on the report findings we also need to strengthen the capability and capacity of this resource, where necessary, to further support the planning and execution of this phase of the project. This process has commenced with the appointment of a new chair of the National Paediatric Hospital Development Board, Mr. Fred Barry, a man with a great deal of experience in delivering capital projects. In line with yesterday’s Government decision, I intend to consider the report findings and recommendations in detail with the Minister for Public Expenditure and Reform, Deputy Donohoe, our respective Departments, the HSE and Mr. Barry and will revert to the Government next month setting out a considered response to the report and an implementation plan. The recommendations provide a firm basis to improve the management of project delivery. We will comprehensively address the recommendations of the PwC report and, in doing so, successfully meet the needs of the children of Ireland for many years to come. I do not intend to give the committee a knee-jerk response today. There is a reason the Government decided that it would take four weeks to come back with an implementation plan but I have no doubt that there is a role for the committee, to be determined by the Chairman, in setting out a comprehensive implementation plan. I look forward to working with the Chairman in that regard. We must take very seriously some of the clear indications in the report in relation to the professional information given to the national development board. Page 4 of the report is very clear on material errors and a peculiar way of doing business in terms of arriving at some figures. It will be significant cause for reflection. I intend to meet the new chair of the National Paediatric Hospital Development Board in the coming days to ask for his response and that of his board to those findings.

I reiterate a point I have made many times previously, namely, the children and young people of Ireland have been waiting far too long for a modern healthcare facility and a new children’s hospital. Some will say that everyone says that, but there are many people who thought we should pause the project, retender it or move the location at this late stage. We will not do that.

The outpatient and urgent care centre at Connolly Hospital is scheduled to open this summer. I will meet Children’s Health Ireland this afternoon. The Connolly part of this hospital project will be handed over to the State this month and will start delivering real service improvements for children this year.

There is no doubt that the children’s hospital overrun has implications. An additional €99 million is required for the project in 2019. The Government decided that €24 million of this additional funding will be provided from within the €667 million allocation, with the balance of €75 million to be met by rescheduling capital allocations in other Departments.

The Chairman’s letter asked that I deal with the Sláintecare implementation strategy. The strategy was published in August 2018. I accept that it has taken some time to get to this point but we now have a very clear implementation strategy. Budget 2019 included €206 million for specific new initiatives associated with the Sláintecare implementation strategy, including negotiating a new GP contract, which the Chairman and I discuss regularly. I am pleased to say that we have achieved significant progress, which has been welcomed by both the Irish Medical Organisation, IMO, and the National Association of General Practitioners, NAGP, in terms of investment in general practice. While there is more to do, and I am sure the committee will have views on that, we will have in place, for the first time, a large-scale structured chronic disease management programme to ensure patients with diabetes, asthma, COPD, and cardiovascular disease can be treated in their community. We will roll out that programme over the next four years starting in 2020. It will ultimately benefit 400,000 patients who today attend our hospitals and outpatient clinics.

We are extending free GP care to children under 12 years but on a phased and careful basis, having learned lessons from the extension of free GP care to children under six years. I propose that we extend free GP care to children under eight years next year. We need to negotiate a fee through the Irish Medical Organisation. In recent years, a bugbear of GPs, which I have heard them raise very clearly, has been their legitimate view that general practice is no longer sustainable and has been left in a difficult position as a result cuts introduced under the financial emergency measures in the public interest legislation and €120 million taken out of the service by successive Governments – that is forgotten. We have now worked out a way of moving beyond that and restoring the equivalent level of funding and more. In return, our GPs are helpfully offering to reform, modernise and work with us on important initiatives such as ehealth, medicines management, accurate waiting lists and virtual clinics. We have a fair and balanced deal which, crucially, will also help deliver Sláintecare.

We have also had the further roll-out of national strategies in maternity trauma, cancer and drugs and a €20 million Sláintecare integration fund. We are inviting the health service, voluntary organisations and individuals to pitch ideas as to how they can help deliver Sláintecare. I launched the integration fund on 22 March and it will be allocated in May. I expect to be back before the committee for a detailed discussion on geoalignment. I am determined to follow the recommendations, which the Chairman co-authored, on how to reform the structures of the health service. The Sláintecare report gave me clear advice on what are known as regional integrated care organisations, RICOs. I do not like the name but I know their purpose. The idea is to merge community health organisations and hospital groups over time, divide the country based on a population health approach rather than any other approach, reduce bureaucracy and establish regional oversight structures. I intend to move on that this summer. I will return to discuss it further with the committee at an appropriate time.

A significant increase in funding for the health services has been achieved in recent years. We are continuing to deal with a growing and ageing population, more acute health and social care requirements and increased demand for new and existing drugs. Sláintecare gives us a new roadmap to support the delivery of high-quality care to our citizens. This year is the first year in which the HSE’s national service plan has been developed based on the new Sláintecare implementation strategy.

I thank the Minister for his statement. I call Deputy Donnelly first.

The Minister is very welcome. I would like to discuss many issues, including the national children's hospital and the provision made for it, Sláintecare and the urgent issues of recruitment and retention. CervicalCheck is another large and pressing issue. When we received the further Revised Estimate, I searched it for allocations for CervicalCheck. There are 80,000 women waiting up to eight months for test results and there is an indefinite delay in HPV tests. I expected to see an additional provision or a figure carried forward from last year to account for the additional cytology required to move through this urgent backlog and provide additional colposcopy capacity when the backlog moves through cytology because obviously there will be increased referrals to consultants. I will begin with the genesis of the backlog and the need to make financial provision to address it this year. The HSE says that two thirds of the backlog and delay to the HPV test are due to the blanket offer of the free out-of-cycle smear test for any woman who wanted one. Responding to a parliamentary question, the Minister informed me that neither he nor his officials received any advice against such a decision before the announcement was made. In the past two weeks, the committee received evidence from Dr. Gráinne Flannelly that such an offer would fundamentally undermine the programme.

We are discussing the Estimates. While it is legitimate to raise CervicalCheck in that context, we need to concentrate on the Estimates rather than the issue of advice.

That is correct. I want to explore the information given to the committee on the decision that led to the need for provisioning to deal with the backlog.

I am very happy to deal with that.

The Minister will be aware that Dr. Flannelly submitted to the committee recently that advice was offered and received by the Department indicating that the offer would fundamentally undermine the programme. This suggests that the Minister's response to my parliamentary question was not true. The Minister stated that any advice he received was significantly after the decision. However, evidence from Mr. Tony O'Brien that he asked the Minister to walk the decision back the following day suggests that the Minister's statement in that regard was not true either. The Minister also stated that the chief medical officer supported his decision. Evidence referred to by Susan Mitchell in the Sunday Business Post just three days ago that the chief medical officer supported a much more targeted approach suggests that statement was not true.

The committee has mounting evidence from multiple sources that the steps the Minister announced were advised against before the announcement, at least to a principal officer in the Department. Moreover, advice against this was received by email from the national screening service and from the director general of the HSE immediately after the announcement. Such advice was also given repeatedly in the months after the announcement. The evidence suggests that the Minister ignored all of that advice, and this has led to the delays in testing and in the introduction of the human papillomavirus, HPV, test.

We need to provision for this and there do not appear to be any provisions in these Estimates. As such, would the Minister like to correct the Dáil record? Given the evidence that the committee has received, it is difficult not to conclude that the committee and the Dáil have been repeatedly misled on the decision to offer a free out-of-cycle test. We now need to provision for that this year. Would the Minister like to take the opportunity to correct the Dáil record on that issue?

I would like to take the opportunity to correct Deputy Donnelly, because I have been listening to these false political charges for quite some time. I have also listened to the patient representatives, including Ms Vicky Phelan, Mr. Stephen Teap and Ms Lorraine Walsh, asking this committee to focus on the more important issues of the present for now and stop focusing on the past and playing politics with the issue. I have also been listening to people who are regularly quoted in this committee as experts on general practice, like the president of the National Association of General Practitioners. As recently as 8 April, he said that while he would be the first to criticise me - which is true - he believed I made this decision in the belief that it was the right thing to do given the situation at the time. I was in CervicalCheck headquarters as the phones were hopping with patients looking for repeat smears. At that stage women had only two options; they could pay for a private smear, which at about €120 is something a Deputy could afford, or they could do nothing. Many women were paying for a private service and a two-tier system was developing. GPs were put in an impossible position as women requested repeat smears. No woman was refused a smear. If a woman was refused a smear, confidence in CervicalCheck would have dwindled further.

I would like a little bit of time on this, if the Chair does not mind. The committee obviously held an entire meeting on it last week at which political charges were levelled. I was not present or invited to attend on that occasion. I made the decision and I stand over it. I made the decision consistent with the advice of my chief medical officer and no evidence has been produced to suggest that I did not. In fact, a letter to was sent to the Ceann Comhairle in February in response to the assertions of Deputy Donnelly's party leader, not from me but from my Department. It said that my decision and announcement on 28 April was consistent with the advice I received from my officials. Moreover, the letter said that the advice I received from the chief medical officer was reflected in the press statement on the issue on 28 April.

I wish to deal with that issue and the issue of the CervicalCheck screening service advice. I worked hand in glove with the chief medical officer, who showed extraordinary leadership at a time when many clinicians walked off the pitch. Dr. Tony Holohan worked night and day on this. Members have even seen my text messages in the newspaper, released under the Freedom of Information Act, which show how much contact we had. Dr. Tony Holohan's advice to me has been confirmed by my Department in a letter to the Ceann Comhairle and by me in answers to parliamentary questions asked by Deputy Donnelly and his leader in February and March. The advice was that this was an appropriate thing to do. It was absolutely an appropriate thing to do where a GP believed it ought to be done. There was no difference on that. We can reduce this to tweets and quote my tweets and those of others if we want. My tweet said that details would follow. My Department also tweeted that - these days Departments tweet too. About 20 minutes later a press statement from my Department followed. There was no difference in opinion between my chief medical officer, my senior officials or myself. We all believed at the time of a major public health crisis that this was the appropriate thing to do. We were hearing directly from GPs and from women. I am sure Deputy Donnelly was too. My inbox was full of constituents who wanted to know if they could have a repeat smear. Doctors wanted to know as well.

It is fair to say that at that stage I could not have known how long that period of uncertainty would last. Nor could Deputy Donnelly or anyone else. In fairness, I acknowledge that we all worked together on the terms of reference for the Scally report. We expected that report to be published in June. This decision was made at the end of April. When the Scally report was released it provided significant reassurance, but because of its comprehensive nature it did not actually issue until September. There is no doubt that the window of worry and concern was longer than any of us would have liked.

As for CervicalCheck management and what advice its members offered, in reply to a parliamentary question as long ago as 12 March 2019, I told Deputy Donnelly "Neither I nor my officials received advice that recommended against these tests in advance of the decision". However, in that reply to a parliamentary question I also stated:

Subsequent to the decision, on foot of telephone contact by the Department, the National Screening Service raised a number of concerns verbally. Following the announcement, the Screening Service set out concerns in an email to my Department, which related to uncertainty about costs, volume, impact on turnaround times, impact on perceptions of the programme's accuracy, challenges with processing GP payments, and the potential difficulty in ceasing the arrangements in due course.

The Taoiseach said the same on the record of the Dáil.

I was delighted to give the committee the email this morning. I have no issue whatsoever with doing so. The email came in at 5.59 p.m., after the decision had been made.

The email notes that the national screening service takes direction from the Department. I make policy decisions. I own this decision. I believe it was the right thing to do and I have 110,000 reasons to believe as much because 110,000 women saw their GP in seeking reassurance. Only 57,000 of them actually opted for the repeat smear, which shows that GPs did their job. I do not believe that any woman needed direction from me on the appropriate thing to do for her healthcare. However, what women needed from me was not to be insulted by being forced to put their hands in their pockets because of this situation.

The advice was not received by my Department in advance of the decision. The chronology is very straightforward. We make the decision as a Department. I made this decision and I own it. I will stand over the decision. While one would not do this in normal times, these were exceptional times. That decision was then conveyed to the screening service and what we would do was outlined. The screening service outlined some of the risks after the decision was made. Of course there were some risks but they were all readily identifiable. One risk concerned how GPs would be paid. We sorted that out. I thought the risk that it could potentially undermine further confidence in the programme was somewhat ironic. The way in which CervicalCheck had been managed, the audit had been handled and Vicky Phelan had been treated had already undermined the confidence in the programme.

The national screening service did refer to the additional impact this would have on lab turnaround times. This was inevitable. I have spoken to so many women, as I am sure Deputy Donnelly has. They were going for repeat smears anyway. People, including women we all know in our own lives and communities, sought that assurance. Until the State could say that its screening service was safe they would seek that assurance. I did not mislead the Dáil. I took this decision for good reasons after hearing from GPs and women. It was consistent with the advice of my chief medical officer and my senior departmental officials, as the Department confirmed in writing to the Ceann Comhairle of this House as long ago as February. I have never hidden from the fact that concerns were expressed after the decision was made. I have outlined the content of those concerns in answers to parliamentary questions. I am happy to give the members physical copies of the email. I have them here and can circulate them.

I have said I made mistakes around CervicalCheck. There is no doubt about it. Fortunately, others have not. Dr. Scally talked about the frenzied political and media environment. I am possibly the only person involved who has suggested that I made some mistakes and would like to do some things differently. However, this was not one of those things. This was far from ideal. It has absolutely resulted in a very significant increase in smears. It has resulted in a backlog. As the Deputy acknowledged, that is not exclusively made up of new women entering the programme, but I accept they do constitute about two thirds. That is a statement of fact. I want to focus on reducing that backlog.

Women were going to seek the repeat smear regardless of whether the test was free. For me the issue was to support GPs who wanted to know what to do if such women turned up. No matter how many times I am asked this question, my view on this will never change. I lived the CervicalCheck debacle 24-7, working intensively with my officials, who worked so hard and showed real leadership. This was seen as an appropriate thing to do. It absolutely would not be appropriate in normal circumstances but we were not in normal circumstances. We are now looking back from higher terrain, with the benefit of hindsight and different views. Some Opposition spokespeople have said that if they were Minister, they would have done exactly the same thing. Others welcomed it at the time and now say I should not have done it. Others criticised CervicalCheck management at the time and are now quoting it as the font of all wisdom. People can do what they want in that regard. I stand by the decision. I own the decision and I am responsible for the decision.

I thank the Minister. He said he wanted to correct me but Dr. Flannelly's advice was given before the announcement. Mr. Tony O'Brien talked to the Minister the next day and asked him to walk the decision back. There was a world of difference between what the Minister offered and what was subsequently pursued, which was an approach with much greater caveats. My understanding is that the chief medical officer did not support a blanket offer under any circumstances, but supported a much more-----

How did I make a blanket offer?

That is what the Minister offered publicly.

The reality is that expert clinical advice was given. Expert clinical advice was ignored.

Regardless of what happened during that weekend, because it was a very busy one, the reality is that once the delays, as predicted by CervicalCheck, began to mount through the year, the Minister was contacted by the laboratories, CervicalCheck, oncologists and a variety of people asking him to stop the test. The Minister continued with the test through the year, and today we have 80,000 women waiting, an indefinite delay to the introduction of the HPV test, and we need to provision for that, which is what this meeting is about. Given that the Minister says he accepts responsibility for his decision-----

-----given that the committee has multiple documented evidence that he was advised repeatedly to stop the test because of the delays it is causing, and given he has admitted that was his call, will he apologise to the 80,000 women who are waiting up to eight to nine months for those test results and to the many more who are waiting for the introduction of the HPV test?

I significantly regret, as I am sure do the members, that women are waiting. How we work to resolve that is what I would like to discuss in a moment, following on from the HSE's contribution to this. The Deputy may be asking me whether I wish I had made a different decision. I do not believe it was possible to have made a different decision. Women and GPs were seeking this. The Deputy keeps saying expert clinical advice was given. My expert medical advice is given to me by the chief medical officer, a man who showed extraordinary leadership in this situation, after the failure of others, the mistreatment of Vicky Phelan and the appalling decisions made, namely, that if a woman dies, just stick a note on her file and do not tell her husband. These decisions were made by people carrying out a botched audit. Dr. Tony Holohan stood up to the plate. He is the person from whom I was taking my advice.

It is down the road - the advice from the chief medical officer.

The Deputy is suggesting-----

I am not suggesting. I am asking the Minister a question.

Allow the Minister to respond.

The Deputy is speaking for my chief medical officer somewhat, suggesting that my chief medical officer gave different advice from what I advised the public. I did not.

I am not, to be clear. I am saying that Susan Mitchell, in an article on the front page of The Sunday Business Post, directly makes that allegation.

She does and she makes it based on reading a tweet I issued and what I was actually offered. My tweet stated that we put a facility in place and that arrangements would follow later. About 20 minutes later we issued those arrangements via my Department's Twitter account and via a press release.

That is fine. That is what Susan Mitchell is saying.

I and the chief medical officer were ad idem on this issue, just to finish that point.

In the interest of saving time, the question I am asking is-----

The Deputy is 15 minutes into his contribution.

I will finish on this point and then we will come back to the Estimates. The direct question I put to the Minister is that he has now accepted responsibility for the decision he made. The committee has multiple documented evidence that there was expert clinical advice given to the Department before the announcement and that the director general of the HSE advised him to walk back the next day but, more importantly, as the year progressed and the delays mounted, he was contacted directly from multiple sources to ask him to stop the free test, he refused, and we now have 80,000 women waiting up to eight months and we have many women waiting for the introduction of the HPV test. Given that the Minister accepts responsibility, will he apologise to all those women who are now waiting because of the decision he made against all of this advice?

The Deputy is trying to conflate issues and say I made a decision against advice. I made a decision to do the appropriate thing that I was requested to do by GPs and by women at the height of a crisis, and that decision, I believe to this day, was the appropriate decision in a crisis. I regret extremely that there are women waiting a long time. That is why we have been working night and day with the HSE to source additional capacity. This committee heard very clearly last week from Damien McCallion, another person who has worked tirelessly through this time, about the efforts of the HSE to identify additional capacity, and it has done so. This week, as we are speaking, quality assurance and negotiations are going on regarding bringing that extra capacity on stream. If - I can only say "if" at this moment because I need hear back from the HSE - we can get this capacity on stream, I expect the backlog to be significantly and overwhelmingly reduced during the summer months. That is what my focus has to be on. The Deputy is not suggesting this, in fairness, but obviously we have different turnaround times in different laboratories. Some of our laboratories are turning around these tests in three to four weeks, some in six to seven weeks, and in the case of one laboratory, there is a very long wait. Of that there is no doubt.

The clinical risk, because it is important for women watching these proceedings outside the politics of all this, we are told by people like Dr. Peter McKenna is negligible and very low, but that does not mean it is not stressful for people waiting. I fully accept that. We will work night and day to resolve this situation. However, I believe, and I think many women believe, that in a crisis they did not need any politician to tweet or to make any decision. They were going to seek reassurance themselves with their doctor. The question was whether I made them pay for it. I felt, after the significant disrespect that had been shown to women in terms of how the audit had been carried out, that the appropriate thing for the State to do was to fund this. What I will do and what I have asked the HSE to do is to keep this committee very closely apprised, and I would welcome the members' co-operation in terms of working as we try to bring this extra capacity on stream. I know that is what we all want and I am hopeful that we can see progress in that in a very short period.

I thank the Minister and Deputy Donnelly for that. I call Deputy Jonathan O'Brien who is substituting for Deputy Louise O'Reilly.

I will probably go off script a little in terms of the previous speaker. This is my opinion. I believe what people, GPs and women were looking for was a repeat smear test. I do not believe that was the issue. That was not the failing. The failing was doing what the Minister felt was appropriate but not knowing whether we had the resources to fulfil that commitment. Perhaps that is where the failing was - not so much in the decision but the fact that the decision was made. I am not questioning the decision. It was the right decision, but were there any discussions around whether we had the resources to commit to what we were providing?

I thank the Deputy for the honesty of his assessment that he, his party and many people felt that this was the right decision to make based on what women wanted and needed at the time. I accept that. I also accept fully that the challenge has been the fact of the impact this has had on capacity. Being very truthful - I believe my officials have said this previously, as has the HSE - and it is the absolute truth, it was impossible to estimate how many women would seek this, and there were two reasons for that. First, this was a very personal decision a woman needed to make with her doctor. We saw that 110,000 women went to their doctors under this provision and 57,000 decided to go for a repeat smear test. Second, and I am being very honest, one of the reasons we have found a particular difficulty is that the period went on for longer than I would have liked. That is not a criticism of Dr. Gabriel Scally. He has done an incredible job. Because he was doing such an incredible job, we had hoped as an Oireachtas to get his report in June, but he asked if he could carry on until September. There was a longer period of time before I was able to turn off or pause the decision, so to speak.

In October, I received a submission from my Department indicating we had Dr. Scally's report, that it provided good reassurance for the women of Ireland that the screening service was safe in terms of the laboratories we use, notwithstanding the shortcomings, and that I should communicate to the HSE my intention to end the free repeat smear test, and we did that. I accepted my officials' advice in full. We communicated that to the HSE which operated it, and it said that while the decision was accepted, because smear tests and the likes were booked in, it believed it should operationalise that decision at the end of December. It is important to point out, and I believe the Deputy has acknowledged it, that these were decisions being taken in real time. The worry was real, live and present. Women were going to their doctors wanting to know what they could do. The phone line was up and running, women were ringing the phone line asking if they could have a repeat smear test. GPs were asking how they could tell a patient she had her smear a year ago and that she had to wait another two years. We were putting immediate steps in place to make arrangements with smear takers. The Irish Medical Organisation, IMO, negotiated the fee as a GP representative organisation. The president of the National Association of General Practitioners, NAGP, welcomed it as being the right decision. We did not have the opportunity to do that level of screening. I accept that as a criticism but I cannot see how it could have been done differently considering the crisis we were in.

It is not so much a criticism but more an observation that this is the reason the backlog exists.

I accept that.

Can I move on to the children's hospital, and before the Chairman decides it is not within the scope of the Estimates-----

I believe it very much is.

Yes, it is. I have a few question on it. I recognise the Minister has asked that the Government would be given a number of weeks to assess the report, examine the recommendations and decide how to proceed.

I would like to discuss a number of recommendations with the Minister, however. I would first of all like to go back over some old ground and set it in context. The PwC report was very clear that the establishment of the National Paediatric Hospital Development Board, NPHDB, put all of the eggs in one basket. If there were successes, than there was one success but if there were failures then there was one point of failure. That was the reason that the two additional monitoring groups were set up, the steering group and the programme group. We know the terms of reference but who made the decision to appoint individuals to those monitoring groups?

Those decisions were made by the Government as part of the decision to proceed with the large part of the project. There would have been consultation with my Department and the Department of Public Expenditure and Reform and then a decision was made by Government.

There were political appointments to those groups.

Yes, that is correct. The Government approved the structures. I know Deputy Jonathan O'Brien does not mean it like this, but the people on those groups were officials in the Department and not political appointments. The Government did make the decision regarding the composition of the working groups.

Does the Minister believe the terms of reference for those groups were limited? The report states that the groups did not have the ability or the experience to question some of the decisions being taken. The groups could only monitor the information provided to them. If that is the case, does the Minister think that was a failing when the legislation was being developed and the terms of reference for those monitoring groups were drafted?

I want to establish the issue we are discussing today. I know the Minister is happy to respond but as Chair I need to state we are here to discuss the Estimates. There is of course a reference in the Estimates to the revision of the capital allocation to health. It is fine if the Minister is willing to answer those questions. I just wanted to establish that.

I thank the Chair for his clarification and fairness. I am more than happy to answer the questions, however, and I would not like to leave the elephant in the room regarding the national children's hospital. It is a large amount of public expenditure.

Regarding Deputy Jonathan O'Brien's question, a decision was made in 2007 to set up a National Paediatric Hospital Development Board. I cannot speak for my predecessors, but it was a decision I re-endorsed so I can speak to the rationale. It was that this was such a large project, on a mega-scale, that no Department in the public service would necessarily have the capacity to deliver it. The sensible thing to do then was to bring in the experts and appoint a competency-based board. That was done.

As we neared the bigger stages of the project, the major construction stage, Deputy Jonathan O'Brien is quite correct that the Government decided that there was more involved than just building a hospital. We were constructing a building but also integrating three hospitals, setting up an entirely new entity and putting in a new IT system. There were many different moving parts in the project and there needed to be a structure to oversee what was happening. The Government approved that structure. I am not going to give a definitive answer on this issue today, other than to say there is no doubt that the governance structures will need to change and will need to be strengthened. The report does not find, however, that there should be a clear-out of the board. Deputy Jonathan O'Brien has not suggested that it does. In fact-----

The report recommends against that.

Exactly. It specifically recommends against that course of action. I am paraphrasing but in auditor-speak it states that if we were to do that, we would lose so much corporate memory that we could jeopardise the project. The report does, however, state that I need to strengthen the board. Auditors are not brought in if everything is thought to be going great and if the recommendations are not going to be accepted. I will be working on the key areas.

That is one of the questions I was going to ask. The report states the Minister should not have a complete clear-out of the board because it would lose that corporate memory. It also states, however, that the Minister needs to strengthen the board by adding expertise and competency to the board. How does the Minister propose to do that given there is only one vacancy on the board at the moment? People will have to be moved aside in order to bring that expertise onto the board. Is the Minister willing to do that?

I am willing to do whatever I believe it takes but that is not my initial thought. My initial thoughts are that the statutory instrument gives me the power to alter the size of the board and to add people. While I have not made these decisions less than 24 hours after the publication of a report, I can state with certainty that I will be strengthening the board, particularly in the areas the PwC report has identified should be strengthened. The whole area of health construction is one that has been highlighted and that I need to respond to. I will be strengthening the board and I expect that will definitely mean additional members. My understanding, from advice, is that I have the legal ability to do that through the statutory instrument. I also have, as Deputy Jonathan O'Brien rightly states, a vacancy on the board at the moment. It is important to state that the chair of the board, as the Deputy knows, is brand new to the role as well. There also will be a new project director because that individual has also announced, previous to this report, that he is intending to step down.

My short answer is I will be strengthening the board. I also expect we will be changing the governance arrangements. I, the Minister for Public Expenditure and Reform, Deputy Donohoe, and our Departments need to do some work on that aspect. The Government has, however, accepted all 11 recommendations. Let there be no ambiguity about that. We have to operationalise them now and come up with a detailed implementation plan. I welcome input from this committee in that regard and I also propose to meet the authors of the report. It is possible to read a report - and I have read this report several times - but also very useful to have the authors talk me through it and scrutinise some of the lines and what was behind them in respect of what the authors think I should do next. I will also meet Mr. Fred Barry in the coming days, as chair of the board, to get his sense of what further skill sets can help the project.

To whom was the steering group responsible? I am referring to the information passed by the development board up to the steering group. Where does it go after it reaches the steering group?

Does the Deputy mean the group chaired by the Secretary General of my Department?

The Secretary General of my Department reports to me and he kept me briefed at the appropriate junctures. I published all of those documents in advance. The good news is that the PwC timeline tallies with that. There are two interesting points in the report regarding the governance issue. One is that while it states the governance structure was complex, it also states that it did not impede information flow. The report does not seem to be suggesting to me that that caused that problem.

Crucially, however, there is a line in the report that is very important about the role of my Department and the HSE. I suppose it concerns the Government as well, although it does not name the Government. The report states that the Department of Health and HSE were "impaired", that is the word used, from doing their job because of some of the mistakes or errors made in arriving at accurate figures. A person in government, a Secretary General or someone in the HSE, whomsoever it might be, depends on accurate information from professional firms. I do not want to name individual firms but we hire-----

And timely information.

Yes, that is correct. I do not want to name them here. Even though we have privilege, I am conscious the board will have to consider all of these matters. We depend on professional expertise to give accurate, factual information. We hire such firms because we do not have the expertise ourselves. We can then scrutinise them and bring in other people and other experts to look at that information again. It was clear in respect of the national children's hospital project that the business case was not just flung on my desk and I brought it to Government the next week. It went through a very deliberative and intense process.

It now appears, however, that some of the information we were given appears to have been fundamentally wrong. When this issue was at its height, I heard the Taoiseach ask if this was a case of taxpayers' money being wasted or was it that the project was always going to cost more and we were given the wrong figures. The PwC report has largely come down on the latter view. It found that there was not a massive waste of taxpayers' money. There was, however, a significant error in calculating an accurate cost. That is astonishing when we depend on such experts.

I agree with the Minister. Where we have a difference of opinion, and where I have a difficulty, however, is that the Minister appointed the board.

The Minister put that expertise on the board. That board was tasked with the responsibility of bringing this project to fruition within budget. If there were failings of the board, then those have to be laid directly at the feet of the Minister. I do not know if the Minister accepts that responsibility and those failings. I am firm in my belief, however, that the political accountability for the failings lies at the feet of the Minister. Does he accept that?

I accept responsibility for the challenges with this project. I will explain why. If I was coming in here today and the project was ahead of schedule and €200 million under budget I would be taking credit for that, and so would the Deputy if he was the Minister. The good has to be taken with the bad in government. We put experts in place and so did my predecessors. They were good, decent hard-working people with expertise. Something clearly went wrong. The PwC report has given us an indication of where that might lie. The board needs to reflect very seriously on that, including on the contracts it may have had.

This is the board-----

I appointed the board and I accept the responsibility in that regard.

While we are on the issue of political responsibility, I have to make the point that I had to make a major political judgment call in December with Government colleagues. I was given three options, namely, to proceed, retender or pause. They were the three options I was given.

The Minister did not really have an option.

I considered them-----

Let us be fair. The report was very clear. The Minister did not have an option at that stage.

The Deputy is an honest enough person to say that, but there are other people in this House, and let the record show it clearly, who said, if not in this committee room then certainly on the floor of the Dáil, that I made the wrong decision. They said I should have paused it, retendered it or moved the site. We have brought in financial auditors who found that the Government and I did make the right decision. The Deputy has to take political responsibility in the round.

The difficulty is that by the time the Minister was in a position to make that decision, it was too late to do anything else because of the failings that had happened previously.

That is correct, so-----

We could have retendered at an earlier stage if we had been aware of the issues that were coming down the line.

Certainly-----

The big issue for me, and it is nothing personal in terms of the two people sitting on either side of the Minister, is that, to the best of my knowledge, both Mr. Desmond and Mr. Breslin were on the steering committee. They became aware in April that there was an issue with a potential cost overrun. Ms Tracey Conroy asked for a memo to be sent to the Minister in, I believe, May. That memo did not reach the Minister until August, yet the board was reappointed in June. I do not know if Mr. Breslin or Mr. Desmond want to answer this question, but one of the questions I have is why those issues were not brought to the Minister's attention knowing that the board was being reappointed in June and that there were issues that had not crystallised but which we knew would arise in regard to cost overruns. There was a request by an official in the Minister's Department that a memo be sent to him prior to the reappointment of the board. That memo was not sent. The Minister went away and reappointed the entire board. He did not ask any questions of the board because he clarified that in a reply to a parliamentary question. A request was submitted and he decided that he would reappoint the board members. There were no questions asked and progress reports were not requested, yet Mr. Desmond and Mr. Breslin were both aware of the position. I accept they would not have been aware of the extent of the overrun at that point but they would have been aware that issues were coming down the line. Why did Mr. Breslin and Mr. Desmond not convey that to the Minister given that one of their colleagues had asked for a memo to be sent to him?

In fairness to my officials, because it is a select committee-----

On the Deputy's last question, the Minister is the only person who can speak this morning.

I understand that.

That is the way it should be. I am accountable to the Oireachtas and my officials are accountable to me. I am satisfied that my officials behaved entirely appropriately during this and the reason I am satisfied is because the PwC report does not find anything to the contrary and actually finds that their work, and this is my clear interpretation of what it found, was impeded and impaired as a result of some of the failures that happened - let us call it - further down the line.

Regarding the National Paediatric Hospital Development Board, and in fairness the Deputy raised this a number of times before the PwC report so he has a consistent record on this, which I acknowledge, the PwC report finds that a changing of the board could have caused a bigger problem, so the right decision was to reappoint the board. The question I am asking, and I am asking it now as opposed to answering it but I will be asking it of Mr. Barry and considering it with the Minister, Deputy Donohoe, and I will be reporting to Government in due course on an implementation plan, is about the information the development board received when it hired quantity surveyors who hired other people to cost the project. On page 4 of this report PwC finds that there were - I have to be careful with my words - very peculiar ways of going about some of the business there that did cause difficulty. There is quite a detailed chapter that shows that as well.

I accept the bona fides of my officials. Nowhere in the report does it suggest that there was a difficulty with information flow. In fact, it actually states: "Despite the complex governance structures there was not an issue with information flow".

Despite all of that, and this is my final comment, we had an official from the Department of Public Expenditure and Reform sitting on that particular board. That raises even more concerns for me given the position he held within the Department of Public Expenditure and Reform and what this report states in terms of the information that was coming forward to the steering group and the ability of the steering group and the programme group to act on that information. The difficulty is that we have a board which, in my opinion, this report questions in terms of its capability. That is my reading of the report. We have a situation where we need additional members and additional expertise brought in and the difficulty is that people do not have confidence in the current board. I certainly do not have confidence in the current board given what I have read in the report. The report also states that we can have a widespread clear-out, but the question is how that is managed and how we regain that credibility in the development board without having a complete clear-out and leaving in place some of the individuals who were directly responsible, in my opinion, for some of the failings and the fiascos we face.

Just as I accept political responsibility, as does the Government, the board members have to accept responsibility, which I am sure they do, for the decisions they made. The report is clear, and I agree with the Deputy on this point, that the governance structures need to be strengthened. The board will need to be strengthened and I will act on that as well.

There is also an interesting and important recommendation in the report - I believe it is recommendation No. 11 - about the need for Government as a whole or the public service to get a challenge function for future projects. We are building a children's hospital. I want to build a new national maternity hospital. I want to start that later this year. The Government will want to do the metro project and, I hope, broadband provision. There will be other major projects, and what the report is suggesting, and the good thing about bringing in orders is that they are meant to show us how to improve processes, is that we need to create a more proactive, challenging structure and that we need to have the expertise.

I will give the Deputy an initial view. Since the establishment of the HSE, my Department does not have a building unit. I have a chief medical officer - we have been talking about him - a chief nursing officer and a chief dentist. I am sure I have a chief of other things as well in the Department of Health. I do not have somebody who is a chief construction officer or who can give me an expert view on quantity surveying, QS, and the likes. Perhaps having those functions available would help provide a further layer of scrutiny and challenge. We need to reflect on that. There is a need to strengthen the skill set further in my Department and in other Departments. That is not to be disrespectful to anyone in the Department.

I and the Minister, Deputy Donohoe, will take the four weeks. We would welcome the committee's input and we will be back to Government, ultimately, to publish an implementation plan-----

We may not have that expertise but we have a building control policy framework. We have many layers of oversight outside of individual Departments.

Of that there is no doubt, but how we strengthen that is the question for us all.

This is an unusual appraisal of the Estimates in the sense that two issues seem to dominate the agenda. I point out that we need to examine the rest of the agenda as well because it is a very important and expensive budget and one that has required further attention as the year goes by.

To dispense with the other two subjects first, when we have the benefit of hindsight, we generally are correct in everything. It is a case of 20-20 vision afterwards. However, we should remember one thing about the cervical smear tests. It was not the greatest day in the delivery of services to the women who tried to avail of those services when it transpired that some of them were not told the outcome. At one stage somebody said there should be a pause and their health suffered. A considerable number of women still have not had their issues resolved. We tend to dismiss the seriousness of that with the passage of time. I have no doubt that the obvious thing to do was err on the side of safety and take whatever steps had to be taken to ensure that reassurance was given to all the women who wanted it - the counselling and the GP service - and on the basis of that advice either to have another test, which many of them did not have, or not have one. That was the right decision and milling around with it afterwards is playacting. We can spend the next 12 months doing that but it will not change the reality of the issue, namely, that there were serious problems, some of which still exist in regard to the speed with which tests are carried out and in regard to the various laboratories. This was an appalling thing to happen and it should have not happened, but we must remember that that system was not put in place last month or last year but several years ago.

Some of us did not think it was very wise at the time, but it was there and it did serve its purpose in the sense that it did save the lives of many women. That has already been illustrated again and again. It is a bit like the Minister taking responsibility for the bad news and the good news. We in the House, in general, have to do the same thing. It did address the issues in so far as many women were concerned in general. We know that it was not an accurate diagnostic procedure. Notwithstanding disclosure decisions, full disclosure still does not seem to take place. I cannot understand why that is but that is a matter for another day. Ultimately, in the courts evidence emerged to the effect that there was a considerable neglect of the procedures that should have taken place in the interests of health and safety and of women who were the subject of particular tests. It would be totally unacceptable if anything other than moving everything that could be done to ensure that those women who still have a question mark in their minds over their health should be reassured because the panic causes other problems as well for women. I am weary of listening to the same story over and over again. We need to improve the quality and veracity of the tests and the speed with which the results are obtained but going back over what happened in the past 20 years will not solve that problem. We all should recognise that the extent to which women were traumatised and women's health and lives were put in jeopardy was totally unacceptable.

I do not wish to continue for as long as my colleagues, which is not to suggest for a moment that they should curtail their outbursts in future. I will, however, try to deal with the children's hospital insofar as I can. One of the issues I raised in the committee at the very outset is that there was a number of boards sitting in parallel, as it were. I was not satisfied that the degree of discussion between those boards was adequate, and I am still not satisfied that is the case. The fact is that in a project of that size when one has a number of bodies all dealing with the same project and all, hopefully, going in the same direction, there needs to be a common membership, which is not the case. That is my opinion; it is not an expert opinion. With common membership then the various parts of the jigsaw, as it were, are all alert to what is happening all of the time.

There has been misleading information throughout the entire debate. I have not seen the PricewaterhouseCoopers, PwC, report at all and I have not read any part of it. Unfortunately, I had other things to do as well in recent days, as I am sure everybody else did. I believe the original estimate of the cost was wrong. It did not take into account the magnitude of the project and therein lies a flaw in the system. When any other projects are being undertaken we need to know the cost at the very beginning. There are prime cost, PC, sums added in all construction projects that would enable the committee, the Minister, the HSE or whatever the case may be, to come to a conclusion if something is going in the right direction or something is going wrong. It would appear from what I have heard of the PwC report that issues arose that should and could have been nobbled at a much earlier stage. What would happen as a result of that is another thing. It might well have brought a halt to the entire project, and I am not so sure that would be a good idea.

This is the second or third attempt at providing a children's hospital, site-wise, and in every other way. An attempt was made previously to superimpose it on the Mater Hospital but that did not work. There was much debate about it at the time but An Bord Pleanála made the decision in the end. A lot of money was wasted. A lot of money was spent on that particular endeavour. I asked questions at the time about whether the initial expenditure could be of benefit in the subsequent sites with a view to using whatever information we had gleaned from the first episode but it did not happen other than to a small extent.

We must make another decision as well. An attempt was made by the board and the HSE to curtail what looked like an overrun in comparison to the original estimates but at that stage it was probably too late. It would have caused a major hiccup and the project to be abandoned. That would not be in the interests of anybody, certainly not the interests of children or value for money, which is something with which this committee does not deal and nor should it, as we have a policy role. I cannot understand how it transpired, if a quantity surveyor's report was available at the very beginning, that the estimate for the original costing emerged, based on the information that was available at the time. Perhaps we could get more information on that.

Perhaps Deputy Harris would like to comment.

I thank Deputy Durkan. I reiterate that that was the basis on which I made the decision for the repeat smear test, namely, to endeavour to provide reassurance women were already seeking. Whether I issued a press release or did it or not, they were going to seek reassurance because women make their own decisions about their own healthcare. I thought that was a place we had moved to in this country and it was a good place in which to be.

I am pleased Deputy Durkan mentioned open disclosure because it is something on which we can all agree. At the heart of the CervicalCheck debacle was the failure to openly disclose. It was about non-disclosure. We are now legislating through the patient safety Bill, which the committee has considered at the pre-legislative scrutiny stage. The Bill is on the Government priority list and will legislate for mandatory open disclosure for serious reportable incidents.

Deputy Durkan made some valid points about governance. As I said to Deputy Jonathan O'Brien, there will clearly be a need to strengthen the governance. Of that there is no doubt and the report is very specific in that regard. It also talks about the need for closer alignment, as we move closer to the opening of the project, between the Children's Health Ireland board, which is the group within the health service that will run the hospital and the build board, the National Paediatric Hospital Development Board. That becomes all the more important when we consider that the Connolly part of the hospital will open this year. We are still having a debate in the Oireachtas about whether it is the right site and other such matters when the Connolly part is opening and the St. James's part is well under way. There are approximately 400 people working on the site and more than €200 million has been spent. How I square that circle in terms of recognising that they both have separate functions and roles with the view of PwC that there needs to be closer alignment between them is something I will reflect on in the coming weeks.

Reference was made to cost reduction. I acknowledge that Deputy Donnelly asked that it would be included in the terms of reference and it was specifically included at his request. The report is clear that the opportunities are limited. On page 6 it states that the cost reduction opportunities are limited because 85% of the budget is already contractually committed, which suggests that the focus of the board should now be on reducing further the risk for additional costs at this stage. That is where I hope its focus will be. It does say that there is a technical possibility of reducing some costs but they would need to be offset against any risks. When I meet Mr. Barry I will ask that the board formally consider that and give me its view in relation to that.

The other point I raised was the relationship between the various levels of management. I know the Minister referred to governance. I believe the linkage between the people with responsibilities was inadequate. How they were brought together and how often they meet are questions about which I automatically have concerns. I put that question to them previously and some of those present as well. The answer was to the effect that they were kept up to date but it sounded like it happened on a monthly basis, which is not nearly enough for a project like this. These things shift very rapidly and things can change suddenly. Waiting for a monthly meeting at which one updates one's colleagues about something is not the way to do it. In some cases, it could be more than a month. It could be two months depending on the time the meetings took place. I am not sure if the Minister wants to address that as well.

Regarding future overruns, if we are dealing with a quantity surveyor's picture, we should know fairly well where we are going early on. The extent to which future overruns can take place must be minimised for a range of reasons. If there is some mystery about what the future holds for us in this scenario, it is dangerous. Notwithstanding the PwC report and its benefits, which we all accept, unless we have found a way to ensure that the contract prices we are now looking at are stable, will remain stable or will escalate, we will all be at fault because it could be alleged at some later stage that we discussed this and something happened afterwards. I ask that this question be addressed in particular. I assume we did not get an accurate estimate of the quantities involved in the beginning. They were not available or we proceeded before we should have. We need to be far more accurate from now on when it comes to all the quantities involved and any changes that might take place. If changes take place, we need to know about that and for what purpose. Otherwise we could face another problem.

I very much take on board the Deputy's points and we will consider them in the context of our response to the report.

I thank the Minister for coming before us. I will start with the national children's hospital. I have not read the entire report yet but something in it under governance neatly sums it all up. The report stated that:

The level of trust that the National Paediatric Hospital Development Board (NPHDB) placed on the National Paediatric Hospital (NPH) executive and design team gave rise to insufficient scepticism and challenge. The structures above the NPHDB became reactive, limited by their terms of reference.

I have read the executive summary and the recommendations. The price is now reflective of the quality of the project and what is being put forward as to what is going to be above the ground. The Taoiseach said the report made for grim reading and I am sure the Minister did not find the report overly pleasant. The board was in place to be accountable to the taxpayers of Ireland. When we see fancy designs, and I mean this in the nicest way possible, and when we see big glass curvy buildings, that is just an architect's dream. That is when people with a specific remit, which is design, go down that route. Usually, in a project, there are quantity surveyors on both sides. A group of quantity surveyors acts for the client while another group acts for the builder and some other contractor. Somewhere along the line, it is decided to how much money will be spent on a metre of cable or whatever the basic product is. My interpretation of this is that it was almost free rein, there was no challenge to the design and, therefore, by the time the design was done and set in stone, it was too late to pull back. I believe the Minister made the correct decision. I know Deputy Jonathan O'Brien said he probably had no choice but to make that decision but, as Deputy Durkan said, this project was first mentioned in 1962. For so long, we have said that we are desperately in need of a children's hospital. The Minister made the right decision and it was the only decision to make. If he had made a different decision at the end of last year, this hospital would never be built. It definitely would not be built in my lifetime or his. Despite the political challenges, historic and current, and despite the hospital and medical politics and every other form of politics, delivering this will, hopefully, be key to what the Minister has done along with the rest of his achievements to date.

That does not take from the fact that for taxpayers and all of us, when there is a large sum and the report basically says that the people representing us on the board did not challenge, it is annoying. It is frustrating because it seems obvious that if we were talking about a big fancy curvy glass building, a quantity surveyor on our or the taxpayers' side would say, "Hold on now a second, is there a need for that many curves or that much glass or is there need for that much aluminium?" That is normally what happens. That is what people find so frustrating in light of some of the overruns in the past. They find it frustrating that it does not appear that the people we were paying - the quantity surveyors acting on behalf of the HSE, the board or the taxpayer who are, ultimately, supposed to represent good value for money - did this for us. What recourse exists when the State pays fees to a professional body to act on its behalf in an expert role and that body does not do its job right?

We have discussed CervicalCheck and the capacity issue for so long but, again, like the national children's hospital, it is worth remembering where CervicalCheck has come from. I imagine that the Chairman is very much aware of the pushback 15 years ago when cervical screening and HPV vaccination became possible. I remember a particular bishop in the south of Ireland suggesting that HPV vaccination or cervical screening would not be needed if women led pure and chaste lives so we have come a significant distance from that sort of rhetoric to where we are now. I think I am correct that as a result of cervical screening, 65,000 women have had issues picked up which required minor intervention up to and including invasive treatment. I think I heard the Minister say that in the Chamber. If the Minister who brought that in had not been brave enough to have done that back in the day, some of those 65,000 women would be dead while some of them would be incapable of having children or would have varying degrees of complexities as a result of no intervention.

There was commentary last week about suspending the system. There was a lot of discussion regarding other countries that ramped up capacity in cervical screening before they brought in HPV screening. I am not here to advise the Minister as there seems to be so many people who advise him, but given the amount that has been invested in cervical screening and the amount of personal capital invested by progressive Ministers for Health over the years, it would be the wrong decision to pull back in any way on a system that has had a positive impact on 65,000 women and the others who did not have a negative result.

I mentioned it here last week. We were operating in an information vacuum when it broke. We did not know who owned the slides and, in the immediate instance, whether they were in the custody of a laboratory. We did not know if it was a standards issue in the laboratory and what the reason was for the emerging cases. That caused huge fear, about which I have spoken and there is no need for me to repeat what I said. How does the Minister for Health reassure women and their families in some cases, given that there was destructive commentary from many sections, with people talking about a misdiagnosis and using terms that were not reflective of the situation? What is the best way to reassure them? Is it by sending them a note? Is it by putting an advertisement on television? Is it by running a radio advertisement on Newstalk? In the following week or two weeks, would it have been of any benefit to me or any other woman of my age to listen to an advertisement on Newstalk: "Don't worry women of Ireland. You are in safe hands. Cool off. There is no need to go to the doctor"? It is my personal view that neither the public health nurse nor the community pharmacist was skilled to deliver this reassurance. The only person who was capable of delivering it - with no offence to the Minister - was the GP. The Minister and I are not medical doctors. The level of reassurance required had to be given because we were in an information vacuum, something which seems to have been forgotten. Reassurance is sometimes very personal. If somebody had a history, including a family history, she might have needed a level of reassurance that was greater than that for somebody else. The Minister might speak to the reassurance issue.

On vaccines, what are we going to do about the massive drop in measles vaccination rates? We have been very successful with the HPV, with the help of Laura Brennan, the Department and various others, which has meant we have got the rate back up to over 70%. However, it is a little late when there are wards and isolation units full of children infected by measles, at which stage, it is out of control. We can have problems with Brexit and the national children's hospital, but if there is a measles outbreak where the patches and pockets join up across Ireland, we will have something far bigger than Brexit, the national children's hospital or whatever other issue with which we are dealing. Babies and those who are immuno-compromised will actually die, while children will be left with life-limiting conditions as a result of infections. We can spend all of the money we want on health services, but if the basic fundamentals of protecting population health are not maintained, there will have been a huge waste of money since vaccines were invented. I know that the Minister has a commentary in the newspaper today, although I have not yet read the article. He might speak to that issue in terms of how we protect the population and get value for the money we have invested. There would obviously be a massive cost if there was to be a massive outbreak of measles.

I thank the Deputy for her questions. On the issue of cervical cancer, it is something on which we are all united. We can effectively eradicate it. There are many diseases about which we cannot say this, but it is one we can eradicate. I used to refer to the huge progress made in Australia and New Zealand, but now I need only refer to Scotland, a much nearer neighbour. I was only reading last week about the huge progress it was making. We know how to do it. The one good thing to come out of all of this - we always want something good to come out it - is that it is now our national aim to eradicate cervical cancer within a generation. We know how to do it, namely, through HPV testing and vaccination and continuing to invest in screening. That is a very important point to make. I am very pleased that the Deputy acknowledged the progressive moves made by some of my predecessors in that regard. We were in opposition at the time and, with the benefit of hindsight, I think Mary Harney was given an awfully hard time, although perhaps that is just the way it goes when one is Minister for Health. However, if we actually look at some of the decisions she took, we owe her a huge debt of gratitude for the work she did in cancer care in the Governments of which she was a part. The decision she took on the cervical screening programme is one that has saved lives. When one is Minister for Health, one often takes a decision today and will only begins to see the positive impact in the following years. I hope some of the decisions we have taken collectively, be it in the Public Health (Alcohol) Act, on women's reproductive rights, the things we are going to do in the assisted human reproduction Bill or the extension of the HPV vaccine to boys, will, in time, when there will be a different Minister for Health sitting here, have had similar public health benefits. I wanted to acknowledge her contribution.

Deputy O'Connell again hit the nail on the head in saying there was an information vacuum in the CervicalCheck crisis. Understandably, women were worried. They were not worried irrationally. Nobody could have said, hand on heart, that the screening programme was safe. What do we do to try to provide that reassurance? We brought in a brilliant expert in Dr. Gabriel Scally who did a superb job. However, what do we do in the interim? What we do is support women in making decisions that they want to make for themselves on their personal health. They, not me, were making the decision to go to their GP because that is what anyone does when he or she is concerned about his or her health, as the Chairman knows as he is a GP. The question is, when a woman is sitting looking at her doctor, what can he or she do? He or she can do what he or she is meant to do, that is, provide factual information and try to reassure. In the case of many of the 110,000 women - pretty much the majority but at least 50% - this satisfied their concern and they decided they did not need a repeat smear test. In 57,000 cases the woman decided this in consultation with her GP and who the hell are we to second-guess that decision? How offensive is it to "mansplain" what went on in those consultations, or endeavour to suggest, as I heard someone say on the floor of the Dáil Chamber yesterday, that it was unnecessary? The woman had had a consultation with her doctor and decided, in the round, that having a repeat smear test was the appropriate thing to do. My only job was to fund it, which was the least we could do.

There is a point to be made about learning when there is a public health crisis. I have put up my hands in that regard and conceded that I made mistakes. Sadly, I am in a lonely place in that regard because many others have not done the same, despite Dr. Scally's findings about the frenzied political and media environment at the time. What do we do when there is a public health crisis in providing reassurance? The Chief Medical Officer showed what we should do. He showed huge leadership, went on national television and brought clinicians together. However, in my words - not his - it was a somewhat lonely place to be in. We need to look at what we will do the next time and there will be a next time when there will be another crisis in the public health service.

On the issue of vaccination, I am unapologetically pro-vaccine. Like the Deputy, I have very little time for misinformation and the nonsense spread about vaccination. It saves lives. Unfortunately, the misinformation on vaccines is not just an irritant, it is also costing lives. As the Deputy rightly said, it is costing the health of many children. Nonetheless, I need to set the matter in context. It is worth saying there is still a very good uptake rate under the child immunisation programme. We have a target of 95% this year. I think it was 92.5% last year. Therefore, the overwhelming majority of parents are deciding that they should vaccinate their kids. I was asked in recent weeks to look at what was being done in other countries in Europe and some parts of the United States where enrolment in school was being linked with vaccination. I have not definitively said that is what we must do, but Ireland should be part of that debate. There is a discussion happening across the European Union about what should be done in dealing with the issue of vaccination. If parents decide not to vaccinate their child, they will sending him or her unvaccinated to a school or creche where potentially he or she will spread illness. I intend to look at what other European countries are doing in that regard. I know that Italy and the state of New York made some changes recently. While the health committee has a very busy agenda, in due course it might like to hold hearings on how we can proactively use all levers, as a public service, to promote vaccination. As parents, there is a responsibility on us that is greater than our responsibility to our kids. There is also a responsibility to the children of others. Sending a child to school unvaccinated is extraordinarily irresponsible and dangerous. As I said, Ireland needs to be part of the debate that is happening across the European Union.

The Minister mentioned children going to school unvaccinated, but what about an unvaccinated child going into a hospital? In Crumlin hospital there are kids going around wearing masks.

There seems to be a level of unawareness of how serious measles can be.

There was an outbreak of mumps in some of our universities recently. The Minister briefly mentioned the Assisted Human Reproduction Bill and it is important to point out that there is a knock-on effect on the fertility for young men affected by mumps in university. People may avoid being fertile in college to some extent but, in the future, they may look to have children when they settle down. There has to be pushback for the patient or child who was not vaccinated to gain knowledge of the effects that can have on one's life in the future. Are there plans to make young men realise that, if they were not vaccinated as a child, there could be a serious problem in their future, which could have massive knock-on effects on their lives and hopes?

I will reflect on how best to get that message across. The HSE, in fairness to it, is a good organisation that gets much criticism for many issues. It has stepped up in promoting vaccination and the national immunisation office has done a good job with powerful patient advocates on the issue of cervical cancer and we think particularly of the late Ms Laura Brennan who did so much.

We often hear accusations that we are a nanny state and all this sort of nonsense. This is life and death, health and public good. We have vaccinations which have effectively eradicated diseases so that people of my generation think we should only read about in history books. Diseases are beginning to come back due to the misinformation being spread, often through social media, although not exclusively, and we need to be on that pitch and pushing back. We all need to work together on it. The HPV alliance was a good example of politicians, clinicians and patient advocates coming together and we need to look at other examples of that. We should not rule out any measure. We need to say we will explore every and any measure to ensure vaccination is the norm. We all need to realise it is not just a personal decision an individual is making for his or her child because it has an impact on other people's children. Vaccinations only work when there is herd immunity and enough people are vaccinated.

I welcome any guidance from the committee on this. I intend to speak to my EU counterparts about what is being done in other countries to consider how we approach schools, crèches and places where our children go on a daily basis.

Is there an answer about the accountability of the quantity surveyors or the professionals?

I need to be careful because, while we have privilege here, I do not want to say anything that could undermine a decision that may or may not be made. The National Paediatric Hospital Development Board has contracts for professional services with professional bodies on our behalf, effectively, as taxpayers. My initial reading of this report from PwC, which was brought in as a financial auditor, raises questions about the accuracy of some of the information that was given which then had a complete knock-on effect in the cost estimation. The PwC report does not find that there was a waste of taxpayers' money but it does find that this project was always going to cost more than we thought.

Page 4 of the report suggests that some of the information given had material errors in it. There are significant questions for some professional companies to answer and I do not intend to go further than that today but I intend to meet with the chair of the National Paediatric Hospital Development Board to get his view on that and I presume the board will seek advice on this and I hope they do.

I come back to the Estimates, the topic for today. The briefing document states that funding has been provided for CervicalCheck and the introduction of HPV testing as a primary screening test. Perhaps the Minister will elaborate on that and how close are we to moving towards HPV testing, which will revolutionise the screening programme and reduce the burden on cytology which is the reason there is such a large backlog.

There is a new subhead within the Estimates relating to Sláintecare. Some €206 million has been allocated to Sláintecare, much of which is money that was announced and relates to mental health, the National Treatment Purchase Fund, the GP contract, etc. There is no reference in the Estimates to a transitional fund, which was a recommendation of Sláintecare. There is an integration fund but no reference to transitional funding which is so important to getting Sláintecare off the ground. The Minister might comment on that.

There is an allocation of €24 million in the Department of Health's capital spending to comprise part of the €99 million that will be required this year to fund the national children's hospital. What re-profiling will take place within the Department of Health and its capital plan? The national service plan, in its commentary, states the HSE will have difficulty maintaining existing services this year and will have very little money, perhaps €198 million, for new developments in the health service. The plan highlights that there may be difficulties in meeting its budget target this year. The Minister might comment on that.

The development of the individual health identifier and electronic health record are catalysts for change and implementing Sláintecare. According to the briefing document, an additional €25 million has been allocated to ICT for this year, bringing its allocation up to €85 million. When does the Minister think the individual health identifier and electronic health record will be rolled out?

I will try and take those questions in sequence. The Chairman is correct that there is not a specific transition fund in this year's Estimate and that is a fact. There are a number of areas where significant resources are being spent on Sláintecare measures, which I believe passionately in. The culture change that needs to happen, and is happening, in the HSE and the Department means that everything we need to do is in the direction of Sláintecare. I will come back to the transition fund shortly. The decisions to reduce the drugs payment scheme cap and prescription charges were taken directly from the Sláintecare report. The money for the GP contract, of which €27 million will be spent this year, is funding that was held in my Department that is in line with the Sláintecare programme. The measures that GPs are agreeing to in return in integrating with primary care, medicines management, waiting list validation, e-health and, from January, chronic disease management, are Sláintecare in action.

The Chairman referenced this but there is some degree of transition funding for the e-health and ICT areas and I will come back with a timeframe for those in a moment. That is, no doubt, classified as Sláintecare and is transition funding. I have an integration fund this year. I expect that, now that has been created as a discrete area of expenditure, we can look to increase it significantly next year. That is my aim. There is €20 million in it this year but it would be unfair to suggest that we are only spending that on Sláintecare because other elements are also clearly delivering Sláintecare.

Much work has been done. Sláintecare has begun to come alive in the past number of weeks. There is a briefing for members of the committee today with the director of the Sláintecare office. It is now up and running and 2019 is the first year of it in action.

We are preparing the HSE capital plan by engaging with both the HSE and the Department of Public Expenditure and Reform now. I expect to publish the report shortly after Easter. Being blunt and honest, I am trying to arrive at a point where I publish more than just the 2019 capital plan for obvious reasons. The published 2019 capital plan will give a piece of the picture but people in every constituency will want to know if the many projects that will start in 2019 will be built in 2020. Sending projects out to design or tender is one thing but people will want to know if the Government has the money to build them in 2020 or 2021. I am endeavouring to publish a plan for two or three years hence and it is complex. If we take the Chairman's part of the country as an example, we want to show not just the modular build for University Hospital Limerick but the profiling for that funding for the next couple of years. I expect that the committee will invite me back in May to discuss the capital plan that I expect to have published by then. There is intense work going on to achieve that at the moment.

With regard to the reprofiling, the Department of Health was asked to make a €24 million contribution this year. That has come out of the minor works fund in the HSE, which replaces a piece of equipment or the like as it is required to be replaced. There is still more in that fund this year than there was last year, and we have been able to ensure that all projects that are contracted and under way are continuing. I have not had to delay a project or say something will not happen because of the national children's hospital. That is thanks to the collective work of Cabinet colleagues and the Minister for Public Expenditure and Reform, Deputy Donohoe, in that regard.

Can I get you a note on the individual health identifier and the e-health record? My Secretary General is writing an updated note for me as we speak. It will be rolled out in phases but I can send you a detailed note on that.

Did I miss a question?

I asked about the funding for CervicalCheck and the roll-out of HPV testing.

I am sorry about that. Yes, there is funding this year for HPV testing. It was allocated in budget 2019. Mr. McCallion and Dr. Doherty will have told the committee last week that they are working to come up with a definitive timeline. We are working towards the fourth quarter of 2019, which will be challenging. There are a couple of moving parts involved, the big one being the tender. We have the funding and I am working for it to be delivered this year. The HSE is very clear that this is the policy direction and would have confirmed that to the committee last week. It is important to point out that we will be among the first countries in the world to make this transition, although not the first. A number of countries have done it, including the Netherlands and Australia. There are a number of stages and I expect to receive a definitive timeline on it from the HSE in the next couple of weeks. Everyone is working as hard as they can to bring it in by the end of the year.

You are saying that the money has been allocated to fund it should a provider be identified.

Without being smart or dismissive, because we all know what happened, money was allocated last year as well. The money is allocated to deliver it this year.

HPV testing was to start in October 2018.

However, the likelihood is that it will not start until the last quarter of 2019, at the earliest.

That is correct.

With regard to Sláintecare and the transitional funding, do you expect to create a transitional fund in the budget for 2020 for Sláintecare-----

-----over and above the integration fund?

Yes, I do. We have not been able to discuss this previously because we have been in negotiations with GPs. We had considerable success in securing a large investment pot for general practice. GPs will rightly say that some of it is giving back the money they lost during the difficult years, and there is no doubt about that, but it is still a good deal above that at €210 million. That was one of the big requests I have been working on with the Departments of Public Expenditure and Reform and of the Taoiseach. Now that we have it secured and in place, the issue of a transition fund will be a priority for me in the next budget.

In the reprofiling of the capital plan some €100 million extra was required for the national children's hospital this year and €220 million will be required in 2020, 2021 and 2022. Where do you see that funding coming from? Will it come from the health capital plan or will it be spread across other Departments?

They are decisions for the Government to make collectively on the recommendation of the Minister, Deputy Donohoe. The Government has not taken a decision in that regard so it would be imprudent of me to speculate, but I expect that the Government will adopt a common-sense approach like we tried to adopt this year. However, these are decisions for the Minister, Deputy Donohoe, and he will make them in due course. I am endeavouring, working with his Department, to see if we can publish a two or three-year iteration for the capital budget in health. That would be very important because it would allow us to get a number of projects under way. There are many projects we want to get under way in health where the expenditure at the start is quite small, such as for tendering, design and planning, but it must be done when getting ready to build the project, whether that is an extension to a hospital or a new primary care centre. I will be better able to answer some of those questions in the coming weeks.

I have a final question on the Sláintecare integration fund. The briefing document outlines four different streams. Perhaps you could expand on those.

I can. These four streams are all areas where Sláintecare is pivoted. Basically, we are asking, rather than telling from the top down, what people should be doing in the local health organisation. We are asking hospitals, community health organisations and voluntary organisations to tell us what they believe they can do. People tell me as we go around the country all the time: "I have a really good project down here and I could take some people off the waiting list" or "I could work better with the local hospital if I was able to get this technology". We have set out the streams - right care, right place, right time and what more one can do. These are the objectives of the scheme. There is the scaling of current successful integration projects, patient-centred improvement projects, cross-agency collaboration and changing the model of care.

You are right that there are four funding streams linked to each of those actions. The first is scaling and sharing existing examples of best practice and process for chronic disease management and care for older people. For example, an organisation or part of the health service might be doing something very good in its community looking after older people with diabetes and it might believe that with extra investment it could scale it up or it could be replicated in a different part of the country.

Funding stream two is supporting scaling and sharing of existing examples of best practice approaches to reduce waiting time for consultation and treatment. For example, and I am not pre-empting these but just giving illustrative examples, we all talk about the Sligo eye model, which did a really good job of taking a number of eye procedures and eye outpatient appointments out of the hospital and into the community. Could that be scaled up? We know it worked in that part of the country so why does it not work in another part of the country?

The third one is supporting digital innovation including patient access to health information. Again, does one have a way of using technology to improve the delivery of health services? The new addendum to the GP contract, for example, suggests that virtual clinics could be held. We have one in the country at present in cardiology and it commits to another four. It is where consultants and GPs interact about individual patients. Is there a digital solution to help implement Sláintecare?

The last is supporting new approaches in the community, industry and voluntary sectors. We should not believe that the public health service has all the answers because many of our health services are being delivered by voluntary operators. People are being invited to pitch their ideas. They have until 18 April to send in the ideas and I expect we will allocate the funding in May.

Can I take it that the HSE is the only nominating body for the first three streams and the fourth stream is open to other organisations?

No. It is fair to say the fourth stream is probably more applicable to other organisations but a voluntary organisation can apply under any of the streams. The fourth is nearly non-HSE specific but non-HSE people are not ruled out for the other three.

Thank you. I call Deputy Lisa Chambers who is substituting for Deputy Murphy O'Mahony.

We are here to discuss the Estimates, but I will focus on CervicalCheck as it obviously has an impact on the health budget. On the last occasion the Minister appeared before the committee, I asked a question about the decision to offer the free out-of-cycle smear tests and who gave the Minister that advice. After pressing him for a while the Minister said it was his idea but that it was supported and agreed by the chief medical officer. There was no caveat attached to that. The question asked at the time was about a free blanket offer to any woman who wanted one. The Minister told the committee that the chief medical officer supported what was essentially the Minister's idea and decision, that nobody else advised him to do that and that he had come up with the idea himself. However, new evidence has come to light that the chief medical officer did not support a blanket offer of free smear tests to everybody.

Deputy Chambers, this question was asked earlier.

It is not a question. I am just framing my next question. Does the Minister still stand over the evidence he gave to the committee that day, that his decision was supported by the chief medical officer, in light of Dr. Flannelly's evidence? In addition, what advice did Mr. Tony O'Brien give the Minister on Sunday, 29 April?

I answered some of the question previously but I welcome the chance to answer it again. I am somewhat uneasy with other people speaking or suggesting that they are speaking for my chief medical officer. The chief medical officer in the Department and I are ad idem on this, as are my officials. Deputy Chambers does not have to take my word for it. My Department at official level, not me, wrote to the Ceann Comhairle in response to the Deputy's party leader's parliamentary questions. I believe the letter was sent on 12 February but it was certainly sent in February. As I said to Deputy Donnelly earlier, the letter says that the Minister's decision and announcement on 28 April were consistent with the advice received from his officials, and the advice of the chief medical officer to the Minister was reflected in the press statement that issued on 28 April.

I will move on the question about Dr. Flannelly and Mr. O'Brien, but I wish to be clear that the chief medical officer supported the decision I made.

As I said earlier, our text messages were even subject to freedom of information requests and published in a newspaper. We were in very regular contact on this. He, I and my Department believed it was the appropriate thing to do, not in a normal time but in these exceptional times. The Deputy used the word "evidence." There was never evidence that I intended to provide a blanket offer. I do not even know what the phrase "blanket offer" means. I do not need to explain to any woman that smear tests are carried out by healthcare professionals. Women go to see healthcare professionals. There was only ever one decision implemented. There has been a lot of focus on my tweet. My Department tweeted as well moments later and also outlined how the process would work. A press statement was issued from my Department that night. A fee was agreed with GPs. Some 110,000 women went to their GP and only 57,000 of them decided to get the repeat smear after that engagement. The Deputy has not said so today but others have said it in recent days; it would be wrong to suggest that a repeat smear was unnecessary when a woman and her GP decided together that it was the appropriate course of action, which was the case for 57,000 women but not for the other approximately 50%.

The Deputy asked me about Mr. O'Brien. I do not recall Mr. O'Brien saying that to me. That is not to say he did not do so; he may well have. I presume the Deputy is referring to the interview on the Marian Finucane show. I think Mr. O'Brien said that he believed he told me that we should walk it back. I do not recall that conversation. Perhaps he did. At the time, the Deputy's party was planning on backing a motion of no confidence to remove him from his job. That was how Fianna Fáil viewed him and his position at that time.

That is not factually correct.

Deputy Donnelly went on the Drivetime radio show and reversed his position and said he would be voting to remove Mr. O'Brien, an unprecedented move.

Not at all. Not at that time.

Maybe it was a couple of days later but that is how the Deputy was viewing the director general of the HSE.

The Minister has no idea how we were viewing the director general at that time.

Fianna Fáil had no confidence in him.

Allow the Minister to continue.

I am not sure who is actually asking questions here but I am just pointing out-----

I am just correcting the record.

I am pointing out that the Deputy wanted Mr. O'Brien to resign from his job in respect of the CervicalCheck debacle.

Perhaps the Minister could answer my question. I know there is a bit of a thing going on here but I am waiting for answers.

There is not a thing going on. It is just that there has been lots of misinformation put out in recent days.

I would agree with the Minister on that, actually.

I am sure the Deputy does, for different reasons. I do not recall Mr. O'Brien having a conversation with me. That is not to say that he did not. We had many conversations. The reality of the situation is that I take my medical advice from the chief medical officer, who is a doctor. I had lost confidence in the management of CervicalCheck. I do not wish to speak for Deputy Lisa Chambers but I presume she had, too; certainly most women in the country and most politicians had. I had expressed no confidence in it and was taking my advice from my Department officials, who stepped up to the plate and were doing a superb job in the middle of a major public health crisis of confidence. That is where I took my advice from. I have heard this put forward, too. The moment I received advice from my officials was in October. I accepted their advice on that day and we communicated our decision to the HSE on that day in writing. The HSE said it wanted to continue it until the end of December for operational reasons, which was logical because people had booked their tests. When my officials advised me to stop the test, which was after the publication of Dr. Scally's report, we conveyed our decision to stop it immediately.

Yes, and the Minister actually stopped it two months later.

The HSE stopped it two months later. I conveyed my decision to the HSE and it said women had already booked in and asked to allow them to have those appointments.

There is a timeline of making the decision, communicating it, and taking the memo to Cabinet on 1 May. On the last occasion I asked the Minister whether, prior to taking that decision, anybody advised him against it or warned of any potential problems. The Minister answered, "not to my recollection". I said, "not one voice" and the Minister said, "not to my recollection". That is becoming less credible as time moves on. It does appear there were communications to the Department from CervicalCheck. Tony O'Brien's evidence and his word are that he asked the Minister to walk it back or pull back from that decision. It is not just that there was one instance of advice that this could go wrong or could have negative consequences for the programme; there were multiple voices. I believe the Minister heard those voices before the Cabinet memo of 1 May. That still does not answer the question as to why, after making that decision, the Minister consulted with CervicalCheck basically directing it that this was his decision, without looking at the capacity or the resources. It is pretty obvious even for an ordinary citizen who is not the Minister for Health that making an offer of this nature is going to increase demand. That is pretty obvious.

To make that decision without considering capacity and resources was reckless. That is my view. The Minister will probably disagree, I am sure.

CervicalCheck was before the committee last week and was being asked about the new HPV screening programme. Regrettably, it is now looking as though it could be 2020 or 2021 before that comes into being. When I pushed on why it was not being made available sooner, the answer I was given was that decisions of this nature must be based on clinical evidence and they must be safe. The Minister's decision was to offer what I consider to be a blanket, free out-of-cycle smear regardless. That is what the Minister's tweet did say. My view on Twitter is that if the Minister chooses to use it to communicate a message, he is responsible for how it is taken up. Perhaps it is not the best way for a Cabinet Minister to conduct his affairs. That is a matter for the Minister, however.

Would Deputy Lisa Chambers give up Twitter if she was in Cabinet?

It is not about giving it up. My point is that the Minister is responsible for what he tweets.

It is not credible that not one dissenting voice made its way to the Minister's ear before 1 May. That is my view. What I find completely incredible is that the Minister did not review that decision until October. May, June, July, August and September make five months. On the last occasion the Minister was before this committee, he said he was engaging with CervicalCheck almost on a fortnightly basis. He said himself that he would have been aware of the backlog when it arose. That backlog was quite evident from at least August onwards. The Minister decided to do nothing. I know he is going to refer to the Scally report. I do not really care about the Scally report right now. The report does not stop the Minister from doing his job. He is not bound by the Scally report, nor can he hide behind it. If that backlog was evident to the Minister at least in August - we will give him that much - how did he leave it until October to make the call to end the free out-of-cycle smears? He only made that call because CervicalCheck wrote to him on 21 October to ask him to stop because he was crashing the system.

Even when he made the decision, it was not implemented until December. Not only did he make a bad decision initially for the wrong reasons, because he was under political pressure, he made it without the proper advice. He did not consult the actual organisation that was going to carry out his promise. I cannot understand that. Even if the Minister had no confidence in them, the free smears he was giving out were being sent to CervicalCheck anyway. That makes no sense. If the Minister is saying he did not have confidence and did not want to consult them but he had no problem directing another 100,000 women to their doors, it does not add up. He went a full five months without reviewing the decision, knowing the backlog was building; I do not know how the Minister can stand behind such inaction. That inaction allowed the backlog to build and build, and the Minister still has not sorted out capacity. Can the Minister outline to me how he can justify waiting until October to make that decision, whatever about not implementing it until December because people had booked in? The Minister could have dealt with those who were already booked rather than taking new bookings so I do not buy that either, frankly. Why did the Minister wait so long? If he answers with "Scally report" as he did on the last occasion, I ask him to keep it brief.

The Deputy will understand why I take my advice in respect of whether it was a good or a bad decision from other sources than Opposition politicians. The president of the National Association of General Practitioners, someone the Deputy and her party cite quite regularly as having an expert view on primary care, stated again this week that he believed it was the right decision because many women were sitting in front of GPs looking for reassurance. I will not take the committee's time repeating what I already read into the record earlier. General practitioners were put in an impossible position and if I had not taken that decision, confidence in the screening programme would have dwindled further. The Deputy and I have different views on this and I reckon we are always going to have them. I am reassured that my decision was appropriate considering the exceptional times we are in, based on what I hear from GPs and on what I hear from women who availed of this. I appreciate that the Deputy has a different view. There does seem to be a premise to the Deputy's question that had I not offered this, women were not going to seek it anyway.

I did not say that and I do not agree with it.

The Deputy has suggested that I tweeted and created all this demand on capacity. Women were already going to their GPs. Women were turning up at their GP looking for reassurance, 110,000 of them. I made the decision not just about the repeat smear but also a free GP visit, which is different from the normal screening service protocol. I decided to offer a free consultation with the GP and, if the GP believed it to be necessary, a repeat smear. Some 110,000 women took that up. They did not do so because they listen to every word I say. They did so because they wanted to talk to their GP. I genuinely believe that was the right thing to do. I believe women would have gone otherwise and that women who could afford to go were going anyway. I have heard from many women who went private anyway. This was a case of who was going to pay and whether we were going to allow women who could afford to pay to have it and deny others who could not. Many in opposition and in the Deputy's own party called on me to do just this. Many Opposition spokespeople on health called on me to do so and they maintain the position that, while they criticise me for many things, this was still the right decision. Others take a different view.

I do not hide behind the Scally report, to be clear.

We arrived at a point where we could provide the much-needed reassurance in our screening service when Dr. Scally's report came out. That is why, following consultation with my officials, I suggested that we would then stop the thing. I will take the criticism from Deputy Chambers on the period from October to December because I think there could be some validity in that. I would need to reflect further on why the HSE decided to go to December. Could it have been handled better? I have an open mind on that and the Deputy may have a degree of legitimate criticism of me on that issue. However, I will genuinely never believe that this was the wrong decision. I reckon we will never agree on this. I believe it was the right decision taken at a difficult time for good reasons and was based on listening to women and general practitioners. It has absolutely caused a capacity problem. There is no doubt about that, and I have discussed it with the Deputy's party colleague. Our priority has to be finding the capacity. The HSE officials signalled good progress on this last week when they were before the joint committee. They have identified potential extra capacity. I use the word "potential" because until it is over the line, that is what it is. Deputy Chambers and women will want to know about more than potential. I take that point too. I expect the HSE officials to be back shortly, certainly by the end of the month, with an update on where we are in that regard. If we can bring that on board, and I am hopeful that we can, then we will clear the backlog quickly.

The Minister did not deal with why he did not review until October. He is saying he was waiting until the Scally report was finalised and that was the point at which he had reassurance from the laboratories. However, the Minister was still sending women to the same laboratories and to the same service. To me that does not add up, but I realise that we will not get further on that issue today.

I was not sending women anywhere. Women were going to their GPs.

The HSE has attributed two thirds of the increase to that offer. The HSE is saying that. It is not me saying that.

It is not Opposition politicians. The Department and the HSE are saying that.

The HSE has not given any positive signals about capacity. We are one year on since the promise was given and the offer made. There is no extra capacity. The Minister made a point about women going to private operators and paying privately. A strong point was made by Deputy Donnelly on the previous occasion. He said that shows there is capacity somewhere if people pay for it. The question still applies. Why can the HSE not buy it? If private individuals can source it, why can the HSE not source it? The delay in sourcing this extra capacity leaves a great deal to be desired. I was going to ask when the backlog would be cleared. I think we could be looking at the next year or two because it is such an utter mess.

I have a more specific question around MedLab Pathology. Is MedLab terminating its agreement with the HSE? When is that happening? What is happening to the smears or slides that have gone to MedLab? What is happening to the workload the company has?

In recent days the Minister has referred to triage being used. Will he explain what he means by that? Does he mean it applies to anyone who presented for a repeat reassurance smear who has a history? What does a history constitute? Where does that put a woman in terms of one, two or three? Will the Minister explain the triage element?

Deputy Chambers asked about the issue of capacity. What I meant by positivity was that the HSE officials, and I can single out Damien McCallion in particular, who were before this committee last week have worked night and day to try to identify additional capacity. They have assured me that it is not an issue of funding but of a shortage of cytology around the globe. For the first time last week the HSE officials said publicly at the joint committee and to me in meetings that they have identified extra capacity. This week there are intensive engagements under way to try to bring that capacity on board. I cannot go any further than that because I do not want to jeopardise it but I am hopeful. I will be clear to them, not that I need to be, because they get this, that any extra capacity needs to comply with Scally in terms of quality assurance. A conversation is ongoing to ensure that happens.

Deputy Chambers made a fair point on the issue of MedLab, and I hope it is one on which we can agree. It shows that some laboratories have capacity available. The issue is that they do not want to do business with the Irish public health service. I am not speaking for MedLab, but I think that is something we need to reflect on in the aftermath of the CervicalCheck debacle. Some laboratories made the decision that they are out of Ireland and no longer want to do business with Ireland. I cannot speak for them on why that is but it does perhaps go back to some of the comments in the Scally report on the debacle. I will confirm this in writing to the Deputy to be sure, but my understanding is that MedLab has a legal responsibility in respect of what it has processed, as does any laboratory in respect of any slide taken. I am reluctant to go further because there are ongoing discussions and I have no wish to jeopardise them. I know Deputy Chambers takes the same view. I am confident that if the HSE officials can get their discussions or negotiations over the line, there will be additional capacity in the programme above and beyond any decision that any individual laboratory may make.

Deputy Chambers is right about triage. It is a phrase I have used to try to provide reassurance. This is because there was an understandable view that if a woman had an additional risk, she would nevertheless be sitting in a queue along with everyone else. I have been informed that it operates in the laboratories where there is a backlog. In the particular laboratory where there is a backlog, they are now triaging people on the basis of medical history. I would be more comfortable if I could get the Deputy a note that I could share with the committee. I will get that for the Deputy today or tomorrow and outline exactly how that process works so that I do not articulate it incorrectly. I would like a clinician to write the letter, but that is my understanding. I gather those responsible triage people on the basis of medical history.

I wish to clarify one point. MedLab is servicing rural parts of the country. If a woman is living in County Mayo, where I live, she is waiting for eight or nine months. That is far longer than anyone else. It is of particular concern to women living in that region because the laboratory with the biggest backlog is now looking to pull out. We need reassurance from the Minister on how that will work, especially for those women in the system.

The reason I asked the Minister about triage is that I am not convinced it is happening, if I am to be honest. I will ask the Minister to look into that. I appreciate he may not have the answer now, but will he clarify what constitutes a history that might send a red flag that a woman would need to get her results back? I am questioning whether that is happening. I say as much because I have certain information that I do not wish to disclose at the meeting. I am asking the Minister to check that.

Certainly I will check that and I am happy to discuss the matter privately with Deputy Chambers. I will check it and come back to the Deputy in writing. I fully accept the bona fides of the reasons the Deputy is raising these issues. It is a particular challenge in the part of the country where Deputy Chambers comes from. I fully accept that for the reasons outlined by her.

My clear understanding is that there is a legal responsibility on the laboratory that has the test to complete the test. My point to Deputy Chambers and those she represents in Mayo and that part of the country is that I am conscious of the fact that we have three laboratories or organisations that we are using. The Coombe does not seem to have a backlog and is processing within approximately three weeks. From memory, at Quest the period is between seven and nine weeks while there is a significant wait in MedLab.

It is 33 weeks.

It is 33 weeks, absolutely. I am telling the Deputy today honestly that the HSE is actively involved in trying to find additional capacity to rectify that problem. I will come back to the Deputy and the committee as soon as I have further news on that.

We will bring in Deputy Donnelly to start the second round of questioning presently. The issue that arose last April with CervicalCheck surrounded non-disclosure of the audit. The audit was the icing on the cake for screening programmes. The programme looked back on people who had been identified as having cancer to see if their previous smear had been accurate. It was the non-disclosure of the audit results to those women which led to the controversy that raged at the end of April last year. The Minister expressed a lack of confidence in CervicalCheck management, but really he was, I assume, expressing lack of confidence in that element of the programme.

Unfortunately, the Minister's expression of no confidence in CervicalCheck management led to women having a lack of confidence in the programme in general and in the process of the programme. That is what led to the demand for an out-of-cycle smear. The issue was non-disclosure of the audit as opposed to the working of the programme. It has been, is and will be a successful programme. As Deputy O'Connell mentioned, 65,000 women are walking around today, having had early changes identified and having been treated successfully. It was the expression of no confidence in CervicalCheck that led to the controversy. Is that one of the errors that the Minister has admitted to making? Was that one of the critical errors he made?

No, I will answer the question a different way. I have spoken about the error I think I made before. I am not sure it would have worked if I had tried this but, however long I am in politics and however long after politics, I will always regret that I did not request a bit of time. We were operating. I have to take the findings of the Scally report on board too. I respectfully suggest they are more broadly applicable in this House than simply to me, but I am willing to accept my part. What needed to happen was that I needed to urge people to take a few days to think on it.

This is not a go at anyone as it is the way this place works. On the idea that I was handed new information as I walked into the Dáil Chamber and then presented with this dilemma, if I told the Dáil, I would have caused worry and if I did not, then it would be claimed I misled it. This is a frenzied environment. I am the Minister and should have tried to call a halt to all of it. I remain to be convinced it would have worked but I should have tried to.

I do not wish to talk about people who are not here. However, Dr. Gráinne Flannelly has done much good work for screening and tackling cervical cancer. That should never be taken from her or the people who worked in the management of the programme. On this I agree with Deputy Micheál Martin. These people helped build our screening programme with my predecessors and saved lives.

I could not, however, have confidence – it did not matter whether I did because women did not –because an audit was overseen that was botched. Will the Chairman understand my position on those days when I was asking basic questions but not getting the answers? How many other people are in Vicky Phelan’s situation? The inability of that organisation to give me that information fed into the general worry, which is one of the issues which Deputy Lisa Chambers and I have discussed at some length.

I continue to reflect regularly about CervicalCheck and what could have been done better by me, by my Department, by the HSE and by this institution, as well as by media and public commentary. There are lessons for all of us. I accept my part in it for definite. I also clearly hear the words of the patient advocates pointing out that this is all grand but can we ensure something good comes out of this to try to eradicate this awful disease.

One of Dr. Scally’s key recommendations was that the audit should be paused. I believe that was entirely appropriate. Audit is a good process but this one was not executed in any way that was appropriate. Dr. Scally did call for it to be paused. I recently read a report on the front page of a newspaper in which a medical negligence lawyer suggested the programme had been paused to stop future litigation. The audit has been paused for no reason other than to implement Dr. Scally’s report and address the concerns expressed by women. We now have established an expert group, which is meeting to work out how one properly designs an audit which works for women and the programme. That work is under way and the audit will be recommenced then in a way in which women, as well as patients in general, can have confidence.

Sitting suspended at 11.23 a.m. and resumed at 11.33 a.m.

We will start our second round of questions now, which might be somewhat shorter than the first round.

We will do our very best. There are not that many of us here.

On a procedural issue, the Minister has referred to having an email that many of us have been looking for. Will he make that available to the committee?

I will do that now.

I thank the Minister. This is a comment more for Mr. Breslin than the Minister. The Parliamentary Budget Office did some excellent work to prepare the committee to look at the Estimates. One of its main findings is that it is impossible to conduct decent scrutiny because the numbers are not comparable. It states that there are a number of challenges in undertaking effective scrutiny of this money. It is a €17 billion pot. I have looked at what the Parliamentary Budget Office said and I agree with it. It said that we are meant to be able to compare the figures from today to the figures from December but that it is essentially impossible to do so because the headings are not like for like. It talks about €400 million on pensions being pulled out of many areas and dropped into others, as well as other issues. I am aware this is not a small amount of work but I ask the Department to read the Parliamentary Budget Office's report and to then come back to report to the committee, taking these issues on board, in order that we can properly scrutinise the Estimates, since that is what we are here for today.

Absolutely. My officials will look at that and see how it compares with our briefing note and how we can produce something further.

The Minister does not need to respond to this. I just want to reflect on CervicalCheck. I heard the Minister say to Deputy Lisa Chambers that he believes, knowing what he knows now, that it was the right decision to make. The Minister's Department was told at a principal officer level that his decision would crash the system. The Minister was repeatedly told throughout the year that his decision was crashing the system. We are now dealing with the results of the system having been crashed. Some 80,000 women have been waiting for up to eight months, with hundreds of thousands of women waiting for a HPV test. To state now that the decision was right is extraordinary and, in my opinion, is an insult to all of those women. We do not need to get back into it. We have had a good go at it. If the Minister wants to respond, that is fine, but we then want to move on to the children's hospital.

I will respond briefly. I will provide the email to the Deputy, having already given him the content of it. The email states that the named individual, having spoken to Jerome and Gráinne, felt it was important to make me aware of the key risks arising from such an open access policy. It then lists the risks, all of which were readily identifiable to my Department. It stated that we would have to work out how to pay the general practitioners and that it would of course result in additional smears being taken. It also goes on to state that it is understood that they take direction from the Department. The phrase "crashing the system" is one that I have only heard Deputy Donnelly use and I do not mean that disrespectfully.

The exact wording we got from Dr. Flannelly was "fundamentally undermine the system and lead to delays". In anybody's language, that is what happened.

I did not receive, and my Secretary General and the director general of the HSE told the committee that I did not receive, any contrary advice prior to making the decision. The overriding point I make is that with the unique circumstances that we were facing, this was going to arise and women were going to seek repeat smear tests. How we dealt with that was the issue.

I accept the Minister's point but the HSE contradicts that. It clearly states that there is a narrative, the Minister's narrative to which he is entitled, that it was going to happen anyway so it was made free. There are two conflicting narratives. One came directly from the HSE to this committee to state that that is not true. It directly attributes two thirds of the backlog to the Minister's offer. It does not state that it was going to happen anyway. No one was disagreeing with it being made free where appropriate. The significant error appears to have been in this open offer. The Department quickly added a caveat and stated that it was in consultation with GPs. The Minister did not.

Deputy Donnelly is still criticising the decision. I do not accept the difference because there is not a difference between the chief medical officer and me on this matter. The Deputy is still criticising that decision, which he believes is wrong.

I take exception with the Minister saying it is correct now. Of course the Minister believed it was the right decision at the time. He made the decision and that is fine. I find it extraordinary that he would state that it is correct now. There are 80,000 women around the country waiting for eight or nine months, with hundreds of thousands waiting for the HPV test, which he said would be in place last September but which we are now told may not even be this calendar year. The Minister's decision is directly linked to that. We also had evidence last week that there was no medical benefit. It was about reassuring people. It is extraordinary that knowing everything we know, with the evidence to the committee that the Minister was repeatedly asked to stop because it was causing these delays and fundamentally undermining the system, that he would still say it was the right decision today.

A decision can only be made at a point in time. At the time I made the decision, I believed it was the appropriate decision. The Deputy and I have different views on this.

We will move on to the national children's hospital and PwC. This is a procedural point, but it is nonetheless important. Several weeks ago the Dáil passed a motion, accepted by the Minister and his Government, by an overwhelming majority, to include in the PwC report an analysis of the implications for cost and timing of moving the site. I wrote to the Minister directly after that motion was passed and asked that that be done. It was not included in the PwC report. Did the Minister instruct PwC, further to the Dáil vote on same, to include the cost and timing implications of potentially moving the site?

The Deputy has asked an important question, and I will have to check what conversations were held with PwC. I did not have any direct conversations with it. I accepted the Dáil motion as I believed it was an honest attempt by the Deputy to ensure that we had robust terms of reference, and I accepted a number of his changes to and suggestions on the terms of reference. I have been listening to the Deputy commenting on this a bit in the last day or so, and I do not accept that we can presume that PwC did not look at this. It says on page 8 of the report that to take any other decision would have cost more. I am not sure that we can presume that PwC did not consider the effect of moving to a different site. I will be meeting with the authors of the report in the coming days to tease that out further, and I will come back to the Deputy with an answer.

To be clear, we did not want PwC to ascertain what the implications of moving would have been in September last year. The direct call made by the Dáil was that the Government instruct PwC to include an analysis of the effect of such a move now, because a number of paediatricians, parents of sick children and concerned citizens around the country believe it is still the right thing to do. I will be surprised if the analysis comes back and backs that up, but out of respect for those people and their very strongly held views - and they may not be wrong - the Dáil called for that analysis to be included in the PwC report.

I will discuss that with PwC and revert.

Can the Minister confirm whether, after the Dáil vote three weeks ago, he instructed his officials to contact PwC and tell it to include that analysis? We were adding in an additional term of reference.

I have to seek clarity on that; I do not want to mislead the Deputy. I will make the point that PwC was acting as a financial auditor, and the decision to locate the site was not entirely a financial decision. Nobody has ever suggested otherwise. There are different views, and I accept that. People watching this will have different views from the Government. However, the decision was taken for a number of reasons, including clinical and medical reasons. The Dáil voted in 2012 to endorse the St. James's Hospital site. I am not making a presumption about the way the Deputy voted, but I certainly voted to endorse that decision in 2012 as a backbench TD. I also voted on a private members motion in 2017 to re-endorse that decision. We voted twice on this issue. I will revert to the Deputy on his question.

The guaranteed maximum price potentially has a huge implication on this year's Estimates. This committee was told repeatedly, not by the Minister but by the development board and the Department of Health that the great advantage of this two-stage process was that the State now had a guaranteed maximum price and that any future cost overruns would now be borne by the contractor. That was the single biggest defence given to this committee for this ill-fated two-stage process. The PwC report blows that completely out of the water, saying that it is complete nonsense. In fact, nine of the 11 recommendations speak about controlling further cost escalation that it clearly says will be borne by the State. Can the Minister explain why, on this huge issue, which might require hundreds of millions in additional required expenditure, there is such a massive discrepancy between what the Department and the development board believe or believed, which was that the guaranteed maximum price was as it appeared, and PwC saying that it is complete nonsense and that the State is potentially on the hook for hundreds of millions of euro in additional spend?

They are two separate issues. On page 4 of the report PwC comments on the two-stage process. Many people raised questions and asked whether it was the right process to use. It is one of the things PwC looked at. It said: "The two-stage procurement process used to award the contract for the construction of the children's hospital is a widely used approach and can deliver significant benefit in relation to accelerating project timelines." It did not say that it was the wrong approach. Many of us thought that it might, but it did not say that it was the wrong approach to procurement. It went on to say, however: "The necessary controls required to mitigate the risks and consequences of this approach were not put in place." The PwC report only landed 24 hours ago, but my view is that it has said that there are benefits to using the two-stage approach to procurement but that the execution was appalling.

In the interests of time, I am not asking the Minister about the two-stage approach. The Department and the board came here and told us that the State now had a guaranteed maximum price.

That is the two-stage approach.

It is the result of the two-stage approach. The important point is that we were told that any future cost escalations were going to be the responsibility of the contractor. PwC said that was complete nonsense, and that the future cost escalations will be borne by the Irish people. Can the Minister explain why there is such a total divergence of views between the Department and the development board on the one hand in terms of what the guaranteed maximum price actually means and what PwC has just told us on the other?

It is not entirely accurate to say that my Department said that there was no further risk to the taxpayer from the guaranteed maximum price. That is not what the Government was apprised of. My comments to the committee were that residual risk was always flagged, particularly in relation to further user changes, but also on the issue of inflation. It is fair to say-----

-----that the possibility of residual risk was always highlighted; it is not a total divergence. User changes to the project were always exempt from the guaranteed maximum price. It also includes things outside our control. I do not want to bring Brexit into everything, but the PwC report references the risks it poses in terms of access to supplies. It would be-----

There is still a fairly big divergence between what we were told and what this report says.

There is still far too much risk around future cost rises to this project. The Deputy asked us to ask it if there was a way of reducing the cost of the project. It came back and said that there may be technical ways of doing that, but that the board should be putting its effort into reducing the risk of further cost rises arising from this. That is where the focus needs to be.

People have been asking what the final cost of this project will be, which is a perfectly valid and reasonable question. If we used a traditional procurement model we would not have been able to determine the final cost until the project was completed and the claims were submitted. It is normal in any project for claims to come in at the end. This was the case during the building of the Luas. It would be difficult to find an auditor anywhere in the world who will say absolutely and definitively that there is no further risk of cost rises.

The Minister referenced cost reduction opportunities. This was one of the biggest disappointments of the report for me. In 128 pages only two pages were given over to that issue, and one of those pages was mainly a pie chart. I do not accept PwC's findings on this. It is strong in some areas but it is very weak here. It is essentially saying that 85% of the total cost is already contracted and therefore nothing can be done about that. As anyone who has ever built a wall, an extension, a house or a large building will know, as costs escalate he or she can sit down with the developer, builder, project manager, architect or someone else and say that the costs are getting out of control, and that despite there being a contract in place to build a particular item it has to be reigned back in. PwC has said, in the project involving the biggest capital spend in the history of the State, that this cannot be done. BAM stated that it would walk away. I understand that it is more than open to looking at the contract with a view to pulling costs out of this value engineering project. The shape of the building makes it as expensive to build as one could possibly imagine. It is shaped like a big glass donut, and there is a reason why none of us lives in glass donut-shaped houses; they are extraordinarily expensive and do not represent a very good use of space. Does the Minister accept the assertion that because 85% of the cost has been contracted- critically, the money has not spent and could be reversed from an engineering perspective - that we therefore have to let all of these potential cost savings slide?

I accept the report, to be clear, but I am not willing to concede yet on the potential for cost reduction. The report does say that it is technically possible to reduce costs, in both the summary and on page 75. However, there is a caveat that if that was done other difficulties might arise for the project. It says that a value engineering report could be carried out, but it might create planning difficulties.

We could end up delaying the project further, which could cause other costs. When I met Mr. Fred Barry, the new chair of the board, before the PwC report, I asked him to cast a fresh pair of eyes over what cost reduction measures could be put in place. I do not want to mislead the taxpayer and I do not want to suggest I have a report that states there is significant room for savings because that is not the case. However, I want to talk to Fred Barry and I want him to prepare a report on the possibility of savings. I would also like him and his board to engage with this committee. It was said that it would be better to expend the energy and expertise of the board on making sure there are no further cost rises. We have to balance that but I do not concede the point yet.

I have a question on the maternity hospital.

The Deputy's time is nearly up.

In that case, I will squeeze both my questions together. In a recent response to a parliamentary question, the Minister stated that no serious work was yet under way on the maternity hospital and that the design phase had not started. One of the most important parts of this hospital is its co-location with the maternity hospital. Is there any provision in the Estimates to seriously ramp up the design phase, along with procurement and all the other professional services? A lot of money has to be spent on getting this maternity hospital moving. What provision is there in the Estimates for this?

Last year the overrun on the HSE budget was approximately €600 million. How is it doing at this moment regarding what we signed up to last December? What is its run rate and the level of spending in the context of what the Dáil has sanctioned?

There is no provision in this year's Estimates for the maternity hospital and there is no point in me suggesting there is. There is, however, some money for the theatres at the Coombe Hospital.

Does the Minister think that is acceptable?

It would be highly desirable to move ahead with it. There are funding priorities and we have had discussions about capital. I would not want to mislead the committee by suggesting we have the funding to do it. We need to have another look at it as the year progresses. There are many sceptics out there, though I know the Deputy is not one, but there is no doubt that we are going to build the hospital on the site and that there will be tri-location. It would be a good confidence-building measure to show a bit of progress on it. I have spoken to the master of the Coombe Hospital about this. In the context of meeting the risks of our current maternity services, this year we have decided to prioritise the works at the Coombe theatres.

On the financial situation of the HSE, we will shortly put in place a new board and that will be a key governance control which we have been lacking for a number of years. A new director general-CEO will take office next month and I look forward to this committee having an opportunity to talk to him. I will be clear with him on his budgetary responsibilities because we cannot have a repeat of last year. It is something we can deal with in one year but not over two years. I understand that the HSE is technically on profile in terms of its costs but I will not mislead the committee by suggesting there are no emerging pressures, on which the Deputy has commented in recent days. There is a need for the HSE to put a pay and numbers strategy in place so that we can have realistic recruitment plans that match the budget, and where individual hospital managers or CEOs do not make their own recruitment decisions. There has to be a centralised approach and the Minister for Finance, Deputy Donohoe, and I will keep a close eye on this. We are awaiting the final outturn from 2018 which will be audited shortly and it will be important to see what that amounts to.

We will know more as the money is spent but is the forecast for the year that the health budget will come in on profile?

We have approximately two months of data so far and they suggest it is on profile but there are emerging pressures and getting the pay and numbers strategy right is key. I am in no way complacent about it and a lot of hard work is being done to ensure the HSE does repeat last year's performance.

I am reluctant to do so but I will go back to the CervicalCheck issue. Can the Minister outline say what would have happened if the free smear tests had not been offered at that time?

My very clear understanding from GPs and my officials was that women were making the decision to seek reassurance. They were going to go to their GPs for that reassurance but their GP would have not been able to provide clarity on what might happen. A two-tier system was emerging in which women who could afford it could have it. There was a risk of further undermining confidence in the programme by telling women we were not sure what was happening and were waiting for a report to come out first while not being able, in the meantime, to give them a repeat smear. The helpline was beginning to receive lots of phone calls from worried women seeking reassurance and not doing it would have added to the chaos of the time. I am sure that Members of the Dáil would have demanded that I do it and some have been honest enough to have admitted that. General practitioners showed significant leadership during this situation but they would have found it even more confusing and more difficult to get guidance and clarity, though Dr. Peter McKenna stepped up to the plate by providing clinical guidance to GPs at the time. I think many people would have sought free repeat smears anyway and that would have caused a capacity issue but the smears would not have been done in a way that was uniform. It would not have been fair either as it would have been a two-tier system.

I introduced a fee to pay the GP to see a woman and it was up to the GP and the woman, together in consultation, to decide whether a repeat smear was required. That worked to a certain extent and a significant number, some 50%, of those consultations did not result in a repeat smear. There was enough reassurance for those women from the conversations they had with their doctors to enable them to decide they did not need another smear.

I presume medical criteria had to be met for a doctor to decide whether to refer a woman for a repeat smear. Perhaps the Chairman can answer that question.

There were a mixture to some extent. This was a reassurance mechanism but, as Minister for Health, I cannot put myself in that consultation room. I trusted women and their doctors, together, to make what they believed to be the appropriate decision. I did not want a situation where some women could access a repeat smear and others could not or where a doctor believed it was appropriate but had no access to one. This was far from ideal, of course, and I would not want anybody to misunderstand the position of me or my Department in this regard. This is something we would never wish to do. It is meant to be a population health programme that is done on a scheduled basis every number of years or in accordance with risk. This was different, however. People have said we could have undermined confidence in the screening programme but that had happened with the failure to disclose. Chatting about it a year after the debacle does not capture the situation we were in at the time.

The conversations GPs had with concerned women were quite complex. The advice was given on the basis of the woman's history and her risk profile. Some women are at higher risk than others and some will have had several smears in the past that assured one of the accuracy of their latest smears. They were difficult consultations and if a woman was very uncertain or worried, she would have been given the smear.

However, many women just required reassurance that the cervical screening programme was a very effective programme, that it was working properly, and that the issue was around audit and non-disclosure rather than any deficiency in the system, but many women did not understand that it was a screening test rather than a diagnostic test. They expected that the screening test would be definitive, but no screening test is definitive. It is a population programme, so it benefits the population. When it comes to the individual, there will be some individuals who will not be picked up by screening. That is the issue in all screening. It was a very complex consultation, and in my experience, if the woman was very worried, she proceeded to a smear test, but if she was reassured within the consultation that the programme was working effectively, she did not proceed to a smear test.

That is a very helpful clarification because it gives us an insight into what was actually happening.

It is important because there is a narrative being put out that because a free smear test was offered to women, everyone who went to their GP ended up getting a smear. We now know that 50% did not get a smear test. This is a personal opinion but if the Minister had not done what he did at that time in real time, given where we were in terms of confidence in the screening programme, I probably would have been calling for his head. I do not have an issue with the decision taken. There were consequences subsequently in terms of the capacity of the system to facilitate that.

That is regrettable. I also accept that when that decision was made, it had to be made in real time. I want to give the Minister the opportunity now to explain how we will address that because he said earlier that that is where the conversation needs to be focused. We are in a situation now again where we need to provide confidence to the 80,000 women who are waiting for those results. We need to speak to them directly. We have provided them with the smear test to reassure them. We now have a backlog. How can we reassure them in that regard? What will be the next steps?

I thank Deputy O'Brien for providing me with the opportunity to do that. The first thing it is worth saying is that I accept that two thirds of the backlog is made up of out-of-cycle smears where women decided, as we went through the process, in consultation with their GP for reassurance, to seek another smear test. One third, or one in three, of those is made up of new women entering the screening programme. I say that as it is a positive development. We talked about the way our screening programme can save lives. The fact that one in three of the backlog are new women who, after all this discussion about screening, decided to get screened and, for the first time ever, had a smear test is welcome. We see that in other countries too. They saw it in the UK at the time of Jade Goody's passing when there was a lot of discussion about it. It is worth remembering that many new women came forward and, it is hoped, some good will come of that.

The Deputy is right. What are we going to do now? We have to find extra capacity. That is not something we have been saying today or yesterday. It is something on which the HSE has been working tirelessly, and I singled out Damien McCallion for leading that effort. Until very recently, the HSE had not been able to say it had identified potential extra capacity. That changed last week when it was able to tell this committee and me that it has identified potential extra capacity. That does not mean we are over the line, and I do not wish to suggest that. This week, it is engaging with that potential extra capacity looking at quality assurance and all the other negotiations it has to do. If we can get that over the line, and I can only say "if" today, my understanding from talking to the HSE is that we will see a significant reduction in the backlog over the summer months. I would hope that if the extra capacity comes on stream, by the time we get to the end of the summer months, the end of August or so, the backlog will largely have been dealt with. I will be back to this committee when I have more news on that, or the HSE will be back to it, but I expect we will know one way or the other the direction of travel in that regard in the next couple of weeks.

In the next couple of weeks we will have a greater idea of whether we can secure that extra capacity.

I am sure the Minister is not just reliant on that particular capacity which has been identified. If we cannot secure that extra capacity, are we still looking at trying to get it elsewhere or is it the case that we have this potential capacity which we are now exploring and we are not looking outside of that?

No. We are continuing to look to and explore every opportunity. The other issue that will come into play, and a clinician will explain it much better than I will, is the benefit that the introduction of HPV testing will have in reducing the demand on cytology. There is an interplay in that regard between the introduction of HPV testing and the positive benefit that can have on capacity. There are other ways of looking at this but, to be blunt, the most straightforward way is to secure the extra capacity. As I said, those talks are ongoing this week.

I will not say too much else on the children's hospital but I have been asked to put on the record that at the next residents project monitoring committee meeting, a senior official from the contractor will be in attendance to discuss it with them. I am aware some of the residents are here. I am just confirming that will happen.

I had an opportunity, with Senator Devine, to meet some of the residents this morning. There is no way of avoiding the fact that when a person lives very near a large construction project, that causes upheaval for local residents and a great deal of difficulty for the local community. I know we all understand that. My understanding is that there is a structure set up for engagement between the local community, the contractors, etc. I have been advised by some of the local residents that they believe that needs to be refined and approved and that there must be better and more senior attendance from both the contractor and the health service at those meetings. I have given a commitment that I will ask that that happens at the next meeting, which I believe is scheduled for either this week or next week.

To turn to the Estimates, there are two areas in particular on which I want to focus, namely, inclusion health and the palliative care section in terms of the budgets. In terms of inclusion health, I refer to the issue of drug misuse and the number of referrals for addiction services. It is welcome that we are meeting our targets. The target last year in terms of the percentage of substance misusers under the age of 18 for whom treatment has commenced within one week following an assessment was at 99%, which is effectively everyone. My concern is about the waiting times to be assessed. There are two different issues in that regard. Once somebody gets assessed, he or she is getting the treatment within a very short time. We are meeting all of our targets in that regard. I do not see any information, and the Minister might be able to provide it by way of a note to the committee later if he does not have it now, on the number of people seeking assessments and the period of time they are waiting.

I have a particular concern based on my personal knowledge of individuals, particularly around opiate addictions, for instance, heroin. We are meeting the targets from the time someone is assessed to when treatment starts, which I understand is four days. That is the target for next year. The target was five days last year and we did it in four, so we have a new target for this year. My concern is the waiting times to be assessed, especially with regard to heroin use. I am sure the Minister is well aware that if somebody is addicted to an opiate such as heroin and for whatever reason that person has an awakening on a particular day that he or she wants to kick the habit, that person cannot wait around three or four weeks for an assessment because within three or four days the chances are that person is no longer in that frame of mind and the opportunity is lost. Will the Minister give us some indication of what we are doing to try to improve the waiting times to be assessed rather than the waiting times from assessment into treatment, which are excellent?

I thank Deputy O'Brien for this question. I know he is a strong advocate on this issue. He is right to say that some progress has been made in terms of the waiting time from referral to assessment, but he is asking what is happening in regard to the assessment to treatment aspect.

The waiting times from assessment into treatment are on target.

Four days, yes.

We are meeting them. My concern is the waiting times from referral to assessment. We are decreasing the waiting times, but much more work can be done in that area.

In consultation with officials here, we think that the target is still four days for this week for the actual referral to assessment. We believe that the four days refers to not just referral but referral and assessment. I will clarify the matter for the Deputy in a note.

The needle exchange programme is a very important public health initiative and is coupled with the methadone programme. I have received feedback and some pharmacies have decided not to continue with the programmes. How does the methadone programme work in partnership with pharmacies? Is it done on a contract basis? If so, once the contract is up is it renewed on a yearly basis? How is the programme implemented?

My understanding is that the contract continues unless somebody resigns from the programme. It is a contract that continues to roll unless somebody opts out of the programme. I will get a note for the Deputy. I have not been made aware of particular problems emerging, as the Deputy has but he is probably better informed than me on this matter. I am happy to discuss them with the Deputy and I get him a note.

One or two chemists will cease to trade and they have not been replaced in terms of alternatives.

I understand and ask the Deputy to provide me with the geographical area.

I thank the Deputy.

How will next year's funding for the National Treatment Purchase Fund have an impact on waiting lists?

I am very pleased to do that. The National Treatment Purchase Fund, NTPF, has a budget of €75 million for 2019, which is an increase on last year again. We managed to reduce the overall number of people waiting for inpatient day cases, hospital operation or hospital procedure to just below 70,000 in 2018. The aim is to reduce the figure to just below 60,000 in 2019. This year, we should continue to see reductions in the number of patients waiting overall. What is probably more important, which we never really get to discuss, is the length of time somebody is waiting. We are projecting that, currently, at the start of this year there were 40,200 people waiting for more than three months for operations, and the Sláintecare target is three months. We will reduce the figure to 31,000 people by the end of the year. We will reduce the number of patients longer than nine months for an operation from 14,900 to 10,000. This year, the NTPF funding will pay for 25,000 additional inpatient day case treatments and 5,000 scopes.

We are trying a relatively new initiative this year. For the first time in quite a while the NTPF will be used to fund first appointments for outpatients. The NTPF will carry out 40,000 outpatient first appointments this year. By the end of the year we should see the outpatient list lower than it was at the beginning of the year but an awful lot of work remains to be done. We are getting to a much better place for inpatient day cases. The number of patients now being seen in under three months or less for hospital operations is improving all of the time. The number of people waiting on the list overall is improving all of the time.

Outpatients, being very honest, are the big bulk or overwhelming amount of our waiting lists. This is where the Sláintecare stuff starts coming in. I am not suggesting there is a panacea here; there is not. If we are starting to fund GPs over the next four years to do more in chronic disease management that, potentially, removes people from our outpatient waiting lists. If we are looking at, through the Sláintecare integration fund, new and innovative ways of treating things like ophthalmology, one may be able to take some of that out of the hospitals. There is a lot of work. Last week or the week before, I chaired a meeting for a couple of hours and discussed how do we get on top of outpatient figures. We keep talking about a global figure but we need to look at the specialties of which ophthalmology is a big part. In a lot of ophthalmology cases if one can see someone at the outpatient clinic one can nearly do a see and treat, and be done, rather than putting somebody on an outpatient list, getting them seen eventually but then having to go somewhere else for the inpatient or day case procedure. We have a lot more work to do with outpatient figures.

To directly answer the question, the NTPF has a budget of €75 million. It will see the inpatient day case waiting list overall reduced to under 60,000 people by the end of the year, and it will see the reductions and times that I have outlined.

My last question is on the new abortion legislation. The last time I saw statistics I noted that not all 26 counties offered a service. Perhaps there were two counties that did not but I am willing to stand corrected. Can the Minister update us on whether there are GPs in every single county offering the service? What percentage of GPs provide the service?

I will have to get the Deputy accurate figures because they are growing and changing.

I am pleased that the figure is growing in terms of the number of GPs signing up. I get a fortnightly report on this matter and I am due a fortnightly report any day now. From my recollection, the last figures that I saw showed that more than 300 GPs had signed up, which is quite a significant increase from where we started. There are some counties that do not still have a GP signed up. I will confirm those counties to the committee and the Deputy.

I am relatively satisfied, as we approach 100 days since we introduced abortion into Ireland - abortion was always here but as we legalised and recognised as a country that it was a reality - I am satisfied that access is in place and that the helpline is working very well. The website called myoptions.ie is working well. The Coombe was the last major maternity hospital to come on stream but it did some work and is providing the service now as well. The general feedback that I am getting from the HSE is that the system is operating as expected. There have not been any particular issues flagged with me in that regard.

I am mandated under the law to lay information before the House after a year of the legislation. That will be the first opportunity for all of us to have a conversation. We also put in the law a mandatory statutory review of the legislation. We heard a lot of people say that there would not be enough GPs or hospitals. The general sense is, thanks to great clinical leadership by the Irish College of General Practitioners, ICGP, and others, and from hospital doctors, that the services are working well and women are accessing the services. A small number of counties do not yet have a GP signed up.

What about legislation on exclusion zones?

I expect to have a general scheme before Cabinet this summer, and as early as possible this summer. This is a priority for me. Unfortunately, Brexit and other things have dominated a lot of time for a lot of our drafters and the likes. I still expect to have safe access and a general scheme of legislation to Cabinet this summer. I look forward to being back here and interacting with colleagues this year. We should aim to pass, which I believe we will, that legislation this year.

I thank the Minister.

Before I bring in Deputy Durkan I wish to ask a question. What percentage of the reduction in the waiting lists for outpatient and inpatient procedures is related to validation, as opposed to the provision of treatments?

The Chairman has asked a good question. The central waiting list validation, according to my note, was established in June 2018. Let us remember that these are estimates because obviously it is to be a legitimate exercise where one has to decide one does not need an appointment. The general estimate is that about 30,000 outpatient appointments will be validated during the course of the year so the focus this year is largely on outpatients. There is a sense that when one has such a large figure, inaccurate data and lack of systems, there can be duplication or people can be treated in other hospitals and the like. I acknowledge we had a disparate way of carrying out validation and some GPs expressed the view that there was an unfairness or lack of uniformity about it, we did centralise things in the NTPF. My feedback is that the scheme is working quite well. Largely speaking, GPs think it is a fairer system and GP organisations and the like have been briefed on it. I am happy to supply the Chairman a detailed note on the matter. I understand that they reckon about 30,000 from the outpatient list is the number that will be validated. Let us remember that is 30,000 outpatients out of 516,000 outpatients.

Have 30,000 people been removed from the outpatient waiting list?

It is estimated that 30,000 people will be removed by the end of the year. That figure is subject to people not needing the appointments. It is not an exact science.

Will approximately 30,000 people be removed from the outpatient waiting list by the end of the year through the validation process?

That is an estimate, yes.

I want to discuss another subject but I will return to the most prominent issues again. I ask the Minister to shed some light on the full extent of staffing levels in the public health sector and the extent to which an embargo, which has been suggested, is likely to affect staffing levels.

Which areas are likely to be most affected, if any? What are the exact numbers of the increase in staffing levels over the past two to three years?

I very much welcome the question. Let me be crystal clear that the aim is not to have to apply a restriction. The HSE is meant to publish a pay and numbers strategy each year on how many people will be taken on in the health service that year. I am pleased to say, as the Deputy hinted, that thankfully in recent years we are back in an area of growth. We are hiring more nurses, doctors and therapists and we have a job of work to do in that regard. Imagine if the Minister for Education and Skills got his budget on day one and it said that the Department would hire a certain number more teachers this year and then individual schools throughout the country started asking for more teachers. Then the Department of Education and Skills would not live within its budget. It has to be the same in the health service even though it is a larger organisation. The same principle has to apply. The Oireachtas votes through a budget. The budget says that this year the Department will hire a certain number of thousand more staff, and it is roughly 2,000 additional approved and funded development posts by the end of this year. Last year, we saw the health service increase by more than 3,000, and to give the Deputy a flavour of that, we saw 867 new nurses last year, 175 new therapists and 125 new consultants. To be very clear, we are growing the size of the health service this year. There will be more nurses, doctors and therapists at the end of the year than at the start of the year, and that is right and proper because that is what members voted for when they passed the budget.

That is different from saying it is OK for the HSE at a local level to employ whoever it wants willy-nilly. It has to align with what we want it to do. Otherwise members will be back in here asking me why the HSE is over budget or they will be asking me how the hell we appointed all these people in different roles, be they roles to which members might not attach the same degree of priority. While I have not seen the letter, nor should I because I do not see every individual letter that is issued by the HSE, what the executive seems to have done in preparation for the pay and numbers strategy is to say to its system that if there is a plan in place, then recruitment can be continued with in accordance with that plan once it is credible, but if a credible plan has not been put in place and there is no intention to put one in place, then recruitment will have to be paused until one is put in place. I have spoken to the HSE about this over the weekend because I immediately saw it being portrayed as a moratorium and a ban on recruitment etc., and the HSE has emphasised to me very clearly, and I to it, that the aim is not to apply the restrictions to any hospital group or any community healthcare organisation that has a plan and is living within that plan. There cannot be a situation where managers carry out their own plans ignorant of the budget that we voted through. That is where we are at on that.

On the areas where recruitment is taking place, has that been of benefit to those sensitive areas which have been under stress over recent years? For instance, my colleague, Senator Colm Burke, has raised this issue on a number of occasions, which would seem to suggest that administration comes first and the front line services come afterwards. He says, and I agree, that it should be the other way around. The question that arises from that is who decides on the category of staff and who decides on where they are deployed?

Achieving exactly what the Deputy is suggesting is the purpose of a pay and numbers strategy because if there is not one in place, the question of who decides becomes very opaque and individual, localised decisions are made. Of course we want to give people individual flexibility but we have to make sure that the areas in which recruitment is focused are the areas which the Oireachtas and the Government have prioritised and want to prioritise. I believe they are. I quoted the number of extra nurses we have seen in the system last year, namely, 867, along with 175 therapists and 125 consultants. We still have a way to go, particularly with consultants. This is a document we publish every year called Health in Ireland: Key Trends, and if we look at the medical dental category, which has been going up since 2010, there were 8,817 people in that category in 2014 and that is now at 10,400 as of last year. If we take the nursing category, in 2014 there were 34,509 nurses and there are now 37,220. As for health and social care professionals, there were 13,640 in 2014 and there are 16,193 as of last year. The numbers are growing right away.

There is often a misrepresentation of management and administration grades because it is often an easy thing to do, and I am not suggesting the Deputy is doing it because he did not, but a somewhat populist view can be put forward that administrators are not playing these key roles and they often are. The person who is booking the appointments in the hospital or the person who is working with the consultant is making sure that a patient gets seen. It might be classified as administrative work but if we have the doctors and the nurses answering the telephone instead of somebody else, that is a waste of their skill as a healthcare professional. The Deputy is partial to an odd parliamentary question, and I say that in good humour, but they all need to be answered by people who might fall into that grade as well. Having said all of that, my honest view is that we need to slim down the management of the HSE and we do that through the Sláintecare programme which is put in place through geo-alignment, where instead of having dual management structures, one for a hospital group and one for a community healthcare organisation, we end up with one. The pay and numbers strategy is about exactly that. It is about making sure there is a clear understanding from all of us on what we as taxpayers are getting in extra recruitment for the extra investment we put into the system.

The Minister did not answer the question on the areas that have shown the most stress over recent years, but he might come back to it again. Incidentally, waiting lists are not a new phenomenon in this country. I have been around for a few years, and I was involved in the health services as well in a previous incarnation, and I can remember the same questions coming up year after year. I can remember the same constituents coming in to talk to me while waiting two, three, four and five years for hip operations and various other operations, notwithstanding the pain those patients were suffering and so on. It is not true to say that this is a new phenomenon. It is not. Neither are the expenditure overruns a new phenomenon. They have been going on for as long as I have been around. They have been happening every year to a greater or lesser extent depending on certain circumstances at the time, but it is not true to say that these issues have not arisen before. It most certainly is not.

The point I would emphasise is that in raising the question, I was trying to find out who deploys the staff to deal with the sensitive and overloaded areas. For example, I talk to many medical professionals and they all have their own opinions. I have my opinion about the HSE itself and it is fairly well known at this stage, so while I will not go into that particular rant at the moment, I have no doubt that there will be another day for that as time goes on. The point that is being brought to my attention by medical professionals is that there are specific areas where severe stress arises regularly from a shortage of staff to deal with the day-to-day running of the health services, and those areas not seem to get the same attention as they would like. Are they right or wrong?

This is a challenge in general. What we are trying to do and what I am doing more and more is that as we allocate the budget each year, we identify the development posts. We do not just give the health service €16 billion or €17 billion for the year and ask it to come back with a plan. We are trying to be collaborative and not adversarial in working with it to agree the priority areas. For example, one of the areas we have decided on this year is that there is a real pressure point with therapists, especially in therapies for children. This year, therefore, we have taken a decision to hire 100 additional therapists into the system. That then goes out as an understanding that it must be included in the service plan before I can approve the plan. When dealing with an organisation as large as the HSE in terms of staff, I am not, nor should my Department be, deciding the individual nursing numbers in each hospital, and the Deputy is not suggesting that I should be either. We are trying to identify those pinch points across the system that the Deputy rightly identifies and incrementally address them, budget on budget. We have had some success in some areas while work remains to be done in other areas.

From time to time, by way of parliamentary question, I have tried to ascertain, as the year progresses from the first quarter to the second quarter and the third quarter, the extent to which the budgetary provisions are seen to meet the requirements or the demand.

I have put that question repeatedly to numerous Governmentsm, but, for some unknown reason, it does not seem to be possible to identify precisely the extent of an overrun until the time comes when drastic measures have to be taken, either by cutting services or increasing the budget.

There are two parts to the Deputy's question, the first of which concerns the governance structures in place in the health service in general which the Sláintecare committee decided unanimously were inadequate. That is a view I expressed when I came to the committee and why I have worked hard to put a board in place. One could argue that the HSE has had a board before now. That is factually correct, but it was a different type of board in terms of skill sets. I do not mean that in a disparaging way towards former boards, but having the right skill sets is essential. The committee has a view that I have not got the skill sets fully right and wants me to put clinicians on the board. We are working our way through to have a robust, competence based board which I expect to take office at the start of June. We have to get the governance structures correct, but we also, through the accountability structures, have to ensure that when the money leaves the Department of Health or the HSE, it is spent appropriately locally. One cannot have a situation where one hospital group works really hard to try to come in on budget and another that blows its budget and the hospital that is performing well is expected to compensate. One must reward good behaviour. The regional board structure will provide for a greater layer of oversight in order that every question will not have to be referred to the Minister of the day or the Oireachtas. There is a need for greater scrutiny. I know that the Deputy is a strong advocate of the health board structure. I suggest the new model we are proposing under Sláintecare offers the best of both worlds, such that one would have a strong slimmed down national centre, with more functions devolved to the regions, with better regional oversight, in order that, as the Deputy said, one would not hear in September that the HSE had overshot its budget by X hundred million euro, that there were early warning signs and about the ways to work through the budget both at individual hospital level and national level.

The problem is that when the times comes to take action to curtail expenditure, usually it is in very sensitive areas, resulting in maximum impact and a public outcry. Action taken earlier would have the effect of avoiding the glitch at a sensitive time and there would be more scope to rearrange funds, for want of a better description, to meet oncoming challenges.

Overruns are not free of consequences. Even if the taxpayer can find the money needed from buoyant tax receipts, as we could this year, it is money that could be spent somewhere else. The first area should not always be the politically sensitive or patient sensitive area. I am not involved in politics as long as the Deputy and do not have the same experience, but I share his viewpoint in taking a healthy scepticism to what is often presented as the appropriate course of action.

On the reassurance offered to women in presenting for cervical smear tests, are we satisfied adequate provision has been made to enable us to say, hand on heart, that they will not find themselves stressed out? I know that we have the best intentions, but that is not way things happen. Within reason, can we reassure women that everything has been put in place, that everything that can humanely be done has been done to address the issues that have caused serious concern, including death, as a result of a failure to identify a condition on time? We know that cases have ended up in court which have made decisions. This should not be happening. I have come to the conclusion that a great deal of time and energy and, more particularly, expenditure, will now be put into addressing the legal issues involved, but that does not address the health issues involved. In actual fact, addressing the health issues involved does not require litigation. The question is what will be the level of expenditure in defending cases. I know that there will always be a certain amount spent on legal fees, but if we reach a situation where an inordinate is being spent on legal fees, we will have to question the service we are providing. We are in the business of providing a health service, not legal services.

I thank the Deputy.

I have one more question. I am a patient man and wait for everything.

A figure of €360 million has been budgeted for this year for the State Claims Agency. Of course, that is not all for legal fees - nor am I suggesting it is - but that is the Estimate for the State Claims Agency this year. As a Government, we are doing a number of things to try to address the issue and reduce the amount involved, of which open disclosure is one element. We all know - Dr. Scally talks about this issue passionately, with conviction and from experience - that often an early admission that a mistake was made, a genuine apology and learning are what we want as citizens, but all too often we have found someone has to go down the adversarial route to get answers.

Is the level of expenditure increasing?

Yes, it is. The figure was €320 million in 2018.

We have introduced periodic payments through the Department of Justice and Equality. When people go to court, they often do not want to receive a massive lump sum, but they need to know that they will be able to care in an orderly manner for themselves or their loved ones affected by an adverse incident.

The third element is a big body of work, on which the Department of Justice and Equality is leading, but we are contributing to it. An expert group chaired by Mr. Justice Charles Meenan will examine the reform of tort law in this area in general and the reasons medical negligence cases need to be so adversarial to see if there are better ways to deal with cases. We have seen an element of this in the piece of work done on CervicalCheck and the tribunal legislation we will bring forward, but there is a broader piece of work to be done. I do not disagree with the point made by the Deputy.

On how we can reassure women that lessons have been learned from what went wrong in non-disclosure following an audit in CervicalCheck, I think the Deputy made the point which I will reiterate. Obviously, screening is not a diagnostic tool; there are always false positives and false negatives in any screening service. At the very heart of this debacle there is the issue of non-disclosure. Disclosure was meant to happen. It is not a question of whether disclosure is good or bad. It was agreed that disclosure would happen, but clearly something then went very wrong. I say to the women of Ireland and their families that we have key recommendations in the Scally report that will fulfil what I believe was Vicki Phelan's ambition when she first spoke to me to say she wanted some good to come out of this. We will eradicate cervical cancer within a generation and I am determined that we will do so, as is my Department. Doctors are determined that we will do so and we will do it through vaccination and a really robust screening programme. We can eradicate this awful disease. The Scally report is so detailed in its recommendations and people are working very hard on them. I asked Dr. Scally to stay to oversee progress and he has just produced his first progress report in which he note very good progress has been made. Encouragingly, he has praised the Department of Health and the HSE for the seriousness with which they have taken the recommendations made in his report.

My last question resonates with a point made by a number of speakers. It relates to whether the oval shape design of the national children's hospital is the most expensive structure to build. That is not necessarily the case, as it depends on the curvature of the building. If it is a tight curve, it will costs quite a lot more, but the larger the building, the less likely it is extra costs will be incurred for the simple reason that the curvature will be more gradual. I hate to impart knowledge, as I usually ask questions, but for the benefit of the multitudes, all of whom have gone home and are issuing press statements, I throw in that fact just to alert them that some of us are watching that matter too.

That was a comment, rather than a question, but, as always, an informed one.

The bed capacity review of last year indicated that if substantial health reforms were implemented during the next ten years, there would be a need for 2,600 beds, but if substantial health reforms were not introduced in the next ten years, there could be a need for up to 8,000 beds. The actual figure will probably be somewhere in between. Obviously, there is unmet need in the system, as evidenced by the trolley count which is a crude measure, but nevertheless it indicates the lack of bed capacity to meet the needs of those on waiting lists.

When will we see new build beds being provided in the next ten years? Sláintecare suggested we should have elective surgery-only hospitals. My understanding from the Sláintecare implementation strategy and plan is that the choice of location and the design of hospitals will not be available until 2021, but perhaps that is not accurate. The Minister can clarify the matter. When will we see the expansion of bed capacity to meet unmet need? There are approximately 450 consultant vacancies in the system, which is undoubtedly leading to a delay in service provision and meeting unmet need. Pay disparity between consultants appointed pre and post 2012 is a factor, as are working conditions. It is a huge problem in service delivery.

It is very welcome that the Department and the Irish Medical Organisation, IMO, have come to an agreement on the restoration of funding for general practice, but it leaves the issue of many communities being left without a GP when one resigns. The issue is most acute in rural areas, but it also arises in urban areas and towns. Will the Minister speak about guaranteeing a community will have a primary care service independent of market forces which often dictate whether a GP will be replaced when someone retires or resigns? There is a proposal which I presented to him last year for a fellowship programme which the University of Limerick, in particular, is proposing. When a practice becomes available but cannot attract a candidate, the graduates from the GP training scheme would rotate through the practice, perhaps sharing their work commitments to hospital medicine and research in order that young GPs could supply a service to a community that cannot attract a GP. They could maintain their university connections and continue to carry out research. There is a proposal that, as part of a fellowship programme between the university and the HSE, services be provided for a community that cannot attract a GP.

The Minister might comment on the three items to which I have referred.

We are beginning to roll out additional bed capacity. The Chairman asked when new builds or extensions would open. There are 40 beds due to be opened this year in Clonmel. I think there are approximately 50 due to be opened in Drogheda, while 60 are under way in University Hospital Limerick. When we publish the capital plan shortly, it will show how we will endeavour to roll out further beds in the coming two to three years.

On elective surgery-only hospitals, I bow to the Chairman's knowledge, but I would not be satisfied with not selecting sites until then. My understanding was sites would be selected this year, but I will check and come back to the Chairman on the matter. As the Department keeps explaining, there is a bigger body of work to be done, as opposed to just picking a site, in deciding what will be provided in the elective surgery-only hospital. It varies from country to country. When I visited Scotland recently, I saw what had been done there. There is even an intensive care unit. The services to be provided will have a bearing on the site chosen. I know that the committee will receive a comprehensive briefing on Sláintecare this afternoon.

The Chairman made a fair point about consultant vacancies. We have seen the number of consultants in the system rise, but there are many vacant consultant posts, which is a cause of concern to me. I have recently met several consultants. I have met the Irish Hospital Consultants Association and the IMO and discussed the issue with individual consultants. The Public Service Pay Commission states there should be a process in place to deal with the issue of consultant pay. I will be working my way through it with colleagues to see how best the Government should respond.

The Chairman welcomed the restoration of funding for general practice. I will consider the fellowship programme again. The Department and I will respond to the Chairman's suggestion, for which we thank him. With the IMO we have agreed to increase the rural allowance by 10% from next year and, for the first time ever, establish an urban deprivation fund, something about which the Chairman had spoken to me. The Deep End group had made a point about the inverse relationship between the availability of health services and meeting the health needs of a community. There is a fund of €2 million available this year and will be every other year. We need to work out how best to utilise it. I will come back to the Chairman on the idea of a fellowship programme.

On consultants' and GPs' pay, we very much welcome the reversal of the financial emergency measures in the public interest, FEMPI. It was one of the things for which Fianna Fáil had pushed hard in the budget negotiations. There is also the huge issue of a pay discrepancy for new entrant consultants where consultants have the same qualifications and it so happens one of them worked abroad for a few years but is paid €70,000 less. It has been identified as one of the big reasons we are finding it so hard to attract back consultants trained in this country or in attracting foreign consultants. We have the lowest number of consultations in Europe per head of population, which is a major issue. Within the Estimates are we seeing any provision or is there any thinking to include a provision to unwind or begin to unwind the pay discrepancy for new entrants in order that we can begin to hire the consultants we so badly need?

I am aware of the Deputy's commitment to general practice and pleased that we could collectively make some progress on the issue. Being very blunt, there is an issue with consultants' pay. How we resolve it requires the Government's collective thinking. Quoting from memory, the Public Service Pay Commission was clear that there should be a process in place to consider the issue. The decision is not mine alone, but I intend to engage with the Government more broadly on it in the coming weeks to see how we can respond. As I said to the Chairman, I have had some meetings recently with the IHCA, the IMO and individual consultants. I cannot go further than that today as there is no agreement. It would be a new pay agreement.

The GP contract provides for the reversal of the financial emergency measures in the public interest, FEMPI. To the best of my knowledge, there was provision made for this in the Estimates in anticipation that the unwinding would begin this year.

There is no provision made in the Vote because the issue of new entrants' pay is dealt with centrally by the Government. It is generally dealt with through the Vote for the Department of Public Expenditure and Reform.

Provision would still be made for consultants' pay in the budget.

Not necessarily. The issue of new entrants' pay could be dealt with centrally. We have dealt with GPs' issues, or at least I hope we have dealt with them. It is a matter for them to decide. We have made good progress in dealing with the issue of restoration issue, among others. I accept that consultants' pay is the next big issue from a human resources perspective, with the staffing of the health service. It will have my full focus in the coming weeks.

The Chairman asked several questions about Sláintecare. From memory, the Sláintecare report estimates that the requirement in year one will be around €600 million or €700 million. The requirement for activity specifically related to Sláintecare as opposed to things that were happening is about €20 million. Do the Minister and the Department broadly accept the Sláintecare figure of several billion euro for the transition fund, or has the Department made its own analysis and has its own profile? Does the Minister accept the figure €20 million for this year, regardless of the Department’s figure which is way below what is needed to launch Sláintecare properly?

There are two parts to that question. I think the Deputy knows I do not accept there is €20 million for Sláintecare this year; there is €20 million in the Sláintecare integration fund. I will not rerun my view from my opening statement. Even the €27 million for the GP contract this year is clearly Sláintecare. The DPS and prescription charges are directly from Sláintecare in the budget. We have the figure of over €200 million this year for Sláintecare. I know there will be a briefing later at which the Deputy can scrutinise that, but that is the figure we have.

I accept the Sláintecare plan; however, I do not accept and have never accepted the sequencing of it. While I do not speak for the Deputy, I doubt if he would either. I am not sure if the Chairman would accept it either. If I accepted the Sláintecare plan sequencing, I would have introduced free GP care for another 500,000 people this year, which obviously would have come at a considerable cost, but would have collapsed general practice, without dealing with how to fund general practice. Through the work of Laura Magahy, we have tried to sequence the aim of Sláintecare in a better way.

Does the Minister have costings attached to that revised sequencing?

Yes. To be clear on this, I accept the overall cost estimate of the Sláintecare report over a ten-year period, but I do not accept its sequencing. Even the ramping-up period was not, in my view, taken into consideration. The Sláintecare report is an excellent report and I fully accept where it wants to get us. It was not an operational or implementation plan. We did considerable work to detail it. We published our response to it last year and now we have published year 1 of the implementation plan this year, so we do have costings.

While I think the Deputy will understand I can brief Deputies and talk to them about some of the costings, we cannot crystallise them publicly. There are some big things. For example, one of the big recommendations of Sláintecare, which I support even though not everyone does, is taking private practice out of public hospitals. I commissioned a report from Dr. Donal de Buitléir, which I now have, and once I have deliberated on it, I will bring it to Cabinet in due course. The cost of that, for example, is likely to result in significant negotiations. It is hard to crystallise all the costs but broadly speaking, I do not disagree with the costs of Sláintecare; I just disagree with the sequencing of it.

Regardless of its sequencing, I am asking about the costs in the first three years because we need to make provision for them. I ask the Minister to provide the overall spend per year required to deliver Sláintecare in order that we can look at that, relative to what is outlined in the Sláintecare report.

I am happy to provide the Deputy with all that I have on Sláintecare. In some areas I will not have the level of specificity pending negotiations, big policy decisions and legislative change that the Oireachtas must make.

Just today I was contacted by many people about the drug, Spinraza. Obviously many people were very disappointed at the decision not to proceed at the current price. Do the Estimates we are considering today make provision for Spinraza to be made available at some point this year?

When setting out a drugs budget, for obvious reasons we do not outline at the start of the year all the drugs we will provide because new drugs come on stream, negotiations go on etc. I hope we can make Spinraza available. The legal responsibility lies with the HSE. I know many parents are very anxious and stressed. While I do not have a note on it, I understand the company has now submitted a revised offer to the HSE that is being considered. I hope we will have news on that shortly. I would be happy to come back to the Deputy on that in writing today or tomorrow.

I will finish where I started. I thank the Minister for providing the email with the advice from CervicalCheck to the Department on the offer of free out-of-cycle tests. It makes for very interesting reading. It details many of the risks and predicts much of what happened. When the decision was made at Cabinet the following Tuesday, was this email made available to the Cabinet?

No, nor was it available to me.

It was not available to the Minister.

To be very clear, this is not a criticism of my officials. I believe they behaved entirely appropriately in how they dealt with this and indeed showed great leadership. The email was not made available to me or the Cabinet. It was not passed on to me because all my officials believed all the risks outlined in that were risks that were readily identifiable to them. There was nothing in this that was new to them. They knew the risks associated with this and still believed it was the appropriate action to take. The email pointed out that it was a matter for my Department to make the decision. The email came post the decision and post the announcement of the decision.

When was the Minister made aware of the national screening service's concerns?

I think I became aware in February of this year - in recent weeks or months.

Does that mean the departmental officials never told the Minister that people running the programme advised in the strongest possible terms that the offer of the free test could fundamentally undermine the system and lead to these delays?

These concerns became available post the decision being made. I was taking the advice directly from my officials, who were at this stage effectively stepping into the breach. These concerns were not passed on to me. I believe it is somewhat irrelevant as to whether they were because I believe the decision was right, based on the advice I had from my officials and the time we were in. All of the risks in this are similar to risks the Deputy has been outlining in recent weeks. Indeed, I believe I outlined the content of this email to him as far back as March. I am satisfied that my officials' explanation that there was nothing in this that they had not already identified was appropriate. These were readily identifiable risks.

I wish to ask about the sequencing of Sláintecare. One of the foundation recommendations in the report is to expand universal primary care to the entire population. The report outlines that the expansion of services cannot take place until we have adequate GP manpower on the ground to deliver it. While it recommended a roll-out of 500,000 a year, this was only to happen once capacity was available within general practice. We are talking about whole-time equivalents. We know the number of GPs on the Medical Council register and who have a GMS contract. They may not all be whole-time equivalents and the capacity issue relates to the number of whole-time equivalent GPs delivering a service in the system.

As the Minister is aware, a significant number of practices are not taking on any new patients because they cannot deliver the service. For safety reasons they have closed their lists. The Minister has come to an agreement with the IMO on restoration of funding, but that may not necessarily deal with the manpower issue. In order to deliver free GP care to different cohorts of people, such as those aged up to eight, ten or 12, we need the capacity to deliver it. While the Sláintecare report proposed delivering 500,000 new patients to free GP care each year, it was only provided the capacity was there. There has been no move to increase GP capacity.

I did not mean to be critical of the Sláintecare plan and I hope it did not come across in that way. I just make the point that in that sense, if one were to be negative, it is somewhat contradictory because it is saying that this must be done in year 1, but later on it states that it can only be done when something is in place. I thought we needed to make it more programmatic and that is the work Laura Magahy has been doing.

I accept we have more to do on this. I hope the measures we have agreed with GPs will help to fix the capacity and manpower issue. We are significantly restoring fees; it is for the IMO and the NAGP to outline that. We are also going beyond that by increasing the rural allowance, putting urban deprivation in place and providing funding for, I believe, 247 whole-time equivalent practice nurses. I hope this will make general practice a more attractive career choice in the future.

I think that concludes-----

I have a good few questions, but I will keep them until next week.

I am sure the Minister will communicate with the Deputy directly.

I thank the Minister for appearing before the committee to discuss the Estimates. I also thank the Secretary General, Mr. Breslin, and the assistant secretary, Mr. Desmond.