Vote 38 - Department of Health (Supplementary)

This meeting has been convened to consider the Supplementary Estimates for Public Services 2020, Vote 38 - Department of Health. I welcome the Minister for Health, Deputy Stephen Donnelly, and his officials to the meeting to consider the Supplementary Estimates. I also thank them for providing the briefing note relating to the Supplementary Estimates. I invite the Minister to make some brief opening remarks, after which members will contribute. I remind members that, in accordance with Standing Orders, discussion should be confined to items constituting the Estimates.

I thank the select committee for the opportunity to bring this Supplementary Estimate for Vote 38 before it today. I apologise to colleagues for not being available earlier today, as the committee had requested. I was attending a meeting of EU health Ministers, an annual meeting. It was quite long, but it included matters such as a briefing on Covie-19 vaccines so, regrettably, I could not make it to a meeting this morning. I thank the committee for accommodating this time today.

The additional funding I am seeking for 2020 is €514.5 million. In June, the Oireachtas approved an additional €2 billion to meet the costs of the health service’s response to Covid-19, bringing the new adjusted total for the health Vote to €19.9 billion. The Supplementary Estimates request for Vote 38 relates primarily to the costs associated with Government decisions on Covid made subsequent to the Revised Estimates in June. This includes additional funding for measures, including personal protective equipment, PPE, testing and tracing, €200 million for this part of the winter plan, escalation of no-deal Brexit measures, one-off funding to support disability services, one-off funding to support palliative care providers and the costs associated with the Covid-19 vaccination programme.

In June, I said that the additional approved funding of €2 billion would not represent the totality of the cost of Covid-19 for this year and that further funding would be required. This is that request. The health Vote has required Supplementary Estimates each year for the past number of years, and the HSE worked very hard last year to bring down the additional funding requirements. I am committed to working with the HSE and the Department to continue to strengthen the financial management.

On a side note, I draw members’ attention to the recently published Economic and Social Research Institute, ESRI, report, “How does Irish Healthcare Expenditure compare internationally?”. I am sure colleagues have seen it. It compares healthcare expenditure in Ireland to that of other OECD countries. It is the first report of its type that does this accurately. It is something I have sought previously, as have health committees in the past. There has been an ongoing perception that Ireland spends more than other countries on healthcare. The ESRI report shows that when measured per capita and on a like-for-like basis Ireland’s total expenditure on healthcare ranks ninth among the EU 15 and it drops to tenth when one considers just the public aspects of healthcare expenditure. It is a topic I would like to engage on with the committee on another day, if the committee is interested. Between us, we could re-frame the conversation about healthcare expenditure in Ireland with a view from me and many of my colleagues that if we are not as high up the tables, there is room for us to continue pushing.

The health service has responded in an unprecedented fashion to Covid-19 and has incurred substantial additional costs in doing so. The single most significant medium-term cost is PPE. Included in June’s Revised Estimates for the Covid-19 allocation of €1.997 billion was €253 million for PPE. The HSE has forecast PPE expenditure of €920 million to the end of this year, which includes planned stock levels at year end of approximately 12-years supply in line with clinical management guidelines. This leaves a supplementary request of €667 million compared to the original allocation.

The June Revised Estimates approved €208 million for testing and contact tracing. This initial allocation was to fund testing and contact tracing until 31 August. Included in the Supplementary Estimates today is a request for €68 million, which is required to fund testing and contact tracing to the end of the year. Up to the end of November, almost 2 million tests had been carried out.

A significant element of the request relates to the HSE winter plan. The Government committed €600 million in total to deal with winter pressures and the additional pressures presented by the pandemic. This includes €600 million for 2020, which is in today’s Supplementary Estimates, and €400 million for 2021, which essentially is January, February, March and April. The winter plan is increasing the capacity of the health service and ensuring continuity of service by providing additional commute and community resources, staff and beds, as well as funding initiatives including the flu vaccination programme and many other items. Budget 2021 funds the permanent retention of many of these measures, which is very exciting.

Taken with the June Revised Estimates, the Supplementary Estimates today bring the total net cost of Covid-19 supports provided to the health service to over €2.5 billion and total health expenditure in 2020 to just over €20.4 billion. While the financial impact is very significant, the value of this investment in protecting our citizens in the face of the global pandemic is unquantifiable and, I would argue, priceless. I seek the select committee’s approval of the Supplementary Estimates of €514.5 million for Vote 38.

I will start with subhead J1, regarding the vaccine and procurement at a European Union level. Page 5 of the briefing document refers to 15.6 million doses of vaccines that we could potentially procure. That is across a range of different pharmaceutical companies and types of vaccines. It states that the estimated cost would be €117.6 million. Is that €117.6 million for 15.6 million doses? We may not draw down 15.6 million doses because we may not need that many. It depends on what vaccine comes first. Does the figure of €117.6 million relate to those 15.6 million doses of vaccine?

Yes, my understanding is that it does. I do not want to eat into the Deputy's time but I could give him the number of millions of doses for each of the five or six vaccines we have.

Yes, if the Minister wants to do so. This is important.

AstraZeneca’s vaccine is the first one, of which we have 3.3 million doses. We have 2.2 million doses from Janssen, 3.3 million from Sanofi and 2.3 million doses from Pfizer. From Moderna we have 875,000 doses. The sixth vaccine is from CureVac. For the first five companies, we are signed up to the advance purchase agreement and those are the initial doses Ireland will get from them. CureVac is the sixth and we are not required to enter into the details of that just yet.

The total cost of all those vaccines will be €117 million. It is unlikely that we will have to purchase all of them. Will we have to pay for them anyway because they are advance purchases? Are we locked in to those purchases and that cost of €117 million? If we did not draw down some of them would it be a lesser amount?

My understanding is that we are locked in. The mechanism in which the EU is engaged is the advance purchase agreement, which essentially helps with the incentive for the companies.

We are locked in. That is fine. We obviously do not know which vaccine will come first. We see what is happening in Britain and all the different vaccines that are coming on board are very encouraging. Aside from the procurement costs, I imagine that there will be storage, distribution and administration costs as well. Are those factored in? Have we an estimation of what those costs will be?

They are factored in. The Deputy will remember from the budget debate that there is a pot of several hundred million euro as a provision against Covid measures and such things would be pulled from there. The distribution should be, relatively, cheaper than the vaccines themselves. The task force is currently working with the various State agencies on exactly how it would work. The different vaccines will have different distribution mechanisms. For example, the Pfizer vaccine has to be stored at -70°C most of the time, although the temperature can be higher for two or three days before it is used. The doses must be taken 14 days apart and that has to be quite tightly matched, whereas somebody-----

I appreciate that. Different types of vaccines will have different storage requirements and could involve different costs but we have to plan for that. The expert group will be looking at all of those things. That figure of €117 million, and whatever storage, distribution or administration costs there will be, is still quite small in the context of the overall cost of Covid. Covid has cost us tens of billions of euro economically and that is leaving aside the social costs, including the people who have lost their lives, and so on. Is it the Minister's plan, regardless of which Covid vaccine comes first, that it would be rolled out for free?

Yes it is. I was talking to the public health experts about this today in the context of the statement from the UK yesterday. It is not necessarily the case that whichever vaccine comes on market first will simply be the one that everybody gets. My understanding is that different vaccines may be more suitable for different people or age groups. When we get the validation data from the European Medicines Agency, EMA, which will provisionally sit on 29 December to make a decision on the Pfizer vaccine, at that point or before then the EMA-----

It will be free. Does that include not just the vaccine cost itself but the GP costs, pharmacy costs and administration costs? Will everything be provided for?

No Government decision has been made on that but my unambiguous view is that the State should cover all costs, just as does with the flu vaccine. We cannot have a situation where there is any question of access being a problem because of affordability.

Given that we want the vaccine to be rolled out as quickly as possible, in a safe way, I imagine that there would be a hierarchy of who should get it first and so one, similar to the flu vaccine. We will wait and see what the expert group comes back with.

That is actually decided by NPHET.

We will have to wait for NPHET or whichever body does it. Is there a need for additional supports beyond GPs and pharmacies? Would we have pop-up centres to support GPs, for example? GPs have a very difficult job and there is a shortage of GPs in some parts of the country. Are we looking at additional supports to support and add value to the work GPs and pharmacies will do to make sure a vaccine is administered as quickly as possible?

That is a good question but I do not want to pre-empt the task force. Professor Brian MacCraith's group will report to the Government on 11 December, which is not that far off. This is exactly the kind of matter on which it will be coming to the Government with details and proposals.

I will make one final point on the vaccines. I will be at the top of the queue after all those who are at risk and who should be prioritised. I certainly will be taking it myself. There is a need for a public education programme but it must be rolled out by experts, scientists, doctors and nurses because that is who people will listen to. They may listen to politicians but they will listen to public health experts and those who will know about vaccines. A number of people, including Professor Karina Butler and many others, have done a first-class job of explaining the importance of vaccines, their history and their safety. That will be hugely important and I hope that will be part of the plan.

It is. To reiterate, while the EMA is moving faster than normal in making its decisions on the Covid vaccines, it is applying exactly the same quality control. The only reason it is able to move faster is because it has set up special teams, for obvious reasons, because this is so important.

I will move on to hospital wait times. I raise these questions in the context of subhead J2 and the €200 million that was allocated to fund the winter plan. I had this conversation with the head of the HSE recently. Outpatient wait times are now out of control, if we are to be honest. At the end of October 2015, there 396,000 people waiting to see a consultant. At the end of October this year, that figure was 612,000. More worryingly, the number of patients waiting 18 months or longer has gone from 13,353 to 153,000. Much of this predates Covid. Obviously, Covid has complicated the problem and added to it but the vast majority of those increases occurred in the years 2016, 2017 and 2018. I will not go through all the increases but they have been incremental every year. In the context of the additional money the Minister says has been spent on nurses, doctors and beds, does the HSE have a plan? Does it have a target to reduce outpatient and inpatient wait times? For example, would it hope that by the end of 2021, outpatient wait times will be reduced by 5%, 10% or 20%?

I share the Deputy's concern about this issue. The situation is probably understated in the figures because referrals have also dropped during Covid. The numbers relating to unmet or undiagnosed demand are probably higher in reality. What we are doing at the moment with the HSE is going through exactly that. We have supplied a very large amount of money for the permanent capacity in the healthcare system, at a community level and at an acute level.

In addition, we have a large access-to-care fund of about €350 million.

I do not want to be rude, but that is not the question I asked. I know all that. That was well dealt with by the head of the HSE and by the Minister in his budget speech. I asked if we have a target.

Sláintecare, which we all signed up to, promised that people should not wait any longer than four months. However, despite that, the wait times are going in the wrong direction. If we are going to spend more money, as we should, on our health service and if there is a plan to recruit more staff and open more beds, that should be matched with a target to reduce outpatient and inpatient waiting times by a percentage. Is there such a target?

That is exactly what we are working through with the HSE at the moment.

Is there a target for 2020?

No, but by the end of 2020 in the next few weeks we will have targets for the national service plan for next year.

Is that something new?

I have looked back at the service plans and I cannot find any targets. The Minister is saying that for the first time he will introduce targets with an objective to reduce waiting times. If that is the case where and when will we see that?

We will see them by the end of the year. I want to reach the point the Deputy is talking about. There is much talk about waiting lists and the number of people waiting. The Deputy's question is a much more important question: what are the waiting times? If 1 million people are waiting no more than a week, that is fine. The problem is that people are waiting too long. As a first step, we will look at the number of people waiting. I then want to move on quickly to answering the Deputy's question on the amount of time people are waiting which ultimately is much more important.

I will give two real-life examples of people waiting for treatment. When we talk about waiting times, it is hundreds of thousands of people. These are real people with real lived experiences. One is Elin who has Down's syndrome and suffers from arthritis. She is non-verbal and her parents have told me she is in constant pain. She has been waiting for two years for an MRI scan. She had an appointment in November; it was cancelled. She was told that the next appointment date is July 2024. I cannot figure that out. She is on drugs to dull her pain. Her GP has advised that has severe consequences for her immune system.

A second example is Sophie Redmond who was outside Leinster House this week. She is an 11-year old child who was diagnosed with scoliosis in 2017. Her spine is twisting into her lungs. She has been waiting nine months for surgery. The waiting times and the number of children who have been waiting more than 12 months for scoliosis are truly shocking, despite a commitment by the previous Minister for Health.

If we do not hire the specialists, consultants and all the support staff, we will not reduce those waiting times. Earlier this year, the Minister and I attended the conference of the Irish Hospital Consultants Association. I imagine he also engages with the IMO. They have told me that unless he deals with the two-tier pay issue, we will be unable to hire the consultants we need. Elin, Sophie and all the other children and adults who are waiting for treatment will need to continue to wait for treatment. I ask the Minister to speak to the long waiting times. How can we reduce those waiting times if the HSE cannot recruit the staff that are needed? If the staff needed are not recruited, we will not get there.

I have raised Be on Call for Ireland with the Minister several times. I got the most recent figures from the HSE today. A total of 1,470 people who came home or who applied through Be on Call for Ireland are still job ready. Half of them are in a pool and still need to go through the final interview process. The other half have completed all of that and are ready to be hired and have not been hired. Why is that the case? I cannot explain how 1,470 people who want to work in our health service despite all the promises and commitments the Minister has made. In the budget the Government promised to hire 15,000 or 16,000 additional staff and yet these people are ready to be hired. What is the problem? I ask the Minister to explain that. I ask him to deal with the issue of the consultant contracts.

I do not know of the case of Elin who is awaiting an MRI scan. When I was appointed one of the first places I went was to Crumlin where I met the scoliosis team. This covers the situation for both Sophie and Elin. The hospital at Crumlin needs another MRI machine and the staff to operate it. The waiting list at Crumlin for urgent MRI scans under general anaesthetic for children is four years. For non-urgent scans I believe it is seven years. That basically means we have no such service. I am working to put in place as quickly as I can temporary measures to ensure we can carry out paediatric MRI scans under general anaesthetic, which is a rather specialised thing. I have spoken to the team in Crumlin about exactly what is needed because nobody could stand over the present situation. It is just not fair. We are failing these children and failing their parents. It is just wrong.

Children with scoliosis are waiting for far too long. Progress has been made and another consultant has been hired. I will meet representatives of the scoliosis network soon. I have been in contact with some of the advocates there. I assure the Deputy that it is a priority for me as it is for us all and was in the last health committee. What is going on is indefensible and we need to move on it.

The Deputy asked if part of hiring those consultants is sorting out new entrant pay inequality for the post-2012 consultants. Yes, it is. I spoke very strongly in support of it in opposition. I feel just as strongly or even more strongly about it now in my current role. I have every intention to ask Government to solve that as quickly as possible. It is urgent and important for the very reasons the Deputy mentioned.

The offer the Minister has made clearly is not acceptable to either the Irish Hospital Consultants Association or the IMO. They are telling me that what is on offer has always been offer. There is nothing new here.

No new offer has been made. I am working towards fixing the new entrant pay inequality. There is no lesser offer on the table at the moment.

When will it be possible to conclude discussions with a view to making an offer that will at least ease the tension in the system at present?

Which discussions is the Deputy asking about?

The consultant-----

Is it the new entrant pay inequality?

Yes, and public health doctors.

As quickly as possible. I raised this and pushed it as soon as I was appointed to the office. Along with Deputy Cullinane I addressed the conference and recommitted publicly to them. It is essential. It needs to be done very quickly. It is an all-of-Government decision because other groups are looking at this in the context of upcoming public sector pay talks. My intention is to move it as quickly as possible and seek Government approval to reverse it.

As quickly as possible is a bit too loose for what I had in mind and I believe the Minister would say the same thing if he were sitting here. I know how the health system works. Every year we all strive to achieve particular targets and invariably fall slightly short. Given that other negotiations are taking place which may or may not have knock-on effects - some in the health service say they will not have a knock-on effect - can he give us even an educated guess as to what "as quickly as possible" might mean?

I can only speak for myself. I cannot speak for an all-of-Government decision. If it were solely up to me, I would have unilaterally reversed it in full in July. That is when I would have done it. That is the priority I think it has.

Does the Minister mean July 2020?

Yes. I would have done it in the first week I was appointed. I looked into it immediately. It is an all-of-Government decision. Because there are wider pay considerations with upcoming pay talks, it was not possible at the time to do it. However, I consider it to be a very high priority. We are looking to do several good things as soon as possible.

By as soon as possible, I do not mean in a year or two, I mean as imminently as possible. The first is to move the public health doctors onto consultant contracts. They would be to the existing A contracts. The second is to create the Sláintecare contract. The detail of that must be done with the representative body, as it has to be done by agreement, but there is provision in next year’s budget for full-year Sláintecare contracts. The third, not necessarily in that sequence, is the new entry pay and equality issue.

I have several questions and I want to try to move through them as quickly as possible. The Minister referred to different vaccines for different people. I realise that the Government has had to indemnify the producers in the usual way. I accept all that. Is the Minister aware of any system whereby people may be tested before vaccination for a potential reaction or side effects?

I do not know the answer to that question. It would be part of the technical information that would be coming from the EMA post its decision, whichever way it goes, on the various vaccines.

Presumably, the distribution of the vaccines will flow in the way that has been outlined by my colleague, in line with the requirements, whatever they may be. There should not be glitches appearing mid-stream giving rise to questions being asked about why this happened. I trust that is all being provided for.

Does the Minister believe that the provisions in respect of the winter plan remain sufficient, given the challenges that exist and all the other issues referred to by Deputy Cullinane?

I will speak about both the winter plan and next year's budget. The winter plan is a big plan worth €600 million, which makes it approximately 20 times bigger than previous winter plans. The budget for next year is the biggest funding package, but it is also the biggest set of targets in terms of new beds, new hires, community home care, etc. What we have done with the money is worked with the HSE to put a package together that we believe is right at the edge of what is achievable. The question was less around what we could do with this much money, it was more how far we think we could go for the winter and through next year. For example, the question on critical care beds was not how many of them we could have for this much money, it was what is the total number of additional beds we think we can get into the system next year and we will fund that. The flip side of that is because we are pushing on every single lever, or certainly many of them, in terms of beds, acute beds, community beds, eHealth, new drugs and hiring, inevitably, they are all stretch targets and there may be some of them that will be hard to hit. Even if we had more money, the view is that it would not really be possible to deliver more because there are only so many people one can hire at any one time. There are only so many beds one can build at any one time. We feel we have pushed to the edge of what is possible.

Is it true, as has been referred to already, that several people have been tentatively identified as being future employment prospects in the health service, and that they have not been approved or that they are pending? Has any thought been given to non-binding temporary appointments that could be carried forward to the future and approved or not, as the case may be? Can that be done in order to alleviate the pressure at this time?

Yes, let me give the Deputy an example. The Irish Hospital Consultants Association came out in the past day or two and said there were 728 unfilled consultant posts. That is correct, in that there are not permanent full-time positions in those posts.

So what is the status of the appointments? Are they temporary whole-time, temporary part-time or just temporary?

There are a few. There are fixed-term contracts. For example, of the 3,446 posts that are currently filled, 2,680 are permanent, 520 are fixed-term contracts and 246 are specified-purpose contracts. There are actual vacant posts and then there are posts which are filled by temporary contracts or agency staff. What I want, and what I think we all want, is full-time people in those posts.

Correct. Are there posts waiting to be filled at the present time that could be filled on a temporary basis?

I have no doubt that there are, but the HSE is actively filling them with temporary staff where it can, as per the consultant contracts. The Deputy can be sure that on an ongoing basis there are other posts that could have temporary people in them.

Could that and will that be done in order to address deficiencies in the labour force, for the want of a better description, in the short term?

Yes, I think it is being done. For example, agency nursing staff are being used right across the system. I would like a HSE where we never need agency staff or perhaps if there is a surge somewhere that one could bring in agency staff. What I want is safe staffing levels for nursing and midwifery so that the reliance on agency staff is reduced.

When consideration is being given to the possibility of agency staff or temporary, whole-time or part-time staff, is the advice towards the appointment of the temporary staff, as opposed to the agency staff? Which is it?

It depends on the different types of roles. If Deputy Durkan wishes, I will ask the HSE to revert to the Deputy with a note on that?

Yes, please. I will move on. Could I ask the Minister the extent to which Sláintecare has bedded into the system, albeit in the face of considerable other challenges? Has adequate, sufficient or anticipated progress been made in incorporating into the health service the terms of the Sláintecare report?

No. I do not think so. If we go back to when the report was published and when the implementation plan was published – I do not have the latter in front of me – if we were to pull that out and look at the Gantt charts and what was meant to happen by when, I imagine we would find that Sláintecare is behind in an awful lot of areas. If there is any silver lining within the health service from Covid, it is that a lot of Sláintecare initiatives and thinking, in particular around innovation, community-based care and one of the most important areas to me, which is linking up the care pathway for patients and designing it all around the patient, is happening at a level it has not happened before. For example, I was in St. Vincent’s University Hospital the other day, with the emergency medicine team, and by following through on the Sláintecare principles and by providing the funding in the winter plan, there was nobody on a trolley. The people who were in the emergency department were in their own rooms. The emergency medicine consultants said to me that they had not seen that in many years. One of them said he had just given up on there ever being a solution. What is interesting is that people are still coming to the emergency department. Admissions are still at 90% of last year, and people are still being admitted to hospital. Admissions are still at approximately 90% of the figure for last year, but the number of people waiting on trolleys is at approximately 30% of the figure for last year, and it is because of the Sláintecare philosophy on patient flow. One of the things we have done is put funding in the winter plan into home care, which means the delayed transfers of care happen. Deputy Durkan was a member of the relevant committee. The flow is beginning to happen. We are seeing it.

I thank the Minister. I wish to ask about elective procedures, which are stockpiled at this stage to a considerable extent. Was consideration given to referring them under the treatment purchase scheme to the private hospital sector, which has been available? Some criticism has been made of the fact that it has been underutilised. To what extent, if at all, has it been utilised? To what extent can it be utilised in dealing with what will become an interminable backlog? While some of these issues may not be emergency issues today, they will become emergency issues. If we wait for everything to become an emergency issue, the whole thing will descend into chaos.

We should be able to deal with these issues as they arise. I know the Minister will agree. What action has been taken to do that and use the treatment purchase facilities, if and when they are available?

I will get the Deputy a note on how many operations have happened this year, both in HSE and private hospitals. The NTPF puts out bids asking, say, who wants to perform 20 hip replacements or 100 cataract operations. Public and private hospitals can bid if they feel they have spare capacity or they want to ramp things up. Given the length of the waiting lists, I would like us to be more strategic and ambitious next year, so I am putting together an access to care task force. There is a pot of €340 million. I want as much of that as possible to go into the public hospitals, but the private hospitals can be used too, and start to go through the list of more than 700,000 to establish the priority groups. Rather than putting out bids as we do now, that we might say we have so many thousands waiting on orthopaedics, ear, nose and throat procedures, cataracts, etc. and see if we can get that down.

So they should be contract out quickly. I thank the Minister.

Scoliosis was raised earlier. For parents with a child awaiting scoliosis procedures, a month is a long time and a year is an awful long time. In some cases, the wait has gone on far longer, which is interminable and unacceptable. I ask that the Minister put in place some emergency measures, whether outsourcing to the private sector or something else, to get ahead of that.

In the area of mental health services, drug detox services are appalling. I do not blame the Minister for that but I spent recent days trying to access services for people in an emergency situation. The parents are distraught and unable to get residential services for their teenager or child. There is no ready access. To be fair to some of the service providers, they are doing their best but they are totally short of resources, space, and expertise. Will the Minister urgently call together those involved to help them out and spearhead the attack on the deficiencies that exist, because they are appalling?

I agree wholeheartedly with the Deputy. The Minister of State, Deputy Feighan and I are working very closely on this. We have allocated sizable additional funds next year for exactly what the Deputy has outlined to help the providers and the residential care facilities. The waiting lists are too long. Again, during the Covid pandemic, many things were done that had never been done. People were helped and wrap-around services were provided, but we can do much more. The Minister of State and I will push that hard.

Will the Minister send the committee a written breakdown of where the funding is going as there is confusion on the task force about this?

The Minister's opening statement referred to Covid vaccinations, the thing everyone has pinned their hope on. On my way to the Dáil this morning, I heard several radio station carrying sound bites of the Minister's counterpart in Britain, Matt Hancock, announcing how they had the refrigeration facilities and the capacity to roll out a Pfizer vaccination beginning next week. A comprehensive plan is being developed here but, on foot of the bold plans in Britain, have plans in Ireland progressed further? Can the Minister give the committee a timeline or some detail on how the roll-out will happen? There is a debate whether distribution should be at GP level, where they know their vulnerable patients or whether other State mechanisms should be used, perhaps the Army, or whatever is needed undertake an emergency mass vaccination of the population?

I was at an EU health minister's meeting earlier at which the new executive director of the European Medicines Agency, EMA, Ms Emer Cooke, who is Irish, gave an update. The EMA will authorise the vaccines. The exact timeline is as follows: on 1 October the EMA started rolling reviews of three of the vaccines, from AstraZenica, Pfizer and Moderna; yesterday, Pfizer and Moderna submitted their marketing authorisation applications to the EMA; and yesterday, the agency announced it was starting a rolling review of the Janssen vaccine. The EMA has been working hard in the background, has set up special task forces to examine this and the first two companies made their submissions yesterday. Yesterday, Emer Cooke told us that if the applications are sufficiently robust and complete, and hopefully they are, an EMA opinion for their marketing authorisation within the EU and, therefore, Ireland could be issued within weeks.

Specifically on the Pfizer vaccine, she said the committee for medicinal products for human use planned to conclude its assessment during an extraordinary meeting scheduled for 29 December, at latest. The same committee plans to conclude its assessment of the Moderna vaccine during an extraordinary general meeting scheduled tentatively for 12 January. Once we get EMA approval, if we get such approval, as with the UK, we can distribute it in a matter of days.

Special refrigeration is required for the Pfizer vaccine. That arrived in Ireland last week. The supply chains and logistics are being put in place now. This morning, I spoke with Professor Brian MacCraith who is leading the task force. He is confident that the distribution networks will be in place if and when the EMA authorises the various vaccines.

That is encouraging. The Minister’s opening statement referred to the cost to the State of PPE. There were many teething problems early on with ill-fitting gowns and gloves, and masks that were sub-specification or did not work properly. Has this supply chain changed? Have we adequate supplies at a quality that meets the needs of our front-line health staff?

Yes, it is. The Supplementary Estimates for which I seek the committee’s approval today include a substantial amount for PPE for this year.

To give a sense of scale, the HSE normally spends €15 million on PPE annually; this year it will be close to €1 billion. The Supplementary Estimates contains almost €700 million just for PPE. They put in place very comprehensive systems. I get a weekly report on PPE. The reports I have received to date are that the various supply chains are working well and the quality control issues have been dealt with. We are also providing PPE to the nursing homes.

The Minister mentioned testing and tracing. It is not his responsibility but there is optional PCR testing at point of departure at our airports. For some, it could cost €100 on top of their air ticket to fly. It is a transport issue but if it gives rise to increased Covid cases it will become the responsibility of the Minister for Health. Should testing at airports be compulsory so that we know that people coming in and out of Ireland are Covid-free and not adding to risk levels here?

Anyone travelling should pay for the test themselves. I do not think that public money should be used for that; I would prefer to use that to hire doctors and nurses, pay for vaccines and so on. I think Ireland and Finland are the only orange zone countries in the EU. For anyone leaving Ireland for another member state, the rule states they must have had a negative PCR test within three days of flying.

Regardless of what anyone does on the way out, it is the journey back that we are selfishly interested in. We have a position if one is coming into Ireland from any country in the EU, other than Finland, or from any country within the wider EEA, although Iceland is in the orange zone as well, and most of the world, including the western world, is red. The unambiguous position on that is that when one comes in, one must restrict one's movements for two weeks. One can shorten that to five days if on the fifth day one takes a test and that comes back negative. That is the situation for Ireland and for most of the rest of the EU as well.

I am sure the Minister also received the same correspondence as us today.. Many nurses have been in contact with all of us regarding their annual Nursing and Midwifery Board of Ireland, NMBI, registration charge. As a teacher, I had to pay something similar each year to the Teaching Council and one would bemoan it when one would see this letter coming in. On top of all they do in the workplace, teachers have to pay this charge to be officially recognised. Nurses feel that the charge this year has come at a time they are giving everything on the front line. The charge is €100 whereas their counterparts in Scotland have been given a £500 gratuity. Has the Department been engaging with NMBI to look at that charge for the year it is in terms of potentially waiving it?

I would be open to considering that. It is not something that has been considered. This issue has largely come up today as part of a good and well-worked campaign. I was asked about it early this morning for the first time and it is something I am happy to consider. As it happens, if it is €100 and we have approximately 30,000 nurses, that would be a cost of approximately €3 million. The Supplementary Estimates we are considering do not include €3 million for that.

Nurses have done an extraordinary job and more so than ever this year. It has been incredible. When the rest of us were staying at home, particularly during the first wave, they were going to work every day and keeping people safe. I would be very well-disposed to doing something to try to recognise that. I cannot give a commitment because it is additional spending and it requires a Government decision but I will be looking at it closely.

We would be very open to welcoming the Minister back with Revised Estimates if he was to look at that €3 million charge or thereabouts because it is deserving of them all for the very tough year it has been.

I wish to raise the matter of cataract care. There is a successful scheme operating in the north-west, specifically in Sligo, with backing from the Department. It is a simple scheme whereby there is a pathway between appointments and follow-up care. It is shared between hospitals and local private optometrists. It is proven to be successful and has driven down waiting times, as well as times in transitioning between phases of care. The previous Government promised and the new programme for Government promises a national roll-out of that. Has the Minister examined advancing that? I know there is a huge amount of work on his plate but has he looked at advancing that roll-out to a national scale?

Is this what is happening in Sligo?

Yes. It is the Sligo scheme.

I put it in the programme for Government.

I met with the optometrists before the programme for Government talks, they told me all about it and it seemed like a fantastic idea so I asked that it was included in the programme for Government. It is Sláintecare. It is joining up pathways of care and designing and wrapping the care around the patient. It is an excellent idea.

Are there any timeframes for that?

Not as of yet but we are committed to doing it.

I wish to raise statutory home care. It is another feature of the programme for Government. There has been a serious beefing up of home care hours in budget 2021. Just yesterday we had another report released, which again gives us an insight into the major strain nursing homes have been under since March. Many families with elderly people in the care of nursing homes are saying that if the mechanisms were in place, they would much rather have those loved ones in a home environment where they could be cared for by a care professional.

I have been digging deep into all of this and there is a certain type of person who goes into working in home care in Ireland and the OECD has statistics on this. Home carers in Ireland are 80% female and they are of a certain demographic. There is a trend in western European countries but there are also barriers to these people entering this type of work. Many people who have made representations to me would like to take on this type of work. One can train quickly and successfully as a care assistant but there are barriers if one is on a low income or in taxation bands that do not make it worthwhile.

In any given community such as the rural community I come from, there could be 14 or 15 people in direct nursing home care and there could be two or three people at community level in receipt of a social welfare payment or in a low-paid job. If procedures were to be adjusted and if there was a little bit of ingenuity between the Department of Health and the Department of Finance, a lot more people at ground level could be helped to get to the statutory home care phase an awful lot more quickly. They tell me the barriers mostly relate to taxation bands and finance. There needs to be an incentive to do it. Statutory home care is a feature of the programme for Government and I would like to hear if that has been progressed since the Minister took up office.

This is one of the areas that is exciting and that we can make an awful lot of progress on in the coming years. When we launched the expert review on nursing homes, one of the leads, who is a consultant geriatrician, was comparing the percentage of people we have in nursing homes in Ireland with the percentage in Finland. Finland is probably seen as the best example. I cannot remember the exact figure but it is at a fraction of what we are at. The goal is to keep people at home.

The Minister of State, Deputy Butler, is taking a lead on this. We have fully funded the interRAI system for next year. We are rolling that out straightaway and a number of assessors are being hired. They will do a full assessment of every person's needs. Rather than saying one can have five hours or six hours, it will be a bespoke individual assessment. The programme for Government commitment on increased hours was for 5 million hours over five years. We have allocated funding in the health budget for next year for all 5 million of those hours next year. That does not mean we will not do any more in the future. We are going for this.

The Deputy is correct that it is not enough to have the systems and the money. We have to have the carers and to do that we have to look at caring as a profession and at the kind of supports they need. The exact matters the Deputy is talking about will be considered by myself, the Minister of State, Deputy Butler, and the sector. I am excited about this. If we get this right, we can revolutionise growing older in this country and have far more people living at home for longer. Our length of stays in nursing homes and so forth are out of kilter with many other countries. There is a real opportunity here.

It would be a cost-saving measure to the State if we could keep more people out of nursing homes and going into-----

And it would save money.

One of the private home care providers in the country gave me a pretty decent briefing, and we get a lot of these. Sometimes one has to let these briefings in one ear and out the other but I was told clearly that there is a significant cohort of people willing to take up employment. These people might respond to an advertisement online or in the local press that is seeking for care assistants and offering to help them to get trained up but people quickly discover there is a large number of barriers. Those barriers should be broken down. For a lot of these people it might have been a choice to be a stay-at-home parent for a number of years. Perhaps if the rules were changed and if they were allowed to go out during school hours and provide home care within their communities for that four or five hours, be freed up in the evening and not have their income overly taxed, it would be a great incentive to get this growing at grassroots level in an organic way. I hope those aspects can be considered in parallel with the health aspects because income, taxation and threshold barriers are preventing more people joining. They cannot recruit people.

People have been looking to stay at home and families have been looking for their older members to be able to stay at home with supports for years. The high number of people in nursing homes is a direct result of Government policy, which incentivises it. At various times, a figure has been put on the number of people who are in nursing homes and who should not be there and who do not need or want to be there. However, Government policy has made that happen.

There is potential for significant additional employment if we respect older people's desire to stay at home. However, it is important that it is decent quality work so that people have guaranteed hours.

It should not just be minimum wage work. Much of it is currently like that without any kind of job security. That has to be considered when moving to a new system. It is essential that the health authorities work with the housing authorities, because there are a small number of examples of supported housing complexes with health services provided. That is an ideal situation where a person is not able to stay in his or her own three bedroom house, with the upstairs part not being accessible or with the house needing proper maintenance. There are a few examples of where it has been done really well and we should learn from that. Housing has to be part of that solution.

Will the Deputy send those examples on to me, please?

I would be happy to do that. A number of us raised the waiving of nurses' registration fees with the Taoiseach in the Dáil this morning and he categorically ruled it out. It would be welcome if the Minister tried to change the Taoiseach's mind on that.

There are two concerns about the decision to approve and roll out the vaccine in the UK. According to Kingston Mills, this has not been tested on children, which is a problem. It has not been established that the Pfizer vaccine is effective in cutting infectiousness. It may prevent somebody from getting the virus but it does not mean that the person is not a carrier. To what extent are those issues being pursued at a European level? Does the Minister expect that it is likely that approval will be given with caveats about key elements, as has happened in the UK? I understand that there is a requirement for states to take on liability in the event that anything goes wrong. That is potentially a blank cheque. We do not know what is involved. In normal circumstances, the fact that pharmaceutical companies have to carry the liability for their products is a break that is put on developing new vaccines or medications, which can be good because companies have to be cautious in developing new products to ensure that they do not do harm. Is the Minister concerned that because of the fact that the significant responsibility of taking on liability by a pharmaceutical company is being waived, there could be issues with a rush to roll out the vaccine?

In response to the Deputy’s first question, I had this conversation with the public health team this morning. They made a few points. We are going through the European Medicines Agency, EMA, process. The UK has its own process. That authorisation comes with advisory notes. Our public health people are saying that Ireland is signed up to six people. They are at various stages with the EMA. It looks like a decision will be made about the Pfizer vaccine first, then the Moderna vaccine. They are saying that different vaccines may be appropriate for different groups. Some vaccines may work better for people who are more vulnerable to it and people of different ages. They are looking to the EMA to provide this advice. Our experts will look at the UK’s advice too, but we will take our lead directly from the EMA. As the EMA issues that advice, it may well indicate the priority groups and say that it is not looking to vaccinate children in the short term, and so on. We will take our lead from the Health Products Regulatory Authority, HPRA, and the public health teams.

The Deputy is right about liability. The EU has waived liability, so Ireland, as with every other member state, is indemnifying the pharmaceutical companies to get access to the vaccine. I am not concerned from a safety perspective because the EMA is the regulator and I have been assured that even though the process is quicker because of the nature of Covid, the same standards and bars have been set as for every other medicine that we take. It will have the same safety standards as everything else that we go into a chemist to buy, whether it is prescribed or not.

This Supplementary Estimate is not just the figures that the Minister has presented today. There has been some moving around of budgets too. One relates to capital spending on the national children’s hospital. We know that there has been an underspend of €166 million. We had the children’s hospital board here to address the delays which have happened for various reasons and the underspend. I was told that €100 million of that is being ring-fenced and carried over to next year, but another €66 million has been diverted into other expenditure. Will the Minister tell us where that has gone?

I will get the Deputy a note on it. The Estimate before us today does not include any additional spending, so the allocation the Deputy is talking about is for the total budget. Today’s Estimate does not include any capital element. The Deputy is right. The site was empty for quite some time because of Covid. There was underspending. We have carried as much of it forward as we are allowed to by the accounting rules. I will get the Deputy a breakdown of where the other money was allocated.

Another area where there have been savings is from the cost of patients, including low-income patients. We were talking about Sláintecare earlier, and apart from reorienting services, a key element of Sláintecare, if not the key element, is removing cost as a barrier to accessing care. There was an announcement in last year’s budget of a number of measures which would improve affordability of care with medical cards, prescription charges and the drugs payment scheme. Unfortunately, the current Government decided not to implement that in July as had been promised and people expected, and it was delayed until November. What was the total saving from delaying those measures?

There was no saving. It was delayed because in last year’s budget, bringing in those measures was contingent on savings that did not happen because of Covid. When I came into office, there was no money available to bring those measures in. Even though it was in last year’s budget, I had to go back to Government with a new memo and say that I wanted additional funding to bring those measures in this year. Not only were there no savings, an additional cost was required for having brought them in.

This idea of introducing something because of savings being achieved somewhere else is nonsense.

I would not disagree with the Deputy.

There could be the same savings anywhere in the health service, except where services were cut.

I would not disagree with that. That is what happened. There are no measures coming in next year which are contingent on savings.

Does rent for the Department's current accommodation come out of the Department's budget, the Office of Public Works, OPW's, budget or the Department of Public Expenditure and Reform's budget?

I presume it comes out of the Department's budget. I will get the Deputy a note on it.

There is an issue about calculation of the floor space in Miesian Plaza, where the OPW has made a mistake. Is the Minister aware of that?

Is the Minister aware of that? Apparently, the State is caught with having to pay €10 million extra. That works out at approximately €344,000 per year in additional rent, over and above what it should be paying, because a mistake was made in measuring the floor space.

It was approximately three years ago. The Department of Public Expenditure and Reform or the Office of Public Works do not seem to be in any rush to compel the landlord to calculate the rent based on the actual floor space. That €3r4,000 per year is a lot of money-----

-----which could be put to much better use. I know the last contact with the landlord was in January.

I will certainly ask.

Perhaps, the Minister will come back to us with a note on that, if he does not mind. I will come back to the issue of consultants' contracts. There are a number of questions around that and I am aware the Minister has spoken about some of them already. We cannot run the health service unless we have enough consultants. It is clear there is a major problem. Whether it is with consultants or nurses, why do we continue with agency staff when it is much cheaper to employ full-time permanent staff? Why are so many consultants, in particular, doing agency work? Is it the case that a person is better paid as an agency doctor over and above what he or she would earn on contract? Are there other advantages compared with being on contract?

We have an ambitious hiring programme in place for nurses. I have stipulated that next year, the hiring will be done along the safe staffing levels that have been agreed. There is, therefore, now a new system in place, which was brought in for the pilots, where the acuity of the patients in each ward is basically put into a computer and it will tell what the staffing needs are. That is what we are scaling up to.

The HSE believes, therefore, the levels it has put in for hiring next year are at the edge of what is possible. If we could, I would replace all agency staff immediately and I believe the HSE would too. The plan is to get to a point where, certainly for the day to day work, agency staff simply are not needed because one we have the safe staffing levels.

I will get the Deputy a note on the consultants. Certainly, from all the conversations I have had over the years, the vast majority would prefer to be on permanent contracts. The agency work suits some, in fairness, but the vast majority want to be on those contracts. To be honest, they have never really mentioned pay reasons to me. They have always said they want to be part of a permanent team, whatever their specialty is, and spend the next number of years of their life being part of that team and growing that service.

My understanding is that we need to fix the new entrant pay and equality fast. We need to put the Sláintecare contracts in place fast and hire people into those posts, keep the people we have, offer them permanent contracts and then try to get home some of our good people who are working abroad.

Regarding the Sláintecare contracts, the Minister said the commitment is 500.

Five hundred what?

Sláintecare contracts. Is that correct?

No. We want as many people as possible on the Sláintecare contracts. That is where we want to transition to.

Sorry, new contracts. I thought the Minister's predecessor said that. I could be wrong. I do not know.

He may have. I do not know. I would not see any limit to it.

Is it the Minister's intention that the existing vacancies would be filled with Sláintecare contracts?

Yes. All new contracts will be Sláintecare contracts. That is number one. Number two is that my view is that the current A contract-----

Sorry, including existing vacant posts.

I believe we should just be hiring into Sláintecare contracts. We want to move to public-only work in the public hospitals. This still all has to be worked out; this is my view. All new hires should be on the new Sláintecare contract. I imagine as soon as we have it in, everyone on an A contract will move across straight away because it is kind of the same but with more money and supports around it. Then, there is a good conversation to be had with those on the B contracts to see who wants to move across. My view and, I believe, that of Deputy Shortall is that we want as many as possible on the Sláintecare contracts as quickly as possible.

That is welcome because that is new, as far as I am concerned. I had not heard that before.

My final question is on that pressing issue on the need to create those public health consultant posts. It is the only specialty where they are not consultants. This year, of all years, given everything the public health people have been doing, let us not have a strike. Is the Minister prepared to upgrade the existing specialists, of whom there are only approximately 60, to give them consultant posts?

This was moving fast. Our public health consultants, doctors and public health specialists have been looking for this for decades for all sorts of reasons, for example, for professional recognition, professional standing and the money they earn, which is approximately €111,000 or €113,000 at the moment. Their consultant colleagues on A contracts are earning tens of thousands more than that and, indeed, the Sláintecare contract, when it comes in, will be a significant increase again. They have worked hard this year. Never has it been more obvious how important the public health groups are.

Will the Minister make them consultants?

I understand the Deputy's question. Here is what I have done. We have funded the doubling of the public health workforce, not over five years but now.

Will the Minister make them consultants?

I know he is talking about the theory and so on. The Minister knows what they want and he knows what will solve this problem.

That the 60 existing people are given the grade they deserve and for which they are qualified.

I understand and I am coming to that. From my conversations with the public health doctors, it is not all they talk about. What is important to them is that they have the resources and teams they currently do not have. It is just as important, from what I am hearing from them, that we give them the teams and staff they need.

Several hundred interviews are happening now. This real and it is live. Is there going to be a public health consultant contract? Yes, there is, and the exact mechanism for how that will work must be worked out between the Irish Medical Organisation, IMO, and the Department or Government. That process is under way. The business case for all of it is with the Department of Public Expenditure and Reform. I have given a commitment that there will be consultant contracts. The IMO has a view on the exact mechanism and how it works. We must respect that and go through that process. I understand the frustration of the people in question. My understanding is that they really do not want to go out on strike, particularly during a pandemic. I certainly-----

It is in the Minister's hands to stop that. He knows exactly what they want.

I thought we were. Think about what we have done in the last few months. We have done more in the last few months than has been done in 20 or 30 years. There is, therefore, no need for the strike, in my view. I know they do not want to go out on strike.

There will not be a strike if the Minister gives them the status they are asking for and deserve.

I am going to bring an end to this discussion. I call Deputy Hourigan.

I welcome the position from the Minister that all new contracts should be Sláintecare contracts. That is a positive development.

I will go back to the Supplementary Estimates. I will bounce around a bit so I hope that is okay. On section 4.3(7), overseas treatment, there was a €74.1 million overseas treatment estimated spend and the current Estimates have a €32 million underspend. In the section on capital funds, the document states the Department has written to the Department of Public Expenditure and Reform to ask that funds be carried over to 2021. Is that also the case for the overseas treatment fund? It is a bullet point on the overseas treatment surplus of €32 million. Obviously, there will be a backlog and Brexit presents a number of challenges in that regard. Is that money now unavailable to us?

Regarding the overseas treatment, based on the cross-border directive and treatment abroad scheme, there would be an estimated amount for how much we would have spent this year. All this does is say that, obviously, because people could not travel, that money did not get spent. It is just reduced from the extra amount we need.

Are we rolling the money over?

One does not roll it over but there will be provisioning in next year for the amount that would have been in for this year. It is there for next year.

Okay, great. Section 4.2 of the briefing document relates to Brexit preparation. The Minister will excuse my ignorance. I am trying to get to grips with these Supplementary Estimates. My interpretation of the wording is that the section implies there is a pot of money to look at things like ports and airports, to which the Department has contributed €7.116 million along with other Departments. Is that a correct reading of it?

Yes, more or less.

Is that physical infrastructure?

My understanding is that most of that is staff-related costs. We will now have public health staff at ports in a way that we never had previously because of Brexit.

I understand. Given that there are some shared treatment services across the island, I wonder if there is a separate fund dealing with some of those issues. I guess the one I am particularly thinking of is the human milk bank in Enniskillen, which is one of the few examples of a shared-island service that really works. They supply 22 neonatal units across the country. They organise an amazing band of volunteers. There is a great deal of volunteer help but it also needs State support. The service is quite fearful of the impact of Brexit and the need for supports, such as in IT and in distribution. I wonder if that is something the Department has funding for or has considered.

I want to make sure I get the Deputy exactly the right level of detail. Can I get her a note on that?

Yes, I would welcome that.

Palliative care is covered in the briefing document. We have all probably been contacted by constituents who, unfortunately, have been unable to be with their loved ones as they pass away, some due to Covid and some due to whatever conditions they have as normal. The once-off funding, as outlined, is hugely welcome and is desperately needed. That is fantastic. However, I note from the outline given that it is very much geared towards existing specialist palliative care settings. Is there any funding available, or can that be broadened out, to include additional financial supports to palliative care or end-of-life care in a hospital setting because that is an issue?

Not within this €10 million, but for next year. The €10 million that we are looking at here was a one-off fund we created for the voluntary sector, €8.5 million of which went to voluntary hospices around the country. As for the other €1.5 million, there are community palliative care voluntary services in a few of the community healthcare organisations which we funded as well, and then we gave Laura Lynn Foundation, the Irish Hospice Foundation and two others €100,000 each.

We are putting additional money in for next year as well. For example, probably the nicest thing I have done since I got this job was to go and meet representatives of the Laura Lynn Foundation last week. I had the extraordinary pleasure of doing a video call with them a while ago and saying that we are allocating €1.5 million to them next year. Their funding is approximately €4.5 million and they have never got anything from the State. I had the immense pleasure of being able to say to them that on top of the €1.5 million, they are getting €750,000 of the €10 million we are now talking about. I had the absolute joy - it is the first time I got a clap since I became Minister for Health - of going to meet them last week and saying that the €1.5 million we are giving them next year is now in the base. They are getting that from now on. There is really strong support from the Government for palliative care and for the hospice sector. That is only one example.

Might we see that rolled out to hospital settings in 2021, although not that specific funding?

Not that specific funding, but certainly there is an expansion of palliative care services going on.

The briefing document also refers to PPE provision, which is likely to be with us well into next year, unfortunately, even with a vaccine. It will have to be rolled out across certain sectors first. We have heard at previous committee meetings - it might have been at the Committee of Public Accounts - that the HSE has relatively high levels of non-compliance with public procurement processes. In the past few years, it has fluctuated up and down. It was 28% in 2018. It was 49% in 2016. The Department and the HSE are doing huge amounts of work to try to lower those numbers. Has the HSE undertaken a procurement review on the PPE procurement process for quarters 2, 3 and 4?

I thank the Deputy. It is a really good question and one I have asked. I wrote to the HSE quite some time ago to say almost exactly what the Deputy has said. Given the vast amount of money that is being spent, much of it outside the normal checks and balances that are in place for procurement, I asked whether the HSE could do an audit of it and come back to us. It has given an undertaking to do that. We are all quite rightly focused on the appropriate expenditure and the good expenditure of PPE. When this audit comes back, it is entirely possible that there will be have been purchases outside of the normal procurement process. In fact, I suspect we will see that. When that happens, and it probably will be the Committee of Public Accounts which will look at it, and maybe this committee as well, let us remember the pressure that they were under and that we all put them under to do whatever was required.

I take that point. We all felt the pressure throughout the year. In general, in these times of stress we can learn a lot about the process. We have a way to go in Ireland in terms of our procurement process. I wonder whether the Department will be doing a more general value-for-money review of Covid expenditure during 2020 at some stage.

That is a great question. It is certainly happening on PPE, which would be one of the biggest amounts. For example, in the amount we are looking at here, €667 million is for PPE alone. It is a vast amount of money. Testing and tracing, obviously, involved a huge amount of money as well.

In my constituency, the private hospitals delivered really important capacity but there are ongoing questions around value for money there. It might be something to consider.

I do not know whether the Minister noticed that the Irish Fiscal Advisory Council, IFAC, criticised the Government yesterday for budget commitments to non-Covid expenditure. Appendix 3 sets out the initiative funded under the 2020 winter plan, all of which is worthwhile and I am not questioning. There are measures that we all have wanted to see happen for years, such as an increase in community beds, GP-structured access to diagnostics and community health networks. I understand that these are in some cases putting down the systems that will make Sláintecare possible. However, they seem like fairly long-term commitments and they will add to the base. Has the Minister any response to IFAC's position? Is there a plan for funding it in the long term?

I agree that they add to the base. We have done it quite differently this year. Last year, the winter plan cost €30 million. This year, it is €600 million. We are doing things at a completely different scale. In fairness, what we designed with the HSE was a winter plan. So far, it is working. The trolley numbers are at 30% of what they were last year but presentations are still at 90%. We are entering into the biggest pinch point, now through the end of December, but so far it is working.

We have not entirely designed it as a once-off winter plan. We have said that there is €600 million for the winter plan. I am looking for the permission of Deputies for €200 million of this for the current year. In next year's base, there is €400 million for January, February, March and April of next year. Essentially, what we are doing with the rest of the budget for next year is saying that this is permanent now. I refer to the extra beds, critical care beds, ward beds, community beds, community assessment hubs and the extra staff that we are hiring. We have designed the budget to bring capacity up for the winter really quickly but then lock it in as permanent capacity. IFAC is correct that many of the commitments for the winter plan are permanent funding commitments.

We may need a funding plan for that.

Budget 2021 includes provision for that and it actually states that our capacity has gone up and we are continuing it with the rest of the budget. This is one of the reasons that the budget was so high. I felt it quite right to point at the Government budgets but as I said at the start, if the Deputy has not already done this I suggest she look at the ESRI report on comparative healthcare spending, led by Professor Maev-Ann Wren led, which is so important. The narrative in Ireland for years has been that we spend more than anybody else and we do not get the outcomes. The ESRI’s report is really complicated stuff when one compares country to country but it has done it. It turns out that we are ninth or tenth of the EU 15. I say as Minister for Health, let us proudly invest more in healthcare. IFAC may not agree but it has a different job.

Yes exactly, it has a completely different job to the Minister.

Section 6, as I mentioned earlier, states that the Department will ask the Department of Public Expenditure and Reform to carry over the 2020 underspend. I can fully understand if the Minister does not have an update for the committee today but would it be possible for the committee to get an update on whether the Department of Public Expenditure and Reform comes back to the Minister on that carryover?

Yes, it would, absolutely.

I thank the Minister.

As I have two minutes, I would like to address the Chairman for a moment. We have had a very interesting discussion at this Estimates session. However, it has been very wide-ranging. Much of what governs our healthcare system is how we spend our money. The committee cannot approve or disapprove an Estimate but perhaps if we were to take a position on an Estimate there might be a more targeted or directed questioning of the budgets.

I was fairly flexible with members. If they change their question a bit, it is all within a discussion of the Estimates.

I take that point but money is important and it has to be dealt with at sectoral committees and perhaps maybe there could be-----

I note what the Deputy is saying and perhaps we might discuss that at a later stage. I call Deputy Gino Kenny now.

I thank the Chair and the Minister for his presentation. On PPE, as the Minister stated, annually the HSE would pay a fraction of that. It is an astronomical amount of money. I am not aware if the Minister has been watching what is happening in Britain in respect of PPE, where it was bought at prices that were completely inflationary compared to what it would normally cost. Where was most of the new PPE sourced? Was it outside the EU, inside the EU, or even in Ireland? Can I have a breakdown of that, please?

I will get the Deputy a breakdown of that. I can tell him that of that amount, €208 million of it was for the China Resources Pharmaceuticals deal and there was money spent with Irish providers, EU providers and further afield.

What item of PPE was the most sought after, as many governments were chasing after this PPE?

If we assume that demand and supply were broadly matched in that the HSE got what people were ultimately looking for, this will not be perfect but when things calm down I will get the Deputy a schedule of exactly what was bought. If we assume that that broadly matches supply, then it will answer the question around what was needed.

Obviously, the Minister would be open to an audit or review of costs around PPE.

More than that, I formally requested one from the HSE and it has agreed to this. The HSE will come back to me with an audit on that in the first quarter of next year.

That will be a breakdown of what the costs were and what was purchased and so forth. That is good.

On the private hospitals, does the Minister think that the nearly €400 million spent to date was cost-effective?

With the benefit of hindsight, I do not think that any of us would have done it the way it was done. Together with the Deputy, I was highly critical of the deal at the time and sought for it to be ended early. I did not think it was the best way to proceed and am firmly and repeatedly on the record to that end. Even at the time, however, I was saying that it was easy for me to say that and a review will be done. Inevitably, it will show that with the benefit of hindsight, were one doing it again, it would be done differently. Indeed the conversations that we are having with the private hospitals now are not about simply taking over their hospitals and that is because of what was learned the last time. One would probably do it on a pay-for-use basis and this would seem to me to be the sensible way to do it. Again we have to be very cognisant of the environment at the time. We were all looking at the television and seeing car parks in Italian hospitals with patients who were very sick. The HSE, the Department and the Government at the time did what was required to secure that capacity instantly.

Was capacity used at the time for Covid-19 in those 18 acute hospitals and if it was not used for Covid-19, was it used for any other procedures that the public hospitals could not do themselves? Could the money that was spent during this period have been spent on these procedures in the private hospitals?

My understanding is that there was not any work done on Covid-19. The Covid-19 patients were all brought into the public hospitals and the private hospitals were to try to keep the urgent non-Covid-19 public work going. I may be slightly wrong here but, for example, my understanding is that the public St. Vincent’s University Hospital took over St. Vincent’s Private Hospital’s operating theatres and so forth and many of the urgent cancer work for public patients ended up being done there using their resources. However, there were other hospitals such as, for example, the Bon Secours Hospital, Limerick, where there was a very small volume of additional care undertaken. It is a mixed bag. At the time, I submitted parliamentary questions to get exactly what the numbers were for different types of procedures done and I presume that all that information is available. I can get that information for the Deputy if he would like.

Yes, please, if the Minister could. On the underspend of €95 million on the private hospitals arrangement, why was that the case?

My understanding is that there was a provision made for potentially extending that contract for longer. It was decided, quite rightly, to end the contract.

On what basis was that done?

We did not need the capacity and it was the wrong deal.

I know hindsight is great but a significant amount of money has gone into private hospitals’ hands. At the time, the Government acted because it saw what was happening across mainland Europe. As the Minister said, however, there are significant question marks as to whether this was cost effective for the taxpayer. When all of the dust settles on Covid-19, questions will be asked about the amount of money that was given to private hospitals because these are run by some very wealthy people who have done very well out of this deal. There are significant questions as to what we got back as taxpayers. As the Minister has said himself, this was wrong deal.

It was, but although I am repeating myself, let us just remember the state of fear and anxiety in the country at the time. Our doctors and the Army were setting up tents in car parks of public hospitals. That is where we were at.

I agree, I do not think it will be done like that in the future and it is certainly not how we are thinking about doing it if it is needed again, and please God it will not be needed. We cannot judge what happened through a normal, peacetime lens. It was not a normal time.

The Minister mentioned student nurses. Does he have a timeframe for the review of the way in which student nurses are treated and paid prior to their graduation? A motion was heard in the Dáil today on the retention and reimbursement of student nurses in the health service. That is very important. The Minister has said that he will do a review and look at reimbursement and so forth for student nurses. Does he have a timeframe for that review?

We do. I wish to apologise because I know that the Deputy was one of the signatories to that Private Members' motion. I received it last Friday and worked on a response to it in the Department over the weekend and I talked to the Irish Nurses and Midwives Organisation, INMO, about exactly what we could put in place. I put in a lot of work but, unfortunately, I could not attend. I wanted to be in the Chamber today and partake in the debate but there was an annual EU health ministers meeting that I could not get out of. I had to be there, for obvious reasons, so I apologise for not attending the debate.

As the Deputy will know from the countermotion, we have secured an exemption to allow student nurses access to the pandemic unemployment payment, PUP. One of the things that the INMO quite rightly put to me was that there are student nurses who do not qualify for PUP because a job still exists but the nurses cannot take it up. Students who were working in a shop or bar that had to close are entitled to PUP because that job is not there. However, some student nurses found themselves in a position whereby their job still existed, the agency was still hiring or the care home was still taking people in, but, for obvious reasons related to Covid-19, those nurses could not possibly be working in a hospital during the week and a nursing home at the weekend. There were infection prevention reasons that could not happen. I did not think that was fair at all so we have secured an exemption for these students if they can show any loss of earnings. Anyone who can say they were earning money and are not any more will get PUP, and this exemption applies only to them. I have also secured a commitment that any healthcare costs associated with getting sick at work will be covered.

The INMO was keen for an independently verified review to take place which would not just reflect the Department's view of the world. The INMO wants a meaningful input into that report. We have agreed with all of that and I think those measures are all in the countermotion. I want the INMO to input to the review. I want independent verification of the report and we will then publish it. It will happen in a matter of weeks.

I will return to the issue of private hospitals. Most of us accept that it was the right road to go down, but many looking in found it frustrating that many of the hospitals were not being fully utilised. There was a lack of flexibility within the HSE or the Department. Somebody should have called stop and said that we need to use the private hospitals for something. That was not going on and was frustrating to many looking in at the system. We would like to think that we learn from these mistakes in case we are ever in that situation again. The HSE seems to be such a monolith that no one was able to make that decision. Would the Minister accept that as a fair analysis of what happened, particularly in the first lockdown?

That is all fair. I do not think the HSE would do the same again if put in the same situation. It is obviously easy for all of us to talk about it now. Could or should what the Chairman has just said have happened? Could people have stepped in and said that we need to get the utilisation rates up? Along with the Chairman and Deputy Kenny, I was advocating for exactly that. At the start, there was not a lot of it but the HSE, in fairness, was trying to do something that no one had ever done before. It took over an entire hospital sector. There were legal and IR implications and all sorts of different implications. As quickly as it could, the HSE began to get the volumes up. I was getting replies to parliamentary questions showing that the volumes of care were going up, although they did not at the start. Perhaps it could have worked better. The Chairman will remember the pressure the HSE was under in taking over a whole hospital system and having it ready overnight. We were all afraid of the worst-case scenario in which our public hospitals filled up and we would end up with thousands of Covid-19 patients quickly filling up the private hospitals as well. The Army was setting up tents in car parks. That needed to be looked at, and it has been, to inform our current talks with the private hospitals. We need to be cognisant of what was going on at the time.

I apologise for being late, I was at another meeting. The Minister was talking about the issue of community paramedicine. I have raised this matter before and have seen no evidence of a change for the coming year. We have taken on an additional 21,500 whole-time staff in the HSE. Including part-time people and everything else, 30,000 extra people are now working in the HSE compared with five years ago. Of that, only 70 are public health nurses.

I put this question to representatives of Sláintecare who were before the committee. They were shocked that only 70 additional public health nurses have been taken on in recent years. We have gone from 1,560 public health nurses to 1,630, there or thereabouts, and I have seen no evidence that that will change. The Minister talks about community paramedicine. We need nurses in the community.

A similar situation also applies to public health doctors. I am advised that at the most recent meeting, the Department was prepared to allow only 30 people in under that category. There was no agreement over all public health doctors. It seems to be sending out the wrong messages. On the one hand, we have Sláintecare saying one thing and, on the other hand, there is a policy that allowed an increase of 20.9% across all sectors of healthcare in the past five years, including nurses, junior doctors, consultants and administrative staff, while there has been less than a 5% increase of public health nurses. Are we serious about Sláintecare or is it all bluster? I am becoming more and more convinced that a lot of it is bluster. I can see no evidence that we are recruiting people to work in the public healthcare sector. That is one issue.

The second issue I want to raise relates to cataract operations. I raised this at the previous meeting and I raise it again. The response I got from the HSE was nothing but downright appalling. All I got back was a memo defending people travelling abroad to Northern Ireland for cataract operations, without any response to the question I had raised, which was about having people examined at an early stage, put on the list for the procedure and then, if the public health sector cannot deal with doing the cataract operation, it comes in under the National Treatment Purchase Fund. There was no reply to that question. The reply I got was appalling and extremely defensive of the fact that we are sending people out of the country to have a basic operation. That really needs to be dealt with.

There is a third issue on which I wish to touch. My understanding is that there are 685 applications for GP training this year. That is the largest number ever. One in eight of our existing GPs are over 60. What can we do?

Can additional training places be provided? Obviously, that would be done with co-operation. For a GP to go into training, he or she needs a practice that is prepared to take him or her on and go through the whole programme. What discussions have been held with the Department about increasing the number of GP trainees in order that we will have enough people in three to five years' time to fill the vacancies that arise?

I wish to refer to an issue that I raised recently with Revenue. We gave a special dispensation to meat factories to bring in people to work in particular jobs and earn less than €30,000. Some of my colleagues have mentioned that we need people in the community to provide home care and everything else. A huge number of people live in the same home as those to whom they provide 24-7 care five days a week. As happens in other countries, these carers are provided with food and accommodation. However, the cost of providing accommodation and food is not taken into account by Revenue when assessing people for tax purposes. Let us say that a person wants to bring in someone from abroad who is experienced in the provision of home care and care of the elderly. The same criteria are not in place for people from abroad to come here and provide home care. Interestingly, in Israel, more than 5,000 people are allowed to enter to provide home care full-time because there are not enough people to do the work and we will face that challenge here as well. We need to provide a home care package where people call two or three times a day to different individuals. However, there are those who need permanent home care. I ask that this issue be examined.

In terms of the community healthcare issue, I am not convinced that this happens and there is no evidence to support the claim. Can the Minister indicate where in HSE budget has money been set aside to deal with this matter?

I will go through the various questions and the Deputy is free to tell me to stop whenever he wants. The overall question is linked to the community healthcare question of whether Sláintecare is for real. For me, Sláintecare is a roadmap to universal healthcare and having high-quality care when people need it. I am taking this matter deadly seriously and I hope the Deputy can see that from the €600 million winter plan and the budget for next year, which is the biggest additional healthcare budget in recent times, possibly ever. It has the single biggest target ever for acute beds, critical care beds, hospital doctors, hospital nurses, community beds, step-down beds, rehabilitation beds and community clinicians, which is daunting because this is a massive task.

As the Deputy will see when he looks at the budget, we have very deliberately broken it up into big chunks one of which relates to community care. We are looking at a level of investment in community care for next year that is unprecedented for all of the reasons he outlined. This is in today's Revised Estimate because it included €200 million of the €600 million winter plan. If one considers the whole approach to the winter plan, it is exactly that. It is home care hours, GP access to diagnostics, public health nursing and home intervention teams. Let me give a brilliant example. There is a pilot scheme, called frailty teams, at St. Columcille's Hospital, Loughlinstown, County Dublin. Teams of an advanced paramedic, advanced nurse practitioners, occupational therapists and, sometimes, consultant doctors are sent to the houses of people who normally would be brought to the emergency department of St. Vincent's Hospital. The teams stabilise people in their homes. The cars that accompany the teams contain some advanced diagnostic equipment. The teams can conduct a teleconference with the emergency departments and specialists at St. Vincent's and in St. Columcille's. The pilot scheme has led to a 90% reduction in the number of people having to go to hospital. I am seeking the €200 million in funding to which I refer in order do these amazing things.

The next issue is cataracts. I acknowledge that the Deputy has raised the issue before and is absolutely spot on. My understanding of the issue that he has again raised with me is as follows. The problem with the National Treatment Purchase Fund, NTPF, is that one can only access it if one has been examined by a consultant.

That is right.

When the problem is that one cannot get to the consultant for an assessment, the NTPF is of no use.

That is right.

To date, part of the fix has been for people to travel by bus to one private hospital in Northern Ireland, which is covered by the cross-border directive. That is not right and not what we should be doing. As part of the access to care thinking for next year, which is the pot of €340 million, these are exactly the kinds of issues that I want to examine. It is a great example.

I raised the issue with the HSE when its representatives were before us. The response given did not deal with the issue and there was no indication that the HSE would deal with this issue, which is disappointing.

In fairness to the HSE, the solution to the question is in a task force that has not done the work yet so the HSE was in no position to do anything. The issue required a policy response and we will work with the HSE on exactly that.

In terms of training for GPs, absolutely. Really, it is a conversation that the Minister for Further and Higher Education, Research, Innovation and Science, Deputy Harris, and I need to have about providing additional places. I take the point that Deputy Colm Burke made about the ageing GP population. It is fantastic to see such interest.

I will outline one of the places we are putting this. There is a workforce planning team that is doing a flow analysis on all of the different aspects such as how do we get people in, are we training enough people, are we retaining them and so forth.

In terms of foreign carers or home care workers and tax reductions, I do not know. I guess it would have to be a conversation between the Minister for Finance and me. If the Deputy thinks there is an opportunity there, then let us take a look.

I ask the Minister to reply in writing to the query about the number of public health nurses.

Yes. It would be good if we got some indication that the matter is being taken seriously. Over the past two years, I have raised the issue on quite a number of occasions and absolutely nothing has changed.

As my colleague stated, another issue is that relating to public health doctors. It is important that we examine the issue and reach an agreement at the earliest possible stage.

Deputy Hourigan raised a matter in respect of the Estimate. Clearly, the Estimate is massive and perhaps we need to examine how it is done. Maybe we should provide supports for committee members. We do it for overseas aid and it is done in other parliaments. It is something that we should consider. I did not got a sense that we have dug into the Estimates and where the money will be spent.

I have a question about the national children's hospital because I am unsure about the funding, particularly the €107 million underspend. A couple of weeks ago, the National Paediatric Hospital Development Board was before the joint committee. Its representatives talked about the difficulties they face with hundreds of claims being before the High Court and the project being behind schedule. We also heard that the Tallaght urgent care centre is seven months behind and how they were worried about a big claim. On the one hand, we are saying that there has been an underspend but, on the other, we clearly know that there will be a demand.

It is clear there will be an overspend, not necessarily this year but certainly next year. Is that budgeted for? We are also told that 15% per month to the contractor, BAM, was being withheld. Does that come under the Minister's Department? How is that held? We do not have the time to go into them today but those are some of my concerns about it.

To get back to the Tallaght Hospital issue, a 72-bed unit project is with HBS Estates. We are told it is needed because of the number of elderly people presenting at the accident and emergency department but also because of the young population in the area. Is there any way of fast-tracking that because it is in an area of high unemployment and also because we need more beds within the system?

I am sorry to interrupt the Chairman but I was taking a note. Is that a specific project?

It is a specific 72-bed project-----

In Tallaght Hospital.

Palliative care was mentioned. All of us have been in hospitals when people were informed that their loved one was going to die. I was in a hospital one night when someone was dying on a trolley. A man nearby was being transferred to a bed and there was much effing and blinding, so to speak, while this woman was dying with her family around her. There is a need for those family palliative care systems within hospitals.

We are bringing in the people involved in the vaccine in two weeks time. The main concern is the hesitancy on the part of many people with regard to vaccines, particularly across Europe. In the past decade the numbers have gone down again. As one of the members said earlier, there is a need for a campaign around the efficacy of the drugs we are getting but also their safety and the speed with which they are being made available. That conversation needs to be had with this committee at some stage but also with the wider population. I am aware from talking to people that many want to get the vaccine but many others would prefer to get one from the next batch rather than the first. We need to convince them in that regard. Other vaccines were introduced in recent years and there was not the desired take-up of them.

I thank the Minister for coming before the committee. He might get back to me regarding some of the questions. On the Estimates, we do need support as a committee because even as late as yesterday we were getting notes from his Department about significant changes in terms of the allocation of specific moneys. That might be taken on board by the Minister and his officials. Does the Minister want to make any concluding remarks? We are over time now.

I just want to thank the Chairman and the committee. I will get him written notes on the various issues he raised. I spent the past number of years on the committee and anything I and the Department can do to help make the financial information more user-friendly I would be very support of-----

I think it goes across all Departments.

Can I raise one matter before we conclude? It is the issue that arises when the Dáil is sitting in the Convention Centre and committees are expected to sit at the same time. We need to get something done about that, perhaps even a simple change such as that votes would not take place before, say, 6.30 p.m. It is an issue we need to examine.

We will write to the Ceann Comhairle, and I believe it needs to be raised at the Business Committee also.

That concludes the consideration of the Supplementary Estimates for Public Services 2020, Vote 38 - Department of Health. I again thank the Minister and his officials for attending the meeting this evening.