Vote 38 - Health (Revised)

Apologies have been received from Deputy Neasa Hourigan. This meeting has been convened to consider the 2021 Revised Estimates, Vote 38 - Department of Health. While the committee has no role in actually approving the Estimate, there is an opportunity for it to make scrutiny of the Department's budgetary performance more transparent. The briefing prepared by the secretariat illustrates the difference between the 2020 and the 2021 financial allocations subhead by subhead within each programme. In addition, briefing has been provided by the Department of Health, which goes into more detail and offers further analysis and focus on those subheads.

I welcome the Minister, Deputy Stephen Donnelly, and his officials who are presenting remotely within the precincts of Leinster House. We are meeting this afternoon to consider the 2021 Revised Estimates. I thank the Minister for providing a briefing note related to the Estimates. I propose the Minister makes his opening remarks after which I will invite members to contribute.

I welcome this opportunity to address the Chairman and members of the select committee on the Revised Estimates for 2021 for my Department, which is Vote 38. Unlike other Votes, the Health Vote is not configured along programme lines. My Department continues to work towards the development of programme budgeting and changing the structure of the Health Votes to reflect this. It is going to take some time as financial systems in the HSE have to be adapted to allow for this in the context of a financial reform programme that is under way. In line with Government policy, and in the context of Covid-19, budget 2021 provided an unprecedented level of investment. The investment supports the resilience and preparedness of the health service to increase capacity and permanent staffing levels, to progress the implementation of a number of national strategies, and to advance the Sláintecare vision of universal healthcare.

I am delighted to have secured a further €4.039 billion in funding on top of the 2020 allocation. The level of funding provided will enable the advancement of a number of important priorities this year, including the protection of vulnerable groups, service users, patients, health care workers, and the wider public in the face of Covid-19, in line with national and international public health guidance; the delivery of increased levels of healthcare to our people in community and primary care settings, encompassing the mainstreaming of the Sláintecare integration fund initiatives; the delivery of the ambitious capacity enhancement and reform plan in line with the health service capacity review of 2018; improving access to mental health services, including progressing the implementation of the Sharing the Vision policy; improving access and enhancing specialist disability services with a focus on implementation of the Transforming Lives programme; continuing projects, including the development and adoption of an integrated financial management system by all statutory and larger executive-funded voluntary services, alongside further development of activity-based funding for hospitals and community services, together with enhancing procurement governance and systems.

The provision for the Health Vote in the 2021 Revised Estimates allows for a significant expansion of the health sector workforce, with an increase of 16,000 whole-time equivalents over the original January 2020 estimate of public service numbers. The allocated pay budget has increased from €7.95 billion to €9.055 billion in 2021. The impact of the latest Covid-19 surge in the first quarter of this year has had an obvious impact on service delivery. Some areas, such as additional home support hours, are behind where we would have hoped they would have been at this point, but the HSE is working to bring these back on track. Demand for the nursing home support scheme is also down on estimates, but this has not impacted on waiting times for applicants. It is expected that, all things remaining as they are, certain pent-up demand will see expenditure reach estimated levels by the end of the year.

The Health Act 1947 was amended to provide for a system of mandatory quarantine at designated facilities. This system of mandatory hotel quarantine is necessary to prevent and mitigate the risk of Covid-19, particularly variants of concern.

The Government has established a proportionate and carefully balanced system for mandatory quarantine, which is necessary to address the risk posed by travel from states where there is known to be sustained human transmission of Covid-19 and, in particular, variants of concern, or from which there is a high risk of importation of infection or contamination with Covid-19 and, in particular, variants of concern. This is necessary to protect the public, our health system and our vaccination programme.

The cost of mandatory quarantine was originally estimated at €7 million with costs to be recouped from the people placed in quarantine. However, as further capacity and hotels are added this estimate will inevitably increase. Funding to meet these costs is being provided from within the departmental allocation and will not impact on the allocation to the HSE.

The programme for Government reaffirmed its support for universal healthcare via Sláintecare. Sláintecare is being funded and is on track to improve access, expand eligibility, improve the patient experience and bring care closer to home. In 2021, there is continued commitment to Sláintecare with €1.353 billion being provided to fund programme reforms, including increased acute and community bed capacity, providing enhanced community, social and primary care services and improving access to care including a new access to care fund.

The move to a public-only health system is a key priority for the Government and central to the Sláintecare vision of universal healthcare. The programme for Government provides for the introduction of the Sláintecare contract. Arrangements are currently being finalised to facilitate the introduction of the contract in the coming months, following the enactment of the Public Service Pay Bill 2020, currently referred for Committee Stage. My officials will write to the representative bodies shortly inviting them to discussions on the contract.

There has been significant growth in consultant numbers recently, with numbers increasing by more than 200 in the past year to 3,470 but I recognise that further progress is required. I want doctors to stay in the Irish health system and for those who have emigrated to return home. As part of budget 2021 nearly 600 additional consultant posts are being created. The introduction of the Sláintecare contract will give us an opportunity to grow consultant numbers and move towards universal healthcare in a public-only system. The introduction of the contract also represents a significant opportunity to address the current number of temporary and unfilled consultant post and I have requested the HSE to develop a plan to achieve this.

Following intensive engagement, my Department, the HSE and the Irish Medical Organisation, IMO, have reached an agreement to the introduction of a fundamentally reformed and strengthened model for public health in Ireland in line with international best practice. This will require the implementation of a consultant-led and consultant-delivered public health model. Implementation of this model will enable recruitment and retention of public health consultants. It will deliver an agile, dynamic, intelligence-led public health medicine service to protect the population from health threats, promote health, improve health services and tackle inequalities in health.

Women’s health is a priority for the Government. Commitments made in the programme for Government include specific support for the women’s health task force and the development of a women’s health action plan. Budget 2021 allocated a dedicated multi-annual €5 million women’s health fund to implement a programme of actions from the work of the women’s health task force and appropriate activity is being identified for implementation and funding. The first two funded proposals, which were announced last week, are €1.4 million for two community-based ambulatory gynaecology services governed by Tallaght University Hospital and University Maternity Hospital Limerick and €.6 million for the expansion of the endometriosis service at Tallaght University Hospital, which creates specialist service for very complex cases. These proposals will significantly increase access to these services for women and support their care at the earliest point.

Some €20 million is being provided to progress the implementation of the national cancer strategy, including surgical and medical oncology; rapid access clinics and early diagnosis and radiotherapy. The national cancer control programme is allocating initial "once-off" funding to each hospital group to assist with the costs associated with their efforts in service recovery and continuity. This funding will support measures to increase resilience and address clinic backlogs.

I now turn to the 2020 outturn. The gross provision for the Health Vote in 2020 was €20.875 billion, comprising €19.801 billion in current expenditure and €1.074 billion in capital expenditure. This €20.875 billion represents the gross funding position for both the Department of Health and the HSE and includes additional funding of €1.777 billion made available for current expenditure in 2020 in response to Covid-19 and €547.5 million granted by means of a Supplementary Estimate.

The initial 2020 capital allocation was €854 million. In response to Covid-19, an additional allocation of €220 million was made bringing the total capital allocation that year to €1.074 billion. The total cost of Covid-19 supports provided by Government to the Health service in 2020 was €2.5 billion. Among the key measures covered by this expenditure was testing and tracing; supporting nursing homes and home support; enhanced GP services; community assessment hubs; caring for people in acute services; private hospital capacity; expanding and protecting our health workforce and essential workers; expanding physical infrastructure including isolation facilities; and maintaining access to essential health products, equipment and services. These measures continue to be relevant in 2021 as the pandemic continues

In framing the 2021 budget, the Oireachtas allocated significant further additional Exchequer funding for the health sector. I thank committee members for their support in this. In 2021, gross health funding is €22.13 billion comprising €21.081 billion in current expenditure and €1.048 billion in capital expenditure. This represents an increase of €1.28 billion, 6.5%, on the 2020 post-supplementary current expenditure budget and recognises the Government’s commitment to providing a health service that seeks to improve the health and well-being of the people of Ireland.

While the 2021 capital allocation is €26 million below that of the final 2020 figure, it represents a significant increase on pre-Covid-19 allocations and reflects continuing investment to meet the infrastructural challenges in responding to the pandemic. The capital funding for health in 2021 will contribute to the delivery of modern health facilities and equipment to improve and expand service provision and capacity across the country, both key aspects of Sláintecare and Project Ireland 2040. While the scale of this funding is significant, the value of the investment in protecting our people in the face of the Covid-19 is unquantifiable. This Government is steadfast in our commitment to protect everyone and to enhancing the resilience of our health service. This commitment is evident in the level of funding made available in 2021.

The issue of health funding is a major policy challenge internationally, as committee members will be very well aware. Despite welcome funding increases over recent years, the need for effective financial management remains crucial. The health service is dealing with a larger and older population, with more acute health and social care requirements, increased demand for new and existing drugs and the increasing costs of health technology. The costs associated with these service pressures will increasingly need to be managed, not solely through annual increased Exchequer allocations, but also through improved efficiencies, productivity and value from within the funding base in 2021 and beyond.

Demographic pressures, including a rise in chronic diseases and ageing populations, are major challenges to health funding internationally. The additional funding secured over recent years provides a substantial basis for the health service to maximise the level and quality of service delivery while also implementing the Sláintecare programme.

A significant increase in funding for the health services has been achieved this year. Much of the recent increases have been Covid-19 related. The health system responded quickly and efficiently to the Covid-19 emergency. Additional spending has facilitated the necessary and rapid introduction of testing, provision of essential personal protective equipment; enhanced support to critical health services; and the introduction of additional hospital capacity and community services. Oversight structures are in place to ensure this significant investment is approved, monitored and reported in line with agreed sanctioning processes and financial procedures.

The programme for Government places a major focus on health service reform and investment in our public health system. Building upon and learning from the Covid-19 response will be central to the Government’s approach. In addition to Covid-19, dealing with a growing and ageing population, more acute health and social care requirements, increased demand for new and existing drugs and the increasing costs of health technology, will all continue to pose a financial challenge into the future.

Improving the way services are organised and delivered and reducing costs in order to maximise the ability of the health service to respond to growing needs must remain important points of focus. It is essential that those managing and delivering the service continue to demonstrate good practice in the year ahead by delivering the best possible healthcare within the limits of resources that have been made available by the Government. I thank my colleagues and the Chairman.

I thank the Minister for the presentation. May I touch on one or two issues? First, additional funding was provided to the private nursing homes to deal with the pandemic. I did not see any figure for public nursing homes and community hospitals. I believe there are 119 of them. Could we have a breakdown of the additional funding that had to be made available, particularly to increase the level of care so the facilities could deal with the new demands and challenges posed by Covid.

Second, I want to touch on the expansion of home care. The pandemic has created new demands. As the Minister said, the number of people over 65 is going to continue to grow over the next ten years. The number is about 720,000 now and it will be 1 million by 2030. On the rolling out of additional home care supports and the regulation of the home care providers, what progress will be made during 2021?

The final point I want to touch on concerns Sláintecare, to which the Minister referred quite a bit. The Sláintecare team produced a report on the three elective hospitals for Cork, Galway and Dublin. It is a totally watered-down proposal. I am getting no response from anyone regarding where we are going on this. We put considerable money into new healthcare facilities in Dublin. The population of Cork has grown by 130,000 over recent years and it is a question of new hospital beds, yet a Sláintecare report is suggesting that Cork should have only a day facility, which could not cater for anyone with diabetes or other underlying conditions. Where are we going with this Sláintecare report? Where is there provision in the budget for 2021 to deal with these issues?

I thank the Deputy for those questions. Regarding the public nursing home supports, I will ask that a note be provided to the Deputy. Obviously, a substantial amount of support was provided to the nursing homes across the country, and this was supported by Nursing Homes Ireland. I will get a detailed note not just on the money but also on the additional capacity provided through the community healthcare organisations.

On the expansion of home care, we have a very ambitious target for this year, that is, to add an additional 5 million hours. Some €150 million for additional expenditure was allocated. Of this, €140 million was for the provision of the hours and €10 million was for the provision of what is called the interRAI system. We are fundamentally changing how home care is provided in the country. The interRAI system will essentially allow for the individual assessment of patient needs and their care requirements. There are many advantages to it, including around transparency, but I am very keen on the fact that it helps in terms of health equality. It will allow us to ascertain what parts of the country have the level of service provision they need and the parts that need additional support.

The Deputy mentioned regulation. I actually brought a memorandum to the Government today and we got agreement on the drafting of the heads of a Bill on the regulation of home care. It is a really important move. There is a major focus on it. The Deputy is very aware of this, not least because he and Deputy Higgins tabled a Bill on it. There was much progress today. We will be drafting a very comprehensive Bill on the regulation of home care services and also expanding it, essentially bringing into line the regulation of nursing homes and the regulation of home care because there needs to be more of a continuum. My view, which is shared by many members of the committee, is that we need to maximise home care over nursing home care, not that there is not a role for nursing home care. Of course there is, but it is a question of keeping people at home as much as possible. A really important step was taken today.

The Deputy continues to advocate very strongly regarding the elective facilities, including the elective hospital in Cork. Some of the thinking of the Sláintecare team is that the elective hospitals could be day care only. The thinking is that if the quality and speed of care are maximised for less complex procedures, it frees up inpatient beds and acute beds for complex care. However, I am aware that there are strong views on this in Galway and Cork. The Deputy and other Deputies have expressed them, and some in the clinical community have done so in regard to wanting a mixture of inpatient and day care beds in any new elective hospital. No decisions have been made on that. The thinking is still being worked on.

Regarding the elective hospital, how long is this issue going to be kicked around the place? Consider the case of South Infirmary Victoria University Hospital, Cork, for example. The building has been in place for 150 to 200 years. It cannot be modernised unless major work is done. We either go down that road or build a new hospital on a greenfield site. The elective hospital proposed by Sláintecare is a day facility. A facility operating for six days per week for 50 weeks of the year will not be able to deal with a large number of patients because many patients coming in for minor enough procedures will also have underlying conditions. For how long will this debate go on? We are now into year four of talking about elective hospitals but with no clear plan.

I thank the Deputy. I share his frustration. There has been much talk about these elective hospitals for a long time. I would much prefer if we were farther along. What I can tell the Deputy is that the Sláintecare team is working hard on it. It is examining the various sites and models of care. As I know the Deputy will understand, much of this work, because of the pandemic, has not moved at the pace we would all like. The Deputy's points are well made and I will feed them back, as I have done previously. I will feed them back again to the team looking at both the sites and the model-of-care options for the elective hospitals.

May I just touch on the National Treatment Purchase Fund? In talking about that, I am also talking about the treatment abroad fund, which is different. People are now being encouraged to travel abroad for some medical treatment although there are facilities in the South to deal with some of the treatments being provided abroad. What are we doing to deal with this issue, so we can keep the work here and make sure it is done in a timely manner rather than requiring people to travel long distances? Is adequate funding provided for the National Treatment Purchase Fund? The problem is that our hospitals will all be under increased pressure due to the backlog of work not done in 2020.

How can the Minister make sure there is catch-up, particularly where there are facilities where this work can be done?

As much work as possible should be done within the public health system. We should not have the waiting lists that currently exist. The question is what do we do about the far too many men, women and children who are still waiting while we build the permanent capacity of the public system to be able to meet demand,. The answer is that it is a combination of things.

As the Deputy stated, the treatment abroad scheme is used. If we had the level of capacity we ought to have here, the scheme really should not be needed. I will give an example. Funding is being provided for an ophthalmology unit in County Cork, which will be able to deal with many people with cataracts who are currently travelling to private hospitals in Northern Ireland for cataract operations. To me, success is people no longer needing to travel but, rather, being treated in the unit in County Cork or another HSE hospital.

In the short term, to make progress on waiting lists we need to use a combination of things. We need to use the treatment abroad scheme. We need to provide additional funding to the HSE, both in terms of permanent capacity, such as the ophthalmology unit, but also in terms of additional short-term capacity, such as running operating theatres out of normal hours, payment by procedure within HSE hospitals and using the private system to treat as many people as possible as quickly as possible. The total funding being allocated this year is substantial. We have an access to care fund of €210 million. There is an additional amount of €30 million to the NTPF, bringing the total amount for the fund up to €130 million. There is €33 million for alternative care pathways, which is part of the Sláintecare work but essentially will help to tackle waiting lists. There is the acute hospital service restart fund of €35 million and cancer screening of €10 million. In total, that comes to approximately €418 million. It is the intention to bring the waiting lists down as quickly as we can and using every available mechanism.

One of the problems relating to the NTPF is that people are being sent out for assessment and the assessment comes back and then they have to be referred again. Has reform been made in that regard, that is, the situation whereby people who are referred, are referred not only for the assessment, but also for whatever procedure is required? One of the complaints I am getting in respect of the fund is that the system is too complicated and needs to be reformed.

The Deputy is correct. There is a bit of a catch-22, which is that if one has to wait too long for a procedure, one can use the NTPF, but to do so, one has to get an assessment for which one has to wait too long. It is a catch-22 and too many people are left outside the system. They cannot access the service they need through the HSE and they cannot access it through the NTPF because they cannot access the assessment through the HSE. We are taking a fresh look at it this year. We are looking at the €130 million in the NTPF and the additional €210 million for the access to care fund, as well as those other pots of money, and asking how we can do this better. For example, one of the things we are doing is expanding access to diagnostics, which was not available previously. The Deputy is entirely correct. The current situation can be improved and it is our intention to do that.

The Minister referred to the recruitment of additional consultants. Have particular areas been prioritised in that regard? There are several areas in which there is a shortage of consultants. Have those areas been prioritised? What particular areas have the Department and the HSE decided to focus on?

I refer to amending legislation relating to people who were not regarded as being on the specialist register that was put in place. However, the regulation has not been put in place by the Department. When is that likely to happen?

The answer to the Deputy's first question is that two things are happening. The first is that the HSE is hiring on an operational and clinical basis to the high-priority areas. Second, there is a relatively new team within the Department of Health, namely, the workforce planning unit, which is seeking to determine where the gaps are. Believe it or not, there is not yet a model that tells us how many of each specialty we need. As we know what we have, such a model would identify the gap. There is significant work ongoing in the Department, again under the auspices of Sláintecare, on the area-based healthcare analysis to determine what we need in each specialty in each area, what we have and what is the gap or the number we will hire.

I ask the Deputy to remind me of his final question.

It relates to certain people who were not regarded as being on the specialist list, in the context of consultants. Amending legislation was put in place to allow them to join the specialist register but the regulation to allow that to happen has not been put in place. These are consultants who were appointed but are not regarded as being on the specialist register.

I will need to look into that matter in more detail. Is the Deputy referring to consultants who had been consultants for some time but never elected to transfer across-----

-----or is he talking about the new public health doctors?

No, I am referring to consultants who were employed by the HSE and with regard to whom we had to bring in amending legislation because, for various reasons, they did not qualify under the specialist registrar scheme. Some of them were filling positions for several years but had never been on the specialist register when they were then appointed as consultants.

I ask the Minister to provide a note for the committee on that issue. We have gone over time on this section.

Sure. No problem at all.

I welcome the Minister and his staff. With regard to the headline figure, that is, the total gross provision figure of €22.13 billion, how much of that does he anticipate will form the baseline for next year as we look towards budget 2022? Obviously, a portion of it is Covid-related and allocated to dealing with issues such as testing, contact tracing, personal protective equipment, quarantine and all of those measures. I assume some of this will be with us for some time to come; it will not disappear any time soon. However, there may come a need to scale back these measures. In terms of the overall expenditure, is it the Minister's intention to keep that figure of €22 billion as the baseline figure going forward into budget 2022?

We do not have an answer to that question yet. It is a really good question. As the Deputy will be aware, the €4.039 billion breaks down into €2.121 billion for Covid measures, €1.163 billion for new non-Covid measures and €755 million for the existing level of service, ELS. I anticipate the ELS funding will stay at that level by virtue of what it is and the €1.1633 billion for the additional new measures will stay at that level. Obviously, that has to be agreed by Government but that is what I will seek and what would be normal practice. The next question is how much of the €2.121 billion relating to Covid stays. I do not think we know that at this stage. As the Deputy and I were discussing only yesterday, there will be an ongoing need for testing and tracing and genome sequencing. There may be an ongoing need for quarantine facilities. What the experts are telling us is that, globally, Covid will be here for some time, no matter how well we do in Ireland.

If I may interject, my point is that at a policy level, whatever about what the money is spent on, the Minister or the Government could decide that we have to invest more in health. There is a commitment this year to slightly more than €22 billion. Some of that money could be re-profiled and spent in other areas of healthcare, as all present know is necessary. Is the Minister saying that decision has not yet been made and that it is possible that the figure of €22 billion may not be what will be in budget 2022?

That is a decision that will be made later. No policy decision has been made at this time to baseline that figure. Is that what the Minister is saying?

That is right. Two things could happen. I will be pushing for additional funding for new measures. At the same time, I hope the funding allocated for Covid significantly reduces. Where the two of those land in net terms, we will know later this year.

I move on to the briefing note we got from the Department. On page 15, under acute services, it talks about a €236 million additional spend on acute beds and says there will be an additional 1,146 beds by the end of 2021 as compared to 2020. What is the anticipated number of funded beds?

I want to check we are looking at the same documents. Is it €276 million the Deputy has?

It is €236 million. It is on page 15 of the briefing document.

In my note, it is €276 million. That includes €40 million in capital funding, which probably gets us to that figure. I think we are talking about the same amounts.

Let us stick with the beds for a second. We are told it is 1,146 additional beds. What will be the total number of funded beds we will have at the end of 2021?

The latest target for the end of this year is an additional 1,063. That is acute beds and does not include critical care beds.

I know that. I am reading from the briefing document we got. If we have different documents and different numbers, it is concerning. It states that, "The funding provided in 2021 will ensure that the [total] number of funded acute beds in the system will increase by 1,146 by [the] end of 2021 when compared to 2020." I have pointed out before and point out again that that is not correct. It is based on 2019 figures. In 2019, the number of beds we had was just over 10,700. That was the baseline figure. Can that be clarified?

Absolutely. Here are the latest exact figures. The Deputy is absolutely right that total figure we have is as of 1 January last year, so it is essentially two years worth.

It does not say that in the briefing note. We had a discussion on this in the past. It is right when it comes to ICU beds but wrong when it comes to acute beds. It gives the impression that there are 1,146 beds for one year, when in fact it is two years. That is what I want to clarify.

It is a fair question. The Department has presented it like this because last year was a very unusual year in that a large amount of Covid funding was used to set up temporary beds. The beds came into existence last year. Those beds were one-off beds. This year, through the budget, we have permanently funded those beds. Some 611 of the beds were brought into existence physically last year but only funded to the end of the year. Through the winter plan and this budget, we have turned them into permanent beds for this year. The total permanent beds we are getting through this budget, which I guess is the question for us all, is-----

It is over a two-year period, and that is what I was asking.

To be clear, it is permanent provision. The answer is that the 611 from last year and the total from this year add up to 1,063.


I move to the issue of the public-only Sláintecare consulting contracts. That was meant to be in place since last June. All new contracts were meant to be Sláintecare public-only contracts. Is that happening and what is the take-up? What engagement has the Minister had with the Irish Medical Organisation, IMO, on this issue? Are the IMO and the Irish Hospital Consultants Association, IHCA, buying into these Sláintecare public-only consultant contracts?

We are writing to the representative bodies now to invite them in for initial discussions. I do not want to pre-empt what the IMO will say. The IHCA will have a view as well, and it has a view on various other issues which we have all discussed.

From the Minister's knowledge and experience of discussions with the IHCA, is it a positive view? Is it in agreement with the contracts? Does it see it as a way forward?

The Deputy will appreciate that I cannot, do not want to and would not presume to speak for the IMO or the IHCA. They will give their own view. I can say we are moving towards the Sláintecare contract. Once the contract is in place, the only contracts that will be given out for new entrants to the HSE are the Sláintecare contracts. Critically, and I think we are all agreed this is a core component of universal healthcare, the new contracts will only allow for public work in public hospitals.

Okay. On a related issue, when I talk to hospital consultants, the two-tier nature of the pay is an issue and they want the contracts to reflect that reality. As, if not more important, is the support they get when in their jobs, including access to equipment such as diagnostic equipment and to theatre space. While we might have ambitious plans to increase the number of consultants, we also need to increase theatre space because that is part of the problem. We also have to increase access to equipment. They tell me part of their daily struggle in their work life involves battling the system to get access to theatre space and equipment. I argue that, while we are funding additional consultant posts, in tandem with that we should look at expanding theatre space and equipment so we get bang for buck and have an opportunity to put them to full use and reduce wait times.

I could not agree more. The whole approach is that we create the new Sláintecare contract but, on the Deputy's point, that is not enough. I would like to see things around the Sláintecare contract like funding for research and clinical trials and some of the things the consultants do not have access to at the moment. That will be part of the talks. At the same time as putting the Sláintecare contract in place, and hopefully hiring 600 new consultants this year, we are expanding acute beds, critical care beds, community beds, step-down beds and rehab beds. We are expanding the safe staffing model for nursing and the whole point is to take the pressure off the system so that our clinicians can do the job they want to do, have access to their patients to assess them when they need to, diagnose them when they need to and either treat them with the drugs they need access to or in operating theatres.

I move on to a number of other issues. I put in a parliamentary question on the CervicalCheck tribunal and I have got the costs back. Before I go into the costs, the most recent response I got back was that there were three cases that have been referred to the tribunal, which seems quite low. Is that the most recent figure? Is it accurate? If so, does it concern the Minister that the number is so low and the take-up is so low?

I will get the Deputy the latest position. My understanding is there have been more referrals than the three. Much interest has been expressed and questions have been asked by the various legal teams representing the women and families involved. My view is it is a far better option than the High Court. However, we have to respect the rights and decisions of the women to use the tribunal, the High Court or both. At any time during the tribunal, the women can elect to leave it and go to the High Court instead.

Is the Minister confident that more women will? I am looking at the costs and some of them seem strange to me. There is €140,000 for furniture and fittings. It also refers to an art allowance. What is that for?

I am not aware of the document the Deputy is looking at. I can say that when-----

It is a response I received to a parliamentary question. Sorry, I should have said that. It refers to an art allowance, construction fit-out costs and consultant fees and it breaks down some of the additional spend, including €140,000 on furniture and fittings. I am just looking at the art allowance, trying to figure out what that is about.

I will get the Deputy a detailed note on that. On the fixtures and fittings and the buildings costs, there was a significant amount of work done to make the tribunal Covid-friendly. We wanted to make sure any women coming in, some of whom could be immunocompromised, had the appropriate facilities. For example, the women and families involved can now do all the proceedings from their own rooms. They do not have to go into the same rooms as the lab or the State. Work was done by the Office of Public Works, OPW, to create a suitable environment in Covid-19, which many courts also have.

That is right and we would all support that. The Minister might send me on a detailed note on it. I have only two further questions. Has a decision been made yet on the location of the major trauma centre for Dublin?

Yes. That was agreed by Government today. The major trauma centre will be in the Mater hospital.

I want to ask a question regarding the national maternity hospital. I discussed this in private with the Minister recently and it is useful to have the opportunity to discuss this publicly. There are concerns about the company which essentially owns the land. My understanding is it is pre the Sisters of Charity. Issues have been legitimately been raised regarding the ownership of the hospital and what impact it will have on the running of the hospital. Will the Minister address that point? Has the Department at any time considered purchasing the land by way of a compulsory purchase order? Was it possible to do that? I assume that would be one way to solve this issue and to make sure both the building and land is fully in public ownership and fully managed by the HSE and the State.

On the Deputy's first question on religious ethos, I can tell him clearly my view is that there can be no imposition of any religious ethos and any impact that might have on services delivered in the hospital under any circumstances. That is an absolute red line. It cannot happen. I have looked into this in some detail and have assurances the structure being put in place absolutely does not allow that to happen. However, I am also aware some very well respected people have a different view. I understand Deputy Shortall organised a meeting recently on that. I would be very happy to ask the unit and the lawyers to look at all that evidence. I think we are all on the same page on this. This needs to be a public hospital that delivers the public services the Government of Ireland and the HSE deem to be the right services.

I commend Deputy Shortall on the meeting she organised. An all-party delegation will be seeking to meet the Minister. These are important issues that need to be answered.

I have a final question. I do not think the Minister will not have the information to hand but I am seeking a detailed note on this. As we are examining expenditure, the Estimates and public spending in health, will the Minister ask his officials to provide me with a briefing note on the total private spend on healthcare in our total public healthcare system? For example, I am referring to the total spend on outsourcing to the National Treatment Purchase Fund and the total spend on consultancy fees. In the Minister's briefing note he referred to community beds being purchased privately. There is the issue of locum and agency staff and it is too much to go into in this session. For the purposes of future sessions and engagements, will the Minister arrange for that breakdown to be given to us? I might send the secretariat a note of exactly what I am looking for. I assume the Minister has a sense of it. He might provide that as soon as possible. I thank him for his answers.

I thank the Minister for being at our select committee meeting, for his detailed overview, and for the material that was circulated to us yesterday, which I appreciate. In a year of negatives, as Covid has been a major negative in everyone’s life, it is good we are coming to a point where it has become more manageable. There are two trajectories almost at intersection point now, namely, the vaccines versus a declining or at least a levelling of the Covid rate. There is a much to hope for and it is hoped Thursday will allow for a safeish reopening of the country or at least the next step in that process. It is also welcome that the Government has awarded an additional €4.03 billion to the Department’s budget on top of its 2020 allocation.

I wish to come at this from an angle that has not been covered thus far in our deliberations. Another potential budgetary constraint on Minister Department is the digital green certificate, which is being worked on at European level. Although it deals with international air travel, my understanding is it will come under the remit of the Minister’s Department. A vote is to take place on it in European Parliament this week. We know the technical specification of it was agreed and published yesterday by the European Commission. The meat is very much going on the bone. We will be at the point shortly where this will be put to each member state to ratify and then to decide how they will implement it. There are three pillars to it. It will certify those across Europe who have been vaccinated, those who have been PCR-tested and who were negative at the time they presented themselves at the departure gate at an airport, and it will also carry data relating to those who have recovered from Covid. The European Commission is intimating there will be a six-week lead-in or implementation period.

That concerns me a little with Ireland being geographically peripheral and a little more cut off from Europe, with our nearest neighbours having departed the European Union. That lead-in period could throw us a little bit off kilter, with opportunities lost to other nations. Have we as a country and the Minister's Department the allocated finances for this, given we are talking about his Department's budget for this year? Are the finances in place and, more importantly, is there a team, a structure, and the necessary software in place? Is everything ready to roll as soon as the digital green certificate is agreed by European Heads of State in order that we can implement it in Ireland?

The short answer is that it will be. As with many other countries, the technology is being developed in the background and there is a co-ordinating role from the Commission in terms of making sure it works interjurisdictionally. in other words, if an Irish citizen lands in Paris, he or she could show a unique code on his or her phone, which the French authorities could recognise as that person having been fully vaccinated and, similarly, we could recognise that in respect of people arriving from other member states into one of our airports or ports. That work is going on in the background. Very significant work has been done on exactly this point in Ireland. Certainly we are looking very favourably at participation in the digital green certificate. It will be very welcome. If it works as we want it to work and as the European member states want it to work, for those who are exempted, namely, for fully vaccinated people, it will enable free travel in a way that has not been possible since this virus arrived.

You could not believe half or probably a tenth of what you read on Twitter, but there are some in the relevant industries who are already speculating, even though the European Union is only starting to trickle out some detail, that Ireland could Ireland could be a laggard in terms of implementing this process and being able to be at the races with other European nations. When it is agreed, will we be at that same pace as other nations in terms of its roll-out? It is important a lead-in period is communicated, particularly to the travel and aviation industries. Many of our pilots and cabin crew are out of hours, to use a parlance from their profession. They need to return to training. They need a lead-in period. Will we be able to provide a lead-in period and to keep pace with other nations? I understand Greece, Spain and other Mediterranean countries are eager to get this in place for their tourism markets. Will we be able to keep pace with them and not be laggards in that regard?

The briefing I have is that we are on track to be able to join it at the same time as other member states.

Good. That is welcome. If I can continue in a European vein, and I spoke on this issue in the Dáil Chamber recently, the Minister leads the Department of Health and he regularly meets his counterparts and colleagues across Europe. Ultimately, while we have own structures in Ireland, there is the European Centre for Disease Prevention and Control. I presume as a member state of the European Union we contribute financially to that entity. It has a budget of in or around €50 million per year, which is paltry considering its American equivalent has an annual budget of $12 billion. There is not much the Minister can do in that regard but I ask that at the next meeting of the Council of Ministers he would be an objecting voice or at least a voice of concern in the room. This entity, which was set up following an outbreak of the first ever SARS disease 18 years ago, has proven itself to be largely inept and ineffective. It is ultimately the source of information for each member state to have its trickle-down of policies in terms of managing this. Does it interact with the Council of Ministers much? Are they as a bloc concerned this entity has not been that steady backbone they would have needed it to be for the past 14 months?

There is certainly a clear understanding at a European health minister level that significant investment is required in the systems in place to deal with pandemics, including the European Centre for Disease Prevention and Control, ECDC, the European Medicines Agency, EMA, and other groups. We know that in Ireland, regardless of what happens at a European institution level, significant investment is required. The public health system here was not fit for purpose in terms of dealing with a global pandemic. We should have, and now will have, a consultant-led public health system. We need a much expanded public health system, which we are now doubling, as the Deputy is aware. We also need much better IT systems. We need to move on some of the other things that not only are related to public health and the pandemic but also run through the Sláintecare system, such as unique patient identifiers. We are laggards on e-health and that has to change. Significant investment and work are going into the system to that end.

When it comes to the ECDC, I can tell the Deputy that the public health teams certainly rate its advice very highly. The National Public Health Emergency Team, NPHET, regularly refers to and interacts with the ECDC on international comparative analysis around public health and Covid-19. The core question the Deputy asked was whether the European institutions need to be further enhanced and I certainly would be supportive of that.

I will end on a note about e-health. We as a nation are going to go so far in the coming weeks. There is a bit of an unknown here but the details are starting to come from the European Commission. We are going to have an e-health system that will probably be on our phones. It might be like what we saw a few weeks ago on the "Prime Time" special. We saw a little snippet of people going around Tel Aviv and Jerusalem in Israel with little digital certificates on their phones that acted as their passports for entry into cinemas, pubs and restaurants. If we are going the whole hog of having a digital system in place to allow people to present themselves at an airport departure gate, would the Department consider operating that system, which will be up and running, in certain contexts around the country, for example, to allow people to go to matches, concerts, weddings and venues in which large numbers of people will congregate? If we have the system in place, will we give it a dual purpose and use it on the domestic front as well as at the airport departure gate? Israel and some other countries have done that. If we are going the whole hog on software, smart and e-health infrastructure, it would be great if we could use the device in our pockets to gain entry to a place. Has there been any talk within the Department of a deeper role for that technology in the months ahead?

The principle is already enshrined in the regulations in terms of being exempt from mandatory hotel quarantine and being able move to home quarantine, for example, if you can show you are fully vaccinated. The EU digital green certificate is built on the exact premise that there are things you can do because you pose less of a risk to other people. It is less about protecting the individual and more about protecting other people from international travel.

There is a philosophical question to be discussed when it comes to applying similar measures in a domestic setting. I would be interested to get the committee's view on that. Is it right or proper to discriminate in terms of access to domestic services, whether that is, as the Deputy said, a concert or something else, based on whether somebody is vaccinated? There are strongly held views on both sides of that argument. I would be interested to get a view from the committee, if it were to discuss the matter. The same question would have to be applied to the legality of creating different levels of access for people based on the situation the Deputy has described.

I thank the Minister and appreciate his time. I thank the Chairperson. I am finished my questions.

I thank the Deputy. We drifted away from some of the issues. The Minister is asking whether the committee will have a look at a particular area. He might come back to the committee at some stage on a situation where someone who has had Covid is travelling. One of the requirements at the moment, of course, is that you need a PCR test, but I am told that if you have had Covid within a certain period, the PCR test will come back with a positive result. That is one of the difficulties. I have recently been dealing with cases of people who were quarantined because they did not have a PCR test but had been told by Department officials that it was not needed. That might be something at which the Minister could look and come to back to the committee on at some stage.

I thank the Minister and his officials for the detailed briefing they provided. I will talk about the reform programme and where we are on elements of it. Before I do, I will return to the issue raised by Deputy Cullinane about the new national maternity hospital. As the Minister said, there was a very well-attended briefing yesterday on that issue. It is true to say there is a lot of concern about the fact the new entity, St. Vincent's Holdings, that has been created to replace St. Vincent's Healthcare Group, is operating on the basis of the same ethical code as St. Vincent's Healthcare Group. The constitution has not been changed and there are concerns about the implications of that for women's healthcare and services that should be provided in a publicly owned hospital as well as the question of handing over or gifting a publicly funded hospital to a private entity. A cross-party group has been formed. There is an email on its way to the Minister to request an early meeting on the issue before any final decisions are taken. I hope the Minister will be in a position to accede to that request for a meeting at an early date. I hope he is agreeable to that.

I absolutely am. I restate that this all boils down to a question of whether services that must be provided for women can be stopped because of a religious ethos. We know that has influenced things in the past. My unambiguous position on the matter is that will not be allowed to happen. I have sought assurances that is the case, based on the new governance structure, and have absolutely clear assurance it is the case. I know the Deputy has convened a meeting of smart and informed people who have a different view, and perhaps that is mentioned in the email she is sending. I suggest the group of people the Deputy has convened send on their views, and I will ask for a response from the Department and the legal teams and send it back to the Deputy before we meet. There can be no question of any services for women being stopped or watered down or anything else because of any ethos. The Government and the HSE will decide and that can be the only way we proceed.

I do not know if the Minister is aware but reproductive health services are not currently provided to women in St. Vincent's hospital and it is hard to see that situation changing, given the expected structure of the new company, its basis and origins, particularly in the context of the repeal of the eighth amendment. Other basic women's health services, such as sterilisation services, prescribing of contraception and so on, are not currently provided in that hospital. It is a matter of concern and I look forward to engaging with everyone.

I can tell the Deputy that there will be no hospital created or put in place that denies women access to any of those services. I would be happy to engage in a lot of detail to ensure all of the issues are addressed.

I thank the Minister for that. I will move to the question of expanding services and dealing with issues over recruitment and retention, which are pressing issues in all kinds of disciplines right across the health service. Is there work going on at Department or HSE level to do essential forward planning to ensure our colleges have enough places to train the people who will be needed over the coming years? We need to address the kinds of issues that lead to people leaving this country, rather than staying here and working in the Irish health service. Where is there work being done on that?

The short answer is "Yes". A new team called the workforce planning unit was set up last year and those are exactly the issues at which it is looking.

As the Deputy knows, Laura Magahy leads the Sláintecare team. One of the things they are doing is the area-based analysis to see how many of each specialty we need in all of the areas, which will give us the gap and will allow us to hire in. At the same time, the whole pipeline coming in is being looked at in regard to different nursing specialties, different medical specialties, different health and social care specialties, how many of these people we need, how many training places there are, how many we can retain here and so forth.

I take it it is not the Sláintecare team doing that work. Is there a separate unit in the Department?

That is right. The Sláintecare team is doing the area-based analysis and then there is a different team, which is the workforce planning team.

Does the Minister expect that team to report soon?

They are reporting on an ongoing basis. There is not a big single report they are doing. They are looking at it profession by profession and working their way through it. They would be in regular contact, for example, with higher education on places that need to be made available.

Is it possible for that group to provide an update to the committee? We were talking earlier about this being one of the issues we intend looking at.

That is no problem. I will ask for an update for the committee.

I thank the Minister. To pick up on the issue of the Sláintecare recommendation on three elective hospitals, it is disappointing to hear there seems to be a watering down of that. This was a key recommendation following on from the experience in Scotland and how it dealt with pressures on its acute hospital sector. There is a very strong case for having elective hospitals but they have to go beyond day case, or while they could obviously do day cases, there is a need for inpatient cases as well. For example, one of the key pressure areas is orthopaedics. That is something that should be done as a matter of course, with people in and out in a matter of days, as some of the private clinics are doing very successfully. What was done in Scotland was that a private hospital was bought to kick-start that whole new approach. Has consideration been given to that? I urge the Minister to ensure we are not just talking about day hospitals and that it is full inpatient hospitals.

It was in Glasgow, where they bought a private hospital and I think they bought the hotel beside it as well, so people could be rested and prepared. What I can tell the Deputy is that it is the Sláintecare team that is doing the elective hospital work and its thinking is around the day case. It is not because we do not need more inpatient beds, and we all know we do. It is really around providing the most effective healthcare possible. Part of the thinking is, first, to separate it from emergency departments, so it is planned elective care only and it does not get disrupted by emergencies coming in, and so it is physically separated, for example, like Tallaght is doing with its unit. Second, the thinking is that if we create it as day case, it is not that we are not creating additional inpatient beds because what we are doing is pulling the less complex care out of the bigger model 4 hospitals, and they can turn some of their day case into inpatient. However, it is worth reiterating, as I did to Deputy Colm Burke, that no final decisions have been made on that. I will certainly feed the views of Deputy Shortall and Deputy Burke into the team that are looking at this. As I said, I know there are strongly held views, both in the community and in the clinical communities in Cork and Galway, that the elective hospital needs to be day case and inpatient.

I thank the Minister. Two key elements of Sláintecare are improving access and removing cost as a barrier. First, where do things stand in regard to the extension of free GP care for children and when can we expect children up to 12 years of age to have access to free GP care? My second question is in regard to e-health. The experience over the past year has shown the huge weaknesses in terms of the hugely underdeveloped e-health provision within the HSE. Over what period would the Minister expect to implement the full existing e-health programme that was developed a few years ago?

On the increase in eligibility and, essentially, the reduction in cost, we increased GP care last year and there are no plans to increase that further this year. However, there are plans in further years to do so. Excuse me, what was the second part of the question?

It was in regard to e-health.

There are two big budgets. There is a new budget of €58 million and that is looking partly at what the Deputy has referenced, which is e-health innovation. Obviously, telemedicine was a huge success as part of the Covid response and we are looking to put that on a permanent footing. There are also some really exciting things happening. There are pilots going on around the system for things like remote sensors for people at home, so we move the chronic disease management-----

I am sorry to cut across the Minister. While I appreciate that, an e-health programme was drawn up and the price tag was, I think, €800 million to €850 million, to be developed over a number of years. The original plan was to implement it over 15 years but Sláintecare recommended, given it is so critical to the efficient delivery of healthcare, that it should be implemented over a five-year period. Where do we stand in regard to that plan?

Let me get the Deputy an update on that. What I can tell her is that in the Estimates we are looking at right now, there are two pieces. There is the €58 million for e-health innovation for the new things, and then there is money in capital for the backbone, for the infrastructure and for things like unique patient identifiers and making sure the GP systems talk to the local acute systems or, indeed, to all of the acute systems. There is a total within the figures we are looking at of €255 million. I was very conscious of that figure the Deputy referenced, which was an enormous figure as part of Sláintecare and was around creating a backbone. The total we are looking at now is €255 million in annual funding for health ICT just in this budget. That is about building the backbone the Deputy is talking about. The €58 million is around innovation, chronic disease management in the community and so forth.

I would appreciate a note on the timescale for the implementation of the full e-health plan.

That is no problem.

I thank the Minister for his overview of the health budget. Last year was an annus horribilis in regard to the health budget and this year will probably be the same. In regard to some of the positive news on the women's health task force, it is very welcome to see funding in regard to the expansion of the endometriosis service in Tallaght, which is positive.

To clarify the financial position, does the €1.074 billion capital expenditure include expenditure spent on personal protective equipment, PPE, last year in regard to the pandemic? In fact, the Minister might just explain what the capital expenditure was for.

I thank the Deputy. The capital funding is right through the budget. There are two big pieces: the Covid funding and the non-Covid funding. The new Covid measures are €2.121 billion and there is a capital allocation within that of €155 million. Then, obviously, there are the new measures of €1.163 billion, and the capital funding in there is an additional €13 million. The capital funding is right through the programme. If we take non-Covid care, for example, there is capital funding in the €276 million which Deputy Cullinane and I were talking about. There is €236 million of current expenditure, which is the money to fund the teams, the staff, the nurses, the doctors and so forth, and then there is €40 million of capital funding in there. It is the same for critical care, sub-acute beds and community beds.

Deputy Shortall and I were talking about e-health. There is current and capital funding but a good portion of the €255 million is ICT infrastructure, which is capital funding. I can get the Deputy a break down, line item by line item, on exactly which is capital and which is current funding in a programmatic way. For legacy reasons, the way we are presented with the figures is not very helpful in breaking out the capital. We get a capital line item, but what we really need to know, which is relevant to the Deputy's question, is how the capital line item is allocated according to the different programme areas, such as acute care, community care, e-health and so on. I will get a detailed note for the Deputy on exactly how that capital funding works across the programme areas.

My second question is on the allocation of funding for eating disorders. The pandemic has compounded many issues around mental health, especially eating disorders. I understand the national clinical programme for eating disorders, set up in 2018, had a certain budget. In previous years, the budget was underspent. That would seem extraordinary really. From what I can gather, there is currently an underspend at this time, especially with the roll-out of this particular programme. Is that money ring-fenced for the programme, in particular around the hubs, as stipulated under the programme? Perhaps the Minister will comment on underfunding in the area of eating disorders.

I share the Deputy's concern. I will also be talking with some of the mental health clinicians, teachers, school principals and parents. They have seen a worrying spike in eating disorders among younger people during the pandemic, especially among younger women and girls. It is really concerning. With the numbers in front of us, we have a significant increase in mental health funding. I will come to how eating disorders is dealt within that.

The total increase in mental health is €83.2 million. There is €23 million in new measures and €15 million in Covid-19 programmes. Something that is below the radar, which some people would see as a technical adjustment but which is hugely important in getting the mental health services running, is the €45.2 million also being allocated to existing level of service, pay rate funding and technical adjustments. Essentially, the HSE has maintained a position for the past few years, of which the committee will be aware, where it said that it could not provide the new services because it was not getting a sufficient increase in its base funding for the existing services, which is covered under existing level of service, ELS. This year we have put a huge amount of funding into ELS to cover the increases required for this year and the historical deficit. This year we really need to see the health service providers stepping up to add all the new services.

There are a few things happening specifically around the child and adolescent mental health service, CAMHS. New CAMHS staff have been funded. We have an increase of 10% on last year in the CAMHS community mental health budget nationally, which is important. This is for assessment and treatment. There are three new CAMHS tele-hubs nationally, which goes back to the conversation on e-health. There will be a new high-dependency unit in CAMHS in Galway, which will commence construction later this year, which is very welcome. There is also additional bed capacity being put in place.

Specific to progressing the specialist mental health programmes, four that are getting particular attention are dual diagnosis. There is a real problem with dual diagnosis whereby a mental health service states it cannot treat a person because he or she is in addiction, and addiction services state that they cannot treat the person because he or she has mental health issues. We are cracking that nut. Quite a lot of people who have fallen into the dual diagnosis are being failed.

I fully agree with the Deputy that early intervention in psychosis, eating disorders and mental health intellectual disability is a big focus. It has become a real problem during the pandemic. We are funding to scale up in staff, early assessment, treatment, beds and community healthcare provision.

My other question is on the finer detail for the roll-out of the medical cannabis access programme, MCAP. I looked at the Estimates but did not find an allocated budget for the programme. I understand the programme will commence some time in June. Is there a budget for the programme? It is a five-year pilot project but is there an annual budget? Where are we at with regard to the programme commencing?

The answer is "Yes". We have allocated funding for MCAP this year for the first time. The Deputy has been a very strong advocate for this and he will be very aware that the programme has been in place for some time but there has never been any funding for it. This year we are allocating several million euro from the new drugs budget. We must wait to see what the uptake is. Several million euro will be allocated, so it is now a funded programme.

I am aware, as is the Deputy, there are some drugs, such as Bedrocan, that are not included in the programme. While much progress has been made, more is needed. We are aware that some of the products, such as Bedrocan, fall outside MCAP. Those who are using them, or their parents, are in an unenviable and unacceptable position whereby they are having to pay for the drugs upfront and then be reimbursed for them on a monthly basis. It is a huge amount of money. I have asked the Department to find a way to deal with this. One of the issues we have with Bedrocan, unfortunately, is around exporting from Holland. It is not that we do not want to do it; it is just that there are international constraints. We are working through them.

I am very aware that the MCAP will be very useful for people. We have put a multimillion euro funding package in place. There are other outstanding issues, such as the one I just discussed, that are causing real difficulty for people. This is a difficulty they should not have to experience. I am working in the background with the Department to put solutions in place to that.

I thank the Minister.

I have some questions for the Minister. The national children's hospital has not been touched on today. Do we know how much it will actually cost? Earlier in the year some of the board members were before the committee to outline some of the difficulties they are experiencing. We are aware that compensation claims are coming through the courts and that building was closed down for a period. Do we have a ballpark figure or does the Minister know exactly how much it is going to cost? It will be a big figure in relation to the Estimates.

I do not raise this to frighten people but a conversation is needed around long Covid and people having difficulties with vaccine-associated illnesses. I am currently dealing with two cases in my constituency with vaccine induced clotting, or VPIT. This has required blood tests, treatment, in-stay beds, medication and an inability to work. One person developed a clot on the brain. There needs to be a conversation around this. They have told me they have spent a significant amount of money and they are getting bills, having been released from hospital or while still in hospital care. They are worried about being out of work and out of a job and about mortgages. Two of these people are women in their 30s. If a person gets a bill for €1,000 from a hospital, it is a lot of money.

It is only right that there be some sort of support scheme to address costs incurred because of the side effects of vaccination. When I recently asked a parliamentary question on the matter, the Department stated that a policy was being developed. Has any amount been set aside in the health budget for vaccine-related costs incurred by people who have suffered side effects? The State has indemnified many of the manufacturers and so on.

The Minister spoke about quarantining. I am told that there is an avalanche of cases waiting in that regard. Has funding been set aside for them? Is he worried about the cases coming down the track?

I have been on my local drugs task force practically since it was established. We seek funding every year. The major challenge this year for many communities, particularly so in Dublin but it is spreading to other areas, is the rise of crack cocaine and its impact. In November, there was a one-off funding bump of €480,000 for the whole of the State. That worked out at approximately €20,000 per area, which was a drop in the ocean. We know the challenges facing people. Deputies mentioned the impact of Covid. It is impacting on people who have difficulties with substance abuse, be it alcohol or drugs. In that regard, has the Minister considered increasing funding for projects for vulnerable people in many of our communities?

St. Michael's ward in Beaumont Hospital has been closed during Covid. It provided valuable work on the north side of the city. There has also been the closure of residential beds and support services in Keltoi in the Phoenix Park, causing significant difficulties. Alongside the question of funding, the issue of residential beds keeps arising at task force level. Has the Minister spoken to the Minister of State in this regard? The latter has been out in some communities looking at the challenges facing them.

When the Minister appeared before us previously, we asked him about the backlog in scoliosis procedures. Has funding been found in this Estimate for that group of people, many of whom are young children who, as the Minister is aware, are suffering the horrible effects of scoliosis on their young bodies? They could be left with deformities for the rest of their lives if their conditions are not dealt with sooner rather than later. The Minister referred to difficulties at Our Lady's Children's Hospital Crumlin in terms of staffing for the MRI machine.

The Irish Dental Association appeared before the committee recently. Its representatives spoke about hundreds of dentists leaving the medical card scheme. It was concerned that talks had not resumed. Has funding been set aside in the Estimate for a possible deal?

One of the positive things that the committee did recently was to publish a report on the impact of vitamin D on Covid and general health. The report made proposals in respect of nursing homes, front-line staff and areas with large Covid outbreaks and examined the role of vitamin D in building up people's immune systems. A report from the Department did not go as far as ours in terms of the age group, given that we considered a much younger cohort, but is there funding available in this regard?

I have asked the Minister a number of questions. If he cannot reply to them today, perhaps he will in future. These are some of the main issues that are still outstanding where the work of this committee is concerned.

I thank the Chairman for his questions. As the committee will be aware, the capital budget for the children's hospital, including the three satellites, is €1.433 billion. There will be commissioning costs on top of that. However, that figure does not take into account the impact of Covid-19. It would not be appropriate for me to speculate at this time as to what that might cost, given that it will be the subject of ongoing negotiation between the board and the contractor.

I agree regarding long Covid. We need to get an important message out to people, particularly now as we see case numbers beginning to tip upwards again. Even though those who are younger are significantly less likely to fall seriously ill or die from Covid, there are emerging cases of long Covid among all age groups. It is concerning in some instances. The Chairman referenced several cases. I am aware of research into potential permanent neurological and heart muscle damage. Part of the message that we need to get out while we are still in the gap between the most vulnerable people being vaccinated and others getting vaccinated is that, even if people are in a relatively safe category in respect of fatalities, what the Chairman just referenced in terms of long Covid is very serious. People of all age groups are taking months and months to recover from Covid and are exhausted. This matter is being examined. Money has not been explicitly ring-fenced for it, but a substantial contingency fund relating to Covid is in place and can be tapped into. The Government will not be found wanting in the research, treatment and supports required.

Regarding mandatory hotel quarantine,-----

I am sorry. While my question was on long Covid, it also related to vaccine-related illness. I do not know if there has been a large number of cases, but we are all hearing anecdotally about side effects. That some people will experience negative effects is bound to happen regardless of what vaccine is handed out to them. Will there be supports for people in that situation?

We will need to see how that situation evolves. The current position is that the vaccines are incredibly effective and very safe. As the Chairman rightly stated, there are side effects within the normal parameters of people being vaccinated. For the moment, that is the focus.

We are aware of a number of challenges to hotel quarantine. I can share with the committee that, when the additional exemptions were put in place, particularly for those who were fully vaccinated, a few of the potential cases fell away. Exemptions are also in place in respect of professional and elite sports. The cases are being fought in the normal way. A substantial contingency fund is in place for Covid-related issues, though, and I would not anticipate seeking additional funding from the Oireachtas this year for those issues.

I could not agree more with the Chairman regarding local drugs task forces. I met the members of the local drugs task force in Ballymun early last year. The stories they told about the impact that crack cocaine was having on the community there were horrifying. We are seeing it in parts of Wicklow as well. People working in addiction services and the drugs task force there are watching the situation closely and are very concerned. Many of the team members I met in Ballymun had been involved in the response to the heroin epidemic. They are hardened, seasoned professionals, but they said that they had never seen anything like the damage that crack cocaine was doing. As the Chairman stated, the Minister of State, Deputy Feighan, is leading on this matter. A sizable additional fund has been provided to Healthy Ireland, homelessness and addiction services.

It is certainly something on which I want to see more and more done.

There are other issues we are trying to fix in the background. For example, if a person somewhere in Ireland is living in addiction, there is a fair chance that he or she will receive a rent supplement. If he or she moves into a residential addiction programme, he or she will lose that. One of the steps we are trying to take is to have a more co-ordinated approach in the State. If, for example, that funding can be transferred to the addiction service providers, more and more people can get addiction help. I could not agree more with the Chairman on the need to fund an increased capacity for the local drug task forces but also for the myriad services around them in order that we can treat addiction as a health, rather than criminal, issue, which is exactly what we want to do.

The next issue the Chairman raised related to scoliosis. The current circumstances are not acceptable. On 26 March this year, a total of 119 patients were waiting on spinal fusion, excluding the suspensions, which was an increase of 20 patients compared with March 2020. We know that many waiting lists have increased because of Covid and the suspension of some surgery, but 70 patients were on the waiting lists for other spinal procedures, which was a decrease against March 2020. Nonetheless, the current waiting times for scoliosis treatment, if someone needs to go through the public system, are not acceptable. It is an area we are examining as we put together the detailed planning around the access to care fund. All of us who are party health spokespeople or were involved in the Committee on the Future of Healthcare are acutely aware of the untold suffering of young men and women and boys and girls, and the awful implications of having to wait. It is not acceptable. There is going to be money available and we are going to crack this so that on the public system, these young men and women and boys and girls get not just the care they need but the care they need when they need it.

The next issue related to dentists. I might get the committee a detailed briefing note on that, given that it is not related to the Estimates today. I am aware that, as the Chairman referenced, the association has stated that more and more of its members are leaving the public list, which, obviously, we do not want. Again, everything we are doing is about building up our public health system and increasing access, and there is no question but that in the area of oral health, very significant financial barriers are in place. That is not acceptable and needs to be acted on.

On vitamin D, I saw the report and thought it was excellent. All I can do is agree with the Chairman. On foot of the report from the committee, I sought a review from NPHET of the relationship between vitamin D and Covid, and it reverted to say that while it did not have evidence of a reduction in risk specifically from Covid, it wholeheartedly endorsed taking the recommended dose of vitamin D for general well-being and a strong immune system.

On the extension of free GP care, the Minister stated that nothing is proposed on that for this year, which is quite disappointing given that over a five-year period, there was to be an incremental extension of free GP care to the entire population. We are probably the only country in Europe where the majority of patients have to fork out the full cost of visiting a GP, which very much goes against the principles in Sláintecare of early intervention and lowest complexity of care. I think it is a mistake not to accelerate that. I accept there are industrial relation, IR, issues but I urge the Minister to revisit the issue and try to accelerate the extension of free GP care because it makes sense on many levels.

Is the Minister doing anything specific to reduce drug costs in this country, both for the State and for individuals? As a proportion of the overall spend on health, they seem to be much higher than in most other European countries. We know from when people used to go abroad that the cost of medicines in other countries is often much lower. What is happening on that? It is not a sustainable percentage to spend on drugs.

My final question relates to the proposed restructuring and reform of the HSE. It was parked for a while last year with all that was going on. Where are we with that and when does the Minister expect recommendations and action to be taken on restructuring the HSE to make it more responsive and accountable at a regional level?

On universal access to primary care, including free GP care, I agree. It is worth saying that the measures we brought in towards the end of last year increased the total number by several hundred thousand children. The Deputy was critical of it at the time, as is her right, because she wants more to happen faster, but several hundred thousand children - I will seek the actual figure - were added. It is a serious step in the right direction. The Deputy will be aware that we have to have the capacity for this in primary care, and we are asking much of GPs at the moment. Obviously, they have been instrumental in the test and trace system and the vaccination programme. We are asking for pretty fundamental reform in terms of chronic disease management in the community. We have got rid of dot matrix printers for prescriptions on the public list system, which GPs are very happy about, as they are about the access to diagnostics within the community. The Deputy understands this issue very well. I would like it to move as quickly as possible. We increased provision by several hundred thousand last year but we have to ensure that the capacity is there as well. Nevertheless, the Deputy's point is very fair. We are signed up to universal healthcare and it is exactly what we need. As she pointed out, we are an outlier.

On drug costs, there are two issues, one of which relates to the new drug budget of €50 million. It was zero last year, so that is a very sizeable increase. A backlog of drugs from last year is being moved through at pace by the HSE. The €50 million will not reduce drug costs but rather provide for free, because it will be through the public system, some new drugs and existing drugs for new treatments, which will help.

A total of €45 million in the budget was allocated specifically for prescription charges. For prescription charges for the over-70s, it will reduce the charge per item from €1.50 to €1, while for the under-70s, the charge will fall from €2 to €1.50. The net effect, it is believed, is that it will benefit more than 1.5 million people with medical card eligibility, and the drug payment scheme threshold will reduce from €124 to €114. It is a €45 million step in the right direction.

The question on restructuring probably demands a longer conversation than we have time for now. I took a decision last year that during the pandemic, it would not be the right time to move to the regional structures. It was not that they are not the right way to go, and much work has been done on them. I think we are all broadly in agreement on the single greatest advantage of making the change, namely, joining up the budgets for acute care and community care because one of the big problems is the siloed budgeting activity. I took the call that the pandemic was not the right time to do this. Based on what has happened over the past year, I think that was probably the right call. What we have not yet answered, and it is the question the Deputy is now posing, is whether we have a time at which we expect to move to the regional structures, given that the pandemic will be behind us soon enough.

We do not have time but I can tell her that people who are involved and very bought into it are already agitating for us to begin moving in that direction again.

I thank the Minister.

Does the Minister wish to make any concluding remarks?

I thank members for their time, questions and ideas. There are several pieces of follow-up work that we will do, be it on the National Maternity Hospital and various technical notes people have. My view is that this is a really exciting budget. It is a lot of money. There is a lot of technical stuff happening in the background in respect of financial reporting and IT systems on e-health and enablers but, ultimately, there are a few really exciting things happening in this budget. The first is around beds. It is a massive increase in beds at approximately €342 million in terms of acute, critical care, sub-acute and community beds. They will make an enormous difference and catch us up on the 2018 capacity review. The first big chunk of investment is in building out the capacity. Obviously, that funding is not just for the physical beds. Arguably, that is the easy bit. It is also about the staff and all the professionals we put around it.

The second is what I think is an unprecedented investment in community and social care. This is the big structural change so we have €408 million going into this. It involves home care packages, community health networks, community specialist teams, GP access to diagnostics and some of the issues Deputy Shortall and I were just talking about in terms of reducing the costs of access to care.

Significant additional funding is going into disability and mental health, something I know everyone on the committee is committed to. A new piece about which I am really excited involves nearly €150 million for the national strategies. Before I sat down with the committee, I came from meeting the people involved in the national trauma strategy. A lot of funding is now being provided for that. There is also funding for maternity care and a lot of funding for women's health, paediatrics, dementia, palliative care, the carer's strategy and positive ageing. The various clinical leads and clinical groups across the system in these really important care pathways have the funding to implement some wonderful strategies that have been put in place in recent years. There is a big investment in public health and well-being. The Chairman asked a question about the national drugs strategy, which comes to €53 million. There are new drugs and various things we discussed. A really important piece is the access to care fund, which will involve €130 million from the NTPF, an additional €210 million, which is a new allocation, alternative care pathways, and screening and hospital restart grants. That brings us to in excess of €400 million, which we need to tackle these waiting lists.

We have probably set ambitious targets right across the board. We will hit as many of them as we can. It is entirely possible we will not hit them all. We have set really demanding targets in so many different ways. All of our amazing clinicians have been working flat out and are, quite frankly, exhausted from the pandemic and all the additional work they have had to do in the pandemic. The budget in front of us is really exciting because it allocates money in new ways, be it the national strategies or community and care services as well as building up acute services. I ask for the committee's patience and understanding as we try to hit all these targets, ultimately to make things better for patients and the public in the year we are having and with our amazing clinicians and non-clinical staff across the system. They are working so hard and are so tired. They have done such an incredible job. As the pandemic dies down, the focus of the committee and I along with that of the Oireachtas, our health service and the Department will quite rightly be on all of these wonderful areas and getting them going.