Joint Committee on Health díospóireacht -
Thursday, 10 Nov 2016

Quarterly Update On Health Issues: Discussion

Chairman

The witnesses will forgive me if I do not mention everybody by name because I may forget somebody. On behalf of the committee, I would like to welcome the Minister, Deputy Harris, who is accompanied by the Minister of State with responsibility for mental health and older people, Deputy Helen McEntee, the Minister of State with responsibility for disability, Deputy Finian McGrath, the Minister of State with responsibility for the national drugs strategy, Deputy Catherine Byrne, Mr. Jim Breslin, Secretary General of the Department, Ms Frances Spillane, assistant secretary, and Dr. Siobhán O'Halloran, assistant secretary. I would also like to welcome the director general of the HSE, Mr. Tony O'Brien, who is accompanied by Mr. John Hennessy, Mr. Liam Woods, Mr. Pat Healy, Ms Rosarii Mannion and Mr. Jim Ryan, to our quarterly meeting. I would like to thank Mr. Ray Mitchell and Mr. Derek McCormack for their assistance with the questions submitted by members. I am conscious of time. We would like to conclude the meeting by noon if possible.

I would like to 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 this committee. However, if they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to so, they are entitled thereafter only to 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 that effect where possible. They should not criticise nor make charges against any person, persons or entities by name or in such a way as to make him, her or it identifiable. I also wish to advise them that any submission or opening statement they have submitted to the committee may be published on the committee website after this meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I now ask the Minister, Deputy Harris, to make his opening statement. I will then invite Mr. O'Brien to make his opening statement.

Minister for Health (Deputy Simon Harris)

I am very pleased to have the opportunity to appear before the committee again.

I am joined today by my ministerial colleagues, the Minister of State with special responsibility for disabilities, Deputy Finian McGrath, the Minister of State with responsibility for mental health and older people, Deputy Helen McEntee, and the Minister of State with responsibility for communities and the national drugs strategy, Deputy Catherine Byrne. The Minister of State with responsibility for health promotion, Deputy Marcella Corcoran Kennedy, sends her apologies as she is in Brussels. I am also accompanied by officials from my Department, Mr. Jim Breslin, Secretary General, Ms Frances Spillane, assistant secretary with responsibility for disability services and older people and Dr. Siobhán O’Halloran, chief nursing officer and assistant secretary with responsibility for mental health and drugs and social inclusion. I also welcome Mr. Tony O'Brien, director general of the HSE, and his officials. At our last meeting we had a frank and positive exchange. I look forward to an equally interesting discussion today.

One thing that was clear during my last meeting was that health should not be a party political issue. At any one time we all know someone who is accessing services, a family member, a friend, a colleague. We all share the same goal. Each of us wants a health service where people feel valued, respected and well cared for. Since I was appointed six months ago, I have visited more than 20 hospitals and other primary care health facilities throughout the country. It is vital and has been very beneficial for me to see for myself what professionals, front-line health service staff, patients and families experience. There are positives and negatives to report. Do I feel heartened when I witness the levels of professional commitment? Yes. Do I feel encouraged when patients tell me that their lives have greatly improved since they had their surgical procedure or obtained treatment in an Irish hospital? Yes.

Equally, I am not blind to the fact that we face significant challenges. We face increased demand from a growing and ageing population and the increasing incidence of chronic conditions. I know that patients and families and, indeed, clinicians are frustrated by waiting times. To address these challenges I, as Minister for Health, and this Government accept that significant investment is required. In recent years the health Vote has typically required an annual supplementary budget to cover deficits. In July of this year, in an effort to properly fund health and break the cycle of Supplementary Estimates, the Government provided an additional €500 million funding to the health service to bring the total gross funding to €13.695 billion.

When we last met we were in the last phase of budget 2017 negotiations. I am pleased to report that budget 2017 delivered the highest health budget ever at €14.6 billion. Of this amount, just over €14 billion is for current funding and just over €450 million for capital funding. This unprecedented investment will serve to make a real difference in the services we can deliver. Budget 2017 includes €18.5 million to support the development of primary care services; €10 million in new development funding for home care supports like home help and home care packages; €20 million to enable people with a disability to move to more appropriate accommodation in the community. The budget also provided for automatic medical cards for an additional 10,000 very sick children, whose parents are in receipt of domiciliary care allowance. These increased resources will also allow the health services to plan for the challenge of increased demand from a growing and ageing population, and begin some significant new developments which will over time deliver real improvements for patients.

Before going on to talk about the services which will be delivered in 2017, I want to refer to industrial relations matters, which is a topical issue at the moment. Members will all know that the INMO executive council has decided to ballot on industrial action. I respect its decision but industrial action is not the way to address the medium-term or long-term needs of the public health system. This Government is committed to a collective approach to industrial relations and public sector pay policy as the most effective means of delivering economic security and stability. Any approach to pay restoration must be within the terms of what is available and affordable. I am pleased, therefore, that the INMO has once again confirmed its commitment to the Lansdowne Road agreement. Through that agreement we have been able to deliver benefits for our front-line nurses such as the restoration of the increment for nurses who graduated between 2011 and 2015, amounting to some 4,000 nurses working in the Irish health service today who will see pay restoration of over €1,000 from January 2017. The public service pay commission has started its work and the Government will continue to work with ICTU over the coming weeks to ensure the continuation of a collective pay policy framework that meets the needs of public servants and society. I am well aware of the pressures felt by nurses and that is why budget 2017 provides funding for an additional 1,000 nurses to join the payroll. This is a very important role and I want to work with the INMO on recruitment and retention issues.

I want to see how we can improve and enhance the Bring Them Home campaign we have in place through the HSE to bring our nurses back home from abroad. I will be meeting the Irish Nurses and Midwives Organisation, INMO, next week as part of my ongoing engagement with key stakeholders on important issues relating to the health service.

The health services to be provided within the available funding will be set out in the HSE’s 2017 national service plan which is being finalised. I take the opportunity to outline key priorities for the year. One of my priorities when I was appointed Minister for Health was to reactivate the National Treatment Purchase Fund, NTPF. This year I secured an investment of €1 million specifically to treat approximately 3,000 additional people who had been waiting for an endoscopy treatment. As a direct result of this initiative, as at the end of October, the number of patients awaiting a gastrointestinal endoscopy had fallen dramatically, from 5,700 to 1,200. The NTPF is confident that by the end of the year there will be no patient waiting longer than 12 months for an endoscopy. Budget 2017 provides an additional €50 million to be allocated to the NTPF in 2017 and 2018 to treat patients who have been waiting the longest. It is important that we focus on those who have been waiting the longest. I am not sure that was always the way the NTPF worked in the past, but it must work that way now. In August the HSE developed a waiting list action plan focused on reducing the number of patients who had been waiting the longest. Throughout 2017 my Department will continue to work with the HSE to reduce waiting times through driving efficiencies and process improvements, with a particular focus on adherence to chronological scheduling and validating waiting lists.

I am delighted that the €40 million allocated as part of the additional €500 million secured in July has been provided on a recurring basis for the winter initiative. Winter comes every year and it is important that funding be provided on a recurring basis. I am pleased that has happened. As part of the winter initiative, €7 million has been allocated to fund a targeted waiting list programme for orthopaedics, spinal surgery and, importantly, those with scoliosis. The initiative had provided resources to treat patients on orthopaedics and scoliosis waiting lists, with over 600 patients benefiting. Since the initiative was announced recently, 354 patients have either been treated or given an appointment to receive treatment within the next six weeks. This funding is crucial in enabling winter preparedness measures to be introduced across the health service and reducing overcrowding pressures in hospitals.

I very much welcome the additional funding in the budget of over €90 million for acute and emergency services. The increased allocation demonstrates the Government’s commitment to driving key policy and strategic initiatives to improve and expand acute care and emergency services for patients.

Patient safety and the delivery of quality services to patients will remain priorities for me, my Department and the HSE. Provision is made for costs associated with the new primary care centres and the extension of medical cards to all children in receipt of the domiciliary care allowance. Work will continue on the development of appropriate primary care services through primary care teams.

Of course, improving health services is not only about resources, but I hope the additional resources demonstrate our commitment to investing the gains from a recovering economy in a better health service. With increased resources we can at least plan for the challenge presented by increased demands. While we need to consider the challenges facing us, we should also recognise where progress is being made.

At a previous committee meeting Deputy Kate O'Connell and I spoke about maternity services. This is one area, in particular, where we are beginning to make a difference. This has been a landmark year for maternity services with the publication of the country's first ever national maternity strategy, Creating A Better Future Together, 2016 to 2026. The publication of the strategy demonstrates a new and enhanced focus on maternity care, both at policy and service delivery level. It provides a roadmap for how we can improve maternity and neonatal care in the years ahead. The Health Information and Quality Authority will publish in the coming weeks new national standards for safer and better maternity services. They will provide a framework for maternity service providers to ensure they are meeting the needs of women, their babies and partners and that a consistent service is being delivered across the country. These developments represent the necessary building blocks to provide a consistently safe and high quality maternity service.

The HSE’s national standards for bereavement care following pregnancy loss and perinatal death guidelines are also a positive step in the right direction, recognising that in the midst of devastation there are practical ways by which we can and must help bereaved parents.

I am aware that recently the committee was briefed by the National Paediatric Hospital Development Board and the Connolly for Kids Hospital group on the development of the new children’s hospital. The committee has asked me to address the issue and I am more than happy to do so. I want to be clear about this, as I read the transcript and watched much of the debate at the last meeting of the committee. It is very important that we all accept that every single person involved in, and every single doctor working in, the health service shares a common desire to try to put in place a national paediatric children's hospital. Some of the language used at the last meeting of the committee in terms of there being a suggestion anybody involved in the project, from a policy or medical point of view, would want to see anything but the best outcomes for the children was, frankly, offensive.

We are all united in a desire to build a national children's hospital. We can have disagreements but let us not get into the gutter. Let us not attack the bona fides of the people involved in this project. I have seen the people work and I have talked to the clinicians, who were working so hard on delivering this landmark project for Ireland. It is really important that the legitimate issue people want addressed, explained and discussed be addressed. Accountability is important. Please do not doubt the bona fides and intentions of any of the people in my Department or the HSE, or those on the National Paediatric Hospital Development Board. They are working tirelessly to deliver this landmark project.

Independent reviews since 2006 have reaffirmed the importance of colocation with a major adult academic teaching hospital. St. James's Hospital has the broadest range of national specialties of all our acute hospitals, in addition to a strong and well-established research and education infrastructure, making it the hospital that best meets the criteria to be the adult colocation partner.

Importantly, enabling works began this summer on the campus of St. James's Hospital and they are under way as we speak. The National Paediatric Hospital Development Board is currently reviewing tenders for the main works contractor and specialist subcontractors for the new children's hospital.

I will now address some of the issues raised at the Oireachtas committee meeting on 27 October. The issue of access to the children's hospital is of great importance to everyone associated with this project. The design of the hospital has recognised the need of most parents to access the hospital by car, and parking has been provided for families based not only on current demand but also on projected future demand. The parking system will also allow families to reserve spaces ahead of arriving at the hospital, and emergency drop-off spaces will also be provided. St. James's Hospital campus is better served by public transport than any other hospital in the country. I acknowledge, however, that most people will arrive by car. That is why it is essential to provide adequate parking.

The question of transporting neonates quickly and safely was raised during the hearing. This is very important for any parent, and it is important to raise it. The national neonatal transport programme serves the whole neonatal population across all 19 maternity centres and three paediatric hospitals and retrieves patients from anywhere in Ireland and abroad. In the programme's 14-year history, it has transported over 5,000 sick babies and, thankfully, there has not been one single fatality in transport. Let us acknowledge the work of the programme over 14 years. It has resulted in the safe transport of over 5,000 of our sickest babies.

It was suggested a children's hospital could be more easily, cheaply and quickly built on another site, such as that at Connolly Hospital. People have suggested it is not too late to change the site. I want to make clear that the cost of transitioning the new children's hospital to another site has not been assessed in any detail as no such project exists. We do know, however, that the transition of the new children's hospital from the current site at St James's would require the abandonment of all the work undertaken to date and a whole new design and planning process. At best, this would lead to a delay in developing this hospital, and it would also mean that construction inflation would be likely to have a significant impact on project costs. Together with lost expenditure on the project to date, that could off-set much, if not all, of any savings to be obtained from building on a greenfield site. That is the best-case scenario. The truth is that such an application would have no guarantee of success.

Let us not forget that An Bord Pleanála's report ruling on the planning permission for the hospital rightly referred to congestion on the M50 and seriously called into question the view that unfettered access to the Connolly site and to on-site car parking can be accommodated. Let us also remember when we are having these conversations that the National Children's Hospital at St. James's will be supported by satellite units at both the Connolly and Tallaght hospital sites. I have visited Connolly Hospital to discuss that exciting development with management, staff and patients there.

We all know at this stage, being truthful, that further debate will not create consensus on this issue. The debate has been running for a seriously long time. There are children whose parents could, understandably, have expected to have benefited from this hospital who are now no longer children. My priority is now to make progress on the new hospital as soon as possible. The decision on the location was made in 2012 and it was reaffirmed by my most immediate predecessor. My priority is now to get on with building the hospital so we can ensure children, young people and their families have the facilities they deserve.

I want to see continued engagement from the national children's hospital and the new National Paediatric Hospital Development Board with parents who have legitimate concerns. This is a hospital for the children and parents of Ireland. The voice of children has to be at the centre of this, and ongoing engagement with parents and children is essential although we will not agree on every issue. The commitment I give to this committee is that we should continue to engage on all the issues.

The hospital will be built on the St. James's site. Let us continue to engage on all the issues and provide assurances, information and exchanges of ideas. That is absolutely vital and I am happy to commit to this happening.

Another topic which came up during our discussion at the committee the last time was the opportunity e-health offers. Deputy Louise O'Reilly asked me several questions on this. Projects under development in this area include the implementation of a new individual health identifier, a new national laboratory information system and a new maternal and newborn information system.

I also want to refer to some key initiatives being progressed by my ministerial colleagues. Several members are interested in disability services, an area in which I too have an interest. My colleague, the Minister of State with responsibility for disability issues, Deputy Finian McGrath, has been driving specific measures in this area. While he will be happy to discuss this in greater detail, I will highlight some positive developments. The task force on personalised budgets for people with disabilities was established by the Minister of State, Deputy Finian McGrath, in September.

The terms of reference of the commission of investigation into a former foster home in the south east are being advanced, informed by the recent Dignam report. The registration of designated centres for the Health Information and Quality Authority, HIQA, inspections was successfully extended through legislation, while HIQA's excellent work through its inspections continues to be carried out. Children with disabilities continue to be a priority and in 2016 the health sector worked closely with our colleagues in the Department of Children and Youth Affairs to launch the new access and inclusion model for children with disabilities to avail of the free preschool year. There is a renewed commitment to continue to move people with disabilities out of congregated settings to enable them to live independently and to be included in the community. This is being supported by €100 million in capital funding from the Department of Health from 2016 to 2021. This will also be supported through the service reform fund which represents a combined investment of €45 million between the Department of Health and Atlantic Philanthropies. An additional €31 million of the overall health budget was secured in additional funding for disability services in 2016 and included in the 2017 Estimates.

In the area of mental health, my colleague, the Minister of State with responsibility for mental health and older people, Deputy Helen McEntee, established a youth mental health task force. This is a community-led group with representatives of the public, private, community and voluntary sectors, which is mandated to act as a galvanising force to improve the mental health and well-being of our young people. An important project advanced at budget time by the Minister of State, Deputy Helen McEntee, is the national forensic mental health facility at Portrane, County Dublin. This project was spoken about for years and now will be developed as a result of the additional funding secured by her.

It has long been Government policy to help older people and others to stay in their own homes and communities for as long as possible, with long-term nursing care being seen as a last resort only after home care and other community-based supports have fully utilised. Under this Government that emphasis is being strengthened. Overall funding for services for older people has increased to €765 million in 2017, an increase of €82 million since the HSE's 2016 service plan. This has focused on additional funding for home care in particular and is aimed at allowing people to continue to live in their own homes and at facilitating discharge of older people from acute hospitals.

Since her appointment as Minister of State with responsibility for communities and the national drugs strategy, Deputy Catherine Byrne, has launched a national public consultation process and published an expert review guide which will inform the development of a new national drugs strategy. This will be published in early 2017.

The Minister of State with responsibility for health promotion, Deputy Marcella Corcoran Kennedy, launched the A Healthy Weight for Ireland - Obesity Policy and Action Plan 2016-2025, with 60 actions to improve Ireland's health and to reduce the burden of obesity across society. This policy and action plan aims to reverse obesity trends, to prevent health complications and reduce the overall burden for individuals, families, the health system and the wider society and economy. We are on track to be the fattest nation in Europe if we do not get this right. This is an important initiative.

These, of course, are just a sample of the many initiatives being progressed by my colleagues. The development of primary care is central to the Government's objective to deliver a high-quality, integrated and cost-effective health care system. The programme for Government commits to a decisive shift in the health service towards primary care. This involves enhancing primary health care services, building up GP capacity, increasing the number of therapists and other health professionals in primary care, and continuing to expand the development of the primary care infrastructure.

The development of a new, modernised contract for the provision of general practitioner services will be key to achieving our objectives of treating more people in the community. Engagements to date have seen the Department of Health, HSE and the Irish Medical Organisation, IMO, agree several service developments including the introduction of a diabetes cycle of care for adult patients with type 2 diabetes, an enhanced support framework for rural GPs, and a revised list of special items of service under the contract to encourage the provision of more services in the primary care setting. The next phase of discussions on other aspects of a new contract is expected to commence before the end of the year. I have made it clear I want that process to be inclusive of GP organisations and look forward to the process moving ahead over the next several months.

We see the continued enhancement of speech and language therapy services for children and adults.

This has been a particular focus in recent years and development funding of €4 million was provided this year to focus specifically on speech and language therapy waiting lists in primary care and social care for children up to 18. This investment is allowing the HSE to fill 83 new posts in primary care to address waiting lists, prioritising the longest-waiting children for speech and language therapy. When these positions are filled, the number of speech and language therapists will be close to 700 whole-time equivalents.

The development of primary care centres to accommodate primary care teams is obviously an ongoing area of importance.

Regarding medical card coverage and developments, at 1 October 2016 there were just over 1.7 million medical cards, representing 35.9% of the population, and over 460,000 GP-visit cards, representing 9.8% of the population. Over 45% of the population has free access to GP services under universal GP care and the GMS scheme. This compares with nearly 38.1% at end of 2010.

Before I finish I wish to mention an upcoming event. I will shortly establish the new patient safety office based within the Department of Health, which will lead a programme of significant patient safety measures focused on initiatives such as new legislation, the establishment of a national patient advocacy service, the introduction of a patient safety surveillance system, extending the clinical effectiveness agenda and setting up a national advisory council for patient safety.

While we have secured a significant increase in funding for the health services, I do not underestimate the challenges involved in the delivery of a safe efficient health service. We must maintain our focus on improving the way services are organised and delivered. I hope I have given the committee a good overview of the many initiatives and reforms that are under way. I thank members of the committee for the opportunity.

If I can be so cheeky, I remind people that every Member of the Oireachtas has received an invitation from me to raise awareness about blood donation. We need more blood donations. It is something I have not done to date and I will rectify that wrong today. I hope as many Members of the Oireachtas as possible will join me after this meeting in donating blood. Transport provided by the Irish Blood Transfusion Service will leave Leinster House at 1 p.m.

Chairman

I thank the Minister.

After the opening statements we might address issues in the statements before proceeding to questions that have been submitted.

I invite Mr. O'Brien to give his opening statement.

Mr. Tony O'Brien

I thank the Chairman and members for the invitation to attend the committee meeting. As this is my first attendance and that of most of my colleagues at this committee since its establishment I take the opportunity to wish the committee well with its work and assure it of our fullest co-operation and assistance. I am joined today by a number of my colleagues, whose names and titles are in the written version of the statement. I will save time by not reading that out.

The committee requested information and replies on a range of specific issues, which have been provided. I will therefore confine my opening remarks to other matters. On income and expenditure, as at 31 August, the latest published figures, the HSE has recorded expenditure of €8.925 billion against a budget of €8.902 billion leading to a deficit of €22.7 million or 0.26%. Pensions and demand-led areas represent two thirds or €15 million of the overall deficit with the remaining one third or €7.7 million arising within operational service areas.

The HSE is in the process of developing the national service plan for 2017. We are in discussion with colleagues in the Department of Health on the development of the plan and we expect to submit it in draft form on 15 November, which is next week.

In emergency department, ED, performance, there were 909,468 emergency presentations up to August, an increase of 6.1% on expected activity. ED patient experience registrations in August 2016 were 4.8% higher than the corresponding period in 2015. Despite this increase, the INMO 30-day moving average for trolleys in August 2016 was lower than the corresponding period in the previous year by up to 5.6%.

The national service plan for this year prioritises a reduction in waiting times for hospital care with a focus on those waiting the longest so that there will be no inpatient or day-case patient waiting more than 36 months by year end. Hospitals are also required to reduce by 50% inpatient and day-case waiting lists for patients waiting 18 months or longer. At the end of August, 89% of the inpatient and day cases were waiting less than 15 months. In addition, 83% of patients on the outpatient waiting list were waiting less than 12 months and 90% were waiting less than 15 months.

The HSE is supported in the implementation of the winter plan this year, with the provision of €40 million, to provide a comprehensive range of actions and measures across community and hospital services to increase the availability of community care, facilitate timely discharge from hospital and increase hospital capacity.

Specifically, the €40 million provides for an additional 950 new home care packages and 58 weekly approvals for transitional care to support discharges from acute hospitals. An additional 55 acute hospital beds are being provided across a range of hospitals as well as 18 step-down beds provided by the Mercy University Hospital in Cork. The funding will support the expansion of minor injury services in Dublin for an additional 100 patients per week.

Community intervention team services will be expanded and there is an increase in funding for aids and appliances specifically to support targeted discharge of patients from hospitals. A targeted waiting list programme for orthopaedics, spinal care and scoliosis care is being implemented in designated sites by the year end.

In summary, the outcomes to be achieved through the implementation of this plan and through integrated working across community health care organisations and hospital groups are the reduction of delayed discharge levels and reduced numbers of patients on trolleys in emergency departments as well as improved patient experience times. In primary care, the HSE is continuing to work on the shift of clinical activity to primary care. Community intervention teams are now operating in 13 areas and expanding further for the coming winter period. Structured chronic illness programmes are under way for type II diabetes patients and asthma care for children. Improved access to diagnostic tests such as ultrasound is in place for general practitioners and minor surgery is also under way at 20 GP practices around the country. This programme of work is ongoing and scheduled to increase further in 2017, enabled by developments such as the review of the GP contract and ICT enhancements such as Healthlink, eReferral, individual health identifiers, IHI, and the development of a shared electronic health record.

In mental health, the allocation of an additional €15 million to initiate new developments in 2017 with a recurring full year value of up to €35 million will allow for the ongoing development of services in line with A Vision for Change. Approval has been received for the awarding of the contract for the construction of the new national forensic mental health facility at Portrane. This facility, estimated for completion in early 2020, will replace the existing Central Mental Hospital in Dundrum with a modern facility providing 120 Adult forensic beds, a ten-bed forensic child and adolescent mental health unit and a ten-bed mental health and intellectual disability unit. There is an ongoing need to improve access to psychological therapies for children. Funding is in place to develop this service and approval is now awaited and expected from the Department of Public Expenditure and Reform to recruit in excess of 100 assistant psychologists.

The 2016-17 'flu campaign which was launched as part of this year’s winter planning is well under way. This year’s campaign is targeting the challenges encountered in increasing uptake levels last year with each community health care organisation, CHO, and hospital group required to develop a 'flu plan. Staff are a particular focus this year with staff vaccination clinics being held in CHOs, supported by peer-to-peer vaccination training. In addition, poster campaigns, text messaging, screen saver reminders and other innovative ideas are being utilised to encourage staff, in particular, to get the vaccine.

This concludes my opening statement and together with my colleagues we will endeavour to answer any questions the committee may have.

Chairman

I thank Mr. O'Brien. I call Deputy Louise O'Reilly.

Deputy Louise O'Reilly

I wish to address a matter that was fairly conveniently not raised in Mr. O'Brien's opening statement, which is the memorandum that was sent. I note that the Minister for Health was outraged, as I was. I am well used to reading memoranda from the HSE. In fact, this morning is a little like a reunion of the national joint council.

The memorandum that was sent was disgraceful. How is it that it was drafted? Who approved it? Will Mr. O'Brien apologise to the staff at whom it was directed? Is this some kind of policy that is in place in the background which has leaked out by accident? I was outraged when I saw the contents of the memorandum as were nurses, midwives and other workers in the health service. Those people are owed an apology. That is the least they are owed. We should hear from Mr. O'Brien on the memorandum before we go any further.

Did it come from Mr. O'Brien's office? Was he aware of it and, if so, did he sanction it? If not, will he explain how a document of this nature was circulated without the knowledge of senior management?

To be fair to the Minister, he was first out of the blocks in expressing concern about the memorandum. I do not want to put words in his mouth by saying he expressed "outrage" but he definitely expressed concern. I have no hesitation in expressing outrage because that is how I feel about this issue. While I have other questions, I would like this issue to be addressed before the meeting proceeds to other matters.

Mr. Tony O'Brien

As my colleague, Mr. Liam Woods, confirmed yesterday, what we are talking about here is a memorandum prepared by the office of legal services for his information. The memorandum was shared only by him with a group of chief executives and for some reason was disseminated more broadly. From where does it come? In 2012, a particular case arose in a particular hospital that I will not name. It was related to a patient whose acute care phase had been long completed and who was refusing to leave the hospital and move on to a more appropriate care setting. The staff in the hospital, which included nursing staff, sought guidance as to what rights, obligations, duties and powers were available to them and a senior counsel provided advice at the time.

This issue is not about a general policy but about cases which are very rare in the context of the total number of patients who pass through Irish hospitals. In exceptional circumstances, it occasionally arises that there is a refusal to move on from a hospital for whatever reason. There have been other instances more recently which gave rise to similar inquiries to the office of legal services. As a result, based on that advice provided by a senior counsel, a memorandum was prepared and sent by legal services to the national director setting out various steps that would need to be taken to ensure every possible step had been taken to make appropriate provision and provide appropriate care to each patient and what steps might be available thereafter.

I emphasise that this is not about patients who have recently completed their care but about rare and exceptional circumstances which arise perhaps a handful of times each year. They occur when patients or former patients have, for whatever reason, a desire to remain in a care setting occupying a bed which they do not need but another patient may need and refusing to move on to another more appropriate care setting that has been provided for them.

The memorandum should not have been distributed as widely as it was. It was only available as a background note to advise people of the appropriate steps that should be taken to ensure patients get the right care in the right circumstances in these rare and exceptional circumstances. The memo had already been withdrawn from circulation almost two weeks ago because the person who received it took the view, which I share, that it should never have been distributed in that way. To the extent that it has caused distress to any staff member who received it or to members of the general public as a result of being disseminated, we absolutely regret and apologise for any concern to which it has given rise.

I am pleased to have an opportunity to make very clear that this is not about something that happens in the generality. It is about exceptional circumstances which, in a hospital system as wide as the Irish system, will arise only a handful of times each year. It is necessary, in the context of patients occupying beds that they no longer need while other patients may be waiting for those beds, to have a clear understanding of the appropriate steps that should be taken in such circumstances. I am not sure if Mr. Woods wishes to add anything.

Deputy Louise O'Reilly

I did not see the memorandum but watched the RTE reports on the issue. It is my understanding that the memorandum contained a reference to the use of minimal force.

Mr. Tony O'Brien

Yes.

Deputy Louise O'Reilly

The use of force, minimal or otherwise, should not be encouraged in any circumstances, however limited. That the Health Service Executive was examining the possibility of staff members having to use minimal force is what caused concern among staff representatives and patients. Mr. O'Brien stated the memorandum had been withdrawn.

Am I to take it that the memo is withdrawn so therefore the HSE is very clear that nurses, midwives, doctors, porters etc. will never be required - or asked in any way, shape or form - to use force, however minimal, to remove a patient from a bed? Mr. O'Brien referred to specific cases where people would not move on to more appropriate care. Mr. O'Brien will be aware that in very many instances people are stuck in hospital beds because there is not more appropriate care available for them. He must understand that the use of the word "force", even with the word "minimal" in front of it, is going to set alarm bells ringing. Mr. O'Brien has the opportunity now, if he could, to put a bit of distance between himself and that phrase, which is the one that caused concern.

Mr. Tony O'Brien

Sure. Let me step back and put that into its full context and then I will deal with the specific point raised by the Deputy. This was a total recitation of all the legal provisions that relate to a situation where a person refuses to leave a hospital bed. This is one line in a very long memorandum that deals with everything that should be done to facilitate the patient in moving to a right location. This is not about patients who do not have some place to move on to such as a nursing home place or supported discharge. This is about patients - and it is very rare - who, in the face of every possible thing having been done and provided, still refuse to move on. The reference to minimum force was not a suggestion that minimum force should be used. It was a reference to what the law provides for and what it was saying that people need to be very careful in these situations. There is reference to the necessity to protect people's interests, for example, by a referral to the appropriate courts to determine a situation if that should arise. To be clear, there has never been - and never will be - a direction that people should be using force, minimum or otherwise. It was a valid, comprehensive explanation of what the total legal position was. The use of the term "minimum force" is generally intended as dissuasion to the usual force. This is not about asking our staff to use physical force to remove patients from wards. It may well be the case, however, and it has been the case - and I suspect that in the future it will be the case - that there may be circumstances where the HSE or the individual hospital may have to seek the assistance of the courts to persuade an individual, in very rare circumstances and in the face of every possible assistance having already been provided in regard to alternative placement, to vacate a hospital bed to which they have developed an attachment but not a need, and where there is another patient who needs that bed. I hope I have clarified it for the committee.

Deputy Simon Harris

Deputy O'Reilly asked about policy. Policy is set by me, not by lawyers or anybody else. Let me be very clear that it is not the policy of the Irish health service - in any way, shape or form - to interact with patients in the manner suggested by the memo. Not only is that not the case, it is also not the case that front-line staff would or should ever find themselves in that position. I described this as utterly offensive and unacceptable. I did not just do that in public yesterday when the memo came into the public domain. I did it on 27 October, the day I was made aware of this by a nurse, in a communication on my behalf to officials, who communicated to the HSE. I was assured that the memo had been rescinded from circulation the following day. In fairness to the people with whom I work within the HSE, I do not believe it is in any way a fair refection on their commitment to, or how they view, patients. Yesterday was a bad day for the health service in that regard, but this is not the policy of the health service or the HSE. This was a legal memorandum referring to some very specific and rare situations. Let me provide assurance today to patients, to their families and to staff members in this regard.

I shall also pick up on the very important point that was made with regard to delayed discharges. We must all focus on reducing the length of time that people find themselves having to stay in hospitals. When I travel around hospitals it is clear that generally people do not want to be there any longer than they have to be. When one considers the metrics on delayed discharges, it is worth noting that on 13 September there were 643 people who found themselves in Irish hospitals, who were medically fit to go home but had nowhere to go. As of yesterday that number has been reduced to 538 as a result of winter initiative funding, extra home care packages and extra transitional care beds. That is where all our focus has to be. I welcome the clarification provided by the HSE and the apology offered by the director general this morning. I need everybody's attention and focus to now be back on reducing delayed discharges and providing the best service possible.

It is important and appropriate to raise this issue because it caused serious concerns.

Deputy Louise O'Reilly

The Minister referenced the ballot for industrial action by the Irish Nurses and Midwives Organisation that is currently under way. I suspect its members will be joined by other colleagues in the health service. You would not need a crystal ball to figure that one out. I understand also that the Irish Medical Organisation is balloting its members. It is safe to say that the health service is not a place of industrial harmony, rather it is a place of industrial unrest.

The Minister referenced pay and the Government's commitment to the Lansdowne Road agreement, but that agreement is at an end when it was breached. I and all of us here will know the terms of it, the manner in which it is applied and the strictures it places on people. It has been breached. The issues that the INMO has raised are not only about pay, they also relate to services. The Minister addressed pay in his contribution but he might address the services.

Another issue is that of recruitment. We would all be interested to know what it is that the Minister will do that has not been done to date. What has been done to date is not working. It is having a very limited impact. The Minister had targeted recruitment but he did not come anywhere near reaching his targets. I also know that some of the people who came to work in the health service have now gone back to where they came from. Whatever it is that the Minister has been doing to date is not working. We would like to hear what will be done that has not already been done.

Regarding Connolly Hospital and the location of the new national children's hospital. We have all been in receipt of representations and have met representatives from the Connolly for Kids Hospital group. Has the suggestion that the sites be flipped been given a detailed look - I am not talking about there being a report on it - whereby the satellite centre would be located in St. James's and the main hospital would be located in Connolly Hospital? The campaigners will know it is my party's view that this needs to be done and done quickly. We did not get hung up on one site over another but we do not want this to be delayed unnecessarily. Given the level and depth of concern that has been expressed, to what extent have the other alternative options been examined?

What is the timeframe for the colocation of the maternity hospital with the national children's hospital? I understand an application for planning permission for the maternity hospital has not yet been submitted. The trilocation element is key. We all know that. There will be an adult hospital and a children's hospital, but I struggle to know where it going to fit in on the campus. I am very familiar with the St. James's Hospital campus and I have seen an aerial view of the site that is marked out for it. However, the proposed site also raises concerns because, first, there does not seem to be any urgency about this project and, second, when all the people arrive at the hospital where will they park their cars and how will they get in and out of the hospital? If one has occasion to use the maternity hospital that is planned for the campus at 3 a.m., one will not be travelling to it on the Luas but by car. We need to have some idea of when we will see the colocated maternity hospital, as we do not know that. The concerns that have been raised, justified by the by the campaigners, should be addressed. It may be that we will never reach agreement on this but at least those concerns, which are heartfelt, should be addressed.

Deputy Simon Harris

I thank Deputy O'Reilly for those questions. First, the INMO has decided to ballot but I do not think the ballot has yet commenced. I am due to meet the INMO towards the end of next week. I would ask the INMO to do what it, in fairness, has always done during my six months in office, that is, to constructively engage. It has reaffirmed its commitment to the Lansdowne Road agreement and to operating within it, and I welcome that.

I cannot remember the exact word the Deputy used but she effectively said the Lansdowne Road agreement is dead. There is an onus on anybody who says that to explain where we will find the €1.4 billion that this would result in if we were to immediately end the agreement. We do not have it within the health Vote and I do not believe we have it within the education of the justice Votes. Many of the issues the Deputy rightly asked me about and on which she keeps me under pressure involve spending more money on public services. The budget looked at improving public services, public sector pay in terms of the Lansdowne Road agreement and trying to modestly increase everyone's take home pay in a fair way through tax reductions. If one disproportionately favours any one of those three elements over the other, it clearly impacts on the ability to do the other two, and we must be conscious of that.

However, there has been an ability, through the collective national framework, to address some of the issues which nursing representatives brought to me and my predecessors. I can give two quick examples. One is the unfair anomaly relating to pay for graduate nurses between 2011 and 2015. Approximately 7,000 graduated then and there are approximately 4,000 working in our hospitals. I concede that 3,000 are not, which is a sign of the problem with recruitment and retention. They will see their pay restored by between €1,000 and €1,500 from January. That happened through the Lansdowne Road framework, so there are flexibilities within it. Another example is the task transfer, the ability to recognise that the Lansdowne Road agreement refers to task transfer and that our nurses are doing jobs in hospitals that previously had been done by other health care professionals and must be paid for that. That has taken place now as well.

There are other issues in the Lansdowne Road agreement relating to nurses that need to be explored and discussed. However, it is important that everything is done in a collective manner. I listened to a former trade unionist on the media at the weekend who said that when there was no collective agreement in the past workers' wages decreased overall. A collective agreement works not just for workers and the Government but for stability for all of us. The INMO is a member of the Irish Congress of Trade Unions. The general secretary of the INMO sits on the ICTU public services committee. The Minister for Public Expenditure and Reform has met with that body and he said this week that he intends to continue to engage with it. I will meet the INMO next week. I always enjoy meeting the INMO because I find it a very constructive organisation. There are issues relating to recruitment and retention, and I accept that some of them are linked to the overall pay and conditions of nurses, but they must be addressed in a collective way. The sectoral, siloed way of looking at things will not serve this country well and it is not Government policy. It must be addressed-----

Deputy Louise O'Reilly

What does the Minister call the deal that was done with the Garda? A deal was done with the Garda which will cost more than €60 million. I do not know the exact cost, but it is extensive. Is that being done at the expense of services? That is the argument the Minister is making, that if he settles a dispute with the INMO he will have to cut the services somewhere else.

Deputy Simon Harris

If one settles any pay dispute, one will have to find it from the existing budget. There is no spare money.

Deputy Louise O'Reilly

Is that confirmation that the Department of Justice and Equality is going to cut back services to settle a pay dispute? I do not believe so.

Deputy Simon Harris

The Government made it very clear this week that the resources to fund that Labour Court decision, which was not a Government deal but a decision by an independent part of our industrial relations mechanism, which I presume the Deputy's party supports as well as the Government, will have to be found within the existing budgets. The INMO is a member of ICTU. ICTU is in a process of engaging with the Minister for Public Expenditure and Reform on behalf of the Government. The INMO members voted to be part of the Lansdowne Road agreement and this week the INMO reaffirmed its commitment to that agreement. The Minister for Public Expenditure and Reform has made it clear that there are significant challenges as a result of the independent decision of the Labour Court in terms of how that impacts on other unions within the Lansdowne Road agreement, but these must be addressed collectively.

The Deputy asked me what I will do about recruitment and retention, which is a valid question. The budget refers to 1,000 additional nurses. We are actively advertising to recruit nurses. One of the problems in recruitment and retention, as we all know from our lives and from talking to people, is that so many of our nurses and nursing graduates left the country because they were not being offered jobs, or they were being offered jobs for two or three months while the UK was offering them full, permanent contracts. That is the second piece. Every nursing graduate this year has been offered a permanent contract in the Irish health service. There has been an improvement in graduate pay from 2011 to 2015, although a number of that cohort went abroad. We now must bring them back and this is a further tool in the basket to do that. Their pay will be restored somewhat from January. We are recruiting for another 1,000 positions and we are now offering people permanent contracts. The Deputy is quite correct that it is not all about pay. It is also about the conditions in which people are working. We are investing in the health service again. Instead of cutting health budgets, we are expanding them. We are putting more resources into trying to make our health service function in a better way.

It is important not to have this conversation in a vacuum. While nursing numbers are still down on their peak, and I am certainly not suggesting that they are back to where they must be, the numbers have increased from September 2015 to September 2016 by 1,391. There are 1,391 more nurses working in the system this year than there were in September last year, so the numbers are moving in the right direction. There is significantly more work to do and I look forward to engaging with that.

On the issue of Connolly Hospital, I share the Deputy's view, from talking to parents, that people who express concerns are doing so in a legitimate manner, and they are legitimate and sincere concerns. I was simply making the point that in the dialogue and discourse it would be useful if people understood that the motives of the people trying to develop the national children's hospital are also good.

They too want to see improvements in paediatric services. All of the various options for acute hospital sites were considered by the Government of the day in the decision it made in 2012. Obviously, I was not in this role at that time. It is important to look at the multi-specialties available in St. James's that, quite frankly, are not available elsewhere.

I think the Deputy made a very reasonable point about the Coombe. St. James's is about the tri-location of the paediatric hospital, an adult acute hospital with a level of specialties that others do not have, which is vital for our children, and maternity services. The Deputy knows that there are plans to move the Coombe. The Deputy will ask me where it is at and will ask me to show a bit of movement on that-----

Deputy Louise O'Reilly

Is the planning permission even applied for at this stage?

Deputy Simon Harris

No, it is not, but let us be clear about a couple of things. While An Bord Pleanála did not look at a planning application for the Coombe, and I am not suggesting it did, it did look at the capacity of the St. James's site. The capacity is there. I will say this for the first time today - I have not said it before - I would like to see us now moving ahead with the planning permission phase for the Coombe. I have to be honest that the building of it is not going to happen today or tomorrow. However, let us move ahead to show the direction of travel because a number of parents that I have spoken to want to know that the maternity services are going to be there. That is vital and it is our policy to have them there. I will work with my Department and with the HSE to try to advance the design and planning of that. I will keep the committee updated on it.

Senator Colm Burke

I thank the Minister for his contribution this morning. I wish to raise a number of specific issues, particularly about the maternity and gynecological services. My understanding at the moment is that there is a substantial waiting list in Cork University Hospital for gynecological services. I understand that the HSE is aware of this. What action is proposed to deal with it? I think this issue has been raised but yet it appears that no progress has been made in reducing the list. What do we intend to do with this issue?

The second issue I wish to raise is the Portlaoise report regarding the maternity services in the midlands in which recommendations were made. What stage are we at in implementing those recommendations? I am a little bit concerned about reports. In terms of maternity services, back in 2003 there was something like slightly more than 100 medical consultants in obstetrics and gynaecology. It was suggested then that by 2011, we would have 180 such consultants. My understanding is that we now have 130 whole-time equivalents. The Minister spoke earlier about maternity services and when I see reports coming out, I wonder about implementation. We are now 13 years on from the report of 2003. The number of deliveries increased dramatically in the period from 2003 to 2010. It has reduced a bit since, but that does not mean we should now park employment in both gynecological and maternity services.

It is not just about consultants, but also is about nursing staff. The report on Portlaoise recommended the appointment of a director of midwifery - I believe that was the title used - in each of the 19 maternity units. What is the progress in that regard? I also understand that we may not have the people to meet the criteria that have been set out for that role before someone can be appointed. To how many of the 19 units has a director of midwifery been appointed? What progress has been made in filling the remaining positions? Will I be asking the same question again in 12 months' time? I am a little concerned about that.

I also wish to raise the issue of additional staff, particularly junior doctors and nursing staff. In 2015, we spent €225 million, almost a quarter of a billion euro, on agency staff.

Up to June of this year, we have spent €113 million. We will come out with the same figure for 2016. One reason for that is that the education grants for junior doctors were withdrawn. If some of that was reinstated we might be able to reduce the cost of agency staff. What are we doing to cut the agency budget and to give the funding to people who are making the commitment and want to get on with a career in nursing or as junior doctors? When will we see a reduction in the cost of agency staff and an increase in the allowances that are given to the junior doctors?

I have another question to put later. It is one I asked in October 2013 and three years later I am getting the same answer. That is not good enough. I do not want to be asking the same question on these issues-----

Deputy Simon Harris

Which question is that?

Senator Colm Burke

I wanted a detailed breakdown of the number of consultant positions in each hospital and the number of vacancies. Fifteen years ago, every hospital under the old health board system planned the recruitment of a new consultant when it knew someone was retiring. We now seem to have no mechanism in place. An average of 120 or 150 consultants retire every year. There is no reason that we should not advertise those posts 12 months before those people retire so that there is someone to fill the posts the minute the retirees walk out the door. The answer I got to that question today is as if someone pressed a button and did no research because when I put that question in October 2013, I got the same answer as I got today. I put the question in 2014 and I got a detailed reply. I cannot understand why that detailed reply in 2014 could not have been updated for today’s reply. I do not think it is acceptable. We were asked to submit questions four weeks before this meeting and it is not acceptable that someone can press a button and give me an answer without doing any research, especially when it was already set up in January 2014. We have made no progress since then on this issue, which is an extremely important matter. There are three parts saying it is not possible to give the answer, yet in January 2014 I could get an answer to the same questions. Surely there should be a carry on from something that was decided in January 2014 and records could be updated accordingly without someone pressing a button.

Deputy Simon Harris

I agree and will try to get some answers to those questions. The questions are largely about operational management of the HSE, in respect of agency staff numbers, filling maternity posts and the question Senator Burke asked, and the gynaecological waiting lists in Cork. We will try to give an assurance that Senator Burke’s question will be answered with the information that was not provided to him.

From a policy perspective, we are actively in the business of converting agency posts to permanent posts. That is not always possible and I will let the director general of the HSE give the committee a detailed update on where we are at. The problem is that where one can replace an agency post it makes sense to do so, from the cost and service delivery points of view.

In respect of maternity services, 2016 is a landmark year because we are putting the policy building blocks in place. Last year, we did not have a national maternity strategy, or bereavement standards for people bereaved during pregnancy or by a perinatal death. We did not have Health Information and Quality Assurance, HIQA, standards, which are about to be launched for maternity units, and we did not have an advanced plan to try to relocate the national maternity hospital. A significant amount has happened this year which leads me to believe that priority is attached to maternity services. Would the director general like to refer the questions on?

Mr. Tony O'Brien

Yes, but I will ask Mr. Woods to respond to the questions about maternity and gynaecology.

Mr. Liam Woods

I am aware of the point that the Senator raised about Cork and Kerry and the waiting list issues for gynaecology services.

As part of our overall approach to waiting lists for this year, to which the Minister referred earlier, we are seeking to remove all of the long waiters. There is a focus on bringing those waiting, in both time and number terms, back to 18 months, but also behind that mark as best we can. The challenge, from our point of view, is interesting. Looking at our own data, the slight fall in the number of births, back to approximately 63,000 to 64,000, is leading to an increase in the provision of gynaecology services, but there is also an increase in demand and we are working with that. I have dealt with the south-south west area group on that issue specifically in recent times.

On the Portlaoise report and the recommendations, a detailed list of all the recommendations is reviewed on a monthly basis, both by the HSE and the Department of Health, and it is published on the Department's website. I will make a couple of observations about the points Senator Colm Burke referred to specifically.

On obstetrician numbers, as I understand it, the number the Senator quoted is approximately the number - 130 whole-time equivalent obstetricians. If the Senator requires any further information on that, it is available. We appointed some additional obstetricians during the course of last year because funding was made available for that purpose and we will be able to do so again this year. In terms of numbers, we would be talking about between five and seven obstetricians per year. That is in hand.

On midwife numbers, a specific piece of work was done last year on the number of midwives required for the number of deliveries by unit. That report identified the need for an additional 100 midwives nationally. We have invested in those midwives in the course of this year and last year. Those numbers have been put in place and that analysis will continue. It is a dynamic analysis because the numbers are clearly changing with the volumes of service. That investment has been made.

On the appointment of directors of midwifery by site for the 19 units, four sites had directors of midwifery in place. I do not have the exact number in my head for those advertised and filled, but we still have another four or five to fill based on the first round of competition. The rest are recruited and are being put in place. We are going back to the market. Senator Colm Burke is also well informed in the point he makes about the specification for the role. We have had a look at that. We are working with our colleagues in HR to see how we can express that specification and still maintain a standard, but I understand the Senator's point.

The agency cost generally is over €225 million, over half of which is medical and most of the balance of which is on the nursing side. The HSE has been recruiting with a view to displacing agency staff and it will continue to do that. It is within our current operational remit to do that and it makes sense, as the committee would understand, in every way. There is some amount of agency that is endemic to the system because of the nature of the system, but we are above that amount, which, I understand, is the point the Senator is referring to. We have open flexibility around that recruitment. We are doing that and we have done some of it this year. That represents a financial saving to a hospital and also brings in permanent staff. Therefore, it is very positive. We are doing everything we can both to attract and retain staff in that context.

On the point the Senator raised about the replacement of consultants, in terms of the response I am quite happy to go back and look at a more comprehensive reply and pick up what was referred to in 2014. Perhaps I can deal with the Senator directly on that. In terms of the recruitment process within the HSE generally, there is full capacity to fill replacement posts and there is no obstacle to early approval of posts based on the notion that a replacement is required within a period of time. I understand the Senator's point, which is that it can take time - perhaps up to 12 months - to recruit a consultant and leaving a post vacant or having a locum for that period of time is less desirable than having a planned replacement. I fully get that point. I am aware that some posts are notified in advance and go to recruitment before the posts are vacated. Assuming reasonable notice of the intent to vacate the post, and it is almost always the case that it would be known, there is capacity for that. It is something that would be useful to encourage and pursue further. Operationally, it is within our flexibility to undertake that form of recruitment.

Senator Colm Burke

On the issue of 2014, a detailed list of all the posts in all the hospitals was given. It would have been easy to use that as a template to update the list every six months, but that does not seem to have been done.

We know that employees automatically retire at 64, 65 and 66. We can take it that 125 to 150 medical consultants retire every year so each unit should be able to identify who will retire in the next 12 to 18 months. We should be planning ahead for that but instead we are waiting until the vacancy arises and then advertising it. As a result, it is taking 12 months to three years to fill posts, which is not the way to do proper planning.

Mr. Liam Woods

I am very happy to refresh the particular data set the Senator has received but I would make the point that I agree we should be prospectively recruiting where we have vacancies arising. I am more than happy to authorise those kinds of posts within our current control environment; there is no difficulty with that. The point the Senator makes is a valid one and we should be encouraging it. In terms of the information, I apologise if it was not sufficient. We will come back to the Senator with that. I understand that the point he is making is to use it internally. Some of that practice is already in place. We need to grow it.

Chairman

The next contributor is Deputy Kate O'Connell.

Deputy Kate O'Connell

I thank the witnesses for coming before the committee this morning. First, to follow on from one of Senator Burke's questions and Mr. Woods's response regarding the 125 nurses and midwives that have been put in place, does that mean they have been recruited? What does "put in place" mean? Are those 125 personnel now working in the service?

The Minister for health promotion is not here but the Minister for Health might address the matter of the notable decline in the uptake of the HPV vaccine in the past year. When the former Minister for Health, Mary Harney, introduced this she expected an uptake of the HPV vaccine of approximately 80%. My understanding is that we exceeded that, with an uptake of approximately 90%, but due to various factors, including a fairly aggressive social media campaign and various claims about the side effect profile of the vaccine, we are heading towards an uptake rate of under 50%. That is concerning because it is in breach of the concept of herd immunity and in terms of how we had the possibility of eradicating cervical cancer for people like my young daughters. My understanding is that the fall-off in the rate of the vaccine uptake could translate to the deaths of 40 girls who are now 12, 13 and 14 years of age. Forty girls in that cohort will die of cervical cancer directly as a result of the fall-off in the vaccination rate. I would like the Minister to outline how that can be addressed. I want to highlight that the next phase in vaccination was for young boys. There has been a huge rise in head, neck and anogenital cancers in men. The HPV vaccine was to be rolled out to boys but as a result of the impact of a campaign, young boys are now not being vaccinated. There is a sense of inequality in that boys are not getting what we planned to give them.

Second, the Minister or the Minister of State, Deputy Byrne, might update me on the policy regarding medicinal cannabis use, about which there has been much talk lately, where we are going with that and the timeframe. There is concern among people with multiple sclerosis and parents of children suffering from seizures that this particular medication could assist them. The Minister might outline the position on that.

I am delighted to hear that the Minister is progressing the planning for the tri-location model at the St. James's hospital site and the maternity hospital. One of the main reasons I entered politics was to seek to have a maternity hospital and a children's hospital on the same site.

The effect of having one's child taken from one at birth and brought to a separate hospital is something I would not like anyone to have to go through.

We have a wonderful national maternity strategy. It reminds me of the introduction of the cancer strategy when I first returned to Ireland from the UK. We have a wonderful document to which many skilled clinicians in this country have given their time and expertise out of sheer dedication to the health service. Those of us who are elected - those who recently came to the House and those who are longer serving - know that we are very good at doing reports but there seems to be a major problem in the context of taking action and implementing policy. Could the Minister indicate how we will outline the national maternity strategy? If she is not in a position to do so today, perhaps in the future the Minister of State, Deputy McEntee, might refer to how the mental health of mothers could be incorporated into the strategy in order that we can combine maternity services and mental health services when women go into hospital to have children?

Deputy Louise O'Reilly mentioned workforce planning. That is a major issue. What I hear from doctors and others working in the health service is that in the past medical people went away and did training in Canada or Australia and they always wanted to come back to Ireland. Now, however, it appears that they do not want to return. This is just anecdotal evidence that I have heard. When there is a vacancy for a well-paid post, first, nobody applies for it and then sometimes the person who applies for and gets the job is not the individual one would ideally want to fill the position. There is a knock-on effect on the quality of care. I am concerned about the lack of buy-in on the part of medical professionals in respect of the system. I would like to hear if our guests are aware of any new initiatives to try to encourage medical professionals who trained here and who had their education paid for by the State to return to Ireland. We are essentially exporting them and not getting them back any longer. In the past, we used to benefit from the experience of other countries but now we are not getting those people back.

Deputy Simon Harris

I thank Deputy O'Connell. She raised many issues I am very pleased that she raised the issue of the HPV vaccine because it is really important that - based on all of the medical advice available to me, the Department and the chief medical officer - I get to put on the public record my support for this very important vaccination programme. The Deputy is aware that the immunisation programme in Ireland is based on the advice of the national immunisation advisory committee, which is a committee of the Royal College of Physicians of Ireland and which comprises experts in a number of specialties including infectious diseases, paediatrics, and public health. The committee's recommendations are informed by public health advice and international best practice. In 2009, the committee recommended the HPV vaccination for all 12-year old girls in order to reduce their risk of cervical cancer and the vaccination programme was introduced for all girls in first year of second-level school in September 2010. As the Deputy is aware, there are two licensed HPV vaccines available in Ireland and Gardasil is the vaccine used by the HSE in the school immunisation programme. It is provided free of charge to girls in the first year of second-level school.

In September 2011, a catch-up programme was started for all girls in second-level schools and the 2013 and 2014 campaigns were the final years of the catch-up programme. I am very much aware of the misinformation out there to which Deputy O'Connell referred and I am extremely concerned about the impact that is having on the health and well-being of young women. Cervical cancer is the fourth most common cancer in women worldwide. Each year in this country approximately 300 women are diagnosed with cervical cancer and approximately 100 women will die from the disease. All cervical cancers are linked to high-risk HPV types of infection.

There are more than 100 different types of HPV but published figures for 2014 and 2015 show that the HPV vaccine uptake was 87%. That was the highest ever uptake since the programme began in 2010. While I do not have final figures for the 2015 to 2016 programme yet, preliminary figures released by the HSE do indicate that approximately 5,000 fewer girls received the HPV vaccine for the period compared with the previous year. That significant decline in uptake does vary across the country, with some western and southern counties most affected. The decline is extremely regrettable and I am concerned that it might be related to unsubstantiated concerns about the safety of the HPV vaccine raised by groups.

Information is available for parents and I encourage them to check out all vaccines. The information leaflet on the vaccine is available on the national immunisation website, immunisation.ie. The website has been accredited by the World Health Organization, WHO, for credibility, content and good information practices. It allows members of the public to contact the national immunisation office to ask questions if they require further information. Where possible, the questions are answered by a member of staff in the office within one working day. I encourage the parents of this country to access this service, ask questions and look at the information. The information that is provided on the website has been accredited by the World Health Organization.

Gardasil is a safe and fully tested vaccine which protects against the main cancer-causing strains of HPV. Approximately 300 women are diagnosed in this country each year with cervical cancer. By January 2016 more than 200 million doses of Gardasil have been distributed worldwide and in Ireland more than 580,000 doses of the vaccine have been administered. More than 220,000 girls have been fully vaccinated against HPV since it was introduced in 2010.

It is not just me who is saying this vaccine is safe and it is not even just evidence in this country. We have also seen the results of the detailed, scientific review carried out in November last year by the European Medicines Agency, EMA, an agency which I hope will locate in Ireland. It examined the evidence surrounding reports of two conditions, namely, complex regional pain syndrome, CRPS, and postural orthostatic tachycardia syndrome, POTS, another condition which causes symptoms such as dizziness and fainting as well as headache, chest pain and weakness. In line with its initial recommendations, the EMA confirms that the evidence does not support a causal link between the HPV vaccine and the development of the conditions. Therefore, there is absolutely no reason to change the way the vaccines are used or to amend current product information. The agency’s committee for medicinal products for human use also looked at the issue and concurred that the available evidence does not support that CRPS or POTS are caused by the HPV vaccine and it therefore also did not recommend any changes to the terms of licensing or product information for those medicines. Furthermore, on 12 January this year the European Commission endorsed the conclusions of the European Medicines Agency that there is no change to the way HPV vaccines are used or to amend current product information. The final outcome by the Commission is now binding on all member states of the European Union. The review recognised that at the time more than 80 million girls and women worldwide have now received the vaccines and in some European countries they have been given to 90% of the age group recommended for the vaccine. Use of the vaccines is expected to prevent many cases of cervical cancer - cancer of the neck of the womb - which is responsible for more than 20,000 deaths in Europe each year, and various other cancers and conditions caused by HPV.

The benefits of the HPV vaccine are well known. They are well endorsed, not just domestically but internationally and they are now binding on member states of the European Union since the European Commission examined the issue in January 2016. I assure members that the safety of the vaccines will continue to be carefully monitored, as is the case with all vaccines and will take into account any future new evidence. I am genuinely concerned about the much lower uptake of the vaccine this year compared to last year based on preliminary figures. That will result in people dying of cervical cancer, a cancer which could have been prevented were people vaccinated. I again encourage parents to check out the expert medical information available to them and the information endorsed by the WHO on the website, immunisation.ie. I would like to see the expansion of the vaccination programme to boys and we will come back to Deputy O’Connell with plans in that regard.

I know maternity services is an area of particular interest to Deputy O’Connell. In terms of the national maternity strategy, she is correct in identifying the similarities between it and the national cancer strategy because the model of the former is based on the national cancer strategy. We are about to launch a new national cancer strategy in the coming months. The country has made so much progress in terms of cancer services because not only did we have a coherent strategy but we drove it on. It was driven on quite courageously by my predecessors.

The national maternity strategy replicates that model. We will now see the establishment of the national women and infants' health programme to drive on the delivery of that strategy, which is really important, and the HSE has advised my Department on it. The HSE representatives may wish to comment further on it, but it is now at an advanced stage regarding the appointment of an interim programme director for a period of two years. The clinical director post will also be advertised shortly. This is about putting the meat on the bones of what is a world class document on which so many people worked very hard.

It is stating the obvious to say that global competition for medical consultants remains extremely keen. Comparing September 2016 to September 2015, we have seen 116 extra consultants employed. We recognise the need to work on various issues. The issues, as many Deputies and Senators have stated, do not concern pay alone. There is a range of issues in terms of making Ireland attractive. The MacCraith report provides a plan, which we need to get on with and implement. It speaks of a range of issues above and beyond pay, particularly in respect of training. In 2015, in line with the MacCraith recommendation, we increased pay rates for new entrant consultants. This was done within the context of the Lansdowne Road agreement. We have also allowed for incremental credit for previous experience so that new entrants do not have to start on the first point, but this work is very much ongoing. Perhaps Mr. O'Brien may wish to comment further.

Mr. Tony O'Brien

I wish to give some degree of reassurance on the national cancer control programme. The previous cancer strategy was published in June 2006 and the programme was up and running in September or October of the following year. We are following a broadly similar trajectory. As the Minister stated, it is a successful template and we are putting in place exactly the same building blocks. I do not have any fear that this will be one of those documents that does not get implemented. I was heavily involved in the cancer strategy and we are definitely following the same trajectory and will get the same benefits. There is a slightly different context, however, and some of the questions that Senator Colm Burke asked earlier highlight some of the particular challenges in the area, particularly those around workforce planning.

Ms Mannion may wish to comment further on workforce planning, but the reality is that Irish graduates, be they medical or nursing graduates or graduates of allied health professions, are increasingly attractive as poaching targets around the world. This is not new, but its incidence seems to be increasing, particularly in the English-speaking world. We are operating in a much more competitive environment than ever before, which is showing in some of the competitions that were referenced. We would want to have the greatest field of competition for every post that we advertise so that we can continue to appoint the very best that we can.

Ms Rosarii Mannion

I agree that workforce planning is an area on which we need to work collectively with colleagues in the Department of Health. It is covered in the response from the Chairman - question 33 - around the cross-sectoral steering group that colleagues in the Department of Health have been working with us on. We are really pleased with this and within health, through leadership, we are setting up a strategic integrated workforce planning group. This will have representation from national doctors training and planning, nursing, health and social care professionals, support grades and management and administration. That has been established within the HR division. Our inaugural steering group meeting, which will be co-chaired by my colleague, Mr. John Hennessy, will take place next week on 17 November. That might give the committee some level of assurance.

Since January of this year, we have been looking specifically at the issues around consultant workforce planning, including what we might do differently and how we can improve. We have an excellent report - I agree that we are very good at reporting - but the strength of this would be simply in its implementation. The group behind the report was chaired by Professor Frank Keane. It was signed off on on 8 November, having been through our leadership, and the official launch is on 2 December. It will be supported by a national employment record which, referring to the previous Deputy's point, will give us all that data at a touch of a button by the first quarter of 2017. I have that report with me. It is entitled Towards Successful Consultant Recruitment, Appointment and Retention. We have the appendices. The e-module is established. If it is appropriate or if it would be deemed suitable, we can provide demonstrations to any Deputy in terms of how we are collating the data and how it will operate. They will be able to view the whole system.

We are also taking online feeds through the Irish Medical Council twice a day in order to ensure that we close off any issues in terms of data collection. As I stated, we are happy to give demonstrations. Further, I have the report with me and it can be given to the clerk to the committee if that is deemed appropriate.

Deputy Simon Harris

I forgot to answer one of Deputy O'Connell's questions.

Chairman

On medicinal cannabis.

Deputy Simon Harris

Yes, the Chairman also remembered it. My colleague, the Minister of State, Deputy Catherine Byrne, has responsibility for our national drugs strategy. Issues that concern drugs on the whole will be dealt with in that strategy and I will ask the Minister of State to comment further on it. However, in terms of my area of responsibility within the Department, it is important to provide an update to the committee on it from a medical point of view. As have all Members of the Oireachtas, I have been contacted by many patients who have a strong belief that medicinal cannabis could provide them with significant pain relief or even allay symptoms of what are some very serious conditions. Yesterday, there was a briefing by Deputy Gino Kenny on a Bill that he intends to propose. I also met with Ms Vera Twomey, who has been advocating for this change based on the medical conditions of her daughter, Ava Barry, yesterday.

Last week I decided to initiate a review of Ireland's policy on medicinal cannabis. We have to be led by the evidence. My instinct is that I would like to see a change in policy, but it has to be evidence-based and based on best international practice. We must follow the clinical and scientific evidence. Therefore, I have asked the Health Products Regulatory Authority, HPRA, formerly the Irish Medicines Board, which is the body that is available to us in terms of clinical and scientific evidence, to do a body of work and to report to me in January of next year on its views based on its research into medicinal cannabis.

From our conversations and meetings on it and from the work of the committee, I know that the Chairman intends - commencing this month - that this committee would also carry out work on the issue, which I welcome as it will be extremely complementary to the work of the HPRA. In that regard, I understand that representatives from the HPRA will attend a meeting of his committee on 24 November. I have asked the chief executive of the HPRA to keep this committee up to date with its work so that the work of both bodies might dovetail, with a view to being in a position in January where, collectively, we would have the information available to us in terms of the scientific and clinical evidence.

I do not intend to dilly-dally in terms of progressing any recommendations made but nor do I intend to buy into the myth that we can just snap our fingers and make changes in this regard tomorrow. There is an appropriate process, which is for both the HPRA and the committee to carry out their work. Having spoken to the Chairman yesterday, I know that a number of other countries have pursued a course of action in this regard. I do not wish to tell the committee its business but it may be of use to it to hear from them. For example, this week I wrote to my counterpart in Denmark. Denmark changed its policy in this regard on a four-year trial basis. I am eager to work on a cross-party basis. We will need to work on such a basis if we are to move this forward. I envisage that we would have a sense of the direction of travel we could collectively take by the end of January if people are prepared to take it.

Minister of State at the Department of Health (Deputy Catherine Byrne)

I have little to add to what the Minister has already stated. I know that the Private Members' Bill will be examined by the committee in November. It will also be examined by the Department of Health and the Department of Justice and Equality. This does not concern the medical use of cannabis, but during the week I launched a report on the prevalence of drug use and gambling in Ireland, including Northern Ireland and the Republic. As part of the overall picture of illegal drug use in Ireland, cannabis has one of the highest rates of use among all different ages, from age 15 to 65 plus. There is a huge emphasis on how we deal with the use of cannabis in the country. Once the Department of Health and others have examined the Bill, we will need to take some kind of proper action if certain reasons are identified for the use of medical cannabis in the long run. It is one of the most prevalent drugs throughout the country.

Minister of State at the Department of Health (Deputy Helen McEntee)

On perinatal mental health, the Chairman is right in stating that we do not have a developed policy. We do not really have any initiatives in the area, which is something that has been very much brought to my attention through various groups, including the National Women's Council of Ireland, and within the Department.

It is also an area identified for the task force on youth mental health. We have divided the zero to 25 years of age category into zero to 12, 12 to 18 and 19 to 25 years of age. The zero to 12 years of age profile begins at the very beginning. Expectant mothers are scanned for diabetes, high blood pressure and various other conditions, but there is really no type of scanning for the development of depression or other forms of mental health illness during pregnancy. In developing my priorities for this year's budget, developing a new initiative on perinatal mental health is very much part of them. I am happy to update the Deputy and others once it progresses.

Deputy Alan Kelly

I welcome the witnesses and I am glad to be here today. As the Minister knows, the Committee of Public Accounts sits at the same time as this committee and I rarely get to come here. I missed having the privilege of asking him questions approximately a month ago so I am glad to be here.

Who is running health care in this country at this moment in time? We must learn something from this. There are 15 people here, which is too many. For future quarterly reviews I ask that we have the Minister and the Ministers of State, and I hope the Minister of State, Deputy Corcoran Kennedy, is back at the Department holding the fort, the Secretary General and the head of the HSE. If they cannot answer questions that is fine, but the idea of having 15 people here is insane. It is ridiculous. I ask that we set this or some variance as a standard. Several minutes ago the Minister was asked a question and passed it on to Mr. O'Brien who passed it to Ms Mannion who said she would send on the report. It is ridiculous. I sat on the other side many times myself. We filled the role once or twice when I was there. The idea of having 15 people to answer questions is absolutely ridiculous and it is not good value for the taxpayer on a day like today.

I wish to ask about nursing. I do not know what the Secretary General is laughing at. Perhaps he will tell us. Does he have something to share?

Mr. Jim Breslin

It was regarding a previous point. It was not with regard to the point the Deputy was making.

Deputy Alan Kelly

Good. My colleagues have asked questions about nursing. We are facing into strikes in several months time. That is guaranteed unless the Minister can do something about it. I listened to the answers he gave earlier. I admire his energy and respect his capacity, but he cannot be all things to all people and he should not try to be. He will have to be imaginative to solve the issue. On behalf of the Irish people, I ask that he be imaginative now rather than at the last minute. Obviously he cannot reveal all his cards here, but I hope he has a plan in place to deal with what is glaringly obviously facing all of us given the decision on the Garda last week. The Minister can throw out the line it was a Labour Court recommendation and the Government took it, but we all know, and I know, how this works with regard to the Labour Court, the Department of Jobs, Enterprise and Innovation and the process by which it came about. The Minister needs to face up to this now to be able to deal with it in several months time. Let us not be back here speaking about planning for the strike and that the Minister has a way to solve it in an imaginative way within the Lansdowne Road agreement, which may or may not be possible. I want the Minister's assurance he is doing this.

Will the Minister guarantee he will come within budget this year? I will be delighted if he does but I would like a guarantee. I welcome the winter initiative and I have spoken to the Minister about it. In fairness, he discussed it in a good bit of detail with me in advance and I respect him for this.

We have a huge problem with home help hours. Will the Minister consider looking at a reallocation for this in the budgetary arithmetic? Financially there is huge value in it. I know from speaking with many of those working at senior levels in the HSE that they believe it would be something that could help them quite a bit.

I have a number of questions on maternity hospitals. I am a huge supporter of the national maternity strategy as I believe it is an excellent strategy. We must learn from what happened at Holles Street and in Portlaoise. It is all very well having a strategy, but it needs to be implemented pretty rapidly because of the issues I just referenced, and I would support the Minister on this. Unfortunately we will have issues while the strategy is being implemented. How will it be funded? Can we be innovative regarding how we fund it? I have some ideas I will share on this because we need to think outside the box as to how we will fund it.

Approximately three or four weeks ago, during Question Time in the Dáil, I asked the Minister about the use of private accident and emergency units for public services. He committed to get back to me on it but he has not done so. Will he, through the Secretary General, document the conversations and meetings which have happened in the meantime to show he has taken it seriously? He did commit to coming back to me. It is absolutely immoral and wrong that in 2016 an 85 year old woman can be left on a trolley in a public hospital in the Mater, while 100 yd. down the road there is a private hospital with a vacancy and that we can get into our cars and listen to the same hospital advertising for patients. It is wrong and immoral, and the Minister has a duty to deal with it.

Will the Minister confirm to me no partial or full review of the National Ambulance Service is taking place that will have any negative impact on the provision of the service throughout the country? I raised the particular issue of the mid-west with the Minister a number of weeks ago and he has not reverted to me. Will the Minister confirm there will be no diminution of services, particularly of advanced paramedics, in the country and in the mid-west? Will the Minister confirm this because he committed to come back to me on it?

We have a real issue with GPs. The Chairman is facing a critical issue with Shannondoc in his home county of Clare. The loss of services, particularly in rural locations, is absolutely frightening people. The Chairman and I will face a public meeting on this on Friday week. The services in County Clare are dropping significantly and the Chairman probably knows more about this than anyone. What is the Minister doing to ensure the loss of these services can be prevented or what alternative mechanisms can be put in place? We need a more holistic view on how we can get GPs into rural areas in particular and on how they can provide services.

I welcome the roll-out of community intervention teams and I am a big supporter of them, but we need consistency of approach throughout the country. How can we push this along in a consistent way rather than leaving certain parts of the country lag behind for a long period of time? I welcome the Minister's thoughts on this.

Will the Minister guarantee that medical postgraduate colleges will train enough specialists to provide for the health service and GPs? Will he guarantee to us here and now that issues will not emerge on the corporate governance of these colleges and how they ensure we have the volume of specialists and GPs coming through to meet the needs of the health service?

I am asking this very specific question for a reason.

Finally, will Mr. O'Brien issue a circular to the various regional authorities or HSE groups, if he sees fit to do so, in relation to some kind of consistent approach to the management of their communications? Some regions are using public relations firms and other regions are not. I do not see why some of them are spending taxpayers' money on public relations firms. Will Mr. O'Brien ensure there is a consistent approach here? I believe this is not a good use of taxpayers' money. When public relations are managing HSE regional corporate communications, it creates another layer. I suggest Mr. O'Brien needs to deal with this immediately.

Deputy Simon Harris

Deputy Kelly is making up for not being here the last time. I ask him to bear with me while I try to work through the questions he has asked. I share his view on the composition of delegations attending these meetings. I discussed this issue with my own team earlier. Respectfully, it is largely a matter for the committee to tell us who it wants here. I will come here, stand in the middle and answer questions all day long if the committee wants. We bring the full delegation-----

Deputy Alan Kelly

It is not a show trial, so the Minister is all right.

Deputy Simon Harris

Not yet.

Chairman

I will limit the number of invitations the next time.

Deputy Alan Kelly

I do not get to attend most of the meetings of this committee. I think this is just the second meeting I have attended. I cannot be in two places at the same time.

Deputy Simon Harris

We are more than happy to limit the number of delegates. It is a matter for the committee to order its business. As there are a number of Ministers of State in the Department of Health, perhaps thematic ways of discussing these issues would allow people to get into a level of detail. That is entirely a matter for the committee. While I am grateful to the Deputy for asking me about the serious issue of industrial relations, I suggest we need to take a step back. No decision to take industrial action has been made. Certainly, no decision to strike has been made. The INMO's executive council has decided to ballot for industrial action. I do not think that ballot has commenced yet. The result is due on 15 December next. The Deputy is entirely right when he says that as Minister for Health, my job is to look at how we are going to address this issue before that date nears. I believe it has to be dealt with as part of the collective challenges that have been identified by the Minister for Public Expenditure and Reform arising from the Labour Court recommendation with regard to the gardaí. The INMO voted to accept the Lansdowne Road agreement. In its statement on its intention to ballot its members, the INMO this week confirmed its commitment to living and operating within the Lansdowne Road agreement. As Deputy Kelly knows, the INMO is a member of the Irish Congress of Trade Unions, ICTU. The public services committee of ICTU contains the general secretary of the INMO.

Deputy Alan Kelly

That is all factual.

Deputy Simon Harris

It is, and it is important.

Deputy Alan Kelly

It does not deal with what is facing us.

Deputy Simon Harris

The facts I have mentioned are very important because I believe the solution to any industrial unrest, industrial action or sense of grievance within the public service, including the health sector, should be dealt with within the ICTU structure. My colleague, the Minister, Deputy Donohoe, met representatives of ICTU earlier this week and will have further meetings with them. I will meet representatives of the INMO next week. I will be happy to keep Opposition spokespeople briefed on the situation. In fact, I think it would be appropriate to do so. Members of the committee will understand that I do not intend to say too much in this public forum. I know Deputy Kelly is conscious of the point I made to Deputy O'Reilly earlier, which is that the budget for the year is the budget for the year and there is no more money on offer to me, or any other line Minister, to deal with new public sector pay claims. We have funded the implementation of the Lansdowne Road agreement.

Deputy Alan Kelly

There was no more money available to the Department of Justice and Equality either.

Deputy Simon Harris

That will have to be found within the new resources available to the Government. That was made clear earlier this week by the Cabinet and by the Minister for Public Expenditure and Reform in his public comments. I am proactively engaging with this matter. At the same time, I am saying very clearly to the INMO and this committee that the INMO voted for the Lansdowne Road agreement. It is within the framework and it wants to stay within the framework. It is a member of ICTU, which is engaging with the Minister for Public Expenditure and Reform. I will meet representatives of the INMO next week. I will be engaging. I agree with Deputy Kelly that we should use the period of time between now and any potential industrial action in January, if that is what members ballot for, to try to sort this issue out in the interests of patients and front-line staff. We need to operate in the context I have set out. I will keep in touch with the Deputy on the matter.

Deputy Kelly also asked whether we will come in on budget. The answer to that question is "Yes", but with one caveat because the State Claims Agency, which sits within my Vote, is not within my control or the control of anybody sitting in this room.

As these decisions are often made at High Court level, we will not fully know and we cannot possibly know-----

Deputy Alan Kelly

Is there not a built-in contingency in this regard every year?

Deputy Simon Harris

A level of contingency is built in, but no one can say with any certainty when the payments will fall due. This is why there is a caveat. The director general can comment further on this if the Deputy wants.

Deputy Alan Kelly

If the State Claims Agency is left out and indexed separately, is the Minister confident that he-----

Deputy Simon Harris

Yes.

Deputy Alan Kelly

Okay.

Deputy Simon Harris

I agree with what the Deputy said about the winter initiative. I know he wants to prioritise this issue and feels particularly strongly about home help. I will ask the Minister of State with responsibility for this area, Deputy McEntee, to speak about this issue. We have funded more home care packages and home help hours in the budget. My strong view is that we need to look at the policy underpinning home help and home care because there is a lack of consistency in this area. I do not know whether my colleagues around this table share that view. Like all politicians, I want people to grow old with dignity in their own homes. However, I am conscious that the only statutory scheme we have to underpin supports for older people is the fair deal scheme, which sends older people into nursing homes. It is not as easy to resolve as I might make it sound with that commentary. Some suggestions have been made. Deputy O'Dea has published a constructive Bill in this regard, but it has a number of limitations and challenges that we need to explore. I would be very interested in engaging with people on a cross-party basis in this regard. I do not think the current model of home care is sustainable unless we look at statutorily underpinning it as we did with the fair deal scheme. Why should the only statutory scheme be the one that involves sending people to nursing homes? Maybe we could discuss that further.

I thank Deputy Kelly for his comments on our world-class national maternity strategy. It is astonishing that we have not had such a strategy up to 2016. I am reassured by the fact that it replicates the model of the national cancer strategy, which got on and did things. As I have already outlined to Deputy O'Connell, an interim director has been appointed to drive the women and children programme within the HSE. The same model was used under the cancer strategy. Obviously, there is funding for the maternity strategy this year and into next year. I will get the figures for the Deputy. As Mr. Woods has already made clear, some 100 midwifery posts have already been filled as part of the driving on of this strategy.

Deputy Alan Kelly

What about the capital side?

Deputy Simon Harris

There is capital allocated for the national maternity hospital, but not yet for the other hospitals.

Deputy Alan Kelly

How will they be funded?

Deputy Simon Harris

I hope they will be funded in the context of the capital review. At present, there is no capital funding other than for the new national maternity hospital.

Deputy Alan Kelly

We will know early next year.

Deputy Simon Harris

Yes.

I have been working on the issue of private hospitals. I will ask the Secretary General to write to the Deputy in response to his queries in this regard. As I have said previously in the Dáil, there is merit in what the Deputy is saying. I know there is merit in it because my officials and I have met representatives of the Private Hospitals Association. We will document that for the Deputy. I will mention some of the challenges that exist. We have to acknowledge that many private hospitals do not have 24-7 accident and emergency departments, intensive care facilities or critical care units. Many of them provide episodic care to those with defined conditions, rather than those who turn up with emergencies. We are using them as part of our waiting list initiative. Their use is likely to increase in the context of the reactivation of the National Treatment Purchase Fund. They are also being used in the context of some of the winter initiative funding in areas like scoliosis, orthopaedics and spinal surgery. I will give an example of public-private collaboration under the winter initiative. Under a collaboration between the Mater public and private hospitals, respiratory patients can go directly to the private hospital rather than the public hospital. We will send the Deputy details of this in our letter. We are also trying to pursue a public-private collaboration under the winter initiative with Charter Medical's minor injuries service in Smithfield. That will commence in December. These are pilot schemes.

Deputy Alan Kelly

I accept all of that. As we face into a very difficult winter, the Irish people will find it immoral if there are private hospitals advertising for patients while accident and emergency departments in public hospitals are jammed with people on trolleys. The Minister needs to deal with this. I intend to keep raising it. It is completely immoral for this to be happening in 2016 and 2017. I know the limitations of the private hospitals, and I agree with the Minister in that regard, but I emphasise that they have some capacity to deal with people and thereby ensure we do not have backlogs in public hospitals. If we do not look at initiatives to solve this in advance, we will be facing into hell in such hospitals. This is just one component that could help to avoid that.

Deputy Simon Harris

I agree with the Deputy. I appreciate his statement that this is "just one component". A range of measures will be necessary.

Deputy Alan Kelly

I accept that it is not a silver bullet, but it will help.

Deputy Simon Harris

I also make the point that using these hospitals and the capacity that clearly exists within them - and which I do not dispute - for scheduled care also frees capacity in the public hospital.

Deputy Alan Kelly

I accept that.

Deputy Simon Harris

By sending the lady or man who may need a procedure to a private rather than public hospital through the National Treatment Purchase Fund, we free up a bed in the public system. In the conversation about using capacity in a private hospital, it should not just be about-----

Deputy Alan Kelly

This is a very specific issue. Somebody in the Minister's position will some day have to face it down. I hope that in future years we will deal with the accident and emergency crisis across the country. There are many aspects to it. However, in the short term, this is one way of helping to alleviate it. I understand all the scheduled procedures and the use of the treatment purchase funds. If we have a bad winter, they will not help the volume of people ending up in accident and emergency departments. Will the Minister please sit down and speak with those people in order to rent or otherwise use or take over their facilities in a crisis? It would be immoral to allow those facilities to lie idle or if these people believe it is okay to discriminate and say they want people who can afford to pay to go into an emergency theatre while 100 yd. up the road, there are people queuing out the door.

Deputy Simon Harris

I will but beyond morality I must point out the limitations, as I do not want to create an expectation this year that the public accident and emergency department process will be replaced by a direct access route to a private emergency department when that private department may not have the medical capacity to address some of these issues.

Deputy Alan Kelly

It has-----

Deputy Simon Harris

It has capacity and we are using that. From an operational perspective, I can ask the director of acute hospitals to give an example on how we intend to utilise that. I am open to further dialogue on this. I have given three examples of how we intend to utilise capacity in private hospitals.

Deputy Alan Kelly

The Minister did not answer with respect to the accident and emergency departments.

Deputy Simon Harris

I have with regard to the Mater public and private hospitals and a pathway for respiratory patients.

Mr. Liam Woods

We have had dialogue with the Private Hospitals Association, formerly known as the Independent Hospitals Association of Ireland, and we will have more shortly. As the Minister pointed out, we are engaging in a couple of areas of discussion. The Charter Medical service in Smithfield runs successfully and we are looking to expand it under the winter initiative so it can be used by GPs across the city, which would be welcome. We have discussed the accident and emergency department issue specifically with private hospitals. There may be some opportunity there and we are still exploring that with them. There are challenges. I have had dialogue with them about when we get into "surge" in the public system and if they have the capacity to support us or how it would work. Typically, we find that when we are in surge, so are they. To the extent that there is a capacity and we can use it, we are very open to that dialogue, which is ongoing as part of our preparation.

Deputy Alan Kelly

Being "open to that dialogue" are lovely words but what is happening?

Mr. Liam Woods

I highlight that we have had meetings and we will have more with a view to identifying whatever capacity is available. I have given two examples but we are open to more.

Mr. Tony O'Brien

This is not the simple solution that I think Deputy Kelly may think it is.

Deputy Alan Kelly

That is an unfair comment. I never said that. If Mr. O'Brien saw the discussion in the Dáil, I outlined how it would not be that easy. I understand the matter but in the pie chart of solving this issue, a percentage could be solved through this method.

Mr. Tony O'Brien

Yes, but we must also be careful that only the right patients are using these services, which are often described as emergency departments but they are not emergency departments as we commonly understand them.

Deputy Alan Kelly

I agree.

Mr. Tony O'Brien

I can give one concrete example.

Deputy Alan Kelly

I agree with Mr. O'Brien.

Mr. Tony O'Brien

I want to give a concrete example in the fact that it is a regular occurrence for 999 emergency ambulances to attend at some of these departments to remove patients and bring them to public accident and emergency departments.

Deputy Alan Kelly

I know it is true.

Mr. Tony O'Brien

We need to ensure-----

Deputy Alan Kelly

The witness is asking a question he has not been asked. I understand this and I agree with Mr. O'Brien.

Mr. Tony O'Brien

Deputy Kelly earlier stated he wanted "Yes" or "No" answers.

Deputy Alan Kelly

Not with this. Stop picking words.

Mr. Tony O'Brien

Look, I understand this committee should work by the members asking the question and the person called as a witness being able to answer it. The Deputy is hectoring me.

Deputy Alan Kelly

I am not.

Mr. Tony O'Brien

He is. I have told him definitively that this is a much more complicated issue and one of the factors we must address is that these centres described as emergency departments have quite varying capability. They operate to different hours.

It is not unusual for blue light ambulances to have to remove patients from the vehicle to public accident and emergency departments. The term "accident and emergency department" has no specific meaning that makes one comparable with another. Therefore, this must be done carefully. Mr. Woods has indicated the dialogue is ongoing to the extent that when it is safe, practical and reasonable to use those private facilities, they will be used, and when it is not, they will not be used. That is and must be our position.

Deputy Alan Kelly

I look forward to it.

Deputy Simon Harris

I said to the Deputy in Cashel that I wanted to speak to him about the ambulance service but we never got to it. I checked out the inquiry he made and I have been informed there is no intention to reduce service levels with regard to paramedics or advance paramedics in the area the Deputy asked about. We will write to the Deputy to confirm that.

On the issue of Shannondoc, it would be useful and I would be happy to meet Oireachtas Members from the affected counties. I should make it clear, as the HSE has made the fact clear, that this did not arise from a funding issue. The Deputy did not suggest that. This arose from a decision taken by the co-operative and I understand the rationale for taking that decision. I am very eager to try to see the position improved, and if there is a way the HSE or the Department of Health can assist in improving that in the short term, let us do it. I know there is a meeting either this Friday or next Friday about it so I will arrange to meet Oireachtas Members from all parties on it. The Deputy referred to a governance issue regarding a medical college, but I have no knowledge of it.

Deputy Alan Kelly

The Minister might come back to me about it.

Deputy Simon Harris

If the Deputy has specific information, I ask him to bring it to me as well. If there is any specific information, I would like to know about it. I will ask the question but I certainly have no information on it.

GP training is one of the more challenging areas. I know it is a priority project for the Chairman and for me as it is vital to ensure we have a sustainable health service delivered to communities. The key to making general practice sustainable is a new GP contract and engagement on that will start this year. That contract must be meaningful for GPs and the delivery of primary care. There is a body of work ongoing to ascertain what we want as a State and what we need from a new GP contract as people have been talking for decades about moving things into the community. Although there has been some movement, substantial parts of the process have not come about.

As the Deputy will know from his involvement with the previous Government, we have seen an increase from July this year in the number of GP training places, and we are now training 172 per year, an increase from 157. In 2010 we were training 119 GPs per year, so it is an increase. The Chairman would be much more knowledgeable about this than me, but particularly in rural communities and areas of urban deprivation, there are business sustainability issues, if I can put it that bluntly, for GPs. These are places where there is a need for a GP but there may not be a possible business case for a GP to justify establishing what will effectively be his or her own business. That is why I have made it clear in the context of the GP contract negotiations that we might consider the option of salary for GPs. If the State recognises the need for a GP in an area but there is none there, we could make an intervention and offer a salary. I have spoken to younger GPs who want a work-life balance. One should not have to be a wonderful business person to be a wonderful clinician or vice versa. If there is an opportunity for a possible role, we could explore that in the context of the negotiations.

Chairman

I have a question on what is being discussed. The Minister mentioned some critical issues, with one being the GP contract. Is there a timeframe for negotiating this contract? It has become critical. We are losing our newly trained GPs and established GPs who are retiring early or emigrating. There is an ageing population of GPs, with 33% being over 55. This feeds into the lack of GPs working in rural areas and deprived urban areas. Certainly, the problem with Shannondoc and other co-operatives is not just confined to Clare or Tipperary. It is a national and international issue as it is very difficult to attract GPs to work in rural and isolated areas if the conditions of service are so onerous that it is impossible to run a practice, make a living and have a reasonable lifestyle. The timeframe of the GP contract is essential to how we deal with out-of-hours issues and recruitment of GPs.

Deputy Simon Harris

I can give a timeframe for the commencement but I will not give a timeframe for the conclusion. I would be an awfully bad negotiator if we got to that.

We need a new contract. GPs recognise it, the Government recognises it, every political party recognises it and the patients recognise it. We do not need an effort to put in place one big-bang new contract to be a static document for the next few decades. Primary care developments are moving at too fast a pace. We are operating off a contract that was originated 44 years ago. Both the body of work and timeframe that would be involved in replacing it with a new contract would be colossal.

The negotiations will commence this year, which gives a very narrow window of opportunity. I would like to take a phased approach to it. While it will be very difficult for GPs and the State to agree a big-bang approach to a new contract, we can make progress on a number of issues in an incremental timeframe. This year, I have made it clear that I would like a range of organisations to be involved. That is not with any preference. As a policy-maker, I should not care of which representative body a person is a member. I should be willing to engage with all GPs in the interests of all patients. Work is ongoing. My officials recently met the National Association of General Practitioners, NAGP, and the Irish Medical Organisation, IMO, to try to work out the structure of the dialogue.

Mr. Tony O'Brien

I reiterate what the Minister said about the size of delegations. I have been criticised for bringing both too few and too many. We are happy to take guidance from the committee. Like the Minister, I would be happy to attend if the committee wants me to, with the understanding that I will follow up with any information not in my possession at the time.

As the Minister said, with the sole exception of the State Claims Agency, costs that are difficult to quantify in advance are expected to come in collectively on the nose. I would always include the caveat "in the absence of any public health emergency arising" in that regard. While I do not believe we will have one, if one arose, we would have to deal with the attendant costs. There is no such thing as contingency in a public sector Vote. There are provisions based on best estimates, and the State Claims Agency has such an estimate against it. It could be right or wrong.

Deputy Kelly and I will find ourselves in a good measure of agreement on communications.

Deputy Alan Kelly

That is a first.

Mr. Tony O'Brien

It is not the first. We have done it before.

Deputy Alan Kelly

I am joking.

Mr. Tony O'Brien

This is an unintended consequence of two issues One is the proto-establishment of the hospital groups at the same time as restrictions on employment led to the development of communications capability on an outsourced basis. It is not universal, but applies to some groups. We have assessed the variability to which it gives rise, given that we also have groups that have insourced communications. We intend, as strategically as we can in light of employment numbers, to move towards an insourced basis. In the performance and accountability framework that will be published alongside the service plan for next year, the specific issue of the way information, reputation and good accountability through communications is stewarded will be addressed. This will be directed centrally.

Senator John Dolan

The Minister said he did not regard health as a party-political issue and he also spoke about the increased incidence of chronic conditions. I hope health does not become a party-political issue. It is important for us to say what health is, as distinct from what it might not or should not become. For me, it is a societal issue. I come immediately to the 600,000 people with disabilities or chronic illnesses and the 200,000 carers. Everybody will find themselves in this space. This is about how we see the trajectory and the planning regarding services into the future.

In my first question I talked about knitting the commitment to ratify and implement the UN convention into the statement of strategy, specifically that it would state that it is a matter for ongoing consideration at a senior management level in the Department. Although the reply was helpful, it was a little shy of that. Everybody comes into the disability or chronic illness space at some stage.

Given the increased incidence of chronic illness, planning is extremely important. As I said earlier this week, I am very concerned that if there is any increase in costs of paying people who provide the services, it will come from the level of service the Minister is struggling hard to try to provide. Employment is a major element of what is a personal service. I am not saying whether there should or should not be any movement in it.

We talk about the winter initiative. There is a disability issue morning, noon and night, winter and summer, but probably more in the winter time. Many people are on a knife edge and are already getting less than they need. This is another worry and concern on top of it. The Minister understands the load he and his officials bear when they go into negotiations and try to be fair to everybody. We have a huge distance to travel regarding the UN convention.

The director general's opening remarks were the opening remarks for this meeting. They were examining many issues that are here and now. We should have a decent idea of the trajectory of chronic conditions. This is not a criticism of the Minister but must be dealt with. Some of the causal factors are behavioural, and some are due to the parents people had which we cannot do anything about. However, we can do more about amelioration, early intervention and good self-management, and there are many organisations in that space. In parallel with dealing with the hot issues at the moment, it is important that we see the template regarding what Ireland is facing. For example, at a presentation here a few weeks ago, Dr. Joe Harbison said that in 20 years we will have twice the number of people who have suffered strokes. Let us start to put those things together and figure out what can be done in a range of ways about them.

I have written to every Department about disability and the statements of strategy. Disabled people are simply members of the public to be served. Health has taken up more of a load than it ever should have regarding people with disabilities. In many Departments, there is a knee-jerk reaction to send any disability issues over to the Department of Health. There is plenty for the Department of Health to get on with, and there is plenty for other Departments to do.

The success and value for money from health spend around disability and chronic illnesses is what people can do outside health. Can they get jobs and be part of their communities? It is a major issue.

What has to happen outside health to get the good bang from the investment that health is struggling to put in? A strong statement on this should be in the statement of strategy and that might encourage others to do the same.

What will be the quantum of the additional delivery of services to people using personal assistants, PAs, next year? The Minister helpfully said increases in PA services are needed. His service plan will not be published for a week or two. What improvement will there be in the hours and services available for people in the year ahead? If he cannot reply now, that is fair enough but that is the question.

My third question relates to the provision of neurological community and hospital-based services in 2017 over and above the current level of service. I am in the same time warp in this regard. Hopefully, the reply will be one I would like to hear. Specific condition support organisations and other disability organisations, the Department and the HSE could do better work on early intervention and supporting people. The Minister mentioned that the fair deal scheme is statutorily underpinned whereas community services are not. Provision has been shaved away over the years. Putting supports into the community will take pressure off acute services and make sure people who should never be in the acute system do not end up there.

Mental health reform groups were buoyed up when they heard €35 million would be provided next year but now they are hearing the figure will be approximately €15 million, increasing to €35 million the following year. They are concerned that this amount will not be available next year because it is needed.

Senator Keith Swanick

I have been liaising with my party colleagues, Deputy Butler and Councillor Murphy, on Waterford hospital. Dr. Herity recommended that the hospital should be funded for an additional two angiography sessions per week, which would deliver approximately 3,000 more appointments. What is the timeframe for this to be implemented? Will it be later this year or early next year?

I welcome the additional €18.5 million in funding for the primary care strategy and I also acknowledge the work on the development of primary care centres around the country but it is not all about bricks and mortars. It is about the activity that happens within the centres. Bearing that in mind and the serious manpower crisis in general practice, will the Minister consider specific funding for practice nurses in the context of nurse prescribing? There are many inadequacies within our health system in so far as GPs perform nursing duties and consultants perform GP duties. If GPs are considering sending their nurses a on nurse prescribing course, they have to fund it themselves.

Given 90% of all patients are seen in general practice on a day-to-day basis, a specific model to fund practice nurses in nurse prescribing would help the transition of the patient through the system in a more timely manner and would help alleviate the pressures we are witnessing in primary care and it probably would reduce the referral rates to secondary care.

Deputy Simon Harris

I intend to visit Waterford hospital shortly and I made clear in the statement I released when I published the Herity report and in my correspondence with the HSE in the context of the service plan that I expect those service improvements to be advanced and progressed in the context of the HSE's 2017 service plan. I expect to deliver on them early in 2017 and I will have an opportunity to detail more of that when I visit the hospital shortly. I look forward to doing that.

Senator Swanick made an important point on primary care. I had the honour of addressing a practice nurses conference in Santry recently. They left me in no doubt about this valid point we are discussing. The GP has an important role in primary care but there is an issue about resourcing the practice nurse to do more as part of the GP's team. These issues will be considered and addressed in the context of the GP contract negotiations. The negotiations cannot just be about the GP and the State; they have to be about the GP and the GP's team of support, including other health care professionals. That will be addressed in that context.

I refer to Senator Dolan's questions. I am aware of his work in this area for a long time and I admire his commitment. It is important to have him in the House on behalf of the 600,000 people with disabilities. We are lucky to have Deputy Finian McGrath as our Minister of State with responsibility for disabilities and he will go through the specific issues raised by the Senator but we will make sure disability issues are front and centre in all our Department's strategies.

The neuro-rehabilitation strategy is important. I had an excellent meeting recently. I would like to acknowledge Deputy O'Reilly's colleague, Councillor Natalie Treacy, who has done superb work in this area. Councillor Treacy and representatives of the Neurological Alliance of Ireland, MS Ireland and another organisation came to see me recently. I asked them informally to do some work with me on the need to improve our neuro-rehabilitation services. We will detail improvements in the service plan for 2017 but the key element - I think there was agreement at the meeting - in this regard is the need to publish the implementation plan as quickly as possible. It is due shortly and it is a priority. At least then, we will have the long awaited roadmap. In fairness to the HSE and all those working on the strategy's implementation plan, they had the common sense that when the feedback came in from the consultation that people were not satisfied with the implementation plan to have another go at it to try to make it better. I expect the implementation plan to be published shortly. I also expect to visit the National Rehabilitation Hospital in Dún Laoghaire shortly. I have asked again that the delegation would accompany me because while there is a significant project of work planned for the hospital, which is exciting and will result in significant improvements for patients, there is a bigger campus. We should have a discussion about a master plan and look on the development at the hospital as phase 1 with a view that more needs to be done.

We also have to look in the context of our hospital groups structure at the ability of some of our lower level of acuity hospitals to do more in the rehabilitation space. I think of County Louth when I reference that. Our Lady of Lourdes is the acute hospital but the stroke rehabilitation work being done in the county hospital in Dundalk is impressive and it wants to do more. I visited Roscommon hospital recently to announce and progress funding for its rehabilitation unit. The idea that all roads lead to Dún Laoghaire must be challenged because of the significant burden that places on families and support structures.

Minister of State at the Department of Health (Deputy Finian McGrath)

The issue of time and resources was raised. I am coming in at the tail end of the meeting on disabilities but any time the committee would like to talk about me these issues, I would be delighted to attend.

Importantly, a number of colleagues, both in opposition and in government, have come up with new ideas because I want to be a listening Minister of State for the disabled. Even in last night's debate on the Social Welfare Bill, the Chairman raised the point of allowances for people employed as carers which is a creative idea because we have a major problem in getting staff when it comes to carers. The Chairman should think about that but that is his decision.

Like my colleagues, I commend Senator Dolan on the work he has done for a number of years on the rights of people with disabilities with his group the Disability Federation of Ireland. I have a comprehensive plan and strategy to deal with services for people with disabilities. My whole ethos will be about investing and reforming. My focus will be on the person with the disability; the services have to be person-centred. I will ensure all services are planned around the person with the disability. My ambition is to rebuild the services. We accept they have been devastated over the past seven or eight years and part of the plan is to try to reinvest, reform and develop the services. In my first six months in the job, I have met approximately 2,800 people with disabilities, their families and service providers throughout the country. By Christmas, I hope to have met everybody who works in the sector. That is just the background.

On the UN Convention on the Rights of Persons with Disabilities, the Department of Health will shortly issue a statement of strategy which will outline the objectives of the policies and which will contain specific actions to enable and support people with disabilities to live independently and lead active lives in their communities. The lead responsibility for the ratification of the UN convention lies with the Department of Justice and Equality. However, the Department of Health will provide significant input into the drafting of the legislation.

The forthcoming Department of Health statement of strategy will reflect the importance placed on empowering people with disabilities to lead lives that will allow them to have greater independence and to gain access to the services they choose. The statement of strategy is coming out soon and we will include it in the latter. I will talk to the Minister, Deputy Harris, on the details of this issue.

The Senator asked that the needs and interests be considered at a senior level at all times in the Department. The answer in that regard is absolutely -100% yes. That view and the views of all people with disabilities are reflected in my meetings at the Department of Health and the HSE, and regularly at Cabinet meetings. As the Senator has told me on many occasions, disability rights and services are broader than just health. I need to focus on that. I think the Cabinet has accepted it at this stage. That is why I indicated that I will work closely with the Minister, Deputy Harris, to include the viewpoint to which I refer in the statement, which is very important.

Not only does the Department need to change radically, but so do society and political parties. I would always ask the question, "What are you doing in relation to the issue of people with disabilities?" That is very important.

The Senator also asked about personal assistant hours. We are looking very closely at this in preparing our service plan. I cannot give a specific commitment at this meeting. The provision of personal assistant hours is very important for people. We need to ensure that the people who have them get more hours. I take this opportunity to pay tribute to the late Martin Naughton, a great campaigner on disability rights. He pushed for that issue for many years and he reminded me of it regularly when I took over as Minister of State. That was one of my reasons for putting him on the task force for personalised budgets. We need to deal with these issues. We are starting that process. I will do my best to include personal assistant hours in the service plan.

Of course, I have my own personal issues regarding respite places for intellectually disabled people and quality day services.

We had a few successes regarding day services this year. It is very important that people know that. We have to rebuild and invest in our services. The bottom line is that we have to ensure that every person with a physical or intellectual disability is respected as a citizen of the State and that their rights are protected. Part of that strategy will be radical reform and investment in the services to ensure that every person with a disability gets his or her rights.

Deputy Helen McEntee

I know it is now 12 noon, but I wish to touch on two things. In the area of home help, the objective is to keep people within their homes for as long as possible. The Minister of State, Deputy McGrath, rightly said that disability should not just be related to health. I share the view that when it comes to supporting older people within their homes, it is not just a health issue.

The national positive aging strategy is the first strategy of its kind to identify that. I look forward to working with every Department next year in moving that strategy forward and identifying how we can help to keep people in their homes. However, obviously home help is one of the biggest elements of that. As was pointed out by Senator Colm Burke in the Seanad last night, there is a complete inconsistency in people being able to access the nursing home support scheme and obviously home help. That is because we do not have the framework. Work to develop a more stabilised framework or a formalised system is already under way. The Health Research Board is preparing a report on the financing and regulation of it. It will look at the regulation in other jurisdictions, the legislative framework, the registration process, the inspection regime, self-assessment, training requirements and the national standards. If we are going to make it work, we need to ensure we have a framework for older people or people with disability who need care. I hope that report will be presented to me by the end of this year and we will get working on it next year.

On budget day we announced €35 million worth of new initiatives. We were very clear that as in previous years, we have not been able to spend all of that. The increase overall is €24.7 million and while some would argue that only €15 million of that is on new developments, the €9.7 million on increasing staffing wages will help us to be able to spend the full €35 million or whatever figure we decide into the future as well. Mental Health Reform has identified that we need to inject €35 million every year for five years to fully implement A Vision for Change. The Government fully supports implementing A Vision for Change over that five-year period. However, if we do not plan and make those changes, particularly in the area of staffing, while we can allocate it, we will never be able to spend it.

There were a number of questions earlier about what we were going to do to increase staffing numbers. Thankfully, in line with the other nursing elements, over 90% of the psychiatric nurses coming out of college are getting full-time positions here. However, I am aware that we need to increase that. This year, funding was allocated for 60 new additional training places. That number will increase by 70 again. We hope that in the next four years, that number will increase to 520, which is a 45% increase. Obviously the €35 million and the new developments depend on being able to get those numbers. While I understand the disappointment that it is only €15 million, that is in the context of it being a full €35 million, with the addition of €50 million for a new forensic hospital, which I think we would all agree, is also a significant element of implementing A Vision for Change.

Deputy Finian McGrath

I forgot one short point when responding to Senator Dolan. The allocation for disabilities services this year will rise to €1.654 billion in 2017. We are putting in place a number of legislative items to ensure that we will be able to ratify the United Nations convention. As we go along, in order to ratify the UN convention we are also putting in place these services and extra issues as well. The Senator probably recently heard that the children who qualify for the domiciliary care allowance will be getting a medical card. These are all little rights and services that we are putting in place so that we can reach the target of ratifying the UN convention.

Deputy Louise O'Reilly

I seek clarification from the Minister of State, Deputy McEntee, on the percentage increase for the number of nurses.

I am aware, as are the witnesses, that the age profile of psychiatric nurses indicates there is a significant number of retirements coming up so the figure given by the witnesses has factored in all the retirements and the differences relating to the preserved pension age. I am sure Dr. O'Halloran is more than acutely aware of this. Some can go at 55 while others can hang on. Is the number based on all of them hanging on until 60 or is the Department building in the assumption that most will go at 55 because they would still be in the category that can go at 55?

Dr. Siobhán O'Halloran

The gradual increase is a factor of a number of things. It takes into consideration the previous earlier retirement rate of mental health nurses.

Deputy Louise O'Reilly

Could we get those figures?

Dr. Siobhán O'Halloran

We can send them to the Deputy.

Chairman

In the interests of time, and I know people have to go, Deputy Durkan will ask a number of short questions. Senator Colm Burke has one short question before we finish.

Deputy Bernard J. Durkan

The Chairman knows I am famous for my short questions. Unlike my colleague, Deputy Kelly, with whom I get along very well, I do not agree with having very few people at meetings of this nature. Occasionally, one needs a full house in order to get a comprehensive response to the issues that are likely to be raised by an equally large delegation from the committee. I compliment the Minister and Ministers of State and their officials for their attendance and wish them well in the work they have done so far and the work they are about to do.

I am a bit more radical than Deputy Kelly in the sense that I totally disagree with the concept of the HSE as a vehicle for the delivery of health services. I have always held that view. From the outset, I asked Mr. Brendan Drumm if he thought it was the appropriate vehicle and he said that on the day of his appointment, he did not know. I presume that over time, he came to a conclusion on that as well. I mean no disrespect to the good people here who do an excellent job and the people who have tremendous expertise in their own field and have a huge contribution to make to the provision of health services in this country. It is a second opinion. I believe there can only be one opinion, which is the Minister for Health and the Department, and no policy-making body other than one to carry out the decisions taken, as used to be the case once upon a time when the old health board system was in existence. One of the greatest things about the health board system was the fact that at a meeting of the health board, all the services involved sat in front of one at least once a month. It was a great way to keep up to date. The crises such as those one reads about in newspapers did not appear then because there was somebody there in situ knowing what was going to happen before it happened. I just want to mention that point. The Minister knows my views on this subject, as did previous Ministers.

I welcome the concept of budgeting with reasonable accuracy. We hope it is accurate at last in order to deliver services. Over the past seven or eight years, nobody could conclude with any kind of security what would be available to spend on anything. Virtually every service is short. Cuts fell on some like a guillotine and nothing could be done about it. Health, education, environmental and housing services have suffered. Everything suffered to a huge extent and the people suffered but the people who suffer most are those directly affected such as households where someone has a disability, whether a child or young adult or where someone has had to care for a relative with a disability for a long period of time, particularly the carer who may be a mother in some cases looking after a father, daughter or whoever the case may be. I and everyone here has seen this. I hope we are getting to grips with this situation. Somebody may have been caring for a relative for 40 years who was originally a child, the care of whom became a huge burden over time for the caring relative with consequent damage to his or her own health such as back problems. We all know people who have been affected like that. I acknowledge the presence of Jonathan Irwin. I also acknowledge the late Martin Naughton with whom I launched a service in that area many years ago.

If one looks at a household with a child with severe disabilities and asks how many people are available to care for that child as he or she progresses, we all have seen situations where women in particular may have spent 25, 30 or 40 years caring for the same child in a dedicated fashion, show the stress of it and do not always get the response they would like from the HSE, which is the delivery body at this stage. I am not criticising any of the witnesses. In recent days, I had occasion to try to source a location for residential care because I believe there is an interaction between the residential care and respite care that is available and the carer's ability to care indefinitely. It is not possible to move one without the other. The unfortunate 20 year old was being referred to a nursing home, which is totally inappropriate for a person of that age. I remember visiting St. Dympna's Hospital in Carlow as a visiting committee member many years ago to find a child having an epileptic fit in the middle of a group of much older people. I thought this was appalling. We need to move away from those prehistoric times. While we talk and all claim to know about it, it is only when one meets the person directly involved face to face that one fully appreciates what it means.

I ask the HSE not to allow situations to develop where that kind of resolution is proposed because it is inappropriate and does not work. We need to recognise that the mother, as was the case in this situation and a number of other cases, may have dedicated her whole life to the person needing care. There may be no other partner there to help, as is often the case. The trauma suffered by that carer over a period of time can be really serious. If that person tries to hold down a job, sometimes in the health care area, it makes it even worse because they must now juggle one and the other. Can the HSE seriously consider a form of residential care in particular areas where it is appropriate to cater for those kind of cases? I know the witnesses will tell me that we have respite care but we do not have it in the way we need it. There will be some cases where there is a need for weekly residential care with provision for the person to come home for the weekends, and that can work and has worked quite well.

Due to the budgetary restrictions over recent years, we have had to cut transport provision. Again, this is a huge problem for the unfortunate people to whom I have just referred and who the witnesses all know about. Could the mobility grant or something similar be introduced to replace what was there to ensure we do not differentiate between one patient and another and that if one mother has to drive her child to special educational needs services or work therapy, she is able to do so and is not excluded from a transport service provided to other children at the same time?

In respect of disability and psychiatric services, we could do nothing up to now. We may not be able to do all we need to do in the short space of time offered by the next year or year and a half, but perhaps we could focus on those issues in a way we have not done previously with a view to engaging in the forward planning that is necessary in order that it can kick into place when the time comes.

The home care package is an excellent idea. In a previous incarnation, I used to hear about how wonderful home care packages were and how everybody was going to be cared for at home. That is not so. It is not possible to do that and there will always be a need for institutional care of a high quality for a certain number of people who cannot be cared for at home because it would cost a multiplicity of converging arrangements to provide any degree of worthwhile care for them. The key point here is the quality of life for the person being cared for.

We must put in place the necessary measures to ensure the best possible service to ensure their quality of life can be provided for the person being cared for and also for the carer.

As I said, I welcome the provision of primary care centres but I am a bit suspicious of them. I would have thought the emergence of the primary care centres would show a dramatic reduction in the number of patients presenting at accident and emergency, particularly for minor ailments or even where minor surgery was required. I tabled a number of parliamentary questions to the Minister and his predecessor and I have not got the answer that I want. I am aware that patients still pass by the primary care centre and go on to accident and emergency. That should not be happening because it involves duplicating services and wasting money. One cannot have two staff doing the same job side by side, with one of them overcrowded and the other not. That is apropos of what was referred to by Deputy Kelly in a different context. As the Chairman will be aware, we need to deal with these matters.

On the question of the delivery of services to rural areas, there is a notion developing within some elements of the HSE that if everybody is brought into an urban setting, services can be delivered there. They tried that in the UK long ago and it did not work. It is as simple as that. That was found to be at fault. I would ask that we recognise that the purpose of this exercise is to deliver the highest quality services to the broadest spectrum of the population in the most efficient and effective way, including in terms of both cost and health.

I am in favour of medical cannabis. I assure the Chairman, unlike quite a number of others, that I have not yet even experimented with it and I do not intend to. I have experienced severe pain due to a particular condition I have. I know all about that and I know that those who suffer severe pain will do anything to alleviate it. The most important point is we strictly differentiate between recreational use and medical use. We need to get a second opinion on that to ensure we legislate for the patient, not for the frivolous.

The Chairman will be glad to hear I have come to my last point. This is something I hold a strong view about as well. When I was Opposition spokesman on health, there was a group of public hospitals that provided care for older people. Those hospitals were well established and built up over the years, but gradually they became the poor relation. People said these kind of hospitals brought about a stigma and that we could not have people living like that and so forth. We eventually got to a situation where somebody somewhere decided we would have no more such institutions and we would care for the people in the community. That would be a good idea if it happened, but it does not always happen. There are a number of such hospitals and residential community care centres which are public and which are doing a great job. I do not want to see them replaced by private institutions because there is an important element here that we need to keep on board. We need to be able to compare the private sector delivery with the public sector delivery without overlapping and side by side in order that we can have a clear evaluation of who is doing what.

Close to the Minister's heart is Crooksling where the highest quality of services have been available. I disagree entirely with the antics of the Health Information and Quality Authority, HIQA, in its efforts to reduce it to make it inoperable and uneconomical. There has been a dedicated staff there who have worked diligently to ensure the provision and delivery of the services, and they have done a great job. The patients they have - women only - could not possibly get the same quality of services in the home. It cannot be done.

One cannot deliver the services to 60, 80 or 100 patients in the same way as they can deliver them there in that fashion. As the Minister will be aware, we have a service in Athy in County Kildare and we have an excellent service in my own town, Maynooth. I am sorry for being parochial in these matters but those services are working extremely well and just because some genius, in working out decimal points in some place in the system, has come to the conclusion that he can do a better job elsewhere does not mean that he can. One such person emerged in recent times in the case of the location of GPs throughout the country. I would be delighted to accommodate that argument at any time whenever those individuals want to present themselves.

Generally speaking, the population of this country is almost double what it was in the 1950s. There are double the number of people working in this country than there were in the 1980s. We are in a far more demanding atmosphere than previously. This means that we now carry out an evaluation as to what we require in the future. Senator Colm Burke asked about various appointments, etc. All this information is available at the press of a button. One should not need to dig for it at all. If it is not available at the press of a button, somebody is not doing his or her job. All that information is right there. One can find out what are the requirements, how many staff are retiring, how many spaces are left to be filled, how many consultants will retire next year and how many GPs will retire next year.

Incidentally, I cannot see for the life of me why everybody should have to retire at 65. I assure the Minister that there are several GPs throughout the country who would be quite happy to continue on working well after 65, and well after 70 at which time they are obliged to retire, but who resent being asked to retire. They have given an excellent service which they built up themselves.

Chairman

I thank Deputy Durkan for his contribution.

Deputy Bernard J. Durkan

I knew the Chairman would be appreciative of that.

Chairman

If Senator Colm Burke would be ten times more brief, I would appreciate it.

Senator Colm Burke

President-elect of the United States, Mr. Trump, has now proved the issue in relation to retirement anyway.

Returning to my own queries, the reply to Question No. 15 was inadequate. It was not dealt with and I do not understand it. The reply is confusing. It is a simple question. My understanding is that in the case of the HSE north Lee public health nurses, at any one time there were ten staff either out on sick leave or maternity leave and replacements were not provided while they were out. I have no complaint about staff being out on maternity leave or sick leave. It is about the lack of a procedure for replacement. That amounts to almost 15% of the staff out at any one time, which puts an unfair burden on the staff who are there. I ask that the situation be addressed and that I get a proper written reply to that question.

I return to another question I set out earlier in relation to consultants. As far as I am concerned, the template was set out in 2014. I should not have to wait until January to get a report. I ask that I get a detailed reply before the end of the month on that matter. I do not believe I should have to wait three months. I do not have the privilege of being able to put down parliamentary questions in the same way as the Deputies have. We only ask questions once every three months and these are two questions where replies have not been adequate.

The other point related to persons with intellectual disabilities. The reason I raised that question was that I understand there is a difference in funding provided to organisations. One organisation is getting 19% less funding than comparable organisations which cater for the same number of people. The reply gave the cost of residential care as working out on average at €80,000 per person. My understanding is the average cost of the organisation I was in discussion with is €56,000 per person per annum.

The questions have not been dealt with appropriately. They are tabled once every three months. In submitting questions three weeks beforehand, we should be able to get the replies.

Chairman

I thank Senator Colm Burke.

I have one final question and it is a matter of urgency. In relation to bed capacity, there was a review and reconfiguration of services in the mid-west seven or eight years ago and acute beds were taken from Ennis and Nenagh.

Yet, the regional hospital in Limerick, University Hospital Limerick, as it is now called, has a major trolley problem. I realise the Minister visited the hospital some weeks ago but the same problem may not have been as acute as it was on Tuesday. A total of 66 people were on trollies in Limerick on Tuesday, a record number. This goes back to the reconfiguration and the bed capacity issue. I know a bed capacity review is under way. The living evidence of the shortage of beds is the trolley queues that continued throughout the summer. They never dipped unlike in previous years. Now, the hospital in Limerick has the highest number in what is probably the mildest winter we have had for several years and there is no influenza problem at the moment either. What is the situation with regard to bed capacity, in particular for Limerick?

Deputy Simon Harris

I will begin with your question, Chairman. I will ask Liam Woods to comment in a moment as the director of the acute hospitals division. Bed capacity is one of the issues contributing to the trolley situation in Limerick, but there are others. Bed closures or bed capacity not being opened in nearby hospitals, where they are available but where there is a staffing issue, is another contributing factor. Possibly, the primary care Shannon Doc configuration could be a contributory factor as well. Certainly, I am concerned that it could become a contributory factor. Another challenge in Limerick relates to the capacity of the emergency department - I am referring to the physical capacity. I was struck by this when I visited the building. I realise plans are under way for a new emergency department and staff will be moving in to it early next year.

We have opened a further 53 beds as part of this year's winter initiative. I will ask Liam Woods to comment on that in a moment. We are going to carry out a bed capacity review in general for the country. I am keen for the bed capacity review to be complete in time for the Government's capital plan review. Obviously, there is a cost associated with accommodating and physically fitting in to our hospitals more beds and for this to be done in time for the capital review.

It is important to consider several points when we are discussing trolleys. Specific hospitals have specific problems and there is no disputing that whatsoever. It is important to discuss the figures in context. We still have a situation whereby despite emergency department attendances being up, on average, in the system by approximately 5%, the number of people on trolleys this year is still down by approximately 4%. I accept this is not a defence of the point and the figures are still far too high and unacceptable, but it means almost 4,000 fewer people have been on trolleys in the health service this year to date than for last year for the same period. This is simply a contextual comment.

Deputy Durkan asked several questions. I will ask the Minister of State, Deputy McGrath, to address some of them and I will ask the Minister of State, Deputy McEntee, to deal with mental health and older persons questions.

The Deputy raised specific issues regarding structures and the HSE structure in particular. I get the impression that we have been talking about the structure and model of the health service since God was a boy. I am sceptical about whether our patients have benefited significantly from such academic and deep discussions. That is why we need to have consensus. What we do not need is for Ministers to arrive and start tinkering with structures and models and ending up all over the place for a period, only for a new Minister to come in to do more tinkering and re-modelling. This is why the Oireachtas cross-party Committee on the Future of Healthcare has to come up with a vision for our health service that is owned not by me or the Department of Health but by the Oireachtas and all parties within it. I look forward to receiving the report of the committee.

Deputy Durkan is right in respect of his comments on primary care. I have been consistent in the view that primary care is about more than bricks and mortar, although bricks and mortar are important. Figures available to me indicate that approximately 30% of the minor surgical procedures currently carried out in our acute hospital settings could be undertaken in general practice. That represents a sizeable number of people. Much of this needs to be addressed in the context of the general practitioner contract, although some work has been done in this area. Under a pilot project on minor surgery in general practice, we have seen 4,263 minor surgical procedures carried out. Approximately 55% of these were carried out on medical card patients. We now have a comprehensive accreditation system for GP surgeons. Practices have been tested in what we are calling the minor surgery pilot study. A final report on the project has been published and we are now planning to progress it further and to extend it to more practices. Patient satisfaction as well as outcomes is important and 96% of patients who had surgery carried out in the GP practice rated the overall experience as very good or excellent. A similar project in respect of the provision of ultrasound services in primary care is under way. This started as a pilot in 2005. Funding of €700,000 was provided in 2015. A further amount of €13.5 million of held-back funding for primary care developments was provided for access to diagnostics this year. I have visited several places. I was in Tipperary recently in a centre where people are now getting an ultrasound done in the GP practice rather than going to the hospital in Clonmel.

I agree with the views expressed.

We need to do more and the general practitioner contracts are important in this regard.

I will make a final point on older people. I agree with the views expressed in this regard as well. If an older person comes into our hospital system, he or she needs to be dealt with in a particularly sensitive and careful manner. While the debate about specific hospitals is probably for another day, we can develop the pathway of care for older people. The first place should always be at home in the community. The point made is right. That will not always be possible. Under the winter initiative this year, we have piloted a new development for older people whereby there is a specific place where the older person comes in on entry to the hospital. A specific nurse will be on hand to deal with the older person. Sometimes older people have acute needs and are in a fragile situation. Our older people should not have to go through the general milieu of the emergency department. I am watching carefully the project we are about to initiate in St. Luke's General Hospital in Kilkenny with a view to further learning.

Deputy Finian McGrath

I will comment on two aspects. Deputy Bernard Durkan raised the question of a person with an intellectual disability in a nursing home. First, it is important to know that 60% of all young adults and adults with an intellectual disability live in their family homes. What we have now is a situation whereby families are considering the idea of combining living at home with a mixture of respite care and day care. Again, Deputy Durkan is correct to point out that we must have these services in place. Otherwise we will end up with people outside the system or in some cases on the streets. That is not acceptable. The principle of having someone with an intellectual disability in a nursing home as a long-term answer is not acceptable to me as the Minister of State. We are prioritising these issues, especially the questions of residential, day care and respite care in the service plan. We have to deal with these issues.

Another issue might assist the families affected. I set up a task force in September to look into the possibility of a personalised budget. Many families are coming to me privately inquiring about this. I accept that it will not suit all families. However, a substantial number of families throughout the State are telling me that if they were given the budget for 12 months, they could spend it wisely. That would deal with the issues raised by Senator Colm Burke.

Someone mentioned a cost of €80,000 per year for the service and another €56,000 per year per person in further service costs. I am also finding out the consequences of emergency crisis situations. These can happen in several cases where people with disability have high dependency needs. If the person ends up in the emergency department, we will end up spending twice the amount of what it would have cost with a better planned service. I am sitting down with people from St. Michael's House, Prosper Fingal and similar organisations such as St. John of God. I am suggesting to them that they need to focus on these issues and work closely with us in developing the services.

The value-for-money review of disability services in Ireland is being implemented through the Transforming Lives programme. There is a need to monitor performance, control expenditure and shape services. These are issues we need to deal with in a comprehensive way.

I will go back to the original question from Deputy Durkan. It is unacceptable to have a person with an intellectual disability in such a particular service. That is probably as a result of a crisis situation. We need to ensure that the services and funding are put in place and that we respect the families involved, as well as the person with the disability. That is my objective. I do not make big promises, but I am giving the commitment that this is the direction in which I want to bring the services.

Chairman

Sorry for going over time. There has been a gap of nine months since the Department and the HSE last came before the committee for various reasons. There were many pent-up questions as a result.

I thank the Minister for Health, Deputy Simon Harris, Jim Breslin, Tony O'Brien and the Ministers of State, Deputies Helen McEntee, Catherine Byrne and Finian McGrath. I will not mention the others among the 15-strong delegation by name in the interests of time, but thank you all very much for your attendance. As there is no other business, we will adjourn until 24 November when we will discuss medicinal cannabinoids.

The joint committee adjourned at 12.35 p.m. until 9 a.m. on Thursday, 24 November 2016.