Non-Covid Healthcare Disruption: Waiting Lists and Screening (Resumed)

We are joined this afternoon by representative from the Department of Health, the HSE and the National Treatment Purchase Fund on the topic of non-Covid-19 healthcare disruption: impacts on waiting lists and screening.

From the Department of Health I welcome Mr. Greg Dempsey, deputy secretary general. From the HSE, I welcome Mr. Liam Woods, national director of acute operations; Mr Damien McCallion, national director emergency management and director general of Co-operation and Working Together, CAWT; Professor Ann O’Doherty, lead clinical director of BreastCheck; Ms Siobhán McArdle, head of operations, primary care and Mr. Eamonn Rogers, national clinical adviser in urology. From the National Treatment Purchase Fund I welcome Mr Liam Sloyan, CEO, and Mr John Horan, chairperson.

I wish to advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If you are directed by the committee to cease giving evidence in relation to a particular matter and you continue to so do, you are entitled thereafter only to a qualified privilege in respect of your evidence. You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise nor make charges against any person or persons or entity, by name or in such a way as to make him, her or it identifiable.

I invite Mr. Dempsey to make his opening statement and ask that he please confine them to five minutes to allow time for questions and answers.

Mr. Greg Dempsey

The invitation indicated that it was discretionary as to whether we made opening remarks so we decided that we would not in order to leave more room for questions.

That is fine. I thank Mr. Dempsey.

Will Mr. Woods be making any opening remarks?

Mr. Liam Woods

No, Chairman. The only comment I was going to make was to introduce those present from the HSE but you have done so already. The invitation said that based on the submissions we had made to the committee, there was no requirement for an opening statement.

There certainly is not. I thank Mr. Woods.

Will Mr. Sloyan be adopting a similar approach?

Mr. Liam Sloyan

We can, Chairman.

I thank Mr. Sloyan. On that basis I will open the floor.

The first speaker is Deputy Durkan for Fine Gael.

I am easy Chairman, as always. Will I have five or ten minutes?

Deputy Carroll MacNeill is on the list but you do not look very like her. Sorry for the confusion, it was my mistake.

I presume I will have ten minutes.

I welcome our witnesses and am glad to renew our acquaintances, it is not so long since we met in different capacities, in a different time, in a different era.

A few things have come to mind which were raised in the earlier session. They concern the challenges facing the delivery of health services at present. The Irish Medical Organisation, IMO, made a submission earlier. Its representatives were concerned about the incapacity of the health services to deliver, alongside the continued combating of the virus, while at the same time providing for the extra surge and service requirements that will arise as we approach the winter. They are concerned that the incapacities are at two levels, namely, in respect of buildings and ancillary facilities on the one hand and in respect of qualified staff on the other. They also made reference the unattractiveness of work in the Irish health service at the present time, for a variety of reasons.

I would like to hear a response on that point first, if I may.

Mr. Liam Woods

That is a real concern for us.

In some of the submissions we have made to the committee the Deputy will see we have identified that there is a challenge. As the committee will be aware, what has happened over the last number of months is that we have seen a significant fall-off in attendance at hospitals. We have seen that recover substantively in the emergency care and emergency flow areas. We saw a significant fall-off in scheduled care. We compensated to some extent in the private system for that three-month period. We are entering into further arrangements with a view to extending that.

The challenge identified is a correct one. The Deputy mentioned facilities and there is a challenge there. We are currently pulling together a lot of proposals to expand capacity physically. That challenge is most apparent in areas like outpatients and emergency departments. Some measures are already in place around that. As part of our winter planning process, which has accelerated this year, we are identifying further requirements. Indeed, the new Minister has instructed us to do so on an urgent basis. From our point of view there is definitely a facilities challenge.

In terms of staffing, it is correct to say this whole pandemic experience and what it has meant to the health environment and to the wider public has been extremely difficult. That has been the case for staff also. It has really only been through the Herculean efforts of staff we have gotten to where we are. Staff numbers within the overall health system in this period have risen by over 3,200. There has been a significant increase but, of course, there has also been significant absence associated with Covid-19. Growing that staff and growing key service areas, like intensive care, acute beds, community homecare and other supports, is a key priority for us. They are all falling into being considered as part of our winter planning process.

I agree that the challenge will lie more in identifying issues. Our task is to grapple with that and put in place the best arrangements we can now for what the Deputy rightly identifies will be both a potential return of Covid-19, depending upon the trend in the pandemic, and also the emergence of winter.

Have staff levels at consultant level been adequately replaced or replenished?

Mr. Liam Woods

The number of clinical staff and doctors employed has risen significantly. The replacement of consultants is not problematic from an approval point of view but, as the Deputy will be aware, there has been difficulty in recruiting consultants in some areas. It is also quite a lengthy process. We continue to recruit and, in fact, we had a number of doctors return to practice in Ireland to support the pandemic response. We will continue to recruit consultants for the remainder of this year in key areas of service priority.

Concern was expressed about the need to provide cancer care services and screening in the present climate to restore to the required levels the screening and diagnostics needed, and at the same time provide for, perhaps, a second wave with regard to the pandemic. Are sufficient provisions in place to be able to withstand both challenges at the same time?

Mr. Liam Woods

I will ask colleagues to address screening in a moment. Regarding the arrangements for our cancer services within the acute environment in the first wave of the pandemic, rapid access clinics remained open but attendance fell significantly. That can be attributed to the numbers of patients coming forward and referrals from GPs. We also displaced urgent surgery into the private system and actually that worked very well. Mr. Rogers can talk more on that, if required, but that worked very well for first three-month period.

The notion that we have adequate capacity to deal with the Covid-19 surge and the demands of cancer and other urgent elective surgery within the system as it is currently configured is a real challenge. Before we came into the pandemic Sláintecare said there is not sufficient capacity, and that becomes a larger issue now. The Deputy will be aware that at the height of the pandemic we had 2,200 beds closed in the acute system. That was a significant shift, partly associated with public intent around coming into the hospital environment, but also with the shift in staff toward ICU and intensive care. From our point of view, it will be very difficult to respond to both the elective and unscheduled care demand with the surge we know is coming this winter. I will ask colleagues to address screening briefly.

Mr. Damien McCallion

There will be significant challenges in screening. It is important to remember we are only coming through the first phase of the pandemic. The capacity of the screening and treatment centres will drop from anything between 30% and 70% across the different services through this phase.

Clearly, if we have a resurgence, or a number of resurgences, that will bring further challenges. I will ask my colleague, Professor O'Doherty, to describe what some of those challenges are in the context of BreastCheck to give the Deputy some real examples of the practical issues on the ground in the service.

Professor Ann O'Doherty

The most important aspect of any screening programme is to do no harm. We made the difficult decision to suspend screening because many of our women go up to the age of 69. It is a very close contact examination so we suspended screening very reluctantly. That was the right decision at that time. We also had, at the time, approximately 500 women with screen-detected abnormalities so we set about doing that. We are conscious that we have a lot of ground to make up. It is the last thing in the world that I would want to do. I have spent my whole professional life advocating screening and it is the last thing I would want to do.

If we screen 1,000 women, we will pick up seven cancers. If we look after 1,000 women with specifically urgent symptoms we will pick up 100 cancers. We had a situation where we did not have the ability to do everything. The hospitals were being protected for the big surge. It was a challenging time and there was a lot of fear. I want to congratulate all our staff for helping us to deliver the service at all stages during this time. We have been working to look after women with symptoms and that is the priority. We must maximise our efforts. We are in the middle of a pandemic. Our ability to get back to screening normally is limited until we get to a situation where we do not need to have 2 m social distancing. It is not that we do not want to, but that is the reality and we will do everything in our power.

There is, however, a whole area of work. The European Society of Breast Imaging has given us guidelines on what to prioritise in the Covid-19 situation. We have been following exactly that guideline and the lowest priority at the moment is screening healthy women. We have women with a family history who have an 80% lifetime risk of breast cancer. They are in the hospitals and we are screening them at the moment. We are screening women with previous breast cancers. They have a much higher incidence. We are using our resources to the best of our ability in a very challenging environment.

At the present time, it is suggested that considerable numbers of people are awaiting oncology results or tests and could be on a waiting list for some considerable time, which is obviously not a good place to be. It is the same with regard to endoscopy services. To what extent are the witnesses monitoring the requirements there? What actions are they taking, or have they taken already, to address the issues?

Mr. Liam Woods

During the months of the first phase of the pandemic we had a significant problem with endoscopy. The urgent cases, of which there are normally no breaches on a monthly basis, went up to 1,500 breaches in the month of April. That reduced to 1,000 and is now back to 500 so the hospitals are putting a lot of energy into prioritising urgent scopes. The challenge is that in the Covid-19 environment much greater caution is required in terms of undertaking scopes and so the time to complete each scope is greater. There is a productivity issue around that. It ties back to what the Deputy was saying earlier. We also need more facility for scopes and that is something we are working on. We are aware of that. It is recovering somewhat.

The challenge and the international experience is that, unfortunately, it is likely that in total volume terms we will do well to get 70% or 75% of the previous volume. We will have a challenge there. We are aware of it and we are working at it. I believe the priority scopes, both for bowel screening and by referral, will come back on track over time where we will see difficulties in the routine and surveillance scopes. That is something we will have to work at further.

Yes, you are but you may come in at the end. There will be a bit of excess time.

I am out of time, not for the first time in my life.

The next speaker is from Fianna Fáil. Deputy McAuliffe has ten minutes.

I refer to the discussions we had this morning with the Irish Cancer Society and the IMO, particularly the discussion about a national flu vaccination programme. Can the witnesses flesh out some of the plans for that? Is that being done in parallel with the fight against Covid-19, particularly, the roll-out to non-prioritised groups?

Deputy Bernard Durkan took the Chair.

Mr. Liam Woods

Ms. McArdle might deal with this question.

Ms Siobhán McArdle

From a HSE perspective the flu programme forms part of the public health response and is very much part of our winter plan every year. Plans are in development to extend it with particular attention to ensuring there is high uptake in our staff cohort across both community and acute services. We will also extend the programme to higher-risk groups such as people with chronic disease and children to ensure that there is very robust management of flu. That very much ties into our response to the winter plan.

Is there a reason the HSE is not approaching the flu vaccination programme with the whole population as the target?

Ms Siobhán McArdle

The implementation falls to the operational part of the HSE but our clinical colleagues are best placed to advise on that. At the moment, the priority is, as I said, the age cohorts that are more vulnerable to the effects of flu and respiratory disease. Also included are people with chronic disease and people with respiratory illnesses such as chronic obstructive pulmonary disease, COPD. We are very much encouraging people who are living with chronic disease, as well as older people and children who are living with chronic disease to engage. We will be guided by our public health colleagues on the breadth of the population that receives the vaccine. Everybody is invited but particular attention is being given to priority populations. We will be working with our GP colleagues, as well as our community pharmacy within the HSE and our support organisations, in terms of occupational health and supporting our staff to deliver and manage flu in that environment.

Is the HSE aiming to have the maximum possible roll-out of the flu vaccine to as many people in the population as we possibly can, or are we limiting that ambition to the target groups, just as we might ordinarily do in a normal year?

Ms Siobhán McArdle

It has certainly expanded in the current year. Over the past winter we identified that expanding it this winter would be an advantage in managing in the context of Covid. As such the flu vaccine has been extended to a wider cohort. It is a question we will take back to our colleagues and maybe give the Deputy further information on the extent of the flu vaccine programme for 2020.

From some of the clinical advice this morning there is talk that the flu season may reach us in September or thereafter. We have very little time to prepare for that. From both a social and an economic perspective, and speaking as a public representative, there is a benefit to reducing all levels of influenza that we can in order to avoid it being mistaken for Covid-19. Even the slightest symptoms of influenza will lead to people having to self-isolate, to take time off work, and perhaps even entire businesses having to shut down. There is also the idea of false-positive spikes or surges, so the more we can do on the influenza side the better. We need much more detail from the HSE on that at this point.

Ms Siobhán McArdle

We have a flu plan in place and will be encouraging people when that plan is launched to ensure that we have maximum take up of it. We will provide the Deputy on the flu plan outside of this.

When the HSE is coming back to me on that it might also look at the issue of pharmacists. I understand flu vaccination can be availed of in the local pharmacy, but that pharmacist is not able to administer the vaccine in a person's home, for example. That is additional capacity that could provide the greater than normal ability to deliver the flu vaccine and I urge the HSE to consider that. I imagine there are other concerns but I urge the HSE to consider this also.

Ms Siobhán McArdle

I agree.

Capacity issues were raised this morning as well. The chief one was the idea of the 500 consultant posts. There was also an alarming enough figure that of the 160 specialised registrars, SpRs, who are exiting rotation this year, only one of them has had an informal consultant post. Can the HSE explain what the delay has been in appointing people to those 500 consultant posts?

Mr. Liam Woods

By way of the background facts, the number of consultants has risen by 140 since the start of this year, with a further increase in registrars and interns of nearly 400. We have seen an increase of 526 in medical posts in total in the hospital system since the start of the year. On the question of delay in the recruitment of consultants, there is a process, as I referred to earlier on, that can be a bit lengthy. We are very keen to retain as many of our senior clinical personnel as we can. In fact, in a way, there is an opportunity at this time to do that that might not have existed in previous years, which we are pursuing.

Can I clarify the figure of 526? Is that a net increase?

Mr. Liam Woods

Yes, it is. That is a growth in whole-time equivalents. This includes people who may have retired and new appointments and is a net increase.

My second question was around the greater access to diagnostics for those at primary care or GP level. Can Mr. Woods talk to that issue, please?

Mr. Liam Woods

Yes I will, and I may ask Ms McArdle to comment too if she wishes. That is a key priority for us. More generally, under the heading of what we can do best to alleviate pressure on the acute system to allow it to do what it needs to do and what it does best, but also to support primary care, the provision of diagnostics to GPs in the community is one target that we are very clearly focused on. From our point of view we are going to market specifically for the purpose of acquiring private diagnostics to support GPs but also to look at the use of public facility. We have recently looked at the access to diagnostics in public hospitals for GPs. As the Deputy would be aware, nearly half of the laboratory work at the moment in public hospitals is in fact from GP referral source. There is also access to radiology. The key requirement, which in our own dialogues with GPs is very clear, is that the provision of additional diagnostics and of dialogue with consultants and with specialists, is a key ingredient to treating people at or closer to home and not in hospitals. We are very much pursuing this as part of our own winter planning process for this year. Perhaps Dr. Rogers might like to say more about that in his own area.

Dr. Eamonn Rogers

I totally agree. Cancer has to get the optimal care in the right location but we can move certain services that are non-cancer into the community. The national clinical programme in surgery has started looking at this with its models of care, looking at benign conditions that can be managed in the community with shared care initiatives, with general practitioners using nurse-led clinics in the community. These initiatives have actually started and are being piloted at the moment in my own health region. To make this work it involves moving traditional work that comes into hospital which clogs the outpatients. The idea is to reduce footfall in hospitals, which is more important now with Covid-19 risk, and to move this work as much as possible into the community, closer to home. These initiatives are live and also depend, as Mr. Woods said, on getting diagnostics in primary care centres.

When Mr. Woods talks about going to market on diagnostics, does he have a number for the diagnostic machines that can be delivered and the types of machines?

Mr. Liam Woods

When I speak about going to market, it is to seek private providers to be in contractual arrangements with us to provide that kind of equipment which is both CT and MRI, as well as potentially ultrasound and X-ray, but the big demand is for CT and MRI for GP referral. That is part of a wider tender that we are doing at the moment with regard to access to private services as part of our ongoing addressing of capacity this winter. It is likely therefore that we will contract entities, it is not specific machines that can provide a service.

What level of service or increased level of service will that provide?

Mr. Liam Woods

We already, as Dr. Rogers has said, have a number of pilots under way and we will certainly be looking to support those. We will also be in dialogue with the GP community seeking to support in as much as we can the location of appropriate care in the community. In volume terms, I cannot give the Deputy a number right now but we are seeing this as a significant piece of our winter planning. We are open to acquiring as much diagnostic capacity as we can to meet this demand.

We are out of time and we have to move on to the next speaker, Deputy Cullinane.

I welcome all of our witnesses. I will start with Mr. Woods. This afternoon, I commended the Irish Cancer Society and the IMO on what were substantial and helpful briefing documents. I also want to commend the HSE because the document it has sent is helpful and expansive. I want to thank the HSE for that first and foremost. Did Mr. Woods hear the committee's exchanges this morning with the IMO and the Irish Cancer Society?

Mr. Liam Woods

No, I did not.

Did Mr. Woods read their opening statements or submissions?

Mr. Liam Woods

No, I have not seen those.

There was a deep frustration coming from both organisations, which I will go through in a moment. It strikes me that at this point there are three strands to healthcare delivery, namely: dealing with Covid-19 care; dealing with non-Covid-19 care, which is all of the modalities of care from acute care to primary care, mental healthcare and community care settings and so on; and the need for a catch-up programme, which Mr. Woods talked about. Is it fair to say that under current capacity constraints, we will not be able to keep up, never mind catch up, if there is a surge in Covid-19 in the coming weeks?

Mr. Liam Woods

The Deputy rightly identified the fact that there are a number of elements to healthcare delivery that begin to interconnect as we move on. It is fair to say that we face a real capacity challenge, and depending on the trend in Covid-19 data and what happens with this year's flu cycle as winter approaches, we face a capacity constraint. We have a fixed capacity against an as yet unknown demand.

My point is that there is a question of how in God's name we will roll out a catch-up programme if we have increased levels of Covid-19 in our acute hospitals, as well as all of the ongoing day-to-day non-Covid-19 care that would have to happen anyway. That brings me to my first question on capacity. The Irish Cancer Society and the IMO, like many other organisations, are calling for temporary accommodation and physical capacity to be made available. Is that something that is being examined by the HSE and the Department and if so, to what extent?

Mr. Liam Woods

Yes, it is. I should say that over the past three months we were already putting in additional capacity, such as the 324 additional acute beds and, critically, the 42 ICU beds.

I am asking about additional capacity beyond that again.

Mr. Liam Woods

Beyond that, in terms of looking at modular development on a rapidly accelerated basis across the acute environment, we are also examining proposals as part of this year's winter plan. They are looking at areas such as the displacement of outpatients to create more clinical space. The other capacity issue I should mention is that we will seek to further contract with the private system, which worked well in providing urgent elective care.

I want to ask about staffing because that is the physical side of the question covered. That depends on what happens and on the extent of what happens so we will have to see the colour of the money in the context of what that means. On staffing, from a combination of Be on Call for Ireland, the return of retired and overseas staff and locum cover, how many additional staff were brought into the system in full-time equivalent posts to cater for Covid-19?

Mr. Liam Woods

On full-time equivalent posts, we have 3,271 additional posts since the start of the year, the bulk of which would have come on stream since February, which is the period to which the Deputy is referring.

Will Mr. Woods provide the committee with a breakdown of those posts in categories? How much does that cost? One of the things we know is that we did not have enough capacity in the public system. Now that we have 3,271 additional staff who have come into the system, they need to be maintained insofar as is possible. Those who need to be kept in their positions should be kept on. What was the cost of those 3,271 posts?

Mr. Liam Woods

I do not have the cost figure in front of me but, on a full-year basis, I would have to do a sum that multiplies that by an average salary. Maybe I could provide the committee with that figure because it varies by staff type and grade.

It would be great if Mr. Woods could provide that figure. I want to move to screening because this morning the representatives from the Irish Cancer Society were concerned more than critical about the screening services and wanting them to be back up and running. They stated that there were potentially 450 cancers that had possibly gone undetected so far. Would Mr. Woods agree with that figure?

Mr. Liam Woods

I might ask my screening colleagues to address that.

Professor Ann O'Doherty

May I explain that? It depends on the length of the interval between when a patient would have been diagnosed and when he or she is diagnosed. That is largely down to the type of cancer and the age of the patient. The European Society of Breast Imaging has written in its introduction that a relatively short delay in screening healthy women of six to 12 weeks has almost very little impact on survival. However, in terms of younger women who present with aggressive symptoms in our symptomatic services, that is where the life years can be gained by treating them very quickly. We must acknowledge that we have lost a lot of ground in-----

I am sorry, Professor O'Doherty. My question was in relation to a number. The Irish Cancer Society has put out a number of 450. I am asking if the HSE has a figure that was done on analysis.

Professor Ann O'Doherty

May I explain that? It is impossible to put a number on that in terms of mortality. We could not possibly do that because it depends on the length of the delay. It would require a mathematical statistical analysis-----

Professor O'Doherty does not know from where the Irish Cancer Society got its figure.

Professor Ann O'Doherty

I have no idea where it got its figure. I do know that if we were screening, we would be detecting cancers all the time. There is no doubt that we have lost ground but I cannot put a number on it.

Mr. Woods or Professor O'Doherty might answer this question. The comprehensive briefing document they provided states that in terms of the four screening programmes, it will take time for screening programmes to build up, but is it fair to say that we do not have time? How quickly are we looking at getting those screening programmes up and running?

Professor Ann O'Doherty

For BreastCheck most of our screening - 70% - is done in a mobile breast screening unit. We normally would have screened 40 women a day in a mobile unit. We now have put a mobile into Beaumont Hospital to help with symptomatic services and we are managing 21 women a day, which is better than we expected. It will have an impact because social distancing has a major impact on our ability to deliver clinical services in all areas. We have a huge challenge, which I am not underestimating and I do not want to give the impression that we can surmount it easily, but we have to put all our efforts and resources into doing so, and we will be doing that.

I want to put on record the deep concern expressed by the Irish Cancer Society and many more advocate groups about the need to get screening up and running. I know Professor O'Doherty accepts that.

Professor Ann O'Doherty

I share that view, yes.

I want to put the final question to Mr. Woods. It is regarding capital funding. A reply to a parliamentary question on cardiac care in the south east, and this is only one project, so it will now involve every project, states that a capital plan is being reviewed and revised to take account of the impact of Covid-19. Are we now saying that every capital project is being reviewed, that even ones to which capital money was allocated may not be allocated that money, that we are looking at a full review of the capital project, and that projects that people felt were in the bag and would be delivered may now not be delivered?

Mr. Liam Woods

I am not aware of any project that is not proceeding. The point being made is that the demands on capital, which have been many over the past three to four months, give rise to a need to review. The particular project the Deputy is referring to in the south east is recommenced. Some of these projects are being impacted by the incapacity to work during a time interval, but from our point of view we have not done any review with a view to not proceeding with projects.

The HSE is not reviewing individual projects and saying that is in and that is out.

Mr. Liam Woods

No. I think it is a general reference to the fact that we have spent a lot of additional capital on ventilators, other equipment and on buildings in a very short timescale. I commend my State colleagues on the work they did in that regard.

I thank Mr. Woods.

The next speaker is Deputy Shortall. A number of speakers are not coming today so the Deputy may take ten minutes if she wishes.

I thank the Chairman. I welcome all our guests. I want to concentrate my questions on the issue of the flu vaccine. Earlier in our session here, and we are all only too well aware of it, there was discussion about the fact that, pre-Covid, we had a very severe shortage of hospital beds. I think we are all aware of that from the capacity review. That situation has been exacerbated greatly through Covid-19. Obviously, there is the whole question of reserving 20% of bed capacity in the event of a second wave. There are also severe constraints imposed as a result of the need for better infection control and distancing within hospitals, which reduces the bed capacity even further.

On top of that we are heading into the flu season. There is now the prospect of a perfect storm developing in which our hospitals could be overwhelmed. What is the situation in terms of preparation for the flu season? Recently, I saw the figure for the number of people who were hospitalised last year due to the flu, which was 4,300. That is significantly in excess of the total number of people who were hospitalised as a result of Covid-19. There are real challenges facing us and a real prospect of the hospital services being overwhelmed. What steps are being taken to improve the uptake of the flu vaccine to avoid a fairly severe situation arising in the hospitals? The uptake last year and in previous years was not great. What is the current estimate of the number of vaccines the HSE will have to procure? Last year, I believe the figure was 1.2 million vaccines. We should certainly hope to improve on that if we are to avoid serious problems in the hospitals. What number is the HSE estimating for the demand and what number of vaccines has it ordered and is confident it has secured?

In addition, in recent days the EU Commission urged all member states to launch earlier and broader vaccination campaigns against the flu this year to reduce the risk of simultaneous flu and Covid-19 outbreaks in the autumn and to avoid what the Commission refers to as a cocktail of risks. Is the HSE taking that advice from the EU Commission on board and when does it intend to start that campaign for the uptake of the flu vaccine?

Deputy Michael McNamara resumed the Chair.

Mr. Liam Woods

I will respond and my colleagues can make any further comments. As the Deputy rightly said, the challenge is clear. That we are facing into winter and Covid and, as mentioned earlier, a backlog of demand is putting the health system in a very difficult position. In terms of the uptake rates in hospitals specifically, they have been improving over the past two years but need more focus. The Deputy asked what we are doing. There have been active campaigns, some very successful, on peer-to-peer vaccination within the hospital environment and we will be encouraging and promoting more of that.

Are those campaigns running at present in terms of hospital staff?

Mr. Liam Woods

No. The Deputy asked when that will start. I do not have a date on which the current year's vaccine is available to us. I will have to refer back to the Deputy on that.

I meant the campaigns to encourage greater uptake. Have those campaigns started?

Mr. Liam Woods

They will run coterminous with the availability of the vaccine. In the hospital environment specifically, it is very much about having the vaccine and engaging in peer-to-peer vaccination within the sites. At public health level, we have an ongoing engagement with hospitals on flu vaccine uptake, and our public health leads are engaged in that. On the Deputy's specific questions, I will have to refer back to her. I do not have the date for the start of the campaign as it is not within my remit, but I can get it for the Deputy unless Ms McArdle is aware of it.

Ms Siobhán McArdle

The planning for the flu vaccine programme has commenced. That is under the governance of our chief clinical officer. Our colleagues in health and well-being are very much involved in rolling it out on two fronts. One is for the target populations. We work very closely with our GP colleagues. For example, over the past winter there was a focus on ensuring that people in the older population took up the flu vaccine. There was a targeted campaign to advertise the flu vaccine and then we worked directly with our GP colleagues-----

I am sorry to interrupt, but I am wondering what preparation is being made for this year, given the massive challenges associated with Covid-19.

Ms Siobhán McArdle

The flu vaccine programme-----

My questions are what the estimated number of vaccines that would be required is and how many vaccines the HSE has secured at this point.

Ms Siobhán McArdle

I do not have that information at present, but we will revert to the committee with it.

What are the witnesses' views of the adequacy of the number of vaccines the HSE has secured?

Mr. Liam Woods

I will take that. Looking at past practice, would we like to see greater uptake of vaccine? The answer is "Yes", both in the healthcare environment and outside.

I am not talking about uptake. Obviously, there is a need for greater uptake. My question is whether or not the health system will be ready for the flu season, given the huge challenges that are there as a result of Covid.

Mr. Liam Woods

As Ms McArdle has said, we have an active plan in place. Our public health colleagues and some people specifically leading on vaccine can provide information on that. We do not have that information with us but we do not foresee a problem at this stage with access to vaccine. We will revert with both the detail of the plan and the start date.

I would really appreciate it if the witnesses could provide the actual figures or the number of vaccines procured.

Mr. Liam Woods

I think Mr. McAllion may have some further information.

As a result of the advice from the European Commission this week, is it the HSE's intention to start that campaign earlier, as is being advised?

Mr. Liam Woods

As I said, earlier and broader. The answer to both is "Yes".

What is the date on which the HSE intends to start?

Mr. Liam Woods

It will depend on the availability of vaccine, so I am afraid we will need to revert with that information.

Mr. Damien McCallion

I think I can help. I was trying to come in earlier. As for the vaccine, the number we have this year is 1.4 million, which we believe is sufficient for a 90% uptake among the at-risk groups, which will include healthcare workers. We have also placed an order for the vaccine that is available for children between the ages of two and 12. I will have to confirm that number but it is in the region of 500,000 plus. We can confirm those numbers separately. As Mr. Woods said, it is part of the overall briefing.

I wish to concentrate on those figures now for a couple of minutes. Last year, I understand, we got 1.2 million vaccines. Mr. McCallion is saying that that is now increasing to 1.4 million. That is only an additional 200,000. Given that there are three vaccines for all children up to the age of 12, and given the need to increase the uptake among healthcare workers in particular but also among the general population, how can Mr. McCallion make out that an additional 200,000 is sufficient?

Mr. Damien McCallion

As I said, in addition, the children's vaccine is over 500,000 as well as the 1.4 million for the adult population. That is believed to be sufficient at the moment to achieve 90% coverage in the at-risk groups, that is, the groups identified as priority, including healthcare workers.

Does that figure of 1.4 million include the dose for children, which-----

Mr. Damien McCallion

No, that is separate. I am sorry. I may not have explained that well enough. The figure is just under 1.4 million for adults, and those are for the priority groups that have been identified, including healthcare workers, and then over 500,000 for the children's vaccine.

It does seem quite a small additional number. My concern is that we will not be prepared for the flu season on top of the other constraints that are there.

Mr. Damien McCallion

Sure. From a public health perspective, we can try to give the Deputy more detail on the priority groups Ms McArdle has set out. The number is deemed to be sufficient if we get a 90% uptake, which is high. Obviously, this year in particular we hope we will see high uptake, both in the general population and particularly in our staff groups. I think Ms McArdle and Mr. Woods mentioned earlier that a lot of work has started in respect of our own staff groups. Then the programme for roll-out in the general population and the communications campaign will be aligned with the availability of the vaccine. Perhaps we can get the Deputy more specific dates on that separately.

I thank Mr. McCallion. Does the HSE actually have the vaccine at this point or has it just placed orders?

Mr. Damien McCallion

I will have to confirm the precise situation in that regard with our public health people. I have just the broader picture of where we are, but we can get the Deputy that information.

I thank Mr. McCallion. I would appreciate that.

I wish to come back to Mr. Woods. The other big challenge in the hospitals, apart from the inadequate number of beds, is the high number of vacancies among doctors in particular. We were promised a few months ago an additional 1,000 consultant posts and that they would be employed on the basis of what is called a Sláintecare public-only contract.

Where are we in preparation for that as regards the legislation for the contract and the discussions with the relevant groups? At what point does Mr. Woods expect to be starting that recruitment campaign?

Mr. Liam Woods

I will ask my colleagues from the Department to respond to that as it is a policy question. We are still working within the current consultant contract framework so the whole-time public consultants we recruit at the moment are type A.

Mr. Greg Dempsey

Unfortunately, I am not overly familiar with the detail of this matter. It is a commitment in the programme for Government and is therefore a priority but I might have to come back to the committee with more details.

Does Mr. Dempsey know if any work been done on it?

Mr. Greg Dempsey

I have not been briefed on it.

Is there anybody among the witnesses from the Department who deals with legislation and contract negotiation?

Mr. Greg Dempsey

There is no one here today, unfortunately.

I would appreciate if we could get an early report on that.

I return to the issue of bed capacity. There have been calls for some time for a proper programme of hospital extension and new hospital provision in order to increase the number of beds available. There also have been calls for an immediate response to the dire shortage through the provision of quick-build temporary facilities. Is any work under way on that at the moment? How soon can we expect an increase in the number of beds, even on a temporary basis?

Mr. Liam Woods

There is work under way on a few sites of which the Deputy may be aware. Clonmel hospital has opened a modular build with 40 beds, which thankfully were available to come on stream early this year. Limerick University Hospital is currently building a further 100 modular beds. As I was saying earlier, as part of our winter planning we are looking at deploying modular technology to put as much capacity as we can on the ground in preparation for winter. There is an active programme and working plan for that at the moment.

Is Mr. Woods saying he expects to have those beds in place for this winter?

Mr. Liam Woods

We will have some modular facilities for this winter that we do not have today. The timescales for larger-scale modular builds would probably exceed this winter to an 18-month window, but there are some areas where we can make some progress within the interval available.

If there is any time at the end I will bring back in Deputy Shortall. I call Deputy Bríd Smith.

Professor O'Doherty said earlier that BreastCheck is using the resources to the best of its abilities. I honestly believe that but the problem here is the lack of resources. She can correct me if I am wrong, but she said she reckons that 450 cancers could have been missed. Is that correct?

Professor Ann O'Doherty

I did not use that figure. That figure was cited by the Irish Cancer Society.

How many cancers does Professor O'Doherty think may have been missed?

Professor Ann O'Doherty

The number depends on the interval between when a woman should have been screened and when she was screened. As I alluded to earlier, the European Society of Breast Imaging has stated that a 12-week wait for screening does not adversely affect a healthy woman. I work in both symptomatic and screening services, and the real problem is ensuring that younger women and women with more aggressive tumours are dealt with. That is what we have to factor in and that is why I cannot give the Deputy an exact figure. We have managed throughout Covid to deal with all the urgent patients in the symptomatic service and that has been a huge challenge. I am not for one minute avoiding the question or saying there will not be an impact. I just cannot put a figure on it. We are very lucky in one way, in that we have a two-yearly screening programme, which was very hard fought for. The UK has a three-yearly screening programme, so women are already waiting 35 and 36 months. We do not have anyone waiting more than three years. We are doing everything we can and we will be back----

I honestly believe that. The problem is the lack of capacity and resources. Professor O'Doherty said that out of every 1,000 checks, one would expect to find about seven cancers. Could she not put a figure on it on that basis?

Professor Ann O'Doherty

It depends. If we look at our screening programme, we should be screening within two years, plus or minus three months. Looking at our backlog, it is 25,000 for that period. Going back to two years plus six months, we have a lower rate. I have the exact figures here. What I am trying to say, however, is that it is impossible to state the numbers because if we get to people quickly enough, then we will not have the adverse effect. I will give the numbers to the Deputy.

If we are not able to pick people quickly enough, we could have more adverse effects than what would be normal.

Professor Ann O'Doherty

What I am trying to say is that we have lost ground in screening and symptomatic services. Our focus has been to save the maximum number of lives possible, which has meant getting the symptomatic women done. Under normal circumstances, we would never have used screening resources to deal with symptomatic women. Even if I was given a huge amount of money tomorrow, the trained staff are just not out there. It takes 14 years to train a radiologist and six years to train a mammographer. We were not expecting Covid-19, so we have lost ground and I cannot pretend that we have not. It is not a resource issue centred on money, however. It is a resource issue regarding personnel.

I want to ask the HSE representatives a question. We are limited with time. The HSE has stated that it has added 3,271 posts. We do not have a breakdown of that figure, but how does that compare with the number of people who applied for positions as a result of Be on Call for Ireland?

Mr. Liam Woods

I can provide a breakdown of that figure to the committee afterwards. Regarding the number from the end of May, however, for the whole-time equivalent increase, that is reflective of any clinically trained person who made himself or herself known to the system and who desired to work in the system during this time. To clarify the Deputy's question further, was she asking me for a percentage?

I was asking for a comparison of that figure with the number of people who applied for positions. I think we all know people, at least one nurse and probably some doctors, who were left waiting around for months after responding to the Be on Call for Ireland campaign but did not get an interview or a post. It was stated earlier that the recruitment process is lengthy and cumbersome. I would like Mr. Woods to comment on that aspect. Why were more professionals not recruited into the system when they were needed and available?

Mr. Liam Woods

I was referring specifically to the recruitment process for consultants, which we have looked at streamlining but it still takes quite some time. The recruitment process more generally has substantively accelerated to bring in those 3,200 posts. In fact, that number of posts would equate to closer to 4,000 people. The system, therefore, has been seeking to take on everybody it could. Where individuals have experienced delays, that may sometimes be because of issues regarding Garda clearance or similar matters. We have certainly sought, however, to accelerate the recruitment process, and the intention in both the hospital and community system overall was to bring on board as many healthcare workers as was achievable to face what was, at that time, an unknown surge level.

Will Mr. Woods comment on what the IMO stated this morning regarding the two-tier consultant contract inhibiting recruitment?

Mr. Liam Woods

We are recruiting into the existing consultant contracts. That comment earlier, which I did not hear, may relate to the post-2012 consultant contract as against the various types of contract that exist. It is not a matter for the HSE, however, but I understand that it is intended that that issue will be addressed as a policy issue. From our perspective, therefore, we are recruiting into the currently available contract types and on the post-2012 pay scales. I suspect that earlier remark was a comment on the post-2012 pay scales, which are a matter for the Government and not the HSE. Having said that, however, I understand that the commitment has been given to review and address that issue.

That is fine. I have a question for the witnesses from the National Treatment Purchase Fund. It was stated that one third of the work of the fund concerns securing public capacity. The problem we have, of course, is that if we continue to rely on the NTPF to solve the waiting lists, we are then effectively building up the private system and not dealing with the capacity issue in the public system. We are therefore continuing to add to a dysfunctional system of public versus private. There is also then the question of the costs. What would the witnesses say about the efficiency and costs of contracting out these needs when they should be in the public system?

Mr. John Horan

To put this is context, and without going back into ancient history, the National Treatment Purchase Fund, NTPF, working with the HSE, the Department and the hospital system, had significantly reduced the waiting lists up to the beginning of this year. In fact, in the early months of this year we had arranged surgery, procedures and scopes for more than 9,000 patients. We had arranged outpatient consultants for 8,500 patients. Then, at the end of March, because of the pandemic, non-critical care or elective care had to be postponed and this definitely had an impact on waiting lists and waiting times. Since June and this month, we have started to commission again.

In terms of where we are doing this work, whether it is private or public, probably the best indicative figure I can give the Deputy is that last year, approximately half our money was spent in public hospitals and the other half in private. We do not have a particular hang-up as to whether it is private or public. It is not an ideological position with us. Our simple view of this is whatever works best. We have worked well with our colleagues, as I say, in the HSE and in the hospital system, to get things done and we think we can help there again once we get out of the enormously difficult situation that we are currently living in.

I will ask my colleague, the chief executive, Mr. Sloyan, whether he wishes to add anything to that.

Mr. Liam Sloyan

I suppose I would just add that there is not a reliance on the NTPF to bring waiting lists down. We work closely with our colleagues in the HSE and the vast majority of treatment of waiting list patients continues to be done by the HSE in public hospitals.

The value of a commissioning system, adding on a relatively small level of extra capacity there, is the flexibility and agility of such a system. It is the case that challenges arise for waiting lists in many different places, many different ways and many different times and a commissioning system can have the flexibility to address the different types of challenges as they might arise. For example, it may be in one public hospital that they require more theatre time and that can be rented in a private hospital to facilitate them. Others may need more staff or funding to provide work at the weekend or in the evening. The NTPF and a commissioning system can look at the different types of problems that have arisen and find a solution to fit a particular problem. I would point out again that the vast majority of waiting list patients are addressed in the public system through the HSE in Ireland.

Surely the NTPF would not exist if we did not have a dysfunctional public care system. There would be no need for a national treatment purchase fund if we had a fully effective national health service instead of the dysfunctional one we have.

Mr. Liam Sloyan

Many health systems internationally have a commissioning element to them. It is not peculiar to Ireland. It recognises the fact that sometimes there are temporary problems that need temporary solutions. In fact, all the time these type of issues arise in waiting lists and there can be different problems in different years.

I thank Mr. Sloyan and Deputy Bríd Smith.

I thank our guests here today. I stated in the previous module today that the submissions that had been received earlier today largely reflected a great deal of frustration and some of that is coming across in this meeting here too. I would rather concentrate on what we can do rather than on what, potentially maybe, we think we are doing.

I brought up in a previous module the issue of scoping and radiology. I believe there is capacity now in the public system to do increased scoping and radiology later in the afternoon or in the evening because of the capacity constraints during the day. I wonder has the NTPF looked, as I stated earlier, at using some of the specialist registrars, SpRs, using some of the consultants on-site to try and expand hours into the evening. They could go quite late into the evening, maybe to 7 p.m., 8 p.m. or 9 p.m., to do additional procedures.

Mr. Liam Sloyan

We do, across public hospitals. A public hospital may come to us with a plan of the extra cost that it would require in order to do more scopes in the evenings or at weekends and we would agree an arrangement with them and fund them.

That is exactly the type of thing that Mr. Horan spoke of when he was speaking about the level of funding that goes into public hospitals through the NTPF.

With respect, NTPF officials should go to hospital management rather than waiting for hospital managers to come to them. I doubt there is a hospital manager in the country who has time to sit down and consider how the hospital is going to extend services and hours beyond what they are doing at present. Surely it is the remit of the fund to acknowledge it has the purse and the ability to pull people together. The fund should be prepared to implement plans in respect of vacant operating theatres, the availability of cleaning staff, whether there are surgical bed days and bed nights and whether it can provide capacity. That is the remit of the NTPF rather than taking the view it is available to engage with the hospital management.

Mr. John Horan

I can take that particular question. That is very much what happens. This is very much a two-way street. As with other sections in the health service, we now realise that we are going to have to find new and more innovative ways of working. We are going to have to find ways to support patients in this new, changed environment. They include measures such as virtual consultations, diagnostic services and clinical validation. Several areas like these could extend the approach we have taken. We are open to suggestions but we are not behind the door in making suggestions ourselves or in coming forward with ideas. My colleague, the chief executive, is very much at the coalface and brought forward many such ideas long before Covid-19 appeared on our doors. He will be at the forefront again in bringing forward even more innovative solutions in future.

I am happy to hear that but we need dynamic thinking now. We need people to become far more energised rather than saying simply what they can do. It is a question of what initiatives we have to put on the table and how are we going to move them forward.

Speaking of dynamic initiatives, I will turn my attention to Mr. Woods. I am keen to highlight the situation that Deputy Cullinane alluded to earlier, which is the closure of a catheterization laboratory in Waterford since February. This is adding between 30 and 50 diagnostic cases to the waiting list every week.

The problem is that essentially the engineers who are required to travel from abroad will not come into the country to observe a two-week isolation period. If we gave them a Covid-19 test and they proved that they were covid-free, they could come in and do the work. I have been asking the HSE in recent weeks to expedite this. To date, nothing has happened. It is not beyond the wit of man to have this done. Will Mr. Woods give categoric approval to put in place Covid-19 testing, communicate with the squires of that laboratory, get these engineers in and get this cath lab up and running please?

Mr. Liam Woods

My understanding is that the project has recommenced. It was not only about the engineers. I will do what-----

My information differs. I understand the project has not commenced on the ground. I do not know what else has commenced but no other work has commenced there as of yet. That is my information.

Mr. Liam Woods

I will address the core question. I will do everything I feasibly can with the South/South West hospital group to get the project recommenced. I understand from conversations with those involved recently that it is recommencing. If there is any difficulty with that I will certainly communicate with them to ensure it is resolved.

I wish to highlight to Mr. Woods that I spoke to the former Minister for Health, Deputy Harris, in April on this subject. He agreed with the Department that this was classed as essential work. It is beyond understanding why it has been suspended for so long.

Earlier, Deputy Cullinane mentioned the procurement process for the second cath lab. This has now been extended by another four months without any understanding. We are to have an Office of Government Procurement review of a review of a tender that has now taken 20 months to compile. Will Mr. Woods please use his office to look at this? We had a commitment that building works could start in October. There is no reason they should not. This laboratory is needed. Patients are being added to the list every month. It is absolutely unacceptable that potentially critically ill patients are being denied diagnostic testing because of administration and the ongoing failure to deliver.

Mr. Liam Woods

If it is helpful, I would be happy to provide a further report to the committee. I know there has been a brief report on this but I will certainly provide a further report to the committee on timescales to completion.

I imagine we would welcome the report, but what I would like to understand is how in 20 months we have only moved a project to design stage and planning permission. That took 20 months when a private laboratory was able to install a functioning cath lab in 12 weeks in the same area.

Mr. Liam Woods

I can comment on the public piece and I will certainly get whatever information that is helpful to the committee to support that.

One final thing, which was brought up earlier today but not developed to any degree, was the use of e-health solutions as we go forward. A person can walk into a hospital in Switzerland or France, present a card and get all his or her diagnostic tests or medical information pulled up on a screen. When will we get to that situation in Ireland?

Mr. Liam Woods

There has been some very good development in the use of technology. The Deputy is right to say technology is critical to the next number of months in terms of enabling the system to work effectively. That has already happened successfully in the past three or four months using software to connect both GPs and hospitals and GPs and pharmacies. The system in the National Ambulance Service, which is a national call receiving and dispatching system, has worked effectively to support testing and Covid-19 response. We are doing further work at the moment to support integrated working between GPs and consultants specifically with such technologies. Ms McArdle may wish to say more about that in terms of the community work.

Today, as a member of the Regional Group, I called for Covid-19 testing at all of our airports. We are in great danger of bringing infection into the country with people travelling abroad to hotspots. It is absolutely feasible to do this using both public and private laboratories. I hope the group we are addressing today will bring that message to NPHET. We need to get this implemented as quickly as possibly in our airports and, potentially, our ferry ports before we finish up in October with a complete surge and no ability to treat critically ill patients.

I thank the Deputy. His comments are noted.

I brought this up earlier and the witness mentioned that facilities for 100 beds are being built in Limerick at the moment. On 13 July some 56 patients were on trolleys in one area in University Hospital Limerick, UHL, with capacity for 20 patients. This number has increased to 40. Some patients are sitting on chairs with no social distancing and with staff exposed. The Irish Nurses and Midwives Organisation, INMO, has asked for an internal investigation.

We are opening 100 beds in Limerick, which is welcome. If one groups all the hospitals in the country into areas, why have we got such a high turnover of nursing staff and consultants within the hospital system? Do certain hospitals have a high turnover of staff? Are they leaving because of the conditions they are being forced to work in?

Mr. Liam Woods

First, staff turnover varies by type of staff. Consultant staff does not turn over at a very high rate. Nursing staff actually has a higher rate. The Deputy asked about the specific trends. There is definitely a trend from Dublin to the rest of the country, which is visible in both acute and community services. That is often about facilitating a return to a home base.

On the Deputy's comment in terms of Limerick specifically and his observation on trolleys, overall, paradoxically, trolley numbers in the country have been greatly reduced. They are at 86 today and would have been at more than 400 this time last year.

I am asking about Limerick specifically.

Mr. Liam Woods

There are specific challenges presenting in Limerick and one or two other sites. Regarding the query about the infection risk, one will find in many instances what is now counted as a trolley is, in fact, a single area sometimes equivalent to a room with a proper door and walls. The infection risk is being managed. The trolley is being counted in the same way as before but the environment and location is different. At times outpatient space is being used which, of course, is compromising our outpatient capacity.

Some patients are sitting on chairs. That is not a trolley, a bed or a room with a door. Why are numbers in Limerick always higher? Is it because it covers counties Tipperary, Clare and north Cork and Mr. Woods probably does not have adequate staff to do this?

Mr. Liam Woods

The region has a population of approximately 381,000. It is recognised, and was pre-Covid, that the bed capacity in Limerick is not sufficient to the demand.

The additional beds, including the 60-bed block, are intended to partly address that. Hospital capacity on its own will not be successful at that. We need significant additional investment - which is a part of what our winter planning process is about - in community services, general practitioner and GP support services.

The UL hospitals group has offered to help. This has to come from management. Is that not correct? The hospitals have offered to help with the overflow. This has to come from management.

Mr. Liam Woods

Yes.

Let us consider other hospitals and the management of other hospitals throughout the country. I asked this question in the Chamber earlier today. Are there certain areas of certain hospitals where we might have a small problem with management of the systems rather than the hospital itself? Might there be a problem around management and asking for help?

Mr. Liam Woods

In the University Limerick hospitals group there is a strong management focus on addressing the challenge. In fact, this is giving rise to the current investment with strong clinical input, as well as a general managerial input.

Deputy O'Donoghue asked whether the nature of management varies across the country. Of course at some level the answer is "Yes" but from our point of view there are certain key determinants. Let us consider the trend in Limerick over the period of Covid-19. Limerick was probably the only area in the country where there was little fall-off in attendance at the emergency department. This suggests a demand pattern, which Deputy O'Donoghue referred to earlier, in a way, that is putting the hospitals in the UL hospitals group under considerable strain. We have to continue to invest in and develop management throughout the country, but if one looks, one will find real demand and supply issues too. Sláintecare has been clear about that. It varies across the country.

What about the employment of consultants? I said this earlier but not in the Dáil. We have no Ehlers-Danlos syndrome consultant. For two years they have been looking to replace the Ehlers-Danlos syndrome consultant. When will we have one?

I have a second question. Perhaps Mr. Woods can answer both together. It relates to our personal protective equipment if we have another outbreak. I have brought this to the HSE and the Government. There is a company within Limerick that produces PPE. The company is in talks with the HSE about putting a machine into the factory. It would employ 40 extra jobs in Limerick and would be self-contained from a manufacturing point of view for PPE. Not only would it increase jobs but it would mean that we have a constant supply of PPE if there is another pandemic. It would mean the HSE would have PPE on a cost-neutral basis after three years. This has been on the table and has been brought to the Dáil and the HSE. It needs to happen now in case the pandemic happens. It needs to be put in place. It is a common-sense approach. It is all done within the Irish system, including the manufacturing. As all raw materials will be produced on site, we will never have to be without masks again, like we were before.

Mr. Liam Woods

I can revert to the committee with a response on the individual consultant post. I am not aware of the particular post.

Clearly, PPE is a matter of national concern and priority as is the desire that we would have some manufacturing base. While it is not specifically the role of the HSE, I understand that in the context of our industrial development promotion business in the country, it would make a great deal of sense to have domestic supply. We would certainly be interested in that. We do not, as an organisation, engage directly in funding or sponsoring commercial entities, but we have a strong interest in domestic supply in light of our recent history in accessing PPE. I understand dialogue is taking place in other areas nationally. The idea is to look at prioritising that as an area for development. Our procurement function, which has worked with domestic and international suppliers, is keen and will be part of that dialogue. I am not aware of the individual company but I will certainly refer the matter to our procurement people. I imagine they are aware of this.

Mr. Woods has said he will provide a written reply to Deputy O'Donoghue. The next speaker is Deputy Colm Burke.

I thank all the witnesses present today for taking the time to be here and for the work they have done over the past four months.

I will ask four questions because other members want to get in. First, what is the current advice on the wearing of masks to all staff working in hospitals? Are they required to wear masks at all times within the hospital premises? Second, according to the IMO presentation this morning, 160 specialist registrars, SpRs, have completed their training in full and not one of them has been offered a job. Can I get clarification on the reason there has not been engagement to employ them, especially when there are quite a number of vacancies across a range of specialties?

I raised my third question on forward planning three years ago. It concerns the number of consultants who will retire between 1 July 2020 and 1 July 2021. The old process was that jobs were advertised before the person retired. There are more than 3,000 consultants. That figure was increased by more than 1,000 in the past ten years but quite a number of consultants will retire over the next 12 months to two years. Is there forward planning in respect of consultants who are retiring?

My fourth question relates to the need for additional hospital space in Cork. We had the benefit of both the Bons Secours and the Mater private hospitals during the three-month takeover. What is the plan now? Cork University Hospital, CUH, could not deal with the volume of work it had even before the Covid-19 pandemic. The Mercy and the South Infirmary hospitals are under serious pressure. What additional space is being identified as suitable for setting up patient treatment in the Cork area? The consultants in CUH used the Mater private hospital to try to reduce the waiting list for gynaecological services and it worked very effectively. Can that be used in other areas whereby the consultants employed by the HSE would go into those hospitals and transfer people on their public lists with a view to doing particular day care procedures? What progress has been made on those issues?

Mr. Liam Woods

I thank the Deputy. I will take those questions in reverse order. In terms of capacity, we are looking to contract some continuation of access to private facilities both directly and through our working arrangements with the NTPF. We are looking to continue to some extent the kind of work the Deputy is referring to in terms of the private system over the three months to the end of June. That would support additional work. The South/South West hospital group has separately made proposals which will be incorporated into our winter planning approach relating to additional space that can come on in the short term in modular form across the group. That goes from Waterford over to Kerry, as the Deputy will be aware, but includes Cork. That will be considered in the coming weeks as part of our winter planning.

On the retirement of consultants and the national doctor training programme, we have information on approximate numbers of consultants who will retire at any point in time. I do not have that information here. The Deputy asked for a number up to July 2021. We might be able to return some information to him from the doctor training programme in that regard and perhaps from our HR in terms of a pension retirement view. That information is known. The intent of the Deputy's query was to ask if we can start recruiting prospectively to shorten the gap between a retirement and a new recruitment. That was a recommendation in a report that was done to accelerate consultant recruitment within the HSE by Professor Frank Keane so there is no reason that cannot take place. In fact, I have seen many instances where it does take place.

On the SpRs and the completed training, I understand dialogue has taken place and there is a strong desire to retain as many doctors as possible.

I will come back to the committee with further detail but it is our intention to retain as many as possible and work is under way to support such retention.

From this morning's session I understand that people who have completed their training in the past two months have not been offered contracts other than for locum work. There is no forward planning with regard to their full-time employment as consultants in any area.

Mr. Liam Woods

I hear the Deputy's comments. I will revert to him with regard to what is actually intended but I know there is a strong intention to retain trained clinical staff to face what the Deputy has rightly referred to as a very significant emerging challenge.

New infection prevention control guidance is about to issue. Once it is finalised, I would be more than happy to provide the committee with a copy. It relates to the wearing of masks within hospital environments. Masks are available for wearing extensively within hospital environments. I believe the Deputy asked whether they are worn in all areas. As I understand it, our latest guidance is that they should be worn in all treatment areas. There may be some areas of the hospital where the risk is not so great and masks may not always be worn in these areas. Substantively, however, they are worn-----

Care assistants, cleaning staff, nurses and doctors are not required to wear them when working on a ward.

Mr. Liam Woods

No, staff wear masks in all treatment areas. I was just saying that some areas are not treatment areas.

There appears to be some confusion about the requirements in some hospitals. People who are visiting hospitals and wearing masks arrive to find that not all staff are wearing masks. I have got a number of phone calls from different areas of Cork on that matter. Can that be clarified?

Mr. Liam Woods

I will certainly clarify that locally with the group. I will also make the guidance we have on infection prevention and control available to the committee.

I thank our witnesses for all of the information they have provided and for their commitments to follow up on some of the information requested. As an aside, I welcome the fact that some Independent Members are now joining Sinn Féin's call for a domestic supply of personal protective equipment to be made available. We were a bit of a lone voice in that regard so it is very nice to have a few people join us.

I have a couple of questions. I have been trying to keep up with what was happening but I had a meeting in the middle of the session so if my questions have already been answered I can check the record. I believe it was Mr. Woods who said that private providers were being sought for diagnostics. What kind of value for money audits are carried out when engaging private providers? Does the HSE check over the last time it did business with a provider and the value for money it achieved? Are there any processes in this regard within the contracts? Is there an automatic review? It is hard to calculate but how can the HSE be sure the private sector provides the kind of value for money people seem to think it does?

Mr. Liam Woods

In terms of value for money, our initial tender will clearly state what we require. That work is going on at the moment. The selection process will be about choosing the most economically advantageous tender response. From a value point of view, the evaluation is initially done at this point. We consider our views of the nature and quality of the service and the price.

Is it considered on a per item or per procedure basis or is it about obtaining a certain number of theatre hours or CT scan hours or a certain amount of diagnostic capacity? Is it a matter of a certain amount of money for a certain procedure, with a reduction if a certain amount is bought? I am confused about that. I have been looking at this for a while and it strikes me that not much value for money auditing, if any at all, is carried out. If it is carried out, that is very confusing. Will Mr. Woods talk me through that?

Mr. Liam Woods

I am saying that a tender is being put in place. We will have a decision to make at the beginning. The Deputy is asking what the unit of purchase is, whether clusters of product or so on. In areas such as that of radiology, the contract will most likely be set out by modality.

Other areas are MRI and CT and, perhaps, packages. It depends a little on how the market responds.

The Deputy also asked whether we ask what is the value of what we have previously acquired. This is something that will happen in the future with regard to this contract because we have not yet entered into it. From our point of view, we understand this in terms of the clinical outcomes, patients treated and the overall clinical benefit. From our perspective, the future value consideration will be about what work got done, what benefit it brought to patients and whether it supported the provision of GP diagnostics.

I am sorry, but when Mr. Woods says things such as that it will depend on how the market responds it does not fill me with a massive amount of confidence. The market responds by making as much money as the market can make and Mr. Woods knows that as well as I do.

The catch-up programme is something I raised with the previous Minister for Health on a number of occasions. We know there has been a lot of missed screening. We know exactly why this is and how necessary it was. Nobody was calling for screening services to be restarted at a stage when they simply could not have been restarted. We understood that. I checked the record before I came here and I never really got a satisfactory answer to the question I had put to the Minister on a number of occasions. There are a number of issues with regard to the catch-up programme that will be needed. If we take CervicalCheck as one example, we all know what happened when a commitment was given on tests without the capacity in the laboratories having been secured. We saw what happened there. I am sure nobody wants to go back to that. Has additional laboratory capacity been secured to be able to complete the catch-up programme? Has a target been set for the number of missed screenings that will take place before the end of the year? Does the HSE have a longer-term plan for catching up on screening? The figures from the Irish Cancer Society this morning with regard to missed cancers are very worrying. We all fully appreciate why screening could not take place but does the HSE have a catch-up programme in mind and has it secured the additional capacity in the laboratories that will be necessary to be able to deliver on it?

Mr. Damien McCallion

The Deputy has asked about CervicalCheck but she is right that the principles apply across each programme and each programme is quite different with regard to the solutions. CervicalCheck has restarted and a number of priority groups have been identified for the first round. More than 20,000 invitation letters were issued in the first month. The priorities are people on a one-year recall, people who are being recalled in the short term for a repeat test within three months and new women entering the programme for the first time. These are based on clinical risk determined by our clinical advisory group. Approximately 80,000 people will be called back in and they will all be processed between now and the end of the year. We are satisfied that we have the laboratory capacity in place. There are challenges with regard to general practice given the new public health guidelines on Covid, if it were to reoccur. We are monitoring each programme weekly with respect to uptake, what is coming through each programmes and where that leaves us.

There are challenges with regard to the public response. We are trying to put in place communication campaigns to support people coming back into the screening programmes where they have restarted and as they restart. We will have to review this regularly. Each programme is discrete. Earlier, my colleague, Professor O'Doherty, described the challenges BreastCheck faces, which are very different with regard to 2 m physical and social distancing. Each programme will have discrete challenges as we move through them.

CervicalCheck and our diabetic retinopathy screening programme have restarted. We have seen a reasonable uptake of diabetic retinopathy in the first month. It is very early days. CervicalCheck has been slow but it will take some time for it to come back. Pre-Covid, many women took some time from receiving the letter of invitation to taking up an appointment with their GP. There is often a gap in the process. This is something we will have to work through. As was alluded to by other speakers earlier, if we hit further surges or if there is further impact on general practice or clinical hospitals with regard to treatment services, this will also have an effect.

The 80,000 women who will receive a test will be additional to the normal 20,000 tests that fall due every month.

Presumably they are the women who would have had their smear test in the normal course of events if it was not for Covid. Does the HSE have the laboratory capacity for that? I had suggested an information campaign and I am glad that it was taken up. If they all respond between now and Christmas to that campaign, as we all hope that they do, will we be back to another situation where tests are left for such a long time that there is a danger they might expire? That happened previously. Has the additional laboratory capacity been sourced, notwithstanding that there might be a second wave which would change things? As things stand, has additional laboratory capacity been sourced to be able to do that catch-up?

Mr. Damien McCallion

This is a different set of circumstances from the situation that the Deputy referred to previously regarding cervical screening. We will need to monitor the take-up as we go. We can control some of that take-up and that is what we will try to do, with invitations and so on, to make sure that we align what is happening with invitations, general practice and also colposcopy, because treatment is equally important in ensuring that that space and access to that service is in place.

I am not certain that that answers my question but I will move on anyway.

There are 97 people on trolleys today. I have always used the INMO figures that track it and do not want to get into it with Mr. Woods. What is the status of additional capacity in the Arena in Limerick and in City West? I know there was talk earlier about using and creating modular capacity. For the capacity that we have already paid for, is there a plan to utilise the field hospital, as it is being called, in City West, or indeed the additional capacity in Limerick?

Mr. Liam Woods

The facility in Limerick is open and there are patients in the facility. If it is helpful, we can get a report on the volumes there.

Is the capacity 100?

Mr. Liam Woods

I believe so. I will confirm that. I will give the Deputy a report on it. There are two dimensions to City West but I think the Deputy is referring to the conference centre which is set up to receive patients, not the hotel. The conference centre will not open to receive patients. The contract with the HSE will end at the end of October. In the short term, we are looking to use the facility for some projects that relate to outpatients. There is a project coming from the Mater relating to glaucoma testing, which we will support in the facility until the end of October.

Has anyone ever been in the City West conference centre facility?

Mr. Liam Woods

Yes, I have been there.

Mr. Liam Woods

Sorry, I lost the Deputy there. Has there been an inpatient in the facility?

I am talking about sick people.

Mr. Liam Woods

Apologies. I was okay when I was there. No, it has not admitted patients.

How much are we paying for it?

Mr. Liam Woods

I would need our estates colleagues to give me data on that. I will have to send the Deputy a report on that.

It has been in the papers, which state that it is approximately €25 million.

Mr. Liam Woods

The price is inclusive of both the hotel and the conference centre, so they would need to be disaggregated.

Does the HSE have staff to work at it, if it is to be used? We are paying for it and there are 97 people on trolleys, so I can think of 97 people who might go there.

Mr. Liam Woods

The outpatient and glaucoma initiatives will be staffed by current staff within the hospital environment. Those proposals come with staffing reflected in them.

Are they staff already in the system who would be redeployed? Presumably Mr. Woods would be taking staff out of Tallaght if there are people on trolleys in Tallaght, and they would be moving to City West. There are no additional staff.

Mr. Liam Woods

The Deputy has reflected well on our capacity constraints. One of the key challenges is outpatients. It would be staff who are working in those areas but are now being afforded the opportunity to work in a capacity that may have been constrained at some level in the public hospital in which they are working. With regard to glaucoma, the proposal from the Mater foresees that up to 2,000 patients could be seen before the end of October.

There will not be any additional staff employed. Student nurses will graduate and presumably they will all get a contract of employment, but there is no additional recruitment or a plan to staff these. To provide staff for these centres will only remove staff who are already working in hospitals.

Mr. Liam Woods

That is correct for these proposals, which are short-term.

It is only until October.

Mr. Liam Woods

Yes.

Winter is coming.

I welcome our witnesses. I acknowledge the excellent work that has been done by the HSE and its staff, both administratively and medically. They have given huge support to people. The public perception of the HSE has changed significantly as a result of the way in which it has responded to the crisis. Its interventions in places such as Dealgan House nursing home in Dundalk have been hugely important. In terms of the HSE's plan for autumn and an unfortunate but probable return of Covid-19, what relationships has the HSE built with the private nursing homes?

Mr. Liam Woods

On the acute side, the infection prevention control teams and geriatricians within the public system have worked closely with private nursing homes and community colleagues to address the issues that arose. That support remains in place. The Deputy referred to an individual site but there are many instances where support was provided from community and hospital services to private nursing homes. I ask Ms McArdle to comment further.

Ms Siobhán McArdle

Nursing homes or residential care facilities for older persons, both private and public, in each community healthcare organisation area are treated equally in terms of levels of support. As Mr. Woods said, the supports for this cohort include the provision of PPE and advice on prevention and control. In recent weeks, we have been supporting all nursing homes, both private and public, in the provision of Covid-19 testing on a serial basis to ensure we are supporting the staff to remain well and healthy in the context of Covid-19 and to protect the health and well-being of the residents in that setting. We see the approach to all our nursing homes, particularly residents for whom these facilities are their home, as core to the way we deliver our services in the community. We do not really differentiate between them. They are treated equally in the advice they receive and in the Covid-19 response we are putting in place to ensure safe levels of care.

I welcome those responses. The HSE will spend €1 billion this year on PPE. What is the expected cost of PPE to the private nursing home sector and is the HSE charging the sector for its use of PPE?

Ms Siobhán McArdle

Approximately 30% of the PPE we provide across the health services is provided to nursing homes, both private and public, and that is provided without charge. The HSE provides that free of charge to support the staff to provide safe levels of care in that environment.

The standard is being provided when it is needed but people are paying €50,000 or €60,000 per year for their care in many of these homes. I agree on the medical issue and the need to provide PPE when nursing homes do not have it. However, the HSE should be charging the private nursing home sector for PPE because these homes are certainly charging their residents. I am unhappy that the HSE does not propose to do that. I welcome the HSE's significant engagement with the private nursing home sector.

On 1 January 2020, approximately 8,000 people were on the HSE's waiting list for home care. How many people are on that waiting list today? What are the most recent figures? I ask that in the context of the HSE's note indicating that it is seeking a substantial increase in home support hours in order to fully support patients at home, which I 100% support.

Ms Siobhán McArdle

Home support is a key part of our community provision to keep people well and safe at home and to support enhanced discharge from acute hospitals. I am not sure if I have the figure to hand. We have some waiting lists in some areas but not in every community healthcare organisation area. I will revert to the committee with an update on that but every effort is made to ensure that home support is provided to the highest level of need and to ensure the provision of intensive home care packages where required. These are higher levels of home support to make sure that people who have more complex needs are discharged from hospital quickly.

My experience is the opposite to what Ms McArdle just said. I do not accept that the number relating to the waiting list is not known. I do not mean it is not known to Ms McArdle personally. The waiting list has been growing significantly and the HSE has refused to supply to me the information I sought on the communications between CHO directors and the HSE head director of services for the elderly. There is a lack of transparency in that regard. Before we can understand how the HSE needs to address the future in terms of home care and Covid-19, we need a lot more transparency from the organisation, which I have not got. I have been frustrated at every turn. It concerns me when my constituents who, in many cases, have complex needs are not being made or are being met for only half an hour a day, which is impossible for people. While I welcome the initiative and what Ms McArdle had to say, I ask that she or one of her colleagues would release all of the information I sought. It was refused on the grounds that the communications formed part of the deliberate process of the HSE in the last financial year. I asked that the information be released at the end of that year and I was promised it would be released, but it was not.

It is important to point out that where home care is being provided there is a significant lack of development of Covid measures. I have discussed this with some of the organisations. Home care protects people much better than institutional care. Do the witnesses have figures on that? They are of huge importance and would support the argument being made. Where does the proposal for a statutory home care package stand in terms of calendar months?

Ms Siobhán McArdle

Home support is a core part of the service we provide in the community to people. In terms of the figures, at the end of April over 1.1 million hours of home support had been provided to people in their own homes across all parts of the country. This is in excess of 41,000 different people receiving home supports. Within that are people with low levels of home support and others with more advanced packages of support. There is a further group of people who receive intensive home care packages, the provision relating to which is in excess of 20 hours per week. Outside of the adult services, we also support home nursing and home care under our paediatric home care package, which is important for families in ensuring that children can transition to home safely and be provided with safe levels of care in that environment.

In terms of the statutory home care package, I am aware that it is under design. There is a lot of work being done by the HSE and our colleagues in the Department of Health in terms of advancing that package. It is a joint initiative. I do not have the details as to where it is at now but I can revert to the Deputy on the matter. My colleagues in the Department have further information.

I thank Ms McArdle for her reply. I am trying to understand how the money is given out through the CHO areas. It seems that in the area I live in, which is CHO 8, people in receipt of home care had to die before there were hours available for allocation to somebody else. This is unacceptable. I understand that the "recycling of hours", which, I understand, is the administrative term for it, was stopped because the CHO had gone over budget. At the start of the year a CHO has a budget. It is important in terms of how it uses that budget that people get the care that they need regardless of where they live or in what month of they year they apply for it. They are two serious and important issues for me.

Mr. Liam Woods

In terms of the waiting list data, the difficulty may relate to the reassignment of staff in the community to more a front-line purpose but I can check that. We should be able to get the waiting list data and make it available to the Deputy.

We have no intention to make lists invisible. In fact, the reverse is the case because we need to look clearly at the challenge we are facing.

Ms McArdle addressed the point about legislation, and Mr. Dempsey may have something to say about the statutory basis of home care packages from the point of view of the Department.

At a wider level, in terms of the resources required to respond to Covid-19 - and I understand the Deputy may also be referring to an earlier period - the HSE has spent significant resources to provide care at home, in acute environments and community care settings as best it can over the past number of months. The resources deployed have been well beyond what would have been experienced previously. We are anxious that the committee has the waiting list data and we commit to providing them. Mr. Dempsey may wish to comment on the statutory arrangements that might come into place.

Mr. Greg Dempsey

I thank Mr. Woods, and the Deputy for his question. The development of the statutory scheme is being led by the Department. Work is ongoing but has been delayed somewhat as the Department and the HSE have been responding to the Covid-19 crisis. Its development is slightly behind where we would have liked it to be. I will get a note to the committee on where we are and our expectations in that regard.

I would welcome a note but that is not much of an answer.

Was the Deputy refused access to the waiting list data because they were a part of the deliberative process?

I looked for data for the most recent projected period in 2019 and it was refused to me. I will tell the Chairman the full story.

I can hear the full story afterwards. I am anxious that we-----

The key point is that the HSE refused to give me the data even though there was no bar to giving them to me. That is what is wrong with the agency.

Mr. Woods has now said he will give the data to the committee.

I will await the data with bated breath.

I want to ask a couple of questions and Deputy Shortall wants to come back in. IMO representatives before the committee this morning called for a total vaccination programme. They said that 75% of the population would need to be vaccinated to achieve herd immunity. They explained what they meant by a total vaccination programme. It means that everybody has a vaccination that is free to them, although obviously someone would have to pay for it, namely, the State. They suggested two months ago that such a programme was necessary. Do I understand from what Mr. McCallion said that while there are plans to vaccinate two to 12 year olds and the elderly, there are no plans for a vaccination programme for the general population of people between those ages?

Mr. Damien McCallion

Adult vaccination applies to more than just the elderly. It also includes healthcare workers and other priority groups to which Ms McArdle referred. There are still constraints as to what will be available in the market. Work has been going on for some months and this is not something that kicks in around this time of the year; it starts almost as early as the end of the previous winter. The vaccine is only developed in the southern hemisphere during the winter. We have approximately 1.4 million doses of the vaccine for adults and 500,000 to 600,000 for children. That is the total number of vaccinations available and deals with the priority groups. As I said, it works on the basis of a 90% uptake in the adult population to whom it is made available.

Is "No" the hard answer to my question?

Mr. Damien McCallion

Pardon?

I have never taken a flu vaccine before but we live in extraordinary times. Can I take it that there are no plans to introduce a vaccination programme for ordinary people who are not healthcare workers, do not have an underlying condition, are not normally recommended to take the flu vaccine and are not children?

Mr. Damien McCallion

Target groups will be prioritised as we go into this winter. It is about targeting those who have the greatest need and are most at risk.

I will ask specifically. Are there no plans for a vaccination programme for the general population who are not in the target group?

Mr. Damien McCallion

Other than for those in the categories that Ms McArdle mentioned earlier.

Is "No" the answer to my question? There are no plans for a vaccination programme for the general population outside of the-----

Mr. Damien McCallion

That is so for the flu. The flu programme extends to the 1.4 million adults and 500,000 to 600,000 children that I mentioned earlier.

I sometimes wonder how it takes two minutes to answer one question. I sometimes wonder whether these meetings are exercises in information provision or obfuscation.

I am sorry to say that but it is sometimes difficult to get answers to simple questions. We have been told repeatedly that once the flu season kicks off, whether it will be in September or December this year, there is potential for catastrophe in our hospitals. Would you accept that?

Mr. Liam Woods

I will take that question. Yes, there is a fear that the hospital system could come under very severe pressure.

Notwithstanding that, there are no plans to vaccinate the general population.

Mr. Liam Woods

There are two points. First, it is our intention always to answer your questions clearly and concisely.

I appreciate that.

Mr. Liam Woods

If we do not have data we are very happy to provide it to you. Second, on the pressure that will come on the acute system, which may be partly influenced by flu and vaccine, there is a requirement for the committee, and I hear it from a number of members, to have a detailed public health briefing on the vaccination programme, its priorities and where we are going with that for this winter. To your wider question, the pressure that will come on the acute system associated with the ongoing known growth in demand for service for emergency care and Covid-19 and, potentially, flu - normally we see a precursor to that being respiratory infection in paediatrics - is a matter of very significant concern. It is a fair reflection to say that the burden the system is facing as we move into this winter is very concerning.

Is it hard to get flu vaccine? Is availability of flu vaccine a difficulty that the HSE faces?

Mr. Liam Woods

Our public health person with a specific interest in that would have to answer that question, but we will get that in a proper briefing for you.

Mr. McCallion seemed to indicate that there was. Could he elaborate a little? Is it difficult to get flu vaccine in unusually high quantities? I accept that 75% of the population would be three to four times the quantity the HSE would normally buy. Is flu vaccine typically unavailable in that quantity or is there a difficulty in sourcing it?

Mr. Damien McCallion

Yes, there are challenges every year with flu vaccines. Obviously, every country in the world is looking for it at the same time, and those challenges are exacerbated this year with regard to Covid-19.

Mr. Woods, you referred to specific challenges and demand patterns in Limerick. Could you elaborate on that? Limerick consistently has the highest numbers of people on trolleys and you mentioned demand patterns in the emergency department there.

Mr. Liam Woods

The bed capacity in Limerick vis-à-vis the population was what I referring to at one level. That was assessed and is known to be beneath what was required, which is the additional 100 beds we are referring to. Indeed, earlier developments in Limerick that have supported capacity such as the ICU, the ED, dialysis and the Leben Building have all been directed at growing and improving capacity. Clearly, there has been a demand and supply mismatch and those 100 beds will support addressing that.

However, I also said that hospital beds are not the solution in isolation in the health environment. In fact, excess focus on hospital beds as against community investment will lead to an ineffective situation. From our point of view, we must also focus on investing in community services around Limerick. The community intervention team that is working opposite the hospital there and out into the community is very successful. Supporting that and expanding community initiatives would be very useful. There are initiatives under way in Limerick and across the wider region out into Clare and in Nenagh relating to cataracts that are helping to support the health of the population without bringing patients into Limerick at all, and investing in more of that type of work in our model 2 hospitals in Ennis and Nenagh would be very useful. There are some outreach clinics running in primary care centres from Limerick and we need more of that to support GPs and to bring specialist consultant advice to GPs at local level without having to refer patients to the hospital base.

The previous Minister for Health accepted that there was a necessity for more outpatient procedures to be carried out in the model 2 hospitals, and you referred to that in the case of cataracts. Are there any other procedures in which there is an increase of provision in the model 2 hospitals?

Mr. Liam Woods

There are certainly areas of opportunity regarding work that could move. I will ask Dr. Rogers to give some examples, because some good work is going on in Roscommon hospital, for example, and that may be of interest. While it is outside of the University of Limerick region, it is interesting work.

Dr. Eamonn Rogers

This question has been asked several times, and in Roscommon one of the ways of getting capacity is to use the model 2 and model 3 hospitals. Cancer care is complex and must be maintained in the model 4 hospitals. Regarding diagnostics, however, there is a delay in diagnosis and treatment because of Covid-19. In Roscommon hospital, which is a model 2 hospital, over the past 18 months we have been taking blood in the urine - I will use my own area as an example - which has a high rate of cancer detection. It is a see-and-treat model on a walk-in basis in Roscommon. There are no outpatients.

The letter arrives and the patient goes directly to the hospital. Importantly, in these times of Covid-19, there is no waiting in waiting rooms and the patient has an X-ray procedure and a camera procedure on the same day. We have done nearly 700 patients, but I can report on up to 500 patients. We had a cancer detection rate of 10% within 26 days of the letter being received and 70% of patients were reassured on one visit. This is an important area when looking at capacity, and we should use the model 2 and model 3 hospitals much more in this regard. We have evidence and this can be rolled out to other model 2 and 3 three hospitals.

I would welcome that. The obvious follow-on question is whether there are similar plans to increase the capacity of the model 2 hospitals in Ennis, St. John's in Limerick and Nenagh hospital. I ask that in the specific context of Limerick being the most consistently overcrowded hospital in the State. If we are going to continue to channel the vast majority of patients from the mid-west region into the most overcrowded hospital during the Covid-19 crisis, that is a catastrophe waiting to happen and the clock is ticking.

Mr. Liam Woods

The answer is "Yes" to the Chair's question. We are considering specific proposals from the UL Group as part of our approach in the coming months and to the winter period. That approach will include things like the integrated care programme for older people, including projects to support older populations who stay at home and out of hospital. That is about investment in staff, including geriatricians, working cross-hospital and in the community. Other proposals involve surgical assessment and radiology. These are due to be considered in the next few weeks as part of our response to winter. There are proposals, therefore, to make more use of Nenagh and Ennis hospitals, and to support Dooradoyle and St. John's.

Deputy Shortall would like to come back in.

I share the Chair's frustration at not being able to get straight answers because earlier I had asked for an assurance that we were able to secure sufficient quantities of the flu vaccine and it is only in the past 15 minutes that Mr. McCallion has spoken of constraints in the market. Will he explain to us exactly what are those constraints? Is it a question of availability or of cost?

I put on the record again my serious concern regarding the HSE planning for only an additional 200,000 vaccines. In the context of the enormous pressures on the hospitals and the greatly reduced capacity, we simply cannot afford to have anything like the same number of people hospitalised this year as a result of the flu as we did last year, which was 4,300 people. We need an assurance at this point that the preparatory work has been done and that adequate quantities of the vaccine have been secured. Will Mr. McCallion explain, therefore, what the market constraints are, please?

Mr. Damien McCallion

There are two different aspects to this issue. Public health advice is what guides the roll out of the vaccination programme for adults and children. We can provide the Deputy with more detail from our public health people regarding how that programme was designed. What I was summarising for the Deputy earlier was that we have enough vaccine for 1.4 million adults and just over 500,000 children. That is the total capacity available and that is based on prioritisation from a public health perspective.

It is what guides the public vaccination programme for the flu season and is particularly targeted at groups who are at risk if they are hospitalised. It totally aligns with what the Deputy is describing.

I ask Mr. McCallion to wind back a little bit and clarify. He referred to the total available doses. Are we operating on the basis of the available total or the required total?

Mr. Damien McCallion

If I may differentiate, the public health advice guides the vaccination and what we purchase.

Does the figure of 1.4 million vaccines refer to the available total or the required total?

Mr. Damien McCallion

That is what we require for the adult vaccination programme for the winter from a public health perspective.

Could Mr. McCallion provide the detail on how that figure was calculated, given that it is a relatively small increase on last year's number?

Mr. Damien McCallion

We will get the Deputy a public health paper briefing on the rationale behind the vaccination programme and the numbers involved. All I was reflecting on when speaking to Deputy McNamara was that the market is still competitive.

I refer to the rationale behind the numbers the HSE is working towards.

Mr. Damien McCallion

We will provide that.

I ask Mr. McCallion again. Will he explain the market constraints on accessing or procuring the vaccines?

Mr. Damien McCallion

To be clear, I was saying that at the moment there is a global push for the flu vaccine due to Covid-19. That is all I was articulating. Separately from that, my point on public health is that we have clear guidance on the supply for the winter. We have secured 1.4 million doses and more than 500,000 doses for children. We will provide a detailed breakdown of the criteria that were used to draw up those numbers.

I am sorry. I am asking Mr. McCallion for the third time. Is 1.4 million vaccines the available total or the required total?

Mr. Damien McCallion

That is the figure which public health advice has indicated we need for this winter.

In that case, why was Mr. McCallion talking about market constraints?

Mr. Damien McCallion

Deputy McNamara asked whether there were challenges in the marketplace in regard to the vaccination. I was merely reflecting that there are challenges in the marketplace because of Covid-19.

What are those challenges?

Mr. Damien McCallion

Several countries are seeking the vaccine at the same time. That is a common problem.

Is there a shortage? Do we have a difficulty in securing adequate quantities?

Mr. Damien McCallion

We have defined the needs from the public health perspective and we will respond to the Deputy on that. I am not a public health physician. I am simply describing what we have secured at the moment on that basis. Ms McArdle has described the groups that are part of the flu vaccination programme. Separately, I have described the challenge that exists in the marketplace due to Covid-19, namely, that a large number of countries are looking to secure the vaccination at the same time and extra pressure is created by Covid-19.

The clear implication of what Mr. McCallion is saying by referencing market constraints is that we cannot procure sufficient quantities and we are limited in the amount we can procure.

In fairness, Mr. McCallion is saying that the public health advice that he and the HSE have received is that it is necessary to vaccinate children between the ages of two and 12 as well as other people who are deemed to be at high risk, namely, healthcare workers, the elderly, people with underlying conditions, etc. He said the necessary percentage equated to 1.5 million doses.

Mr. Damien McCallion

I was describing the uptake. We have accounted for the specific groups and the necessary percentage uptake. Regarding the challenges on the procurement side, I am articulating what we have seen in the market. I can provide the Deputy with a note summarising the distinction between the public health guidance on the vaccine, which we articulated earlier, and the availability of the vaccine in the marketplace.

I would like more clarity in a written reply.

The serious question is whether a vaccination programme beyond what has been described is necessary. I appreciate that this is a clinical-----

Mr. Damien McCallion

It is public health advice. I will not try to describe that.

Given the challenges Mr. McCallion has identified, which will emerge in the next six to 12 months, there is likely to be a cost. Has the HSE made a submission to the Government on the extra challenges and how they might best be met? For example, should the responses to them be funded by grants, loans raised under the European Union's €800 billion coronavirus recovery fund or some other source?

What plan exists to deal with the challenges ahead? Do we have a number of options? Has the Department sought Government provision for those options?

Mr. Greg Dempsey

I might have a stab at that. As the Deputy will be aware the Government has already provided over €2 billion to the Revised Estimates for health during the Covid crisis. At that stage we had indicated we would probably need further funding the longer Covid went on, to resume services and so forth. As part of the planning process for winter, that will culminate in a further request which we will then refer to the Department of Public Expenditure and Reform, either as part of the budget process or in advance of that, but probably as part of the budget process.

I thank all the witnesses for answering all the questions put today. We have gone slightly over time. I greatly appreciate the time they have taken to answer our questions.

The committee adjourned at 4.41 p.m. until 9 a.m. on Tuesday, 21 July 2020.