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Joint Committee on Health díospóireacht -
Wednesday, 4 Nov 2020

Update on Covid-19 and Review of Budget 2021: Minister for Health

I welcome the Minister, Deputy Stephen Donnelly, to the meeting. He will provide us with an update on the Covid-19 response and the health provisions of budget 2021 and related matters. The Minister is joined by Mr. Gerry O’Brien, director, Department of Health. I am told the Minister of State at the Department of Health with responsibility for mental health and older people, Deputy Butler, will join us shortly. The Minister of State at the Department of Health with responsibility for public health, well-being and national drugs strategy, Deputy Feighan, is joining via video link as is Mr. Paul Bolger, director, Department of Health.

Before we hear the Minister's opening statement I must point out to the witnesses presenting remotely that there is uncertainty as to whether parliamentary privilege will apply to witnesses giving evidence from a location outside the precincts of Leinster House. This includes Ministers of State. If witnesses are directed, therefore, by me to cease giving evidence on a particular matter, they must respect that direction.

Before we get the Minister's opening statement, which some of us have just received, as this is the first meeting we have had with him I wish to say we look forward to meeting with him and his Minsters of State. We want to work with him and not against him. However, last week we had witnesses before us who deal with tracking and tracing and the issue of key staff seconded to that area was discussed. I think we would all agree that the use of trained professional occupational therapists, OTs, physiotherapists and speech and language therapists is less than ideal. It is impacting on other services and is not sustainable in the long term. I think we would all agree that our health service has to be about more than just responding to Covid and while it is a priority, we cannot ignore or disregard other life-changing and life-saving elements of the service.

To put today's meeting in context, the general secretary of the Irish Nurses and Midwives Organisation, Ms Phil Ní Sheaghdha, was before the committee two weeks ago. She gave evidence that across the State, 15 nurses a week are contracting Covid-19. This is probably a failure from the point of view of occupational health and safety, but what can we do to reduce the number to as close to zero as possible? Perhaps we can support front-line workers who are living with the long-term fallout of Covid-19 and that was one of the points Ms Ní Sheaghdha made.

Student nurses were also mentioned and they have been working above and beyond the call of duty during this crisis. There was a scheme in place earlier and I do not know if the Minister will address this point in his statement but we would be keen for some sort of scheme to be introduced for them. Do the Minister and the Department have any plans to work with training colleges and hospital groups to bring in a standardised, liveable payment scheme for student nurses?

The issue of medical cards for the terminally ill is a topical issue which I raised last year with the then Minister for Health, Deputy Harris. I believe that will be discussed today. It came as a surprise to many of us that it was not included in budget 2021. There was support from members of all parties and none in the Oireachtas. If the Minister does not have time today, he might come back to us on that point at some stage.

The committee looks forward to the Minister's introductory remarks.

I thank the Chair for his remarks and his welcome. I also thank the committee members; I am delighted to be here today. It is my first time to attend a meeting of the new health committee and I wish all its members well in their work. I look forward to engaging with them to that end on a regular basis.

I am joined by my colleagues, the Minister of State with responsibility for public health, well-being and the national drugs strategy, Deputy Feighan, and Minister of State with responsibility for mental health and older people, Deputy Butler.

The committee invited me to give an update on the implementation of the resilience and recovery plan for living with Covid-19 and the timeframe for delivery of budget 2021 measures. As I believe has been communicated to the committee, the implementation of the budget is being developed with the HSE and the implementation plan will be available as part of the national service plan that will be published in December. I am happy to return to the committee and discuss that plan when the detail is finalised.

I am going to focus on Covid for now, if that is okay. As we all know, it has been a difficult year for everyone in Ireland and across the world. Tens of thousands of people here have contracted Covid-19. Many have made a full recovery but some have been left with serious long-term health issues. We all know that, as of today, 1,922 women and men in Ireland have lost their lives to this virus. We all mourn this tragic loss of life.

The decision to move to level 5 two weeks ago was made due to evidence showing the rapid increase in case numbers and the need to get the virus down to much lower levels. I am glad to share with my colleagues that there have been positive signs in recent days. As of yesterday, the 14-day incidence rate was 228 cases per 100,000. There were 278 per 100,000 in the previous 14-day period. The rate is falling in 23 of the 26 counties. I am happy to share new information that the R-nought, which was at 1 last week, has been recalculated as of this morning to between 0.7 and 0.9. Critically, the average number of close contacts has fallen from approximately six to three and the testing positivity rate is also falling and now stands at 4.7%. By moving early and comprehensively, Ireland is currently bucking the trend that is being seen in many parts of Europe. The 14-day rate in France, for example, is 830 per 100,000. In Spain, it is 567 and in the UK, it is 469.

While our figures are hopeful, the number of positive cases remains of serious concern and it is worth reflecting on the fact that almost 11,000 new cases have been reported in the past two weeks. We must continually and actively suppress this virus to the greatest extent possible. Part of this response comes from our testing and tracing system. Our testing rates are high by international standards and we continue to run serial testing in nursing homes and food production facilities. As committee members will be aware, the HSE initially put in place capacity to meet the advice of the National Public Health Emergency Team, NPHET, to be able to do up to 100,000 tests per week. I met with representatives of the HSE some time ago and asked if they would look to increase that capacity. Testing capacity was recently increased from 100,000 tests per week to 120,000 tests per week. I am delighted to be able to share for the first time that the HSE has now confirmed that it can do up to 140,000 tests per week. I want to give the men and women working in the HSE great credit for that. They are working night and day and to go from 100,000 tests, which was already favourable by international standards, to 140,000 is fantastic work. I thank them for it.

In parallel, it is important that demand for testing has gone down by at least 40% in the past week. That is obviously in line with the number of infections coming down. At the same time, the HSE continues to recruit contact tracers and community swabbers. It is important to say that testing and tracing alone is not going to suppress this pandemic here or anywhere else. We must work together to protect our health services for both Covid-19 and non-Covid care, ensure our education and childcare facilities remain open, protect jobs and move the country to lower levels on the framework. With that in mind, I recognise the work of every member of this committee, on all sides, in fighting against this pandemic. I thank every member for everything they have done in the past eight months to support the country during what has been a very difficult time. I have no doubt that the members of the committee will continue with that work in the months to come.

During this first session, there will be ten minutes for each group, followed by seven minutes. The difficulty is that we have to be out of the room within two hours.

I thank the Minister, the officials in the Department and the HSE staff for the work that has been done over the past eight or nine months to deal with a serious issue and challenge for everyone. I will touch on a few issues. I know that the Minister may not have all the answers to the questions I ask but he might provide some written replies.

I had a call this morning from someone whose daughter had been in contact with somebody who had been identified as positive for the virus. When that person rang their GP, they were advised that the GP could not refer them for testing but instead they had to wait to be contacted by the HSE. It was a further five days before there was contact. From start to finish, there was a gap of 12 days. In a case where someone knows they were in contact with a person who is positive for the virus and that person has not been contacted by the HSE, surely we should have a mechanism whereby a GP can refer the person for testing. That is my first question.

My second question is about elective hospitals and I have raised the issue for the past two years. We do not appear to have made any further progress on that issue compared with this time last year. We have not identified sites, the size of the hospitals, or when we are going to start going through the planning process. Where are we in relation to the three elective hospitals that are in the 2040 plan? Have sites been identified? When will that be progressed? When will we take decisive action on this matter?

The third issue I raise relates to employment in the HSE and is a particular bone of contention. We have taken on more than 20,000 additional staff in the HSE over the past four years. We have gone from 103,000 to 123,000 staff. We talk about developing community healthcare but, in that period of time, there has been an average 17% increase in all areas except public health nurses. Staff numbers have only gone up by 3.5% in that sector. Will that issue be dealt with?

It is fine to talk about increasing the number of acute beds but do we have the ability to increase capacity for doing testing, whether X-rays, MRI scans or any of the other tests that patients require?

Opening an additional 1,200 beds is fine, but will we at the same time increase capacity for testing and ensure that those beds are used efficiently, rather than it just being a case of people being in beds and waiting for access to the various scans and tests they require?

I agree with the Deputy on the tracing issue. There is a balance to be struck. The public health teams identify close contacts. If someone is designated to be a close contact, he or she will be referred for testing and be subject to a two-week period of self-restricted movement. It is inevitable that some people will know they are close contacts. Speed matters on this, as does people being tested and restricting their movements. The HSE is examining the issue. The example the Deputy gave should not be happening and I will take it up with the HSE.

There is a balance to be struck. In school settings, for example, the public health teams have been working closely with teachers and principals. I have seen a number of cases where people believed themselves to be close contacts but when the experts took a look, the close-contact number is dramatically reduced. There is a balance to be struck between speed and obvious cases where people know they are close contacts. We need to facilitate them being able to self-refer to a GP. As part of that balance, we do not want a large number of people deemed not to be a risk, at least by an expert analysis, to be included. I will certainly take up the Deputy's point.

On the question about public health nurses, the short answer is that it is being expanded. Several steps are being taken with the public health departments at the same time, one of which involves creating consultant contracts for public health doctors. There is ongoing dialogue between the public health doctors, their representative body and my Department about the process. It is essential, and the doctors have been waiting a long time for it. I intend to put it in place as quickly as possible. At the same time, we are doubling the public health workforce. There are currently 71 public health doctors and a total workforce of approximately 250, a good portion of which comprises public health nurses. In doubling the public health workforce from 250 to approximately 500, work is ongoing between my Department and the HSE to determine the best configuration of that. In line with the Deputy's point, it will examine what are the best numbers of nurses, scientists, doctors, support staff and so forth. A bunch of them will work at the Health Protection Surveillance Centre, while others will work in the various public health departments.

The question about acute beds was a good one. There is no point in us spending a great deal of money and effort putting in place acute beds, ICU beds, doctors, nurses and safe staffing levels while leaving a bottleneck at diagnostics. There are now serious bottlenecks in many parts of the country for various diagnostics. We are, therefore, approaching this in two ways. There is a long waiting list of people who need to be seen. I have created an access to care fund of several hundred million euro and a large body of work will start soon with the HSE, my Department, the National Treatment Purchase Fund, NTPF, and other stakeholders to decide how we will deal with these long waiting lists, including for diagnostics. Up to now, the NTPF has not been able to fund diagnostics, but we will change that and get access as quickly as possible for people who have been waiting a long time. The second step we are taking relates directly to the Deputy's question. As we scale up acute beds, community beds and staffing, we are scaling up diagnostics too and there is funding in the budget for that.

Turning to the Deputy's final point on the three elective hospitals, I acknowledge that he has raised this many times and is continuing to advocate hard on it. The elective hospital we have discussed previously is that in Cork. The elective hospitals oversight group, chaired by Professor Frank Keane, is developing the high-level facilities spatial brief and the order of magnitude costs, which detail the clustering of the appropriate elective activities for each of the three facilities in Dublin, Cork and Galway. This will also include an output and facility specification based on efficient and effective service delivery. The spatial brief will be important in determining what size each elective hospital will be and the numbers of operating theatres, rooms for patients, outpatient units and staff who need to be employed. This information will be contained in a preliminary business case, in line with the public spending code, and I am happy to report it is due to be completed before the end of the year.

We have previously heard about issues with the elective hospitals and timelines were outlined. Is the Minister satisfied that something will happen and that decisions will be taken? We have yet to identify sites and then we will have to go through a planning process. It will be three years down the road before even a sod is turned on any of these hospitals. That is why the issue is now a priority. Can we bring forward the decision-making process on this?

It is being done in line with the public spending code. Based on the outcome of the strategic assessment report, the business cases will be prepared. It is now November. The information I have suggests the hospitals will be ready by the end of the year, which is a small number of weeks away. When they are in place, we can carry out the project design, planning and procurement, and put the final business case together. Critically, at the same time that we are identifying, procuring and buying or building the facility, we will plan in a detailed way the services that will go in there, as well as the staff, the equipment and so forth.

My final question relates to the NTPF. A simple example concerns cataract operations. The main problem at the moment is people trying to get appointments even to be assessed before they get on the list. If they get on the list, they can avail of the NTPF, but the problem is getting on the list. Can we do anything to expedite the issue in order that people will be assessed on the list for surgery and then, if necessary, the service can be farmed out under the NTPF?

The Minister might revert with a written reply because we have run out of time.

I would appreciate that because there is a long list of people waiting to be assessed, yet the list of people waiting for work to be done is quite small relative to the number of operations.

I welcome the Minster. I ask that he reply to my questions with succinct responses. If I intervene, it will be only because I feel the questions are not being answered. My first question relates to the statutory instrument the Minister signed a couple of days ago to extend medical card access to certain categories of people, namely, the over-70s and six- to eight-year-olds. I assume there have to be negotiations with the Irish Medical Organisation, IMO, in respect of some aspects of this. Have they commenced, and if not, when will they do so?

Is the Deputy asking about medical cards for the over-70s or six- to eight-year-olds?

Six- to eight-year-olds.

That has not yet started. As the Deputy and I discussed in the Chamber when we were debating the legislation, my view, and I believe it was also that of the Deputy at the time, was it was essential that it happened in view of the fact that Ireland is an outlier in terms of high costs for some primary care. Right now, however, the capacity is not within the general practice system, particularly as-----

My question was whether the negotiations have commenced. They have not yet commenced.

The Deputy is referring to the negotiations with the IMO on expanding access to medical cards.

No, they have not commenced.

I asked the Minister a question yesterday on the floor of the House and also inquired with the clerk to the committee. There is some controversy over previous negotiations with the IMO, as the Minister will appreciate. As an Opposition party, we have sought any documentation, emails or correspondence, between April and May 2019, with the National Association of General Practitioners, NAGP, which has since disbanded. Will the Minister commit to the committee, given that it has written to him and the Department on the matter, that all such documentation will be forwarded to the committee as soon as possible?

Will the Deputy outline specifically what documentation he seeks?

It is any documentation that would have been exchanged between the NAGP and the Department of Health, the HSE, the then Minister for Health, and the Taoiseach at the time, between the months of April and May 2019.

I am more than happy to provide the committee with the documentation that falls within my remit, but correspondence with the Taoiseach at the time is a matter for the current Tánaiste.

What is in your remit?

What is in my remit is the Department of Health, and-----

-----and the HSE, I will check. The committee may need to write to the HSE directly. I do not see it being a problem and I am more than happy to support the request. Between the NAGP and the Department of Health from the start of April to the end of May 2019-----

And the then Minister for Health as well.

Yes, within that as well. Can I just check, is it specifically with regard to the GP contract?

No, it is any correspondence.

Any correspondence, whatsoever?

I would imagine it would have been on those issues anyway, but I mean any correspondence.

I can certainly ask the Department to prepare that.

I would like to move on to the extension of the provision of medical cards to terminally ill patients. I asked the clerk and the committee to write to the Minister regarding the publication of the clinical advisory group report. I understand that the Minister did have a meeting with some campaigners on this issue, and I welcome that. We all want to see progress, but we also need to see the report. I am sure that if the Minister was sitting where I am, and he knew that the report had been sitting on the Minister's desk for some time, he would want to see it. As the clerk and the chair of committee wrote to him asking for that report, he can appreciate that we want to see it, for good reason, because we want to see what is in it. It is a report that was written to advise, so can the Minister inform the committee of when that report will be made public, or when the committee can be given a copy of the report?

Very shortly. The first thing I wanted to do was to get sign-off on the report from the clinical advisory group. The next thing I wanted to do was to make sure that Mr. Wall was briefed on it. That was very important, because he fed into the report. I presume he is the campaigner to whom the Deputy referred. I had a very long and useful meeting with Mr. Wall last week, and I will be speaking to him again later on today. So, the process-----

I genuinely welcome that, but the Minister also has to engage with the committee as well as health spokespersons. As the chair has said, there was cross-party support for this, and support from everybody across all sections of both Houses. I ask the Minister if this is something on which he is going to deliver.

On extending the provision of medical cards-----

The report or the policy?

-----to terminally ill patients. Yes, is it something that the Minister can, and will, deliver on?

This is a conversation that needs to be informed by the report. It was important to me that Mr. John Wall saw the report first. He was briefed on the report last week. I am going to talk to him later today and I want to make sure that he has had time to read the full report. If that is the case, then I will immediately ask the Department to release the report. I want to have exactly the conversation that the Deputy wants to have, but could I suggest that the committee gets the report, reviews it, and then maybe we talk it through, if that is okay? The recommendations and the views of the clinical advisory group are very important for the conversation.

That is acceptable, but at the same time, when we hear words like "reform", and reform is then put into the same context as delivery, it can take an awful long time for the delivery to actually happen. We can see that in so many areas. People need to get this done, and it needs to be brought over the line. Indeed, the Minister campaigned for it himself. I want to see it delivered and I hope the Minister wants to see it delivered. All I am saying is that we as a committee will work with the Minister to make it happen and we want to see the report.

Can I just, very briefly-----

Of course, we have to give the report due consideration. I have three minutes left and I have two important questions I want to ask.

-----just very briefly, then. I agree, and I will say that we can get into the detail on another day, but I am looking at short-term and more comprehensive longer-term actions, as well, in response to the point the Deputy just made.

I wish to raise a separate issue with the Minister, and it is one close to my own heart, to pardon the pun, in Waterford, namely, the cardiac care issue. I have not had the chance to raise the issue with the Minister as a member of the committee, but I have done so on two occasions on the floor of the Dáil.

When I looked at this issue, it struck me that the plan to add a second cath lab was signed off on in 2018, and we are now in late 2020. It is a case study of how long it takes for a capital project from conception to delivery, and for the lab to be opened. We are now being told that it will be 2021, if not 2022, before it is open and operational. There was a private hospital in Waterford, which, from conception to delivery, built a cath lab in six months, and we are still waiting for the public one. That is because of the procurement process and the very complicated stages that a project has to go through. In my view, it is very similar to the delivery of housing projects, where there is a four-stage process which complicates delivery. I ask the Minister to have a look at that process. Second, the primary issue and the bigger issue for the people of Waterford is not just that second cath lab, but 24-7 emergency cardiac care. Is that something to which the Minister is still committed, and how is that going to be delivered? We are up against time restrictions, so I will ask my final question to give the Minister time to respond. It is on the issue of beds. I think there was a bit of spin in the Minister's budget when when he stated that 1,145 additional beds would be provided. That figure relates to the 2019 baseline and not that of 2020.

No, it does; we have it from the HSE itself. A very small allocation of capital funding is being made available - €45 million, as the Minister said in his opening statement. I have spoken to many hospital managers, including those in my own constituency and elsewhere, who do not have the space to open new beds. A lot of the wards are old nightingale wards, so when these managers hear about thousands of additional beds, they wonder where the staff are coming from, and they do not have the physical space. Is the Minister looking at rapid-build modular units in some of those hospitals? If he is, why was there not a greater capital allocation made? I am concerned that figures are being thrown out in relation to the opening of additional beds. If the capital funding is not made available to match the funding required to recruit the staff, hospitals simply will not have the space to open them. I have that concern myself and I have had the same concern directly communicated to me by hospital managers. I ask the Minister to respond.

On the beds figure, the Deputy and I may just have to agree to disagree. The 1,100+ beds figure is one that relates to a commitment to have, by the end of next year, additional acute beds, over and above the fully-funded beds for this year.

No, it does not.

I am happy to look at documentation that says the opposite.

No, it does not. The Minister is factually wrong.

I am quite sure that that is right, but we can go into it again if the Deputy so wishes.

I am sure the Minister's advisers who have the information can correct him on the matter very easily, because he is factually wrong.

I am quite sure that they were right. However, the Deputy has raised a very fair question on whether capital is being provided. There is over €1 billion in the capital in the budget for next year. It is €1,035,000,000. There is €900 million for construction and equipping, €120 million for ICT and e-health, and another €15 million for agencies, so the capital is there. It is fair to say that what we are doing is that we are being very ambitious in terms of what we can do for patients, in respect of beds in the acute areas and the community, and in terms of hiring. As the Deputy will be aware, we are seeking to hire an additional 16,000 people. I believe that we have pushed it right to the edge of what is possible to do in one year. We have been very ambitious, and the focus now has to be on implementation.

I ask the Minister to respond to the cardiac issue that I raised, which is an important one for patients in the south east.

Perhaps the Minister could respond to that issue in writing.

I will provide the Deputy with a detailed, up-to-date note on that issue.

I welcome the Minister of State, Deputy Butler, to the committee.

I thank the Minister and the Ministers of State for all their work. I have around eight or nine questions, and I ask the Minister to be mindful of the clock. Some of the answers might be appropriate to make in writing, and I have no issue with that being done.

First I ask the Minister to convey my thanks, as a public representative, to his officials and those in the HSE for the continued Trojan work they are doing on the front line in relation to the Covid-19 pandemic and keeping people safe. It is also important to acknowledge some of the Minister's achievements since he has assumed office. Testing has broken through the 100,00 barrier, which it was nowhere near what it was when he became Minister for Health. The Minister introduced localised testing, which had not really previously existed, particularly in the context of the lockdown in counties Kildare, Laois and Offaly, and he moved very quickly on adapting school testing to the needs and concerns of teachers and parents, particularly those that have been raised in the last few weeks. The Minister, his Department and officials, and the HSE have shown a high degree of agility in that. I also welcome the funding in the budget for dementia, disability and the winter plan. That should all go on the record. The Minister has delivered all of that with a calmness, which often goes unacknowledged.

I refer to my own constituency, and the figures available for local electoral areas.

I have four electoral areas. Positive cases are in excess of the national average in one of them. It is a disadvantaged area. This pattern is replicated nationally. What strategies are in place, given that is a consistent figure, to address this in some shape or form or to address the underlying causes of why positive cases may be more prominent in disadvantaged areas? That is a question.

I am scribbling furiously. I am taking note of the question.

I will ask another question while the Minister is scribbling. I read at the weekend that Slovakia is antigen testing half of the population, some 2.5 million people. What is the view of the Minister and NPHET on this? Some 25,000 people tested positive. The regime of tracing and isolation and so on has followed that. Is it a useful exercise? What is the view?

I thank the Deputy for his kind words. I agree with him wholeheartedly about the Department of Health, the HSE, HIQA and the other State agencies regarding the volume of work that the various organisations have to do and the fact that Covid probably doubles the work. The staff have not doubled. This has meant that in the Department, HSE, HIQA, HPSC, HPRA and across the board the same people are working incredibly long hours. They are working at weekends. I have talked to people within the system, including public health doctors, who have gone weeks without seeing their children.

The Deputy referred to disadvantaged areas and high positivity rates. It is a good question. One of the measures the HSE is taking is to bring in mobile testing and try to create high visibility. There is considerable engagement with schools but more needs to be done.

I am unsure whether it is part of the same issue but I am conscious that two districts in Dublin are bucking the trend. Dublin is not reducing its case numbers as much as we would like. In the recent period the figures have gone down in these areas by 13%. That is significantly lower than the reductions we are seeing in other parts. This applies in two areas, Dublin North and Dublin South-West. One is stable. Dublin South-West is not seeing any reduction, but in Dublin North the figures are going back up again.

It is a pertinent question. Mobile testing is being deployed so that there is more visibility. There are supports for nursing homes and so forth, but I am open to other suggestions on what else needs to be done.

I will come back to Slovakia briefly. Can the Minister, the HSE or NPHET communicate on whether they have established any underlying causes? Aside from the obvious reasons, why do areas of economic and social disadvantage find it more challenging? Can they elucidate the reasons in writing for us? Can the Minister comment on the Slovakian antigen exercise?

We have been watching this with great interest. We are going to see where it goes. Other European countries are looking at scaling up rapid testing, be it molecular or antibody testing, quickly. What Slovakia is doing is interesting. The latest figures I have from public health officials suggest such tests, if they are done right and if the testing is good and the sensitivity and the specificity are right, will capture up to 80% of true positives. That is what we are trying to do. We are watching it closely. Right now, I am pushing for us to get an answer on which of these molecular or antibody tests we can use, because I believe they could be a game-changer. For example, PCR testing costs approximately €200 from end to end and takes time. The antigen tests can cost €10 and are done on-site. In fact, I was given one the other day to take a look at. I am told it took five minutes to do.

The Minister might keep the committee informed of that because I believe it is an interesting and developing area.

The Irish Pharmacy Union has been in touch with me and other Deputies looking for PPE. Pharmacists go through a considerable amount of PPE every day. For example, if a pharmacist takes a telephone call, he has to put on a new mask afterwards. There is a significant cost to this. I understand the HSE had approved the funding of PPE for pharmacies and that it is on the Minister's desk but that no decision has been made. Will he update the committee on that?

I will have to take a look at that. I am not aware of the issue.

We are one week into the traditional flu season. Does the Minister have anything to report on figures in hospitals?

A total of 1.95 million vaccinations were procured. This comprises 1.35 million for adults and 600,000 for children. The group being provided with it for free includes those aged between two and 12. I will get the committee a detailed note but, from memory, half of the nasal spray vaccinations for the children, some 300,000 in total, have been distributed. The remaining 300,000 are being distributed at the moment. It is a great success. It is the first time it has ever been done.

What is the incidence of flu? Have we any figures on that?

I am sorry but I do not know. A total of 950,000 doses have been distributed for adults. We assume everything that has been distributed has been administered because there is high demand. The remaining 400,000 have arrived in Ireland. There was a slowdown from the manufacturer but they are all here now and they are being distributed.

Will the Minister furnish the committee with information on that? There is anecdotal evidence from other countries that, because of behavioural changes relating to wearing masks and hand hygiene, flu incidence has not been as high as previously. Obviously, that will be monitored.

Australia essentially did not have a flu season.

We are a week into the traditional flu season. Perhaps the Minster could follow up on that.

My final question may require a written answer. It comes down to essential and non-essential business. We cannot repeat what we have done previously when it comes to the next surge. There will be another surge, so I urge the Minister to keep the tracing numbers up and consistent. We should not make the mistake that was made over the summer of letting tracers go.

We must have data at this stage on how many cases arose in the large multiples and retail stores, including Super Valu and Tesco. What was the rate? What was the rate in non-essential stores? What about barbers, beauticians, hairdressers, hardware stores and furniture shops, etc.? Does NPHET have data on those? How do these figures feed in? We are going to have to be agile and flexible in terms of opening hours for barbers and hairdressers if we reach level 3 again. Perhaps barbers can open between 5 p.m. and 10 p.m. if we want to reduce mobility or have people moving at different times. There must be data. There must also be data on the effectiveness of mask wearing. Is the Minister in a position to furnish the committee with any information on that?

I will ensure the committee gets information on both. At the moment NPHET is conducting a review. I have spoken with the CMO about visors. The unambiguous answer is to stop using them. They do not work. We have to use face coverings. More needs to be done, at a minimum on communications, in terms of how to wear face coverings.

Does NPHET favour compulsory public mask wearing?

I will ask. The Deputy asked about the percentages per workplace. The answer is that this information exists and I will get it to the committee. The one addendum that the public health teams always give me when I ask them these exact questions is that the systems can trace a person's profession and where they have it, but the virus could be in a person's system for two weeks before he or she tests positive. It can take time to build up.

What about the staff in those shops?

They have that data, but it can be difficult to establish where anyone gets it. Knowing that one person got it from a family member or at work or when the person got a haircut or was in a restaurant over a two-week period can be difficult to ascertain.

As a quick aside I would like to address compulsory public face mask wearing. There are several areas throughout the country where people would like to keep farmers' markets open. Some guidance on that would be useful.

I thank the Minister for attending. I presume several Deputies have, like myself, written to him about the constraints on partners who would like to attend antenatal scans and appointments with their pregnant partners.

We have received an answer from the Minister on that. There are guidelines, we all want to keep staff safe and there are constraints in terms of the size of our hospitals. However, I would like to know whether any further work is being done on that and whether the Minister's colleague has information - perhaps this relates to the budget - on funding and support for perinatal mental health.

As with the Deputy, I have been contacted by many people in this situation and there have been some really sad stories. For some people it is frustrating that mums, dads and partners cannot get in for scans. We have also been made aware, as I am sure the Deputy has, of really traumatic situations where things have gone wrong during birth and the partners cannot get in then either, at a time when the women really need the support. It is very difficult. On the back of representations that were made by the Deputy and others, we asked the clinical leads to take a look and come up with national guidelines. They are doing that. We have asked that, within the context of clinical safety, anything that can be done is done, particularly in the most heartbreaking and serious of cases. There is a balance to be struck whereby, whatever local calls are made by maternity services, I need to back them up. If one looks at the infection rates in the maternity services relative to some other parts, they are very low. They have taken a hard-core attitude but in terms of keeping mothers and babies safe, they appear to have done a very good job. However, we have to try to find a balance on compassionate grounds as well.

Outcomes for pregnant people are better when they have that support. We will have another session on the budget but I am interested in that issue of funding for perinatal mental health in the next session.

I have two questions on disability services. There is a recent report of the Health Information and Quality Authority, HIQA, reporting a residential centre for people with disabilities due to concerns around the quality of the care being offered. Are we managing during the Covid crisis to carry out the same level of inspections as we would expect? Second, there is a suspension regarding primary medical certificates. I understand this is a complex legal and policy issue on the back of a Supreme Court judgment. Could the Minister set out a timeline for resumption of those assessments? A number of people will have become disabled during the Covid period and now cannot access the support they want because they cannot be assessed for a primary medical certificate.

The issue regarding primary medical certificates is something that has been raised. I have raised it with the Department and I am looking for a report on it. I will revert back to the Deputy with detail because, as she says, there are complex legalities to it but it has to be sorted out very quickly. On HIQA inspections in disability services, I will ask HIQA to come back to me with the details on those numbers.

On perinatal mental health, the Minister of State, Deputy Butler, might want to contribute.

I thank the Minister and the Deputy for the question. There is a commitment in the programme for Government in relation to perinatal mental health and to develop it. I will get a detailed answer for the Deputy and revert back to her.

That is fine. I thank the Minister of State. The issue around primary medical certificates is an urgent one. I do not suggest people go in a room and do not come out until it is fixed but it is incredibly urgent. I would like to put on record the need to deal with it sooner rather than later.

I undertake, at a minimum, to provide the Deputy with a briefing note this week on that.

That would be fantastic. There was a recent report around HSE staff being sent to nursing homes, including a number sent to private nursing homes, although a smaller number than the overall total. We are all aware that nursing homes are at the front line of the Covid-19 battle and are experiencing some of the greatest number of losses. That level of staff shortage seems to be due to staff contracting Covid-19 or being in self-isolation and trying to do the right thing. How are we dealing with HSE staff being seconded to nursing homes?

I ask the Minister, Deputy Butler, to come in on that question.

It is a valid question. A huge amount of work has been done in relation to supporting nursing homes since the earlier outbreak. The pandemic bore down hardest on older people in nursing homes. A huge amount of support has been put in place in respect of personal protective equipment, PPE, routine testing every two weeks for staff and the temporary assistance payment, which supports nursing homes financially. The Deputy is right to say that one of the issues that has arisen is a lack of agency staff, especially for rural nursing homes. There are 51 nursing homes with outbreaks at the moment. We are working with a nursing home in County Kerry where 19 staff have contracted Covid-19, including the manager and the person in charge. It is a really difficult issue. The Covid support teams in the community, the HSE and HIQA are on site and we are working at the moment to come up with a plan. The issue at the moment is it is difficult to have enough agency staff nurses and if someone works in one nursing home today, he or she cannot work in a different nursing home the same day or the next because we are trying to prevent cross-contamination. We have dealt with a huge number of issues related to nursing homes and as the Deputy correctly noted, the one we are facing now is having enough staff to go in. We are conscious of that and I have a meeting scheduled this week with the HSE and the Department on that issue.

I thank the Minister for coming in. I will concentrate on a number of issues. The first concerns the Minister's submission on budget 2021 and ICU beds. The Minister committed to 321 ICU beds by the end of next year. The Irish Hospital Consultants Association says we need 579 beds right now. There is a shortfall of nearly 260. Is the Minister confident he can deliver those beds? More importantly, as we heard from representatives from the Irish Nurses and Midwives Organisation, INMO, a couple of weeks ago, there is a serious shortage of ICU nurses and staff. Are the Minister, the HSE and the Department of Health confident they can meet the demand for these specialised nurses and ICU beds?

I thank the Deputy. The point he is making essentially concerns whether we are going to get to enough ICU beds by the end of next year. No, we are not. It has to be a multi-year programme. We have worked closely with the HSE to determine what is possible. For example, the HSE had planned to introduce some beds in quarter 1 of 2022. We worked with them to say, "No, we will get them in in the coming year. Let us fund them. Let us push it." For the very reasons the Deputy has outlined, we have to do it over several years. If it were just a question of getting the beds and buying the kit and facilities around it, that would not be a problem. However, each bed needs six full-time staff and they are highly specialised. The HSE, during the outbreak, trained about 1,400 nurses with ICU skills but it is an important point that we miss sometimes that they are not designated ICU specialists. They have additional training so they can step in but we need full specialist training for the nurses in ICU to be completed. What we have in the budget for next year and what we are working through in the service plan is what we think is at the outer edge of what is possible. I want to do the same thing the following year and the following year again because I think we came into this year with 252 beds or thereabouts and it is acknowledged across the system that this is a serious deficit. We have an ambitious programme in place for the next few years to deal with that.

This is coming from a base whereby Ireland has the lowest number of ICU beds in the European Union. There is also the legacy of thousands of beds that were taken out of the health system over the past 25 years. We are coming from a low base and that has exposed the public health system.

Is the Minister confident that during his tenure, regardless of how long it will last, he can meet capacity with regard to ICU beds and the requirement of the Irish Hospital Consultants Association, which has said that we need 579 beds? That is 260 more than we will have at the end of next year.

I would have to see how it calculated the figure of 579 but the numbers I have seen are not a million miles away from that. In terms of the figures I have been talking to people about, it is about how we can get up to about 500 ICU beds. I guess it depends on time. I could look at the detail of the ICU situation. I am confident that we are putting in as many next year as the system feels it is capable of facilitating for all the reasons the Deputy has laid out. We have got to do the same thing the following year and the year after that. If we do so, in the next three years we would be adding somewhere between 180 and north of 200 beds. That would almost double our ICU capacity in just three years. It would be a major task but we have to be very ambitious on this because there is a bottleneck. I have had, as I am sure has every member of this committee, many representations over the years from people who were waiting for urgent, often complex surgery. They were good to go. They were brought in the night before and prepped. The doctors and the operating theatre were ready to go and at the last minute a major trauma case came through the emergency department doors and they were told, "Sorry, we have to postpone the operation again because there is not an ICU bed available." It has to be guaranteed and ready for the person, and that is something we have to address.

I refer to the Minister's submission on budget 2021. The additional personal assistant, PA, hours and additional funding for disability services are welcome. The decongregation of services for those who are living with a disability in a community setting is very welcome.

On a different issue, I raised the medical cannabis access programme with the Minister a while ago. The response I have been getting from the Department is very frustrating. Many people and families who campaigned last year were hopeful that the change in the law last year would mean they would get access and that the access programme would be up and running. However, the Minister got a memorandum during the summer which stated that there was no specific budgetary allocations for the programme, which meant that the programme would not be up and running. This programme has been flagged for the past three and a half years. If we think about it, it makes sense. Fifty people in the State have licences for access to medical cannabis but there is no joined-up thinking in terms of how those children are doing and how people are getting funding for this drug. It is extremely frustrating. Can the Minister make a commitment on when the medical cannabis access programme will progress and start?

I asked yesterday, in anticipation that the Deputy might raise this, for the most up-to-date note from the Department to be able to share it with him today.

The time has expired.

The Chairman will give me a bit more time. I never go over time.

I will send the note to the Deputy after the meeting. The scientific review has been completed and it advises that we should put the controlled access programme in place for patients with one of the three conditions of which the Deputy will be aware. The expert reference group then developed clinical guidelines for the programme. The impact of an amendment to Schedule 1 of the misuse of drugs regulation 2019 is what is being looked at. The regulation set out the legal provisions for the operation of the medical cannabis access programme, MCAP, and the legal obligations for healthcare professionals and commercial operators. Products listed in Schedule 1 are considered by the HPRA as suitable for inclusion in the programme. Manufacturers then apply to the HPRA for products included in Schedule 1. This is how we are driving it through. There are currently three products in the Schedule and I am glad to share with the Deputy that a fourth will be added shortly.

On the question the Deputy has been raising, progress is being made. I know it can seem very frustrating and I hear him on that. The question for us is how we can continue to overcome the barriers that I accept, and the Deputy knows very well, exist. The HSE is in pricing and supply negotiations with suppliers of the approved products, which is critical, and agreement has to be reached before the programme can commence. What we are trying to do is get this programme up and running.

A recommendation of the review is that initially the programme would be run on a five-year pilot basis, which I believe is good. The commencement of the programme is dependent on pricing and supply issues being agreed by the HSE and the manufacturers. Critically, we had the expert review. We had the reference group. Three products are included in the Schedule now. A fourth is being added. The HSE is in discussions with the manufacturers and suppliers. We are going to run a five-year pilot, which is a good lengthy time for this, and when the pricing and supply issues have been agreed with the HSE and the manufacturers, we can commence the programme.

The previous Minister, Deputy Harris, gave the exact same answer last year.

He said the exact same thing one year ago.

No, not all of that. This is an update on that. I will furnish the Deputy with a detailed note.

It was the exact same answer.

We have written to the Department about it so the Minister might get that brief.

I want to first acknowledge the positive progress with regard to the Covid-19 figures, the changes that have been made and the increase in capacity in respect of testing but I want to raise a couple of capital projects with the Minister. In February 2017, the new emergency department, ED, was confirmed for University Hospital Galway, UHG. Funding was confirmed for the design phase of a new ED at this time. It was to be prioritised in the mid-term review of the capital plan. It was included in Project Ireland 2040. In September 2018, when the then Minister, Deputy Harris, visited Galway, we were told that the ED planning application was to be lodged before Christmas of that year. It was then delayed due to this options appraisal in regard to the best use of UHG and Merlin Park lands. It was then announced that the planning permission would proceed prior to the options appraisal. That did not happen. We were then told the project team were requested to include the design of maternity and paediatric services, which is welcome, but the situation is continuing and an application for planning permission has not been lodged.

I am concerned that there are some in the Saolta group who want to delay the commencement of the ED because they want to move all services from UHG out to Merlin Park, which would be a €3 billion project. They say the earliest that could start would be in ten years' time and that it will take ten years to build. We would be talking about the end of 2040. My concern is that the emergency department is being delayed. In the meantime, staff and patients have to endure very difficult conditions in the emergency department in Galway. I ask the Minister to indicate when the design for an emergency department will be complete and when an application for planning permission will be lodged?

I will ask my second question and then give the Minister time to answer both. This day one year ago, 4 November 2019, I attended a public meeting attended by Professor Paul Donnellan on oncology services, again in UHG. I will take about a minute to read the testimony of a cancer patient who, thankfully, is a cancer survivor. This is from a few years ago:

I was diagnosed with colon cancer (Stage 3+) and had surgery in Galway. I had felt unwell for a couple of months and was diagnosed by colonoscopy and following the surgery I was referred to a consultant oncologist who works both in GUH and the Galway Clinic.

My first meeting with my Oncologist was scheduled for GUH, 3 weeks post-surgery. I arrived at the hospital with my wife where we were directed to a waiting room which was completely overcrowded with 60 people. There was no seats available and I took my place along the wall with many other patients and their family members. From listening to accounts and conversations these patients had come from all over the west and north west. Many were elderly and obviously quite ill.

Over the next 90 minutes some were called and others arrived, so I eventually got a seat. The conditions were awful with so many vulnerable, ill people packed into a completely inadequate space in a dreary, poorly maintained building. It would be depressing on any day but following what I had endured it was almost unbearable. Worse was to follow.

I was eventually called and went upstairs to yet another waiting room which was so small and so overcrowded I couldn’t even enter. My wife and I and other patients stood in the narrow corridor, leaning against the wall for another 40 minutes until I was called. I met with my Oncologist on that day for the first time and following my 2½ hour wait – most of it standing up – he went through my diagnosis and prognosis. We decided on a programme of chemotherapy which he said I could receive in GUH or the Galway Clinic. I told him that I never wanted to see GUH again and it was a disgrace what patients have to put up with. Following chemotherapy, I have made a full recovery for which I’m very grateful but the day in GUH was, without doubt the worst of my cancer experience.

There has been no progress in the last year and the staff on the day care ward in the medical oncology department feel that this has not been prioritised within University Hospital Galway, UHG, management or the Saolta Hospital Group.

Can I have an update on plans for the medical oncology and the radiation services? Building is progressing on this project. I also ask about the emergency department, which is critical, and which was described by the former Taoiseach, Enda Kenny, a great many years ago at this stage, as not being fit for purpose. Planning permission has still not been granted, never mind a sod turned or a block laid.

I thank the Senator. The experience as outlined by his constituent is just not satisfactory at all. Nobody should have to go through that. If I run out of time, I will provide a more detailed written answer.

As to the emergency department and the maternity unit, the project design team has requested an assessment of the feasibility, as the Senator said, of the inclusion of a women and children's element to the block, which is positive. This would result in the completion of a full development as opposed to a "shell and core fit-out" of the women and children’s upper floors. The feasibility study has been completed and considered at this point by the HSE at national level. Supplementary information in response to queries is being prepared locally for submission to the HSE nationally. The project is of significant scale, which is right and proper, and has to go through all of the stages outlined in the public spending code. A planning application has not been submitted yet but will be submitted once the design has progressed to the appropriate point. This answer is not satisfactory for the Senator and I am, therefore, going to ask for an additional note on an indicative timeline as to when this will be done, as this is the question he asked, and it needs to be answered.

I will get a note for him on medical oncology services because I do not have one with me but I can give him an update on radiation oncology now. This is better news. Construction of the new radiation oncology unit at UHG was delayed by Covid-19, as we know. A contract was awarded in August and construction commenced in September, which is great. Construction will take approximately 24 months with a 12 month fit-out because it is highly specialised equipment at an estimated overall cost of €62 million, which is significant and important for the entire region,

I thank the Minister.

I thank the Minister for attending . I will discuss just one issue particularly close to my heart, which is student nurses. This issue has been raised at this committee previously, it was raised with the Minister last night and it has been raised in both Houses. I wrote to the Minister about this a couple weeks ago and I am still awaiting a reply. What would he say to a student nurse who is working for nothing in the health service to defeat the pandemic and struggling to afford her rent? What would he say to a student nurse as she is trying to make ends meet by working for free, who is beating back the pandemic, is exposing herself and her loved ones to infection and where her landlord is threatening to evict her because she cannot afford her sky-high rent? Would he tell her that she is being treated fairly? I note the Fianna Fáil tagline of an Ireland for all creating a more equal island. We can all agree that this is very unequal treatment.

We have an apprentice system in the country where trainee carpenters, plumbers, electricians and other tradespeople are paid more incrementally as they progress through their training. Can the Minister explain why he believes it is fair that trainee nurses are asked to work long hours in dangerous circumstances in the middle of the pandemic where health workers are the most likely profession to catch the virus for zero pay? The Irish Nurses and Midwives Organisation, INMO, have said that due to the pressure on the system, student nurses are taking on an enormous burden and are really holding up our healthcare system at the moment.

How much would it cost to put in place a system for trainee nurses akin to that which exists for apprentices and what would that cost be as an overall fraction of the health budget? I am not asking for a figure now but when replying to my letter, I ask that the Minister might include those figures in it?

Two weeks ago, we had representatives from the INMO before us and they said that they hoped they would hear from him by the end of the week. It has been two weeks now. Has anything happened and has he engaged with the INMO? Where does that stand now?

Can the Minister explain why this Government is standing over a system of double standards, where apprentice tradespeople, which is a male-dominated sector, get paid for their work while trainee nurses, which is a female-dominated sector, are not paid at all?

I thank the Senator very much for her question. I will start by recognising the work that student nurses are doing. They are on educational placements as part of their degree programmes, are working damn hard and are doing it in a healthcare system where everyone is working damn hard. The system is under enormous pressure. In the first wave of the pandemic, when there was real fear and we shut down elective care, not only did the student nurses step up, as did everybody else such as all of our qualified nurses, they went in as healthcare assistance, HCAs, not on placement, and they just worked. Their education was essentially put aside for a while. That is a sacrifice that they made at a time they were needed and I want to acknowledge that.

The comparison with trades is not applicable. There was no degree programme for nursing prior to 2004 and most of it was on-the-job training. The nursing degree was set up in 2004 and there was a very conscious move to educational placements. Some people referred to what happened earlier in the year but there was a significant wave of Covid-19 then with many people dying and we were in the middle of a crisis. The student nurses worked as HCAs within the hospital system and, rightly, they were paid for that across the healthcare system. We are not in the middle of a crisis now. We have moved early to avoid a crisis in healthcare. Elective care as well as all of our hospitals are still open. As of this morning, there are fewer than 300 Covid-19 patients in our hospitals against the base of approximately 12,000 beds. It is a fundamentally different situation.

This is an issue that the Chief Nursing Officer, CNO, and I discuss on a very regular and ongoing basis. The strong view of myself, the Department’s, and that of the CNO is that we must protect the education of nurses. As the Senator will be aware, trainee nurses are paid in fourth year and there is a slight difference between psychiatric nurses and all other nursing grades, but it is in and around an annualised salary of €22,000 for their placement. The strong view which I support is that these are educational placements for first, second and third-year trainee nurses. Of all of the clinical students right across the system, be they doctors, allied health professionals, and everybody else, only one group receives a stipend, which is a low and modest one. This group is nurses and the stipend is €50.79.

I am very aware of the hardship being incurred at the moment. For example, many student nurses work in nursing homes at the weekend to make money that they badly need, be it to pay the bills, rent or just to buy food. That is not available to them at the moment and they are trying to do their education placements in a very different environment. There is ongoing engagement with the INMO and the Department and we are seeking significant short-term changes to the educational placement stipend to recognise that the situation that they are working in is very different from a non-Covid-19 world.

I apologise for being late as I was trying to be in two places at the one time as I had to attend the Convention Centre for Leaders' Questions.

I have two sets of questions for the Minister. I apologise if they have been asked and I missed them.

I will step back from Covid and all the other issues in the health service at the moment and turn to the reform programme, and Sláintecare in particular. One of the key measures recommended in Sláintecare was the need to restructure the HSE and to move away from having seven hospital groups, nine community healthcare organisations, various other mental health teams and so on, which has resulted in a completely disjointed and non-accountable organisation. It is a big black hole. All the money goes in and we do not know where it goes. There is no legal responsibility for the provision of services or for budgets.

This was the issue that arose most often at meetings of the Committee on the Future of Healthcare, raised both by all the members and by all the witnesses who appeared before it. They said it was crazy and that there could not be integrated healthcare if different elements and sectors were all doing their own thing with no single budget. The idea of the restructuring that was agreed to at the committee was that there would be a regional structure, a single budget and a single management structure within each region, which would mean there would be accountability for the provision of services and the spending of money. That is essential.

This was also a significant element of the famous agreement with the IMO that we have all been talking about in recent days. The IMO signed up to the idea, which was a huge step forward, while across the board, in the main it has been accepted as something we absolutely have to do. This was announced at the end of last year or early this year and there was a commitment at a political level to getting it done. The then Minister, Deputy Harris, was very strong on it, yet it now seems to have been parked and put on hold. I urge the Minister, Deputy Donnelly, if he is serious about reform, to put that back on the table and to begin the discussions and the planning and so on. I appreciate that everything was difficult, and still is, but this needs to happen and there will not be reform unless it does.

In recent days, there has been much discussion of the article in Village magazine, and I will not get into that at this point. There was another article in the same edition about a concerning interaction between public officials within the health service and the HSE, and the private sector. That needs to be examined and to receive some response. It relates particularly to a proposal mooted in recent years for a private hospital in the Airside area of Swords. It was being promoted heavily with posters and so on by a Fine Gael candidate during the general election campaign earlier this year. I am just raising alarm bells about that. There were also various photographs with very senior people, including the then Taoiseach, at the launch of plans for the hospital, and that needs to be examined. There are big question marks over this. As long as this kind of stuff is going on in the background, with profit being a motive for many people and potentially within the public health service, we will never get serious reform. That is the kind of area that definitely needs to be reformed. It is why we as a country are an outlier in European terms. We are the only country in Europe where half the population have to pay every time they want to access healthcare. The Minister knows that access is the key and that money is a driving force for people. That needs to be removed.

I ask the Minister to consider that. I asked him some questions about it previously. If what is in the article I mentioned is true, it is a matter of serious concern. It will also work to stop any kind of serious reform taking place.

On the second issue, I will need to take a look and revert to the Deputy, so I will respond just to the first one now. I hope she will have seen in the budget a serious commitment to Sláintecare. There are many different factors, one of which is capacity. We just need more of everything and there is a big commitment in that regard. The second is configuration, so there will be a large investment in community, home care and so forth. The third goes to the heart of the Deputy's question and relates to organisation. Critically for me, it is about joining up the budgets and centring everything around the patient, so that it is not a matter of community or acute, or of whether someone is in one CHO but a different hospital group or a different public health group. Those groups have their own targets too.

A great deal of progress is being made across the board. Specifically on the organisational aspect, it is a question of timing. In a previous life, I was involved in some large reorganisations. The international evidence shows that complex reorganisations fail most of the time and the majority of them destroy value, for a bunch of reasons. They are really complicated and tend to be done in peacetime. Something I observed in that previous life is that when someone says a large reorganisation will commence, everyone starts focusing on the reorganisation because they are thinking about their jobs and what will happen to them. I do not know if I am correct, but my view is that while we need to do the planning for it, the middle of Covid is not the right time to press the trigger on it. We need to keep the system focused on Covid and the resumption of services. Laura McGahey and I have discussed it at some length, and as the Deputy will be aware, she is a very strong advocate for this. If it is the right step to take and a call is made to pause formal reorganisation for now and to let everyone focus just on the healthcare system, can we in the meantime start rewiring budgetary lines and start doing the technical joining-up while telling everyone not to worry about what it might look like in a month's or a year's time? We should tell them to do their jobs and to get great healthcare results for patients, but let us start doing some of the joining-up of budgets and so on in the background. That is my thinking on the matter at the moment.

I accept a number of points the Minister made, but aside from Covid, if we are waiting for peacetime in the health service, we will be waiting a long time.

That is fair. Let me instead say "post Covid".

Okay, but Covid might be with us for some time. Hopefully, it will not be but it may well be. We need to move on with the reform programme. Everything we say we are aiming for, such as local services being accessible to people, accountability and value for money, cannot be achieved with the present structures. They simply cannot be. If the aim is to move activity out of hospitals into the community, that will not happen as long as there are two separate budgets.

Yes, the budgets are the key.

The budgets are the key but so too is accountability for services. The HSE is a command and control organisation. I have stated in the context of Covid that there should be a separate agency for testing and tracing. It is so centralised. The idea of Mr. Paul Reid being called on to answer to problems in west County Kerry or north County Donegal just does not make any sense and leads to dysfunction. There has to be devolved management to the regions where the many well-paid managers within the HSE will have a legal responsibility for the provision of services and to achieve those services at the best value for money. That will not be done if the budgets and the management structure are separate. We need to make progress on that. I accept that many different things are going on but we cannot lose sight of that. There is also the implementation office, which we should give the go-ahead. We should get Mr. Reid to pull back on what he announced earlier in the year in regard to the delay.

I thank the Minister for appearing before the committee. I imagine it is a busy and difficult time, dealing with this awful pandemic.

I am also delighted to see the Ministers of State, Deputies Mary Butler and Frankie Feighan. The issue I am going to bring up today will involve all three Departments, and that is the issue of mental health. While I know it is not the Minister's specific remit, I would love to see the three Departments working together because there is no doubt the mental health issues associated with this pandemic are going to surpass anything we have previously experienced. We are facing a mental health crisis, of that there is no doubt. It is vital we get ready for the additional mental health issues that will arise from Covid and work on recommendations on how to prepare for a significant increase in mental health service demand.

Because of Covid, secondary care mental health services are facing a huge escalation in need. I believe it is going to peak in a few months time and will last for many years, and now is the time to flatten that curve. Unless we anticipate, plan and invest in all of our secondary care mental health services as a priority, they will be overwhelmed, with awful consequences for mental health and the economic recovery of our country. It is paramount we start to strategise ways to implement greater Government action to respond to the impending mental health crisis and to strategise a recovery plan for mental health during and in the aftermath of Covid-19. That is why it is very important that the Minister prioritises this, even though I know it is the remit of the Minister of State, Deputy Butler.

The three Departments need to work together on this. We all know the evidence that mental health has a huge impact on physical health. It can start off with mental health and then turn into a physical issue for people. We need to look at an interventionist way of working together in this area. I am delighted this committee will be

setting up a sub-committee on mental health and I would love to work with the Minister of State, Deputy Butler, and her Department on that, along with the Minister of State, Deputy Feighan, and the Minister, Deputy Donnelly.

In order to adequately resource mental health services, it is essential that the Government monitors and reports the mental health impact of Covid-19 nationwide among particular groups of people, including people with pre-existing mental health difficulties. What are the existing plans or are there existing plans to do this? How does the the Minister propose that the capacity of counselling in primary care can be increased and made available to people in an affordable way during the Covid-19 crisis?

I want to stress the impact of Covid-19. As a therapist, I am working on the front line with this. The organisation I am heading is inundated with people coming to us at this point and we have had to take on more therapists on a one-to-one basis. There is a crisis and it has to be made a priority. I would love to see the three Departments working together.

I will hand over to the Minister of State, Deputy Butler, shortly. The first point to make is that it is not three Departments, it is one Department. It is the Department of Health and we have mental health, Healthy Ireland, disability, homelessness and addiction and many other areas. The Ministers of State, Deputies Feighan, Rabbitte and Butler, and I work together and there is joined-up thinking. For example, the Minister of State, Deputy Feighan, and I, with the Taoiseach, last week launched a really cool Healthy Ireland initiative in regard to wellness, with Sláintecare funding, but part of that was Your Mental Health, so the dots are being joined. There is a brilliant initiative, of which I am sure the Senator is aware, in terms of protecting people in homelessness and addiction from Covid. Again, people are being brought in and they then have medical and mental health supports wrapped around them. I could not agree with the Senator more. Where the joined-up thinking happens, the results for the citizen are great. I will pass over to the Minister of State, Deputy Butler.

I thank the Senator for the questions. I also want to thank her for all the work she does in regard to mental health. I acknowledge how important it is to recognise that mental health matters and I acknowledge all the work Senator Black has done previously. I look forward to being part of our liaison with the sub-committee on mental health and I will co-operate in any way I can.

I will first answer the Senator’s second question in regard to capacity for counselling. As she will know, because of Covid-19, the HSE and the Department of Health reached out very quickly to many of the different NGOs with help and support. It is very good that the relationship between the NGOs has been strengthened and put on a more secure basis over the past seven or eight months. Some 85% to 90% of all mental health supports were retained during Covid, which is very positive.

Specifically in regard to the counselling, MyMind, a group the Senator is aware of, is currently providing 3,000 online counselling sessions per month in 15 different languages, which is very important in the modern Ireland we are living in. The organisation has assured us it has capacity for 5,000 appointments per month. It expected to reach 4,000 appointments by the end of October, which was the end of last week, with 5,000 appointments per month up to Christmas.

The Senator is correct that traffic to the HSE mental health website was up 490%, with more than 800,000 visits between March and July. I understand the Senator’s point that we are going to see a huge increase in mental health presentations in the next six months.

On the Senator’s other question in regard to the mental health impact, I agree with her that data are very important. Last week, for example, I visited the CAMHS unit in Galway, which currently has 650 children, youths and adolescents on its books. The point made to me was that it had 18 referrals in the previous week alone, double the normal rate, and very few people are leaving the services at the moment, so this will add to waiting lists. We will be working very hard to collate the data because it is hugely important.

Thank you. To give one example, we had a client who came to us recently who was suicidal. She was moved from Billy to Jack and from Jack to Billy, and she just could not find any services. She was suicidal, she was on the verge, really and truly, and it was only that one of our counsellors worked with her through this that, as she says herself, it prevented her from actually doing the act. There were no joined-up services available for her to really get the help she needed. I need to say that today. I would love to work with the Minister of State on that at some point, if that is okay.

Unfortunately, in 2019, there were 421 suicides that we know of in Ireland and, obviously, the figures can vary. What concerned me was that two thirds of those people who took their own lives were not availing of any mental health supports. It is very important that we try to get the message out that the people who really need help can ask for help. While I know the case raised by the Senator was different, it is very important that people know help is out there.

I apologise to the Ministers for not being here earlier as I was at another committee meeting but I was following this meeting online. I wish to put several questions and I will put the first to the Minister, Deputy Donnelly. In Clare and the wider mid-west, encompassing Limerick, we have Shannon Doc, an out-of-hours GP service operating out of five centres. It is a vital service and all the more vital during the Covid pandemic, as the Minister will appreciate. To use Shannon Doc's own language, it has moved to a “consolidated model” during Covid and there is a lot of very nice terminology, but what it really means is that, on the ground, there has effectively been a diminution of service. People have to go further afield to get to a clinic or they have to phone up the triage nurse and wait a long time for a call back, not because of anyone’s fault but because the service is overwhelmed with phone calls. People are not as inclined to go to acute hospitals because there is fear, some of which is grounded and some of which is illogical. However, while Shannon Doc has never been busier, there seems to have been a diminution of service. I would like to know how the Department can support out-of-hours GP services over the coming months and in the longer term as this is crucial.

I am fortunate to live in south Clare where, if anything were to happen in my home, we are probably a 15-minute drive or less to University Hospital Limerick. However, for people in the northern and western extremities of the county, it is a long drive and could be up to an hour and a half for them to get to accident and emergency or critical care.

They rely on having an out-of-hours GP service that they can contact at midnight or 1 a.m. to properly advise them on a health issue in their home.

It is a really important question. It cuts to the heart of the matter because it is not just about the out-of-hours service. It is about general practice and making sure general practice is fully supported, funded, invested in and configured properly right across the country, including in the Shannon area and, obviously, in Clare. There are a few things we are doing in terms of Covid. I keep hearing from the HSE and the Department that GPs deserve huge credit for what has happened since Covid arrived here. I hear from all over the country that time and again they have stepped up. They reconfigured their practices, moved online and are doing all the Covid calls. A strong view of the clinical community in Ireland is that they have really stepped up, interestingly to the point where some hospital consultants, with whom I have spoken, would have been slightly wary of the investment in and move to community-based care because they believed it would have the impact of a diminution of acute care. As GPs have stepped up and taken on more of that, the hospital consultants are saying this is working out pretty well. There are a few things we can do. One is the ongoing funding for GP Covid calls and the subsequent visits and care, where necessary. GPs have done a phenomenal job to that end.

Another big initiative is e-health. It is one of the silver linings that has come out of Covid. It was well flagged in the Sláintecare report and by numerous people but not much had happened. Over a very short period there has been a massive increase in telemedicine, e-health and so on. In accordance with public health guidelines, general practice has shifted substantially away from the in-person consultations to predominantly telephone consultations. During the emergency patients have shown an overall reluctance to contact their GP about non-Covid issues, which is worrying. It is understood to have changed gradually in more recent months, as people's concerns about Covid have abated somewhat. The area of e-health has benefited from this and significant progress has been made under the objectives of the 2019 GP contract. Much good work is taking place.

Thank you, Minister. I want to fit in another question. Some members of the volunteer support group, SOUND, for people who have developed narcolepsy and cataplexy, which they claim occurred as a result of being given the Pandemrix vaccine some years ago, are following these proceedings. The Minister's Department is quite familiar with the issue, and his predecessors, including the Minister, Deputy Harris, and the former Minister, James Reilly, would have led investigations or inquiries into this vaccine. The case went to the State Claims Agency. The group has a number of asks which the Department of Health and Government might consider. I will articulate some of those. They want, in time, that there would be a full assessment of the needs of each sufferer looking at their educational needs - primary, secondary and third level; the lifelong living supports to provide for what each sufferer endures; and portable supports when sufferers are travelling or working abroad. There is a range of items and I will ask the members of the group to communicate again directly with the Department. To be honest, it is an issue about which I knew very little until I spoke to some people this week who explained how challenging and difficult it is to have a child or teenager suffering from both narcolepsy, where one falls asleep all the time, and cataplexy, where one’s muscles go in to a total state of relaxation, almost a state of paralysis for a while. They want some redress or future for their children and teenagers to which they can look forward. It is probably a bit of a curveball for the Minister to answer that issue today. I will ask the members of the group to communicate with the Minister but I ask that his Department might again engage with them as they have been in contact over the years. They need to bring this issue forward once and for all.

There is no doubt it is awful for anyone who finds themselves in that situation. Can I undertake to get a detailed briefing note to the Deputy?

It sounds like the Deputy is in communication with the group. If he would convey to the group that if they, either directly to me or through him, want to engage and would like an update on progress made, we will certainly facilitate that.

I will certainly do that and thank the Minister.

My final question is for the Minister of State, Deputy Butler. As a former school teacher up to February, I believe this suggestion would be really worthwhile. We do not want to overburden teachers and they are burdened at the moment. It is quite difficult for them. It would be no harm between now and Christmas for each teacher in each classroom in the country to conduct a lesson geared around the mental health of children or teenagers in their classroom. It would be worthwhile to collate that work. Some schools already do this on an ad hoc basis. Schools should not be compelled to do it but it should be encouraged. I ask the Minister of State to engage with the Minister, Deputy Foley, on the carrying out of a little health check on the children and teenagers of our country to see how they are faring. I am quite concerned for many of them. Some children carry anxiety at the best of times and Covid certainly has augmented that for far too many of them.

I thank the Deputy for his question. I advise him that a promotional leaflet providing information on a number of trialled and youth mental health supports is currently being delivered to 4,000 schools across the country to raise awareness of the services that are available. I worked in collaboration with the Minister to get those out to the schools this week in paper form. A quarter of a million leaflets were issued. The leaflet is also available online. I will take on board the Deputy's point because teachers in many cases are the first point of contact and they can see an awful lot of the warnings signs.

Yes, very briefly, as we are short on time.

I want to respond to Senator Black and thank her for the work she has done. The three Departments are working very closely together to address the issues of mental health and well-being. My Department received funding of €20 million for the Healthy Ireland budget. We are working with the Departments maintaining physical and mental well-being among everybody. The three Ministers of State and the senior Minister are working together. We had the first meeting in the Department of Housing, Local Government and Heritage to try to address the issues of people who are homeless and have addiction issues. Much good work is being done through all the various Departments. I thank Senator Black for raising the mental health issue. It is a very important, especially during this pandemic.

A number of issues are of major importance and full of challenges at this time. There is the ongoing challenge of bringing back the standard of services to what they should be before Covid invaded people’s environment and to be able to do so and develop and grow those services in line with requirements. There are challenges between the elective services, the mental health services and the well-being of people who have been stressed by fears relating to Covid. There is also the question of child mental health services which face serious problems and there are countless issues involved, of which the Minister will be well aware, which have been and will be raised again in the House. There is a serious urgency about getting those services back to a level that is acceptable and on which people can depend. I look forward to the Minister’s response on that point.

An equally challenging question is how we will deal with the current lockdown or semi-lockdown with level 5 Covid restrictions and whether it can be used to build up the services or whether we have learned anything from the past in order to be able to contain the virus. What happened is that people, in good faith, decided that it was beaten. It is not beaten and it will not be beaten in the short or medium term but it can be contained. To what degree does the Minister believe strict observance of social distancing, hand hygiene, mask wearing and so on can contain the onward march of Covid? If people can practise that guidance on a voluntary basis, will it be possible to avoid having another extension of current level 5 restrictions? We now must make decisions on whether these things can be achieved without the massive sacrifice of slowing the whole economy down. To my mind, they can be achieved. As I said previously, there is serious evidence to suggest quite a number of people felt they could disregard the restrictions but it is now essential we put in place whatever is required to deal with the situation that arises when we get to the end of the current restrictions. Essentially, I have asked two questions.

Will I take the first one, Minister?

I thank the Deputy for his question. I do have a concern about child and adolescent mental health services, CAMHS. The waiting list is currently about 2,200 children. As the Deputy will know, working with the Minister, I managed to secure an extra €50 million in funding in the recent budget of which €38 million are new moneys for new supports. Of the money that has been secured for 2021, there will be 20 new wholetime-equivalent staff hired for CAMHS hubs and teams to try to reduce these waiting lists. As I said earlier, I travelled to County Galway last week to see the fantastic set-up they have in Galway, Mayo and Roscommon. They have community teams, an inpatient unit in Merlin Park University Hospital and they also have a day hospital. They run it very well with very few on the waiting list. I stayed there for half a day to try to get my head around how well the system is running. The committee can be assured that it is a huge priority for me and the Minister. We have discussed it at length. I am hopeful that these 29 extra staff will have a huge impact on the waiting list. As we all know, early intervention is key and all parents want is for their children to be assessed as soon as possible and to get the right wraparound supports they need.

Deputy Durkan has encapsulated the entire challenge in healthcare right now. It includes resumption of services and expansion of services according to Sláintecare and universal healthcare, areas such as mental health, disability, CAMHS, Covid, etc., that need particular attention and are getting great leadership from the Ministers of State, Deputies Butler, Feighan and Rabbitte.

I refer to the effectiveness of the basics. I am not a public health doctor but what they are telling me is that the single most important aspect of this is the basics. There is no amount of measures that any Government can bring in, and no amount of technology that can be deployed, that will ever work in the absence of people following the basics. The Deputy is asking almost the other side of that question which is whether they are enough in and of themselves. The CMO would be better placed to answer that question so I will give Deputy Durkan my observations. I would say that the short answer right now is probably "No". The reason I say that is that at level 2 a lot of people were following the basics and the virus grew. We then moved to level 3. It worked really well in Kildare, Laois and Offaly. We moved to level 3 in Dublin. It worked initially and then it flatlined and we got no further benefit out of it. We moved to level 3 in the Border counties and then to level 4 there. It worked very well and is working. On the matter of what we shall call enhanced level 3, where there were no household visits, the very significant good news we are seeing now is largely down to enhanced level 3 and indeed level 4 in the Border counties. The public health doctors say it takes a week to two weeks for measures to come through. Consequently the current thinking is that levels 4 and 5 are needed to push the virus back down to very low levels. That is the effort we are in at the moment and it would appear that level 3 holds the virus. It held it at a higher level in Dublin but ultimately, it did not bring it down quickly which is why we still saw exponential growth even though the country was at level 3.

It did not contain congregation, however. There were widespread abuses related to congregation that are well-documented. Whatever it did, it did not contain that. There was not the feeling of responsibility as to what would happen due to people ignoring the regulations. That is where the challenge arises. I do not want to delay the meeting but my own belief is that there must be huge emphasis put on the voluntary recognition of the need to hold the line and to carry to its ultimate the restrictions that have been set out. That, in lieu of a restriction, is a no-brainer.

I hear the Deputy. What we want to try to find post level 5 is a situation where people are all following the basics, as the Deputy said, and then we want to find whatever the minimum additional restrictions required are to keep the virus down. To the Deputy's point, there is very strong anecdotal evidence, with data now emerging to back it up, that a mixture of congregation and alcohol in various parts of the country, some of it post-sport celebrations, some of it house parties and different things is, sadly, the opportunity the virus takes to spread. A lot of the time there may have been people involved in that who followed advice to the letter for seven months and then one night said: "For the love of God, I just need to let loose once." Unfortunately the virus exploits those very small transgressions.

I thank the Minister.

I apologise for being late but I was coming from the west of Ireland and the roads were very bad this morning.

There is not meant to be any traffic on the roads so the Senator should have flown up.

Unfortunately it was the frost. The Minister's aunt would fill him in. I was following proceedings online all the way up.

With reference to a question Deputy Hourigan asked, the Minister was providing a briefing note on the primary certificates. That is important and the Minister might circulate that to us all.

I refer to an issue in the mid-west about the 60-bed modular accident and emergency unit. In a response to me in the Seanad on the Minister's behalf, the Minister of State, Deputy Butler, confirmed that the unit was going to be operational on 9 November which is next Monday. Will the Minister confirm that that is still the case and that patients will be accepted in the new 60-bed modular unit from next Monday onward?

We had the track and trace people in here last week. As of last Wednesday when they were before us, they confirmed to us that they were not asking the full suite of questions that they had been prior to the hiccup that happened three or four weeks ago. The Minister might confirm if they are now asking the full suite of questions and if they are totally back on track with that.

I welcome what the Minister said today about the 140,000 capability and the 40% reduction in testing. It is extremely welcome.

Section 39 companies that are funded by the HSE is an issue I raised when Sláintecare representatives were in. I am curious as to whether the Minister is doing a root and branch review of the funding of section 39 companies because from my observations there is huge inequity there. Some such companies are funded up to 90% of their costs whereas others providing a similar level of service are only getting 70% of their costs funded. That is a job of work that does need to be done because we are talking about billions of euro which the Minister negotiates for his Department which needs to be reviewed.

Can the Minister reply rather sharpish because we have to be out of here? Perhaps in writing if that is possible.

The Minister can give me written replies to all of my questions except, perhaps, the one on the accident and emergency unit in County Limerick and the one on the full suite of questions for testing and tracing.

With regard to the 60-bed ward block at University Hospital Limerick, I am delighted to say works were completed just a few days ago on 30 October. We are expecting final sign-off now so once the three 20-bed inpatient wards in the new buildings are stocked with consumables and given a final clean we expect them to be ready to be made available. It is really good news for everybody there.

With apologies to the Senator, does he want me to respond now to the question on testing and tracing or the one on section 39 companies?

On testing and tracing. The Minister can get back to me in writing on the section 39 companies.

On tracing the short answer is "Yes". The HSE informs me it now has capability in place to contact trace up to 1,500 new cases per day within a 24-hour period. On the basis that yesterday we had just north of 300 new cases - and hopefully the current measures will continue to have an effect - right now the HSE has the capacity it needs. What I want to focus on though, is not just the volume and the speed but the depth of that contact tracing. The HSE is focused on that as well. The experts call it forward contact tracing and backward contact tracing and it involves getting to close contacts and close contacts of those close contacts.

The HSE now has very significant capacity in place and is still scaling up. It has gone from 231 contact tracers in mid-September and is scaling up to 800. New IT systems are being brought on board. At the same time, the seconded staff, many of whom were allied health professionals, are being redeployed to their roles as well, so a lot of good things are happening.

In my view, the focus has got to be, as we come out of level 5, to have the most responsive comprehensive contact tracing system that can move really quickly but go in depth and, essentially, isolate the new cases as well as possible when they arise.

In terms of the 60-bed modular unit, is the staffing complement in place to open next Monday, as committed to in the reply given to me in the Seanad?

I will get the Senator an exact response to that by the end of today.

I thank the Minister.

Just one more question and, again, a written reply will suffice.

On the SOUND group that was raised earlier, we have all had involvement with that organisation. Can the Minister supply us all with a copy of the correspondence that he promised?

Deputy Durkan made a point about the Dublin areas in which the Covid rates are particularly high and bucking the trend, including in my own constituency. Despite the imposition of level 5 the rates continue to rise, and very substantially. Is there a tailored strategy to respond? Unless we do that the virus will be out of control.

Dublin is falling en masse at 13% relative to the rest of the country so it is not falling as fast. There are two areas in particular. The south west is flatlining but obviously it should be falling given that we are at level 5 and, as the Deputy has said, the northside is actually on the increase. It was discussed earlier on. The HSE will look at deploying more mobile testing units. We need to go further because we need to really understand what is driving this and why level 5 is not working. If the Deputy has ideas I, genuinely, would be very happy to meet her or receive an email from her as to what we need to do. The new restrictions should be working but they are not so we must move and quickly.

I suggest that granular tracing is possible in some areas due to the available public health staff but those staff are not on the northside of Dublin. That is the kind of forensic approach that needs to be taken to identify exactly what is going on at community level.

I suggest that this conversation continues outside of the room. I thank the Minister, the Ministers of State and the Department officials for their helpful engagement here this morning.

The Minister has committed to supplying members with a note in response to their questions. I ask him to supply any notes to the committee as well so they can form part of our report for today.

At the next meeting that will commence at 11.30 a.m. on Wednesday, 11 November, the committee will meet the CEO of the HSE to receive a briefing on the winter plan.

The joint committee adjourned at 1.33 p.m. until 11.30 a.m. on Wednesday, 11 November 2020.
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