Chapter 15 - Development of Primary Care Centres

Mr. Paul Reid(Chief Executive Officer of the Health Service Executive) called and examined.

We are joined by the Comptroller and Auditor General, Mr. Seamus McCarthy, who is a permanent witness to the committee, and by Ms Ruth Foley, deputy director of audit, at the Office of the Comptroller and Auditor General. We are meeting the HSE to discuss the accounts of the public service for 2018 and, in particular, chapter 15 of the Comptroller and Auditor General's report, which deals with the development of primary care centres. We made the decision a number of weeks ago, in the interests of time, to try to limit our consideration today to certain key topics because the HSE was here in July just before the summer recess and we discussed its 2018 financial statements at that stage. Given that the HSE is here to discuss chapter 15 of the Comptroller and Auditor General's report, we decided to add a few other items for discussion as follows: an update on measures to reduce incidents of clinical negligence that may lead to state claims, which is an ongoing topic; an update on matters related to oversight of section 38 and section 39 organisations and practice in issuing advance funding to such organisations; private ambulance contracts and; home support services. Those matters were mentioned by the members as being of interest this afternoon.

We are joined by Mr. Paul Reid, chief executive officer; Ms Anne O'Connor, chief operations officer; Mr. Dean Sullivan, chief safety officer; Mr. Stephen Mulvany, chief financial officer; and Mr. Ray Mitchell, parliamentary affairs division, HSE. We are also joined by Mr. Fergal Goodman, head of primary care division; and Mr. Andy Conlon, principal officer, primary care, Department of Health.

I remind members, witnesses and those in the Public Gallery that all mobile phones must be switched off.

I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, 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, persons or entity by name or in such a way as to make him, her or it identifiable.

While we expect witnesses to answer questions clearly and with candour, they can and should expect to be treated fairly and with respect at all times, in accordance with the witness protocol.

I call the Comptroller and Auditor General, Mr. Seamus McCarthy, to give his opening statement.

Mr. Seamus McCarthy

Since 2001, a key strategic objective of the Department of Health has been the establishment of a comprehensive national network of primary care centres, PCCs, in approximately 350 locations, providing accessible accommodation to support the delivery of care by approximately 500 primary care teams. We previously examined and reported on the progress made by the Department and the HSE in delivering the network up to 2010. I felt it was appropriate, after a further eight years, to revisit the issue and provide a further update, and have done so in chapter 15 of my report.

Apologies, I left a file outside. I ask Deputy Aylward to take the Chair while I collect some files from my office. I will be back in a moment.

Deputy Bobby Aylward took the Chair.

Mr. Seamus McCarthy

The HSE reports that, as of March 2019, there were 127 operational PCCs in Ireland. In simple numeric terms, this is just over one third of the network originally envisaged. A target timeframe for the delivery of the centres has not been set. If delivery continues at the current rate, it is estimated that it will take at least a further 20 years to develop the full network.

We sought information from the HSE on the size of the existing centres, the staff deployed to each, the nature of the services provided, the procurement method and the cost. This type of information was not available centrally, so information relating to the premises and their procurement was compiled manually from multiple sources across the HSE. We could not get a clear picture of the range of services offered.

A key finding that emerged is that there is currently no formal definition of a primary care centre in terms of the core services to be accommodated. The HSE currently defines a PCC in very broad terms which encompass pre-existing and new buildings, stand-alone centres and centres co-located with other services such as community hospitals. The absence of a clear definition of what constitutes a primary care centre hinders meaningful tracking and reporting of progress.

In 2011, the HSE carried out a detailed assessment, which identified 297 potential locations for delivery of PCCs, in addition to the 43 operating at the end of 2010. The HSE ranked all 340 locations in order of priority for delivery or development, based on assessments of local service need, existing infrastructure and the level of deprivation in the catchment area. That ranking has not been revisited by the HSE since 2012, despite significant changes in population and economic conditions.

Some 27 PCCs were brought into operation in 2011 and 2012. Following the HSE’s location ranking exercise, a further 57 centres were delivered between 2013 and March 2019, but the delivery of these centres has not followed the ranked order of priority. As a result, almost half of the 50 locations ranked with highest priority in 2012 were recorded in March 2019 as being at "early planning" stage, or had no indication of progress in the delivery of a centre.

The HSE has used three main models for procurement of the centres delivered since 2013, namely, direct commissioning of a building by the HSE; long-term leasing from local developers and-or investors; and a public private partnership, PPP, to build and make available a bundle of 14 care centres on HSE-owned sites. The various delivery models have very different cost structures, making any comparison of the costs and benefits of each option difficult. Given the volume of delivery over the past five years or so, it would be opportune for the HSE to undertake a formal cost-effectiveness comparison of the different procurement methods.

The original model outlined for primary care delivery envisaged that each PCC would accommodate one or more core primary care teams, supported by a wider network of health and social care professionals, as outlined in figure 15.1 of this chapter of the report. However, as the HSE does not currently have an integrated reporting system, specific information is not available on the number and mix of teams in each operational centre, the numbers of filled and vacant posts, or the types of services being provided by the teams. For the purposes of this examination, the HSE reported that, as of July 2019, there were 421 primary care teams in place, of which only about 56% had direct GP involvement. As shown in figure 15.13, most community healthcare organisation, CHO, areas do not have the planned number of primary care teams. Only Dublin north CHO has the target number of teams with GP involvement.

The report makes four recommendations in regard to the management and monitoring of the development of primary care centres. These recommendations have been accepted by the Department of Health and the HSE, which will be able to provide members with an update on their implementation.

Deputy Seán Fleming resumed the Chair.

I thank Mr. McCarthy. We have received Mr. Reid's opening statement.

Mr. Paul Reid

Before I read the statement, I wish to note one correction to it, which was an error on my behalf. The submitted statement makes reference to 341 locations, but that figure should be 340. That was corrected by the Comptroller and Auditor General yesterday. I apologise for that.

I thank the Chairman and members of the committee for the invitation to attend today’s meeting to discuss chapter 15 of the Comptroller and Auditor General's 2018 report. The senior management colleagues joining me today are Ms Anne O’Connor, chief operations officer; Mr. Dean Sullivan, chief strategy officer; and Mr. Stephen Mulvany, chief financial officer. I am also joined by Mr. Jim Curran, our head of estates, who has stayed on from this morning's session. We submitted information and documentation to the committee in advance of the meeting and so I will confine my opening remarks to a few specific issues.

I will first give a financial overview of the situation. A key priority for the HSE is maximising the provision of safe services to the people we serve, while operating within the funding provided to us. This continues to be a significant challenge due to the ever-increasing level of demand on our services, which is influenced by factors such as a growing population with an ageing demographic, changes in technology and clinical practice, and ongoing societal and economic change. We have continued our intensive focus on current year financial management and financial planning for 2020. Senior managers across the organisation have been engaging with us regarding activity and expenditure and the related challenges of operating within available resources.

The latest financial position, as of September 2019, shows a variance from budget, including first charge, of €319 million or 3%. Of this, 37%, or €119 million, relates to our operational service areas. The comparable figure for the same period in 2018 was almost 100% higher at €636 million of which 80%, or €507 million, was in the operational service areas. Pension and demand-led areas account for €200 million of the variance as of September 2019. The greatest cost pressures within our operational services relate to the provision of residential placements to people with an intellectual disability and the provision of specialised emergency care within acute hospital settings, particularly in the context of an ageing population with increasingly complex needs. The costs within our pensions and demand-led areas are mostly driven by policy, legislation, demographics and the macroeconomic environment and are not generally amenable to normal in-year financial management. State Claims Agency reimbursements also fall within this area and there is a significant and ongoing focus on mitigating, insofar as is practical, the underlying risks which give rise to claims.

My monthly financial management meetings with community healthcare organisation, CHO, chief officers and hospital group CEOs will continue to year end. All areas are clear about their allocated financial limits and performance expectations up to year end to mitigate, insofar as is practical, any deviations from those limits, thereby reducing the extent of any challenge to be dealt with in 2020.

The discipline of these monthly financial meetings will continue throughout 2020.

A key focus for ongoing financial management efforts have been on improving compliance with our pay and staffing controls, including whole-time equivalents, agency and overtime. Although staffing levels will increase again in 2019, any increases must be managed in a way that is both planned and affordable. This necessary adjustment to the controls on pay and staffing is proving difficult but it must become part of our normal way of working. I acknowledge that this is a challenging process but the board of the HSE and I are committed to ensuring that there is an improved culture of delivery within the funding provided by the State. I fully believe that doing this will put us in a stronger position to secure investment for the future, which will ultimately be in the best interest of our service users and their families.

The HSE national service plan for 2020 was adopted by the board on 4 November and submitted to the Minister for consideration. The approval process is well advanced with correspondence having been received from him and replied to within the past week. I expect the plan will be published within the next week or so.

The HSE welcomes the publication of the Comptroller and Auditor General’s report on primary care centres. I note that the four recommendations in the report have been accepted and will be implemented in consultation with the Department of Health and in line with the Sláintecare plan. The development of PCCs to accommodate the HSE primary care teams and GPs in the one location is a key enabler for the delivery of primary care services. A number of years ago the primary care division of the HSE, in conjunction with HSE estates, identified 341 locations for primary care centres. In 2012, these locations were prioritised on the basis of service need, existing facilities and level of deprivation. The most suitable delivery model of the primary care centre was also identified.

The three models used for the development of PCCs are as follows: Exchequer-funded development, capital plan; PPP, the Government stimulus programme; and the operational lease. Of the 341 locations identified during the 2012 prioritisation process, 127 locations are now operational. A further 77 primary care centres are in the process of being developed. Taken together, this represents 204 or 60% of the original 340 locations identified. The HSE, in 2020, will complete an overarching review of PCCs that will include an update of the rankings of the proposed locations, and a determination of how further delivery is to be prioritised. This review will help us better understand how PCCs are currently used. It will also allow us to review the characteristics of these facilities to identify the most effective service models.

The review will consider the utilisation of centres and how this would increase as services in the community are expanded, commencing with the Sláintecare investment of €10 million that will increase to €60 million. This will result in to 1,000 additional front-line staff employed in community services. This work will also insure an integrated system among key HSE stakeholders, and a consistent process for coding primary care teams across the networks and CHOs.

Between January and September this year, the HSE provided almost 13 million hours of home support nationally, with an expenditure of more than €320 million. This service provides essential supports to more than 50,000 people to either remain at home or assist with their discharge from hospital. Demand for this service continues to outstrip funding levels and at the end of September, 7,667 people nationally were assessed as requiring new or additional services. The HSE winter plan will continue to support this service by allocating an additional 600 home care packages, targeted at both acute hospital and community waiting lists.

Regarding sections 38 and 39 organisations, the HSE recognises and supports the essential work of the voluntary sector in providing health and social services. We wish to strengthen and deepen the ongoing dialogue between our organisation and the voluntary sector, in line with the recommendations of the Day report. We acknowledge that a number of voluntary organisations are facing difficult challenges, including financial challenges. Various factors may contribute to expenditure exceeding the funding level set out in the annual service agreement signed with the HSE, and any overruns arising require careful analysis of the specific causal factors lest they undermine budgetary discipline within the overall health sector. In the first instance, dealing with any in-year or accumulated historic financial overruns within voluntary organisations, funded under sections 38 and 39, is a matter for the boards of these organisations. We know their boards take that responsibility seriously. I thank the Chairman.

I thank the CEO. The first speaker this afternoon is Deputy Aylward.

I welcome Mr. Reid and his staff. The report of the Comptroller and Auditor General is nearly identical to his reports of 2001 and 2010. We all know that the ambition of primary care is to keep as many people as possible out of hospital and in their homes. We all know it seeks to ensure that people are cared for and treated as near as possible to their own homes without blocking up the system, taking up hospital beds, etc. particularly in view of the current trolley situation.

Governments down through the years have placed great emphasis on primary care and such care has been mentioned in all of the manifestos and by the HSE. However, it seems that great progress has not been made and it seems to be at a standstill. Almost 20 years have elapsed yet only one third of the target set in 2001 has been achieved. Why has it taken so long to roll out primary care? After 20 years more than one third of the target should have been achieved.

Mr. Paul Reid

I agree with the Deputy's summary in respect of the value of PCCs and dealing with our patients and, indeed, the public, in a primary care setting. The ones that we do have up and operational, there is no doubt, where we have a GP presence in place, it provides a significant extra service to the community, and provides specific relief to our acute settings, particularly our emergency departments.

The Sláintecare direction is absolutely the way we want to go. We have a lot of PCCs that do not have the diagnostic capability that would enhance the supports they can give the community.

Why do they not have the diagnostics?

Mr. Paul Reid

In the past, it has been a priority to invest in the current demands on our service. Currently, all of the pressure points head towards our emergency department and hospital acute settings. I am convinced in the six months that I have been here that the shift that we have to make is to reduce the number of presentations, not through anyone's fault, to our emergency departments. That has to be done through a number of ways. Sláintecare sets out a strategy for this. We need more GPs. I have been talking with the training body for GPs. Bringing more on-stream will be key for us. We need to enhance the capacity and capability of our pharmacies in terms of their reach into communities. We can only reduce the number of people who need to present to emergency departments by strengthening our primary care teams.

A positive element of our service plan, which is being finalised and is with the Minister to go to the Government shortly, is an enhanced investment for next year in our complete primary care settings from a number of perspectives. This will enhance investment in the nursing home support scheme and home help hours. In particular, there will be capacity to increase our resourcing in community settings, for example, primary nursing, by more than 1,000 personnel by the end of 2020. There is a €10 million investment.

We need to shift the investment profile from the acute setting, which is under pressure, into primary care settings primarily while supporting the acute setting.

If there has been a failure in the system's roll-out over the past 20 years, can a way to rectify that be identified? Is it down to money? Are GPs not interested in rolling it out? Is it down to structures or grant aid? What is the main failing? Why has it not been taken up more? The centres in Kilkenny, in my constituency, are working brilliantly and there are plans for more, but those have been spoken about for ten years and they are still not up and running. Why is that the case?

Mr. Paul Reid

This is mentioned in the Comptroller and Auditor General's report as well as our report. There are 127 and a further 77 are coming on-stream. Ten will be from our corporate plan next year and 67 will be from primary care operational leases. A significant number will come on-stream over the next three years.

Reverting to the original point, it is not just about building a primary care centre; it is about equipping the centre with the facilities that can enhance the patient and public's experience in them. The Deputy referred to his own experience.

It varies across the country. We do not have PCCs with the capacity that is needed. We do not have sufficient GPs coming on-stream. That is getting better. I agree with the Deputy that we have to strengthen capacity in all of our centres. Diagnostics, GPs and therapist skills are needed to ensure people have outpatient appointments in acute settings. An investment shift is required to strengthen our community settings.

I wish to ask about the 127 centres that are up and running. Mr. Reid might not have this information off the top of his head. Where are they mainly based? Are they well spread around the country? Are they focused in Dublin and the other cities? Are there areas or counties that are very neglected in respect of primary care?

Mr. Paul Reid

We have a very good spread. I would be happy to provide the committee with a spreadsheet, which sets out the full list of locations.

Mr. Seamus McCarthy

Annex 15C of the report lists all of the locations of PCCs by CHO and sets out the status of each project as at March 2019.

Are they well spread geographically?

Mr. Seamus McCarthy

They are well spread around.

I want to move on to the different methods of rolling out private care, which include lease agreements, PPPs and HSE direct builds. Which of these methods is the most prominent? Which of them involves the best system? Which of them is the most effective? As we go forward, which of these methods will be of most use as we try to get the other projects - two thirds of the total - up and running? Which of them is the most cost-effective? Which of them represents the best value for money?

Mr. Paul Reid

The Deputy is familiar with the three methods that we have. We will do a new review of them, as recommended by the Comptroller and Auditor General. A review was done in 2008. It concluded on the basis of a cost-benefit analysis that the operation of lease agreements was the most cost-effective of the three methods. We want to review that again now, based on our experience with PPPs and our own-----

I ask Mr. Reid to explain each of them as he goes along. Which of them is the best? I presume the lease agreement method involves leasing a building. I understand what is involved in PPPs. Someone comes in from the private sector as part of a partnership. The HSE builds some of these facilities directly itself. I ask Mr. Reid to explain each of these methods. Which of them is the most cost-effective?

Mr. Paul Reid

Before I ask my colleagues, Mr. Sullivan and Mr. Curran, to comment, I want to say that each of the three methods is about first-time situations. The Deputy asked which of them works best. If we are enhancing an existing premises of our own on our own land, it calls out for a capital plan investment that we should do. In other cases, we try to reduce, mitigate or share the risk by operating in a PPP environment. From a cost perspective, we enter into operational leases when the opportunity arises. We do not always have a choice because all three methods do not always present themselves. People might not be ready for leases, or people might not want to work on PPPs with us.

Mr. Dean Sullivan

Each of the three models has strengths and weaknesses. Each of the three models is appropriate for different circumstances. Obviously, PPPs depend on the Government policy position.

Which is best for the taxpayer?

Mr. Dean Sullivan

Mr. Reid has mentioned the 2008 review, which concluded that an operational lease is the most cost-effective solution. As Mr. Curran may elaborate in a second, it is not always possible to enter into such a lease. We may wish to put a primary care centre in a particular location through the operational lease model, but it becomes problematic to do so if we cannot attract interest locally or we cannot identify a site locally. That conclusion was reached in the review. We intend to undertake a cost-evaluation exercise next year. This will be informed by the guidance of the Department of Public Expenditure and Reform. We will explore the three different modes or models of delivery again to see which of them is the most appropriate in today's circumstances. Of course we will look at that. The models we have on the ground now reflect that fact that there is no one right solution. Each of them has strengths and weaknesses. Perhaps Mr. Curran would like to add some light and shade.

Mr. Jim Curran

Our focus under the capital plan has been on higher-priority projects where commercial entities have shown an interest in developing primary care. We have also focused on developing our own facilities, extending existing health centres to provide additional accommodation for primary care and upgrading or remodelling some of our existing facilities, including old mental health institutions and hospitals. For instance, we are developing a primary care unit at the St. Davnet's campus in Monaghan. We hope to do something similar in Portlaoise. We have enhanced an old community nursing unit in Loughrea to provide primary care there. We have provided new PCCs in Inchicore and Ballyfermot from our capital plan. We will deliver centres in Finglas and Rowlagh from the capital plan as well. When we pursue the operational lease method, we get the benefit of commercial interest in providing primary care, including the capacity to leverage off PCCs for other commercial developments associated with health, including pharmacies. Other private consultancy suites often come into these facilities. All of these developments enhance the delivery of primary care.

I would like to ask about the level of interest among GPs. Some GPs throughout the country seem to be reluctant to get involved in PCCs. What kind of grant aid is there for a GP who wishes to set up in such a centre? I assume assistance is provided as part of the effort to get full primary care services in place. Is a certain percentage of the cost provided as grant aid to get people interested? What way does it work? What efforts are made to get business people involved in PPPs?

Mr. Jim Curran

There is no grant aid for GPs or anyone else who is involved in primary care.

Is there no grant aid at all for setting up or building a primary care centre?

Mr. Jim Curran

No. The Department commissioned a report that looked at incentives to enhance primary care. I forget what year it was done. It was probably 2013 or 2014. The report did not propose that the provision of grant aid or the introduction of tax measures would be the way to go. The report suggested that the models we had in place should be sufficient to develop primary care. GPs who have invested in their own facilities might be reluctant to abandon what they have developed. They might need see any reason to move into another facility. They might have incurred mortgages or leases. This might mean they do not have the freedom to go into new locations. We offer GPs the opportunity to take out licences in rooms in our own facilities at fairly attractive rates to encourage them to operate from our PCCs.

Does the HSE target centres of population? I presume a small village of a couple of hundred people would not have a primary care centre. Does the HSE focus on bigger towns with larger populations? Are certain areas targeted? What criteria are used when a decision is being made on whether a primary care centre should be rolled out in a certain area? What are the population criteria?

Mr. Jim Curran

A primary care mapping exercise has been done to ensure all of the country will be covered by primary care. As part of the 2012 prioritisation exercise that was mentioned earlier, we identified priority projects in the context of the service requirements, the accommodation available and the deprivation index. That exercise gave us an initial priority list for primary care delivery. It can be seen from the priority list that there is a focus on areas of deprivation with poor facilities and on areas of increasing population without any existing facilities for the delivery of primary care. Such areas tend to be around cities and towns. It is probably timely to review the priority list now in the context of what was referred to earlier as the recommendation report. That would allow us to see where we should refocus our efforts.

Naturally, if PPPs are involved, business people are there to make money. Does the HSE have a problem with such people targeting certain areas? There could be too many primary care facilities in a place like Kilkenny city and no primary care facilities in smaller towns where they are needed. Do people look at the potential footfall and profitability of projects? Can it happen that there are too many offers in one area and no offers in another area?

Mr. Jim Curran

When we advertise for locations in specific areas, we get expressions of interest in most instances. As this is not the operational lease method, it is not-----

Does the HSE provide a licence?

Mr. Jim Curran

We take a 25-year operational lease on the premises. The PPP method is separate.

Can the HSE dictate where these are located?

Mr. Jim Curran

Absolutely. We choose the locations. We advertise the locations. We do not go to one location because it is convenient in preference to a location where a primary care centre is required.

Last night, a colleague of mine asked me to raise the case of the centre in the Rowlagh area of Clondalkin. I do not know whether I can ask about individual centres. Planning permission has been given. It has been six years in the making, but no progress is being made now. Is it allowable to ask about an individual centre?

Mr. Jim Curran

I can answer that one. Rowlagh was one of the high-priority locations. We have been struggling to get a site there. We entered into an agreement with the City of Dublin Education and Training Board on a site beside a community school. We are in discussions with the Department of Education and Skills on the transfer of the site in question. We got permission to apply for planning permission. Now we are waiting for a licence to commence the building there.

Is it in the-----

Mr. Jim Curran

It is in our capital programme.

Will it be one of the early ones to come on-stream?

Mr. Jim Curran

We hope, subject to getting the licence from the Department of Education and Skills, we will commence building early in 2020 on it.

Mr. Reid spoke about home supports. It is a problem we all encounter. I refer to home care hours. It is a help to keep people at home. It is obvious that there is not enough funding to facilitate the demand. Will more personnel and funding be made available to keep people in their homes as long as they can? There is a significant demand on the home support framework that we have, with people only getting half an hour when they should get two or three hours, and others not getting any and having to wait three or four months before they can even get access to some help. Will Mr. Reid comment on that?

Mr. Paul Reid

I thank the Deputy. My colleague, Ms Anne O'Connor, will comment as well.

The home help supports are significant for us in terms of the demands of demographics that we face as a country. With the funding that we have this year, as the Deputy will see, we have set out the number of people that will support. We have sought additional funding, as part of our winter plan, from Government. Positively, this year we have secured additional funding, not in December but in October, which has been invested already. Enhanced home care supports will be put in up to Christmas and during the winter.

Our service plan for next year has to be agreed shortly, but the Deputy will have heard it publicly announced in the Government budgeting process that an extra 1 million home help hours will be deployed into the community settings. Those are welcome.

Our total winter funding of €26 million is very significant. Last year, that was €10 million in total. A significant portion of that is being put into home help, and, indeed, the nursing home support scheme and delayed transfer of care beds.

Are we getting good value for money from home care? I accept there is more funding. We are grateful for getting more funding, and 1 million more home care hours as well, but it is still not fulfilling the demand. What level of demand does the HSE want to fulfil to keep people out of hospital, off trolleys and from holding up beds in hospitals? Does Mr. Reid agree the way forward is more funding on home care?

Mr. Paul Reid

Absolutely. Any extra funding we get in terms of home care supports is excellent value for money when compared to the cost of a patient being delayed in an acute setting or, indeed, in a bed. It is much more cost-effective.

Specifically, there is a number of aspects in terms of the supply and demand. On the demand side, as I said in my statement, we have more than 7,000 people, which is combination of people looking for new hours and extended hours throughout the day. More funding in next year's budget will be supportive of that.

We also have a supply factor in terms of home help providers and care providers, which is a significant challenge in some parts of the country. As the Deputy will be aware, we have a mix between direct labour and indirect labour across the country for historical legacy reasons, but that is where the supply is. We have a bit of supply of the home care hours and help where we want to get more and we have a bit on the demand side in terms of the extra provision required. Positively, next year's budget will reflect significant extra hours.

That brings me on to my final question. I was approached by people who work for the HSE providing home care regarding agencies. There seems to be a bit of conflict, at least in my area, about the HSE employing agency staff instead of employing people directly. What is Mr. Reid's opinion on that? Why does the HSE use agencies when people are available who could do the work and are employed by the HSE? They are not getting full hours and yet the HSE is bringing agency nurses in to do it instead. There is a bit of a conflict over that to the effect that the priority should be given to the HSE workers. I am not going into industrial relations or anything like that.

Mr. Paul Reid

Primarily, where we have a difference between direct provision hours by HSE employees and contracted hours by profit or not-for-profit companies is largely a function of the history of where the supply has been. There have been extra cost pressures on us this year such as wage inflation and Workplace Relations Commission agreements so the cost per hour has gone up.

I am told agencies cost more than direct employment. Is that true?

Mr. Paul Reid

In terms of the home help, I do not believe so. In one of our breakdowns, we submitted the cost of both direct and indirect provision.

Ms Anne O'Connor

The home support was tendered a year or so ago. From our perspective, the best mix is to have a blended solution. We have two areas in the country where we have no direct provision of home support. They are all provided by external providers and that presents some challenges. What we find is that it can be difficult to source carers in isolated rural areas at present, and we work closely. When there is a blend of HSE directly-provided services and agencies, we can work closely together. However, it is challenging in terms of being able to secure carers all over the country.

In terms of the cost that the Deputy referenced, we had the tender which went up. In terms of travel time and paying for travel, that impacted on our own employees but also some of the charges coming in from external providers went up in the same way slightly. Our preferred way of working is to have availability of both.

In 2008, the 304 sites for primary care were allocated. Is it correct they were decided in 2004? Mr. Reid or another official will know the answer. Perhaps it is Mr. Dean Sullivan's area. Is it correct that the total quantity of sites was allocated in 2008?

Mr. Paul Reid

In 2012.

Mr. Seamus McCarthy

In 2012, 340 locations, I should say rather than "sites", were identified.

From reading documents last night, a number of them were deemed to be in existence already. I cannot remember the exact number. In 2012, centres were prioritised based on demographics, need, etc. Is Mr. Reid telling us today that no review has been done since 2012? Is there still need in those areas? My concern is that a pathway was carved out seven to ten years ago and the position has significantly changed in the interim how we deliver healthcare, with Sláintecare being the biggest change . I am concerned that a pathway was embarked on and has not been reviewed since and one of the Comptroller and Auditor General's recommendations is that an analysis be done retrospectively of whether the benefits that the HSE set out to achieve were realised. I cannot see why it would keep going unless it was sure what was being done was the correct thing to do. Will Mr. Reid comment on that?

Mr. Paul Reid

I will ask one of my colleagues to go through a little bit of detail but I will just say upfront that it is absolutely crying out now for us to look at it looking forward because our delivery model is fundamentally changing. We are moving towards a new regionally integrated model where the acute and community settings will work together, as the Deputy will be aware.

It has totally changed.

Mr. Paul Reid

The landscape has changed. The delivery of care has changed. The skills we will put into our PCCs will change in the future. Looking two years rather than ten years ahead, we want to make sure that the next prioritised list takes on board the new direction that we are going in the delivery of healthcare in respect of the regions and integrated care.

It could not be guaranteed that the 77 that are in train are the optimum way of doing this because the model has not been reviewed. Mr. Reid stated that there are 127 already plus 77 on the way, which will be delivered in a certain period of time but that cannot be guaranteed, because not one has ever reviewed it, if they are what is needed in this new era.

Mr. Paul Reid

I would make two points. First, of the 77 that are in train, as the Deputy correctly said, ten are in our capital plan, are definitely priorities and would be delivered under any model. The remaining 67 will be from an operation lease. Twenty-four are in construction at present and 43 are at an agreement stage. I will be strongly recommending we move ahead with them.

What if this is the wrong model? I am not saying it is, but how do we know it is not the wrong model if it has never been reviewed it and we are on this pathway? What happens if we end up with 204 of the wrong thing?

Mr. Paul Reid

Our challenge is not about having the wrong thing. It is about how we particularly equip these centres for the future. One of my colleagues might contribute.

Mr. Dean Sullivan

I will kick off. It is a fair comment. The review was done in 2012. The prioritisation exercise was helpful at the point in time. There has not been, as the Comptroller and Auditor General's report stated, any national reprioritisation since then but there have been a number of local reprioritisations - new locations identified, existing locations merged, etc.

As Mr. Reid has said, the fact that we have the 127 and will have the 77 is of huge value. It is much better than starting from nothing, and they are well distributed across the country. We have the platform here to build on into the future. The models we have will be sufficiently flexible to allow a range of different services to be put in place. The most important thing is that we have something that brings together the integrated primary care teams, including the GPs, in one location as a single one-stop shop for patients. We have prioritised the completion next year of an exercise that will review how we are using the existing centres. We will look at Sláintecare in the round and how things have moved in our thinking over the past ten years. We will make sure as we go forward now, building on the 204 that will be in place between now and 2023 or so, that we redirect as appropriate and maximise the value from the 204 we will have by then.

I do not believe we have ever defined what a primary care centre is. I am reading the notes. We do not have a definition for what is needed in the mix.

Mr. Dean Sullivan

We have a view around a form of words that I think is reflected within the Comptroller and Auditor General's review as to what a primary care centre is. Again, that will be part of the exercise next year to see whether that definition-----

Reading the notes I have here now and last night, there are 127 entities. We have no definition of what they should be. We have not looked at whether they are fulfilling what we set out for them to fulfil in 2008. We do not know whether they are achieving what we set out for them to achieve. I am very concerned that we would continue going down a certain pathway. That is fairly clear from what I have said. Mr. Sullivan said the models would be sufficiently flexible. If 14 are PPP-based, what is the flexibility there? A developer builds the site and leases it to us. Is that how it works? It is a 25-year lease. Who owns the staff? Are they HSE staff? They are.

Mr. Seamus McCarthy

Some of them would be GP employees.

Yes, so perhaps a GP might bring us-----

Mr. Dean Sullivan

That is not the PPP contractor-----

Grand. What degree of input can the HSE have into the operation of a PPP site?

Mr. Dean Sullivan

The point I was making in response to the Deputy's earlier question was in that space. One way in which a PPP is potentially less strong than other models is that it is a slightly more inflexible model than would be the case certainly with a capital build or an operate and lease, whereby there is more scope to turn midstream. There is no flexibility there but it is slightly more complicated to effect that. Mr. Curran can-----

Let us say we wanted to put a diagnostics centre on the same site as one of the 14 PPPs. Such centres are fundamental to Sláintecare. Would we be able to do it?

Mr. Jim Curran

There are restrictions in respect of PPP contracts. There are possibilities there but we have to go through a whole process of negotiating with the PPP provider in terms of the-----

We do not really have control over those sites.

Mr. Jim Curran

We have control as to how we set out-----

Mr. Jim Curran

-----what we require at the start. The facilities and the opening hours we set out at the start. If there is expansion capacity in those sites, we must go through a process of negotiating with the-----

Regarding the PPP sites, the State owns the land and we give the HSE, I think, €50 million upfront in capital costs. This was the position back in the day. The developer built the centre, and now there is this thing called a unitary payment, which is for 25 years, I assume.

Mr. Jim Curran

Yes.

That covers the capital costs of developing the site. We pay the developer to build it. It says that in the notes anyway.

Mr. Jim Curran

There are two-----

There are two elements to the unitary payment, yes.

Mr. Jim Curran

There is the repayment on the capital, so-----

Mr. Jim Curran

The developer gets its repayment, and then there is the operational cost.

Is that operational cost lights and vacuuming or what is it?

Mr. Jim Curran

There is the maintenance, cleaning, security, some element of portering in the facility provided, and the life cycle costing. The building must be kept-----

They have a sinking fund.

Mr. Jim Curran

-----as it was at the start. That is all-----

After 25 years, who owns the building?

Mr. Jim Curran

It is handed over to the HSE.

There is very little flexibility there, though. One cannot really just rock in with an idea for a diagnostics centre to be plugged into a PPP primary care centre unless there are huge negotiations.

Mr. Jim Curran

We must go to the PPP operator and put our proposal to it. The operator comes back and costs the proposal. It does not just cost the bill cost, though. It factors in the life cycle, disruption and risk. All those elements go into the price.

The difference with this operate and lease model is that a developer builds it and-----

Mr. Jim Curran

The developer provides the site.

The developer provides the site, which is the difference between this model and the PPP.

Mr. Jim Curran

It builds it.

It owns the land and builds the building. Are the staff HSE staff?

Mr. Jim Curran

Yes.

There is the GP and whoever else. What do we pay for?

Mr. Jim Curran

We pay the rent on the building and a service charge that covers the maintenance of the building, including the common areas and so on.

Are they more flexible in terms of what we could do?

Mr. Jim Curran

If they have the capacity to expand and they are asked to build a facility on the site, we negotiate the rate or we can get it at the same rate at which it is currently being rented, depending on the scale of the-----

It is not as easy as just going in and making them do what we want them to do. It is a partnership, really.

Mr. Jim Curran

Yes.

That has its complexities when we want to do things.

Mr. Jim Curran

Yes, but equally so on our own sites. It can be challenging to expand our own sites.

I know. This was all decided in 2008 and prioritised in 2012. We have never defined what a primary care centre is or what constitutes a primary care team or what elements are in it. My understanding is that we have not Sláintecare-proofed, so to speak, any of this yet. I read somewhere last night - I think another member mentioned this - that there is not necessarily a GP everywhere. I cannot really understand how a primary care centre would be run without a GP. What happens in primary care centres where there are no GPs? I am not being smart, but what do they do?

Mr. Paul Reid

Two things. First, where there are not even primary care centres, we have combined teams.

Mr. Paul Reid

Therapists and various public health nurses we have. There are some teams in respect of which we do not have primary care centres in our community settings, but there are primary care centres that do not have GPs-----

Is this because we do children's vaccinations and things like that? There would have to be a doctor in the centre. I just do not know what a primary care centre is without a GP. I cannot see what-----

Mr. Paul Reid

There would be some therapists. There would be various skills involved but not-----

How many primary care centres do we have in existence that have no GPs?

Mr. Seamus McCarthy

There is a figure on screen that gives an indication. It gives the number of primary care teams, PCTs, in place by community healthcare organisation, CHO, and whether they have a GP. There is a target figure of the number of PCTs for each CHO. I am sorry for using all these abbreviations.

For CHO 4 we want 74 teams but we only have 35. Am I reading that right?

Mr. Seamus McCarthy

There are only 35 PCTs with a direct GP involvement. There are 42 primary care teams without a GP involvement, but at least in those cases there are a number of primary care teams that are targeted for the area.

Ms Anne O'Connor

As to what they do, historically we have had a lot of health centres that we would all be familiar with for different reasons to do with primary immunisation, occupational therapists, physiotherapists, speech and language therapists, public health nurses, etc. When we started to develop primary care centres, we started there, in a sense. The important thing in the beginning was the development of primary care teams after the primary care strategy of 2001. We had groupings of primary care professionals coming together to work in the interests of the local population. From that we started to develop primary care centres. In reality, we have from the beginning had GPs who were very invested and wanted to be in the middle of the teams. We had other GPs who had invested in their own practices and wanted to work in a more virtual way. The priority for those teams was to ensure ease of referral with GPs and to ensure that the team worked and had a weekly meeting with GPs. There have been different models throughout the years.

Some GPs just do not want to be in the middle of a primary care centre. They want to be in their own practice that they have invested in and which is their own business.

I would have considered that having a doctor present was fundamental to a primary care team.

Ms Anne O'Connor

As part of the team, but they are not necessarily in the same building in some places. We have 421 operational primary care teams around the country. Some 234 of those have GP involvement. They are not necessarily in the same building.

Are we planning on defining what is in a team and what is in a centre so that we have something to work from as a standard?

Ms Anne O'Connor

We had the primary care strategy of 2001 that set out clearly what a primary care team was and what a primary care network was. That is still the core team, including a GP, public health nurse, occupational therapist, physiotherapist and home support, with speech and language therapists, psychologists and dieticians in the mix more in the network. They are the core professionals of the primary care team. In recent years, we have focused on the inclusion of diagnostics. In reality, the core disciplines are very similar. We have looked at the local demography. In Dublin 15, where we have developed centres in Corduff, we have focused primarily on children. We have brought in the children's disability team as well as the primary care team. In other areas, we might have a stronger focus on older persons and the mix of the team will change. Over the years, we have tried to adapt in response to the local population and through collaboration with local communities to see what the best fit for that population is.

The Ballymun model works very well. I know it is unique in that I think it is was bought from Dublin City Council.

Ms Anne O'Connor

It was leased from Dublin City Council. Ballymun is a great model. It is more than just the core primary care team. We have involved mental health services there and in a number of other centres. In the centre I mentioned in Corduff, we have child and adolescent mental health services as well as disabilities and primary care services. Ballymun has community mental health teams as well as the primary care team, with two very committed GP practices. That was quite a big model at its time.

It is the only example and it works so well. One can tax the car and the child at the same time.

Ms Anne O'Connor

It is in the council building so it is a real hub of the community, with a coffee shop and so on.

It is brilliant.

Ms Anne O'Connor

We have other centres that are very impressive too and that are core parts of the community.

When Ballymun works so well and is well attended, it seems that it would have been a great model to replicate as opposed to building up-----

Ms Anne O'Connor

It is part of the regeneration project in Ballymun. It was very central geographically at a particular time.

I think that is it. After reading the documents last night, the recommendations of the Comptroller and Auditor General have to be implemented. If we look back at this in ten years and we have built 204 things for which we do not even have a definition or know who should be in them, which are not Sláintecare-proofed, so to speak, and have not been reviewed to see if they deliver what we wanted them to deliver, it will not be a good outcome for any of us, especially the people who are depending on them. Have we any timeline for the review? I read recommendation 2 last night, which states that the Accounting Officer of the Department of Health agrees and continues, "However, this will require consultation with the HSE and will need to recognise that variation in the design or utilisation of PCCs is a function of local circumstances, population need". That, to my mind, is code for the Department will do this if it wants. It is not defined enough. We have to review what money is being spent on and see if it is working. This seems very loose and sounds like the Department will do this if it suits.

Mr. Fergal Goodman

The involvement of GPs has been referred to strongly. They are a core member of the team, as they were in the 2001 strategy. That being so, at the same time, there were always some GPs, as HSE colleagues have indicated, who were enthusiastic early adopters, but we had no contractual arrangement with the GPs that bound them more closely into the primary care team and network model. In negotiations that we had this year with the Irish Medical Organisation, one of the key objectives that was secured was a contractual obligation on behalf of general practice to work in an integrated way with primary care networks and teams. It is not about the physical co-location. That, as people have explained, is dependent on many other circumstances. The primary care strategy was very much about ways of working, teamwork and multidisciplinary care. GPs are moving closer into collaboration with the salaried staff of the HSE in delivering services to populations. It is worth noting that as part of the service delivery objective.

The 14 public private partnerships, PPPs, are all operated by the same company. Is there any particular reason for that? There would usually be competition in the market. Why is it just one company?

Mr. Jim Curran

PPPs have to be made attractive with this model and need significant investment. It was more than €100 million in this case to get the funders and to have their expensive bids put together. Typically, whether it is in education, the Courts Service or social housing, PPPs are all in excess of €100 million.

There is just one company for the 14.

Mr. Jim Curran

There was a competitive process for that company to be selected. A number of parties were interested. They were shortlisted, they bid and that was the result.

With regard to operational leases, is there any indication that there is an element of control by one company or is it more diverse?

Mr. Jim Curran

It is diverse and fairly competitive.

So many people are looking for these.

Mr. Jim Curran

I would not say many but there is a sufficient number to make it competitive.

Are they indigenous companies or are they from elsewhere?

Mr. Jim Curran

There are a number of indigenous companies. A number of international funds are investing in primary care facilities and we are supporting them.

I will expand a little on the questions that Deputy O'Connell has asked. In the reviews, the HSE will be looking at the location, the components of primary care needs in an area, and so on. This is absolutely the way to go. We want to see a successful model around the country. Some of the shortcomings, for example, would be retention of staff. Would that be the kind of thing that would be part of the review? I went along to my own CHO area. It had a briefing for Oireachtas Members that was very useful and addressed a range of areas. I asked a question about an area that keeps cropping up in the personal experience of some of my constituents. They get an appointment and then there is an interruption in the therapy service. It is often maternity leave since a large number of women are employed in that area of healthcare and they absolutely have to be supported in the maternity leave that they take. They do not want to come back to long lists and such. The functioning of these primary care centres has to take that into account too. Is that an aspect that the HSE will look at? I understand that, at any given time, one third of therapists are on maternity leave, which is a very high number. That goes with the territory when one has a cohort of workers with that age profile.

Mr. Paul Reid

I will come back on two aspects, some of which relates to Deputy O'Connell's question too. There will have to be two aspects to a review.

The first will be what the Comptroller and Auditor General called a "re-look" at which is the best model for delivery in the future between public private partnerships, lease and the capital funded plan. We want to have that aspect of the review done in the first half of next year because it is key.

The second aspect of the review, which Deputies O'Connell and Catherine Murphy just mentioned, is to proof it against Sláintecare. Part of the proposal that went to the Government about the announcement of regions was that we would revert to the Government in the first half of next year about the functioning and establishment of regions and real, integrated operational care between acute and primary care. How we use primary care centres must be a key aspect of our next report. The history of primary care centres is long, going back to the health board system and through the nine CHO settings. We need to look at them as much more of an integrated service which is a very different way of looking at them. It might mean a reassessment of priorities.

The second part of the question related to the staff and therapists in general. If one stands back from the Deputy's point, it is absolutely correct. Some 80% of our staffing, across the HSE, are women and approximately 35% of staff are on reduced working hours, maternity leave, or work part-time, etc. It is a significant issue to manage and, much of the time, we have to manage it through agency because it would not be cost-effective to have all full-time replacements. We meet certain pinch points when it comes to resourcing. Maternity leave also affects some of the primary care centres. We try to cover some of the vacancies through agency or by moving staff between primary care teams. It is an issue that is difficult to manage. That is why we use agency and move staff between some of the primary care teams.

I appreciate that it is difficult to manage. Are there other strategies in place for workforce planning to cover maternity care? It is unattractive for someone returning to work to face long lists and so on because no cover has been provided in her absence. Taking somebody back on a part-time basis is better than not having them back at all, especially when the staff in question are experienced.

Mr. Paul Reid

I will make one point related to Sláintecare. Our strategy, in terms of workforce planning for next year, involves putting an extra 1,000 staff into our primary care settings. That will cost €10 million, rising to €60 million. We should have an extra 1,000 staff in community settings by the end of next year which should give some relief.

The cost of agency cover, for example, is greater than direct employment of a member of staff. It is difficult to have somebody roving and employed in different parts of the country. Cost-effectiveness and retention should be central to the review. Retention obviously gives rise to costs for training and experience and many other factors come into the equation when one looks at value for money and quality of service. We want people to be shouting from the rooftops that this is the way to go and, in order for them to do that, they must have a good experience. They also must have certainty regarding the provision of service when we invest in these primary care centres.

Ms Anne O'Connor

To add to that, the advantage is that, as we develop primary care teams, we know that staff, particularly those who are newly qualified, benefit hugely from working as members of multidisciplinary teams. Historically, disciplines in the community and elsewhere have worked in their own professional silos so, when someone is gone, his or her list is not covered. Multidisciplinary working changes that slightly. It does not mean that we magic up capacity that we do not have but it does mean that families and children coming through primary care centres, whether attending the primary care team, children's disability teams or whatever, are familiar with the team and there is less of a gap when an individual member of staff is lost. There is no doubt that we struggle to cover leave but at least by having teams that are co-located, we are able to work differently with people.

What timeline will be considered in the review? Is it the lifespan of a facility that has been developed through a PPP as opposed to a direct build? Are there real options in the choices that are to be made? Will funding be provided in the event that direct build is found to be more cost-effective way of dealing with the primary care centres?

Mr. Paul Reid

In terms of the review, there is always a dial that one has to turn which balances risk and cost, as has been seen in previous models. The Comptroller and Auditor General highlighted the various models we have. We have seen, in our review in the past, that the operating lease was the most cost-effective. We will look at that again by the first half of next year. There is funding for 30 primary care centres in our capital plan and we still expect those to progress, as they should. Where we have our own sites and are extending an existing site, as I mentioned earlier, the best model is our own capital plan and infrastructure. It is about balancing the risk of the investment.

I want to ask about another area.

I just want to put two questions. I might have to leave in a few minutes so I might ask Deputy Catherine Murphy to take the chair for the last few minutes.

I do not have many more questions.

I will only be a moment. Our guests can send the information on, rather than answering the questions here, although they might give me a quick response. The HSE provides approximately 19 million hours of home care per annum.

Ms Anne O'Connor

It is 17.9 million hours.

Mr. Paul Reid

The figure is 17.9 million hours.

We will call it 18 million hours. The budget provided for approximately 1 million additional home care hours next year. How many hours have been approved for home care for people on waiting lists? Do the witnesses understand what I am saying? The committee gets letters-----

Mr. Paul Reid

Is the Chairman asking how many we will take off the list?

The HSE has invented its own language. For example, "moratorium" means one thing to everyone else and something different to the HSE. One can be approved for home care and find oneself on a waiting list. The HSE has invented a new vocabulary. How many people are on waiting lists?

Ms Anne O'Connor

We would be aiming to increase the number receiving home help from 53,000 people to about 60,000 people.

The opening statement mentioned approximately 7,000 people.

Ms Anne O'Connor

The figure was 7,500.

Does that mean there are 3,500 people approved for home care who will not get it next year but will have to wait until the following year?

Mr. Paul Reid

Some people on those lists are currently getting home care and are looking for extensions.

I ask the witnesses to send the committee a detailed breakdown on the number of these who will be new patients. They can send that in writing because everyone will get it if they send it in writing in due course.

Ms Anne O'Connor

There are approximately 7,500 people waiting in the community but, when we provide home support, we often do so for people who are coming out of hospital. Some of those people would not show up on the community list. Sometimes they are the same people but we try to prioritise people coming out of hospital. We have two different groups - people who are waiting in the community and those who are coming out of hospital.

Are there two lists then?

Ms Anne O'Connor

No, there is one. It is just a matter of how we spend the money.

Is it from a different budget?

Ms Anne O'Connor

It is all from the same budget. There is a waiting list in each CHO area. There are 7,500 people on the community waiting list.

That is not the full list.

Ms Anne O'Connor

There would be more people who come in and might be admitted. Somebody who is not on a community list might be admitted into hospital and then require home support to be discharged.

Are there many such people, over and above the 7,500 on the list?

Ms Anne O'Connor

There would be quite a few more than the 7,500.

Mr. Stephen Mulvany

Typically, those people do not wait for long.

Ms Anne O'Connor

No, they do not.

Mr. Stephen Mulvany

They will wait for a matter of days until they can be discharged from hospital.

I accept that they are recent. I saw a figure somewhere, maybe in correspondence, that it would take an additional 2 million hours, on top of the 18 million hours, to deal with all the applications for home care that the HSE has. I might have done the rough figures, on the basis of 18 million hours divided by the amount of people on the lists, working out what each person is getting on average, and, if there are 7,000 people on the list, I worked out that it would possibly mean an extra 2 million hours.

Mr. Stephen Mulvany

The Chair is right that it would require in the order of 2 million hours to give 7,000 people-----

I did that sum myself.

Mr. Stephen Mulvany

-----six hours of home help a week, which would be at the lower end.

Would that be the average figure? I worked out that figure probably in the same way as the HSE has done. It might be the accountant in me.

I will not go into the politics, but the point is that the recent budget provided 1 million extra home help hours. It appears this will deal with only half of those who are currently approved and are on the waiting list. Perhaps Mr. Reid could send the committee a detailed note on this. I am short for time but I will be happy for the committee to get a written note on this.

Mr. Paul Reid

That is no problem.

I also want to touch on the contract for ambulance services, which I believe Mr. Reid is alerted to. It is specifically on the list. The HSE sent me a letter arising from a parliamentary question I tabled on 12 November. It stated that the HSE had paid out €27 million on private ambulance services that it believes are in the framework. I understand that the framework signed in 2013 could be extended for four or five years at a stretch.

Mr. Paul Reid

Four years.

My reading of this, which is subject to correction, is that the framework expired last year. It appears that €5 million or €6 million per annum may not be in the framework due to the passage of time. The letter also states that payments would be made to service providers who are not party to the framework agreement. This cost is running at an average of €2.5 million per year. As they are not part of the framework, these payments are clearly not compliant. Mr. Reid has said the main ones are compliant. I query whether they are compliant given that the roll-over period has concluded. On 25 May 2017, the HSE advertised for tenders to replace the current framework. This has gone on for a long time. I have had correspondence from people who are very competent. They might be subcontractors for some of the companies approved by the HSE. They are legitimately trying to get on to the list. The most recent letter I received as from the HSE's national director of procurement. He skirts around the current competition but the letter states that, due to competing priorities in the past 12 months with planning for CervicalCheck and Brexit planning, the HSE did not have the resources to replace the existing framework agreement and it has not been processed. However, it will examine the market position in early 2020 and will either progress the existing competition - it would be hard to resurrect because it is now three years old - or relaunch a procurement process with a view to establishing a new framework next year. The HSE has been in the tendering process for three years and my reading of the letter is that it might be abandoned and a new one started. What is going on? I am not talking about €1 million here or there but several million euro every year. Part of this should be covered by the framework. Having been two years in the process, the HSE is now putting its hands up and potentially abandoning the tendering process. This is what it reads like to me. Is Mr. Reid familiar with this?

Mr. Paul Reid

I am.

We flagged this issue and I would appreciate a quick response.

Mr. Paul Reid

I fully respect the Chairman's concerns on this one. It does mean we have abandoned the previous process. We issued a new tender on 21 November.

Just last week.

Mr. Paul Reid

Yes. It is a European tender.

My letter is dated 12 November and a new tender was issued on 21 November. One week after all this happened, a new tender is issued.

Mr. Paul Reid

It was on 21 November. A new complete European process tender has been published in the Official Journal of the European Union. It will complete the various steps by the end of March next year and in May in terms of allocations.

That is good if it is open to tender. All I wanted was to have it open, rather than rolling over contracts and using people who are not in the framework. That is fine. While it is not yet history, does Mr. Reid accept that the current arrangements are outside the framework that expired in 2018?

Mr. Paul Reid

As we have said, we have to start a completely new process. We will not tag off the old one; we will start afresh.

No, that would be pointless. By my reckoning, the old one expired some 18 months ago.

Mr. Paul Reid

Yes, it expired at the end of 2017.

There is no disagreement. My facts are accurate.

Mr. Paul Reid

That is right.

Perhaps Mr Reid could confirm this to the committee in writing. I am very pleased to hear that the contract is going to tender and the position will be corrected. When the committee discusses this matter again - whoever its members are next year - everything will be under a new framework some time next year.

Mr. Paul Reid

It will be. We have tendered, the process has started and it will be a much cleaner process.

I am very happy to hear this. I ask Mr. Reid to give us a note on this. I must be excused and I ask Deputy Catherine Murphy to complete the remaining business in the Chair.

Deputy Catherine Murphy took the Chair.

I do not have much more to ask the witnesses. I will pick up on the points made in the opening statement on cost pressures in operational services with regard to residential placements for people with intellectual disabilities. Two people have contacted the committee about the services contracted out to two different organisations. I will give the names of the organisations afterwards. It was one of the issues I questioned when we had a meeting with CHO 7. I was told that a major audit was to be done of the organisations in question. There is no point in duplicating work but it would be useful for the committee to find out about that audit when it is taking place, including its scope.

Ms Anne O'Connor

Is this related to disability or home support and older persons?

It would be disability services.

Ms Anne O'Connor

We have an initiative under way to look at residential placements. The team is led by a consultant and will look at placements and the appropriateness of placements for people who have gone in to emergency placements in particular.

Mr. Seamus McCarthy

I think the Deputy is concerned about the governance of the section 38 and section 39 organisations.

Yes. It is my understanding that this audit will also look at value for money where a service level agreement is in place for particular clients.

Mr. Paul Reid

The current service level agreement and the oversight of sections 38 and 39 organisations is up for review next year. That process starts around what the service level agreements should look like. That process will be worked through with the sections 38 and 39 organisations. A new group has been established by the Minister, which is made up of representatives from sections 38 and 39 organisations, the HSE and the Department, to look at the recommendations from the report produced by Dr. Catherine Day in terms of engagement with the sector, working in partnership and better communications with the sector. This has started. The group convened last week. In parallel to this, service agreements are up for renewal in 2020. This will also involve direct engagement with the organisations. This may relate to the Acting Chairman's point on audits and oversight of the sector.

Will service users have an input into that review?

Mr. Stephen Mulvany

Allow me to clarify what the Acting Chairman has asked. We have governance reviews ongoing. The last time we appeared before the committee, 22 of X number of reviews has been completed. The reviews are looking at the governance inside section 38 organisations predominantly. They are not value-for-money reviews but look more at internal governance, for example, whether they have internal audit functions, rotating board memberships and so on. We can give an update on that.

Ms O'Connor referred to an exercise that is looking at disability and mental health residential placements around the appropriateness, procurement, cost, effectiveness and value in placements. That is also under way. As Mr. Reid said, next year we will look at our standard contractual agreement with all the section 38 and 39 organisations. That is also ongoing. There is a lot going on in that space. We need to clarify specifically how we can best address the question the Acting Chairman asked.

We need to ensure we do not duplicate this work. The committee is often informed by the experiences brought to members' attention. One cannot get that kind of insight if one has not experienced it directly. When several people start saying the same thing, it piques one's interest.

A range of different services, for example, for young people with autism or intellectual disabilities are outsourced. They are not provided directly by the HSE but by a provider through a service level agreement. People are reluctant to complain because they see the person on behalf of whom they are complaining as a vulnerable person. It is all the more important that the questioning is one step removed from the individuals. There have been questions about how much it is costing to do that, the effectiveness of the outsourcing, and whether there are better outcomes with different providers. Is that part of this review?

Ms Anne O'Connor

That is the review I am talking about. We are looking at everybody who is in a private residential placement with either intellectual disabilities or mental health difficulties. It is interesting because one of the key components, particularly for younger people, is the distance from home and family. That is a key component in what we are looking at as well.

On the value for money question, people are placed in what we call an emergency placement, if things break down at home, or whatever happens. They are left in this placement that can often be very high cost and highly-supported. We are bringing in a new system of reviewing all of these placements. That is under way. We have worked through many different placements to look at the appropriateness of the placement, its oversight, whether there is a different type of placement that would meet that person's needs in a better way, where it is in relation to local community and family, and all of that. We are actively working through all of those at the moment. Hopefully, this will address the concerns the acting chairman is raising.

Is there a proposal to directly provide services or is the review only examining specific organisations?

Ms Anne O'Connor

We could not provide all those services. The reality is that we often have people who have highly specialised needs. We would not be able to keep those services going in respect of staffing, etc. We rely on private providers who often specialise in a specific condition. Our challenge is to ensure that we respond in a more agile way to people's needs. Just because people go into a placement one day does not mean that they should have the same staffing and remain in the same place forever. We must ensure we have a system of reviewing placements to meet their changing needs. This is particularly the case if they go in when they are younger and grow older, or their condition changes, or whatever. Many things can change. The idea is that we look at getting the most appropriate care setting.

There is definitely a value for money component. Sometimes we find that three or four CHOs may be dealing with one provider, unaware that the other CHOs are also talking to the provider. This impacts on the cost and staffing levels. We are trying to join all of that up nationally to make sure that when we are talking to a provider, particularly where there might be three or four people in a house funded by different areas, that we bring all of that together and look at its appropriateness. The most important thing is we meet the person's needs in the most appropriate way.

The HSE is looking at it from the individual's perspective.

Ms Anne O'Connor

Yes, that is it 100%, completely.

When is that review due to be completed?

Ms Anne O'Connor

It is ongoing and, therefore, it is not really a review. We have started reviewing all of the placements but we intend it to be an ongoing initiative. We want to ensure that we have a very proactive way of reviewing all placements.

When are we likely to see output from that process?

Ms Anne O'Connor

There already is. We have formed views on certain residential locations and we are working with local and clinical teams to look at the appropriateness of placements. There is not going to be a big report or anything like that, it is just used to inform our daily work on people who are going to these placements, and as we work with the providers.

There is inadequate provision of autism services and that seems to be the position in many locations.

Ms Anne O'Connor

Two issues arise in respect of autism. The Deputy is correct that we are often challenged to get service providers who can provide the right level of care to people with very complex needs. We received funding last year, however, to look at a specific autism initiative to improve services in one way but also to look at our approach to people with autism. In reality, people with autism need to be able to access our whole range of services. We have an extensive new initiative on autism, which is about to be launched in the relatively near future, and it will be similar to the Understand Together dementia campaign. Much work has been done on autism and we are very happy with that in ensuring that our services and the public are aware of what autism is and what it means for people who have autism. At the other end of the spectrum we need to ensure that we have the right providers to provide for a very complex need. Sometimes people with autism have a range of other needs as well. We are very focused on that at the moment.

I presume the HSE works along with organisations such as AsIAm.

Ms Anne O'Connor

They are very involved. We did a very extensive consultation nationally with families, parents, and people with autism to ensure that we got this right.

Those are all of the questions that I had.

I thank all of the witnesses from the HSE and the Department of Health for their attendance and for the information provided for the meeting. I also thank the Comptroller and Auditor General and his staff. I will request the clerk to the committee to seek any follow-up information and carry out any agreed actions arising from the meeting.

At our next public meeting on Thursday, 12 December we will meet Pobal on the 2018 financial statements. Pobal is an agency that administers and manages Government and EU funding to address disadvantage and support social inclusion.

The witnesses withdrew.
The committee adjourned at 4:56 p.m. until 9 a.m. on Thursday, 12 December 2019.