Joint Committee on Health díospóireacht -
Wednesday, 20 Mar 2024

HSE National Service Plan 2024: Discussion

An Cathaoirleach

The purpose of the meeting is to consider the National Service Plan 2024 with representatives of the HSE. I am pleased to welcome Mr. Bernard Gloster, chief executive officer, Mr. Stephen Mulvany, chief financial officer, Dr. Colm Henry, chief clinical officer, Ms Anne Marie Hoey, chief people officer, Ms Martina Queally, regional executive officer for Dublin and the south east, and Ms Kate Killeen White, regional executive officer for Dublin and the midlands.

Witnesses are reminded of the long-standing parliamentary practice to the effect 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 their statements are potentially defamatory in respect of an identifiable person or entity, they will be directed to discontinue their remarks and 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 any person outside the Houses or an official, either by name or in such a way as to make him or her identifiable. I also remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit a member to participate where he or she is 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 any member participating via Microsoft Teams that, prior to making their contribution to the meeting, they confirm that they are on the grounds of the Leinster House campus.

I invite Mr. Gloster to make his opening remarks.

Mr. Bernard Gloster

I thank the Chair for the invitation to meet with the joint committee to discuss the National Service Plan 2024. I am joined by my colleagues Dr. Henry, Mr. Mulvany, Ms Hoey, Ms Queally and Ms Killeen White. I am supported by senior colleagues, Mr. Ray Mitchell and Ms. Niamh Doody.

The national service plan sets out a significant plan for our statutory health and personal social services in response to the needs of the public for services and the requirement to advance many new ways of provision to ensure sustainability into the future. This is my first full year of a national service plan. It is also the first in which the HSE has two line Departments following the transfer of functions relating to disability services to the Department of Children, Equality, Disability, Integration and Youth in March 2023. The board and executive have worked with the Departments led by the Minister for Health, Deputy Stephen Donnelly, and the Minister for Children, Equality, Disability, Integration and Youth, Deputy Roderic O’Gorman, to produce one national service plan reflective of the need for continued pursuit of integration as core to service provision.

The overall allocation of €23.5 billion for health represents an increase of 4.6% on the opening position in 2023. Some €20.7 billion relates to the health Vote and €2.8 billion to the Department of Children, Equality, Disability, Integration and Youth's Vote. There is provision of €162.8 million for new developments this year. Of that, €64.1 million relates to disabilities. A further welcome €90 million is expected to be allocated shortly in respect of new health developments.

Access and capacity will be enhanced, with €56 million in new investment in acute beds, diagnostics and the waiting list action plan. Service improvements will continue, with €13.6 million in new investment in child and adolescent mental health services, CAMHS, enhanced community care, ECC, and health promotion. Workforce and reform will see progress. Some €29.1 million of new investment is being allocated in respect of GP places, non-consultant hospital doctor, NCHD, training, nursing and midwifery and health and social care professionals, with a focus on student practice. New surgical hubs and digital reform will all aid improved ways of working and provide more convenience for the public. Disability services will continue to develop, with €64.1 million in new investment to support school leavers, residential care and the ever-increasing demand for respite care. Across health and disabilities, we have existing level of service support with a combined €834.7 million and additional support recognising the challenges that arose in late 2023, with a once-off allocation of €918.7 million for 2024.

It is obvious from all of the evidence that in what is clearly identified as a challenging year we need to continue to invest in new developments. Correspondingly, we are also obliged to demonstrate the best use of what we have and the advancement of new ways of working. To this effect. there is now a joint Department of Health HSE productivity task force, and this will assist in guiding further efficiency over the coming years. In simple terms, the productivity focus should allow us to generate more activity with broadly the same resources to respond to public need, in particular access. The new consultant contract and the public sector pay agreement are central to this focus.

I am acutely aware of the challenges and concerns regarding the pause on aspects of recruitment over the past number of months. It is clear that control within and the best use of the staff we employ is central to our responsibilities to the public, not only in respect of the services we provide but also the management of the allocation we receive from Government. It was clear in the latter part of 2023 that recruitment was running at a rate that was not sustainable. The highest ever net growth in the health service occurred in 2023, with an increase of 8,239 bringing the number of whole-time equivalents to 145,985 across the HSE and section 38 agencies. The growth is in contrast with an average increase of 4,690 in the previous five years and well exceeds even the highest most recent year driven by Covid-19 of 6,361 in 2020.

In December, even at the height of the pause, employment numbers grew by 933. We have again seen that continue, albeit less net growth in January, particularly in nursing. Turnover has improved, in that it decreased in 2023 by 1.3%, which is significant for the size of our workforce and the upward trend of the preceding years. Despite the need to get to grips with our affordable numbers and the challenges in this process, we have the largest workforce in the history of the Irish health service. That workforce has expanded by 21.8% since the end of 2019.

Notwithstanding control measures and affordability actions, we will this year see recruitment of new development posts at a minimum of 2,268 in our health portfolio and 683 in disability services. Supported by the board of the HSE, I am determined to ensure that our management of approved workforce levels brings us to a point where arbitrary measures at national level, such as a pause, will not be necessary and the best productivity possible in the public interest is achieved through our most valued asset, namely our workforce.

When I took up this post a year ago this month, I committed to expediting the introduction not only of new regions as set out in the programme for Government and the Sláintecare policy platform, but also to fundamentally reorganise the centre of the HSE in its role, purpose, function and performance. I am pleased to report to the committee that as of 11 March, five of the six new regional executive officers are now in place, two of whom are with me today, with the remaining regional executive officer due to start on 15 April. Reporting directly to me, this represents a significant move towards the integration of services and delayering of decision-making processes in the HSE. I welcome the new executives who, together with redefined roles for people at the centre, will be the mechanism and structure through which we will deliver this service plan, one which aims to improve services for the people we serve, continue to reduce waiting times in all forms and increase the quality of outcome at every point at which the public engage with us.

I am conscious that many people remain challenged in the context of their confidence in us as an organisation. This is in part because there are times when we simply come up short for them. While the evidence shows a lot of improvement, it is clear there is a significant way to go and the national service plan further facilitates that journey.

An Cathaoirleach

I thank Mr. Gloster.

Deputy Bernard J. Durkan

I welcome Mr. Gloster and his colleagues and thank them for taking the time to meet us. I look forward to a fruitful meeting.

I refer to the extent to which Mr. Gloster has been able to focus on the sensitive pinch points noticeable throughout the health service in recent years. To what extent has he been able to concentrate on them and appoint dedicated officers with direct responsibility to ensure that we bring about a change in crucial areas?

Mr. Bernard Gloster

We are grappling with a broad canvas of issues. When I took up this post, the issues I set out very clearly and agreed with the Government on were access, which is all of the times people wait for different services, whether on a trolley or for procedure, timely implementation, because we were very good at planning but not so good at implementation, and public confidence.

The appointment of the six regional executive officers and the delayering in the centre in their direct reporting to me is significant in bringing about the pulling together of all community and hospital services. The six regional executive officers now have full delegated authority for public health, hospitals and community healthcare. Therefore, they can bring all of the systems together to facilitate people. Their dedicated focus on this and their reporting to me directly does that.

I am conscious that there is significant increased demand and there has been a great deal of narrative around emergency departments in the past few weeks. I want to be very clear that one person on a trolley is one person too many. In terms of focusing on improvement, despite increased demand last year over a six-month period in the closing half of 2023 we managed to reduce the real trolley count by about 20% compared with the six months of the previous year. That is significant.

In terms of people on waiting lists, in particular for outpatients, inpatient day cases and scopes, while we reduced the overall size of waiting lists by about 2.7%, fundamentally, we reduced the length of time people are obliged to wait substantially. Rather than concentrating on the numbers on the lists, we focused on how long people are on them. They are early improvements, but to be fair to people who are waiting today my job is to focus on them. As a result, we will have to do a lot more on that side. That is the focus for this year.

Deputy Bernard J. Durkan

I refer to the examination of sensitive issues over the past 12 months or so.

Have Mr. Gloster and his colleagues been able to reassure themselves that it is possible to improve the services to the extent expected by the public, given that some of these services have been highlighted several times in recent years? Is it possible to achieve the kind of progress necessary? If not, what is needed to do that? In other words, do we have the capacity to identify and deal with the situation and take it off the screen to a large extent? I will expand further in my next contribution.

Mr. Bernard Gloster

There are always two parts required for the type of improvement to which the Deputy is pointing. We have tended in the past to focus on the narrative of more - that we need more staff, more buildings, more money or more resources. There is no question but that we can always do more with more. The part where there has been substantial improvement without necessarily just having more has been in areas where we have decided to go after particular challenges for the public. For example, when I came to this post, there was a substantial and increasing problem with people over 75 years of age waiting in emergency departments, including waiting for more than 24 hours. Dr. Henry will be able to tell the committee that the international evidence shows that is not good for people’s outcomes. We focused on that in the second half of last year and we made very substantial improvements. There will be days when a handful of people will be waiting for a variety of reasons, but we really have moved to a zero-tolerance approach to those over 75 waiting in emergency departments. That is about a change in how we practice rather than just having more. That is the type of focus on those critical problems.

Deputy Bernard J. Durkan

Have improvements been achieved in the layout of the various accident and emergency units throughout the country regarding the extent to which security is available to protect staff and patients? To what extent have measures been put in place to ensure that people who are waiting in accident and emergency departments are not intimidated by some of the activity that goes on there? I have brought this very serious issue to the attention of the committee previously. It is a very serious issue when patients who are in severe pain and waiting for attention have to wait incessantly, as they see it, where there are people who are disrupting proceedings, drawing attention to themselves and getting attention out of turn. That does not make for good practice in running accident and emergency departments. What efforts has the HSE made to deal with that in the course of the changes that have taken place?

Mr. Bernard Gloster

Unfortunately, it is an increasingly common feature to have a dependency on security personnel in emergency departments. That is the nature of things, because there are open front doors and people present at them. There is always a risk, regardless of someone's behaviour, that if you turn them away, do not let them in or put them out, you will have a different problem because you have not at that stage determined what their particular need might be. It is a difficult situation and one that, unfortunately, our staff experience due to the nature of their work. We have made improvements but I do not think we will get to the point of eradicating it.

To be fair, the Deputy has raised this matter with me several times. In every emergency department that I have visited, I always look at the layout, even in terms of the limitations of the space that might be available. I have been to Wexford, Naas, Limerick and Cork and have visited most emergency departments. They are all different and have different types of challenges, but there is no doubt that antisocial or unruly behaviour is a challenge for all emergency services, including ours. I would not be sparing with any of my hospital managers who tell me they need additional security. We have to protect the public and we have to protect our staff. We have very good relationships with the Garda in this regard. However, it is a challenge, and I am not going to take from the core concern that the Deputy is expressing.

Deputy Bernard J. Durkan

Have those challenges been adequately identified and has provision been made for improvements that are going to become visible soon?

Mr. Bernard Gloster

It will be different in different departments. I would not like to say that there is a uniform solution as it really depends on the particular hospital. For example, it depends on the number of people turning up in emergency departments. In the first ten weeks of this year, approximately 13% more people turned up in emergency departments than in the first ten weeks of last year.

Deputy Bernard J. Durkan

Is there a particular reason for that?

Mr. Bernard Gloster

We have a demographic of an ageing population. We have sometimes talked about the ageing population in the health services as if it is off out there in 2031. It is not. It is here now; the demographic is here. There is a demographic of chronic disease and many other things that we can go into. There are big numbers turning up in departments. When big numbers are turning up and there is an incident or particular behaviour, it is even more concerning because of the number of people in the department. It is a difficult situation for hospitals to manage.

Deputy Bernard J. Durkan

We continue to receive calls from the families of children with disabilities or children awaiting diagnoses for obvious conditions, who are waiting for long periods during which they seem to be isolated and forgotten. This is causing great stress to parents and the children themselves.

Last night, I met a person with neurological problems. There seems to be a particular problem in this regard. The person is in difficulty, in stress and in pain. The person has a telephone appointment for something like a year’s time but no chance of an appointment for two years. That is not good enough. We have capacity in the private sector, we have access to it and we have budgetary provision made for it. Why do we not utilise that to a greater extent in order to get level before it is too late? We have had the debate on scoliosis many times before. The general public do not understand this. They think there is some sort of conspiracy blocking the system to make sure that nothing ever happens. Because they are in the eye of the storm, they have a more acute appreciation of it than anybody else. The patient always counts. However, there are those patients who cannot speak for themselves and who are at the beck and call of those around them. We need to ensure that everything possible is done for them in the shortest possible time.

Mr. Bernard Gloster

While I cannot talk to the individual case, we did tackle the issue of long waiters last year to a very successful level, although there is more to do. Regarding the use of private capacity for waiting lists, the National Treatment Purchase Fund, NTPF, uses that and it uses every possible option that is available. In terms of private capacity for beds to support emergency care during the winter, we had a full framework with the Private Hospitals Association and we did use and will continue to use private bed capacity. There is no fundamental or principled objection to using that. I will use whatever is available to aid the comfort of the public because I cannot wait forever or expect people to wait. However, it is not always available to the extent that people think it is available.

Deputy Bernard J. Durkan

I will come back to that point.

Deputy David Cullinane

I welcome the witnesses. I will come to staffing and finances shortly but I want to start with Mr. Gloster's commentary in regard to emergency departments. The HSE figures suggest there has been a decline in the number of people waiting in emergency departments on a trolley or waiting for a bed in the last six months of last year. Obviously, Irish Nurses and Midwives Organisation, INMO, figures, which I know the HSE often disputes, paint a different picture. Whichever numbers are right or wrong, the reality is that we still have very fundamental challenges in many emergency departments.

The one that stands out and has been in the public domain in recent times, rightly so, is University Hospital Limerick. I put it to Mr. Gloster that what we are seeing in Limerick is unacceptable, the number of patients who are waiting on trolleys is unacceptable and the human stories that are coming out of that hospital in terms of patients’ experiences are unacceptable. I also put it to Mr. Gloster that there is now a real lack of confidence in the running of the hospital because of what people are seeing and their lived experience. As Mr. Gloster knows, this committee will visit University Hospital Limerick very shortly.

I put it to Mr. Gloster, as head of the HSE, that what we are seeing from Limerick is not acceptable, has to be improved and that whatever measures need to be put in place, including resources, must be put in place to ensure we can resolve some of those issues. Can I invite a response from him on that point?

Mr. Bernard Gloster

Everybody will know, as I am on the public record from two recent significant media interviews, that I do not dispute for one minute the conclusion that what has happened and is happening in Limerick is unacceptable. It is unacceptable to me and it is unacceptable to expect people to tolerate that over a sustained period. That is the first thing. I am not going to get defensive about it and when the committee comes to Limerick, we can go into all the detail. The second point is that Limerick has not been wanting in recent years in terms of resources. There is no question of that. Significant construction is going on there, which validates that they need further investment. I have made some interventions there recently to try to assist that but regardless of the additional resources we bring, there undoubtedly also is a question of reform of practice within the hospital in terms of how it operates from Monday to Friday.

Deputy David Cullinane

I must put it back to Mr. Gloster that before his time as head of the HSE, two emergency departments in neighbouring counties were closed. That was obviously part of the small hospitals framework and there may have been a logic for that at the time. It did, however, put additional pressure on the hospital in Limerick and it strikes me that it is only now or recently that this additional bed capacity is going in when that should have happened at the time of those closures. I also have seen it reported - I have spoken to people in the Department about this - that despite this first 96-bed unit, which obviously we want open as quickly as possible, through refurbishment of some existing wards in the hospital we may also lose somewhere between 40 and 50 beds. If that is the case, then the net increase of beds will be only 50 as opposed to 96, which is far short of what is necessary although I acknowledge there is a second block in the pipeline. What action can the HSE at the centre or at group level take to ensure that refurbishments of that nature do not result in a loss of beds at a time when we are hoping that those 96 beds will be a net increase of 96?

Mr. Bernard Gloster

At group level, they did identify that they have a significant pressure with some of the old Nightingale wards in respect of the comfort of people utilising them. The original plan on the 96-bed block was for 48 new and 48 replacement beds. First, I am currently in discussion with the Minister - and hope to finalise in the coming days - on the possibility of changing that profile fundamentally to increase the number of beds that are new, rather than replacements, as well as to refurbish the Nightingale wards to retain as many of the beds as we can. We cannot, however, retain all of the Nightingale beds; that would not be possible. Second, I hope to get a further advance this year on the second 96-bed block. Recruitment in respect of the first 96 beds will happen in time for it to be opened. I am sure the Deputy, as well as other members, have read that a new community nursing unit is to be constructed in Nenagh, that is, a 50-bed unit constructed under the CNU programme that will serve its long-term purpose of being a CNU. However we have proposed and are proceeding with a plan to temporarily change the use of that and to operate it as a sub-acute unit, which would immediately give us 50 step-down beds.

Deputy David Cullinane

I will make one further point on UHL, as I want to go on to the staffing complement for this year as well. I have visited the hospital twice and have met the full management team, which in fairness answered any question I put to them. They put it back on the political system, in that they need additional capacity. One problem - and Mr. Gloster identified it generally in healthcare - is an ageing demographic and an increase in demand in the hospital. Very often, the problem is what is happening outside the hospital if the alternative care pathways are not there, which adds further pressure on to emergency departments. One proposal I have made in previous committees is that we should look at the possibility of GPs working in emergency departments to better triage patients, to better manage the flow of patients coming into emergency departments. Is that something that could be considered in University Hospital Limerick?

Mr. Bernard Gloster

It is commencing there in the next few weeks and the final plans are being made for that. An issue of clinical governance had to be resolved but to be fair to the new regional executive officer there, it was one of the first things she identified. The hospital was of the view that it had tried that before and it had not worked particularly well for it.

Deputy David Cullinane

Is that a directly-hired GP or is it an independent practice GP that will operate from the hospital?

Mr. Bernard Gloster

We would do it through the GP co-op, which would deploy a doctor for us. Based on the model the regional executive officer is proposing, we should see that making a difference. We know that a substantial number of people, amounting to over 50% of those who present to the emergency department in Limerick, do so without a GP referral. That is not to say they do not need to come to hospital; many of them do. I do not wish to say it is a fault of the public but I think a GP at the front door will be one of several measures that will help Limerick. I am hoping to finalise a full scale of additional interventions with the Minister in the next couple of days and subject to that, we will be showing the continued support of Limerick while they are waiting on the 96 beds to come on stream. I am saying categorically, however, that part of the solution in Limerick is reform of how the hospital works, particularly at weekends.

Deputy David Cullinane

I hear that and we all accept that.

I want to move on to the national service plan and the whole-time equivalent growth in staff from 2019 to 2023. There has been a significant and welcome increase in staff, albeit one that is much more limited in terms of growth this year because of funding, as we know. What really jumps out at me is that while looking at the percentage increases, which overall is a 22% increase from 2019 to 2023 and a clinical staff increase of 21%, if you look at management grades, that is, grade 8 upwards, there has been a 38% increase. In the case of grade 5 to grade 7, administration, there has been an increase of 71%. Looking at Ireland east as another example, the single largest growth in Ireland east was in management grades, which are up by 86% since 2019. In University Hospital Limerick, there has been a 133% increase in administration staff. When one looks at that and sees that clinical staff are up 21% but there is a 38% growth overall in management and 71% overall in administration, how can that be justified?

Mr. Bernard Gloster

The two highest-growing groups over that period were the management and administration grades and the nursing and midwifery grades.

Deputy David Cullinane

I just said that to Mr. Gloster. I am asking how is that justified.

Mr. Bernard Gloster

Bear with me. I clearly identified in this committee as early as last summer that that number on the management and administration side had crept beyond what could be reasonably expected. To be clear, a lot of management and administration grades are in front-line services. There is often a view that they are just sitting behind a desk somewhere. They are not and they all work hard but I introduced a pause on it because it is a distorted percentage at this stage.

Deputy David Cullinane

I am tight on time but want to make the point that while I understand that we need administrators and administration staff to make the health service function and we obviously need management to make the health service function, does Mr. Gloster accept that looking at the figures of a 21% increase of clinical staff but a 38% increase in management and a 71% increase in administration, to the public and to patients that looks very odd and skewed?

Mr. Bernard Gloster

It does and it is a disproportionate equation. There is no doubt about that and as I said, I intervened last summer and the Deputy is aware of that. I spent seven months in escalated industrial action for doing that. I am not negotiating with myself on it but I do accept that the overall percentage in volume growth proportionate to clinical is off line.

Deputy David Cullinane

I will come back in the second round with more questions.

Deputy Neasa Hourigan

There is so much to cover but we might start with the vaccinations which we spoke about the last time Mr. Gloster was here. We spoke about the low uptake of the Covid-19 vaccine particularly among people with underlying issues. I believe it was one in ten at the time.

I wish to broaden that out to get an update on the measles issue. Do the witnesses have anything to tell the committee about that kind of catch-up programme and how we are reaching out? Do the witnesses feel it is fully funded and it has enough resources?

Mr. Bernard Gloster

I will let Dr. Colm Henry answer that question. I am conscious of the measles issue, this week in particular. Dr. Henry may be able to give the Deputy a comment on it.

Deputy Neasa Hourigan

Yes, we are all concerned about this matter.

Dr. Colm Henry

We are very concerned. We have seen outbreaks in Romania and the west midlands in the UK, and there have been five confirmed cases and, tragically, one death here in Ireland, with also 17 possible cases. We know from zero prevalence studies, which are studies that measure antibodies among people, that there is a particularly high prevalence of negativity in young males, reflecting what we call the Wakefield generation, people who were not vaccinated at a designated time when they were infants or during preschool years. The is as high as 18% in some age groups and areas. We know also that, for six or seven successive quarters, our MMR vaccine uptake rate was below 90%. Our national target is 95%. I remind people that measles is highly contagious. People will be familiar with the R value that we were all experts on during the pandemic and the R value of Covid-19 being 5 or 6. For measles, it is 15, meaning that if someone who has measles is in a room, leaves and you enter the room an hour or two later, you are still at risk of catching measles. It is highly contagious. It is a disease with severe complications and up to one in five people are hospitalised. Complications can include pneumonia and, in rare cases, encephalitis.

We have a catch-up campaign which is focused on people born after 1978, focusing on those groups I mentioned: younger males and, of course, females, but especially males because they have higher levels of zero prevalence negativity for some reason. We are launching 100 clinics in third-level institutions this week alone, addressing under-served populations, international protection applicants and refugees, including Ukrainian refugees, and focusing also on immigrants born before 1978 who live with vulnerable people or pregnant women. Our focus is on the undervaccinated and on those under-served populations. We are bringing the vaccine out as well as providing additional cover through the traditional GP service model for those up to the age of 18. What is the right number to vaccinate? We want to catch anybody who is not vaccinated and who is at risk. Those clinics and the way they will be provided will ensure we capture as many people as possible.

Deputy Neasa Hourigan

The clinics are currently focused on higher level learning institutions. Are they going into areas, such as my own constituency, where there is a high population of people from different countries who may not have been caught as children in our own system? Are we targeting locations as well as services?

Dr. Colm Henry

Absolutely. If we look at our figures, even before the current concern, and I referenced that for seven quarters the uptake rate was below 90%, we had a particularly low uptake in Border counties such as Louth, Cavan, Monaghan and Donegal, sometimes dipping as low as 80% in those areas. One of the benefits of having an enhanced public health workforce which is configured along RHA lines is we are tailoring our programme according to local public health intelligence. It is not just based on areas of low uptake but groups of low uptake such as, as the Deputy referenced, international protection applicants or immigrants whose status is unknown or who may have been wary of being vaccinated. This is focused, based on public health intelligence and local intelligence, and it is targeting specific target groups.

Deputy Neasa Hourigan

I thank Dr. Henry. The last time Mr. Gloster was before the committee, we were talking about the move away from private management consultants. Last year, he set a target of a reduction of 30% and he was fairly confident that would be reached by quarter 4, I believe. I wonder where we are in that regard now.

Mr. Bernard Gloster

We had difficulty measuring it due to the industrial dispute. We were not getting accounts and that caused a problem. My understanding that we did achieve the 30% reduction in quarter 4 compared with quarter 1.

Deputy Neasa Hourigan

Which is around €40 million.

Mr. Bernard Gloster

No, that is for a full year.

Mr. Stephen Mulvany

It is approximately €30 million.

Mr. Bernard Gloster

It is approximately €30 million for the full year.

Mr. Stephen Mulvany

The full-year spend is approximately------

Mr. Bernard Gloster

It is €114 million.

Mr. Stephen Mulvany

In a full year, it will equate to around €30 million if you maintain that reduction.

Deputy Neasa Hourigan

Are we on course to maintain that reduction for a full year?

Mr. Bernard Gloster

Yes. In fact, in the past two weeks and in the next two weeks, we will again reduce the dependency substantially. There are areas in which we need additional consulting and help, so we are bespoke tendering those out to very limited amounts with very limited controls to reduce overall general expenditure. However, I am confident we will continue to see that reduction.

Deputy Neasa Hourigan

Mr. Gloster believes right now we are at that 30% reduction for the last quarter.

Mr. Bernard Gloster

I believe so, yes. Further reductions will allow us to decide where additional expertise and help is needed. It may be needed in a particular digital programme or such. For example, two subject matter experts in productivity have gone to tender, but it will be two subject matter experts as opposed to 22. It is controlled and no management consulting is allowed into the organisation without me personally signing off on it.

Deputy Neasa Hourigan

I thank Mr. Gloster. I want to move on to the CDNT groups and staffing. We went through some of the levels of staffing the last time and I know how difficult the current situation is. Is there data within the organisation on the challenges with staffing, both those that are staffed by the HSE and those under section 38 and 39 organisations?

Ms Kate Killeen White

I thank the Deputy. In the national service plan, there is provision for new developments this year, of which €64.1 million relates to disabilities. The Department has now finalised and secured Government approval for the action plan for disability services, which is really welcome.

On the CDNTs and across all of our disabilities services in particular, recruitment and retention of staff is essential to the delivery of the action plan. There is an ongoing targeted and strategic focus on recruitment and retention, especially in our CDNTs.

As for the question of data, we always need more data and enhanced digital capability to collect and analyse our data. There is some data in the system but it can be improved and we are working with colleagues on that.

Deputy Neasa Hourigan

I am interested to know if there are lower rates of staffing among CDNT networks that are being serviced by section 38 and section 39 organisations, section 39 organisations in particular, or if there is a different rate. I do not want the average or the mean. It is interested to me whether there are different levels. If a person is in an area where the CDNT is serviced by a particular organisation that is not the HSE, are the staffing levels likely to be less? That is the first question, and the witness might not know the answer off the top of her head.

Has the HSE, in the past two quarters, revised or cancelled any contracts with section 38 or section 39 organisations because they have not been able to staff those networks over a period of time? Has the HSE reformed or revised any of those contracts?

Ms Kate Killeen White

I think it is fair to say that all CDNTs have been challenged in the face of recruitment and retention. I do not have the specific detail on HSE versus non-HSE, but what I can say is-----

Deputy Neasa Hourigan

Sorry, I do not mean to cut across the witness. Does that data exist and we just do not have it at our fingertips, or does it not exist?

Mr. Bernard Gloster

We will be able to get that data.

Ms Kate Killeen White

We can get that data for the Deputy. Disability posts have been derogated from the recruitment pause and there is ongoing strategic and targeted focus on recruitment into our disability teams.

Deputy Neasa Hourigan

Have any of the contracts that had been entered into with section 39 organisations been revised, reformed or changed due to the lack of ability to staff those networks?

Ms Kate Killeen White

Not to my knowledge, no. There is a continued focus on our disability services.

Deputy Neasa Hourigan

Okay.

Mr. Bernard Gloster

To be fair, there is no doubt that as people apply for posts now, they will be attracted more easily to the HSE and section 38 organisations than they might to section 39 organisations, albeit that the WRC agreement for section 39 organisations has improved that chance substantially. There will always be a variation. In some parts of the country, we are totally dependent on section 38 and section 39 organisations, such as in Cork, and in other parts of the country we are not, like Donegal. It is a very variable quantity but it is an interesting question and we will certainly get the data.

Deputy Neasa Hourigan

Where there is a disparity of whatever level, you would expect to see people voting with their feet.

Mr. Bernard Gloster

The most recent targeted campaign, albeit in the middle of the recruitment pause, focused on CDNTs. We secured in excess of 450 applicants for those posts and we are trying to expedite as many of those as we can.

Deputy Neasa Hourigan

There were 450 applicants.

Mr. Bernard Gloster

Yes, for CDNT posts throughout the country.

The problem is we would be stealing some of our own primary care staff.

An Cathaoirleach

As Senator Black is not available, I call Senator Conway.

Senator Martin Conway

I welcome the witnesses. I want to clarify one issue with regard to Limerick. It was stated by some individuals that the most recent clinical advice regarding not reopening accident and emergency units in Ennis and Nenagh is outdated. What is the witnesses’ view? Is that correct? Should updated clinical advice be obtained?

Dr. Colm Henry

To clarify, the smaller hospital framework document clearly outlines the kind of services one would provide in model 2 hospitals, which have what we call differentiated presentations. Given the health care expectations that people have in 2024, we expect optimum outcomes for stroke, heart attack and other surgical treatments which involve specialised care. The fact is that a fully staffed, 24-7 emergency department requires a critical level of expertise from a range of disciplines, including surgery, neurology, ICU and all the support structures that people expect in order to have the best possible outcomes corresponding to the level of care that we need in 2024.

That said, the model of care that we have for model 2 hospitals envisages, and has seen in practice, medical assessment units that involve a high level of differentiated medical presentations coming to such hospitals. They are adequately and very capably dealt with in those hospitals, and include exacerbation of chronic bronchitis, heart failure and a range of medical presentations. What we have seen in those hospitals is a high level of activity in the medical assessment units and also in the local injuries units, which has the effect of displacing activity away from what is clearly an overburdened model 4 hospital in UHL.

Senator Martin Conway

To be clear, the current medical advice has been updated. It is medical advice that Dr. Henry would stand over as the chief clinical officer.

Dr. Colm Henry

It is almost more pertinent now than it was when it was first drafted almost ten years ago because care is constantly evolving and more complex, and expectations are always rising. For example, I cite the treatment of stroke. In my medical career, this has involved the provision of intervention with time-critical treatment that can affect and improve the outcomes of people presenting with stroke, whereas, decades ago, there was no active treatment. People expect that. We have seen bypass protocols implemented for primary PCI for certain categories of heart attack, stroke and trauma to ensure we get people to the correct destination the first time. There is no sense in revising that to move to a situation where people go first to the wrong hospital, where they cannot get effective treatment.

Senator Martin Conway

I thank Dr. Henry. I have a question for Mr. Gloster. With regard to the interventions he is discussing with the Minister and is hoping to get signed off in the coming days, he might elaborate on what some of those initiatives are.

Mr. Bernard Gloster

Some of them are already widely known in the public domain. There is the step-down 50-bed sub-acute facility for Nenagh, which we are planning to do for one year. That will make a substantial difference. That is the first. The second is the GP at the front door initiative, which Deputy Cullinane raised with me. To follow on from Dr. Henry's comments about model 2 hospitals, my plan is, hopefully, to be able to confirm very shortly the move towards 24-hour acute medical assessment units at Nenagh, Ennis and, hopefully, St. John's as well. There are some other measures. To be fair to the Minister, I do not want to commit him to those until we have finalised that.

Senator Martin Conway

I would consider all of the measures mentioned by Mr. Gloster as significant. Are the other measures that he does not want to speak publicly about significant as well?

Mr. Bernard Gloster

Yes.

Senator Martin Conway

We look forward to that. Mr. Gloster is expecting that there will be sign-off on those within the next week or so.

Mr. Bernard Gloster

To be fair, I only had my most recent conversation with the Minister about it yesterday morning. I am due to have another conversation with him in the coming days.

Senator Martin Conway

Mr. Gloster is hopeful that these interventions will result in a reduction in trolley numbers in UHL very quickly.

Mr. Bernard Gloster

As to the term “very quickly", I would qualify that, to be fair. All of these things take a little of time. They are designed to give further assistance while the 96-bed unit is coming on. There is also the second 96-bed unit. Again, to be fair to the Minister, it is a condition he has rightly put on me in regard to making further interventions outside the service plan in Limerick this year that the hospital has to deliver a plan for how it is going to reform its practice and use of what it has.

Senator Martin Conway

That is what I am coming to next. It is disappointing. The word on the street is that the number of consultants in Limerick who have signed up to the new contract is lower than anywhere else in the country. Does Mr. Gloster think that unwillingness by consultants in Limerick to sign up to the new contract is having an effect on the operation and management of the emergency department at UHL?

Mr. Bernard Gloster

The lower the uptake of the public-only consultant contract for a hospital of the size and type of Limerick, the longer it takes people like me to drive the type of change I am talking about in the context of a seven-day process. I want to be fair to emergency medicine physicians. Whenever I talk about an emergency department, I talk about the whole hospital because, usually, the problem in the emergency department is a problem that originates in another part of the health service. In simple terms, I would much prefer to see a greater uptake in respect of Limerick.

Senator Martin Conway

Does the HSE have figures as to the number who have signed up to the new contract and who are based in UHL?

Ms Anne Marie Hoey

With regard to the consultant staff in Limerick, there have been an additional 50 consultants appointed in the past four years, which is a 37% increase in the number of consultants at the hospital.

Senator Martin Conway

I appreciate that.

Ms Anne Marie Hoey

It is as much about the quality of the contract as the quantity in terms of what is agreed in the work plan in the contract. There is a process of engagement with individual consultants to ensure that the flexibilities that are contained in the new contract to work into the evenings and on Saturdays are garnered as part of signing up to the new contract. It is important to note there has been an increase of over 37% in consultant staffing at the hospital in the past few years.

Mr. Bernard Gloster

In terms of the take-up of the contract, it is the lowest. There are 56 doctors on the new contract in Limerick; 22 of them are new doctors, so they would not have had a choice, and 34 are doctors who changed. Thirty-four is a very low conversion rate.

Senator Martin Conway

It is very disappointing.

Mr. Bernard Gloster

It is, given the success of the contract everywhere else.

Senator Martin Conway

This is the case although their colleagues throughout the country are signing up in their thousands to the new contract. The HSE can only do so much. I call on these consultants to sign up to the new contract. We are all in this together to try to improve things. Is there any possibility of sharing so some of the people who have signed up to the new contract in other hospitals could be seconded to Limerick until such time as we get a handle on trolley numbers? Is there any precedent for that within the organisation? Could it happen and is there any way of making it happen?

Mr. Bernard Gloster

There is not really a precedent for that type of intervention. There might be a precedent for an individual doctor who is willing to assist in a particular challenge. In fairness, specialists do come to help with different things.

I appreciate Limerick has been very much in the news and to the fore. With Dr. Henry and other colleagues, I have been dealing with trolleys seven days a week since the middle of December right up to and including last week. While Limerick is very visible in the headlines, there are also other hospitals under significant pressure, including Galway University Hospital and Cork University Hospital. We would simply be taking the pressure off one to try to help with the pressure on another, and it could have unintended consequences. There is not that scale of an option available to us.

I agree wholeheartedly with the Senator’s call. I have no fear in publicly putting on record that I would urge consultants in the UL Hospitals Group in Limerick to seriously revisit any decision around taking up the new contract.

Senator Martin Conway

Clearly, it is having an effect in terms of the number of consultants that are available at weekends and at night.

Mr. Bernard Gloster

That is right.

Senator Martin Conway

Other hospitals have performed much better. We know that infrastructure and capacity are issues in Limerick, but the number of consultants is also an issue. The situation is very frustrating. It is to be hoped a GP will be in place to carry out triage in the next couple of weeks. Will that operate on a 24-hour basis?

Mr. Bernard Gloster

No, the service will start on a test basis. If it proves itself to be efficient and working, I hope to make available the resources to make it a 24-hour service. There may be pressure in terms of staffing it on a 24-7 basis. We will do the best we can with the local GP community and Shannondoc. It will not be for the want of money that it will not be in place.

Senator Martin Conway

The committee looks forward to visiting UHL on 8 April, when we will have an opportunity to engage in a more forensic way.

Mr. Bernard Gloster

The real benefit people will see with a GP at the front door will be in the measures around that GP and the hospital, in particular the extension of the acute medical assessment unit to 24 hours. That, tied to the Shannondoc system, could make a fundamental difference.

Senator Martin Conway

Absolutely. That is great. I will come back in.

Senator Seán Kyne

I welcome Mr. Gloster and his team. Mr. Gloster came before the committee on 27 September regarding capital infrastructure in Galway. At that stage, he said he had decided to:

... get a full project team with good, strong expert advice from outside as well as inside to the Saolta group and we would rapidly ensure the overall capital plan for Galway is set out in terms of all the requirements. From that, we would prioritise which part would come first ...

He was talking about a period of a couple of weeks. He extended that period to a couple of months at a later meeting. What is the current situation regarding that plan?

Mr. Bernard Gloster

The Secretary General and I went to Galway to meet the project board, which is chaired by the hospital executive. It has subject matter expertise from outside of the hospital, together with the estates function. It is now recruiting and finalising a full-time dedicated project director specifically for the capital plan for the Galway site. I have, as has the Department, made available to the board a resource allocation for it to hire the necessary subject matter expertise it needs to bring forward a plan. It is to be hoped that plan will materialise this summer and that can then go onto the capital priority list for Government and decision making. As the Senator can appreciate, it is a very extensive plan, given the deficits in the infrastructure in Galway which are well known and which I have been on the record as being behind the curve in terms of other hospitals.

Senator Seán Kyne

The work has not started yet.

Mr. Bernard Gloster

Work has not started on the building, but the board has started on the plan.

Senator Seán Kyne

I know work has not started on the building. Has the board started work on the plan? It is hiring consultants.

Mr. Bernard Gloster

Yes. The board has a certain amount of expertise internally and externally. We are giving it the resources to put in place a full-time project director, not just to come up with the plan but then the pursuit of its implementation. That would be an unusual intervention to make.

Senator Seán Kyne

Last September or October, Mr. Gloster gave the impression that there would be no delay. It is now March and work has not started. I heard from a report during the summer that work would start in September. I would believe it will start at Christmas at this stage, given the way things go. There is nothing physical. A detailed design has to be drawn up and planning applications have to be prepared. We are going backwards with projects in Galway.

Mr. Bernard Gloster

I would not necessarily accept that. The intervention we have made in terms of having a project board and director is out of the norm compared to what we have done with former regional hospitals. There is nothing stopping the board coming up with a plan; it is now about the time required to finalise it

Senator Seán Kyne

It still has to finalise the detailed design of the individual components, whichever component it decides to go for first-----

Mr. Bernard Gloster

We have in the past been accused of coming up short on detailed plans at the start of many major infrastructure projects. We then end up in trouble later. The overall site plan is critical. It will materialise and present a very credible basis for the Government to make decisions to invest. Obviously, there are other priorities for the Government.

Senator Seán Kyne

With the best will in the world, it will be next year before any application for the emergency department, maternity and paediatric labs or regional cancer centre would be lodged.

Mr. Bernard Gloster

The first thing we need to see is the overall site plan, which I believe we will have before the end of the summer.

Senator Seán Kyne

There was a public meeting in Clifden the week before last regarding the district hospital. It is, in effect, a respite and step-down facility. It is very important in terms of end-of-life care for people who in their final days wish to pass away in their community and close to family if they have them. That is important for many people. People specifically want to end their days in Clifden, for example, even if they do not live too far away, such as in Carna or elsewhere. It is an important facility. There is an overall plan and the Minister of State, Deputy Butler, has given a commitment on the new 40-bed unit in St. Anne's that will eventually encompass the district hospital.

The hospital is closed at the moment. There was some confusion over whether already committed posts had to be approved for funding in cases where there were difficulties getting staff. It was unclear whether the current embargo extended to posts which had already been approved. The Minister clarified that there was no embargo. I am not sure whether there was no embargo or, if there was, whether it had been lifted. Where are we in terms of trying to recruit staff to ensure the facility stays open? As I am sure Mr. Gloster knows, depending on traffic and driving conditions, Clifden is at least an hour from University Hospital Galway and, taking city traffic into account, at least an hour and half or two hours from Merlin Park Hospital. What is the current position regarding reopening the facility?

Mr. Bernard Gloster

There are two parts to the question. I want to take this opportunity to apologise to the people in the area for what happened and how they found out. To be fair to the chief officer there, people were doing the best they could. On a previous occasion, admissions had to cease temporarily due to difficulties in staffing shifts. Everybody felt, that being the case this time, it would be regrettable but okay. Clearly, it became a matter of serious public concern. I want to apologise for that. I say that sincerely.

I have no lack of value whatsoever in the service. I am not aware that the recruitment pause measures have affected the ability to staff the service. Sometimes it is very hard to staff particular facilities. I spoke with the regional executive officer at the weekend and again this morning to confirm that the intention is to get the service back to full operation as rapidly as possible. If there was any question of the pause affecting that or the jobs the service had already approved, I can assure the Senator that would be dealt with. As I said, I do not think it is just that.

Our ambition is to get the service up and running again and to keep it open until such time as all of the proper arrangements that the Minister of State, Deputy Butler, had committed to are in place. Given its use for respite, in particular supporting palliative and end-of-life care, it is not reasonable for us to expect people to have to go the distance to Galway, which is already congested. I am not in any way defending the position. There will be nothing short at my end in terms of getting the service open again. That is not because there is an outcry. There was, rightly, an outcry. The situation is regrettable. I want to be fair to the chief officer there. He was doing the best he could with what he had.

Senator Seán Kyne

I acknowledge Mr. Gloster's comments on that. My colleague Councillor Eileen Mannion has been to the fore in terms of communication. There was a good process of communication and paused closures during holiday periods. Staff were moved when St. Anne's nursing home needed them. The communication lapsed after Christmas.

It is important that there would be communication and that people would know what is going on.

There is a commitment in the national service plan to provide primary care services to nursing home residents. It states that the HSE will continue to implement a new model of care specifically aimed at nursing home residents to ensure equity of access for the entire population. The HSE would provide aids and appliances to residents in nursing homes as per their assessed need for equipment to support the delivery of safe care. Could Mr. Gloster indicate what has been undertaken to fulfil this commitment? Could he assure the committee and Nursing Homes Ireland that this policy is in place or will be in place throughout the country?

Mr. Bernard Gloster

Yes. This is a measure that I spoke to shortly after I took up the post. I believe there is a fundamental inequity for people who are in care in that just because they live in a nursing home they do not necessarily have access to the same range of services as if they were living at home. The starting point for that was to try to capture the people going from acute hospitals to nursing homes, which for long-term care is about 55 people a week, and to use our now integrated care of older people teams to do a comprehensive geriatric assessment to inform their care in the nursing home and then, where appropriate, to follow them up and support them in the nursing home. They are now doing that in about 13 of the 30 teams. They are the specialist teams. That is part of my target for this year.

There are some matters I will need to deal with under the public service pay agreement. I will have to discuss them with the national joint council of health unions. I hope to do that in the next week. The intention is that it will become routine for primary care services that are available to people living in their own house to be equally available to people living in a nursing home, be it public or private. Not everybody shares my view on that, but I am very clear. That is my view and it is what I intend to pursue. We have done it to a very small degree, but it is nowhere near satisfactory yet.

Senator Seán Kyne

Mr. Gloster said it is being done by 13 of the 30 teams. What is the plan for the others?

Mr. Bernard Gloster

I want to go beyond those 30 older people's teams, and have general primary care staff going in and out of nursing homes. That is my target for this year, purely based on the principle of equity of access. Of course, not everybody gets access to everything they want. I would equally say, including to Nursing Homes Ireland, that it is not a supplement for nursing home providers not meeting their own responsibility to provide the care they are obliged to provide under the contract. They provide the in-house care and the appropriate care, but if somebody needs access to the primary care service for occupational therapy, physiotherapy, speech and language therapy and some other specified community nursing services, that should be on us. I am intent on doing that.

Last year, we introduced mobile diagnostics for some nursing homes and we were able to substantially reduce the number of people being referred to hospital from nursing homes. We know that if we target our community resources to where the most frail are being cared for, we will not just substantially reduce pressure on hospitals, but we will give people a more appropriate type of service that they need and should be able to get from us. The fact that one lives in a private nursing home should not prevent a person from accessing public healthcare.

Senator Seán Kyne

I thank Mr. Gloster.

Senator Frances Black

I welcome Mr. Gloster and his colleagues. I thank them for all the work they are doing. They have a difficult job ahead of them so I just want to acknowledge the work they are doing.

Mr Gloster referred briefly in his opening statement to the transfer of functions in respect of disability services to the Department of Children, Equality, Disability, Integration and Youth, which took place in March 2023. In September, the Ombudsman for Children published the report, Nowhere to Turn, which detailed the harrowing realities faced by children with disabilities and their families. It referred to the reality of being without services and support. The report found that local disability managers believe it is not the role of the HSE to provide residential care to such children and that there is conflict with Tusla in regard to where this responsibility should lie. In the year since the transfer of functions, have we reached a point of clarity on this issue? Has a strategy been formalised in order to meet this need and to plan accordingly?

Mr. Bernard Gloster

I thank Senator Black for her kind comments. This is something that has to be particularly close to us and a focus of our attention. The regional executive officers will have to now mobilise all of their services to make sure that there is a much more positive discrimination in favour of people with disability, in particular children and those who find themselves in vulnerable positions like being delayed in hospital.

I have met the Ombudsman for Children several times since coming to this post. I have a very good working relationship with him. Obviously, having been the CEO of Tusla, I understand both sides of that dynamic in the memorandum of understanding. I have now agreed with my colleague, the new CEO of Tusla, Kate Duggan, that there was a get-out clause, if one likes, on the health side of that memorandum of understanding, which was subject to resources. We have now removed that. Where a case is agreed as a joint case between the HSE and Tusla, the decision is made quickly on which one is to lead. That will depend on whether it is a protective measure or a health measure. Whichever agency is leading the case has to source the care support or care placement for the child and both agencies jointly fund it under the protocol. We have agreed that. We have some loose ends to tie up in terms of how we drive that message back out into our own system. There are parts of the country where it has worked very well and there are other parts where it has not. In some of the cases the ombudsman was talking about, it was not a question of money; it was actually a question of the skill set not being available in the country to provide the type of service or care that was needed, or at least to do it easily. Ms Queally, who is present, dealt with some of these cases in Children's Health Ireland.

To put in place a bespoke placement for children with the most complex needs can take anywhere between three and nine months. I have no difficulty mentioning a case I dealt with at Christmas that was in the public domain where a child spent something like 50 days being cared for in a hospital emergency department although the child did not have any acute illness need whatsoever. It is just shocking for us to see that and not be able to do anything about it. We have done something about it but it does take time when it is complex. I can absolutely state that there is no obstacle to interagency work between ourselves and Tusla.

Senator Frances Black

That is good to hear. Mr. Gloster is correct that some of the stories are truly heartbreaking.

My next question relates to the workforce. Mr. Gloster stated that we now have the highest workforce in the history of the Irish health service. He mentioned that there has been a 21.8% increase since the end of 2019. Is this overall healthcare staff or those employed directly by the HSE? Mr. Gloster may have touched on this already. If so, he should please forgive me as I have had to pop in and out of the office this morning. Has there been a particular increase in the number of healthcare assistants, specifically those providing home care? Is this increase a direct result of overseas recruitment?

Mr. Bernard Gloster

The total of just short of 146,000 whole-time equivalents at the end of last year relates directly to the HSE, section 38 hospitals and the larger disability organisations. It does not relate to section 39 organisations. The number relates to just section 38 and HSE staff, in other words, the staff who are considered to be public servants. The number of staff in section 39 organisations is bigger. Ms Hoey might be able to add to what I have said.

Ms Anne Marie Hoey

In terms of the number of staff employed as healthcare assistants, at the end of January it was just over 20,000. In 2023, we increased the number of healthcare assistants by almost 950 whole-time equivalents, so there was a significant increase last year.

Home help is provided directly by HSE staff and contracted staff. At the end of January we had just over 3,700 home help staff. That is a combination of directly employed staff and contracted staff providing home help services.

Senator Frances Black

I thank Ms Hoey for that information.

I was very pleased to hear that five out of the six new regional executive officers are now in place. Again, I commend all of the work done in this regard. Would it be possible for one of the REOs to outline the work thus far and to highlight any instances of particular challenges that might arise? I would be really interested to know whether cross-region collaboration is one of the mechanisms that will be used to improve service delivery, for example, through allowing individuals to access services outside of their own CHO if wait times were shorter elsewhere. Is it possible to get a little bit more information on that?

Mr. Bernard Gloster

I am hopeful that one of the advantages of being CEO of the HSE with six new regional executive officers in place will be that they will be able to answer those questions. Perhaps Ms Queally might take that question.

Ms Martina Queally

It is a significant opportunity not just for the regions, but for the health service nationally. One of the big challenges and opportunities for us is the integration of services between the hospital and the community and across regions. The Senator is absolutely right; certain national programmes will have centres of excellence that will be required to provide services nationally. One of the opportunities for us is to maintain and make sure that we honour that requirement. Similarly, there is a great opportunity to completely optimise our services. The CEO spoke about GPs working very closely with emergency departments and residential care. Completely optimising the service across hospital and community care is a big opportunity but also a challenge. Restoring and increasing public confidence in our services across some of the areas the Senator spoke about through cross-departmental work between Tusla, the HSE and disability services is part of a programme of work that all six REOs will be addressing. There will be a strength in six people coming together to address some of these challenges nationally. We can make an absolute hero of our size here in Ireland. We have a really well-educated and dedicated workforce working in all of the regions. There is a really significant opportunity in our hands. That is really what Ms Killeen White and all six REOs intend to do to maximise all opportunities available to us, of which there are many.

Ms Kate Killeen White

I can also come in there, if I may. The leadership focus is really about driving a culture of good health that places a greater emphasis on the value of supporting people to have really good health as opposed to an illness-oriented culture. Like my colleague, Ms Queally, has said, the REOs will be working together across all of the regions to integrate our services and to ensure that people have access to services with an equal focus on prevention, early intervention and self-management of chronic diseases across all of the regions. It is a great opportunity for our health services.

Senator Frances Black

I totally agree. If we can focus more on prevention and intervention, it will ease pressure on the emergency departments and even on general practitioners and other doctors. I totally agree with that. I thank the witnesses. I am happy with those answers.

An Cathaoirleach

I have just a couple of questions of my own and then we will take a comfort break. A couple of things have come up. One relates to the working time directive. In the context of the HSE service plan, it was stated that the targets as regards those working 24-hour and 48-hour shifts were met last year. Are there any statistics or data in that regard? That is one of the areas in the plan.

Ms Anne Marie Hoey

There is data but I do not have it with me. We can certainly-----

An Cathaoirleach

It is not within the plan itself. It just says that the targets were met. It is a bit vague in that regard. The HSE might come back to us on that at some stage.

Ms Anne Marie Hoey

We can provide information on that. That is no problem.

Mr. Bernard Gloster

Is the Chair specifically talking about non-consultant hospital doctors?

An Cathaoirleach

I am talking about those working long shifts. The plan is to move away from that. The HSE is saying the targets in that regard were met but the numbers are unclear. Mr. Gloster said "people remain challenged in their confidence in" the HSE. A number of areas have been touched on this morning. I would like to look at some of these areas.

I know I have raised the matter before and it is becoming repetitive but access to services has been mentioned. Children with special needs are awaiting assessment and services. We have touched on that. People are trying to get into the obesity clinic. Again, I have raised this before. The waiting list is between five and seven years. There is something wrong with the system if someone has to wait that length of time. That is one of the challenges some people have mentioned. If you are a diabetic, there are challenges in accessing ophthalmology and podiatry. People with diabetes need to regularly have their eyes and feet seen. People are saying there is a big challenge there. Will the HSE outline what it is doing in that area? People are also saying there are challenges in getting access to a dentist or GP, particularly for those on a medical card. Is there a list for people who cannot get access to a dentist or doctor in a particular area? Is that available through HSE services? The witnesses might outline any details in that regard.

We recently had some groups in, including Chime, which raised the need for a national hearing care plan. Do the witnesses share the view that such a plan is needed? We also met a group called Debra, which deals with epidermolysis bullosa, EB. Parents and advocates came in and spoke about some of the simple challenges families are facing. I will go through some of them, if the witnesses do not mind. They spoke about the challenge of changing bandages. It is challenging because the bandages are not wide enough. They were also saying that there was a high turnover of key staff, that there was an over-reliance on agency staff and that people were moving on. The problem is that, come long weekends, particularly when people are on holidays, there is no one to replace them. That is a big challenge. The big challenge for the parents is that, in many cases, the parents might have to do it. They are hurting their children, which has an impact on those children's relationship with their parents and on the parents themselves. No parent wants to hurt his or her child.

The group was saying that there were simple things being done in other countries that we could look at. On access to bandages, they said that in Australia, Britain and Spain, bandages are delivered to the home once a month. They suggested that bandages could even be sent to a local clinical service that people would have access to. There are simple things that could be done without great expense. Has any thought been given to this? A young child came in and what the parents have to deal with is horrific, although the condition can be more or less severe. Can we learn from other countries in order to take some of the pressure off those families? They spoke about the costs associated with the condition. Like everything else, it impacts on people's ability to work. One of the parents may have to stay home to provide care. That is particularly so in the case of children but it also happens in the case of adults.

With regard to that particular condition, is there any positive news the HSE can give to families? Is there anything we can look to in the service plan? Perhaps the witnesses could go away and look at some of these things, particularly with regard to bandages, that are clearly working in other jurisdictions, that are taking pressure off families and that we may be able to replicate here.

Mr. Bernard Gloster

Obesity and ophthalmology are two striking examples around access challenges. Dr. Henry will talk about how we have fundamentally reformed, and are reforming, our approach to the ophthalmology piece. Maybe Ms Killeen White or Ms Queally will speak to the critical issues for children in cases like that.

Dr. Colm Henry

I turn first to the issue of obesity. In 2023 we saw 45 new appointments, which resulted in the removal of 500 people from outpatients and 207 surgeries. That is all part of our new specifically funded obesity pathway. This follows a model and pathway of care that has been developed to address exactly the kinds of problems the Deputy identifies, such as people waiting for outpatient appointments and then people waiting for bariatric surgery. We have specifically funded posts that will drive through improved performance and waiting times for both outpatients review and surgery for people who require assessment for obesity.

It is timely and appropriate to raise the issue of ophthalmology because it is a Sláintecare-friendly model of care that we have developed. We have gone from a consultant-focused model of care where people are funnelled through lengthy waiting lists to see people in hospitals, to a community-delivered model which is now being implemented and has resulted in the eradication of paediatric waiting lists in CHO 2, CHO 4 and CHO 7. It has also resulted in the slashing of waiting lists for people waiting to be seen for cataract surgery to seven months, and a three month wait for surgery. We have shifted what was a hospital-based model of care for ophthalmology out into the community, to centres like Ballincollig, County Cork, where people are being seen for paediatric eye problems, assessment for cataracts and macular problems. They do not need to go to hospital. Those who are filtered through that who need surgery are then seen through funded theatres in the Eye and Ear Hospital or in Cork, and then followed up in the community. It is a Sláintecare model and we want to see that replicated for other disciplines. We can remove people from waiting lists who do not need to be seen by hospital-based consultants but, rather, can be seen closer to home in the community more quickly and appropriately.

Ms Kate Killeen White

I can take up a number of the points raised about more general matters, including chronic disease. The enhanced community care programme is continuing to roll out across the entire system. There are significant patient contact numbers set out in the national service plan for our community specialist teams, to include our older persons programme and our chronic disease programme. They are set out in the national service plan. The intention is to embrace a home-first approach to service provision and, it is hoped, in time to avoid emergency department and hospital admissions. Those teams are starting to bed down and reach a level of maturity where we can see outcomes from the development of those teams and they will continue. The chronic disease team stretches into diabetes, which the Deputy referenced.

With regard to children, the disability roadmap includes the need to prioritise adherence to and productivity with the national access policy. That national access policy crosses the spectrum of service delivery from primary care to disability and CAMHS. We have already touched on disability services and the new service development investment in our disability services, to include ongoing and targeted recruitment into our CDNTs. However, that has to work hand in hand with resourcing our primary care teams and continuing to develop our CAMHS services in order that the spectrum of service delivery, as well as referral processes and pathways, is more seamless for children and their families. Within that context we will continue to develop clinical and service improvement programmes for young people and support the continued implementation of the CAMHS hub model of care, to work hand in hand with our primary care and disability services.

An Cathaoirleach

One of the things the Debra group was looking for was a care co-ordinator. It is a small group. Would that be possible in the context of the service plan? Is the HSE specifically looking at that for those individuals? The witnesses are saying they will try to base it around the home. It would make sense if those families got access. What they said to us was that if the bandage is the wrong size, that is a problem for the child straight away, and that happens in the system. There is a specific size the child might need. If the child is getting older, it might need to be adapted. The families were saying they may have to go to the local hospital or travel long distances to get a basic thing like the bandages. The other point was the over-reliance on agency staff for a lot of services. When trained-up staff are in place, it is less of an impact on the child or adult. It makes it easier for them to get these bandages which have to be done.

Mr. Bernard Gloster

When I was leaving Leinster House previously, that group was preparing to come in, if I am not mistaken. I may have briefly said hello to them. We probably need to understand it more ourselves. If it would be helpful, we will take up the matter, approach the group and arrange to meet them to hear what they have said to the committee and see if we can help them.

An Cathaoirleach

That would be great.

Mr. Bernard Gloster

I think that would be the best approach to it.

An Cathaoirleach

Brilliant. Has Mr. Gloster any views on the need for a national hearing care plan?

Mr. Bernard Gloster

A national hearing care plan.

An Cathaoirleach

One of the points Chime made was that there is no overall care plan.

Mr. Bernard Gloster

I will come back to the committee on that. I am not aware of the specific point about audiology. I am obviously familiar with our audiology services.

An Cathaoirleach

We had a long session on it.

Mr. Bernard Gloster

To be fair to them, I would need to understand the care plan better.

An Cathaoirleach

There will also be recommendations coming from the meeting.

Sitting suspended at 11.27 a.m. and resumed at 11.35 a.m.

An Cathaoirleach

I will go straight to Deputy Cullinane.

Deputy David Cullinane

I have a number of quick questions for Mr. Gloster. The HSE gave an express commitment to provide primary care services to nursing home providers. Is there anything of substance in the national service plan to back up that commitment? I have been contacted by representatives of Nursing Homes Ireland. They want an assurance that the express commitment will be delivered. Mr. Gloster might indicate what progress or action has been taken to vindicate that promise.

Mr. Bernard Gloster

This relates to a commitment I gave last summer shortly after I came here. I addressed the matter with Senator Kyne earlier when Deputy Cullinane was out of the room. I fundamentally believe that people, whether they live in a private nursing home, a public nursing home or at home, are entitled to the same access to healthcare services. Thirteen of the 30 integrated care for older people teams are now involved in the care of people in nursing homes in different parts of the country. That is just not consistent enough for me. I want to go beyond the integrated care for older people teams. I am hoping, with the utilisation of the public sector agreement and with meeting with the National Joint Council of unions shortly, to introduce a much more consistent approach where all primary care staff will be available to support people wherever they live, including private nursing homes.

Deputy David Cullinane

I thank Mr. Gloster for that. I am looking at the forward to the national service plan written by the chairperson of the HSE. He talks about the significant financial challenges over the next 12 months that will impact on the overall budget and what might happen at the year end. He states that there is a likely requirement for a supplementary budget or supplementary funding support. Would that be an understatement? Talking straight, would Mr. Gloster see it as a racing certainty that there will be a need for a Supplementary Estimate before year end?

Mr. Bernard Gloster

I have said two things about it. One is that my job is to keep it at the minimum level - the lowest level possible - and I have set out the conditions, including inflation, demand and control, which will or will not dictate the level of it. I would say that some level of supplementary assistance will be required this year.

Deputy David Cullinane

If I were a betting man, I would say that it will be close to €1 billion. I know the HSE will want to keep it under that amount, but we will wait and see what the figure is. I will not rehearse all of the arguments. We have made them privately and the publicly in the past. The level of funding for existing levels of service is unacceptable and has left us in a position where we have these Revised Estimates every year, which does not make sense. You cannot plan on that basis. It is not a real-world accountancy and budgetary process.

I wish to ask about Children’s Health Ireland. In response to a Dáil motion we tabled on supporting children with scoliosis and spina bifida, the Minister referenced the €19 million of additional investment made in 2022. He said he was informed by management of Children’s Health Ireland that on the basis of the commitment, if the money was given, by the end of that year, no child would be waiting longer than four months. That has not happened, as we know. The Minister now said that he asked auditors or an audit team to look at the €19 million provided because there is a concern it was not all spent for the purposes for which it was intended. We will have to wait and see the outcome of that audit. That strikes me as a real lack of accountability at a time when those children are waiting far too long for surgeries. Mr. Gloster knows this is a very sensitive issue, so I will not play politics with it. We all know these children deserve better and want and deserve better access to life-changing surgeries. When commitments have been given on two occasions that no child would wait longer than four months and when money is given for a specific purpose with a clear commitment that is then not realised, that is not acceptable. It is unacceptable that auditors are now looking at this.

My question is for Mr. Gloster as opposed to the Minister, although there is responsibility for the Minister here also. What is the accountable relationship between Mr. Gloster's office as the head of the HSE, or the HSE as a corporate body, and Children's Health Ireland in relation to the allocation of funding? If €19 million was given and we are now being told it is possible that not all this money was spent for the purposes for which it was intended, what are the reporting mechanisms and how is it not better captured by the HSE given the prominence of the issue? This was a big political issue. Promises were made, as Mr. Gloster knows, because of a campaign by parents and children. There was a lot of heated debate in the Dáil, as Mr. Gloster knows. This is why I am saying I cannot understand, given all of these circumstances, how we have ended up with no certainty about the €19 million.

Mr. Bernard Gloster

Setting aside the €19 million for the moment, the accountability arrangement for Children's Health Ireland to the HSE is through a service level agreement. There is a process and it does have accountability. There are annual accounts, activity targets and other things to be reported.

Deputy David Cullinane

My question is more that when a cheque is signed for €19 million and the money is handed over for purpose A, how is the spending of that money monitored?

Mr. Bernard Gloster

I spoke to the internal auditor yesterday. I know Deputy Cullinane will leave that process to go to its conclusion. There are many different views about what the €19 million was for and what exactly was expected. In any event, Deputy Cullinane is correct that the overall global target to reduce the waiting time to below four months was given and it did not materialise. I certainly would not be of the view that money we would allocate this year, or in subsequent years, for interventions or measures such as this would not be anything but regularly tracked and accounted for to make sure it is doing what it is supposed to do. We have put in place a new clinical lead in the spinal service in CHI. Because of the dependencies outside of the CHI, I have also put in place a dedicated national project leader in the HSE to capture all of the details in respect of spinal support, spinal surgery and waiting times. We simply cannot continue with the unacceptable position that we have.

Deputy David Cullinane

Perhaps Dr. Henry will be able to answer my next question on the Nayagam review. We are expecting an interim report, which I understand has to do with risk assessment. When is it expected that the interim report will be furnished?

Dr. Colm Henry

As Deputy Cullinane knows, it is an independent report. We have been informed it will not be available before the end of April based on the complexity of the work, which involves reviewing notes and X-rays and interviews with clinicians who are providing evidence and information.

Deputy David Cullinane

It will not be before the end of April.

Dr. Colm Henry

It will not be before then. I would not be surprised, based on the complexity of the work, if it extended beyond April. We will not be putting pressure on the independent reviewer. We want to ensure he completes it to his satisfaction.

Deputy Neasa Hourigan

I want to return to something we have spoken about a lot at the committee, namely, the provision of long-term residential facilities for mental health, particularly in Cork. I acknowledge the seriousness with which the HSE listened to the communities and the concerns and needs of the service users and their families. The way ahead is certainly very encouraging for the community, particularly with regard to Owenacurra in Midleton. I acknowledge that. I would like to have an update on the current plans for St. Stephen's Hospital, which committee members visited at the time. It is an older facility. An elective hospital is planned for there, as is a 50-bed residential project, which is my main point of concern. Do we have a current projected cost for this 50-bed residential project or a timeline for it? Are we at design phase? Where are we at with it? Does the HSE still have a position that is in line with policy?

Mr. Bernard Gloster

I will come back to Deputy Hourigan in writing on where exactly we are at with it. I do not want to mislead anyone. I am not across the detail of it. With regard to pursuing it, I had detailed discussions with the team when I went to Owenacurra. This has led to the decision to build on the site, which I am very happy about. It is the right thing to do. I met some of the residents there-----

Deputy Neasa Hourigan

I know you did.

Mr. Bernard Gloster

-----and it is the right thing to do. That is good. A planning application has been submitted for it and I have certainly made it clear that, regardless of national capital plans, I will not be found wanting in coming up with the wherewithal to provide it.

The team at St Stephen's described to me the service there as having two sides. One is dementia specific, which is necessary. I have seen some of the designs we are now using throughout the country for dementia and community nursing units, such as in Tuam in County Galway. They are very good. The concern about the impact of an institutional site can be well mitigated there. I absolutely believe this, both aesthetically and architecturally. The other side of the service there is for people with enduring mental illness challenges but with a much more appropriate model of care and social care. This is still being pursued and it is not as close to final decision, final design or final implementation as of yet.

Deputy Neasa Hourigan

It is unlikely Mr. Gloster has projected costs at present.

Mr. Bernard Gloster

I do not. Genuinely, I would be misleading Deputy Hourigan as I am not sure of the cost of a 50-bed community nursing unit with construction inflation. I will come back to the Deputy.

Deputy Neasa Hourigan

The 18-bed intensive care mental health service in Carraig Mór more will cost €14 million so we could-----

Mr. Bernard Gloster

The design of intensive care-----

Deputy Neasa Hourigan

I know.

Mr. Bernard Gloster

-----will be different.

Deputy Neasa Hourigan

It will be slightly different. I think also there will be bungalows in St. Stephen's Hospital. We can see the concern in terms of service provision. A large number of residents of St. Stephen's were moved to community services in places such as Fermoy and Kanturk. Now we are building on the site of St. Stephen's. We could see how there is concern about whether we are really moving towards the new policy of community-embedded places. There is also be reasonable concern that a 50-bed unit is considerable. Will there still be enough funding to develop community residences in places such as Clonakilty or Cobh which might need them?

Mr. Bernard Gloster

I genuinely say to Deputy Hourigan that it is not either-or, it is both. The way the intention around the 50-bed unit has been described to me is very different from what the traditional view might be. The expansion of road network, bus and other services in that part of Cork will make it a much more accessible location. The whole idea is not to go back to institutional walls. The design would very much accommodate this. Let me set it out for Deputy Hourigan in writing. It is a fair question on which I do not have up-to-date information.

Deputy Neasa Hourigan

That is fair. There is an undertaking in the programme for Government on the right to statutory home care.

Mr. Bernard Gloster

Yes.

Deputy Neasa Hourigan

Recently, I asked the Minister of State about it and she said legislation is being prepared on it. Has the Department done any outreach with the HSE? This would be a significant undertaking for the HSE if, all of a sudden, there was a statutory right. Has the HSE had communication or talks on this issue?

Mr. Bernard Gloster

The community operational team and the older persons national team are involved with the Department all of the time in working through what this might mean.

Deputy Neasa Hourigan

I thank Mr. Gloster.

Senator Martin Conway

I would like to ask about a couple of additional areas. There has been a big focus on CAMHS recently, and rightly so, but there are waiting lists for primary care psychology services that in some instances are longer than those for CAMHS. What is the plan to deal with this? Clearly it is an area that has not had a large amount of public attention but there is a serious and growing need. If Mr. Gloster does not have the specifics on it, perhaps he will come back to the committee with a note.

My next question is specifically on multiple sclerosis. MS Ireland was given an understanding that it would receive significant funding in the service plan for this year for respite and physiotherapy services, to upgrade its facilities and to provide additional respite and enhanced physiotherapy services for 2024.

Is the funding that was alluded to being provided? The third question is about an area we have spoken about at length before, namely, the eye clinic liaison officers for Vision Ireland. The understanding was that 3.8 whole-time equivalents were to be provided in 2023 and this was to increase to 4.8 whole-time equivalents. Is the HSE still committed to that target. Will the funding be provided to Vision Ireland to proceed with it? I ask because my understanding is that it has had no contact on this to date. We have discussed at length previously the critical role played by the eye clinic liaison officers. While I acknowledge Mr. Gloster is personally committed to this, we need to get the funding over the line and bring it to a finality.

Mr. Bernard Gloster

In response to Deputy Hourigan, we have just brought up a figure regarding the most recent community nursing unit. It was a 60-bed facility and the construction-only cost, excluding VAT, was €24.5 million, which is about half a million euro per bed or thereabouts.

To the Senator on Vision Ireland, yes it corresponded with me again recently. I believe I am due to meet them or talk to them shortly. I did commit to supporting that last year and to extending it this year. I am committed to that regardless and having gone on the public record with that, I would be a foolish man to try to take it back off. I will be opting for that extra WTE that the organisation needs this year to do that. It is phenomenal value for money and I have no issue with that. On the psychology services question, I might ask Ms Killeen White to pick up on that.

Ms Kate Killeen White

Since the reconfiguration of the children's disability services in 2021, there have been increased referrals to primary care for children with more complex needs. The national access policy which I have already discussed is very much focused on integrated services across primary care, disability and CAMHS and all aspects of those services need to be resourced to make the national access policy work. The psychology waiting lists are part and parcel of the wait-list initiative and through increased productivity, among other matters, we will continue to try to bring down that waiting list. There is ongoing discussion with the Department, in particular on primary care and primary care operations around implementing the national access policy in full and what that looks like.

Mr. Bernard Gloster

I will come back to the Senator, I do not have that detail as to who is getting what and to be fair, the service plan is certainly tighter than the expectations would have been coming in to it. That is not a veiled message, I genuinely do not know the answer.

Senator Martin Conway

I appreciate that, that is wonderful. I thank Mr. Gloster.

An Cathaoirleach

Before we finish, could Dr. Henry walk us through the cancer screening figures? We have BreastCheck and CervicalCheck. In some cases there are missed targets and in others, the uptake is better than the targets. Are we ambitious enough in relation to the targets? Would Dr. Henry go through them?

Dr. Colm Henry

To answer the Chair's question, there are three cancer screenings and an additional screening programme in diabetic retinopathy. It might be more useful if I provide a written report on their current activity and their performance against targets.

An Cathaoirleach

That is fine. We hoped as a committee to return to it. We are going to bring in the Irish Cancer Society and we probably will bring in the HSE in relation to it. It is difficult to follow on and I wonder whether we are ambitious enough. It is worrying that there is an increase in people with cancer but I assume that is in part a result of Covid, etc. Anyway, the witnesses will give us a written report.

Dr. Colm Henry

On the Deputy's point, while the screening programme is clearly an important part of cancer detection, the great majority of cancers present through diagnostic services, to contextualise our role. What we will do is provide a report and if you give us notice of the hearing we will provide any information in advance that will help with your deliberations.

An Cathaoirleach

Again, it is worrying that some people are not turning up for tests. That is part of the problem. The tests for bowel cancer are clearly successful, it is not invasive at all and people should be taking up the opportunity. As for prostate tests, again men are falling behind in regard to getting themselves tested, particularly men over the age of 40 but not exclusively so. The message that if you are concerned, if you think there is something unusual or if you are not feeling well, there is help out there should be reinforced.

I thank Mr. Gloster and his colleagues from the HSE for engaging with the committee on this important matter of the HSE national service plan for 2024. The committee will be monitoring the implementation of the plan for the remainder of the year and will be taking a keen interest in the issues as they arise. The meeting is now adjourned until 4 p.m. on Tuesday, 9 April when the committee will meet in private session. The select committee will meet the Minister of State, Deputy Mary Butler, at 9.30 a.m. tomorrow to consider the Health (Miscellaneous Provisions) Bill 2024 on Committee Stage.

The joint committee adjourned at 11.56 p.m. sine die.