Joint Committee on Health díospóireacht

Sláintecare Implementation: Discussion (Resumed)

Chairman

Before we get to the main item on today's agenda, minutes of the committee meetings on 20 and 21 September 2022 have been circulated to members for their consideration. Are they agreed? Agreed.

The purpose of the meeting is to discuss the implementation of Sláintecare, with a focus on workforce planning. To enable to the committee to consider this matter, I am pleased to welcome Mr. Robert Watt, Secretary General; Ms Rachel Kenna, chief nursing officer; Ms Margaret Campbell and Mr. Bob Patterson, principal officers; and Ms Grace O'Regan, assistant principal officer, Department of Health. I am also pleased to welcome Mr. Paul Reid, chief executive officer; Mr. Damien McCallion, chief operations officer; Ms Anne Marie Hoey, national director, human resources; and Ms Yvonne Goff, national director, change and innovation.

Members and all in attendance are asked to exercise personal responsibility in respect of protecting themselves and others from the risk of contracting Covid-19.

All witnesses are again reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if any of their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against persons outside the Houses or an official either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask members partaking via MS Teams that, prior to making their contributions, they confirm that they are on the grounds of the Leinster House complex.

I invite Mr. Watt to make his opening remarks.

Mr. Robert Watt

Good morning, Chairman and members. I thank the Chairman once again for the invitation to join the committee to discuss progress in the implementation of Sláintecare. As he mentioned, I am joined by Ms Rachel Kenna, chief nursing officer, Ms Margaret Campbell, principal officer in the strategic workforce planning area and Mr. Bob Patterson and Ms Grace O’Regan, who work in the Sláintecare implementation division.

We have discussed previously our progress in meeting the challenge of Sláintecare in terms of integrating health responses between the acute and community, and in delivering more care close to where patients live.

I am happy to report we are making progress. Our enhanced community care programme continues to expand and develop as planned. Ninety of the planned 96 community health networks are now established, as are 21 of 30 community specialist teams for older persons and 17 of 30 community specialist teams for chronic disease management, while 21 community intervention teams are now operational and securing national coverage. One of the things we discussed previously was GP diagnostics. Some 170,452 scans have been provided to end August 2022, which is a significant advance on the number provided last year. We plan to expand this service further next year.

We remain on target in enhanced community care, ECC, recruitment. Of the total target of 3,500, almost 1,900 have already commenced their roles, with a further 420 at an advanced stage of recruitment.

As the committee is aware, we are currently at phase one of the regional health area, RHA implementation, which is focused on the high-level design of the service delivery model for the health and social care service - the organisational arrangements needed to deliver integrated models of care. Six RHA streams have been established, focusing on clinical governance and accountability; finance, inclusive of population based resource allocation; digital and capital infrastructure; people and development; change, communications and culture; and programme co-ordination. The work of the workstream groups will feed into an implementation plan that will be finalised by the end of the year. Work has started on the development of a population-based approach to service planning and resource allocation. A population-based resource allocation funding model will be part of the Estimates for 2024. My Department recently published a spending review paper which provides an analysis across six countries to establish international best practice in this area to see how they can best inform our approach going forward.

The transition to RHAs will continue next year, with recruitment for senior posts starting as early as possible. The Minister, Deputy Donnelly, has established an advisory group of patient and staff representatives from across the health and social care sector who continue to engage and contribute to the development of this implementation plan.

Stakeholder consultation is key in developing the new structures for integrated care. Several events have been held with health sector stakeholders to make sure what we are designing better enables integrated, patient-centred care. This has included engagement with the HSE board and senior leaders within community healthcare organisations and hospital groups. The Departments and the HSE are also involved in detailed engagement on regional health areas with the dialogue forum for voluntary organisations, and the engagement will continue. Six regional events for employees are being held in September and October to gain input from staff in terms of this reform.

As regards the specific item on the agenda for this morning, and Mr. Reid will speak about this in a moment, we expect at this stage the increase in whole-time equivalents to be approximately 4,600 this year. By the end of August, staffing levels show a growth of 2,600. All staff categories are showing growth in the year to date with the largest increase seen in nursing and midwifery. All nursing and midwifery graduates in the class of 2022 have been or are being offered permanent opportunities within our health system.

To supplement the national pool, the HSE has implemented a drive to source nurses and midwives from the international market. As the committee will have seen from recent research published by the Department of Health, we must dramatically increase the numbers of nurses we train to reduce our reliance on such international recruitment. This increase began over recent years, and we will have in place an additional 344 undergraduate training places for nurses and midwives.

The HSE has similarly directly targeted all the health and social care professional, HSCP, graduates from Irish colleges, and these applicants are being interviewed and will be offered jobs from October onwards. To supplement the pool, international campaigns have been launched in a number of different areas, and the Department of Health is working with the Department of Further and Higher Education, Research, Innovation and Science to increase the number of HSCP students in Irish colleges over the years ahead.

Our capacity to recruit people is also an issue and significant activity is taking place. Recruitment capacity has increased within the Public Appointments Service, particularly for the recruitment of medical consultants. The HSE is also developing targeted initiatives to enhance the candidate pool, focusing especially on hard-to-fill posts. In recognition of the scale of global competition for health care talent, the HSE has developed and implemented a globally competitive relocation package to attract international recruits to our service.

Working with the Department of Further and Higher Education, Research, Innovation and Science, we have succeeded in securing an extra 60 places on medical courses for Irish and EU students this year, with agreement to increase this by a total of 200 over the next four years, but even that announcement will not be sufficient.

We will have to increase the numbers much more and probably double the places we make available in the quickest timeframe possible. We will need to look at different ways such as expanding or creating new schools, and all options we can to provide more opportunities for people who want to join this important profession. As I say there is agreement to increase the places but I think we will need to go much further than that. In common with other healthcare professions, the numbers of Irish and EU medical graduates we are producing is far short of the numbers we need to meet the healthcare needs of the service, as discussed before. The demographic challenge is increasing demand all the time and we need to increase our workforce and train more people to participate into the future. Clearly a big issue for us is to look at all opportunities to increase the number of graduates we produce domestically. We are making progress on recruitment and reform, but obviously we need to accelerate this and I am very happy to take questions from members of the committee.

Chairman

I call Mr. Paul Reid.

Mr. Paul Reid

I thank the committee for the invitation to discuss a range of Sláintecare programmes, and the issue of recruitment, retention and staff training, including the National Ambulance Service. The Chair has introduced my colleagues in the room and those participating by video link so in the interests of time, I will not do so again. Beginning with the enhanced community care programme, its objective in line with Sláintecare, is to deliver increased levels of healthcare locally with service delivery reoriented towards general practice, primary care and community-based services. The programme has been allocated €240 million for the establishment of 96 community health networks, 30 community specialist teams for older people and people with chronic diseases, to provide integrated services for people nearer to their homes. To date 2,300 staff have either been recruited or are at advanced stage of recruitment. A total of 90 of the planned 96 community health networks, 21 of the community specialist teams for older persons and 17 chronic disease specialist teams have already been established. National coverage for the 21 community intervention teams has been achieved and a volunteer-type model in collaboration with ALONE is being rolled out, with 6,000 people now supported through this coordinated support mechanism.

A sum of €25 million has been provided to deliver increased access to diagnostics for GPs, with 160,000 additional tests provided this year to date. On the regional health areas, the HSE is continuing to take forward this key reform programme, working closely with the Department. As outlined by Mr. Watt, phase one of regional health areas implementation is focused on high-level planning and design, in particular the service delivery model for the health and social care system and the organisational arrangements needed to deliver integrated care models. Comprehensive communication and engagement processes are being progressed, including in recent weeks and as recently as yesterday. Meetings continue with staff and with the voluntary dialogue forum and six major regional health events across community health organisation, CHO, hospital group staffs and other stakeholders throughout the country in Cork, Limerick, Sligo, Kilkenny, Tullamore and Dublin.

Addressing waiting lists is a key priority for the HSE. Hospital groups have been supported to deliver additional in-year activity in 2022, with non-recurrent funding provided to deliver additional outpatient appointments, additional inpatient day-case procedures and additional scopes and diagnostics. Additional longer term investment proposals have been submitted to the Department to support the implementation of 37 modernised scheduled care pathways and a number of hospital group priority investments to address recurring capacity gaps. In the year to date the number of long waiting patients in outpatients has reduced by 19%, inpatients and day cases by 12%, and GI scopes by 65%. Securing further progress on waiting list and waiting times will be a key priority for the HSE for the remainder of this year and beyond.

I will move on to emergency departments and our winter plan. We continue to face significant levels of demand for unscheduled care services. This year to date total emergency department attendances have increased by more than 5% compared to the same period in 2019, with attendances for outpatients aged 75 years and older increasing by 13%. Emergency admissions have also increased, in particular for the over-75s. The HSE is working very closely with the Department of Health to prepare for the winter plan 2022-23. Key areas of focus will be enhancing the local injury units; overtime for staff to support out-of-hours services; transitional care funding; aids and appliances; complex packages of care; utilising private capacity; enhanced nurse staffing in emergency departments; enhanced consultant and registrar staffing in emergency departments; seasonal vaccinations; and communications to support public awareness.

Key areas of focus will be enhancing the local injury units, overtime for staff to support out-of-hours services, transitional care funding, aids and appliances, complex packages of care, utilising private capacity, enhanced nurse staffing in emergency departments, enhanced consultant and registrar staffing in emergency departments, seasonal vaccinations and communications to support public awareness.

On recruitment, retention and training, an area in which the committee is particularly interested, the HSE is working on a range of actions to ensure the effectiveness of our recruitment efforts. Short-term actions are focused on hard-to-fill posts, including recruitment and retention of Irish trained graduates, extended international recruitment campaigns, an easy-to-use, streamlined application process, widening of the skills list and overseas relocation packages. Medium to longer term actions are focused on increasing domestic supply and working towards greater self-sufficiency. In the year to date, HSE staffing levels have increased by some 2,700 whole-time equivalents. In the period since the beginning of 2020, the HSE workforce has grown by more than 15,000 staff.

As the largest employer in the State, the HSE has an extensive and broad offering of training and development programmes delivered both nationally and locally. These programmes are tailored for both clinical and non-clinical staff. Nationally there are over 300 programmes available via HSeLanD. A further 410 are available under leadership learning and talent management programmes and further programmes are delivered by the HSE leadership academy. There is also a range of profession-specific programmes delivered across the country.

The National Ambulance Service college delivers training to staff through education and competency assurance officers, both within the college and across the service. Sixty-two new paramedics qualified from the National Ambulance Service college in August 2022. The National Ambulance Service continues to actively recruit new staff throughout the year and in March 2022 launched a rolling advertising campaign for qualified paramedics, student paramedics and intermediate care operatives. To date, this has secured 161 new recruits.

The processing of the pandemic special recognition payment continues to receive priority across all hospitals and community services. Some 123,000 employees have received the payment, 85,000 of whom are in HSE statutory organisations and 38,000 in section 38 organisations. The HSE is working with the Department of Health to take forward the payment of recognition awards to staff working in other organisations included within the organisation types covered by the Government decision.

Chairman

On Mr. Reid's final point, he referred to 123,000 workers in the HSE and section 38 organisations who received the pandemic recognition payment. Will he give the committee an update on other workers, particularly members of the Dublin Fire Brigade and ambulance drivers, who have yet to receive the payment? What is causing the delay?

Mr. Paul Reid

There is a process ongoing between Ms Anne Marie Hoey, the HSE national director of human resources, and the Department in terms of the identification of other organisations, including section 39 organisations. We do not have a central record of that but it is an ongoing process between the HSE and the Department. We are recruiting some specialists to put the full net around everybody in scope. If any of my colleagues would like to add to that, they are welcome to do so.

Ms Anne Marie Hoey

As Mr. Reid said, we are working towards ensuring that payments to non-HSE and non-section 38 staff are made. Working with the Department of Health, we have to increase some capacity to enable that. We have recently tendered for support and capacity to help us in that regard. That tender has now closed and it will be evaluated this week, with the award being made in the very near future. In line with the Government decision, we will move forward immediately to progress the payments to non-HSE and non-section 38 agencies.

Chairman

Does Ms Hoey have a sense of when people will be paid?

Ms Anne Marie Hoey

The tender has closed and will be evaluated this week. It will be awarded in the next couple of weeks, after which the administration will commence. Realistically, we are looking at November or December before the payments will start to flow, so it will be another couple of months. Plans are in place to expedite that.

Deputy Colm Burke

What kind of timescale are we talking about? One must remember that we have a huge number of GPs retiring in the next five years so we have a challenge from that point of view as well.

Mr. Robert Watt

Chairman

Yes, we can.

Ms Breda Crehan-Roche

As regards enhanced community care and the integrated care programme for older people, ICPOP, teams for the elderly, the best way to explain this is to give an example. Tom comes to the accident and emergency department. He has had a fall, he is seen and it is found he has fractured his hip. He goes into surgery and gets seen there. There is then a discharge programme and co-ordination where he is discharged back into the community. He is seen by the consultant geriatrician, because in Community Healthcare West, which is Galway, Mayo and Roscommon, we have four integrated care programmes for older people, each of which programmes has a consultant geriatrician. There are clinical nurse specialists, CNSs, occupational therapists, OTs, and physiotherapists, who are multidisciplinary and work closely with GPs. Tom goes back into the community but needs a little bit of transitional care. He goes into one of our ICPOP beds in one of our community nursing units and is then discharged after four weeks with a follow-up plan and with multidisciplinary teams involved.

Another situation is that of Ambrose, who has fallen but, thankfully, has not sustained a fracture. He does not need to go into hospital, so he is sent back into the community instead to be seen by a consultant geriatrician. He gets four weeks' transitional care in one of our care homes and is then discharged into the community with a follow-up, which would be multidisciplinary and would involve physiotherapists and OTs, depending on his presentation. He is seen and is looked after in the community and his family are supported with respite and home support.

That is the way it works. If somebody is in hospital, there is great integration between the hospital and the community. There are weekly discharge meetings and we look at what supports a person needs. We also have frailty at the front door. For example, last month in Galway, 133 people were seen in the accident and emergency department and we saved 236 bed days. Again, that was supported through community, step-down, transitional care beds, and being seen by consultants and by the multidisciplinary staff. That is the way it works.

There is also home support, and people get the home care packages they require, including aids and appliances and adaptations to their homes, which sometimes involves the local authorities. That is a very quick synopsis of the way it works between the hospital and the community.

Mr. Gerry O'Dwyer

I apologise to Deputy Burke and I will follow that up directly. Normally, as identified by Ms Crehan-Roche, we have a very close relationship between the community and the hospital, we work very closely, and we have a series of meetings every week, as Ms Crehan-Roche has clearly identified, so I am surprised at what the Deputy outlined. I will follow up with him directly afterwards, because I need to apologise to that man on behalf of the health service and we need to ensure that what happened does not occur anywhere else. It is quite unusual, and based on the clinical background Deputy Burke has given us, I am very concerned about it, so I will follow it up directly afterwards.

As regards exit interviews, which Deputy Burke also raised, we have a series of exit interviews and frequent meetings with the staff associations to try to ensure that, if there are any issues that are not resolved or if there is a particular trend in any location where the staff are leaving for any particular reason, those issues are followed up because we are very concerned we maintain and retain our staff at all costs. We have a regular update by the HR director on people who transfer or leave for other locations. I am quite satisfied that, where issues have been raised, they have been dealt with. If there are any other issues, Deputy Burke should not hesitate to give me a call because I will follow them up urgently. As was said by the CEO and the Secretary General earlier, we are also doing our utmost to recruit internationally to fill all possible vacancies and to ensure we have a seamless healthcare service moving forward following the whole model of Sláintecare. That is very important to us all at this stage.

Deputy David Cullinane

I welcome our witnesses. I would anticipate that this is Mr. Reid's last meeting with the committee and I will maybe say a few words on that at the end of my contribution.

Mr. Robert Watt

We have engaged with the consultant body. We set out, in general terms, what the Government was planning to announce yesterday. We spoke about our commitment in respect of capacity supports and how that would work. There are complexities about how this actually works and there are different ways. We invited the IMO because their members are the ones who are closest. As they are providing the service, they know where the issues are. We asked them to engage with us. There is enormous, detailed work; I think we shared some of the work with the Deputy. I think we published papers on this. There is enormous work being done in understanding the latest supports and demands. The Government has made its commitment and we need to work through it.

Deputy David Cullinane

As it is Mr. Reid's final meeting, I wish him well in his retirement. I know he had a very difficult role to fulfil with Covid-19 over the past number of years, along with the cyberattack and many of the challenges the HSE faced. On my own and my party's behalf, I wish him well and thank him for his work in healthcare.

Deputy John Lahart

I thank the witnesses for their attendance. I want to make a few points on GPs. I represent Dublin South West and there have been closures of GP practices through retirements and for other issues. I do not need an answer on it, but I want to get it on the record. Some of these GP practices served mature populations and seniors. It is very dislocating when that happens, as seniors are concerned about their files and access to their files, etc. It may not be something worth worrying about, having spoken to other GPs when they have taken them on; if there is an issue, they will put them through a raft of tests. I am confident about that.

In Templeogue, the only option for people on the general medical services, GMS, scheme was Nutgrove. It is a long way to travel. It is something to look at. A number of GPs are not taking over-70s, which creates challenges. This is going to happen. A number of GPs have retired, there have been bereavements and other issues that have caused a lot dislocation, particularly concerning patient files. It is a big issue for patients when a GP retires or their GP practice closes. They ask: "What happened my file?" or "Is it my file or the GP's file?" I would like to log that with Mr. Reid, along with the issue of not taking GMS patents aged over 70.

I would like a note on the primary care centre in Ballyboden. We fought for this. It took a decade to get this over the line. It is a spanking new facility. I do not think that GPs are in situ there. That is an issue. I would appreciate if I could get a note on that.

I would like to address my final question to both the Secretary General and the CEO. What is the percentage of unpaid hospital fees? They were abolished yesterday for everybody.

Mr. Paul Reid

With regard to our work with general practice, we hugely value the work GPs do. They are a core part of what we mean by enhanced community care. Where we have GPs in primary care centres, there are very different models and there is very different footfall going to them and they are much more successful. I am not familiar with the Ballyboden case, but we will get the Deputy a note on it.

Generally on GPs, we have worked closely with the Irish College of General Practitioners. We are looking at the pipeline of training coming through. Concerning the investment in general practice, particularly through Covid-19, the latest 2019 agreement provided for an investment of approximately €210 million in general practice. We are concerned, as the Deputy said, about the pipeline and what is coming through. We are beginning to see some positive indications of the pipeline.

Mr. Paul Reid

We see a value for them in this regard. As the Deputy mentioned, they more than demonstrated their value in the vaccination programmes. They play a key role in flu vaccination programmes. Not all of them participate, but we would like to see more of them participating and we are encouraging more of them to do so. We see them as part of the primary care service we provide.

Deputy John Lahart

No. Any approach in addressing the waiting lists on a sustainable basis will need multi-annual funding, which is what the Minister has made a submission on, and we will see the final breakdown on that.

Addressing things like new clinical pathways, for example, will need certain resources and specialties that recur into next year so it is not just one-off funding required.

Deputy John Lahart

Was that not anticipated in the waiting list action plan that agreed with Government and which Government funded?

Mr. Paul Reid

It was, but as you get into the actions and as you define the actions there is a recurring element that had to be incorporated into the Estimates process, which the Minister has brought through and there is funding for it next year as well, so there is a recurring element into 2023, and there will be into 2024.

Ms Yvonne Goff

There are about 45 actions in the action plan and one of these is to do capacity and demand analysis. We have completed the capacity and demand analysis and identified all the specialties that need one-off backlog clearance and all of the ones that need recurrent gap investment. We have completed that and we have submitted the 124 million to look at the specialties that make up approximately 90% of the waiting lists that have a recurrent gap and need multi-annual investment. Therefore we have two approaches, one is to clear the backlog with a one-off payment, and also seeking recurrent, to have sustainable solutions to not only achieve Sláintecare targets but to maintain them as well.

Chairman

I call Deputy Róisín Shortall.

Deputy Róisín Shortall

I thank the witnesses for their presentations. It is very hard to comprehend a situation where the State is spending €23 billion on the health service and we find ourselves year on year with money allocated for different services and the HSE incapable of recruiting people because there has been little or no forward planning in relation to workforce. It beggars belief that given the level of unmet need in the country, our biggest problem in the health service is that we cannot get staff. We are talking about international recruitment but there are ethical issues around international recruitment. There is also the madness in what is happening with hospital doctors, where at huge expense we are training them to leave this country, and then trying to scramble around to get foreign doctors to keep our service together. One has to ask why there is not a clear, robust workforce plan for this year, for the next five to ten years and a plan for the next 20 to 30 years. All of these projections are available in terms of population growth, the kind of numbers that will be needed across health and social care. Why is that not being done and who is responsible for not doing it? That is the question. It is the most fundamental thing you would have in a major organisation with that kind of massive budget. I just cannot get my head around it. Why is it not happening? We have heard comments about how we have succeeded in getting an extra 60 medical places. This should not be a concession. We have succeeded in getting some extra places but it is not anything like enough. That is paraphrasing what has been said by Mr. Watt. Why is it not enough? Why have we not got the figures set out over the next 20 to 30 years?

I spoke to the Minister for Further and Higher Education, Research, Innovation and Science, Deputy Harris, about this, because I am gobsmacked at the extent to which our health service is not functioning and so many members of the public are denied access to essential health and social care because of the failure to plan. He said he is more than happy to extend the number of places in third level colleges if he gets some figures from the Department or the HSE. There are four key areas that need attention and we should be able to set down on paper what the needs are and what the plan is to ensure adequate numbers of staff over the coming years. I do not think such a plan exists. There is no evidence of it, and I have to ask why that is the case. In any major organisation recruitment, forward planning and doing the projections is just basic work.

The first issue is the adequacy of the number of third level places. This is a matter of doing sums and working out what numbers of different categories of staff will be needed over the coming years. There is then the question of work placements and I would like Mr. Reid to address that issue in particular, because my understanding of the situation is that for healthcare staff work placements are absolutely critical.

They are a major part of the whole training process. My understanding is that, within the HSE, the number of placements has been reduced substantially in recent years. That is causing part of the logjam. Clearly, not much attention is being paid to the work experience of people in the health service, where, for example, junior hospital doctors are leaving this country in droves. GPs cannot set up in practice because they do not have the money behind them, and we were promised salaried GPs. We also know that many people right across the health service do not have very good experiences of working within the HSE and prefer to go to other places where there are functioning health services.

The other issue that needs to be addressed is CORU; I think CORU has to be seen as part of the problem. Why is it taking so long to recognise people's qualifications? There is a whole area there that seems to have been completely neglected in recent years.

There was a time when doctors were seen to be the only people in the health service and should be the key decision makers. They certainly were in a very prominent position in the Department of Health. There was an extraordinary reverence towards them. About ten years ago, there was finally recognition of the important role of nursing and the Chief Nursing Officer was appointed on a par with the Chief Medical Officer. That was a very important development. We know that nurses should be on a par with doctors.

There is another area of staff, health and social care professionals, to which I would ask Mr. Watt to give serious consideration. These are essential people within the health service, especially as we move to implement Sláintecare and a different model of care within the community. There are major shortages of health and social care workers. Some of that has been referred to already, where money was provided in recent years for mental health services and disability services. It is a joke that the money is there and we cannot get the people. I would put it to Mr. Watt that consideration should be given to appointing a chief officer for health and social care professionals, to bring them on a par with nursing and medical professionals. This is going to be a huge area that needs to grow substantially if we are serious about patient-centred care. Has Mr. Watt given consideration to the appointment of such an officer at senior management level within his Department?

Deputy Róisín Shortall

Could I have a note on the placements that have been provided this year, for example?

Mr. Damien McCallion

We are trying to grow that in terms of international recruitment and people who have been employed overseas as well. So regarding the adaptation that is needed - Deputy Shortall mentioned health social care professionals - we will see how we can grow the number of places. In nursing it is very strong because of the historical investment that is there.

Chairman

I need to move on.

Deputy Neasa Hourigan

Deputy Gino Kenny

My first question is in regard to the pandemic recognition payment and it is probably a question for Ms Hoey. Overall, we all welcomed that front-line workers were going to be rewarded for their service during the pandemic but the roll-out has been quite haphazard, to say the least. Obviously, workers who were in that kind of environment have still not got the payment, which is bizarre. Why did it need a third party in the tendering process to administer the payment to section 39 workers and other workers who are on the front line? I do not understand why that had to happen.

Ms Anne Marie Hoey

In regard to HSE staff and section 38 staff, our own staff are directly on our payroll and we have direct links with the section 38s under the service agreements. Therefore, we had direct visibility in terms of who was eligible for the payment as per the criteria that had been set out and we were able to put in place the payment quite quickly.

As mentioned earlier, 123,000 staff have received that payment at this stage. That number seems to be peaking at that level now and the numbers in the last couple of weeks have reduced to just a trickle. Regarding the third-party agencies, we do not have the same relationship with those agencies in that we do not have visibility of their staff by staff member. We have service level agreements in place with those agencies for the provision of a quantum of service in return for an annual fee or amount of money that is provided. When making the payment to the staff in those agencies, as we do not have that direct relationship we have to engage with them around which of their staff are eligible for the payment. They would have to provide those details to us at a staff member level, as well as the number of staff and so on. When we have that level of detail we will be able to make the payment to the agency and it in turn can make it to the staff member. It is just because of that gap whereby we do not have that direct relationship on our payroll system with those staff.

Deputy Gino Kenny

I am sure Ms Hoey can understand why workers would be extremely frustrated, to say the least. The goodwill from the gesture has gone out of it in some ways because it is so delayed.

Ms Anne Marie Hoey

I acknowledge and accept that those staff should get that payment as soon as possible, as our other staff have. The capacity issue is something we identified early on as something we needed to get some support for. As mentioned earlier, we have tendered for capacity support and that will be in place in the coming weeks. We have done some preparatory work within the HSE and with the Department of Health around who the agencies are. The criteria have already been described well at this stage. Once the third-party provider that is going to assist us with the capacity piece is in place, we will start to make those payments as soon as possible.

Deputy Gino Kenny

My second question is on the shortage of consultants in our health service. According to the Irish Hospital Consultants Association, IHCA, there are 900 outstanding vacancies relating to that work spec. That is putting enormous pressure on our health service. A press release from the IHCA a number of weeks ago states that waiting times cannot be tackled until these places are filled. What are the HSE and the Department of Health doing to try to fill these vacancies? There is historical context to this since the financial emergency measures in the public interest, FEMPI, pay cuts and so forth. What are the agencies doing to fill these posts?

Mr. Paul Reid

I will respond to the Deputy first and then Ms Hoey will give some flavour of it. We are anxious to fill any number of consultant positions we have funding for and approval to do. I gave some figures for other medical staff that were recruited but I did not give them for consultants. We have had a net increase of consultants of 506 since January 2020. Sometimes we say we are losing consultants but that is a net increase of 506. It is the biggest net increase in the health service in a long number of years. Looking at the gaps we still have, there are 4,040-odd consultant approved positions and 3,548 of those are filled. Of those filled, 412, or 10%, are filled by temporary staff. Some 270 are newly approved so we are still in an advanced process to recruit. There is a significant extra focus being put on them. The new contract for consultants is a process the Department is leading, with the Minister and the HSE, but the issue we are focused on, particularly right now, is continuing that recruitment. It has been quite significant over the past three years, bigger than it has ever been.

Ms Anne Marie Hoey

As Mr. Reid said, we have over 4,000 consultant posts approved. Some 8% of those are brand new development posts that have been approved in the past couple of years. There is a lead-in time associated with being able to fill consultant posts and particularly the newly-created posts.

With regard to what we are doing, we are improving our processes and the turnaround time for recruitment. We have revised all our processes and reduced the time to recruit by 40% in the past year. We recruit directly through the section 38 agencies and the Public Appointments Service. We can see the benefit of the improved process. In this year alone there has been a net increase of 150 new consultants. That is in addition to replacing the turnover rate that arises. We are also working to improve our international reach with the marketing of consultant posts. All efforts are continuing to try to maximise our recruitment efforts and to fill our consultant posts.

Ms Anne Marie Hoey

The nurses come primarily from India and the Philippines. That would be the primary source of the international nurses.

Deputy Bernard J. Durkan

I thank our witnesses for coming before the committee. I would like to congratulate and thank Mr. Paul Reid for his work in the health services over the past years, and particularly in the face of the Covid crisis. It was an extremely hard call and task. It was fulfilled with great efficiency. It is a great model for the future of the delivery of the health services. I thank Mr. Reid once again.

Deputy Bernard J. Durkan

Is it not possible to have a contingency figure encompassed in the budget in such a way as to be able to call upon it as required without having to seek an increase in spending?

Mr. Robert Watt

If there is a contingency budget within the health budget it would become a target to be spent. That could be used up within the first few weeks. It sounds like a cynical remark to make but it is not-----

Deputy Bernard J. Durkan

No, it would not be that.

Mr. Robert Watt

-----within the overall budgetary numbers. Yesterday the Minister for Public Expenditure and Reform, Deputy McGrath, referred to a contingency to be held centrally in respect of Covid as a once-off. We do not know about Covid and if more spending is required above what we budgeted for. Then a central reserve would be held in the Department of Public Expenditure and Reform or the Department of Finance and the Exchequer would release it then. We have had this debate over many years about whether within Votes there should be an unallocated amount. As the Deputy is aware, given his knowledge of public financial procedures, the Dáil votes on the amounts we expect to incur not the amounts we expect to incur plus some unexpected amount. That would involve change. Perhaps the Deputy would argue that we should go down that road but I am not sure.

Deputy Bernard J. Durkan

What Mr. Watt is saying is correct but in some cases we underspend and in other cases we overspend. That puts on its head the argument that Mr. Watt is putting forward.

Let us move on to something else if I might. In general there are particular pinch points throughout the health services in terms of delivery, whether it is in CHO7, in mental health, and in children and adult's mental health. In other places throughout the country there are other pinch points. To what degree is Mr. Watt satisfied now that these pinch points have been identified and remedied? Is that the first thing that has to happen if we are going to produce smooth delivery of health services?

Mr. Paul Reid

I am happy to take that piece and the previous question that was asked. First of all, in the national service planning process and in the Estimates process we do look at demographics, at existing levels of services and at inflation. All of that modelling is done at the Estimates process and it is further done in the national service planning process in the allocation of funding. Consider in particular the last couple of years and this year. If we talk to people in the NHS in Scotland, in Northern Ireland, and in the UK - and I have spoken to them - and if one speaks to those in the Dutch health service, the reality is that every health service has been hit by some unknowns coming from Covid. First of all there was Covid itself, and the volume of activity it has driven. Second, there is some of the delayed care that we are seeing coming from it. Third, we are seeing a higher frailty level of older persons. I gave a figure, probably last week. I was in the University Hospital Waterford two weeks ago. I walked the wards in a 450 bed hospital where 270 of the patients were over the age of 75. That is what we are seeing, and it would not have been predicted to the level we are seeing. Modelling is being done by Dr. Colm Henry and others in the Department that looks at the frailty rate of a 76-year-old person now versus the frailty rate of a 76-year-old person two years ago. Certainly it has deteriorated. There is modelling that we do but there are things that happen that impact on our services. Certainly with older persons I would say that the biggest challenge we are facing in the health service in the next ten years - not 20 or 30 years - is higher frailty challenges in older persons. Thankfully we have a health system and a country where people live longer than any of the EU averages, one of the highest rates in the OECD and much higher than in the UK. We have longer life, we have higher complexity and we have higher frailty. It is going to put further pressure on the funding streams and the health system.

Deputy Bernard J. Durkan

The only problem with that is I have been hearing for 20 years that 2038 would be the real hit year. The problem still remains.

We are not really catching up on it or passing it by despite that a huge influx of young, tax-paying people into the country came in that period. The incoming population has doubled, to say the least. It goes without saying that the extra tax-paying population who are not retired or on pensions puts the whole structure on its head. More taxpayers are coming into the country than are leaving it. We need to look at that again to see what we are doing to use that influx of a young tax-paying population to deliver services to whoever may need them, without seeming to blame one sector or another on the basis that they are taking up space.

I want to move on-----

Mr. Paul Reid

Can I clarify that in case it is misinterpreted? I have never said that one age profile or another is to blame, under any circumstance. That is not the case. It is a fact of our demographics. In five, six or seven years, we will have more people over the age of 65 than we have under the age of 14. The demographics are clear. I am not trying to relay that it is an issue of-----

Deputy Bernard J. Durkan

Where are the incoming working population who are taxpayers brought into the equation? It is a huge number. I do not see them in this.

Mr. Paul Reid

That is all the modelling of our funding streams.

Deputy Bernard J. Durkan

I do not see them referred to in any of the replies. That does not mean that the HSE does not know about them, although it surely must. The incoming working, tax-paying population has doubled in the last few years.

To move on to something else, there are a number of issues that beset the delivery of health services. I know that Covid is one issue. I think the HSE did extremely well there and a great effort was made. To save the public, we need to get on top of this job and to deliver health services wherever they are needed. In the past month or six weeks, I was informed of an outstanding reimbursement under the hardship clause. Pharmacists were not being paid. I spent four days on the telephone. I explored every possible nook and cranny to find the problem. I eventually found out that nobody was dealing with the situation when the requisitions were made to be passed on for payment. It was eventually sought, but I spent four days on the telephone and made about 70 phone calls. That should not happen. What are we doing to eliminate such pinch points? It appeared to be a delay that only affected pharmacists, but it affected the patients in a serious way.

Mr. Paul Reid

We have a primary care reimbursement service which has been well-resourced, well-funded and well-built over the last few years. Ms Anne Marie Hoey, who is my colleague, ran it for the past few years. I would be happy for her to address it. We put significant resources into refund schemes for general practitioners, pharmacies and patients.

Ms Anne Marie Hoey

It would be useful to get the specific details of the incident that Deputy Durkan is describing. The hardship payment is done between the local health office and the primary care reimbursement service. I have not been working there for the past three years but, as I exited, the plan was to centralise the hardship payment in the primary care reimbursement service. I am not sure how much progress has been made in that regard. It certainly should not take 70 phone calls to resolve such an issue, so it would be useful if the Deputy could provide details. The matter can then be reviewed in the context of what arose.

Deputy Bernard J. Durkan

I resolved the particular problem at the time, but it took me four days to do it. I would hate to be in the position of a patient who is waiting in vain for something to happen. Can I ask one last question?

Chairman

Deputy Durkan is way over time. I will bring him in at the end if there is time.

Senator Lorraine Clifford-Lee

I thank our guests. I apologise if I am going over ground that has already been covered. I was called to the Seanad for some business, so I missed part of the meeting. I thank all our guests for giving us the information required by the committee.

I think the Secretary General covered that comprehensively, so I will leave it because I do not have anything to add.

Mr. Paul Reid

I thank the Senator, including for his earlier comments. We are sufficient with stocks we ordered for the flu vaccine much earlier in the year. The flu campaign will start on 3 October, early next week, and there will be a dual campaign relating to Covid, with the new multivariant vaccine that is available, and the flu vaccine. We have a number of media communications programmes to encourage and strengthen uptake. We are more than sufficient in terms of supplies of both the flu and the new multivariant Covid vaccines.

Senator Seán Kyne

I wish Mr. Reid well in the next chapter of his career and life and thank him for his service. I hope that nothing we in this committee said pushed him to leave early. If it did, we did not mean it and it was said in the best interests. Does Mr. Watt have an interest in applying for the position of CEO of the HSE? That is one question I have.

Last year, we discussed the winter plan. One in eight people was on a trolley in University Hospital Galway and there was no provision of acute beds. In the intervening period, has there been any planning for additional acute beds in Galway for the coming winter?

Mr. Damien McCallion

I might make a couple of broader points about the winter before specifically commenting on Galway. There were elements of bed capacity in the winter plans of the past two years and through the 2022 service plan. The total number of beds funded across that was about 1,150, of which more than 900 have been delivered. A further 154 will happen before the end of the year and the balance in 2023.

Turning to University Hospital Galway, throughout the Saolta University Health Care Group, 83 additional beds are planned, of which 12 are due to open. I do not have the specific figures for Galway hospital but Saolta as a group, as the Senator will be aware, covers the hospitals in Castlebar, Portiuncula, Sligo and Letterkenny. I can revert to him with the exact numbers for Galway hospital.

Alongside acute bed capacity, one of the areas of focus for the winter is the vaccination which, as Mr. Reid said, is crucial. We saw the impact of low vaccination rates in our hospitals with Covid-19 during the pandemic so we are really urging people to get vaccinated. We have a big campaign starting around that. The second area is acute capacity but also the community bed capacity. The third piece then is to leverage some of the existing investments we talked about earlier in terms of the community with the older persons teams, in particular, and our chronic disease teams. Fourth, we are looking to put in additional capacity and resource for simple things that can sometimes clog up the system or packages of care, aids and appliances, which are things we know we need to use more of in the winter. They are also forming part of the final discussions to which the Secretary General referred. Lastly then we have looked at initiatives within each geographical area, which may vary.

My colleague, Ms Crehan-Roche, in Galway may also want to comment on this in terms of the other local resources that would most help make the maximum impact in what we know may be a very severe winter this year. We are trying to plan for the worst-case scenario as best we can but it is more than just acute bed capacity. We are working with Galway regularly. Ms Crehan-Roche might want to comment on one or two of the specific local initiatives in Galway as well.

Ms Breda Crehan-Roche

I thank Mr. McCallion. We work very closely with our colleagues in the Saolta University Health Care Group with regard to step-down beds, respite and transitional funding. We have ongoing communication with them. We also work very closely with the private nursing homes with regard to beds. That is an ongoing issue. There are daily numbers on beds, vacancies and visibility. We work very closely on that. We had a very good meeting with Nursing Homes Ireland recently as well. It is, therefore, an ongoing process. We also have the integrated care programmes for older people, ICPOP, teams, the frailty at the front door service and also outreach clinics in relation to keeping people from having to go into the acute services they would be seeing within their communities in the enhanced community care, ECC, ambulatory hubs.

Senator Seán Kyne

I thank Ms Crehan-Roche for that and for the meeting we had on Monday with all Oireachtas Members regarding Clifden District Hospital, which is connected to workforce planning. Talking about the winter programme, we have seen referrals from Galway University Hospital, GUH, to Clifden District Hospital dry up over the last period. In the main, we do not have a physiotherapy service in Clifden because of difficulties in recruiting somebody for that position or retaining somebody in that position. The physiotherapist left in 2021 and has not been replaced. This is having a knock-on effect where we have a facility with staff, beds and capacity. However, because we do not have physiotherapy, we have seen referrals dry up, and this is putting pressure on GUH. This is a perfect example of recruitment and workforce planning impacting down the line to the acute hospital.

Ms Breda Crehan-Roche

As the Senator said, we had a very good meeting. We will also have a following meeting in the middle of next month with all of the political parties and local politicians.

With regard to the physiotherapist, yes, we have had difficulty. What we are trying to do is be creative and look at ways. Unfortunately, even when we offered the person a position in Galway city with outreach to Clifden, it was not possible. We have to provide this, however. That is where the ICPOP teams come in, and we will be looking at a hub-and-spoke model.

It may be useful for us to send the committee more detail based on the trends in recruitment and those in training, undergraduate placement and all the various aspects. It might be useful to set that out and then try to overlay it with the waiting lists, that is, in which areas are people waiting. We can link that list to a shortage of professionals to deal with people on waiting lists and then identify the gaps. That is the demand and supply capacity analysis that we have been trying to do and which Ms Goff touched on earlier. Mr. Reid and I will try to collate the various requests from members and come back with a composite note. The next time we meet, then, members may be able to ask about a particular area and point out that we are not doing enough work there relative to the lists. That is, in effect, what we are trying to do with the workforce planning. We can send members more information that might help to give an overall assessment of it.

Chairman

Okay. At meetings like this, we do not get a sense of the answer to the big question everyone asks, which is whether the system can be fixed. Innovative measures are being taken. Last week, for example, we had people in from University Hospital Limerick, UHL, and they spoke on the big challenge being faced there, relating to senior citizens coming through the emergency department system. We know of the pathway service that has been introduced at Beaumont Hospital and other locations and is being rolled out in different areas. At meetings like this we probably need to hear about schemes that are working as well.

Mr. Robert Watt

Dr. Colm Henry is not present as he has other commitments but I understand he is leading of the reform of the pathways, which relates to some of this, It is about how people can be treated in a different way rather than being referred by a GP to a choke point in the system. It might be useful to summarise some of that at a future meeting. We can work with the committee on it because it might be interesting to see the examples and what the reform programme involves. That is really what it is about - trying to drive the change and the numbers of people who are treated more effectively-----

Mr. Paul Reid

In fairness, at our most recent meeting the Chairman made the same points with regard to getting below the big numbers. There are 617,000 outpatients waiting, 75,000 inpatient day cases and 27,000 gastrointestinal scopes.

We have those figures broken down by hospital, specialty hospital group and community, and some of the waiting lists in the community. That is informing our strategic workforce planning. We are aware of issues in some rural parts of the country in particular, as Senator Kyne raised earlier, where we are having challenges in recruitment. We can, however, give the committee a greater sense or depth in terms of the big list, but also in terms of the level of activity that we carry out every year because sometimes the public do not hear that either. We carry out more than 5 million activities, between outpatients, inpatients, scopes and emergency departments procedures carried out in hospitals. Yes, we have a big backlog and it is our greatest challenge but we are, every year, doing higher and higher levels of activity and it is now about changing it all, as Mr. Watt said earlier. Yes, it is about resourcing, but it is also about changing those patterns. The Chairman referred to the pathfinder service at Beaumont hospital. Pathfinder is being rolled out at UHL, as he stated, and in other parts of the country, as is the whole frailty management piece that Ms Crehan-Roche spoke about. We do not just have pilots, we have pathways that we know work and that we want to roll out across the country as well as recruiting specialists. It is a decision for the Chairman and the committee, but it would be worthwhile to get greater depth on some of that.

Deputy Colm Burke

To go back to the issue of community care, no matter what kind of community care the HSE can provide, it will not be adequate and a certain number of people will have to be admitted into nursing homes for the care they require. There is a significant gap between what it costs per bed in private and public nursing homes. The latter is, on average, €1,650 per bed per week, while the former is €1,000 per bed per week. Several private nursing homes have closed because it was no longer viable for them to stay open. Where is the Department now in taking account of the new challenges private nursing homes will face with the cost of energy, etc.? When will there be engagement on dealing with those challenges so that there are no further closures?

The second matter I wish to raise relates to workforce planning. There was reference to the shortage of nurses. I understand that some private hospitals are now training people specifically as theatre assistants. Those staff are not qualified nurses but they are specifically trained as theatre assistants. That is happening in other jurisdictions as well. Is that approach being considered?

My final point is that nurses are highly qualified yet they are still doing a lot of work that care assistants could be doing. That is not taking from care assistants. In fairness to nurses, they are well qualified now. In fact, many junior doctors will say it is nurses who are doing an awful lot of their training because nurses have so much experience and skill. Is the issue of nurses' responsibilities and delegating some of that work down to care assistants being considered in the whole realignment? Similarly, is the issue of theatre assistants being considered?

Ms Rachel Kenna

As regards theatre assistants, we are looking at the development of roles that will support nurses, midwives and doctors in practice. As the Deputy noted, theatre assistants are well integrated internationally into acute settings, and other types of assistants into community settings as well. It is part of our strategic outlook in terms of policy direction to look at these and other roles. Physician assistants are currently being trained here through the RCSI and are employed in some hospitals through the HSE. These roles are not new to our workforce planning and they are being considered in that regard.

In terms of nurses being highly qualified, the Deputy is correct. Our success in terms of advanced practice is testament to the skills, knowledge and expertise of our nursing and midwifery workforces. In supporting that, there has been an increase. We have a policy target now of 3% of our entire nursing and midwifery work force being at advanced practice level. This year, with the additional 149 posts that are currently in the process of final recruitment, we will be at 2.25% of our workforce. We have achieved significant growth at the higher level of practice, at the top of the licence for nurses and midwives.

To support that, part of the expert review on nursing and midwifery will look at the implementation of the recent healthcare assistant review that was done in 2019. That is about the support and development of healthcare assistant roles within and throughout the service. We are also working in close collaboration with colleagues in the HSE to develop healthcare assistants through apprenticeship-style training processes to fill and meet the demand of what is now developing through Sláintecare.

Deputy Colm Burke

It is something we could set out in the note. A lot of young graduates do their basic training and go away but they do come back - I believe the latest numbers are that 70% or 80% do come back. They go away for a few years but they do return. Clearly there is an issue around retention. There is an issue around the non-consultant hospital doctors and a working group has been established to address various working conditions there, which we are all aware of with regard to hours, rosters, and the moving around in a way that is not necessarily family friendly.

So, absolutely, the Minister has made it clear on this. I will use that dreadful expression "multifaceted", but there are a number of different areas here. To be perfectly frank, I admit that in the past, there has been a failure to properly plan in terms of workforce. Absolutely. We have responded, particularly in the last year or two, but we need to do better. There needs to be a step change, whether that involves a radical expansion of the capacity of the existing medical schools in Ireland, or whether it requires a complete reorientation of the model, or whether we need to establish new medical schools. I was very interested in comments made recently, they may have been by Alistair Darling, but by a former Secretary for Health in the UK. He talked about his ambitions and realised that even when they doubled the number of places there, it still was not enough. The western developed world is thankfully facing a success - as Mr. Reid mentioned earlier - which is our life expectancy. It is currently one of the highest in the EU. The increase in life expectancy is, of course, a positive but it does link to a very different type of model of care than that in the past, and the demands are just very different. We are going to have to do that. We definitely welcome that. Deputy Shortall referred to the commitment by the Minister, Deputy Harris, and we should absolutely engage on that and really have a step change now.

Deputy Róisín Shortall

I have a few questions for Mr. Watt. I am concerned about the number of references that Mr. Watt makes to doctors in the context of staff shortages. Obviously, that is a big problem area but many other staff that are critical in the health service. I put the question again to Mr. Watt about having a chief officer with responsibility for health and social care professionals. That area needs to be very much brought up within the Department. The tendency is to overlook them.

Deputy Cathal Crowe

Who whittled down the options and said the mid-west does not need an elective hospital? From time immemorial, Governments have always followed advice, and this is the same for the current Government, the next Government and the ones that have come before and that will come after. There is the so-called permanent government of the Civil Service, and if it advises the Minister to do a certain thing, it is very rare that the Minister does a complete U-turn and pushes back.

I want to know who in that chain of command whittled this down from "Yes, we need an elective hospital in the mid-west" to "No, we do not". Who is that person who struck a pen through a page and said we do not need one?

Deputy David Cullinane

The Minister is on record as saying that he favours the hospital in Galway.

Mr. Paul Reid

Would it not be uncommon for a Minister not to take the advice? That is a legitimate process, to be clear.

Deputy Cathal Crowe

I get that but I think it is fair to ask. This is a public organisation that is publicly funded. This is the HSE reporting to the Minister for Health. Who decided to whittle down all of these regional demands coming in and said there should only be three elective hospitals? It is a very straight question and this is the third committee meeting. I was placated the last time by being told I would be furnished with the answers afterwards. I never got them. I only have one question. Who whittled down demands and options and said there should only be three? That is all I need to know. It is not the Minister, it is not Government, and it is not the University Hospital Limerick management.

(Interruptions).

Deputy Cathal Crowe

It is not, Mr. Reid. The memo went in suggesting three. I want to know who whittled down all of these demands and options and said there should just be three. That is all I want to know. Beyond that I have to take it up politically. I only need to know this detail.

Mr. Paul Reid

I am just explaining the process. Ultimately, a memo to Government is brought by the Minister.

Deputy Cathal Crowe

It would be very helpful if the memo was circulated to this committee so that we could review it under correspondence.

Chairman

That is hardly going to happen. I do not think that is going to happen. The Deputy has asked the question anyway.

Deputy Cathal Crowe

I will have to wait for the fourth meeting to get the answers.

Deputy David Cullinane

The Deputy might get answers at the Fianna Fáil Parliamentary Party meeting.

Chairman

Sadly, we have come to the end of the meeting. I thank the representatives from the Department of Health and the HSE for their continued engagement on this matter. I look forward to further regular engagement with the Department of Health and the HSE on this important matter.

Separately, it is understood this will be the committee's last engagement with Mr. Paul Reid as CEO of the HSE. I put on record the appreciation of the committee for the many engagements we have had with him since 2020, in particular the assistance he provided to the committee during the challenging Covid-19 pandemic. On behalf of the committee, I wish him very well.

Mr. Paul Reid

I thank the committee. I hope both I and my teams have always presented respectfully and done our research to the best extent we could. I certainly have felt it reciprocated.

Chairman

We wish Mr. Reid well for the future and may he enjoy that family time he was talking about.

The joint committee adjourned at 12.32 p.m. until 9.30 a.m. on Wednesday, 5 October 2022.

Joint Committee on Health díospóireacht - Wednesday, 28 Sep 2022

Sláintecare Implementation: Discussion (Resumed)

Mr. Robert Watt

Mr. Paul Reid

Mr. Paul Reid

Ms Anne Marie Hoey

Ms Anne Marie Hoey

Mr. Paul Reid

Mr. Paul Reid

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Mr. Paul Reid

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Mr. Paul Reid

Mr. Paul Reid

Ms Breda Crehan-Roche

Ms Breda Crehan-Roche

Mr. Gerry O'Dwyer

Mr. Robert Watt

Mr. Robert Watt

Ms Rachel Kenna

Mr. Robert Watt

Mr. Robert Watt

Mr. Paul Reid

Mr. Damien McCallion

Mr. Damien McCallion

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Mr. Paul Reid

Mr. Paul Reid

Mr. Paul Reid

Mr. Paul Reid

Mr. Paul Reid

Mr. Robert Watt

Mr. Robert Watt

Mr. Paul Reid

Mr. Robert Watt

Mr. Paul Reid

Mr. Paul Reid

Mr. Paul Reid

Mr. Paul Reid

Mr. Paul Reid

Ms Yvonne Goff

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Mr. Robert Watt

Ms Rachel Kenna

Ms Rachel Kenna

Ms Rachel Kenna

Ms Rachel Kenna

Ms Rachel Kenna

Mr. Paul Reid

Mr. Paul Reid

Mr. Paul Reid

Mr. Paul Reid

Mr. Paul Reid

Mr. Paul Reid

Mr. Damien McCallion

Mr. Damien McCallion

Mr. Damien McCallion

Mr. Damien McCallion

Mr. Damien McCallion

Mr. Damien McCallion

Mr. Damien McCallion

Mr. Damien McCallion

Ms Breda Crehan-Roche

Mr. Damien McCallion

Mr. Damien McCallion

Joint Committee on Health díospóireacht -
Wednesday, 28 Sep 2022