Vote 38 - Health (Supplementary)

We will now consider the 2019 Supplementary Estimate for the Department of Health - Vote 38. I again welcome the Minister of State, Deputy Jim Daly, and I thank him for the briefing material which was received by the committee secretariat yesterday at 6 p.m. I now invite him to make his opening statement.

I thank the select committee for the opportunity to bring this Supplementary Estimate for Vote 38 before it. The total additional funding sought for 2019 is €338.1 million, €90 million of which relates to decisions made subsequent to the national service plan, including pay agreements, escalation of no-deal Brexit planning, winter planning and CervicalCheck. The balance relates to the impact of the level of activity demand coming into 2019 and the continued growth in that demand during the year and the overrun in settlements by the State Claims Agency.

While the amount sought is significant in monetary terms it represents 2% of overall health expenditure in 2019. The level of funding sought represents a significant improvement on previous years and is indicative of significant efforts undertaken to balance the service challenges in health with the priority of Government to maintain fiscal stability. The enhanced focus on financial management in 2019 is particularly important given the uncertainties arising in regard to Brexit. Over the past five years, the majority of additional health funding has been allocated to pay cost pressures associated with Government pay policy and to maintain existing levels of service, taking account of demographic changes. These allocations are balanced with new developments, seeking to continuously improve the Irish health system. In addition, the growing costs arising from pensions and the State Claims Agency must also be addressed.

I will now set out the items which make-up this year's Supplementary Estimate. In March, the Government agreed to the establishment of an ex gratia scheme for those affected by the non-disclosure of the CervicalCheck audit. The scheme is designed to provide an alternative, non-adversarial and person-centred option for those affected by the CervicalCheck non-disclosure issue. To date, 161 of the 221 cohort identified have made applications and all have been paid. In addition, the CervicalCheck tribunal was set up in July to provide an alternative system for dealing with claims arising from CervicalCheck, reducing the adversarial nature of hearings for the women and families affected.

On pensions, for which €24 million is sought, the budget allocation to cover superannuation costs in the HSE for 2019 is €490 million, inclusive of the first charge from 2018 of €24 million. While expenditure on superannuation during 2018 has been broadly in line with expectation, there was no scope to offset the incoming first charge. On the winter programme, €26 million is sought for the 2019-20 winter plan, with additional funding for the 2020 impact included in the HSE's national service plan for 2020. This funding is crucial to reducing overcrowding pressures in our hospitals and will deliver additional home care packages, transitional care beds, necessary aids and appliances and will allow for the activation of winter action teams to manage unscheduled care performance through various initiatives. Demand for acute hospital services exceeded the resources available in 2018, resulting in the system entering 2019 at an expenditure level beyond the approved level of funding. This was to be addressed through achieving affordable levels of staffing and other savings outlined in the service plan. However, demand continued to grow in 2019 and this countered the impact of any targeted savings achieved and, along with the growth in costs associated with the management of antimicrobial resistance and infection control, contributed to the estimated funding shortfall by year end of €50 million.

A further €50 million is sought for disability services. The deficit within disability services arises from demand for emergency placements, an increase in the provision of home support hours to help alleviate the urgent demand for placements, the changing needs of clients in receipt of services and regulatory compliance. All such factors create significant pressures within disability services, resulting in considerable challenges in maintaining affordable levels of service.

A further €43 million is sought for the nursing agreement. It will assist with the recruitment and retention of nurses and midwives in the public health service. Significant funding will be provided for a range of tangible and specific enhanced nursing practice measures, including an enhanced practice role for nurses and midwives, increases in allowances and an extension of a range of allowances. The implementation of the framework on a safe staffing and skills mix is also a key to the agreement, and a €5 million investment will be made to continue its implementation. It is anticipated that the agreement will achieve savings through a reduction of agency spend where the framework is in place and through productivity measures in the new enhanced practice role. The HSE has a detailed implementation plan in place and a report on all aspects of the agreement, including savings, should be available in the new year.

A further €3 million is sought for the job evaluation scheme for support staff. The funding will ensure that the relevant grades of support staff are uplifted to the recommended pay bands using the methodology and timeframes set out in the Labour Court recommendations.

The State Claims Agency has a statutory responsibility to manage claims to ensure that the State's liability under the clinical indemnity and the general insurance schemes, with their associated legal and other expenses, is contained at the lowest achievable level. Its role also includes the successful recovery of costs from third parties. The agency has informed the Department that, in actuarial terms, the clinical indemnity scheme, established in 2003, has yet to reach maturity and is not expected to plateau in respect of volume and cost of clinical claims until 2020 at the earliest. We are informed that the increasing costs of the clinical indemnity scheme are not due to the increasing numbers of claims but rather to the increasing costs of awards and the high costs associated with catastrophic injury claims. In addition, payments relating to historical Medical Defence Union, MDU, have to be taken into consideration. Such payments arise due to an arrangement put in place in 2005 between the then Minister for Health and Children, the Irish Hospital Consultants Association and the Irish Medical Organisation to ensure that in the event of an adverse clinical incident involving medical negligence, no patient would be left uncompensated and no doctor who was a member of the MDU would be left without indemnity insurance cover in the event that the MDU refused to indemnify him or her. Under the arrangement, a consultant can request the assistance of the Minister in meeting the cost of damages arising from a claim. The State Claims Agency manages the claims. Subsequently, in settlement of litigation related to indemnity cover, the MDU paid the State €45 million. Due to a recent High Court action that was settled, relating to an MDU case, a final lump sum payment of €17.5 million will be paid out of the Department’s Vote in early December.

A further €13 million is sought for Brexit planning, In 2019, the Department and the agencies under its aegis, in particular the HSE, the Health Products Regulatory Authority and the Food Safety Authority of Ireland, were required to be proactive in preparing for a possible no-deal Brexit by ensuring that detailed contingency measures were in place.

A further €157 million is sought or the primary care reimbursement service, €77 million of which is to fund the 2018 first charge, with €80 million to fund the 2019 current deficit, which was primarily driven by overruns in the high-tech arrangement and the long-term illness scheme.

A further €45 million is sought for appropriations-in-aid. They are received by Ireland from the UK in respect of health services provided under EU regulations. Following discussions, a sum of €270 million was agreed for 2019, a surplus of €45 million over the 2018 Revised Estimates Volume, REV, amount. The surplus will offset the gross supplementary requirement of €383.1 million, resulting in a net Exchequer supplementary of €338.1 million.

In summary, the Supplementary Estimate seeks to address the funding requirement arising from decisions made subsequent to the national service plan, particularly central wage agreements and shortfalls arising from increases in eligible demand for medications, access to overseas treatments and the overrun in settlements by the State Claims Agency. The new leadership team in the HSE has succeeded in maintaining the additional pressures in the health sector at less than half the level of last year. In addition, the new HSE governance board is in the final stages of preparing a 2020 national service plan with improved health services for citizens, without carrying over a large financial overhang from this year. Since the Supplementary Estimate was presented to the Government, however, additional costs associated with the State Claims Agency and pensions have emerged. Both the Minister for Health and the Minister for Public Expenditure and Reform were conscious that this was a possibility, given the inherent forecasting risks associated with the demand-led areas. The additional costs arising in 2019 will result in a first charge in 2020, which is currently under discussion with the Department of Public Expenditure and Reform in the context of the 2020 REV to ensure there will be no impact on the service level set out in the HSE's national service plan.

The issue of sustainable health funding is a major challenge, not just in Ireland but internationally. Dealing with a growing and ageing population, more acute health and social care requirements, increased demand for new and existing drugs, and the increasing cost of health technology will continue to pose a financial challenge into the future. Sláintecare gives us a new roadmap to support the delivery of high-quality care to our citizens, improving the way services are organised and delivered, and reducing costs to maximise the ability of the health service to respond to growing needs must remain our focus. It is essential that those managing and delivering the service continue to demonstrate good practice by delivering the best healthcare within the significant level of resources made available by the Government for 2020.

I seek the committee's approval for the Supplementary Estimate.

The Minister of State looks younger every time he appears before the committee. On a serious note, I will start with the process. The Minister of State, the Chairman, Deputy Durkan and I were in the House until 10 o'clock last night to vote. The briefing, which is detailed and concerns almost €500 million of taxpayers' money, was received at 6 p.m. We in the committee started work at 9 o'clock this morning. I was on my way back to the House at approximately 6 a.m. When were we supposed to have time to interrogate a document concerning €500 million of taxpayers' money, given that we received it at 6 o'clock last night, we worked in the House until after 10 o'clock, and the committee meeting started at 9 o'clock this morning?

I do not know why it was left until 6 o'clock yesterday evening to send the briefing to members. I suspect it was a case of, "Events, dear boy, events." Nevertheless, I take the Deputy's point on board and appreciate that it is frustrating to be given that amount of time. Particular circumstances pertained to events in the House last night and members had to return to attend the meeting at 9 a.m. today. I will take it on board and feed it back to the Department to ensure it will not happen again and that more time will be given. I appreciate the seriousness of the issue to which the Deputy referred, namely, the Supplementary Estimate of approximately €338 million to be approved at the meeting and the lack of time.

Last year, we received the briefing at 10 o'clock the night before. The health service is running over to the tune of approximately €500 million or €600 million per year of taxpayers' money. Men and women work their backsides off to earn the money in order that the State can pay it. There is yet again a massive overspend. The children's hospital is massively overspent. It is the job of the Oireachtas to interrogate the money. That is the job we are supposed to do today, but we received the information with zero time to interrogate it for the second year in a row. That says a great deal about the level of financial management and the view from within the Government as to how seriously it takes oversight of taxpayers' money. It is an outrageous insult to every person in the country who pays tax or uses the hospital system.

The money involved is not really €338 million. By my count, it is closer to €456 million because the €338 million includes a reduction of €45 million, due to a contract negotiation with the UK Government over treatment abroad schemes.

It has nothing to do with the provision of services. It is just an unexpected negotiating quirk and an accounting issue, which reduces the total amount required but does not reduce the amount overspent. When the additional €45 million is added back in to try to get to the overspend one gets the €383 million. Then there is the extraordinary line of €73 million which is also taken off the overspend for what they call time-related savings. I was curious to understand, in the limited time we had to interrogate the documents, what time-related savings are. It sounds like a good thing, that we have managed to reduce the overspend by €73 million through such savings. What it actually means is things that were meant to be done this year that did not happen. Going through the document, page 6 refers to the €73 million and says that time-related savings happen because facilities open later than they are supposed to, because negotiations to buy things take longer than they should and recruitment into designated roles does not happen as quickly as it should. That €73 million is, therefore, due to not doing things that the health service was meant to do and has nothing to do with the overspend. One must then add that figure back in. When the accounting quirk with the British Government is removed along with the item that is not a saving at all but is just not doing things on time, the overspend for running the show is north of €450 million.

Before we get into the detail, then, I have a question. The Irish Fiscal Advisory Council, IFAC, said that the overrun in health this year and in previous years is so big that it threatens the entire financial picture and the financial stability of the country. It has done some very useful analysis on the overruns and their figures, not mine, are as follows: in 2005, the overspend was zero and there was no conversation on overruns; between 2006 and 2010, inclusive, it was also zero; between 2011 to 2013, inclusive, it started to increase to €200 million, €250 million, €300 million; and for the past few years it has been averaging €500 million a year. The current Minister came into office in 2016. Between 2015 and this year, the combined overrun is €2.3 billion. One question this committee must grapple with is how year after year, despite multi-billion euro increases to the health budget beyond anything that has ever been seen here or in other countries, waiting lists are getting longer? How is the Government spending more money at a phenomenal rate, up from about €12.5 billion in 2014 or 2015 to €18 billion next year but everything is getting so much worse so quickly for so many people? Part of the answer is the overruns. When one starts adding up €500 million a year one gets to several billion euro that is expended on plugging gaps in places, not on service provision. Before we get into the detail, what was going on that for the first five or six years of the HSE there were no overruns, then from 2011 they were modest and now we are up to annual averages of €500 million?

The Supplementary Vote that I seek approval for today is €338.1 million in addition to what was outlined in 2019. We can keep turning the figures and presenting them in different ways but that is what I am seeking approval for. I do not want to muddy those waters. I have outlined that €115 million relates to an overspend from last year which I inherited this year and approximately €90 million relates to decisions taken since. That is either a prerogative that the Oireachtas would like to retain or we can absolve ourselves of. I refer particularly to issues on which the Deputy was extraordinarily animated such as increasing pay for nursing staff - a political decision that was taken outside of the projections in last year's national service plan - and the CervicalCheck ex gratia scheme. That €90 million resulted from political decisions taken by the Oireachtas and the Minister during that period. As long as that facility is available, there will always be potential for an overrun. We can have a debate over whether the Oireachtas should not have any say in the running of the health service and it should be as it is projected in 2019 or 2020 at the beginning of the year and we can accept that, but we cannot have it both ways.

The Deputy asked about the general overrun. I cannot answer historically for the HSE about what happened in 2005 or 2006. I was a county councillor at that time and had no involvement whatever in national politics. I was a member of the regional health forum and that was as much input as I had into the health service then. In general, as the Deputy knows well, it is a demand-led scheme. Much of the money is spent on pay, on which there are many pressures and demands. Politicians, from all sides, continuously demand pay increases and demand that we pay the people who work in the health service better. It returns to my point that we can stick rigidly to the budgets. I was here this time last year when there was an overspend of €655 million. We do not agree that is acceptable, we do not want that level of an overspend in the HSE, it is not our ambition and we are not satisfied with it. To be fair to Paul Reid and his team in the HSE, and the team in the Department, I am here with an overrun of €338 million rather than €655 million. That is not where we want to be but it is progress.

On the various issues raised -----

On a point of order, this is a debate on a Supplementary Estimate. It is not the same as an ordinary committee meeting. It is normal procedure to alternate between Government and Opposition when offering. Otherwise I will have to vacate, because with the best will in the world, I do not have all day to sit here listening to the wisdom of my colleagues.

I will bring Deputy Durkan in.

The Minister of State is looking for €338 million from the Oireachtas, but within that there is an overspend of €450 million, which is why it is relevant. No one has suggested that we seek not to be able to add things to the budget but, as he said, that amount is €90 million. If he was here looking for the €90 million that the Oireachtas agreed for extra services, that would be fine but that is not what this is. It is €90 million of a €450 million overspend so the measures that the Oireachtas sought account for one fifth of the total overspend; it is the other four fifths with which there are issues. I acknowledge that the Minister of State was not a Member between 2006 and 2009, inclusive, but for five or six years there were no overspends and in the time that he has been here and in a ministerial role the overspends have been approximately €500 million. It seems reasonable that anyone in a ministerial role when overspends were that high would look back to the period when the overspends were zero and have a view and would have asked officials to run the numbers to see why. It is reasonable to expect the Minister of State and the Minister to have a considered answer to that because therein might lie some of the ways by which we deal with the overruns.

There seems to be an absence of performance metrics. Some are detailed but quite a few are not. In acute hospitals, for instance, it says the money needs to go here and there.

Can the Minister of State explain why there are no desired performance outcomes accompanying a request for very large amounts of taxpayers' money?

I reiterate that €115 million of this is an overhang from the previous year that must be factored in. If the Deputy wishes to use the figure of €456 million, he must accept that €115 million comes from 2018. I have already outlined how the sum of €90 million was allocated at the discretion of the Oireachtas, as Deputy Donnelly and I agreed. That leaves a figure of approximately €275 million. That is not where we want to be. I would prefer not to be before the committee looking for that additional money. However, I have to make the point that last year the comparable figure was €655 million. That was not acceptable either and two wrongs do not make a right, but we have moved significantly. It is not possible due to a range of pressures such as central wage agreements, pensions issues such as changes to pension-related deduction, PRD scales, the cost of drugs and medicines that become available at any one time-----

I am sorry to cut across the Minister of State. The specific question is this. There are no performance outcomes associated with these figures. For example, a very large number is quoted for the drug reimbursement scheme. I will try to find the number. As I said, we only got this late last night. However, no reasons are given. The number is in the tens of millions. Some €85 million of the primary care reimbursement scheme funds is for high-tech drugs. This document does not specify what drugs are being covered and why. Is the Minister of State looking for an extra €85 million because the forecast was wrong, or because certain high-tech drugs were okayed whose approval was not forecast? Alternatively, are we paying a higher price than was forecast? Why are we paying €85 million?

We will move on to Deputy Durkan after this question.

I thank the Deputy for the question. I must clarify that I needed to make some of those broader points in response to the Deputy's points. There is an onus on me to respond. I note that the HSE manages the health service. Neither I nor the Minister for Health, Deputy Simon Harris, manages the health service. That is the HSE's responsibility. Some of the questions Deputy Donnelly is asking would be more appropriately directed to the HSE. It has a quarterly meeting with the Oireachtas committee next week. The Deputy will be able to pursue some of the detail which I do not have in discussions with management. I am discussing headline figures within a €17 billion budget.

The Deputy asked about drugs and gave the figure of €85 million. The actual reimbursements for high-tech drugs during the period from June to October 2019 were higher than expected. This was primarily driven by higher reimbursements for rheumatology, gastroenterology and dermatology drugs. High-tech drugs reimbursements are now forecast at €797.9 million, which is €94.9 million higher than the original 2019 budget.

I know the Chair wishes to move on but I wish to say something in response to that. I will not make a long statement. The Minister of State is seeking €157 million in additional funding from the Oireachtas. I know the Minister of State did not write this, but his officials have provided two sentences with no detail. That certainly does not strike me as proper governance, and I doubt it strikes the Minister of State that way. This is not really a matter for the quarterly review. This meeting is the moment to interrogate requests for extra money. A two-sentence explanation provided the night before falls a long way short of what we should expect to justify an extra €157 million for drugs.

I wish to repeat the point that the normal procedure in a debate of this nature is for discussions to alternate between Government and Opposition. Otherwise there is no sense in some of the rest of us coming in until the Opposition is finished. I could come back tomorrow. If the Chair gives me notice I will be quite happy to do that.

I want to draw attention to some of the fallacies in my colleague's remarks. We have had a long debate about various new medicines becoming available. There has been a strong debate in the House and outside of it, and we all know the demands that have been made in the course of the last year. They are legitimate demands. We have to listen to them and take them on board. We also have to take on board the concerns of the patients and families who depend on these innovative medicines and are hoping for a reimbursement programme. There is no sense in coming here at the end of the year and asking what all that was about, where it came from and what has gone wrong because we did not think about it before. That is not acceptable behaviour at all. This is nonsensical stuff. We are having a debate that we should not have at all. It is a waste of time. We are returning to every item of expenditure on the basis that the children's hospital overrun is causing all the problems. It is not. If people had followed the debate that has taken place in this country in the past three years they would not have to ask those questions. It is misleading to the general public to pretend that this is the answer to all their prayers. If people want to say that we should not continue with the new children's hospital, by all means let them say it. Let them embrace that ideology. Let them come forward with it. That puts an end to the debates. They can then spend all the money that was going to be spent on the children's hospital elsewhere, provided, of course, that it meets the criteria. However, fantasising in the committee or in the House about where money should be spent after it has been spent is a waste of time, energy and resources.

The Irish Fiscal Advisory Council has opined on this issue. That is correct. I have listened to its opinions repeatedly. The council has a job to do and I fully respect the need to stay within budget insofar as it is possible. I suggest its officials should go to the hospitals and ask the patients on waiting lists and their families what should be done in respect of A, B, C or D as it affects them. It is about time that we copped ourselves on. We must get away from repeating colourful nonsense in the media. I am not interested in that sort of thing. I want to see something done directly about the subject in question. There is a flaw in the system. We need to identify a contingency sum in the health Estimates on an annual basis, one that is sufficient to meet the projected overrun in demand.

I note the figures for 2012, 2013 and 2014 as compared with 2007. There was a vast difference in circumstances. The country was broke in 2007 and it was very easy to come up with an Estimate that fell within the required levels, even though achieving that level left the country even more broke. We have a situation now where we have to anticipate the growth in demand facing the system. The health service is a demand-led service. We have to make up our minds in this committee, in the House and in the debate nationally. What do we want to do about it? Do we intend to make a cool, calm and collected decision about what is required to run the services at the beginning of the year, given the number of imponderables likely to come before us? The Chair has spoken about this, as we all have. We need to cut out the pretence and actually identify it. I believe that we should be budgeting for a higher level of excess expenditure, for want of a better description, in order to cater for the continuity of the services throughout the year.

There are two groups of people who can deal with that. They are the managers of the system and the economists of the system. There are those who will say that over the years economists have strangled the health services, that their activity and inactivity in other areas have caused problems for the patients and the general population. We have to deal with that. We have to establish the level of growth. To put that in context, members should think of the number of people who left the country in the period from 2005 to 2014. In the latter part of that period there was no money in the country to pay for anything. We must compare like with like. It is utterly outlandish for any spokesperson for any party, Government or Opposition, to pretend that if we curtailed expenditure on the children's hospital we would somehow solve all our problems. We would not. We have a budgetary problem that needs to be addressed. The current budgetary problem is the annual budget for a Department. This is one of those Departments. It is the one Department where outlay is determined by demand. We either meet the demand or we do not. I ask that we confine ourselves to those areas, because they are important.

I wish to mention another area that comes to mind. I will address these points collectively. I will not go through them individually. I read them insofar as I could and I had the same difficulty. I was travelling yesterday and I did not get the chance to read them. I must say this.

The mental health services are still the Cinderella of the system. For example, it is impossible to get treatment for a child who is in need of a programme in any service at the current time. It cannot be done. People are admitted to the accident and emergency departments of general hospitals and spend the whole day there, but there is nowhere to go. There are no beds and no permanent programmes. There are permanent programmes in place to deal with drug addiction and other health matters, but there are no programmes for mental health patients, especially children, who require attention of an ongoing nature as well as treatment and care under supervision outside and inside of a family setting.

In the course of the preparation of the Estimates, I ask the Minister to outline to what extent attention was given to that area. It needs attention. I know of a child who was waiting for 12, 14, 18 or 20 hours on a trolley in an adult hospital, having been diagnosed four years ago as being in need of urgent attention and a programme. The child has failed to get access to a programme from any agency, such as Linn Dara, St. John of God's and so on, for a variety of reasons. However, it all comes down to one thing, namely, the availability of a necessary framework and structure to accommodate that patient.

Can we be assured that there is something to deal with that within the Estimates this year? Whatever happened before was not sufficient.

Can we-----

Unlike everybody else, I will not hog the show for the whole day.

Can we get a-----

By the same token, we all need to be clear about the difference between the current and capital budget. Some projects are more advanced than others, the result of which is that demands will not be made for cheques to be written at a given time. This is not new; it has been going on forever. It is part and parcel of the running of a service. I have listened to every debate very carefully and I am sick to my back teeth listening to people moaning about something they know full well about. The only thing that happens is that they make statements to the media and rush to make sure they stand up to the privileges-----

This is ridiculous.

Sorry Deputy-----

-----that go along with the privileges of the House.

Deputy Durkan, we are considering the Estimates-----

I know. I have been sitting here listening to the debate for three-quarters of an hour.

Can we get the Minister of State's response to the Deputy's comments?

Deputy Donnelley's rant is permanent.

Lads, please. We are very-----

I appealed to the Chairman before and he did not do anything about it.

Deputy Durkan has made up for it now.

There is more to do.

I ask the Minister of State to respond to some of those comments.

I thank the Chairman and Deputy Durkan for his contribution. I accept the point he made about projections and building in a bit of overhead room for contingency planning. It is a very reasonable and valid point. It could probably be calculated to a degree actuarially because it is a demand-led service. Increasing numbers of people are attending accident and emergency departments and so on. I could speak at length about the changing goalposts. What the Deputy said is that there should perhaps be a contingency fund, which is a valid and sound point, rather than having a debate every year about overruns. We will focus relentlessly on that overrun and that has been the priority for the Government and the HSE for the year, with some degree of success. Others may have different views on that.

The Deputy's substantive point was on mental health, an area very close to my heart and for which I have responsibility. I am quite happy to engage with him on that. It is difficult to comment on an individual case for obvious reasons and I do not know the background to the case to which he referred.

On the overall issue of accommodation for young people in mental health units in the country, only three counties in Ireland have inpatient beds for young people, namely, Dublin, Cork and Galway. These figures have not been verified, but this year there were in the region of 300 admissions to inpatient units for young people and teenagers.

I visited Linn Dara in Dublin recently. What it is doing is particularly impressive. It has developed a high dependency unit which is working well. It is also dealing with eating disorders in young people, which are very difficult and challenging for the system because there are young people in acute hospital beds who are medically unwell while also being mentally unwell. Linn Dara is treating such patients very successfully. It has had in the region of 110 admissions this year, which is a significant increase on last year. It has also had a significant increase in the number of discharges, which is very important.

The Deputy also referred to young people in adult settings. The numbers have reduced significantly this year, which I am glad to see, in particular in the second half of the year. This is due to the very good work being done by Linn Dara, which has reduced the reliance on young people being admitted to adult wards. There will also be a certain cohort of young people admitted to those wards, because of geography and the fact that parents may make a choice that they do not want to go to Dublin, Cork or Galway. As I have said, a 17 year old may be very strong and, therefore, be better off in an adult ward, rather than a ward for young people, even though the arbitrary age for such a ward is 18 years. We acknowledge that there are situations where there is no capacity, but they are reducing in frequency thanks to the good work of Linn Dara.

Deputy Durkan asked about the consideration given in the preparation of Estimates to mental health for young people, in particular. There are 70 community CAMHS teams and last year we created a lower level of infrastructure, namely psychology services, in the community. There are now 130 psychologists and assistant psychologists specifically for young people and a phone line was developed, which was launched last week, to direct people to the appropriate services available.

When we started our research, we found almost 1,100 mental health services were being funded by the HSE. However, people are not being appropriately referred, and either do not know where services are located or cannot find them. People are not always in a position to go to a GP, for financial or time reasons, to find out where to access services. The phone line is a significant development in terms of creating a more appropriate referral pathway.

The waiting lists for the 70 community CAMHS teams was 2,500 in January, but had reduced to 2,000 by October, a reduction of 20%. I hope there will be a 25% reduction by year end. That is a direct result of the introduction of psychologist and assistant psychologist services at community level the length and breadth of the country. The better way forward is early intervention and allowing people to access services sooner because there can be continual escalation of issues if people's mental health is not treated in a timely manner. I hope the change to waiting lists for community CAMHS teams for young people is sustainable. As Deputy Durkan knows, our ambition is to treat people in the community and give them the best services there. In the 1960s, there were 20,000 inpatient psychiatric beds in Ireland, but today there are just over 1,000. We have moved significantly away from inpatient beds, but there will always be a cohort of people who will require inpatient treatment. Portrane is being developed and will open in the coming year - the keys will be handed over in the next month or two. The number of beds in the Central Mental Hospital will increase from 120 to 170, a number of which are for young people. We will have increased capacity for CAMHS patients and teenagers. Mental health is very much a consideration in our budgetary planning for the year ahead.

I thank the Minister of State. The overspend this year is €338 million, going on the figures provided, compared to €655 million last year. The Department of Health is getting closer to remaining within budget. Of course, we understand it is a demand-led service and an aging and growing population will place more demands on it. When the new CEO of the HSE took up office in May, one of his first priorities was to try to keep within budget. This may be a reflection of the efforts he has made. There is a balance between supplying a service and staying within budget.

There is much unmet need with respect to waiting lists, access to hospital services, outpatient services and waiting for elective care. Remaining within budget has an effect on unmet need so how does the Minister of State see that panning out over the next year if the 2020 budget is to remain on target? Will this adversely affect unmet need because waiting lists are not improving substantially? They are increasing instead. How will this be balanced?

It is a very fair, important and interesting question. The Chairman will appreciate that the answer is not simple. There is a continuous challenge to keep a healthy tension between the pull and drag in this. We cannot have an open door, with money for everything, in a demand-led service. We have to achieve a scenario such as that driven by the chief executive officer, which is to get people to live within their budget. That is all part of the drive coming from the political side to not have overruns. We cannot on one side tell the chief executive officer that he must meet every demand and deliver every service looked for while at the same time telling him he cannot come back to look for more money.

On one side there are Government and Opposition Deputies saying there cannot be an overrun and the chief executive is doing his job in telling every health manager under his remit that we need to live within budget and if more is needed at the end of the year, a conversation can be had on the amount. On the other hand, there is the issue raised by the Chairman, as patients are real people. They are our mothers, daughters, sisters, brothers, grannies and other loved ones. If we see them on trolleys etc., we are given a challenging pause for thought. There is much more to this system than just money and that is where we can bring in Sláintecare's move away from the current process. Any additional euro we are putting into the system, such as with the nursing wage increases, are negotiated with respect to process, change and better productivity, with more efficiencies and an increase in capacity in our health care system. That can be done and there are initiatives such as the lean sigma programme. I have referred to Sláintecare and the Chairman is well aware of the GP contract. There is also care of patients with the likes of chronic obstructive pulmonary disease and other chronic illnesses in the community, which is a better way.

This is about achieving efficiencies that increase capacity in the system. There is a healthy tension that will continue and must be maintained. We cannot just say that we will give everybody what they need but we must continue to monitor the finances. We are dealing with real people and patients and getting that balance right is not an easy call. There must be structural and procedural change. We must look at how we do what we do and find better ways of doing it. This can only be brought about by having this kind of tension and attention to finances.

There are specific items in the Estimates. There is the treatment abroad scheme and the cross-border directive process, which are demand-led schemes. There is increased allocation for those, and the treatment abroad scheme is used because people cannot get treatment here in a timely manner so they go to another jurisdiction. It is an area that could be addressed with more efficient service so people would not find it necessary to go abroad. It should be dealt with through the budget for our services here.

There is also the question of the State Claims Agency and the increasing amount paid out in claims against the State. It is again probably a reflection of the pressure the health system is under that there are so many claims against the State. I believe there is contingency for future claims of €1 billion, although I am not quite sure if that is the correct figure. How can the Department and the HSE deal with those additional demands?

They are both very pertinent and obvious in looking at the Estimates. We can see there are two pinch points that have been identified very astutely by the Chairman. They are recognised readily. I agree with the Chairman that they need continued focus. The first is the cross-border scheme and it relates to capacity in our system. We can keep purchasing the services where there is capacity or we could use that money to invest in infrastructure. To its credit, the HSE has opened an additional cataract theatre in Nenagh this year, as the Chairman knows. Waiting lists for that treatment have decreased significantly, and numbers have almost halved. I do not have the figures off the top of my head but we will have them for next week's quarterly meeting. The numbers have been significantly reduced because of the additional capacity. There could be further capacity and we might be better off spending €2 million, €3 million or €4 million on a new theatre as opposed to spending that money in other ways. People are waiting for the treatment today, however, and a theatre takes a year to come on stream. It is about getting that balance right.

I mentioned in my opening comments that the number of claims to the State Claims Agency is not rising, which is interesting, and an increase in awards is driving up the figures. Every day we get up our first priority is patient safety and we must continue to drive that agenda from every aspect of the health service. It is ultimately the best way to deal with this. In tandem with this, the level of awards, which is outside of my direct jurisdiction, is an issue across the board in society. It is being addressed currently.

The Minister of State mentioned the €115 million overhang from 2018. Does he anticipate there will be an overhang going into 2020 from 2019?

I think not. There are always external factors that can catch us, such as the State Claims Agency. Something like that could leave us with an overhang or well above projections but we do not anticipate the day to day or bread and butter work of the HSE in delivering services will leave an overhang with respect to the service plan. External factors such as the State Claims Agency or the cross-border process are a bit beyond our control.

Could it be €115 million?

I do not reckon it would be anything in that region.

I thank the Minister of State.

I thank the Minister of State for coming here today. One of the matters raised by consultant representative bodies when coming before the committee is the lack of training posts. As a result of the loss of experienced medical people to other jurisdictions and the reliance on locums, we now have the potential for a legacy issue as approximately half our non-hospital consultant doctors are not in training posts. We do not have expertise in the pipeline. I am particularly concerned about it because we have said so many times that it is not just money that gets people back but rather conditions. We discussed the children's hospital here last week and we hope it will be the best children's hospital in the world so we can attract the best people to work in it. I have concerns on how we will staff it with respect to junior doctors and training programmes. Is there anything the Minister of State can tell us today that will address the matter so that in 2022 we will have the best doctors to treat our children when this much-needed hospital is eventually built, despite many people's best efforts to not have it built?

The treatment abroad fund is very helpful to people who are waiting a long time for treatment but there are administrative costs borne here in our regular budget. The National Treatment Purchase Fund is separate. Without oversimplifying the matter, it is not as simple as sending a patient abroad and we never see him or her again once he or she is fixed up. There is still an administrative burden here. The information from abroad must be sown into the system. It is a good idea but I get alarmed every year at the increase in budget. It is good because we are treating more people but I would prefer to treat them at home and they should be in our system. There has been a year-on-year increase over the past number of years so how will we try to reverse this so we can have our people treated in our hospitals by our doctors?

With regard to the State Claims Agency, we had the CervicalCheck scandal this year and it had a large cost arising from administration and insurance payouts.

I understand the weight of the claims are predominantly based in the obstetrics and gynaecology area. While it is great to have a large budget of €1 billion or whatever it is, no money will ever pay for a catastrophic incident at birth. While it is great to have the money there, my preference would be to have no budget for claims against the State, just as with the NTPF, because we would not have any claims and we would not send people abroad. As we try to address legacy issues from the recession and the impacts they have had on staff quotas, staff morale and the loss of expertise, how can we get our act together to move out of the recession period and repair our health system to serve people with the benefits of modern medicine, demographic pressures and so on? How will that be managed in the future? I acknowledge that is a broad question.

I will do the best I can. We will have the quarterly meeting with the committee next week so there may be some more extensive responses available to the Deputy at that stage and that might provide a better opportunity to put questions to the HSE and so on.

The consultants and skilled staff issue is an important topic that gets a lot of attention and focus in the Department. We want to ensure that, as the Deputy said, when we build the children's hospital, we can address that. I have the same issue in my portfolio in that the new central mental hospital is due to open next year and we want to ensure we have the requisite number of consultants. The Deputy began by asking about training posts. That is something I had occasion to look into recently as well and I am glad that there has been a significant increase in my area in funding next year for higher specialist training that is necessary to work at consultant level. I do not have the numbers to hand but the numbers being trained have increased across the board year on year and more funding will be provided next year again in a number of pinch point areas where there is a deficiency. We are also looking to the challenge whereby consultants can move on after their training and we are competing with the global market and that is linked to terms and conditions. The children's hospital and the central mental hospital in Portrane will be two state-of-the-art environments for people to work in and be part of. That environment is a help.

Significant progress has been made on a number of outstanding issues relating to consultants in the past 12 to 18 months but some issues remain that we would all like addressed and we are trying to get to those remaining issues on a piece by piece basis, notwithstanding what we have achieved in negotiations with consultants on their conditions. The training of advance nurse practitioners, ANPs, across all skill sets is highly important as well. That is a positive development in the health system that offers enormous potential and, again, they work well in my area. They call ANPs physician assistants in the US where there is another level below the consultant level but above hospital doctor level. We have a lot of work to do in Sláintecare to look at identifying the skill set and the skill match. A great deal of work is being looked at in the framework in order that we can meet those demands but that is an ongoing challenge.

I concur with the Deputy on the cross-border scheme. I would prefer if we had the capacity here to treat our own patients but under EU law every EU citizen has a right to travel for healthcare if they so wish, if the treatment they need is not available in their area and we have obligations in that regard. It works both ways. I recall a meeting with the head of the police in Dubai. They are anxious to work with us again as they have been availing of coronary care in Ireland. Any members of the Dubai police force who require coronary care and heart procedures are sent to Ireland. That is obviously not covered by the EU directive because the United Arab Emirates is not in the EU and they are using private hospitals so they are not causing a blockage. People will always travel for healthcare. I would prefer us to have increased capacity but the difficulty is that the money being spent on that scheme could build additional capacity but that lifeline cannot be cut off. It would be illegal to do so. People have to have the right to migrate.

I am not suggesting we stop that.

I appreciate that. We have to try to pull back a little bit and get the infrastructure in place. We have done so successfully with cataract operations. The numbers waiting for cataract operations have decreased significantly but we have more to do on that.

The Deputy asked me about the future. Can she summarise that question again?

The question was about how we address the future and the Minister of State has answered that in terms of the staff issue and that is what I am concerned about. Does he have any solutions to offer on the issue of the State Claims Agency and the expensive bill for same?

The wider debate about the size of awards is part of the issue but patient safety is where the Department and the medical profession have to put their focus and drive. It will always be a case that where humans are delivering a service, there will be error. Until such a time that we reach a 100% robotic delivery of a healthcare system, there will be no scenario in which mistakes are eliminated but they can be significantly reduced with better conditions and a better physical environment. All those matters are improving bit by bit and we have increased capacity but there is no silver bullet for that challenge.

Before I bring in Deputy Durkan again, I want to take up a point Deputy O'Connell made. I refer to the issue of recruitment embargoes or freezes or to the practice of only employing staff within available resources or budget allocations. It can be counter-intuitive that by limiting staff or freezing recruitment, money is saved. Of course money is saved in one budgetary silo but patients generally do not go away and, therefore, if they are not getting service, they will either get it elsewhere in the emergency department or they will deteriorate and require more complex treatment when they eventually get treatment. If there is a limitation on staffing levels, that does not necessarily mean money is being saved. Money may just be transferred to a different budget that providers for more urgent or complex treatment instead. We have been looking at workforce planning in recent months and we have had many different groups before the committee. The consistent message from all of them is that failing to recruit or staff to an appropriate level is costing additional money and no money is being saved. Does the Minister of State have a view on that?

I believe personally, politically and professionally that if we always do what we always did, we will always get what we always got. If we continue to keep hiring and throwing more money at the problem, we will not fix the healthcare system and I am not suggesting the Chairman is proposing we do that. The other extreme is not to hire any more staff so there is a balance to be struck between those two positions. I spoke earlier about the constant tension between the desire to continue to recruit and looking at what we have done. It is about reorganising healthcare delivery and the budgets. We are here as politicians and one day we are giving out about an overrun and the next, we will give out that the service is not there and so on. How do we fix that? It is about structural reform. The regional integrated care organisations, RICOs, are an important development as opposed to the community healthcare organisations, CHOs, because it was maddening to see people in the community considered not to be part of the problem if they were on a trolley or on a hospital bed for an extra week. That did not bother the people in the community who were in charge of home help in the slightest because if one person was in the hospital, that was one less person for them to take care of. That siloing we did in healthcare was not helpful with budgeting. We can continue with additional recruitment in acute healthcare but we could look at more proactive ways and means of avoiding admissions to acute healthcare. Perhaps there should be more recruitment for community healthcare. Recruitment in and of itself is a solution but it is not the solution to everything. Putting a cap on it is about getting people to work within the budget they have so they cannot have an open-ended budget. Otherwise, we will be back here again next year looking for an €800 million Supplementary Estimate

I will give one example and then I will move back to our members. We had evidence from a consultant a number of weeks ago to the effect that if the number of consultants in rheumatology, for instance, was increased from two to four or from one to two, the waiting list would dramatically drop for that service. I refer to that targeted recruitment, not just recruiting for recruitment's sake. Where there is a bottleneck in a service, targeted recruitment improves the outcomes and reduces the waiting lists. That is the type of recruitment I am speaking of because that then leads to better outcomes and probably saves money in the end.

That is understood and we are not significantly behind the curve in respect of the number of people working in the system to deliver a health service to a population of our size. It is about getting the balance right through continued recruitment and finding better ways of providing services. It is a combination of both. I take the Chairman's point. Of course, targeted recruitment will continue for the year ahead.

Waiting lists in general have consumed much of our time. How can the waiting lists be dealt with? It is not rocket science. If we have a waiting list of 1,000, we should be able to figure out how long it will take to deal with it. This is where the planning comes in. Where are the deficiencies that prevent us dealing with that waiting list now? If we cannot deal with that waiting list within a specified period, we should know the specified period within which it should be dealt with and we can then do the budget again. If we cannot do both and identify exactly what is required, the waiting lists will go on forever. If a waiting list is half a mile long this year, it will be two miles long next year because we will have not shortened it. The only way to deal with that is to attack it from all ends together. If that means reverting to the treatment purchase scheme or the private sector, we need to deal with it. There is no good talking about it.

I recently came across a case where the patient was due to come back in two or three years because the condition was supposedly controllable or containable. It was not and I was proved right. If we are telling patients things like that, we are reducing public confidence in the system. I do not attribute blame to anybody in particular, but we all need to recognise it. It is no good talking around the subject; we need to deal with the subject.

Just as in the PC sum to deal with unforeseen issues that come up during the year that we have to deal with - we have to deal with emergencies anyway - we should also draw up a plan to tackle the logjams. It is a farce to have people hanging around in emergency departments all day long and the following day. We have older people sitting on trolleys for two or three days. We should not be dealing with that at all. It is demoralising. Why do we not have a bed to put them into?

Earlier today we had a discussion with representatives from Fórsa on step-down beds. There are step-down beds for women in St. Brigid's Hospital in Crooksling and the Government is closing the place on the basis that the facilities there are old. They are not old; all they need is ongoing maintenance. Such facilities could come on-stream to relieve the pressure we are now facing.

We need to look again at how we are doing it. If we put one doctor into a hospital emergency department and leave him there for three or four days, I guarantee that he will be out the door and down the road after a week. It is not possible for one person to deal with full weight of the demand at any given time. We need a relief system and we must be prepared to recognise that that will arise.

People will claim that I am speaking like an Opposition Member. I am speaking as I have always spoken, as a member of any health committee or body; I have been on a few of them over the years. There is no difficulty dealing with the political element, which means nothing in terms of a contribution to alleviating the problems that now assail the health services. To lift that siege, we need to be able to reassure people with a plan for reducing waiting lists in the coming year.

The IFAC needs to know that as well. I do not propose to take on the council because I know where we went in the past. However, it needs to take into account those areas of current expenditure where we need to deal with the size of the problem as it arises. The result is we do not do anything about it in which case the service becomes run down.

Ireland is the third most expensive of the OECD countries and 27th in public satisfaction ratings. There is something wrong there. I do not know what the problem is. I am not an expert in these issues. I do not need to be an expert, nor does anybody else. However, somebody somehow and somewhere needs to say, "Okay, we're going to merge these two areas. We are going to deal with them. We are going to identify the contributory causes." We are continuously told about the Dutch and Swedish models. They do not work, for God's sake; they have the same problems.

It all comes back to identifying the scale of the issue in a service that cannot be postponed forever. If it was a road building project, it could be postponed, but when somebody's health is at issue, it cannot be postponed. Doing nothing scares the public and demoralises those involved in the service. It avoids facing the decision that has to be taken eventually to deal with the patient.

I agree with the Deputy. The politics is one side of it. To use a medical analogy: we can treat the symptom or treat the cause. Much of the time our energy and money is focused on treating the symptoms and not the cause. The Deputy referred to access to care. In 2020, we will to publish an access plan for unscheduled care looking at how we can deal with this issue.

Talking about the politics of it and politicians, a few months ago a lady approached me. She said she had been out of work for a year and a half because of an injured shoulder and was now fit to go back to work. She needed to be signed back on by her consultant. She rang the consultant's office to find out if she could see him. He told her he would see her in 2021. She told me she did not want to draw disability allowance for the next 18 months or two years, while waiting to see a consultant for five minutes to sign her back to work. She asked if I, as a Minister of State, could so anything for her.

I wrote to the consultant and asked if there was any possibility he could see this lady for five minutes. He wrote back to me saying that he would not discuss any of his patients with me and suggested it was more in my line, as a Minister of State, to provide more money. That shows what happens when people look to politics to solve these problems. There are structural issues. I tell that story for two reasons. One is to illustrate the Deputy's point about the politics of it. More important, it is to look at how we fix the structure.

In one particular discipline in the south of the country, I have sought information from the HSE through the Secretary General of my Department on the time each of the consultants in this discipline is giving to private and public practice. There are enormous anomalies in the one I am looking at. These consultants were contracted by the State and are supposed to be spending a certain amount of their time delivering to the public. These are issues affecting waiting lists because they are all on the public side. Obviously, on the private side there is no waiting list and a patient can be rushed through and there are incentives for people. I am not saying that is widespread, but I have come across one area where it is certainly an issue and I am doing further investigating to try to get to the bottom of it where there is a particularly long waiting list.

Structural reforms like that will fix it as well as just policy and, as the Deputy would suggest himself, not soundbites.

I thank the Minister of State and his officials for attending this morning.