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Special Committee on Covid-19 Response debate -
Tuesday, 2 Jun 2020

Use of Private Hospitals (Resumed)

This is session 2 on the use of private hospitals. From the Department of Health, I welcome Mr. Jim Breslin, Secretary General, and Mr. Greg Dempsey, deputy secretary. They are appearing in committee room 1. From the HSE, I welcome Mr. Liam Woods, national director, acute operations, Ms Angela Fitzgerald, deputy national director, acute operations, and Dr. Vida Hamilton, national clinical adviser and group lead, acute operations.

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 they are directed by the committee to cease giving evidence in relation to a particular matter and continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or persons or entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the provisions in Standing Order 186 that the committee should also refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policies. While we expect witnesses to answer questions asked by the committee clearly and with candour, witnesses can and should expect to be treated fairly and with respect and consideration at all times, in accordance with the witness protocol.

I invite Mr Breslin to make his opening remarks.

Mr. Jim Breslin

I thank the Chair and members of the committee for the opportunity to discuss the arrangement made with private hospitals in response to the Covid-19 pandemic. I note that the committee, in its invitation, indicated it was particularly interested in the use of the capacity of the private hospitals and the impact on continuity of care and treatment of private patients. Before I address these specific issues, I remind members of the context within which the arrangement was rapidly put in place.

The arrangement was concluded at the end of March, at a time when epidemiological projections for the disease indicated we faced a surge in cases with the potential to overwhelm our health system. The European Centre for Disease Prevention and Control, ECDC, was clear that all European health systems faced such a risk at the time as we watched regions and countries struggling to manage. It was recognised that the HSE urgently needed additional acute hospital capacity to deal with the anticipated crisis and to protect other urgent time-critical emergency services.

On 16 March, the Government's action plan in response to Covid-19 identified the need to increase acute hospital capacity and so, on 30 March, following intense negotiation by the HSE and the Department, we reached agreement with the private hospitals. On that day, there were 111 patients with Covid-19 in intensive care units in our public hospitals. The figure had more than doubled over the previous week. The agreement, which has been laid before the Houses of the Oireachtas, gave the HSE immediate access to an additional 2,500 beds, over 100 of which were critical care beds, on a cost-only, open-book basis.

Thankfully, the public health measures adopted so assiduously by the public have meant that, so far, we have managed to suppress the virus and the anticipated surge has not occurred in the manner we all feared.

On 27 March, NPHET recommended a pause in all non-essential health services. This was for the purpose of freeing up capacity and reducing opportunity for the spread of the disease. As a result, during April there were up to 2,000 public beds vacant at any one time, which is unprecedented. The level of patients in private hospitals was initially modest. However, the arrangement allowed the HSE to transfer and thereby maintain critical essential services, such as cancer surgery and chemotherapy, cardiothoracic surgery and urgent cardiology procedures, as well as providing the assurance that extra capacity was available in the event that it was needed, which was the main objective of the arrangement initially. Since then, local co-operation between the public and private hospitals has supported an increase in utilisation and the latest figures show that inpatient bed utilisation across private hospitals is now at 48% capacity and 56% of critical care capacity. The resumption of routine scheduled care has commenced and the HSE is continuing to increase its utilisation of private hospitals for the remainder of the period of the current arrangement.

The committee has also highlighted the issue of continuity of care. Faced with the immediate prospect of a major peak in demand for hospital care, the Government mandated the HSE and the Department to procure 100% of the available private capacity for public patients. The agreement provided that all patients treated under the arrangement would be treated as public patients, with care provided based on clinical priority. The arrangement made explicit provision for continuity of care for patients who were either in the hospital at the inception of the arrangement or who required treatment during the course of the arrangement. Full-time private consultants were offered locum public-only contracts for the duration of the arrangement. Where a consultant accepted the contract, he or she would continue to treat the patient but as a public patient. Where the consultant did not accept the contract offered, the transfer of the care of that patient to another consultant at the point in his or her treatment plan he or she reached was to be facilitated. Implementation issues were encountered and more generally, the pause in non-essential health services, which was only lifted by NPHET on 5 May, has affected private patients as well as public.

The Department worked with the State Claims Agency to make available clinical indemnity to those consultants who have not agreed to the contract, such as those providing care for continuity of care reasons to private patients on a pro bono basis, subject to the agreement of the hospital concerned.

The arrangement with private hospitals was developed in very quick order in exceptional circumstances. It met its urgent objective of ensuring additional capacity was available in the event that the public system was overwhelmed and supported the maintenance of other urgent critical care such as cancer services. The public system faces ongoing challenges as we endeavour to resume operations in the context of Covid-19. The capacity within the private sector is an important feature of Ireland's healthcare infrastructure. It has a role to play in meeting the challenges we face in continuing to be prepared for any subsequent wave of the disease and for meeting ongoing healthcare needs. The Government is currently reviewing the current arrangement and as Deputies will be aware, on Friday, it announced that the current arrangement would cease at the end of June, and the Department and HSE were mandated to open negotiations with private hospitals to put an alternative arrangement in place.

Mr. Liam Woods

I thank the committee for the invitation to attend this meeting. I am joined by colleagues, Ms Angela Fitzgerald, Dr. Vida Hamilton and Mr. Ray Mitchell. I intend to go through a summary of the statement to allow time for questions. In March 2020, the Government approved a proposal from the Department of Health to allow for a formal partnership with private hospitals, which would make their facilities and capacity available to meet the challenges of the Covid-19 pandemic. This put more than 2,200 beds, approximately 8,000 staff, and a range of clinical facilities at the disposal of the public health service. A number of other countries have made similar arrangements, for example, the UK, Australia and Spain. By decision of the Government, the arrangement is now ending with a view to negotiating a new one going forward from the end of June.

The Government’s decision to acquire access to the total resources of the private hospital sector included a number of key principles. The private hospitals would operate on the basis of public-only work. The basis for funding the hospitals was to be through a cost recovery model. Private hospitals would focus initially, at least, on delivering time-dependent care. Private-only consultants associated with the 18 private hospitals were to be offered temporary consultant contracts for exclusively public work. The public hospital system will continue to operate under existing eligibility rules.

Clinical modelling exercises undertaken within the HSE in March 2020 regarding the expected demand for acute and critical care arising from the pandemic indicated that by mid-April we might possibly require up to 1,000 critical care beds and 2,000 additional inpatient beds to match peak demand. Existing public sector capacity was 250 critical care beds and 11,000 inpatient beds operating at close to 100% occupancy, with 650 unavailable due to delayed transfers of care. The timeline was pressing and the options available to ramp up short-term capability were limited. As a consequence, we secured the Government decision and agreement outlined above. On 27 March 2020, NPHET directed that "all non-essential surgery, health procedures and other non-essential services be postponed". As a result, all public and private hospitals curtailed their elective activity during April in the interests of patient safety and protecting capacity for surge requirements.

Approaches to boosting acute activity included stopping all non-urgent elective work, growing critical care capacity and acquiring private hospital capability. The experience to date has shown that private hospitals do not, generally speaking, employ the consultant specialists who work with them. They are served by either public appointment holders with private practice rights or by a group of "private-only" consultants who do not have public appointments. The number of private-only consultants is in the region of 550 and of these, 291 have taken up the offer of a public patient-only contract from HSE, a type A contract, and are treating public patients on the private sites.

A key concern identified was the imperative to ensure continuity of care for private patients. The HSE fully acknowledges this requirement and where there is a justifiable case based on continuity of care needs, we have agreed that private-only consultant rooms can be included in the initiative as a recoverable cost. The HSE agreed a range of measures to ensure continuity of care, including private patients who were in a course of treatment at the date of the arrangement commencing continuing in care; patients who were booked for procedures based upon clinical priority being admitted as public patients without charge; some consultants offering to provide care pro bono to ensure continuity of care; and both the HSE and individual consultants having a duty to ensure care continuity, which has occurred. Additionally, consultants from public hospitals provided care in the private hospital setting and indemnity was provided.

Until such time as there is a vaccine or cure for Covid-19, healthcare delivery will occur in a higher risk environment where outbreak and surge could occur at any time. The underlying capacity issue remains in the acute system. This is amplified by the need to manage in a Covid environment. The private hospital system is not the sole solution for the safe delivery of care in the Covid environment but it is the only immediate acute option that can help provide an occupancy of 80% delivering on the twin requirements of matching non-Covid demand and providing surge capacity for Covid-19.

Against this backdrop, our objectives remain as set out earlier. These are to provide a capacity reserve against surge pressures, to maintain essential service to non-Covid but time-dependent surgery and treatments, to ensure safe environments for both patients and staff and to address the extensive build-up of displaced work as soon as possible. Some of the innovation undertaken in the past two months will need to stay in place. Virtual clinics can support the delivery of up to 50% of outpatient appointments in some specialties, reducing the requirement for face-to-face appointments.

In summary, all the indications are that the pandemic will remain a significant shaper of health services in the medium term. The basic shortfall in acute capacity is a matter we must address, along with Covid-19.

I apologise but I must interrupt Mr. Woods in the interest of time. I appreciate he was giving us a summary.

Mr. Liam Woods

Thank you.

Members will have five or ten minutes for questions and responses from witnesses. We begin with Fine Gael members.

I extend my deepest sympathies to the families and those who have lost family members as a result of Covid-19. It is very important that we acknowledge the pain and suffering of all those people, whether they were in public or private hospitals or nursing homes. All the people working in those facilities have put their lives and health on the line. It is very sad that thousands of people have caught this illness because of their work and commitment to people with the virus.

The expectation at the beginning of this crisis was that at the peak, in the worst scenario, 120,000 people per day could have been diagnosed with Covid-19.

Was that the reason the Department of Health did the deal, which I fully supported, to take on 100% of the capacity of the private hospitals to deal with those potential patients if that apocalyptic number materialised?

Mr. Jim Breslin

Yes, very much so. It was not just that this was modelled. This was what we were actually seeing within our hospital services. I mentioned in the opening statement the figures for ICU. Within the space of a week, the number of people in ICU had doubled to 111. The deal was done at 111. Over the next ten days, which was still within the incubation period for the virus, that number went up to 160. We were on a trajectory that was going to see ICU capacity run out. Two things happened. We took public health measures - the entire country took them - and assiduously implemented them to interrupt the virus. That managed to dampen the slope of the curve we were facing but we also had to put contingency in place and the most immediate and available contingency was in the private hospitals. There were 100 critical care beds in private hospitals and over the space of a weekend officials in both the Department and the HSE, with the full support of the Private Hospitals Association, put together an agreement that allowed the public access to those facilities if Covid-19 took us to the place none of us wanted to go.

The actions the Department took were appropriate and fit for purpose if the worst that could ever happen did happen and that it was prudent and right that it did that. I want to make it exceptionally clear that I laud and support fully all the actions taken by the HSE and the Department of Health. That was acknowledged by everybody. The issue that arose here this morning was the spare capacity when that day did not come, thank God, due to the actions of the public, the health workers and all of us. When that did not happen, there was spare capacity in the public and private hospitals. As I understand it, on 27 March, NPHET made a recommendation that all non-urgent scheduled care be postponed both for safety reasons and to avoid the spread of Covid-19. In fact, a significant portion of the bed capacity that could otherwise have been used could not be used because of that directive. Is it fair to say that whatever issues are building up now in terms of backlogs, which are significant, are as a result of a medical opinion that the Department could not put patients into those beds? It was not the appropriate or proper thing to do.

Mr. Jim Breslin

We have to unravel two things that happened right at the same time. The underlying cause was the same but they were two completely separate things. Because of that exponential growth, NPHET took the public health advice that it would advise all non-essential healthcare services to pause. That included private healthcare. Public and private non-essential health services should pause. That was on 27 March and, on 30 March, the deal with the private hospitals was completed. NPHET made that decision for two reasons. The first was to ensure that we had space for the surge when it came but the second was in recognition that the spread of the virus within the community was such that there was a risk that bringing people in for non-essential healthcare would further spread the virus. Both public and private hospitals experienced that over the course of April. I mentioned in my opening statement that there were 2,000 beds vacant in public hospitals at one point, which is unprecedented. Undoubtedly, and there will be lessons to be learned for the next arrangement we enter into, there were complications in operationalising this arrangement. With 18 different hospital groups and more than 500 self-employed hospital consultants, there are many lessons to be learned but the biggest factor in the utilisation during the course of April and into the early part of May was that NPHET had not lifted the pause on non-essential healthcare during that period, which meant a lesser uptake of healthcare. In fact, when we surveyed the public during that period, 28% of people said that they delayed accessing healthcare during that period. We do not like that. We have tried to get the message across that they should seek healthcare but the public were naturally anxious about it, and both the public and private systems experienced that anxiety.

The charge made is that it was not value for money but it was there if it could be used.

That is the first point. The second one is that it was a value to the lives of all those people who could be put at risk if they caught the illness. That is why the criticism is misinformed in that respect.

The question I wish to ask Mr. Breslin is one which affected some of my constituents, that is, the contract consultants were asked to sign. I appreciate and support the fact all work was public work, whether in public or private hospitals, and the income the consultant received could not be greater than the public pay. The question that arose, and it is a key point that must change, was what if I was an experienced consultant who might have 3,000 patients, and who had always maintained them with my own secretary or PA and in my own rooms? It is fair to say Mr. Breslin needs to look at that again should we have a return of this evil virus. Mr. Breslin needs to be able to meet the real costs of a consultant who has to manage his or her caseload. One consultant told me that it was like an iceberg. The tip of the iceberg was those in hospital but all the other people were outside. One has to meet them regularly and look after communications, appointments, and staff. Does Mr. Breslin think he ought to reconsider that issue now so that in the future, a consultant would be recompensed for those real, tangible, provable, additional costs that do not apply in the public sector? A consultant in the public sector has the back up of the hospital, he or she has administrative staff and so on. Does Mr. Breslin think that is an issue everyone could work on constructively?

Mr. Jim Breslin

If one looks at the phases of this arrangement, I would see plan A as when the surge was imminent. I would see plan B as being when that surge did not materialise, and efforts by the HSE to ensure we got other priority work through those hospitals. Plan C is from last Friday and where we are going to enter into negotiations on a new arrangement. The Government told us that plan A should be public only. The rationale was that if we all had the virus were we going to have different access depending on whether we had private health insurance or not? A legitimate policy rationale was provided at that time, and that is the arrangement that was put in place.

When we moved from the surge into essential and more routine treatments, one of the issues that arose was continuity of care for private patients. We were still able to tell consultants that those patients can be treated, but as public patients. Consultants then asked what was the position with regard to those rooms that bear costs and that they have to fund. We put an arrangement in place with the HSE whereby if those rooms were needed for the purpose of continuity of care, it could enter an arrangement to pay for them and have the use of them. This was very much as we moved along from plan A to plan B.

Where we go next will be plan C, which will be different. It will have a stream of public funds going in, but it will also see the private health insurance money come into play with the protection that if we have a surge we are able to take over 100% capacity again.

These are all decisions that are being made in real time. I do not see it as an issue that one changes one's position as something changes in the environment one is dealing with. It was the right thing to do at every stage.

The question of IT was mentioned by one of the consultants in the mental health area. They do not have computers or technology. Can Mr. Breslin make sure that issue is addressed and does not continue to be the case?

Mr. Liam Woods

I will address the Deputy's question.

In terms of monitoring the work being done in private hospitals, the HSE with the support of the NTPF has put in a system for precisely that purpose. One of our early objectives was to record the work that was taking place. We have enabled and supported that with the implementation of a system. Were there to be other system requirements as we move this forward, of course we will address those in dialogue about the arrangements post-June.

Thank you, Mr. Woods. I will take Fianna Fáil now. Deputy Butler will be followed by Deputy Donnelly.

We all understand the rationale behind the decision to take over the private hospitals at the start of the Covid-19 pandemic, however, as a committee the onus is on us now to look at the Covid-19 response and learn as we face the possibilities of a second surge.

Mr. Woods referred to the fact there were 550 private-only consultants and that only 291 signed up. Many consultants who contacted me, and all the members of the committee, were disappointed that they were only offered a type A contract. Why was the option of a type B or a type C contract not offered?

Mr. Liam Woods

In the early stages of this, as the Secretary General said, the decision of Government was that there would be a singular response to what was a clear and pressing public demand, and that included a type A contract, which is a public-only contract. That is the contract the consultants I referred to signed up to. Signing it was voluntary of course, and a significant number of consultants chose not to do so. They had the capacity to continue their own outpatient practice outside of this arrangement.

I thank Mr. Woods.

Mr. Breslin referred to the fact there has been learning for the next arrangement. Was any consideration given to the long-standing patients currently undergoing treatment and being treated by private consultants, especially those who need regular consultation? We have all been contacted by many private patients. We know there are 2.2 million private patients in Ireland at the moment, and many of them felt they needed ongoing treatment during March, April and May. I accept that it was an unprecedented pandemic, but at the same time many of these patients felt that they were forgotten about. I know all the focus had to be on Covid, and we all accept that, but as Mr. Breslin said, when we are learning for the next arrangement, could more consideration be given to these patients, especially those with oncology issues?

Mr. Jim Breslin

In my opening statement I referred to implementation issues which are available to us in constructing the next arrangement, and that we would learn from that.

I wish to emphasise that from the outset continuity of care was a really important objective of all of the parties that sought to make this work. It was provided for in the heads of terms with the private hospitals in two respects. On the day we entered into the arrangement there were patients in the hospitals, and it was important they had continuity of care. There were also patients who were undergoing a treatment plan with a private consultant, and the arrangement in that case was twofold. The ideal situation was the private consultant signed up to the contract that was offered on an agreed basis, in which case he or she could continue to see all of his or her patients under the new arrangement. The only distinction was that he or she could not charge the patient a fee, but that patient would still get continuity of care, and 291 consultants signed up. In the event that a consultant did not, a patient might wish to stay with that consultant. However, if he or she wanted, for example, to be admitted to a private hospital, he or she would need to be admitted under the care of another consultant. This would be either an existing public consultant, or one of those who had signed up to the private arrangement, in which case the patient's continuity of care would be facilitated by a transfer at the point in the care that he or she was at - not going back to his or her GP and starting from scratch, but at that point in his or her care. Issues arose with that, but that was the clear objective we all sought to try to bring about.

I thank Mr. Breslin. We learned from the opening statements that between 44% and 50% of private hospital capacity was utilised over the last couple of months. We learned last Friday that the arrangement will not continue. Are there any plans by the Department or the HSE to utilise as much capacity as possible during the month of June to tackle some of the extensive waiting lists that are out there?

Mr. Liam Woods

As the opening statements indicated, the decision of NPHET was effective up until 5 May, and from that time we have been growing throughput in the private hospitals significantly. At this stage, in terms of day care, it is in fact at 150% occupancy, so that is 1.5 patients per day, and in terms of inpatient beds it is at 50% occupancy. We intend to continue to grow that, and as part of the dialogue around any new arrangement, we would look to ensure continuity in relation to that. There is a clear intent to get value in the month of June. We will also remain alert to the trends that emerge in terms of the R-nought statistic as we move into the following weeks, and hopefully that remains where it is at a very low level. We need, however, to be alert to the fact that should the data move it will place significant demand on the acute system again.

I thank Mr. Woods.

I would like to thank our witnesses. I will start with two questions. It was exactly the right decision at the start, but the secondary rationale, which was around maintaining capacity, has not worked at all. It should have been ended as soon as that became clear.

At the moment, we are essentially using public money to treat private patients in private hospitals by private consultants. My first question is: why are we not using the public money to treat public patients with the spare capacity and letting the insurance companies continue to pay for the ongoing work for private patients which is still happening anyway? My second question is: why was the contract not ended sooner? I understand the contract was up until the end of June but all contracts can be negotiated by agreement.

It was estimated this morning in this committee that the ongoing reduced capacity in the private system just for June will mean that about 10,000 men, women and children will not get surgery under general anaesthetic, public and private. This is an enormous human cost for continuing with a contract that we know is not working. Did the Department engage with the private providers to see if the contract could be wrapped up sooner, given that it is not doing what we all hoped it would do?

Mr. Jim Breslin

On the first question regarding private patients, I go back to where we started from, which is that all patients were considered public patients. That is the legal position. Every person in the country is entitled to be first and foremost a public patient. They get to opt out of that and waive their entitlement if they wish to but all people, including those with health insurance, are entitled to be public patients. The-----

That really does not answer the question. I do not think there are not too many private patients in the country looking to waive their private patient status in order that they can become public patients and not get any treatment. The question I ask is: why not let the private patients continue to be paid for by the insurance companies, which is what would have happened, leaving all of the money to be deployed for use exclusively with public patients?

Mr. Jim Breslin

What I was trying to go on to say was that that was the rationale of the arrangement I have called plan A, which was that of a single tier. Everybody in the situation of a pandemic would be treated based on clinical need and there would not be two streams of income going into the private hospitals, one from the public purse and one from private entities. The plan has changed and the Government on Friday opened up the possibility of us putting an arrangement in place where we would only pay for public patients.

I understand that. The question I am asking is: why? Mr. Breslin is restating what happened, which is everyone was to be treated as a public patient. I understand that. The question I am asking is: why? For people who get Covid, that decision makes perfect sense. For all of the ongoing treatment, however, if insurance firms are willing to pay for private patients - and perhaps they do not get priority during the crisis, I am all for that - why use public money to pay for non-Covid healthcare for private patients in private hospitals?

Mr. Jim Breslin

Let me try and give the Deputy further insight. There was the principle of the matter, which was that if we were facing the kind of overwhelming surge that was going to take place it should be public and single tier. There was also the practicality of the matter. None of us knew exactly what that would look like during the month of April. What was put in place was a cost-only reimbursement model, where the costs of the hospitals were reimbursed. The difficulty in that situation where one had cost recovery for all of the costs within a hospital of disaggregating how much of that was being incurred by private health insurers and private patients would have left us all with a situation where legitimate questions could be asked about whether the public money going in was benefiting public patients or cross-subsidising private patients who were continuing to have preferential access into what was now fully publicly funded facilities.

That might have been the concern people had but that is exactly what has happened. That is the entire point of my question. That became exactly what happened. Public money is being used. However, we are running out of time. Can I get an answer to my second question: did the Department engage with the hospitals to look at ending this earlier than June, given the vast human cost to keeping this contract in place?

Mr. Jim Breslin

I am not sure that the discussion this morning on the 10,000 fully appreciates how difficult it will be to bring either public or private facilities back up to normal levels. There is no doubt that there will be issues in terms of getting back to the activity levels we saw in the past, not just in the public system but also in the private system. I now turn to the Deputy's question as to whether that was done.

The options examined were whether there would be an extension until the end of August, which would allow those negotiations to take place across June, July or August, or whether the HSE would terminate the arrangement at the end of June, leaving us with the next four weeks to put in place an alternative arrangement that would continue to see public patients access those facilities.

To be clear, nobody asked the private hospitals if they would be willing to continue until the end of June?

We are at the end of Deputy Donnelly's time and I do not want him to take from Deputy Cullinane's time. Is Deputy Cullinane taking five or ten minutes?

I will take ten minutes. I welcome Mr. Woods and Mr. Breslin again. I thank them and the staff in the HSE, particularly those working in the acute hospitals, for their service. I send them my solidarity at this time.

I read Mr. Breslin's opening statement with interest. Does he have the all-in costs for the private hospital agreement? Is there a figure available for that cost?

Mr. Jim Breslin

Mr. Woods will have the figures. We have the cost up to the current-----

If we could have the cost first. I do not mean to be rude but if the cost is available, I would like to have it.

Mr. Jim Breslin

The Deputy can choose whether he wants the cost up to today or the projected cost to the end.

I would like both, please.

Mr. Liam Woods

The cost until the end of April was €97 million. The cost is based on what work is actually getting done, so it will vary slightly. It would appear it will be between €97 million and €100 million per month. Those are estimates, whereas the first cost is a validated figure.

Are we talking about a figure in the region of €300 million?

Mr. Liam Woods

Yes, that is right.

Did Mr. Breslin hear the testimony from the Irish Medical Organisation, IMO, and the Irish Hospital Consultants Association, IHCA, this morning? To paraphrase the IHCA, the agreement was a bad deal, bad value for money and there was no plan for underutilised capacity. Having read Mr. Breslin's opening statement and heard what he said, I presume he does not agree with that statement.

Mr. Jim Breslin

I do not agree with it.

Mr. Varley, the head of the IHCA, said, "the test of time has confirmed that the private hospital agreement, which is costing approximately €115 million per month, represents poor value for money from patient care and taxpayer perspectives". Again, I assume Mr. Breslin does not agree with that.

Mr. Jim Breslin

No. Can I tell the Deputy the reason?

We will get to that in a second. First, I assume Mr. Breslin does not agree with that statement?

Mr. Jim Breslin

No, I do not agree with it.

Mr. Varley then said "the private hospital contract is prohibiting the provision of urgent care required by patients with non-Covid illnesses". I have read Mr. Breslin's opening statement. He does not agree with that either.

Mr. Jim Breslin

No, I do not agree with that.

We will return to the nuts and bolts of the agreement and how it was negotiated. Who was involved in calculating the cost and negotiating the deal on the State side? I do not mean individuals, but what State actors - Departments and organisations - were part of the negotiation process?

Mr. Jim Breslin

The Government provided a mandate, a set of principles that would be used by the negotiators, and the HSE, with the support of the Department of Health, negotiated intensively with the Private Hospitals Association.

It was negotiated by the HSE and the Department of Health. Who carried out the cost-benefit analysis if there was one?

Mr. Jim Breslin

There was input from across Government. The NTMA New Economy and Recovery Authority, NewERA, gave us some input, and the Department and the HSE looked at it. We came up with a cost-recovery model rather than a fee-per-item model. Part of the thinking was that there was so much uncertainty looking into April as to what services would be required. Had we got it wrong, there could have been huge profits-----

Was a cost-benefit analysis carried out?

Mr. Jim Breslin

No, there was not a full cost-benefit analysis.

Mr. Jim Breslin

No, we did not have access to private hospital costs at that stage.

As the party negotiating with private hospitals, I would have assumed the HSE would have sought those figures. Why were they not available? When we get into the nuts and bolts, the fundamentals of this deal, it was with private hospitals. Mr. Breslin will know, as he and I have soldiered alongside one another on the Committee of Public Accounts, that the Comptroller and Auditor General will always say that a cost-benefit analysis is hugely important when taking big decisions that cost taxpayers a lot of money. There may well be a good reason that was not done, and Mr. Breslin can answer on that, but what he is saying is that, as part of this negotiation, no cost-benefit analysis was carried out.

Mr. Jim Breslin

No, there was an options appraisal. We looked at different means of securing this capacity. A full cost-benefit analysis would ask whether we really wanted the capacity. That question was answered for us because we were staring our need for that capacity in the face every night on the 9 o'clock news. The next question was what were the options for securing that capacity.

We did an option appraisal on the different types of options that might be needed-----

I get that, so there was not one carried out.

Mr. Jim Breslin

-----and what was-----

Could I ask if the Secretary General of the Department of Public Expenditure and Reform-----

Mr. Jim Breslin

If I could just finish, what was put in place then was a cost recovery model, where on an open-book basis the private hospitals have to produce their accounts to show that they have incurred the cost.

Mr. Breslin has said that three times. I accept that, but what I am-----

Mr. Jim Breslin

The costs are then met by the HSE, and it is open to the Comptroller and Auditor General to audit those costs, as well as the HSE's advisers.

Yes, that is the third time Mr. Breslin has said that. For the reason he outlined, there was no cost-benefit analysis, because, as he stated, the decision was made to do it, but there still could have been a cost-benefit analysis of sorts in terms of the fundamentals of the cost and I want to get to that.

Mr. Jim Breslin

Could I make one further point?

Before I get to that, I am sorry for interrupting, but could I ask whether the Secretary General of the Department of Public Expenditure and Reform signed off on the agreement?

Mr. Jim Breslin

I would like to answer the last question that I did not get to finish. This was negotiated within a matter of days, basically over a weekend, and that is an important factor. The Department of Public Expenditure and Reform was involved in the submission to the Government on this. It supported the access to these facilities and it supported the cost-recovery financial model that was used.

Did it sign off on it?

Mr. Jim Breslin

The Government signed off on it.

Did the Department of Public Expenditure and Reform sign off on it? Did the Secretary General of that Department play any role in signing off on this?

Mr. Jim Breslin

The Secretary General or a Department are not independent of the Government.

I know that. The national procurement agency is under that Department as well, and from other big projects where mistakes were made in the past, we know that the role of the Department of Public Expenditure and Reform is very important. All I am asking Mr. Breslin is whether that Department had a formal role in signing off on this process. If not, and it went straight to the Cabinet and it signed off on it, that is fine.

Mr. Jim Breslin

It did go straight to the Cabinet.

Mr. Jim Breslin

The Department of Public Expenditure and Reform gave us its advice on the financial model and we adopted it. The advice was consistent with our own thinking.

When Mr. Breslin was looking at this agreement, what percentage of capacity in private hospitals did he lock into the plan? What percentage capacity in private hospitals did he anticipate he would use over that three-month period?

Mr. Jim Breslin

That was the real uncertainty we faced. At the start we considered that we would probably need it all, and more besides.

It was not all used, possibly less than half was used.

Mr. Jim Breslin

If we had had the ICU admission rates that other countries have experienced, we would have needed it all.

In real time, is it correct to say that when Mr. Breslin was negotiating the deal it was on the basis that he anticipated using the full capacity in private hospitals?

Mr. Jim Breslin

We anticipated that we potentially might and we did not want to be in a situation where we did not have access to it.

When Mr. Breslin was negotiating the deal, did he look at a like-for-like cost analysis of a bed, for example, in a public hospital and a bed in a private hospital? In terms of this particular deal that was negotiated, what was the average cost of a bed in a private hospital in the context of the deal which we now know will cost €300 million, and what was the average cost of a bed in a public hospital?

Mr. Jim Breslin

We do have average costs for public hospitals and based on the information we have from the private hospitals, quite a number of them would be more expensive than public hospitals, so we are paying more in that situation.

But Mr. Breslin was negotiating the deal.

Mr. Jim Breslin

If the Deputy would give me a moment to answer, we did not have any other beds. We had all of the public beds that we needed. There were no other beds on the island that we could get access to, so getting it on a cost-only basis was the most economic thing for us to do. If there were cheaper beds out there, we could have got them, but there were not. These were the only beds that were available to us and we did it on a cost-only basis.

I should point out to Mr. Breslin that on many occasions it was pointed out to him by all of the organisations that were here this morning and by people outside of this room as well that there was not capacity in the public system and that we needed more beds in the public system. The very fact that Mr. Breslin had to go to private hospitals is testimony to the fact that we did not have capacity in the public system. If Mr. Breslin is negotiating a deal, he is coming up with a price. I worked in the car sales industry at one point and if I was selling a used car I would have loved to see people like Mr. Breslin coming through the door. What I am trying to establish from him is whether, when he was negotiating the price, he would have had an estimated cost of what a bed costs in a public hospital, as opposed to what the cost was going to be in terms of this deal for private hospitals.

Mr. Jim Breslin

Yes, I have told the Deputy that. We would have had-----

But the Secretary General did not give me the costs. What was the cost per bed, in terms of this deal in private hospitals compared to what it is in the public system?

Mr. Jim Breslin

We will not know that until we have all of the costs verified from the private hospitals. We are not paying them a fixed amount of money; we are paying them what they actually incur in terms of costs. The validation and verification process will be done by a team of accountants to come up with what that cost is.

I accept what Mr. Breslin said that these were the only beds available and it was the obvious place to go for them. I am long enough around to know from my time as a member of the Committee of Public Accounts, and time spent looking at what is transparent, what should be accountable and what is value for money, that it is important to do a cost-benefit analysis and have the fundamentals of a deal properly examined. It does not strike me that that happened on this occasion. Mr. Breslin has given what he sees as logical reasons why not but the fact is that the deal cost us €300 million. He said that he anticipated the full capacity would be used. However, less than half the capacity was used. I put to him again what was said by the Irish Hospital Consultants Association, IHCA, that this was not a good deal both in terms of patient care and taxpayer perspectives. It is hard to disagree with that given that there was no cost-benefit analysis and only less than 50% of the capacity was utilised.

Mr. Jim Breslin

To me, that sounds like a fire alarm went off and we sent four fire tenders to put out the fire and people are now saying we should have sent only three. I am very happy that we sent four fire tenders because what if it needed more than three.

I call Deputy Noonan and he has five minutes.

Now that elective surgeries have resumed and there will be a roadmap soon to outline the return to normality for healthcare services, it is important that both public and private open in tandem. Will the witnesses outline what elective services have resumed and give a breakdown of treatment as between private and public patients?

Mr. Liam Woods

The Deputy is right in saying that there is work going on in terms of a roadmap to recommence what were described as non-essential services, which are being resumed right now. In the public system there is a resumption of some activity. We have seen a significant fall-off in elective activity both by way of the decisions we have already spoken about and the public attitude to attending healthcare facilities. What we are resuming now is surgery such as orthopaedics. Rapid access cancer services continue to run and we are looking to grow the volumes through those. We have directly gone after growing the number of cardiology and stroke attendances because we have seen concern around that. General surgery, to the extent that we can resume it, is resuming. It is important to note, and it was referenced in dialogue, that the capacity to do work within the current environment is more restricted than it was before we had Covid, so our throughput capacities will be limited.

In terms of the private system, as referred to by the Deputy, the National Treatment Purchase Fund, NTPF, obviously has cases identified for priority treatment, and they can be and have been targeted through the private system. The private system is already doing cancer work for the public services. We had moved cancer work from the Mater Hospital and St. Vincent's University Hospital in Dublin. In Tralee, there is a joint roster working around key areas of provision in areas such as general respiratory care and rheumatology. We would anticipate that the caseload within the private system for surgery will also grow in the coming month contingent on what happens to the figures around the trend in the pandemic. The key point to get across is that the challenge of operating in both environments is very different from what it was if we go back three to four months.

Obviously it is not cost-effective to buy out private hospitals and consultants every time that there is a surge or another national medical emergency. What is the long-term plan to prepare for the next medical crisis?

Mr. Liam Woods

The next set of negotiations with the private hospitals, which are not the only response in capacity terms, and I can talk more about that, will be for a more medium-term view. We have to look at the coming winter, getting through that, the risks associated with Covid and flu being present and the demand on capacity, which we know is already constrained and, at the moment, is running at 92%. If we were to return all the work that is currently being done in the private system to the public system, that would immediately drive the public system toward 100%.

In terms of strategies, we have to continue some of some of the innovations that took place while Covid was very present with us, and it remains so in areas like outpatients and emergency departments, to reduce, in effect, the footfall in hospitals and grow the amount of work done in the community in primary care environments. That will include the provision of diagnostic and other services in the community. We are also looking at a range of activities in what will be referred to as intermediate care - care provision between the GP and the hospital.

They would very much be aligned with the kind of recommendations coming from the Sláintecare report. We are working to develop actively those kinds of arrangements right now.

I thank Mr. Woods. Is there a mechanism by which the HSE could transfer patients of consultants who did not sign the contract onto the public waiting list? What will happen to these patients when this deal is over?

Mr. Liam Woods

In the case of consultants who did not sign the contract, if there were patients who needed priority clinical care then that care was provided, very often by those consultants making arrangements with other consultants who had signed the contract. I have come across such cases. When the committee had the IHCA in this morning, it indicated that consultants acted in this way to ensure continuity of care.

Those patients who are already in treatment, in effect, will continue in treatment as a clinical priority. New private patients coming in will go onto a common waiting list by facility. That is the normal rule set within the system.

Have I time for a further question?

The Government says the deal is ending but if there is another surge, it is extremely likely the private hospitals will be needed again. What are Mr. Woods's recommendations for ensuring continuity of care of both public and private patients and continued operation of general operational services should this occur?

Mr. Liam Woods

The key challenge for us is the demand for emergency care through the emergency department, which is by far the largest element of demand for inpatient care within our system. What happens that demand as we move towards winter is the key determinant of that. We have had to constrain elective capacity for reasons arising from the pandemic and we have also seen a fall-off in emergency attendances. As they return, and they are returning - those figures are rising which is a good thing - we have to plan on the basis that we need to retain some empty space to allow for safe care provision within hospitals. When we look to the future - the Deputy asked what the recommendations around that are - we must say what we need to do and what we recommend to keep the system at an 80% occupancy across the full system-----

I thank Mr. Woods. I will have to move on to Deputy Shortall.

Mr. Liam Woods

-----and what is the best use of the full-----

Excuse me, Deputy Duncan Smith is quite correct.

No problem. I thank all the witnesses for their statements and contributions so far. I was taken with the penultimate page of Mr. Woods's opening statement, which states the HSE's "objectives remain as set out earlier; to provide a capacity reserve against surge pressures, to maintain essential service to non-COVID but time-dependent surgery and treatments, to ensure safe environments for both patients and staff and to address the extensive build-up of displaced work as soon as possible". Is it fair to say that the HSE would have liked to have seen this contract continue?

Mr. Liam Woods

As has previously been indicated, the contract was an emergency response to a rapidly emerging situation. It is right, as the Secretary General reflects, to think about phases. Flexibilities were deliberately included within the contract to allow for a review and a break at the end of June and further deliberation around that. From our point of view, it makes sense and we would welcome the renegotiation and working with the Private Hospitals Association around a renegotiated arrangement. It does not have to be precisely like this one but the capacity is clearly relevant as we move towards the winter.

The HSE essentially wants a renegotiated contract, a stronger contract. Although I do not want to put words in Mr. Woods's mouth, is he confident that as this contract runs down over the next few weeks, the pathways are there to use the capacity to a greater extent than it has been used thus far? How confident is he that the next contract will meet the needs of the HSE in terms of its relationship with the private hospitals?

Mr. Liam Woods

The occupancy has been growing, as I indicated in my opening statement and as the Deputy referred to. Since 5 May, when the NPHET decision was reversed, that has been a priority for us. The number of patients going through private facilities has been growing. We will look to continue that through to the end of June and, indeed, beyond based on a new arrangement.

The total requirement for healthcare is increasing. The Deputy knows that. That is clearly documented pre-Covid. Covid brings some new and urgent requirements around providing care. As we look forward in the HSE, we are looking at the winter. In any event, we are looking at a time period that goes beyond the end of August. We have got to look through to March next year and make sure we have plans in place to address what will happen over the coming winter.

Would the HSE be in favour of purchasing one or two private hospitals? Would that not be the quickest way to get more capacity in the public setting?

Has that been discussed? Has it been costed at any level by senior management in the HSE?

Mr. Liam Woods

I have not been party to any dialogue about the purchase of private hospitals. The fastest way for us to respond to the pandemic was to get access to use these hospitals, which was done through a cost-based arrangement, as was previously discussed. The notion of acquiring private hospitals was not part of our early discussions because time was not our friend in putting arrangements in place at the end of March.

Has any indication been given to the public as to when screening services will come back? Will they use the capacity available during the last few weeks of this current contract or will they form part of the renegotiation with the private hospitals for the next phase? Can any information be given to people who are looking for these services?

Mr. Liam Woods

They are not directly connected. The Deputy's point is well made. It is a priority for the HSE to recommence screening services but they are not tied into the hospital arrangement. There are other clinical priorities in respect of the return of screening. Our chief clinical officer has addressed these previously. Our priority is to make sure that it is safe to resume screening services but this is not tied into the private hospital arrangement. That is about planning services in the new Covid environment. The return of screening services is a priority for us.

Finally, what is the current status of the arrangement with Citywest Hotel? Is it being used to its full capacity? I know it is not a private hospital arrangement but it keeps cropping up.

Mr. Liam Woods

There are two dimensions to the Citywest arrangement. Accommodation is being provided for staff members and patients in the hotel. This accommodation is occupied. I do not have the level of occupancy in my head but it is occupied. Separately, the conference centre has been set up as a facility with more than 300 beds. This was put in place as surge capacity to meet what was then an unquantifiable demand as we moved towards the peak in the middle of April. At the moment, that facility is being closely studied with a view to opening it for clinical purposes associated with post-Covid treatment and rehabilitative care. We are also thinking about using the facility for outpatient treatment because the space required for outpatients in the future will be much greater than what we have, even with the heavy use of virtual clinics. More than 80,000 virtual appointments were completed in the month of April.

I thank Mr. Woods and the other witnesses. We are delighted that four fire engines were sent to deal with this crisis rather than three.

I join with Deputy Duncan Smith's comment with regard to fire engines. I thank the witnesses for their presentations. People have spoken about lessons learned. The bottom line in all of this is that our public health capacity is woefully inadequate. Responsibility for that is entirely political.

I have two questions. The first is for Mr. Woods and the second for Mr. Breslin. It has been possible to use capacity for non-Covid cases since 5 May. The HSE seems to have been very slow in ramping up the use of that capacity. I know there was some initial reluctance and people were concerned that a surge would arrive - and I am thankful it did not - but, at the same time, many procedures could have been carried out. I am referring to hip and knee procedures, for example. People could go in for two or three days and be back out. In the event of an increase in Covid cases, the hospitals could have been cleared very quickly. Why are we so slow in ramping this up? There are just over three weeks left to run in the current contract and there is still no roadmap. That is very hard to understand. There is very valuable capacity in private settings and, to a certain extent, in public settings. Why are we not maximising the use of this capacity? That is my question for Mr. Woods.

My second question is for Mr. Breslin. It relates to the future. Many of us would have liked to see the contract continue even up to the end of the year and the capacity be used fully. All Covid patients got immediate access. There was no distinction made between public patients and private patients. There is a strong case to be made for continuing with such an approach for non-Covid cases. Sláintecare talked about the importance of elective-only hospitals. That has been accepted by the Government. Has the Department of Health considered designating certain private hospitals as elective-only hospitals and, in this way, really motoring through elective surgery waiting lists and making progress very quickly?

Has the Department looked at the possibility of taking over those private hospitals on a longer-term basis, as has happened in Scotland?

Mr. Liam Woods

I will address the first question on capacity. Since 5 May the priority has been, as the Deputy has indicated, to use the capacity to the greatest extent possible. In day-case care, it has worked well with occupancy at 150%. On the inpatient side we are now at 54%. It is our intention to grow that. It has been growing, it has come from approximately 40% to 54%. We are seeing progress but would like to see more of that. One critical factor for effective use is the time it now takes to schedule a surgery and post surgery to ensure appropriate procedures are in place around infection prevention and control, which is having a significant impact on throughput. The time to operate, for example, is leading to places like the Mayo Clinic in the US having 60% occupancy. We are at 54%. Normally private hospitals run at around 75%. Our objective is still to push that occupancy figure as high as we can by using NTPF-referred work and by transferring work from the public to the private system, which I spoke about earlier. We will do everything we can in the coming weeks to optimise that. This will inform partly our dialogue around the new arrangements.

Mr. Jim Breslin

On the question about elective procedures only, and building on Mr. Woods's comments, under the new arrangement we would focus on elective. Some, such as cancer care relocations, would be separate but by and large we would focus on elective. I believe the meat of the question Deputy Shortall has asked relates to a project we have under way under Sláintecare, where we have fully mapped and assessed the needs of service delivery mechanisms that would say "Here is the service output we need for Dublin, Cork and Galway". We have also looked at other parts of the State but these are the three areas mentioned in the national development plan. We are now at the phase of moving that into a facility requirement. We will then put a cost on that facility, that is, were we to deliver an elective hospital at that scale for those services, what would be the facility required and what would it cost? Then we would get to the point of making a question to the market as to whether it would be a new build or a purchase. I am agnostic on that but it is important that we do the work over the next few weeks to get us to that point.

Will Mr. Breslin confirm that purchase is under consideration, or is on the table at least?

Mr. Jim Breslin

It will be one of the options, yes.

Would Mr. Breslin accept that we are caught on the horns of a major dilemma here, where one is damned if one does and damned if one does not, arising from the fact that on entering into this crisis we had woefully inadequate levels of capacity in intensive care units, ICU, beds, staff and consultants? That is the fundamental problem. It was unacceptable, on entering into the crisis, that we were already operating at near to 100% capacity, and were sometimes overwhelmed during flu season. On top of this, for the foreseeable future, there is an additional care need around a pandemic that could surge at any point in time. Unless we dramatically ramp up capacity we could be in deep trouble in the near future.

Mr. Jim Breslin

Broadly, I would, but we are all a bit Irish whereby having got through this, we look back and say "We must have been lucky". We were not lucky with the amount of capacity we have. We knew that we had less than the international norms of ICU. We also knew in other areas that we were short, and yet we got through it. It is worth asking how we have managed. It is the quality of the staff, the performance of people on the front line, and the absolute commitment that people have given to that, including those in the HSE and I might even mention the Department and the Oireachtas in that regard. We did manage to do something right.

I do not dispute that. We accept there is an unacceptably low level of capacity given the pre-existing challenges pre-Covid-19, and now with Covid-19.

As a sidebar, I will turn to the heroic work of our health workers.

Are the high infection rates in any way linked to the low staffing and capacity levels, which meant staff were overworked, working excessive hours and therefore exposed more to the virus? It seems to me that there is a connection. Some in this House have made it clear that they want to return essentially to the two-tier system and give the capacity back to the private health system. Is that not reckless in the extreme given that we could face surges in the near future? With the limited capacity we have, do we not at least require a totally integrated system rather than a fragmented one? That means keeping the private capacity under public control. I think that is what we must have. Has Mr. Breslin considered the outright nationalisation of the private hospitals rather than paying them rent of €110 million a month, which is clearly not very good value?

Mr. Jim Breslin

Certainly given that we do not have a vaccine for Covid-19, I think all of us would want to have step-in power or retainer over the private hospital capacity so that if we did get the kind of surge that we fear, we would be able to move quickly. We would also want to have access to the capacity for priority needs. I think the Deputy is bringing me into the policy space when he asks me about nationalisation. What I can say to him is that the Department of Health completed a bed capacity report which found that if we do all of the reforms that are in Sláintecare and all of the changes that we need to reform and modernise our healthcare services, we will need 2,500 beds. We have probably delivered about 500 of them since that report was completed. If we do not achieve that reform, we will need 7,000 beds. It is well known that we are short of capacity.

Fair enough. Given that we have to increase capacity, would it not be helpful if, for example, the Department did not have to negotiate with private hospitals but just had the capacity? Would that not be better? It would be better if we knew what was on their books, which we do not really know, in terms of the cost of beds. Would that not be better notwithstanding the need to ramp up capacity? One of our earlier witnesses, Professor Alan Irvine, suggested that we should be looking at local solutions to quickly ramp up capacity. Are we doing that? For example, there are two buildings of 17,000 sq. m near Merrion Gates called the Seamark buildings. They are sitting empty for the last five years, right beside St. Vincent's Hospital. When there is talk of setting up modular hospital beds, would we not be better going in and purchasing those blocks for increasing capacity on an emergency basis? That is just by way of example.

Mr. Jim Breslin

I do think it depends on the timeframe we are looking at. We talked earlier about the purchase of a hospital, if one has a year or two. We had days at the start of this arrangement and the quickest and easiest way was by agreement with the private hospitals, which thankfully we got and they came forward on that. The other options such as purchase, nationalisation and so on bring one into a much more convoluted policy development and legal process. Mr. Woods has talked about the bespoke solutions that are available at different sites in the public system, which we have been pursuing in parallel with this. I will not commit to making an offer on a building on the Merrion Road but each hospital is looking at its ability to surge and introduce new capacity as part of this.

I have a couple of comments for Mr. Breslin. In respect of his comments about four fire tenders being sent out and are we not glad that we sent them, I would agree with him but I would also say that pretty soon we discovered that two fire tenders had the fire under control. We could have sent those other tenders off to treat fires elsewhere. In other words, the under-capacity was recognised yet nothing was done about it. Mr. Breslin said earlier that a partnership arrangement was entered into with respect to the private hospitals and the consultants. I note that the IHCA wrote to the Department at the end of April outlining the capacity issues and the fact that there was between 20% and 30% capacity being used. What steps did the Department implement at that stage to try to recover some of the cost? What is at issue here is public money. This is what people are questioning, especially considering the timeframe we are now going into and the costs we are going to see as a result of all of this.

Mr. Varley outlined in committee earlier that he learned in the media that a type A contract was to be introduced for doctors. He also learned that indemnity insurance might be removed.

I am not sure that is a partnership arrangement I would want to enter into. Will Mr. Breslin give a response to that?

Mr. Jim Breslin

On the first question, as I said earlier, we moved rapidly through different plans. When we started off, a surge had to be planned for. When that did not materialise, the heads of terms had already provided for further, non-Covid activity that could take place in those private hospitals, and the focus of everybody's effort was to promote that. People keep forgetting, however, that between 27 March and 5 May, NPHET had said routine healthcare services should be paused. It was against that backdrop that we were working.

On utilisation and the IHCA, I will not speak for everybody in the room but I think we have, collectively, spent many weeks of hours trying to engage with the IHCA to try to find a way through that would unlock the commitment of private consultants, about 50% of whom signed up pretty readily but quite a number had significant concerns. We clarified at length, and while we were not in a position to give them what they were looking for, we certainly gave them clarification over a protracted period in the hope that as many of them as possible would come on board. It was a voluntary arrangement and more and more came on as it continued.

I am not sure whether there is an ideological block here. On 8 May, a letter from the State Claims Agency, signed by a gentleman with the initials "C.B.", instructed pathology labs not to process specimens unless the sending consultant had signed a type A contract. How does that fit into public healthcare and cover?

Mr. Jim Breslin

There are two points. That was in a situation where the public purse was paying for the full running costs of the facilities, and the person who signed the letter issued it on that basis. Within 24 hours, that was clarified and arrangements were put in place to facilitate that.

With respect to the payments, in the period of the three months the premium income that will have been paid over to private health insurers is approximately €700 million. The rebate that has come back is about €180 million. That is €520 million of moneys that could have been put into the private hospitals to take account of the efficiency that was there, aside from the fact that consultants were essentially blocked out. I am all in favour of a single-tier health service but the issue is with efficiency and costs. It has to be questioned how we put a contract in place for €115 million a month, yet we were working off bed capacity of 20% or 30% and elective capacity that fell way short of that, particularly in the early months.

Mr. Jim Breslin

I ask people to reflect on the fact that there was a public health restriction on the operation of our healthcare facilities. It is not the whole explanation but it is an important contextual factor for why all of our hospitals were not as busy as they are in normal times. People have associated the impact of that with the arrangement with the private hospitals. There is no doubt there were challenges in the arrangement. It involved 18 hospitals and more than 500 independent hospital consultants, and arrangements had to be made in each of those instances-----

Will Mr. Breslin give a commitment now, in this contract, to finding a way or mechanism to get all these doctors back in, in order that we can get maximum efficiency through both the public and private space?

Mr. Jim Breslin

We will work to a mandate the Government has provided to us, namely, that we will seek to put a retainer in place for capacity to surge if those facilities are needed and that we will put arrangements in place for particular cohorts of patients to be treated, but it will not require 100% of the facilities of the private hospitals. That is the policy mandate we have been given.

With respect, these are elective procedures.

I am sorry but Deputy Shanahan is out of time.

The private hospitals should be directed to give up their bed capacity within 48 hours, so we will not need to focus on this for months at a time.

I welcome our guests. Two months ago, on 1 April, the HSE took over all of our private hospitals in a bid to be prepared for a surge of Covid patients, as had happened in Italy, Spain and other countries throughout the world. While it was very important to put these contingency plans in place, thankfully they were not needed. As a result of the two-month shutdown of normal services, the HSE is now trying to cope with the thousands of patients on waiting lists whose appointments were cancelled due to Covid. The deal between the HSE and the private hospitals will not end until the end of June, by which time the waiting lists will have become longer. One Galway oncologist recently stated he had 60 cancer patients on a waiting list and 3,000 active cancer patients on his room list.

These, he said, were patients he had treated in the past who may be having a relapse during the shutdown period. This three-month delay has affected cancer patients, orthopaedic surgery and all routine elective inpatient day-case and outpatient procedures which were halted on 1 April to free up space for the feared spike in Covid patients. We are all well aware that delays in biopsies, early access and treatment are likely to have consequences for patients. This could mean loss of life. It is a serious issue for all cancer patients, be they public or private. All cervical screening has been paused in the past two months. Now we have a significant backlog which will not be cleared for months, maybe even years.

Why could laboratories not have processed these smear tests in tandem with the Covid testing, thus minimising the risk to women's lives through early detection?

Mr. Liam Woods

The laboratories in hospitals continued to operate and did perform tests. Were cancer tests required through, say, a rapid access clinic, they were happening. The point the Deputy is after is for screening which can give rise to tests. The screening had been paused. That was a real effect. As I said earlier, it is a priority to get that back and running in a safe way.

As I understand, private hospitals are lying idle while patients' appointments have been put on hold. In addition to that, patients were advised to stay at home which meant cancer patients missed treatments while oncologists' waiting lists grew longer. Several of my constituents told me that their appointments had been cancelled with no idea of when they are likely to be rescheduled. Now that the number of deaths from Covid has, thankfully, fallen significantly, as well as a dramatic fall in new Covid cases being recorded, will the private hospitals have to wait until the end of June before they start seeing patients again?

Mr. Liam Woods

No, they will not. Private hospitals are seeing patients now, as we discussed. I think the Deputy is referring specifically to delays in access to outpatients. I would remind him that half of all pure private consultants, of which it is estimated there are just under 600, are not part of the arrangement. They presumably are seeing their patients.

The other consultants who have signed into this arrangement can see their patients in the context of the heads of terms in place. Accordingly, there is not a reason why there is an incapacity to see patients. There is a disruptive effect of Covid, to which the Deputy has referred. That has had an impact, both on patients' own choices and on service provision in the recent period. As the Deputy rightly said, in the public system, where there are 3,200 consultants, our experience has been that there has been a significant fall-off in both outpatient and emergency department attendances. These are now, thankfully, returning to more normal numbers. The key point is that, in advance of this arrangement coming into place, there was a significant fall-off in both public and private systems as the impact of Covid came more into the public consciousness and impacted hospitals.

Of course, our priority is to use the remaining period of this arrangement and the wider public system, which has 11,000 inpatient beds within it, to provide the services that need to be provided. A major challenge for us, not just in cancer care but across all services, is to catch up with what have been growing demands for care, as well as a pent-up demand for access to outpatient and inpatient care.

That leads me to my next question.

Although the intention is to return to a full healthcare system as quickly as possible, it is fair to say we had extensive waiting lists in all our hospitals, both public and private, before the Covid crisis. Considering all the extra precautions which will inevitably have to be taken to ensure social distancing, along with safety measures to ensure patient and staff safety, what plan has the HSE proposed to deal with the enormous waiting list for all types of necessary procedures while ensuring the safety of all involved?

Mr. Liam Woods

It is important to return to a level of service provision, which probably will not be at the pre-Covid level but will be greater than we have seen in the past couple of months. The future of this arrangement with the Private Hospitals Association will also be important in terms of work being done. However, the workflow through the emergency departments, the biggest piece of inpatient work in the HSE, and what happens with that as we approach winter will be of critical concern. An environment in which we have capacity constraints - and as the Deputy indicated additional capacity constraints around safe practice in a time of Covid - is going to present a big challenge. The negotiations with the Private Hospitals Association, in accordance with the Government's decision, will be an important piece of that. There are other elements, to which I referred earlier, around intermediate care at which we are also looking.

I thank the witnesses for all their work to date, and I thank all the staff in our health service, including the HSE, for everything they have done. When I sit here, I sometimes think I live in a parallel world where some of the questions the witnesses are asked seem to be classic Monday-morning quarterbacking. I cannot imagine what situation this committee would be in today if the private hospitals had not been secured, and if capacity had not been secured and we had needed it. I fully support and acknowledge the deal done. It was the right thing to do at the right time. Tremendous credit is due to the witnesses for representing the State on its side of the argument. The private hospitals weighed in quickly enough to put the deal in place. It is easy now for some Deputies to say what they are saying. They seem to sit back and discard the extent of the achievement of the public, through its actions, in flattening the curve and preventing the circumstances we were rapidly heading towards, which were evident in Madrid and Milan. It does us a disservice as a committee not to acknowledge the type of work done.

I want to return to one or two points. The witnesses' fire brigades were well needed and well wanted. I would not send any of them away early; that risk should never be taken. The witnesses, particularly Mr Breslin, were asked a certain question on which they were not really given a chance to reply. The deal was called a bad deal. Mr Breslin said it is a good deal. Why is it a good deal?

Mr. Jim Breslin

It was primarily for the reason the Deputy just mentioned, that is, that it was contingent on our being overwhelmed and the view that we would have the capacity if overwhelmed. We will never be able to value that. Regarding the actual valuation and the cost–benefit analysis - I have done such analyses in my time – I do not know how a figure could be put on it. Capacity was the primary purpose of the deal. We moved to plan B when what was envisaged did not emerge. It is not that it did not emerge on 1 April but that it did not emerge over the course of April. We worked based on what had already been written into the heads of terms, namely, that we could prioritise other essential care and other non-Covid care. The HSE put arrangements in place to try to boost that. Getting that activity through was not easy because it was in circumstances of public health restrictions, nor was it easy because we had moved into an operational environment in the private hospitals that was completely new by comparison with anything the HSE was used to. We have, however, seen a steady use in the utilisation of the facilities.

That brings me to a point I want to make. I am so conscious of time. Obviously, people seem to have forgotten again that there was a pandemic raging. We were told we could not use our hospitals by NPHET. One cannot be blamed for adhering to public health advice. We need to be conscious of the fact that members of the public, including my family and others I know well, were choosing to avoid going to hospitals if they could. This was not based on good medical choice. We forget so quickly that at the stage we were at a few weeks ago, people would not have accessed a medical facility even if there had been all the capacity in the world because they were genuinely terrified. "Terrified" is the right word for it. Thankfully and gratefully, because of what is happening now in our country, a certain level of normality is returning, and we are seeing that capacity.

I agree that a cost–benefit analysis could not have been achieved when trying to do a deal so fast. Does the open cost Mr. Breslin has for the private hospitals reflect the capacity level at which they are being used?

Mr. Jim Breslin


In effect, therefore, we are getting good value for money in the deal. We can see what the costs are and we are paying for what we use. We are not actually paying more because they are at 50%, 30% or 20%; we are paying exactly the amount that relates to what we use. Indeed, if one ramped up capacity, would there not be a surge? I wish to understand this clearly. Are we paying for what we use?

Mr. Jim Breslin

Yes. We are paying actual costs. That is not me saying more activity could not have been pushed through and that it would not have been worthwhile. We were all looking to do that. However, what we are actually paying is the actual cost incurred. If a lower cost is incurred due to less activity, we pay less money across.

Regarding the new deal, I am interested in knowing Mr. Breslin's estimate if the private hospitals are working at a reasonable capacity - 75% of normal capacity or whatever.

If an emergency was declared due to a surge, what do the Department, HSE and State bodies think about how quickly private hospitals could be converted back to deal with the surge?

Mr. Jim Breslin

The quick answer is that it would take days. We will need to model it but it would take days because of how quickly exponential growth can take off and, secondly, because private hospitals would need to be decanted. One would not want patients in them. One would need to run that down over a number of days. I think it would take days rather than weeks.

I welcome the witnesses and thank them for coming. I acknowledge the superb work of our healthcare staff and the gratitude we owe to them. Without a doubt, it was the right decision at the right time to take over the private hospitals. We have to be honest and fair and say that. However, as time progressed, it was clear that the full capacity of private hospitals was not required. The decision has been taken to terminate that contract but there is an acknowledgement that a new contract will be required if, unfortunately, another surge occurs, although we hope it does not. Who will be party to the negotiations for that contract? We heard deep disappointment this morning and indeed an acknowledgement that it would have made the situation less fraught if the consultants were also around the table with the private hospitals to address that. Will the consultants be party to those negotiations? What timeframe do the witnesses envisage to complete those negotiations? I acknowledge that it was terminated last Friday.

Mr. Jim Breslin

On the State side, the HSE will be the contracting authority and the Departments of Health and Public Expenditure and Reform will participate in the negotiations. The negotiations will primarily be with the private hospitals. The National Treatment Purchase Fund has an arrangement to pay for the services of private hospitals. This was a novel situation where we were trying to convert private hospital consultants into public employees and there was a need to engage with them. We will engage with private hospital consultants but I envisage that the contract will be with private hospitals in this case. Regarding how long it will take, contact was made with the Private Hospitals Association on Friday. We have agreed to come back to it later this week with the type of proposal we might seek to bring forward. We would hope to have quick negotiations over the course of the next couple of weeks to try to conclude this in good time for the run into the end of June.

I thank Mr. Breslin. I appreciate that time was not on his side for negotiations previously. To my mind, it would make matters less fractious in future if consultants were part of the discussions from an early stage. I have a question relating to a point that was previously raised about the fact that no pathology specimens could be processed unless the sending consultant had signed a type A contract. I appreciate that Mr. Breslin says that was rescinded within 24 hours. Mr. Breslin suggested the motivation for that was financial. Will Mr. Breslin confirm that no patient was negatively impacted because of that original decision? Will he confirm that this will not arise going forward in the new contract, regardless of the financial or other implications? Is he in a position to tell us who actually directed that? Who made the decision in the first place?

Mr. Jim Breslin

I was not involved in the events that gave rise to that. If I get it wrong, maybe somebody here could clarify it for me. I do not see it occurring in the future because any future arrangement is unlikely to entail 100% control of those facilities, which means the private hospitals will still be able to do work outside of the arrangement with the HSE. Given that it was rescinded within 24 hours and it related to laboratory requests, I do not envisage that it had any significant impact beyond 24 hours of disruption. I cannot see how it could have interfered with a result.

I cannot see how that could have happened.

With respect to how it came about, much clarification was being sought in what was a complicated position around the extent to which clinical indemnity, which is a State insurance or indemnity scheme, covered certain aspects but did not cover other aspects. The communication that issued sought to clarify the matter but left one piece unresolved. When it was seen, it was addressed within 24 hours.

I have a final question. Both the witnesses indicate private hospitals are running at a much higher capacity now even in terms of operating theatres etc. Is that because public hospital theatres are also running at full capacity? Are they both running at almost full capacity at this stage or has some capacity in the public hospitals been stood down?

Mr. Liam Woods

The public system is returning to theatre activity but it is not yet at full capacity. The additional ICU beds that have been stood up in the public system are heavily dependent on theatre and nursing staff to sustain them. Part of the return to normal theatre will arise from being comfortable that ICU capacity that has been stood up on a temporary basis is safe to release.

I thank the witnesses and everybody involved for their ongoing work. We fully appreciate how difficult this is for everybody involved and we know the effort that has gone in to date and which continues. It is possible this could be taken as a given but it is still important to say it nonetheless.

My first question relates to the value-for-money element that is clearly absent from this entire exercise. There was no value-for-money analysis or cost-benefit analysis, from what I can gather. What kind of economic analysis was done? There must have been some. We were talking about spending a large amount of money and Mr. Breslin's Department has frequently had to answer in public about what is perceived by some as being a waste of public funds. Clearly some economic analysis must have been done on the level of money being spent. To what extent was economic analysis done, who conducted it and will the witnesses share the findings with us?

Mr. Jim Breslin

Different economic analyses were done and both the HSE and my Department did financial analyses. We took advice from NewERA, which is part of the National Treasury Management Agency. As we were dealing with the private sector and a commercial sector, we specifically went to NewERA to see what would be the approach. In each case we looked at different options for reimbursement mechanisms. For example, we could have used the National Treatment Purchase Fund schedule of fees but we chose a cost recovery model. Had we used the National Treatment Purchase Fund schedule, there would have been a very significant level of uncertainty because we were not able to specify in advance the schedule of services that we would need over the course of April. It was just too unpredictable. The model we went with, based on all that option appraisal, was the cost recovery model. The HSE has independent advisers in operating that model to validate and verify costs before final payments are made.

That is before final payment but I presume it is after the money has been spent.

Mr. Jim Breslin

The money is spent------

Will Mr. Breslin share that information?

Mr. Jim Breslin

Sorry, we were talking over each other. The money is advanced and a reckoning is done based on accounts, with a balancing payment then being due. I did not hear the Deputy's question.

We will not know the cost of this until long after this deal concludes. Is that right?

Mr. Jim Breslin

We will not know the final cost but the validated costs have come in below the estimates provided by the private hospitals. To that extent the figure has come in lower than initial estimates.

We still do not know the final costs, so the figure could be higher in the end.

Mr. Jim Breslin

I do not think that is likely.

We do not know that. Is it possible for Mr. Breslin to share the information in the economic analysis?

Mr. Jim Breslin

We can provide the analysis as long as there is no commercially sensitive element. I do not believe there is.

Okay. I heard the witnesses earlier compare this to making sure four fire tenders would be available.

If we wanted a complete picture, we could say the conditions were created in advance for the fire to get out of control. That is the reason all of the additional capacity was needed. We had that discussion with the representatives of doctors and consultants this morning. On 24 March, an announcement was made by the Minister for Health that capacity had been secured in the private hospital sector. However, the deal was not signed for another week, either on 31 March or 1 April. Who was involved in the negotiations during that week? Were only officials from the Department of Health and HSE involved or were officials from the Office of Government Procurement, OGP, involved as well?

Mr. Jim Breslin

It was the HSE and the Department of Health throughout that weekend. I think it was concluded on 30 March.

There were no officials from the OGP or the Department of Finance involved at that stage.

Mr. Jim Breslin

No. We had a mandate from Government and we had to get the approval of both the Minister for Health and the Minister for Public Expenditure and Reform for the final agreement.

Was a maximum price set at that stage, given that the announcement had been made? Reference was made earlier to whether this deal was good value for money, and I believe that is what people want to know. In making the announcement when the deal had not been concluded, the officials did not put themselves in a great position to do a deal that was good value for money. I say that notwithstanding that I and others welcomed the decision to make the additional capacity available. We all have a view on the reason that additional capacity was so desperately needed. Watching what was happening in Italy, we could see that our hospitals could very easily become overwhelmed given the conditions that had been created. Does Mr. Breslin believe he was hamstrung somewhat in the negotiations during that intervening week by the fact that the announcement had been made but the deal had not been done?

Mr. Jim Breslin

No, I do not. The private hospitals knew what we were seeking to achieve. There was no way we could have done this in secret. We could not say that we wanted immediate access to all of the facilities of the private hospitals in the State and for them not to know that was something that we really wanted.

I am not suggesting that it could have been done in secret. What I am suggesting is that going out to make an announcement before the actual deal was done would have hindered Mr. Breslin in getting good value for money. It has become very apparent that value for money was not an issue. We will not know the final cost of this, and I think that will be fairly worrying for many people.

With regard to-----

Mr. Jim Breslin

I am sorry but I ask the Acting Chairman that if statements are made that speak to the bona fides of the people here, we get an opportunity to answer the question that the Deputy put again to me, namely, that we had no interest in or did not put a priority on value for money.

That is how it seems to me.

Mr. Jim Breslin

I reject that plainly. We were using the resources of the State for the most valuable thing we could possibly do, which was to prevent people needing to access our healthcare services and not having hospitals available to them. I stand over the decisions that were made.

When it became apparent that a lot of money would be paid for capacity that would not be required, which is a testament to the work done by the general public and the fantastic work done by healthcare workers, and that that capacity, and cognisant, as I am sure Mr. Breslin is every day of the week, of the hundreds of thousands of people who are on waiting lists, was any plan B put in place? I am specifically referring to the period between the announcement and the signing of the deal. In that week, was any consideration given to the possibility that we might not use all of the capacity and making a plan B available to ensure it was utilised? This morning, representatives of doctors and consultants were very clear in their belief that there was no plan B and that the plan was only to secure the capacity but not necessarily to make full use of it? Was any thought given to a plan B in terms of us not using the capacity?

Mr. Jim Breslin

Yes. The heads of terms have been laid before the Oireachtas and they outline the different usage to be made of the facilities. Even before the agreement was reached, part of that was a plan B, that if the facilities were not needed for Covid-19, they would be used for other purposes. That was the priority. In parallel with having them on stand-by for Covid, we would also use them for other purposes. The one-----

With respect, that is not a plan. That is-----

Mr. Jim Breslin

Could I finish, please?

-----a statement about how to use the capacity. A plan would detail what it was to be used for, and I did not see that in the heads.

Mr. Jim Breslin

I think there is a problem in that when I am finishing the reply I am hearing the Deputy and I am not able to respond.

I am conscious of the time.

Mr. Jim Breslin

It is written into the agreement. The HSE could speak to the operationalisation of that and the different cohorts that were identified, both essential care and more routine care, but within the context that NPHET had issued its advice on 27 March that routine treatment was to be paused.

I respect and I am aware of that. However, that advice did not remain in place for the duration of this and it is not in place now. What preparatory work was done to ensure that the best use could be made of that capacity for which the taxpayer is paying very dearly? I will say again, and this is my opinion, that the plan was only to get the capacity but not to make the maximum use of it. I would have thought, given the fact there are hundreds of thousands of people on waiting lists, as I am sure Mr. Breslin, Mr. Woods and others are conscious, that some thought would have been given to a plan with dates, procedures, etc. It strikes me that was not done and we will exit this and enter into the post-Covid healthcare world in the same, if not a worse, situation in terms of our waiting lists and with the capacity constrained by virtue of the fact that physical distancing will apply. It is going to make it even less likely those procedures will be done, and those lists will be even longer. It does strike me as a missed opportunity.

Mr. Liam Woods

In terms of her observations on waiting lists generally, the Deputy is correct. We have seen significant growth in the time of Covid-19.

With regard to the heads of terms, it has been referenced already that there was a provision, which has been exercised, to undertake work that is non-Covid related. There are detailed interactions with each of the private hospitals around that and the National Treatment Purchase Fund, NTPF, as I referenced earlier, has also played a role in identifying patients who are currently on waiting lists and can be treated. The challenge for us, as the Deputy has rightly identified, is to do as much as we can between now and the end of June and negotiate an arrangement going forward that allows us to provide appropriate care.

Thank you, Mr. Woods and Mr. Breslin. Deputy Burke has five minutes.

I thank each of the witnesses for their presentations and the work they have done over what has been a very difficult four months.

The impression being given by some members is that today we could tell the private hospitals we want all their beds and tomorrow we could tell them that we are sorry, we do not need them. It is wrong that this kind of impression is being given out, and Mr. Breslin might clarify this, because my understanding is that the agreement was made for three months but plan B set out that if this epidemic lasted longer, the agreement could be extended further. Am I correct in saying that?

Mr. Jim Breslin

The HSE had the option to extend it by a further two months that it could exercise unilaterally, so that would have been five months. Thereafter it would have been extended voluntarily, so we have an agreement now that it is at the minimum. The Government decision is that we will end it after the three-month period.

As part of the agreement, my understanding is that if Mr. Breslin wanted it to end after the three-month period, he would have to give a month's notice, which has now been given. Am I correct in saying that?

Mr. Jim Breslin

Yes, we gave the notice required which will see it finish at the end of June. That is what we could do under the contract.

In other words, it is incorrect to give the impression, which some people seem to be trying to do, that this was just dreamed up overnight and there was actually quite a careful plan put in place.

Mr. Jim Breslin

There were a number of successive elements built into the plan. One was in respect of the termination provisions, which were in favour of the HSE. It could decide to extend or it could terminate, so having that available to the HSE unilaterally in this situation was a good thing to have and we have exercised it. The second element was the type of services to be provided, which was also at the discretion of the HSE. It was set out in the common purpose of the agreement but the HSE itself could make the referrals over to the private hospitals.

I will move on to the issue of using the facilities for the next four weeks. We had an example in Cork where, more than 12 months ago, we had a particular problem on access to gynaecological services. We had more than 4,500 people on a waiting list, and a lot of these were day care procedures.

Have we identified any list at this stage with regard to particular areas where we can use the private hospital facilities over the next four weeks and get the maximum use of it? Is there a plan in place for the next four weeks for dealing with that?

Mr. Liam Woods

Yes, there is. We are looking to grow the occupancy as best we can to do that. As I said earlier, at the moment we are doing cancer work in hospitals and we have done cardiovascular work and gastroenterology work and transplant work has been undertaken in one hospital. There is a plan to do significant work. With specific reference to gynaecology list in County Cork, there is a strong focus on that. As the Deputy knows, much good work was done in the last 12 months on addressing that list, and there will be a focus on that in the next three to four week period.

To go back to the other issue in relation to elective hospitals, we have identified clearly that there is a need to build three elective hospitals and that has been identified for some time. In Cork there is much land owned by the HSE. Sarsfieldscourt is a site that could be immediately fast-tracked. Is there any plan at this stage to look again at fast-tracking that, now that we are going to have difficulties trying to keep the same capacity for dealing with procedures in our existing hospitals? We now need to urgently look at what we can do in a very short time period.

Mr. Liam Woods

Work is already under way, as I think the Deputy is aware, looking at potential sites in Cork. Sarsfieldscourt in Glanmire is one site owned by the HSE which could form part of that consideration, and there are others. There is a process under way with a view to----

Have we timelines and, if so, can we bring forward those timelines?

Mr. Liam Woods

There are timelines. I do not have them with me, but there is a process under way already, specifically in Cork.

In view of what has now occurred and given that the population of Cork has increased by more than 120,000 over the last number of years - it has gone from about 410,000 to 542,000 and it is growing - can we now bring forward those timelines? We had to take over two private hospitals, the Bon Secours and the Mater Private, in order to deal with this coronavirus.

Mr. Liam Woods

Yes, absolutely. I would emphasise, however, that before Covid-19 there was already a clear programme in Cork, and that should continue, and should conclude as quickly as possible.

Can we get an idea of timelines?

Mr. Liam Woods

If I can return to the committee with that, I will do so.


Given the difficult times in respect of some of our nursing homes, do we have a difficulty moving people out of hospitals? How many beds are currently occupied by people who really should be in step-down facilities? How fast can we deal with that issue in order to create the capacity for procedures patients now require?

Mr. Liam Woods

On delayed transfers of care, at the moment the number is around 400 in the acute system. It has gone up from a low of just over 200, if we go back a few weeks. That is an issue we are working on. It is not all nursing home-related and some of that will be for home care or other specialist care, but that is a factor in the system at the moment. Work is under way with a view to ensuring we move patients to appropriate locations of care as quickly as possible.

Can we get deadlines for bringing it back down to where it was?

Mr. Liam Woods

That is an ongoing piece of work because each week the system will produce a further 130 or so people who need to be discharged to a care environment or a home environment with support. There is a project under way with regard to managing delayed transfers of care, and in terms of the Deputy's information request-----

We have gone way over but we had extra time. I see we have another speaker. I call Deputy McGuinness.

I want to point out to Mr. Breslin that the last time he appeared before the committee, a number of questions were asked, and a commitment was given that we would receive a reply in writing. To my understanding that has not happened to date. Some of the very same questions were asked again today. Will he give us a commitment that the questions from the last day at least will be answered?

Mr. Jim Breslin

The procedure is-----

I know the procedure.

Mr. Jim Breslin

The procedure is that the secretariat writes to me as Secretary General, and I think I got the letter on a Thursday with ten days to respond, which would have been the following Friday.

It would have saved a lot of time today, had those questions been answered. Earlier on, Mr. Breslin asked a question about-----

Mr. Jim Breslin

I was going to reply to the Deputy's-----

---- the State Claims Agency, and the fact that the letter had informed those concerned that if the consultant had not signed the type A contract, the tests would not be processed. Mr. Breslin says that was fixed up in 48 hours but it does bring about a situation where there is a growing mistrust between the consultants and the Department. That was reflected again in the context of the contract itself. Some consultants wrote to us and told us that the type B contract would have cost far less than the type A contract and done the same job. I cannot ignore these comments from consultants but I am not pointing a finger at Mr. Breslin or the HSE. I am simply saying there is a staggering contradiction in terms of the witnesses as they present to us and how they understand what has happened.

The consultants' representatives this morning informed the committee that they had written to the HSE and the Department of Health regarding the contract and how matters were progressing and they had received no written reply. They told us that there were 600 consulting rooms in place and the officials ignored all of this. I am not saying they are right and Mr. Breslin is wrong. I am simply saying that is what was said.

To Mr. Woods I point out that a witness this morning highlighted the serious difficulties relating to telemedicine and dealing with those affected by mental health issues. In a separate letter from a consultant, they talk about the serious mental health issues and the well-being of patients now emerging from Covid-19 and the need for a direct one-to-one consultation. They are telling us that telemedicine will not work.

Another witness this morning told us that the system of technology being used is abysmal. He said that if we went back to - I do not know whether he said the 1800s - that we would probably have the same thing in place, recording matters by manually entering the information. That contradicts what Mr. Woods said earlier. There are a number of other contradictions. Why has such a difference emerged? If the parties were close together, moving towards taking charge of the private hospitals and if they understood what was going on, there would have been a greater and more significant cross-use in terms of public and private healthcare.

Finally, we were told this morning that 1 million patients have been affected by the cancellation of appointments and procedures.

Mr. Jim Breslin

I think all of us had extensive engagement with the IHCA throughout this period. I remember walking up and down my kitchen on a Sunday morning talking extensively to the general secretary of the IHCA. Throughout weekends and late at night a range of different officials were dealing with the association. We had protracted engagement. We were giving clarifications to them. That does not mean that we were agreeing with the IHCA but there was no lack of engagement from us trying to get to solutions. It is important to recognise that we were working within the policy parameters set by Government. One of those parameters was that there would be no private practice; it would be public only. There would be no private fee arrangements over this period. When the IHCA were looking for a type-B contract, they would have understood, though it may not be commonly known, that such a contract would have entitled them to private fees for treating patients. That was contrary to the mandate we had been given and to the heads of terms that had been concluded with the Private Hospitals Association.

Would Mr. Woods like to comment on the issue of mental health? That is a concern.

Mr. Liam Woods

In terms of use of telemedicine, first, we had more than 80,000 consultations using telemedicine in April. I acknowledge that is a significant mechanism to provide services to people who would not otherwise have received such service.

I also acknowledge that it would be broadly acknowledged that a first consultation typically would not take place using telemedicine, in other words electronically, but it would be quite routine in other jurisdictions that further consultations can and do. There are excellent systems for that. The HSE has those systems and they are in use.

The Deputy made a point about 1 million patients affected------

Would Mr. Woods not accept what the consultants said to us this morning, namely, that is simply not the case and the technology now in place is abysmal? I am citing the consultant.

Mr. Liam Woods

There is a diversion of views. Because we are close together does not mean that we agree. We were very close together for quite a while. In fairness, the reference to technology to which the Deputy referred is about recording patients as they attend. A system has gone in, through the NTPF, to private hospitals to support that, as the private hospitals themselves have a variety of systems and we have to depend on what is there given the short timescales.

Another point I should touch on is that the suggestion that 1 million patients are impacted seems excessive. There is an impact in outpatients in the public system, where 3,200 consultants are working. We can see there is a loss of appointments of about 150,000 in April. From our perspective, that is significant and we must catch up on that. I accept the Deputy was reflecting what was represented to him but it sounds to me, bar seeing more detailed information, that the figure is excessive.

Cancer screening was stopped across the country and is still suspended. Some private doctors who did not sign the type A contract continued to carry out screenings in their rooms. They were told on a Friday afternoon that they would no longer be indemnified by the State Claims Agency in respect of those. In effect, they were prevented from carrying out any colposcopies or other screenings. Who made that decision?

Mr. Jim Breslin

I dealt with that earlier. I was not involved in the individual incidents but within 24 hours, a clarification was issued. The State Claims Agency was seeking to clarify the extent to which clinical indemnity was covering the various activities under this undertaking and sought to put clarity in respect of that. It dealt with that issue but very quickly, the agency rescinded that and clarified that it would be covered.

It was a just lack of clarity rather than a decision.

Mr. Jim Breslin

It was an unfortunate issue but it was rectified.

I compliment the Acting Chairman's on this session. It was very efficiently run.

Much better than usual.

I wish to take the opportunity to thank everyone and to thank the witnesses, not just for their attendance today and the preparation for it, but for all the work they have done over this period. The exceptional work and commitment to public service epitomises public service values, has been extraordinary and they have worked extraordinarily hard. If I never got to say anything else on this, I would just want to say this to the witnesses and to thank them. Mr. Breslin and I worked together a very long time ago and I know very well that often, the level of work that goes on behind the scenes in Departments is not always reflected in public.

I wish to ask about the sequence. It is worth remembering, as it seems that we have moved on collectively very quickly from the terrible situation which we faced at the outset. There was a global pandemic with numbers rising, ICU admissions were rising and there was evidence from other countries of ICU capacity being overwhelmed. That would have resulted in exceptionally difficult decisions. It was on that basis that the decision was made to take over the private hospitals.

Mr. Jim Breslin

Yes. Earlier, I gave figures of a doubling of ICU capacity. Given that we are not well endowed with ICU capacity, had that continued at that rate, we would have exhausted our ICU capacity within a week to ten days.

Mr. Breslin said that a decision was made very quickly in respect to private hospitals; in a matter of days. Can he give us a sense of how quickly? What sort of period did he have to make that decision?

Mr. Jim Breslin

At Government, the date that was used earlier was 24 March, and by 30 March, the agreement was in place and patients were being admitted under the agreement into private hospitals.

At the same time, NPHET had suspended - if that is the correct term - general access to the hospitals in order to try to reduce community transmission and infection within hospitals.

Mr. Jim Breslin

We were dealing with the same issue, which is that we were looking at a surge, but we were using different remedies. One was to try to flatten the curve and stop the surge, but we knew that even if we were successful, there was a lag in the incubation period. Meanwhile, we were trying to put the capacity in place for the surge. The fact that the first strategy worked meant we did not need as much in the second, but they were both valuable strategies.

As a representative, the queries I was getting in the first instance related to whether people could get access to treatment, and that got resolved pretty quickly. People were getting access, for example, to injections to the eye - I do not want to get the term wrong - or continuing cancer treatment. Now the questions are about getting access to ongoing diagnostic tests. I am sure Mr. Breslin is aware of that pressure as well. What people are really looking for is that sense of a plan over the coming months. I know Mr. Breslin will be working on it.

We were talking about consultations and the opportunity to do virtual consultations. I was talking about it to Children's Health Ireland earlier. It was talking about parents doing videos, sending those in as consultations and doing a certain amount of diagnostic work, and only then would they have to attend for bloods or other things. There is a great opportunity for innovation at this time as well.

I thank the witnesses for attending and for their work. We will suspend until 4.30 p.m. when we will meet the Department of Foreign Affairs and Trade, the Department of Health, and the National Transport Authority on the issue of travel restrictions.

Sitting suspended at 4 p.m. and resumed at 4.30 p.m.
Deputy Michael McNamara resumed the Chair.