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SELECT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 8 May 2008

Vote 39 — Department of Health and Children (Revised).

Vote 40 — Health Service Executive (Revised).
2008 Annual Output Statement.

As Chairman, I must be totally impartial and non-political. However, I begin today's meeting by congratulating the Minister for Health and Children, Deputy Harney, on her reappointment. I share the Taoiseach's confidence in her. It speaks volumes about her commitment to the health service that this is the third successive occasion on which she has sought that Ministry. By the time of the next election in 2012, I am convinced the remaining problems within the health service will be resolved. I wish her well.

I propose that the Minister complete her presentation by 12.30 p.m. The Fine Gael spokesman, Deputy Reilly, will then have until 12.45 p.m. to complete his opening statement, after which the Labour Party spokesperson will also have 15 minutes to speak.

Members will move on at 1 p.m. to a general question and answer session on Votes 39 and 40, when they will go through the subheads before them in turn. The former Minister of State with responsibility for children, Deputy Brendan Smith, cannot attend this meeting because of his elevation to the Cabinet and the Minister herself must leave by 3 p.m., although she is prepared to return. Members should be aware she may be obliged to leave the committee room to attend the Dáil. Matters are not being rushed and I advise members there will be plenty of time to go through everything. If we do not complete our deliberations, we can return to this matter next week.

I invite the Minister to make her opening statement.

I thank the Chairman for his welcoming words. It always is a privilege to be elected and to serve in this House. It is a particular privilege to be selected to be a member of the Government and it is one that I enjoy and take seriously. Obviously, it brings with it great responsibilities and I am pleased to be returned as Minister for Health and Children. I look forward to the day when the health ministry will be sought after by a large number of Deputies because it is perceived to be a popular place in which to be a Minister and not a place that is constantly embroiled in controversy, difficulties and challenges.

As members are aware, the Ministers of State will not be appointed until next week, with the exception of the Chief Whip, the Minister of State at the Department of Health and Children with responsibility for children and youth services, Deputy Barry Andrews, the Minister of State at the Department of Foreign Affairs with responsibility for European affairs, Deputy Dick Roche, and the Minister of State at the Department of Agriculture, Fisheries and Food with responsibility for horticulture and food, Deputy Trevor Sargent. A health-related Adjournment debate is scheduled in the Seanad and I cannot rely on Ministers of State that I do not have to take it. Consequently I thank members for facilitating me in this regard and for agreeing to postpone the discussion on the Vote on the Office of the Minister for Children until a later date.

All members are aware of the massive resources being invested in the health system and I do not propose to read out the statement I have circulated to members, who are able to read it for themselves. However, I will comment on a couple of issues. In 2008, Votes 39 and 40 involve a gross expenditure of €15.461 billion, €614 million of which is capital funding. By any standards, this constitutes a massive investment into public health services by the Exchequer. At present, 78% of the money spent on health services comes from the public purse and approximately 22% from private sources. The level of spending by the Exchequer has increased substantially, from 71.5% of total expenditure in the mid-1990s to 78% of expenditure at present. This is higher than the OECD average, where 73% of health spending generally is from public sources.

Ireland spends 8.8%, or almost 9%, of its national income on the health services, which is close to the OECD average of 9%, even though its population is relatively young, as 40% of its population is under the age of 25. When adjusted for purchasing power parity, Ireland spends US $2,759 per head. This is a relevant comparison and is higher than the OECD average by approximately $200 per year. I make these points because sometimes the view is expressed that the Government is not making a sufficient investment in public health services. However, together with Norway, Ireland has the highest investment in capital infrastructure and health from national income of any country in the OECD.

It is not all about spending money and the recruitment of employees. The OECD report shows that Ireland has 3.9 employees per acute hospital bed, which is twice the OECD average. Rather, this pertains to outcomes and outputs and my Department has published its output statement, of which members have copies. Instead of concentrating on inputs, such as staffing and financial inputs, we must concentrate on outputs and move to a position whereby we can do so. One cannot deal with outcomes on a year on year basis. In respect of cancer, for example, one refers to five-year survival rates and so on. The transformation programme is taking us in this direction. In particular, it is about trying to deliver better services by changing the way we do the business. Both within hospitals and between hospitals, community and primary care, we seek to change the way in which services are provided so that they focus on the needs of patients

The cancer programme is of particular interest to members and to the country in general. Since 1997, €1 billion has been invested in cancer services nationally and in 2005, 94,000 patients were discharged from hospital following a diagnosis of cancer. This constitutes an increase of 70% over an eight-year period. Moreover, 58,000 people were treated as day cases in 2005, which was an increase of 130%. Increasingly, patients now have the capability of being treated on a day case basis and I will deal with this matter in a moment.

Moves are afoot to provide eight specialist cancer centres and I will repeat comments I made in the House last night. Great improvements in the outcome for cancer patients in Ireland only will take place when initial diagnosis and surgery are provided in a specialist centre. As I noted in the House, the National Cancer Registry has been established and has produced two reports, for example, on survival rates from breast cancer. We know the outcome for those treated in specialist centres in Dublin shows an improvement of 25% when compared to those treated in either the midlands or the west. Moreover, as the data in question have not been compiled since BreastCheck was rolled out, it is not the reason this is the case. I make this point because if one concentrates on outcome, compelling evidence exists in respect of specialist centres. All members recognise that one cannot locate specialist centres everywhere. Specialists are difficult to procure as their expertise is in high demand globally. We must use the expertise available in our health care system to the best effect for patients. This means organising services around eight centres.

I referred previously to our great success regarding cancer treatment for children, which is centralised in Our Lady's children's hospital, Crumlin, although a course of chemotherapy planned in Crumlin can be delivered in 16 other hospitals nationwide. This is what we seek to do with cancer treatment in general. Obviously, Professor Keane started the job last November and is making a major impact. In particular, I salute the massive clinical buy-in from surgeons. Last week he met urologists to discuss issues pertaining to prostate cancer and is gaining huge clinical buy-in from the available expertise. People strongly support putting in place the best possible cancer services for its citizens that this country can provide.

The National Treatment Purchase Fund was mentioned in the supplied statement and recently, the fund acknowledged its treatment of more than 100,000 patients. I had the opportunity to meet some of those patients on that occasion and they certainly were highly satisfied with the treatment they received. A total of 90% of the treatment is provided for in Ireland, of which 90% is provided for by private hospitals. Approximately 10% of the treatment is provided outside this jurisdiction.

On disability services, I recently created a new office headed by a Minister of State with is own director. The office is modelled closely on the Office of the Minister for Children, which has been acknowledged to be a great success. The Minister of State in question has responsibility across several Departments to co-ordinate services for people with disabilities and to make the Government's system suit the needs of the services users, rather than expecting such users to be obliged to find their way around the Government system.

As for services for older people, the amount of money spent on such services has been increased by €500 million in the past three years, which is a considerable investment. Moreover, more than 10,000 older people now are clinically managed at home. This provision did not exist a decade ago and is highly successful. In addition, 53,000 families receive home care support. Clearly, the vast majority of older people wish to remain in their own homes and communities. Not only do I want this wish to be fulfilled, it also is better from a health perspective.

Much debate centres on the fair deal at present and I wish to inform the committee that we are at the final stages in the drafting of that legislation, of which 12 drafts have been completed. Legal issues arose that involved discussions. While I emphasise they were not constitutional issues, complex legal issues exist.

We must put in place a system to support older people in care that is affordable for the older person and his or her family, that removes the worry from the older person and that is equitable in respect of those in privately-funded nursing homes and publicly-funded institutions. As we know, there is a huge discrepancy. In publicly-funded nursing homes 90% of the cost is funded, while in privately funded nursing home, about 60% of the cost is met by the State. This is not equitable or fair. There are 18,000 residential places in the private nursing home sector, and about 10,000 in the public nursing home sector. Rather than concentrate on who funds the infrastructure, what we are doing is providing a system of support that is fair and equitable between both.

We will have standards that will apply to both public and private facilities and an inspectorate that will inspect both. Heretofore, the inspection regime only applied to the private nursing home sector. Recently, HIQA sent me draft standards for nursing home care. These standards are being considered. We must undertake a regulatory impact assessment, which we are required to make for all new Government proposals to ensure the standards we are introducing are considered in the context of the impact they will have. At the same time, we are drafting the regulations to give effect to the standards and expect them to be in place later this year.

In respect of primary care, as I said, one of the major planks of the Government's reform programme as far as health services are concerned is transferring more activities from the hospital environment to the primary continuing community care environment. We know that 95% of health care needs can be met in that context. The HSE is putting in place the resources required to give effect to that commitment. Recently, it invited expressions of interest for the provision of key infrastructure in order to provide a modern environment for primary care. Everybody can read the script to see the amount of money being spent on this area.

As I said, 200,000 more people have medical cards and free access to their doctor as opposed to three years ago. We have the highest number with free access to their doctor than at any time since the 1980s when unemployment was three times what it is today. The number of persons with a GP visit card increased from 51,000 on 1 January 2007 to 75,000 on 1 January 2008, an increase of 23,000. As a result of these changes, 31.56% or 1,369,000 people now have access to their general practitioner.

Prescribing by nurses was something I was very keen to see introduced in the health care system. We provided for this in the Irish Medicines Board Bill. By the end of this year 150 nurses will have completed the prescribed programme to facilitate such prescribing. I had the opportunity to visit a number of health care settings, including the National Maternity Hospital in Holles Street, where nurses were prescribing, and meet some patients. Allowing nurses to prescribe in certain settings is very responsive to patient requirements.

On capital funding, with Norway, we are making the largest investment in capital infrastructure in the OECD. I have documented on page 9 where much of that investment is taking place. Clearly, we are moving forward rapidly in the provision of a new paediatric hospital to provide tertiary health care for very sick children and secondary health care for children in the Dublin area. Alongside this, there will be a facility as part of the paediatric service at Tallaght Hospital. The board is working aggressively and thoroughly to ensure we live within the timeframe set down for the provision of the hospital. I have said and given a commitment to the board that this is a priority for funding.

The consultant's contract has been seen by many, including me, as a key part of the health reform agenda. We have in place a contract of employment that does not meet the needs of the public health system. I am happy to say we reached agreement with the Irish Hospital Consultants Association and the new contract of employment has been sent to its members. The result of the ballot will be announced after 4 p.m. on Friday, 16 May. I very much look forward to the vast majority of the members of the Irish Hospital Consultants Association, which represents between 75% and 80% of practising consultants, agreeing to it. The contract is not so much about money and hours but about a new way of working in the system.

In putting in place a system that will facilitate doctors in being clinical leaders and very much involved in management at hospital level and in the health care system generally, we know we need to greatly expand the number of consultants. There are 6,000 doctors working in our hospitals, of whom 2,000 are consultants and 4,000, non-consultant doctors. We need to change the ratio in the other direction. We have advertised about 120 posts and there will be further advertisements in the next number of weeks.

The new doctors will come in under a new contract of employment that places much greater emphasis on the needs of patients, rather than on whether they are public or private. For example, in accident and emergency departments or in respect of outpatient activity, there will be a one for all system under which patients will access services on the basis of medical need, not on any other basis. This is fundamental to increasing access for many in society. It is not satisfactory that up to 40% to 50% of elective activity in some of our publicly funded hospitals is accounted for by private patients.

Mental health services are a major priority. We produced the strategy, A Vision for Change, which is very much about moving away from the service delivered in the past in large stand-alone mental health institutions to one in which the majority of services will be provided in a community setting, with acute psychiatric facilities at key locations around the country. I always find it heartening when I visit a town like Castlebar which even in the mid-1970s had over 2,000 patients in its psychiatric hospital and see that it is now a place of learning and no longer a facility that houses 2,000 patients who did not need to be there. There is now a small acute facility in the general hospital. That is the story we want to see repeated around the country.

This year new units are being progressed in Letterkenny, where 30 beds will be provided by 2011 and at University College Hospital, Galway. A total of 80 to 100 beds are required for specialist child and adult residential units in 20 residential units. Currently, 20 bed units are being progressed in Cork and St. Anne's in Galway. A six bed unit is being developed at St. Vincent's Hospital, Fairview, while a site is to be chosen shortly for a unit in Dublin-mid-Leinster, most likely in the greater Dublin area.

As always, I am very happy to come to the committee to engage with members, every one of whom wants to see improved health services, even if we have different perspectives on how we might get there. There is considerable emphasis on budgets and activity levels this year. From January to March, in terms of inpatient activity in hospitals, there was virtually no change from last year. The big change is the increase in the number of day cases dealt with. That is the model of care to which we are moving, like the rest of the world. In the first three months of this year we have seen a 7.5% increase in the number of day cases in our acute hospitals, which I find encouraging.

Contrary to popular perception, we are not scaling down activity, but we are doing things differently. We are providing care in the most effective way we can and are learning from what is happening here and in other countries in terms of best practice. I am the first to acknowledge that there are deficiencies in the health care system but, as I said yesterday, huge progress has been made in a host of areas in terms of improved outcomes in treating patients with cancer and heart disease. The number who die from heart disease has been more than halved. Life expectancy has increased by three years in the past six years and by five years in the past 30 years. We are making significant advances as a result of the expanded availability of medical interventions. We want to continue the health reforms to ensure that we respond in a speedy fashion to the health requirements of the population.

Given the limited time available — the Minister is under pressure to be elsewhere — I will include in my opening comments the questions I would like to ask. I welcome the Minister, as it is always good to have the opportunity to inquire of her of the facts. I do not share the enthusiasm of some for her reappointment because the health service has gone through a traumatic few years, in respect of which a long list of issues must be addressed.

I will comment on the Minister's speech. She mentioned the medical card population being greater than it has ever been, but she neglected to mention that the overall population is greater than it ever has been. I welcome that 31.5% of the population can have free access to general practitioners, but what percentage has the full medical card? It is considerably smaller than 36%, the figure in the 1980s and 1990s. On the target of 30,000 extra cards, the Government promised 200,000 extra full medical cards before there was any mention of doctor visit only medical cards.

My colleague, Deputy Neville, will comment on mental health services. The Minister referred to the provision of new units, but her actions in terms of co-located hospitals and the choice of a site at Beaumont Hospital will deny the people of Dublin North and St. Ita's Hospital their right to a new psychiatric unit. Planning permission was received in 2004, but a temporary facility built more than 40 years ago is still being used. It has a bank of three toilets, one shower and one bathroom for 23 women, the same pertaining in the case of 23 men. I will not let this disgraceful situation lie. Those people are the most vulnerable in society and have no one else to speak for them.

The Minister mentioned the improvements in accident and emergency services, but as many as 370 people were lying on trolleys at certain times last month. Everyone would welcome a new contract in terms of general practice, including GPs. The Minister and Professor Drumm have referred to encouraging people to seek care at the lowest level of complexity in general practice, where much of that care can be provided in a cost-effective fashion. However, funding for the extra 30 places required to train GPs will not be provided. There are 120 places per annum, but we need at least 200 just to stand still. Given that 50% of GPs will retire within the next 12 years, some 300 places will be required to stand still. If the Minister is serious about general practice, where is the planning and from where will the GPs come?

The committee was provided with statistics on cancer survival in Dublin and the north west. I hope the Minister will bank my questions. To what year do the statistics relate? Will she explain the comments she made on public airwaves and those of the then Minister of State, Deputy Smith, in the Seanad yesterday to the effect that 37 cases of breast cancer were dealt with in County Mayo last year? A consultant surgeon in County Mayo, Dr. Kevin Barry, with whom I spoke three days ago told me that 97 cases were dealt with. He is not pulling his figures out of the sky. He has histopathological reports on his desk confirming that people had breast cancer. He spoke of people rather than, for example, a single person having four sites of breast cancer, which can sometimes be the case. He told me of 70 cases in the previous year. I do not understand the disparity in the figures and it is a deeply worrying issue for the public. If we are planning cancer and health services based on misinformation, the mess we are in will worsen.

The Minister mentioned spending of just under 9% of GDP on health, close to the EU average, but this has only been the case in recent years. There was gross underspending in the preceding 20 years. Everyone would accept that one cannot catch up on 20 years of deficiency by spending below the average. I agree that more money should not be invested until what is happening to the amount already provided is discovered. We are spending considerable sums on health, but the large bureaucracy does not appear to be delivering. We can discuss perceptions, but it is reality for those lying on trolleys. An external organisation, the OECD, reported a 10% increase in waiting times. The Minister referred to the increased number of employees per hospital bed. Are they nurses, doctors or care, cleaning or catering staff? Are those statistics on inpatient beds or do they include day-case beds and surgeries and related staff? Any increase in day-case surgeries, while welcome, would require more staff. The background must be considered, namely, a population increase of more than 700,000.

I referred to cancer centres when I discussed Dr. Barry. We all subscribe to the concept of cancer centres, centres of excellence and specialist centres. Unlike some others, I had no issue with the prospect of the HSE, a single entity, to deliver health care to 4.2 million people. The concept was one matter, but the manner in which it was implemented was disastrous. During the HSE's formation, the Government failed to bite the bullet in terms of redundancies and the duplication of work. It promised that everyone's job would be kept and that there would be no moves between jobs, an impossible starting point for any merger as any expert would agree. We all agree with the concept of cancer centres, but we must examine the details of its implementation. There are to be four centres in Dublin, half the overall number of centres for an area in which less than one third of the population resides. There is to be nothing north of the Dublin-Galway line. I have not even referred to the private facilities that may be in Dublin. The concept is fine, but the detail makes matters look strange.

The Minister alluded to the surgery undertaken through the National Treatment Purchase Fund. Is it the case that so many must go on that list because the public sector hospitals are having their surgery times cut daily? Previously, lists were cancelled. Currently, they are diluted. Instead of six, seven or eight cases being done per day, surgeons are limited to two. I have many examples of this occurring around the country. It has led to an increase in waiting times and the need for people to seek private care. I reject the concept of co-located hospitals on these grounds.

I wish to ask some substantive questions. The Minister stated that the fair deal is on its way, but we were told that at Christmas. I understand there are legal difficulties with it but I hope that when the Minister produces the heads of the Bill we will have an opportunity to have a long and thorough debate on the legislation and that it will not be rushed through the Houses. People are waiting and depending on this Bill but they are also very concerned about it. I would like to know what has happened to the €110 million which was allocated for the implementation of the scheme. Is that still on the books or has it been spent on something else?

How much is to be spent on outside consultants and how much has been spent to date by the HSE and the Department of Health and Children?

The biggest question must be how a situation was arrived at whereby a budget of €14.1 billion was given to the HSE when it sought a budget of €14.7 billion just to maintain day-to-day services. The HSE was eventually given €14.3 billion, but €200 million of that was for new developments. In essence, it is approximately €574 million shy of its stated needs and we have seen the plans for cutbacks all over the country. We know that home help has been removed from the elderly and hours have been reduced. We know that home care packages have be taken away from disabled children. How did the Minister arrive at a figure of €14.1 billion from €14.7 billion? Where were the cuts implemented? Where did the HSE pare back in order to arrive at a figure of €14.1 billion? Everyone here would be interested in a detailed response to that question.

The Minister mentioned the employment control framework. What progress has been made on redundancies in bureaucracy as opposed to the front line? How will we fill all of the frontline vacancies which are being blocked at the moment? We have read of people who took leave, other than annual leave, not being re-employed at the end of their leave term. We know of situations where people received letters of appointment only to be told they would not be employed because of the recruitment freeze. It does not make sense to freeze the front line.

Where are the primary care teams? It is all very well referring to 97 primary care teams because several hundred GPs signed a letter stating they were interested in exploring the development of primary care teams with the Department. However, the reality is that there is nothing on the ground. There are no additional services to patients. Where are the new buildings and the budget for the development of primary care teams? In 2001 we were promised 400 to 600 new primary care centres. If we even have ten now, that is about the height of it. Where is the capital fund for this?

What of the promises to include speech and language therapy in the National Treatment Purchase Fund? There is an enormous need for speech and language therapy, as recent figures illustrate, with people waiting for 18 months to two years to be assessed. Children only have a three-year window of opportunity during which therapy can make a real difference and two of those years are being lost while they await assessment.

I note that the information technology budget has risen from €22 million to €40 million, a 77% increase. After all the money we have spent on information technology, including on PPARS, do we now have a uniform accounting and reporting system in the HSE across the health areas?

Regarding the cancer control programme, other than closing services around the country, what is being done? What new services are in place now? What progress has been made in terms of new services to patients? What will it cost to outsource the analysis of the 300,000 cervical smear tests that are planned for next year? What is the situation with the cervical cancer vaccine, which has now been recommended by the national immunisation board?

What is the budget allocation for new consultant appointments this year? The Minister mentioned that there are 110 consultants in line. Does she have a budget to pay them? How will it work? Are these new positions? How many new consultant positions will we have by the end of 2008 as opposed to replacing people who are retiring?

Mental health was mentioned and I mentioned St. Ita's Hospital, but in the broader sense, there is no money to implement the recommendations of A Vision for Change this year. Last year, as Deputy Dan Neville has pointed out on numerous occasions, money earmarked for A Vision for Change implementation was used for day-to-day expenses.

What plans are there to increase the capacity of the Dublin Fire Brigade ambulance service? There has been an enormous increase in the population of Dublin city and its environs. Dublin Fire Brigade had 12 ambulances 20 years ago and today it has 13. It can have up to 300 calls waiting in any hour. I wish to know if there are any plans in that regard.

Having quickly perused the figures, I note that €150 million was spent on hepatitis C medical negligence inquiries and legal settlements, which is approximately 28% of the budget of the Department of Health and Children. I ask the Minister to comment on that.

I should begin by stating that I too did not want the Minister to stay in the Department of Health and Children because I do not agree with her policy direction. However, I would add that we will work constructively with her because all committee members wish to do so.

I will deal with the Estimates in a similar manner to Deputy Reilly by making a few general points and asking a number of questions within the 15 minutes that have been allotted.

In her opening remarks the Minister said she was hoping to transfer activity into the primary community arena and out of the hospital arena because 90% of care can take place in the community. However, I cannot see any evidence of that in the Estimates before us. I ask her to expand on that and explain how, in terms of budgetary allocation, that policy aim will be achieved. The evidence we are hearing would suggest the opposite is the case.

Deputy Reilly just referred to the primary care teams and according to some of the documentation from the Department, 200 would be in place by the end of 2007. To date, only 97 have been delivered and it could be argued that even they are not fully delivered. We have evidence of cutbacks in the availability of respite beds and home help. While I agree with the Minister's policy aim to increase care in the community, the evidence on the ground suggests that it is not happening and the figures before us do not back up the Minister's claim.

It has been reported that the HSE budget has been overspent by €95 million in the first four months of this year and that the Minister has had consultations with the HSE, which is considering what steps it will take to rectify the situation. It is further reported that when the Minister receives the proposals she will make a decision on them. What does the Minister intend to do to ensure that services are maintained, in that budgetary context? We have already heard of some hospitals closing wards, reducing theatre hours and so forth. Surely that is the wrong way to go in terms of achieving aims, given that reducing theatre hours, for example, means that highly-paid specialists are underutilised. How will the budgetary concerns be addressed this year?

When one takes inflation into account, the apparent increase in the hospital budget is an actual decrease in real terms of 2.8%. The last time we had that level of a decrease was in 1988, when we were in the height of cutbacks in the health services. How will hospital services be maintained this year with that level of budgetary allocation?

I am finding it difficult to understand some of what has been presented to us today. I wish to ask a number of technical questions regarding the presentation of these budgets. There is a regional tier within the HSE — covering the four regions — which reports to local public representatives. However, I do not see that referenced anywhere in the figures presented here. Where is it located in these Estimates? How can I find out how much money is spent at regional level? Where are the regional figures for the National Hospitals Office long-term charges and HSE national shared services?

I note in the documents we received that a move to a centralised hospitals accounting system is proposed. The budgets we examine at present are based on the former health board areas but it appears that the HSE is developing a system which does not set out the hospital budget on a regional basis, which would make it more difficult for the public and Members to understand how money is being spent. What is the reason for this change?

In regard to the macro level figures for the HSE budget, corporate spending has increased by 20%, from €64,969,000 to €79,868,000, whereas the proportional increases in primary care and the national hospitals office are much smaller. Does that suggest a lack of control over administrative and corporate management costs or that the controls are being implemented at the level of patient care? That is certainly my understanding of the figures but I may be reading them incorrectly.

In reply to a parliamentary question I put to the Minister, I was informed that posts at grade 8 or higher have required the sanction of the Department since the beginning of last year. The latest figures we received indicated that more than 800 staff were employed at that grade, which is a significant increase on the number prior to the establishment of the HSE. Has the Department sanctioned additional posts at grade 8 and higher since the beginning of this year and, if so, why?

In regard to the fair deal issue, the Minister indicated that she is addressing problems in the legislation. Will she tell us when she will be able to publish the Bill? She noted that there are 18,000 private and 10,000 public long-term care places. Are there any plans to increase the number of public places? As Deputy Reilly noted, it has come to our attention that families are struggling to meet the costs of care while they await this legislation. Will the Minister provide funding to directly assist families who are facing difficulties?

Some of the costs of private nursing homes have increased. Has she allocated some of that money? The subvention varies greatly from one part of the county to another, which means that patients who are in similar circumstances could be housed in the same nursing home but would receive different levels of subvention because they come from different HSE areas. That is unfair.

We are training a considerable number of physiotherapists, speech therapists and occupational therapists but they cannot find employment when they leave college. Even before the recruitment freeze many of the sanctioned posts remained unfilled, particularly in physiotherapy. Why was that the case? I received an e-mail from the mother of a physiotherapy graduate who noted that the HSE interviewed 500 physiotherapists this year for panels. The woman's daughter was placed 52nd on one such panel and will emigrate on 18 June. Many of these young people, who have been trained at expense to the Exchequer, cannot find employment despite the long waiting lists that physiotherapy and speech therapy patients face. I urge the Minister to address that issue because we are losing our expertise to other countries. The method by which the figures are presented in the Estimates makes it difficult to discover the level of spending on areas such as therapy.

Has funding been allocated for the implementation of the recommendations of the Rebecca O'Malley report? The former Taoiseach stated that the Government accepts those recommendations.

In respect of the cancer strategy, we fully support centres of excellence but a centre should also be located north of the line between Galway and Dublin. It is wrong there is no centre in such a large geographical area.

In regard to A Vision for Change, particularly child and adolescent beds, I was told in a reply to a parliamentary question that ten additional beds would be in place in Galway and Dublin by the end of March 2008. I understand, however, that only four beds have been delivered thus far. I would like the Minister to specifically set out the funding she has allocated to address this important issue. Young people are being put into adult and general paediatric wards, which are totally unsuitable. The commitment which I received in response to my parliamentary question has not been met.

I welcome the Minister's comments on the consultants' contract. I understand she was to meet the Irish Hospital Consultants Association today. Perhaps she will clarify her statement that the association will put a proposal to its members.

I understand the budget for the new children's hospital stands at between €800 million and €1 billion. In the context of the comment by the Minister for Justice, Equality and Law Reform, Deputy Dermot Ahern, that not a red cent was available for a hospital in the north east, have all the red cents required for the children's hospital been put together and can a timeframe be indicated for its completion?

I understand the Labour Relations Commission may be invited to get involved in the psychiatric nurses' dispute. I urge that the matter be addressed as quickly as possible. Have contingency plans been made for the financial aspects of the psychiatric nurses' dispute and the suggestion that general nurses may ballot for strike action?

We now move to general questions and answers. The subheads have been circulated and members can choose whether to go through individual subheads or ask questions. We have 90 minutes left in this slot, although that does not mean we have to use all that time.

When will our questions be answered?

Between 2.30 p.m. and 3 p.m.

All the questions will be answered together.

I want to arrange the session to suit members so they can have a response to their opening statements now if they would prefer. However, other members are also anxious to ask questions. I ask that we take a few more questions before seeking the Minister's response to the opening statements.

I would be very concerned if we had to wait until 2.30 p.m. for answers to our questions. A number of questions have been asked. I want to accommodate Deputy Neville.

We will try to move on. Members will not ask questions for their own sake, so that will not be an issue. We will take only those who have indicated they wish to ask questions and move back to the Minister's responses as quickly as possible.

I wish to deal with two areas, namely, funding for the recommendations of Reach Out, the suicide prevention strategy, and A Vision for Change. Throughout last year I received repeated answers from the Health Service Executive that approximately €25 million was allocated in 2006 and again in 2007, making a total of €51 million. As late as December I received letters from the HSE saying that money had been allocated. In January, through freedom of information, the Alliance for Mental Health discovered that just €27 million of the €51 million has been spent on that for which it had been allocated. There is a very big divergence between allocation and spending. I take it that the Minister, in good faith, allocated €51 million to the HSE to introduce the recommendations of A Vision for Change according to Government policy. What is the Minister's attitude to the fact that almost half of it was hived off to meet deficits elsewhere? At the end of December we were satisfied that this money had been spent on implementing A Vision for Change. A few weeks later a freedom of information response informed us that almost half of it had been hived off for a different purpose.

Nearly three years ago the Minister embraced A Vision for Change but she has decided to allocate no further funding for the recommendations this year. The excuse is that she is going to review everything and how money is being spent. Of course, it is not being spent. Can the Minister understand the absolute frustration in the psychiatric services that there will be no further implementation of the recommendations this year because the money will not be made available? The money will exist to do what has already been done.

Although Reach Out was embraced by the Government, just €3.5 million was allocated for reducing suicide with no increase in funding this year for implementing the recommendations of Reach Out. I am talking about the recommendations of Reach Out; the Minister should not generalise it into the whole area of suicide.

This year and last year €3.5 million was allocated to implement the recommendations of Reach Out. Does the Minister accept that this is a reduction when one takes inflation into account and that some of the initiatives taken must be pulled back? We repeatedly say this and we get general answers. The last time Professor Brendan Drumm was before the committee, a member of staff came in with a prepared, general answer for a question he did not know I would ask. It is so frustrating that this happens. Could the Minister be upfront and deal with the situation? I ask no more than that she be upfront and tell members exactly why this is happening. If it is because of cutbacks she should say so.

I congratulate the Minister on her reappointment and acknowledge the improvements that have taken place. While obviously there is a lot more to be done, there have been very substantial improvements, many of which the Minister has enumerated in recent years. My main interest is in value for money and knowing in the ongoing comparative analysis what the outputs are like in different elements of the health service, especially in the acute hospitals. Is there tremendous variation in the outputs and staffing levels and what is being done to ensure we have best practice?

On the relationship between primary care and acute hospitals, very many people still go to acute hospitals and once they become patients of those hospitals, they tend to keep going back there. What is being done to ensure they return to their general practitioners or the primary care service and that more of them are seen at the lower level?

I have a question on accident and emergency and outpatient services throughout the country and the number of patients seen by junior hospital doctors. Does this take up beds unnecessarily because of people being admitted to hospital whereas if they were seen by someone more senior, they might be referred back out to the community? What is being done to ensure GPs are appointed in towns and areas where existing family doctors will not take any more general medical services patients on their lists? That is becoming a problem in a number of areas. What is happening about training more GPs?

I do not like to be parochial but Deputy Jan O'Sullivan mentioned the north east in passing. I thought she was going to ask my question for me but she did not. The question is on the siting of the new hospital. I do not have to tell the Minister that it is not acceptable. If it is a hospital for Dublin North-East I am sure it is acceptable to north Dublin. It will be only 15 minutes from Blanchardstown when the motorway is built. I do not know what can be done about that except maybe to return to the OECD suggestion of two hospitals in the region.

My other question relates to the transfer of services from existing hospitals in the north east in advance of a new hospital being put in place. I do not have a problem where it can be demonstrated it can be a better and safer service but I am not satisfied that where the Minister has state-of-the-art services catering mainly for elderly patients in their 60s, 70s and 80s, these services should be removed and those patients transferred to hospitals that will not have the capacity to deal with them. I wonder if the Department specifically might revisit closing the medical unit in Monaghan which compares very favourably with any medical unit in the country. I accept it lacks acute surgery and many other services but I am not satisfied an acute medical unit depends on ancillary services.

All of the questions have been put. As I stated, we do not have to be here until 3 p.m. and it is up to the members what they want to do. I ask the Minister to respond and people will have the right to ask further questions.

A large number of questions were asked by both Deputies Reilly and O'Sullivan. If I do not answer them they are free to come back. I hope I can answer them. The consultants' contract went out before the meeting today. The ballot is under way and is due to be competed by 16 May. I met the Irish Hospital Consultants Association on a number of occasions and was anxious to meet it again in light of the conclusion of the contract and an agreement to recommend to its members that it be accepted. I am particularly keen to reassure consultants of the importance of their being involved in a leadership role in the hospitals. Hospitals with the clinical directorate model in place perform better than those that do not. We do not have all the answers on specifying what that leadership role involves except to say where key clinicians are involved in policy development and its implementation, it has a much higher possibility of implementation than where they are not.

That brings me to the affordability of consultants. Many of the posts advertised are new. For example, in cancer care, 22 new posts have been advertised at consultant level, including medical and radiation oncologists. I do not have the advertisements in front of me but they are dispersed around the eight specialist centres. The new contract, depending on take-up, will involve additional expenditure. That will require a Supplementary Estimate, which has not been provided for in the Estimates before us here. Any new pay agreement is always financed on the basis that the money comes forward in due course. Later this year, if the contract is agreed, the intention would be that the first part would be paid from 1 June. We do not have money in our Estimates this year so we would require a Supplementary Estimate to cover the increased level of pay to the consultants.

The bulk of the money for new consultants is to come by shrinking the number of junior doctors. It is not a question of more on top of the same. To bring in Deputy O'Hanlon's question, it costs us virtually as much to fund a junior doctor as a full-time consultant. As they do not have the expertise or experience, junior doctors are not in a position to make the kind of clinical decisions a consultant can make.

For example, I hear the following largely anecdotal evidence all the time. I frequently meet consultants who go into an accident and emergency department in the morning when arriving at a hospital and they tell me they were able to send home five patients down for admission, for example. The consultant would have the confidence and expertise to be able to make those clinical decisions and see the patient in the out-patient department.

That is the reason it is so important to get the appropriate clinical decision makers into the hospital system. It is inappropriate for patients to be there if they do not need to be and the acute hospital system is very expensive. As we know, the most expensive beds in this country are not in the plushest hotels in Dublin city or anywhere else but acute hospital beds.

Deputy Reilly asked me about the OECD figures on staffing and who they include. The OECD compares like with like and it states that Ireland has 3.9 persons to each acute bed. I assume that includes day and in-hospital beds. That compares with France at 1.81, or less than half, and Germany at 2.04. It discusses in particular the high number of practice nurses we have in the system, 15.2 per thousand, as opposed to 5.9 in France, 8.6 in the UK and 10.1 in Norway. We have a high number of nurses but we do not have a good skill mix.

Clearly, part of the reform agenda is about having an appropriate skill mix and staffing levels. I will be going to the INO conference tomorrow and my good friend, Mr. Liam Doran, will dispute this with me, as he has done for the past four years. The OECD is an independent body comparing each member country on the same basis. It has provided confirmation of what we have known for quite some time.

On survival rates, Deputy Reilly asked me about the HIPE data from Castlebar. This is submitted by the hospital and verified by the ESRI. If I was to accept data coming from every hospital in the country, instead of 2,500 new breast cancers a year we would have approximately 6,000 new breast cancers a year, which we do not. The National Cancer Registry Board confirms data by address.

For the year mentioned, for example, there were 60 women with an address in Mayo who had breast cancer, some of whom were treated in Dublin and Galway hospitals. According to the HIPE data verified by the ESRI, 39 were treated in Mayo. That is not my data and I am not competent to put it forward. It is the data supplied by the hospital and verified by the ESRI. The National Cancer Registry Board deals with the addresses of people and I accept that although there is a large correlation between where a person lives and is treated, there cannot be an exhaustive comparison, as we know a number of women from Mayo come to hospitals in Dublin or perhaps go to hospital in Galway.

On the specialist centres, neither the Government nor the Department of Health and Children came forward on their proposed locations. We put together the best clinical cancer expertise this country could supply, assisted by expertise from abroad, and they advised us. As I stated earlier, it is very important to have clinicians involved in the making of policy, as well as its implementation.

I came to the view quite a while ago that policy foisted upon professionals without their involvement just does not work. In any event, why would we ignore key expertise that we have in the country?

The eight centres were recommended by key clinicians working in this country. Others were in the group but, in the main, key cancer clinicians gave of their expertise to form the opinion. I repeat, as I did in the House, that if any of us or our loved ones had anything as serious as breast cancer, we would travel to get the best treatment in initial diagnosis and surgery. It would be fantastic if we could provide it in every hospital in the country, and if we could we would of course do so. We cannot do so as the expertise cannot be fragmented in that way or the outcome would be very bad.

With regard to data, there is a 25% gap in the survival rate of women treated in some regions, such as the west and midlands, as opposed to women treated in Dublin. The range is from 1980 to 2001, with two periods in that from 1994 to 1997 and 1997 to 2001. That data is from the National Cancer Registry Board, a very reputable organisation with much support. We are all obliged to take that information on board.

As I did in Mayo last week, I emphasise that this is not about the skill set of any individual clinicians and I will not mention any names. We have excellent clinicians but they are working in isolation from other expertise. We cannot provide something as important and complex as a surgical service for breast cancer with a single clinician, no matter how wonderful that person is — if the person is sick or called away, there would be no service.

We must bring that key expertise together. The OECD report makes the point that Ireland competes with the US, UK, New Zealand and Australia for key clinicians. It goes on to indicate that is probably the reason Irish salaries are 50% more than Germany and 80% higher than France for consultants. As we are competing in a very competitive market to get these key clinicians into our health care system, we pay more.

I know Deputy Reilly was at Beaumont Hospital recently to meet the management and I am sure he was told the management and board of the hospital came forward with the co-location proposal and we did not foist this upon any hospital. The Government put out a policy proposal inviting hospitals, if they so wished, to avail of it. Beaumont was one of the hospitals involved.

The planning permission granted for that psychiatric unit has never been funded. I understand planning permission has been granted for the co-locational facility. The reason the psychiatric hospital was not built there is not because co-location took over the space but because the facility was not funded.

One would have to ask why.

That brings me to another question I wish to deal with. I do not mean to sound arrogant and I hope I do not when I say this to Deputy Reilly. When sitting around the Cabinet table running into the Estimates every year — we have several meetings of Ministers in this regard, sometimes on a Sunday — every Minister has a long list of things they want to do. The budget for running the country this year is approximately €60 billion and the health service spends approximately a quarter of it. The Minister for Finance would probably receive bids for money of about €90 billion, or 50% more in demands than available money. Every Minister wishes to do more and more and every agency wants to be included.

This is no disrespect to the HSE but it came in looking for a figure of around €14.7 billion. I will not disagree with the Deputy's figures. That does not mean the Minister is either able to provide this or agrees that the €14.7 should be granted. It is not a question of saying to any organisation, be it the HSE, the National Treatment Purchase Fund or the Department, that it should let me know what it wants and I will get it for them. Life is not as simple as that. As I have stated previously, we do not have unlimited resources in the country.

As our resources are limited we must prioritise our spending. When we get a budget allocation for the year we must decide our priorities as we cannot do everything. We cannot build all the psychiatric facilities we need at once and we cannot do all the wonderful things we would like in one year. The process is incremental and it is the same in every country, whether the system is privately funded as in the US, publicly funded as it is here or a mix of both. Every country must prioritise as every country has limited resources.

I cannot let that pass. The planning for a psychiatric unit at Beaumont Hospital started before the hospital was even built. The unit was taken over by an overflow of medical and surgical patients and a decision was taken to build the new unit in 2004. The Minister said this is a funding issue and that is why this did not happen but she is the Minister for Health and Children, the person who prioritises where funding goes. My point is that people with mental health issues go to the back of the queue every time and it is happening again

I will come back to some of the other issues the Minister touched on but I do not want to delay the meeting. Many of the answers she has given do not stack up. How does she think Dr. Kevin Barry came to say what he said, which was quoted in newspapers? He knows how many patients he looked after last year and he knows how many lumps he excised; he has the pathology reports. We must have an inquiry as to why there is such a discrepancy.

If the Deputy wants to talk to the Economic and Social Research Institute, ESRI, he is free to do so. The figures I have were not compiled by me because I would not have the competence to do so and nor were they compiled by the Department of Health and Children. They were supplied by Mayo General Hospital and verified by the ESRI. Furthermore, the cancer registry, which has the names and addresses of the women treated around Ireland, says there were 60 women involved, not 97 women. The fact is there are two sources of information.

I do not want a row over figures because this is not about statistics or difficulties with an individual. We do not make up our own data and I am careful when I use it. If I made a mistake I would be the first to correct it because that is important. I am simply saying the data we use is independently verified and supplied by the hospital.

I was asked earlier about grade A posts and so on and we have had many discussions on this. As I said before, much of the situation regarding grade A posts relates to people being regraded as part of industrial relations agreements. I inform Deputy O'Sullivan that we now count people working in subsidiaries of the HSE and the disabilities sector, something we did not do before. We also count people who work for the health service employers' organisation, who were not counted previously. We count people who work in general practice — there are five or six such posts — and they were not counted before. We only sanctioned one new post, which was child care manager.

Since the beginning of 2007.

Since the beginning of 2007 I have parliamentary questions that give bigger figures than that.

There has been one additional new post at grade 8 sanctioned since 2007 and the other posts were replacement posts for people who retired or moved on.

The report of the Comptroller and Auditor General last year showed 123 grade 8 posts were created, though only 50 were sanctioned

That is what the report said.

I get my figures from my wonderful officials so I will let them handle that. One new post in child care was sanctioned.

Was the Comptroller and Auditor General wrong?

Perhaps the Secretary General can help as I am not familiar with the figures of the Comptroller and Auditor General.

Mr. Michael Scanlon

I would have to check. Did the Comptroller and Auditor General's report refer to 2006? All I can say is that since we brought in the framework in early 2007 we have received 32 applications in the Department; 31 of these were replacement posts and one was new. As the Minister mentioned, I do not have the details on how the counting of figures has changed. I will check the figures and compare them to those in the Comptroller and Auditor General's report. Much of this relates to areas that are now counted that were not counted before and that were classified as one thing and have now been reclassified as grade 8.

The figures I received indicated there was more than one post but perhaps the replacement posts were included. That was not explained in the reply to the question. More than one post was indicated in the figures I received last year through a parliamentary question.

There were 31 replacement posts and one new post.

Why does the Minister sanction replacements? Can people not transfer sideways?

We wanted to introduce a new employment regime. We wanted to control things.

Is this since the framework came into usage?

Why are they sanctioned when other posts are frozen? It seems what is sauce for the goose is not sauce for the gander. Why are posts sanctioned at that level when they are not sanctioned at the front line?

They are sanctioned because of the concerns raised, including those raised at this committee. We have introduced a tight framework to control the grade 8 situation and have been criticised for it. Prior to 2007, when we had no control, we were criticised because the numbers exceeded what people expected. At that level, because it is a senior grade, the Department must be involved in the approval of posts.

I welcome the control but the 20% budget increase——

The Deputy may make a valid point on replacement posts but we want to ensure replacements are justified.

I will put this concisely. Deputy O'Sullivan is pointing out that there is a recruitment freeze, to which I alluded earlier, that prevents people who have taken leave of absence from returning to their jobs. It prevents people who have been appointed to positions from starting work in those posts. However, when it comes to framework control and administration, 31 people have been replaced.

There is not a recruitment ban.

There is an effective recruitment freeze.

There is tight control. Around 200 extra people have been employed since last September, the period the Deputy associates with a ban. Every post must now be appropriately sanctioned because numbers were getting out of control. Regarding acute hospital beds, committee members heard what I said about the staffing ratio compared to other countries. We have double the staff number of many European countries so numbers must be controlled. By some margin we have more nurses working in our health service than virtually any other country in the Organisation for Economic Co-operation and Development, OECD.

We do not have more doctors.

We are recruiting more doctors.

Deputy O'Sullivan asked about the Psychiatric Nurses Association, PNA, and there was to be a meeting yesterday between management and psychiatric nurses. Unfortunately, the psychiatric nurses representatives did not attend, which I very much regret. However, a meeting is scheduled for the Labour Relations Commission tomorrow and I expect both parties to attend. Obviously the employers will be there and I expect the PNA representatives to be there too. I again appeal to people not to put patients at risk in this dispute over compensation.

This brings me to the issue of contingency for pay awards — we are not conceding pay awards so there is no question of contingency. Everyone is aware of the benchmarking process, which made recommendations. Some 2000, or 10%, of nurses will get a pay increase as a result of benchmarking and other will not. We must adhere to the structures in place on such issues.

On long-stay capacity, the HSE, in its capital programme, intends to put in place 500 additional public long-term beds per year for the foreseeable future. In recent years 860 such beds have been put in place.

On nursing home subventions, I was asked about money for the fair deal. I have approved €13 million that has gone towards 200 contract beds. The fair deal has been delayed so the HSE has requested that the Department allocate additional money to increase the subvention. I sympathise with this because costs have gone up. We are currently in discussions with the HSE on increasing the subvention.

Representatives of the nursing homes association met me recently and drew my attention to the issue the Deputy raised of discrepancies between patients in the same place coming from different regions. This should not happen and we have asked for examples. There is now a common means assessment throughout the HSE, which is a unified system, so there should not be discrepancies. We have asked for specific examples so this can be dealt with. I am not sure if they have been forthcoming with specific examples because the meeting only took place around ten days ago but they undertook to supply them, which I welcome.

The spending on information and communications technology, ICT, in the health service is low by international standards. Earlier this week I met the deputy secretary from the United States and he told me of a visit he made last week to a paper-free hospital in Nebraska. They made huge investments in technology there and, as a result, the hospital's running costs were substantially lower than an equivalent hospital that did not make the investment in technology. There is no doubt that we must continue to make huge investments. As we know, it is very expensive to move from paper-based solutions to technology-friendly solutions but once the investment is made it is far more cost-effective. The HSE has made an application for funding for a single financial accounting system and this is under consideration by the Department of Finance, as is the requirement.

Will it be another PPARS?

The HSE has a new director of ICT in whom I have total confidence. It must be remembered that PPARS was initiated by the old health boards so much loved by the Deputy. I hope that the HSE——

I love the HSE.

As much as the Deputy loves me, I was about to say.

That is on the quiet. It is immeasurable.

The Department is concerned about the high usage of ambulances in what would be considered non-emergency cases. The publication of a new transport plan is imminent, concerning questions of transport in general. In the area of cancer, Professor Tom Keane gave €750,000 to the Irish Cancer Society this year to support transport for cancer patients. This works very successfully in other countries. We must look to new models and innovations as far as transport is concerned because it is an enormous cost to the health service, counting in the ambulance service, the use of taxis and the HSE's own transport facilities. It is important to have a single plan in place for the public health care system and that is what will happen. Ambulances are expensive and important and we do not wish them used for non-emergency cases.

Regarding the roll-out of primary care teams, we currently have 64 of these. The teams are not just about buildings although the HSE did go to tender for expressions of interest for new facilities in 131 locations. Over 400 expressions of interest were received. It is not about a building but about how people work together in the interests of patients. There are 64 teams in place now and by the end of this year there will be 97 with a further 100 to be rolled out. I know from some of the evidence we have, in Ballymun, for example, that by virtue of different health care professionals working together——

In a new building

That happens to be a new building and I accept that. I know that there has been a considerable saving in time. Public health nurses there have said that the amount of time they spend on the telephone trying to contact other health care professionals has been cut by half a day. We want to have modern state of the art facilities wherever possible for all health care settings. However, it is not simply a matter of the building, rather about how people work.

On the issue of GP training, the committee will know that we have doubled the intake of medical students. Last night there was a good meeting between my officials, the HSE and the IMO in respect of some of these issues. I hope we can make advances there.

I answered a question in the Dáil about the figure moving to 150, which was agreed. There has been a slight pause, for financial reasons. I do not disagree with the Deputy's point. We have a big issue concerning manpower needs as far as general practice is concerned.

Regarding medical cards, comparison has been made between the 36% of the population who had cards in the 1980s and 1990s and the percentage today. During the earlier period the unemployment rate was 17% and living standards were substantially lower than they are today. In the past three years 200,000 extra people have become entitled to visit their general practitioner without having to pay. Of those, 150,000 have full medical cards. We are not too far off the full figure of 200,000 and between 50,000 and 60,000 are doctor-only cards. Deputy Reilly's predecessor as health spokesperson was very supportive of the doctor-only, graduated benefit system which does not operate on an all or nothing basis.

On the question of psychiatric services and suicide, Deputy Neville made a point about money. The money was allocated but was not spent on the service at the same level. I fully accept that and it should not have happened. There is no point in putting more money after that if we do not know where it is going to go.

That is not a fair answer.

That is the process underway at the moment between the Department and the HSE regarding the programme, A Vision for Change. There is no point in my saying, as Minister, that the allocation is there only to discover at the end of the year that it has not been spent. That is meaningless.

(Interruptions).

The challenge is to make sure that when money is allocated for new developments, such as the psychiatric services, it then goes to the allocation.

Is there any accountability? The Minister allocated €51 million in good faith and half of it was hived off. Is there any accountability arising from that? The Minister, or her junior Minister, constantly informed us in the Dáil that this money would be spent in the areas for which it was allocated. Stupidly, I believed that.

As the Deputy may know, there have been ongoing discussions between my Department and the HSE regarding budgetary issues. It is known that the HSE has been over budget on its current services for the past couple of years. That is a concern. Clearly, many of the initiatives now being put in place with my full support deal with how to change delivery of the services in a more cost effective way. Deputy Bruton constantly talks about ring-fencing 2% of the spend in every Department for value for money initiatives. That would mean nearly €300 million for the HSE.

That brings me to the issue of hospitals and whether this or that ward is to be open in August. If it is the case that key clinicians are on their holidays in August does it make sense to keep facilities open? There are hospitals in Europe that close down in their entirety, although I accept that these are not accident and emergency hospitals. One would not dream of closing down a casualty facility for the entire month of August. However, in European countries where everybody takes holidays in August there are many hospitals that do not function during that month. I had an interesting conversation last summer with a friend who is a clinician. A patient arrived at his hospital for whom he tried to get medical records but was not able to do so because the other hospital was closed for the holiday period.

The way that holiday activities are organised by the HSE in a hospital must make sense. It makes a lot of sense to have more activities on a day case basis. We know that the world is moving in that direction and we must do so too. In fairness, we have made great strides in that direction. Access to diagnostics is very often a reason why people who do not need to be there are in hospital. Staffing a ward where clinicians might not be available because they are on holiday——

They do not all have to go on holidays together. Holidays can be staggered.

I am usually accused——

It is not much comfort to somebody who is waiting a year for an operation.

Occupancy levels are too high, at 90% when they should be at 80%. Take the example of Galway University Hospital, which each year closes down a significant amount of activity during race week. I learned that at first hand last week. That hospital is going to do something similar this year in pursuance of many of the hygiene issues that have been recommended to them by the Health Information Quality Authority, HIQA. They want to put in new sinks and do refurbishment work and clearly that cannot be done unless there is capacity to do it which is not the case when patients are present. This is normal practice.

It is not normal practice to close a hospital for a month.

It is all into tents if they are sick. Is that the case?

We are not closing a hospital down for a month. I am simply saying that wards will be closed for periods during the summer and that is as it should be. I am satisfied from the data for the first two months of this year that the amount of activity in our hospitals is up by 7.5% on last year. The patients do not care whether or not they are in hospital. What they want is the appropriate treatment as quickly as possible. That is what I support too.

With regard to concerns raised by Deputy Reilly, the National Treatment Purchase Fund was established because we had long waits for many procedures, five years in many cases. Ten years ago a child awaiting cardiac intervention had to wait a year, believe it or not. That is done now to a matter of weeks in the regular acute system. The NTPF has had an enormous impact on the use of spare capacity, 90% of it within the country, in the interests of patients. It has a budget of approximately €100 million and I believe that we get a terrific service for that investment. It is a good use of resources. I am a strong fan of the public and private systems complementing each other and working together in the interests of patients. That is why, as privately funded facilities are put in place, we have been procuring services for public patients, provided that they are of a high standard, as they are in Limerick and in Waterford, where radiation oncology is being procured for public patients.

Concerning the north east of the country, I can tell Deputy O'Hanlon that we have just got the report from the consultants from the HSE regarding the location of the new hospital. It is true that money has not been set aside for that hospital. It will be. Priority is being allocated to the children's hospital. That is the reason there is a board in place to develop the project. It would not make sense to put people in place to design and plan a hospital if it was not possible to finance it. The project is a priority.

For the north east, in the first instance we must make what is in place there now safe. There is a significant transformational programme in place and more resources have been allocated to it this year, with a particular focus on patient safety issues. I recognise what Deputy O'Hanlon, a general practitioner, has to say about the issues in the north east. However, in everything we do we are trying to strengthen the acute hospital services in the region. Some 50% of the surgical patients and 30% of the medical patients — a significant proportion of the patients in the region — access hospitals in the greater Dublin area rather than in the region. Clearly, we want to put in place the infrastructure in the region to ensure patients can access the services there.

As for Deputy Jan O'Sullivan's question on the increase of 23% in funding in the Estimates, some €12 million of that is the innovation fund and 5% represents the increase in corporate spending. We have a €12 million innovation fund to support, finance and encourage innovation, which brings the increase to 23%. If this funding is excluded from the Estimates it is clear the increase in salaries, wages and other administrative expenses for the corporate division of the HSE is 5%.

Is the cost of innovation not included in salaries?

Those interested will have to compete for the funding. For example, we held innovation awards last week and, as I mentioned in the Dáil yesterday, the number of patients being seen by neurology services in St. Vincent's Hospital has doubled. This is not because we have put more resources in, but because doctors and nurses have reorganised the way they provide the service. Instead of a patient having to wait a year to access the service, it will be available in a matter of weeks and with twice the previous amount of time with doctors.

In the physiotherapy department of St. James's Hospital some 21% of the patients were not turning up for appointments, which was clearly a significant waste of resources. As a result of talking to the patients, allowing them to nominate the time of their appointments and reminding them by texting, the department has reduced that figure by half and has been able to see patients a good deal faster. I am simply saying——

Is that funding——

——that money is to support those services and is used for administration costs in the HSE. We put it in that part of the Estimates so it would not get gobbled up in the regular services to support innovation. It is the start of supporting some initiatives.

The HSE will spend approximately €9 million on consultancies this year, which is a relatively modest sum for an organisation that spends billions of euros.

Deputy James Reilly mentioned the costs for hepatitis C redress noting it is 28% of our budget, which is true. This is the reason for the patient safety agenda. The hepatitis C problems go back to the 1970s and 1980s, long before any of us were dealing with health issues. If we do not ensure that we adhere to high patient safety requirements, it ends up costing us a great deal of money. The Neary case is one example and it was addressed on an ex gratia basis since the Government felt it was morally right to compensate those who were so badly damaged as a result of what happened in that hospital and since those people could not vindicate their rights in the courts as the records had been destroyed. Those payments are being made. More than 100 women have received compensation and the remainder will be paid shortly.

I refer to funding with regard to suicide. Unfortunately Deputy Neville had to go to another meeting, which he indicated previously. The committee produced a report during in the previous Dáil term on suicide, particularly suicide among young people. There were between 40 and 45 recommendations in that report. The committee has returned to this matter in the past week. Will the Minister ask the Minister of State to meet the sub-committee on health to assess the recommendations? The recommendations were backed-up by professionals. In the course of six months we talked with many people who have a professional interest in suicide. There are only four or five members of the sub-committee and it will not be a time-wasting exercise. It would serve to flag the recommendations and to see if we could implement any of them. Is that acceptable?

I would be happy to arrange that.

Deputy Neville is the Chairman and Deputy White is the Vice Chairman.

Will the Minister answer the singular question of how the figure of €14.7 billion was reached? It is all very well to say people put in bids, but either the HSE said it needed €14.7 billion to maintain existing levels of service or it did not. If that figure was proposed to maintain existing levels of service then how can the HSE maintain existing levels of service with €14.1 billion? Was this figure arrived at by consensus, agreement, diktat by the Departments of Finance or Health and Children or some other way?

It is a valid question. Each year in the summer the Departments engage with the agencies under their aegis, in our case the HSE, to discuss financial needs for the following year. There follows discussions at official level with the Department of Finance and the Ministers become involved in these discussions in early September. Much is signed off and agreed at this stage including certain costs such as pay and superannuation which are obligatory.

Then the discussions turn to new activities and services and the cost of continuing existing services in the following year. Agreement is reached by a process of negotiation between the Department of Finance and the other Departments, the Department of Health and Children in this case. Generally, the Minister for Finance and the Minister of the corresponding Department will sign off upon agreement and then the spending is approved at Cabinet. The Government has a sum of money available to spend in the following year and public spending will rise by a certain amount each year. In the past three years, public spending has risen in the health sector by, on average, 10%. Since its establishment the HSE has received more by way of an increase in its budget than the entire amount of money spent on the health service in 1996.

I accept all that but--

The amount is not inconsiderable and we are obsessed with the amount of money we can make available. We know now that 9% of our national income is spent on health which is towards the OECD average, even though we have a relatively young population. We need to concentrate more on outcome and working in different and better ways, for example some of the initiatives I mentioned earlier. Consider Ennis General Hospital which had a bad outbreak of C. difficile. Within a few of weeks it was able to put that right without additional resources. Sometimes there is a feeling every problem needs more resources and the HSE——

That is not the question.

We go through the different areas of the Estimates and account for money——

The Minister referred to new services in her answer and what is negotiated. I am asking a straightforward question. The HSE said it needed €14.7 billion to maintain existing services. The spending agreed was a figure of €14.1 billion. The HSE must tell us how this figure was reduced, given the larger figure was what it said was required to maintain existing services. How can this be, unless there was a good deal of fat in the first submission, in which case the HSE has questions to answer? That is the question. If the Minister, Deputy Mary Harney, does not feel there is sufficient scope in this forum to answer the question I would be happy with a long written response, but I would like to know how it was achieved.

Spending is agreed between my Department and the Department of Finance. The Government then approves this and it is published in the autumn. Unlike in previous years, what is published in the autumn is the amount of money we will invest in existing levels of service. That money was made public in autumn last year. The HSE must then carry out a service plan based on that money and submit it for approval, which was done.

I think members have a copy of the service plan, and they can see what it planned to do with the money. After that, in the budget, additional moneys were allocated for new activities — not to perform anything that was performed last year but to do new things, with the exception of the fair deal, which has been delayed because of the legislation. We have facilitated 200 more contact beds being acquired and I am sympathetic to the HSE's request that some of the money should go towards enhancing the nursing homes subvention because of the pressures. That is what the HSE has to do.

I acknowledge what Deputy O'Sullivan said. In the first couple of months of this year, the HSE has been €95 million above profile. In other words, it has over spent by €95 million. That is why it has to do the kinds of things that it will now do around the country. There will be no Supplementary Estimate. We know the budgetary situation is not what it used to be. Everybody has to live within budget. With the exception of new pay agreements, which would require a Supplementary Estimate, the HSE has to provide its service within the available budget.

There are issues around overtime payments. One point that has come to light in the Psychiatric Nurses Association dispute is the heavy reliance on overtime to provide services. There are significant issues that have to be addressed. The HSE has €300 million earmarked broadly in the area of value for money. In other words, by changing how it does things and making things happen differently, it can provide services in a more cost-effective fashion, and it has identified €300 million for that purpose.

That brings me to a question from Deputy O'Sullivan about how we deal with primary care. The hospital budget next year is up by 2.3%. The primary community continuing care budget is up by more than 9%, precisely to make the shift to the community services happen.

The Minister has not answered my question firmly. Perhaps I am not able to understand it. I asked how the funding went from €14.7 billion to €14.1 billion. I would like a full answer to that. Perhaps Mr. Woods could write to me to explain in detail what was accounted for in the €14.7 billion that allowed him to accept the €14.1 billion funding.

The Deputy probably has that already, but he can have it again.

I do not have that.

He would be entitled to it, and I have no problem making it available to him. He can compare one with the other.

Most people would feel it not unreasonable——

What I want to emphasise——

May I finish, Minister? The HSE felt it needed €14.7 billion to maintain existing levels of service. It was given only €14.1 billion to maintain existing services, plus €200 million for new developments. That is why it is €95 million over budget now, and that is why we are seeing the cutbacks. The Minister would like to say that they are not cutbacks, but the reality is that they are. Unless the Minister can give a comprehensive written answer to my question, I do not think any reasonable person would not come to the same conclusion.

They might come to the conclusion that there had been savings.

Let Mr. Woods tell us.

Savings through better management.

Chairman, I thought you were going to be——

I am being impartial. It is just dawning on me that there may be savings through better management.

Do you believe that?

If the Chairman agrees, I will circulate this document, which gives example after example of great improvement in performance with no extra resources. I mentioned the physiotherapy department in St. James's Hospital. With no extra resources, it has shortened by two months the time patients wait to access the service — by talking to the patients and working differently. The urology department at St. Vincent's Hospital doubled the number of patients with no increase in resources. Similar progress was made with diabetes management in three places in Cork. I will send this information to the committee, and it is more of that change that we want to see. The €12 million is to support those initiatives, and the HSE is very keen. Professor Drumm, the finance director Mr. Woods and the HSE board are keen to do things differently and better. It is not just a question of more of the same with more money, with no one ever questioning whether we can provide a better service differently.

We cannot afford that, Minister.

Let me remind committee members about our mission statement, agreed at our first meeting, to ensure value for money.

We agree with that. Do not twist our words, Chairman, as we all agree with that.

As soon as that happens, we have a problem wondering why it is happening.

No, we do not. Sorry, but you are misrepresenting the situation, Chairman. I am sorry to intervene on Deputy O'Sullivan——

Just give me a bit of time before the vote.

Sure. However, it is worth reflecting back. When we came in as a new committee, we raised new ideas on how we were going to run the show.

We wanted clarity——

We said we wanted clarity, which we are getting. We also spoke about value for money, better management and scrutiny of the funding that was going to the HSE.

All of that is now falling into place, and we seem to have a different problem — wondering whether this is a cutback.

With respect, the scrutiny element is not falling into place. That is what I am seeking to achieve today——

I go along with that — the Deputy will get a written response to his detailed question.

I agree 100% with the Minister, Mr. Woods and, I am sure, Professor Drumm that we want to look at new and better ways of doing things. Examples can be given, and the question has to be asked: if they are being done in St. James's Hospital, why can they not be replicated elsewhere? Ultimately, however, the reality is that, although the Government can say that there are wonderful examples of how to improve things, the fact is that we do not have enough neurologists in this country. No matter how smart or quickly they work, unless we get more neurologists we will have serious problems with under supply. The same is true for neurosurgery. Then we have to ask the question that Deputy O'Sullivan asked as to why there are physiotherapy waiting lists for people who are badly in need of it and no jobs for the physiotherapists who are qualifying.

I will make one other point and then keep quiet. Some 57,000 bed days were lost last year between the Beaumont Hospital and the Mater Hospital alone. That is the equivalent of a 150-bed hospital shut for a year. The main reason they cannot discharge their patients is that there is no suitable place in the community for them to go. We could build, very quickly, a resource in the community — modular units commissioned in two months and built in four — to hold rehabilitation facilities such as a nursing home with occupational therapy, physiotherapy and speech and language therapy. The personnel are there but there are no jobs for them, and people are in need of the services but they are not receiving them. I have recently been informed that in recent months there has been a real rise in the vacancies in existing nursing homes. Why is that, when we have huge pressure on hospital beds?

I want to move on. Before I call Deputy O'Sullivan, I say to Deputy O'Connor that he will get his chance. I remind Members that there will be a vote in the House at 2.30 p.m.——

It is at 2.20 p.m.

I apologise — I did not realise that.

I make the point again, based on what we said in our first meeting, that we will have funding for neurologists and everything else if we continue to secure savings in other areas where there has been if not waste then money misspent. That was our mission statement.

I asked one technical question that has not been answered. Where can I find the spending on the regional tier in the documents?

The Minister said that acute hospital beds are expensive. We know that. Does she have a breakdown of the cost of beds in tertiary hospitals as opposed to secondary hospitals? She does not necessarily have to give that to me today, but I would be interested in seeing a breakdown of costs based on what the bed is used for. Are there cheaper beds? Obviously, certain beds will be more expensive because of how they are used. That also relates to the question of patients being in inappropriate hospital beds when they could perhaps be in a long-stay bed.

Another question on which I did not receive an answer was implementing the Rebecca O'Malley recommendations. I know that many of them are in the cancer strategy, but one in particular — recommendation 11 — is about having patient advocacy and a patient liaison system in every hospital, not just the cancer centres. I do not know whether that would cost extra money or whether someone in each hospital could be given the job. However, something needs to be done as it is one of the recommendations. How will the Minister ensure that is done? The Government accepted all of the recommendations.

Deputy Neville is gone and Deputy Kathleen Lynch could not stay, but I will go back to the issue of not spending A Vision for Change money this year. To relieve the pain of families who, for example, have a child waiting for a child and adolescent psychiatric community team — new teams were supposed to be put in place — why can the Government not just tell the HSE to implement that part of A Vision for Change? The same is true for the child and adolescent psychiatric beds I mentioned. Deputy Kathleen Lynch has asked me to raise the question of 320 people with disabilities who are in psychiatric hospitals. Those relate to practical changes that were going to be made under A Vision for Change. It is treating that very weak sector of society with a lack of compassion when nothing is done about funding for this year. They are real people who were hoping A Vision for Change would be implemented. I accept that there must be a system in place to ensure the HSE uses the money in the way intended. However, I am concerned that in the meantime there are vulnerable people on waiting lists or in beds inappropriately in psychiatric hospitals. The same applies to people waiting for physiotherapy or children waiting for speech and occupational therapy. They, too, are real people waiting in queues while the posts are not filled.

Like my colleagues, I congratulate the Minister on her reappointment. I am not sure that I want to take the same road as Deputy Reilly and express love for the Minister but I have certainly always been a fan. She has been very helpful to me in my constituency. I wish her well and hope she will continue to deliver, particularly on the issues that concern me.

With regard to policy on accident and emergency services, I wish to relate a personal story. I often wonder what is the relationship between hospitals and local general practitioners. I am keen to ensure general practitioners in Tallaght have a role with the hospital. Last Christmas I had a problem with a hernia. Instead of clogging up the accident and emergency department I went to my general practitioner, as one is advised to do by the health service. He gave me a letter stating I required surgery. I went to Tallaght Hospital where the staff were very nice, looked after me well and kept me on a trolley for a day. I have no problem with this. However, it made me wonder. If patients are referred to their local accident and emergency department with a letter containing a clear message from their local general practitioner, should the system not take account of this? The HSE tells people they should go to their general practitioner and not clog up the accident and emergency system. What is the position in that regard?

I support the Chairman's remarks on suicide. I am a member of the sub-committee and was a member of the previous one. It is most important that we continue our work. The Minister will be aware that Teen-Line Ireland, a suicide prevention help line, is based in Tallaght. It does good work but is always struggling to secure funding. Could the HSE not be more sympathetic to the organisation?

I particularly wish to mention an issue I have been discussing with the Minister of State, Deputy Devins, in the last few weeks. The Minister also replied to Dáil questions and an Adjournment debate on the issue. A couple of years ago the then Minister of State, former Deputy Tim O'Malley, made commitments to the Catholic Youth Care project which deals with the Travellers suicide issue in Tallaght. Funding was to be provided but we are still struggling to get the message across. Suicide prevention is an important issue and in the course of my political work, particularly in the Oireachtas joint committee, I have become highly aware of the issues relating to suicide. Could the HSE not be more sympathetic in that regard?

I have no wish to appear to be hitting at the HSE but the issues we are discussing involve that body. I have made the point, during an Adjournment debate and in the course of other Dáil business, that the HSE should be highlighting good news stories. One such story is the hospital in the home project which operates from Tallaght but caters for patients throughout the Dublin region. I am sorry if my country cousins do not want me to talk about Dublin but I am from Dublin and I represent the Dublin region——

I doubt that we could stop the Deputy.

Some have tried to do so.

Is Dublin North not in Dublin any more?

Every Dublin hospital has benefited in the past year from this excellent service catering for over 2,000 patients. However, it is now being jeopardised by a decision of the HSE.

Does the HSE not realise when it has a good news story? This is a good story, and even the HSE says as much. The HSE assessment of the project stated it was working well and that it was a good system. For God's sake, why cut it and put every accident and emergency department in the Dublin region under more pressure? I cannot understand it.

I wish to discuss the position in Tallaght briefly. I live there. I might not have become a Member of the Dáil had not Deputy O'Hanlon who is sitting beside me plucked me from total obscurity in 1988 and appointed me to the Tallaght Hospital board. I feel strongly about the hospital and its development and future. The Minister will be aware that a great deal of poor publicity is being generated by the hospital. There was a story a few days ago about the psychiatric nurses dispute in which a local person was quoted as saying it was a downgrading of the hospital. There is such publicity.

There are issues in Tallaght which are a cause of concern for the community and me. Incidentally, the Tallaght Hospital catchment does not only include Tallaght, the third largest population centre in the country, but stretches almost to Wexford through Carnew. Therefore, many are affected. What is the position on cancer services in Tallaght Hospital? The former Minister, Deputy Micheál Martin, opened the breast cancer service there and colleagues have said that, regardless of the national approach and the centres of excellence, with which I have no problem, the great service being provided there should be maintained. There is also the issue of hospital services for children and young people. The Minister will be aware that this is a huge issue not only in my constituency but in hers. There are still issues I must get my head around where that is concerned.

More than once — in fairness the Minister supported me — I have raised issues about primary care services in my constituency. Places such as Fettercairn, a huge local authority estate, should have such services. I am glad the HSE has announced that the new primary care centre, to be located on town centre land, will be operational in a year and will provide those services not only for Fettercairn but also for Springfield, where I live. That is a positive development. I hope the HSE and the Department continue to promote primary care initiatives which will keep people out of hospital. I have no wish to see Tallaght Hospital clogged up any more than it is. I will continue to campaign for primary care services and the excellent home help service located in Tallaght village.

I wish the Minister well. A lot has been done, but there is more to do. I hope she will remain focused and deal with the issues that have been raised by members. Some of the issues I have mentioned are worthy of her attention.

I thank the Deputy. This is fast becoming the committee on health, children and Tallaght. We will have to broaden our remit.

Chairman, if you wish to heap praise on me, I will quote you.

We could all speak about our local hospitals for hours. We refrain from doing so.

I checked with my esteemed colleagues and understand you allowed them to raise parochial issues. I am only taking the advice and counsel of more esteemed colleagues.

It must have gone over my head. I did not hear it.

I am only learning.

The Deputy must have mentioned Tallaght 30 times.

We have reduced the time for the Minister to respond.

I take it Fine Gael and the Labour Party support me.

I support Deputy O'Connor 100%.

Is there time for the Minister to respond?

Let me comment briefly on the hospital in the home scheme. It has worked extremely well. One of my constituents who has a psychiatric illness had to be isolated because he had contracted MRSA when he was in hospital having an open fracture of his arm fixed. He cannot tolerate isolation but was able to go home and receive care and his intravenous drugs there. Now, however, that service has been discontinued. God knows what the outcome will be if he has to go back into hospital to receive this treatment. He is not psychiatrically well. It is terrible.

I have a suggestion for the Minister. It was two hours into the meeting when she announced to Deputy Reilly that she would send him a document with good information. It is important that all members from all sides of the House receive the good information that is available.

All members would be delighted to receive any documents the Minister has with good news, and plenty of it.

We must appeal to the Minister not to suppress good information. It is not good enough. We want as much good information as possible.

If the Chairman arranges a training course on how to handle oneself at committee meetings, I will certainly attend.

That is not the issue. I was simply trying to work out how there would be time for the Minister to respond.

The Minister understands me.

Deputy O'Sullivan asked about data. The four regions she mentioned have regional health consultative forums. We do not have that data, but we have the old health board data and all the hospital data, which the Deputy can have.

Is there no management structure? Are there people?

That is one of the issues currently being addressed within the HSE as it reorganises the management functions between community and primary care and hospitals.

Does the cost of running those regions come under the corporate figure at the moment?

I have it all here and can give it to the Deputy. Obviously, there is a cost variation between hospitals that deal with complex tertiary activity and others. There are also hospitals where levels of activity are similar, yet there is a huge divergence in the cost of running them. One of the best performing hospitals in the country is St. Luke's in Kilkenny. Every time I visit it I am impressed by initiatives that come from the ground upwards. It is fantastic. There is a great spirit of co-operation between consultants, general practitioners and nursing staff who make it happen. There is a real "can do" attitude.

The last initiative in which I was involved was an infusion programme jointly funded by the hospital and a private source. I will not mention it by name, but another hospital with a similar level of activity has a substantially higher annual budget. These are among the issues being addressed in the context of the HSE's reorganisation plans. It concerns how and where things happen. By measuring performance concerning the numbers seen in out-patients departments and so forth, we can put in place a system that sends the money after the performers. We can all learn a great deal from that.

Deputy O'Connor's interest in Tallaght knows no bounds. I am sorry to hear he had to avail of the hospital's services over the Christmas period.

I am in good health.

I mentioned Kilkenny which is a case in point. In Kilkenny, one would not have had to wait in the accident and emergency unit to be admitted for surgery. That would have happened by virtue of the co-operation between general practitioners and consultants. When I visit places such as Carlow and Kilkenny and they hear all the criticism of the health service nationally, they do not know what the rest of the country is talking about. I attended a funeral recently in that region and people told me they did not understand all the criticism of the health service because they have a fantastic working hospital where there is never a problem. That is the way it should be. It is also the case that where we do not have an accident and emergency department we have less people from those regions attending accident and emergency departments elsewhere because they use general practitioner services to better effect. We can learn lessons from that as well.

As regards the hospital in the home, clearly a big part of the change is making more things happen outside the hospital environment. Last year I was criticised because I was accused of more privatisation. One Deputy said it was more Americanisation of the health system with a private company providing the service. Now, however, we are being criticised because the HSE believes that it should not renew the tender and that service will be provided in a public capacity. My official, Mr. Liam Woods, tells me that is what will happen.

We do not want people in hospital if we can provide the service in the community. We must also be mindful, however, of value for money in terms of all this. While value for money is often called a cliché, it is important nonetheless. I accept that the hospital in the home did provide a fantastic service. It is not a question of not supporting the service they provided, but rather one of cost versus what can be provided from public capacity.

On patient advocacy and Rebecca O'Malley, the person responsible within the HSE is Mary Culleton, the director of consumer affairs. Earlier this week, together with Professor Drumm, we launched a new plan involving service users and patients, how the health services are managed and used, and respond to service users and patients. Patient advocacy is part of that and it will be the responsibility of Mary Culleton to ensure that we put in place in each health care setting, not just at hospital level, an appropriate system where patients can voice their opinions whether they are good or bad and have them responded to appropriately. We can learn from that in a genuine sense.

Tallaght Hospital is a good example. A few years ago, the kitchen staff there introduced a new menu for patients from Asia who do not like to eat bacon, eggs and chips, which are alien to them. They discovered that many patients were not taking their food, so the kitchen staff added dietary requirements to the hospital menu for Asian patients and other ethnic groups. That experiment has been highly successful. I have mentioned that because such things can have a big impact.

In the Kildare region, by triaging patients, nurses have been able to greatly reduce the number of young people who required access to acute psychiatric services in hospital. We salute that system. I do not have the data to hand, but I think eight new community mental health teams are currently being put in place around the country. We know there is a large deficit in services for young people who are psychiatrically ill.

We have greatly increased the number of physiotherapists and occupational therapists employed in the public health system. We have gone from 593 physiotherapists, for example, to 1,419, which is an increase of 822. We have increased the number of occupational therapists by 737, and speech and language therapists by 430.

Are those posts filled?

Yes. More disability funding has been given to the HSE. I accept that access to therapy is so important for children with Down's syndrome and other serious disabilities. Access to speech and language therapy, and other therapists, at an early stage is so important. As part of the developments, a large amount of new funding in health generally is for staff. Some 70% to 80% of it is for new staff and in the disability sector much of it is for hiring therapists.

Like Deputy Charlie O'Connor, I want to talk about my own constituency. I welcome the Minister's comments about St. Luke's Hospital in Kilkenny. They have a fantastic system there. I am often surprised why other hospitals around the country do not come down to learn from St. Luke's and find out how its works so well. The public private partnership there works wonderfully for the whole system, including GPs. There is a rumour that a step-down unit — which the Minister opened three or four years ago and which works in tandem with St. Luke's — in Kilcreene Hospital will close down for three months in the summer. That would be a shame. I do not have any proof of this, but I have written to the HSE about it. It would be a pity to see such a facility being closed down for three months, as it is working perfectly. It provides 14 step-down beds from the acute hospital.

I asked earlier about cervical screening. I realise the Minister has had many questions to answer and I appreciate her efforts in answering them. I wish to raise the issue of funding for the Central Mental Hospital in Dundrum. There are serious issues concerning staffing levels on some of the wards. I would like to know about the intention to co-locate this hospital with the prison at Thornton Hall. It may make some economic sense to get better value from the site, but it is a retrograde step and further stigmatises those with mental illness. I hope the Minister will change course on that matter.

Is there money within the budget to complete plans for the cystic fibrosis isolation rooms, not only in St. Vincent's but in other hospitals around the country where people need to be admitted from time to time? They do not want to face the risk of infection.

Will the funding that would be raised from the disposal of psychiatric and mental health institutions be ring-fenced for mental health services? I know the Minister said earlier——

I hate to butt in, but I must inform the committee that a vote has been called in House.

Could the Minister arrange for somebody to write to me on the suicide issues I raised?

I will endeavour to answer all the questions. I refer to step down facilities which Deputy Aylward mentioned. I do not have any information but we will come back to him on that. I acknowledge that one of the issues that arises for the HSE as an employer of many young women is the extended maternity leave which is now a legal requirement. For example, in some respite facilities with which I am familiar, one third of staff will be on maternity leave this summer. In fairness to the HSE, there are huge pressures from that source. I am not suggesting that we stop maternity leave but am simply saying that with a young workforce, particularly with so many young women, it places pressures on some of the services.

I refer to the proceeds from the disposal of mental health property. The HSE is protecting that for investment in psychiatric services. We are not co-locating the Central Mental Hospital with the prison. As I said before, the Mater Hospital and Mountjoy Prison are probably closer to each other than this hospital will be to the prison. Since it is located in the centre of the city, nobody says the Mater hospital is co-located with Mountjoy Prison.

They have both been there for 100 years.

I know that. We must get away from where buildings are located and what happens in them. Obviously, all of this is subject to planning permission and so on. We are at the early stages in regard to the development of the new hospital.

What is the Minister's intention?

The Government decision was to build the hospital there so unless it changes it, that remains the determination.

In regard to cystic fibrosis, work is under way in St. Vincent's Hospital and a number of beds will be available this summer and some more later this year. The total requirement will be available as part of the new development at the hospital. Some €2.5 million has been allocated to Beaumont Hospital and a meeting took place last week on advancing the proposal there for cystic fibrosis patients.

We have given the Estimates a good hearing. On behalf of the select committee, I thank the Minister, Mr. Scanlon and all the officials.

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