Health Issues: Discussion with Minister for Health and Children and HSE.

I welcome the Minister for Health and Children, Deputy Mary Harney, and Professor Brendan Drumm, CEO of the Health Service Executive, HSE, to the meeting to discuss important health issues. They are accompanied by senior officials from the Department. I will ask the Minister to make opening remarks and will then call on Professor Drumm. We will stick rigidly to the protocol agreed some months ago because it worked effectively for us at the last meeting.

I have not circulated a script because I am not using one. I want to stick to the allocated five minutes because I find that in this committee engagement in questions and answers tends to be more productive.

We are living in a challenging economic environment in Ireland and this has an impact on health services. This year we will raise approximately €33 billion and €13 billion of this will come from income tax. The public health system will spend about €16 billion; €2.5 billion of this comes from either charges or the health levy. This means €13.5 billion will come directly from taxpayers, which is more than we will raise in income tax under the current budgetary arrangements for 2009. The transformation of the health service must continue with the momentum it has achieved in recent years. Financial constraints will not set aside the health reform programme; they make the transformation of health services more urgent and important. The manner in which we organised services in the past delivers neither high quality care for patients nor value for money for taxpayers.

In the debate in the Dáil a fortnight ago we spoke of the shortfall facing the HSE for 2009. I gave a commitment that following the budget of 7 April I would come back before either this committee or the House to address the situation that will arise. We are two weeks away from the budget so I cannot address that situation yet. At this point the HSE faces a challenge that amounts to between €480 million and €540 million above what was provided for in the service plan I approved earlier this year. We may later address how these figures break down; I gave a breakdown to the Dáil and the only thing that has changed since that debate is a further €60 million shortfall has come to light due to the health levy — this relates to appropriation in aid for the HSE. Demand-led schemes like medical cards face the implications of rising unemployment.

The recently negotiated contract for consultants is fundamental to the reform of the acute hospital system. Later this week I hope to meet the new clinical directors at a meeting Professor Drumm and his team will convene in Dublin. The new contract does not represent a pay increase for consultants; it means a fundamentally different way of working that involves clinicians in the management and leadership of the acute hospital system. The contract ensures clinicians are involved in the management of budgets and that there is one-for-all access to diagnostics and outpatients in our publicly-funded acute hospital system. It ends the scenario experienced by the late Susie Long, who was told she could have had access within a week, had she private health insurance. Because she did not have private health insurance she had to join a queue.

Some 85% of serving consultants have opted for the new contract and, by any standard that is a tremendous response. I hope to honour the new arrangement because it is fundamental to the reform of the hospital system. There may be issues around timing because the contract does not come without cost, but it is fundamental to the reorganisation of our acute hospital system. In particular, it involves consultants working more as part of a team, with longer days and more structured cover at weekends. This contrasts with the lone ranger approach with which consultants currently work. We have sought changes in the contract for almost 30 years and the changes which will happen are significant.

Outside the hospital system, drugs cost the public health system €1.9 billion. Some €1.2 billion of that is represented by ingredient costs and €600 million by distribution and dispensing costs, with €70 million accounted for by VAT. As members of the committee will be aware, we recently passed legislation — because of the emergency circumstances in which we find ourselves — to give the Minister for Health and Children the power, after a process of consultation, to reduce the fees paid to medical practitioners and to look at the distribution costs of drugs. I intend those changes to take effect from May this year. The process of consultation and dialogue is under way and I hope to be in a position to make decisions based on the outcome very soon. I hope I will have the support of all the members of the committee for the steps that have to be taken to curtail the rising costs of drugs to our public health care system.

I will be happy to deal with any questions that arise.

I thank the Minister for being so concise.

Professor Brendan Drumm

I will outline the challenges we in the HSE are facing in these difficult economic times and provide a brief update on the progress we are making on several fronts.

The Minister referred to the projected financial challenge in 2009. The current economic climate is having a significant impact and rising unemployment is creating a substantial unanticipated drain on the health services budget. Our funding from the health levy is going down, more people are becoming eligible for services such as medical cards and unemployment can impact negatively on people's health and well-being, creating greater service demands.

Due to the worsening economic climate the HSE faces a full-year challenge of in excess of €1 billion. This is significantly reduced by the fact that the HSE has already put in place a programme that will reduce costs by €663 million for 2009. The HSE is now putting plans in place to deal with an additional €72 million of cost pressures which are likely to have a service impact. Proposals to amend the 2009 national service plan are currently being prepared for consideration by the board of the HSE. We will continue at all times to try to make sure services are the last thing to be impacted by this climate, if it is at all possible.

In addition to the nearly €700 million in cost reductions effected by the HSE, the Government is seeking to address a further shortfall of €275 million. This includes an exposure to the emerging deficits in health levy receipts of €100 million which, as the Minister said, may worsen to €160 million. We are achieving the HSE budget targets through huge staff commitment and a series of measures including rigorous control of our employment numbers, budgets, costs and capital expenditure.

Non-core pay is a huge issue. Our 2009 service plan was developed with a core premise of protecting services and retaining jobs. Most of our money is tied up in employing people so any reduction in services results in a reduction in jobs. However, as the economy deteriorated, it became evident that this would prove very difficult without significantly reducing our variable pay budget of approximately €1.2 billion on top of basic pay. A reduction in variable pay can only be achieved through flexibility from staff and unions. Measures sought include the redeployment of nurses working both within and across institutions, reducing the layers of on-call services and eliminating archaic work practices such as paid lunch breaks and living-out allowances for junior doctors, and the elimination of unsustainable levels of absenteeism. These measures are an absolute necessity if we are to be true to our stated aim of protecting patient services. However, three months into the year we may need to rethink some of these principles in the context of the challenges we now face from a staffing perspective.

We are continuing with the transformation programme and it is important to remind ourselves that the Irish health service is experiencing the same challenges facing health services across the globe. We know that the prospect of building a national health service to meet the demands coming down the track in respect of acute hospital facilities is a huge challenge and the present configuration of those facilities is not sustainable. We are ahead of other countries in addressing many of the complex issues needed to shift from a predominantly acute hospital-based service to a predominantly community-based service, which is the goal in many countries.

The development of primary care centres throughout the country is at the heart of this important shift. We are making progress in reorganising many local hospital services based on the principle of putting the safest level of services in place. Despite our current financial challenges, it is essential that we continue to make progress in this area and not only continue with our transformation programme but, where we can, accelerate it. We must avoid becoming immobilised by the size of the challenge ahead and I firmly believe that, given the huge commitment of health care professionals, we are well capable of adding momentum to this programme.

The reconfiguration of acute hospitals is always a source of much debate but we are making progress in reorganising the way services such as emergency care, emergency surgery and critical care are provided. We have specifically focused on the north east, the mid west and south. The purpose of this important reconfiguration process is to develop and deliver safer, better quality services that provide patients with the best possible results. The process will also ensure we use scarce resources appropriately and efficiently to meet the needs of all people in these regions.

In the old mid-west region of Limerick, Clare and north Tipperary, we have two small hospitals, Nenagh and Ennis, with 24-hour emergency departments which see very few emergency patients at night. The analysis shows that the needs of the vast majority of these patients can be met by existing GP out-of-hours services. In addition, we have three emergency surgery teams in place, working seven nights a week and spread across the three smaller hospitals, Ennis, Nenagh and St. John's. Between them they deal with, on average, one emergency patient per week.

In April 2009, 24-hour accident and emergency facilities in both Ennis and Nenagh are to be replaced by local emergency services and medical assessment units operating for between 12 and 14 hours per day. At the same time an enhanced ambulance service will be put in place, with 12 advanced paramedics, to quickly respond to the needs of patients in this region. In July 2009, all emergency, cancer and major surgery will be centralised in Limerick Regional Hospital.

Rather than having services reduced, the smaller hospitals will see many of their services grow. For example, Ennis hospital is to receive a new endoscopy and day ward facility.

Is Professor Drumm close to the end of his opening presentation?

Professor Brendan Drumm

Yes. Teamwork management services in HSE South also undertook a review of acute hospital services and it is intended that its report will be published in June 2009. Professor John Higgins has taken the lead on the reconfiguration of hospitals in HSE South. The reconfiguration of acute hospital services in HSE North East continues. As the new 6-bay medical assessment unit in Cavan is due to open in March 2009, it is expected that the transfer of acute services will take place in June 2009. Other enhanced services in the north east include an additional 800 home care packages to facilitate early discharge and an extension of the ambulance services.

The appointment of clinical directors represents a milestone in the management and development of health services in Ireland. This is the first time for many years in which clinical leaders will be central to the development of our services. We are confident of patient outcomes and clinical effectiveness. We are likely to improve under such structures. The inaugural meeting of the clinical directors has been held and, as the Minister stated, there will be a further meeting between them and hospital managers within a few days. Clinical directors are enthusiastic about becoming centrally involved in driving the services' transformation. This situation is changing considerably.

Party spokespersons have five minutes each, starting with Deputy Reilly.

I welcome the Minister, her team, Professor Drumm and his team and thank them for their written responses.

I will revert to a number of issues, beginning with the capital programme and the HSE's budget shortfall. Earlier this year, the Minister mentioned the 25% reduction in the capital allocation to approximately €540 million. It is being reduced further to €390 million, constituting a reduction of approximately 50%. Who sanctioned this cut, when was the decision made, when will the national service plan be approved by the Department of Finance and when will we receive a revised schedule of projects, an important matter?

The HSE's 2009 service plan lists 129 capital projects, 68 of which relate to the necessity of upgrading acute hospital infrastructure and 28 of which relate to the development of central services for the elderly. Which of these projects will be dropped? They comprise a total of 750 new beds for the elderly and 492 replacement beds, including the community unit at Clonskeagh, the 50-bed unit at Harold's Cross, a new 100-bed unit in St. Joseph's Hospital, Raheny, and another in Clontarf. Outside Dublin, the projects include St. John's Community Hospital in Enniscorthy and three 250-bed sites in Ballincollig, Fernlee and St. Mary's Orthopaedic Hospital in County Cork. The projects also include seven ICU beds and eight replacement high dependency unit, HDU, beds at St. James's Hospital, the 30-bed cystic fibrosis unit in St. Vincent's Hospital, 56 replacement beds at Connolly Hospital, a new emergency department at Our Lady of Lourdes Hospital, 21 beds for Cavan General Hospital, phase 2B of the Mullingar Regional Hospital's day procedure unit, the renal unit at Cork University Hospital and a 23-bed ward at South Tipperary General Hospital. Where will the cuts be made?

Could the committee be supplied with information on the internal budget rebalancing programme? From where will the €240 million be taken? Will the committee be given a clear breakdown of how planned savings of €530 million will be achieved? Will the Minister confirm whether the Government has committed to providing the €275 million of the €480 million in unanticipated financial demands? Will our guests outline where the HSE's savings of €133 million have been identified and how it intends to make the further savings of €72 million?

What front line services will be affected by the funding shortfall and what are their specific locations? What are the implications for patient care? When will the amended national service plan be published and what will be the shortfall's implications? People need to know precisely what is occurring.

I will allude to a few e-mails I have received, one of which was sent by a 34-year-old lady from the Minister's constituency who has a brain tumour and has been waiting for six weeks for neurosurgical treatment at Beaumont Hospital. However, nothing has occurred. Despite being told that letters would come, none has arrived.

Deputy English received a response from Beaumont Hospital concerning one of his constituents to the effect that no bed was available. The letter states that, at the time, 12 seriously ill patients in outlying hospitals were awaiting admission to Beaumont Hospital's unit. Those people have critical conditions, such as growing brain tumours, but there is no service for them. Our guests can discuss transformation and reconfiguration all they want, but this is the reality.

I received an e-mail from a gentleman with diabetes. For his sake, I will not read all of it aloud, but I will relate what is in the first few paragraphs. A 35 year old type 1 diabetic, he is disgusted by his level of eye care treatment. In 2000 when he experienced problems arising from diabetic retinopathy, the Mater Hospital dealt with him as an outpatient. In August 2000 when he attended the eye clinic, he was told that his appointment had been cancelled. The receptionist apologised for not contacting him and an appointment was made for the next available clinic. Several weeks later, he moved to London for work, but he returned to Dublin to attend the clinic. One morning in October, while he was still awaiting his appointment, he awoke to find that he was blind. Had his initial clinic not been cancelled, the burst blood vessels would have been seen and lasered, preventing the blindness. This is what he was told by the wonderful staff at Moorfields Eye Hospital in London. They immediately set about providing laser treatment for his right eye and told him that, if the procedure had been carried out in Dublin, he would still have had vision in his left eye.

The man goes on to discuss three or four more attempts to attend an eye doctor. Whenever he approached his six-month appointment, it was cancelled. The last line of his e-mail tells of how the over-stressed secretary, who had been fielding similar calls all day, finally told him that it was not her problem. He goes on to say some rather unkind things about the health service, which is understandable.

Funding was set aside for diabetic retinopathy screening, but the service was not delivered in 2007, 2008 or 2009. Dr. Smith appeared before the committee to discuss a man who had diabetes for 37 years but had never seen a diabetologist or consultant endocrinologist.

Discussing generalities is all very well, but our health service is in a mess. More people are on trolleys than ever before. Last year, delayed discharges increased by 30%. Ambulances are delayed at Beaumont Hospital's accident and emergency department for hours. The number of cancelled operations has increased by 10%. The list goes on.

Will the Deputy conclude?

I will ask one or two further questions. I have mentioned urology services. Will the planned improvement at the neurosurgical unit at Beaumont Hospital be affected by the cutbacks? Will people get their service? What about collocation? According to Professor Drumm on Newstalk yesterday, collocation is in the hands of the private sector. If this is the plan to improve our bed situation, having already removed 1,100 beds from the system, it is of concern. Will the children's hospital be affected by the budget?

I fail to see how the new consultants' contract will end the two-tier system, as people will still attend private hospitals to receive private treatment. The public waiting list is still seven or eight months long. Dr. Michael O'Keeffe, a notable eye surgeon, appeared on "Today with Pat Kenny" yesterday morning and asked why he could get the same amount of work done on a Saturday in a private hospital as he could during a week in the public sector. He pointed out that the longer hours for consultants would be meaningless without beds for the patients on which they proposed to operate.

I ask the Deputy to conclude.

I thank the Chairman for his indulgence. While the HealthStat is a useful information tool and accessible by the public, did the HSE, which has existed for more than four years, not have the information in question before now? Why are hospitals still performing so poorly?

I welcome the Minister, her colleagues, Professor Drumm and his colleagues. I will focus on the major issues before the committee and seek clarity on the figures. Professor Drumm referred to €1 billion as being the amount to be removed from the year's planned programme, but the Minister referred to €480 million to €540 million above the service plan. What are we discussing exactly? After the service plan was produced, but before the new year, a certain amount was to be found. A subsequent series of amounts needed to be found, including the €72 million referred to today. Will our guests provide the committee with clarity regarding how much money must be saved by the service plan which was agreed last autumn?

Regarding reform, will the Minister proceed with the proposed reduction in administrative staff in the HSE and the plan to remove management layers? Rather than a general redundancy programme, this was our proposal. If such cumbersome layers are maintained while front line services are cut back, how does the Minister propose to reform the system? The written replies received today by members admit that front line services are being cut back. For example, the written reply to Question No. 2 on national priority issues states:

Given the pressure already on the finances of the HSE and the wide ranging measures under way, this additional €72 million cannot be met without reducing service levels and so proposals to amend the national service plan are currently being prepared for consideration by the HSE board. Decisions on where services will be cut...

It goes on to state how such decisions will be guided. Consequently, it has been acknowledged that front line services will be cut. Members need to know what is on the table in this regard and when they will hear about such cuts. I find it extremely disturbing that front line services will be cut.

Approximately €100 million will be required to cater for the additional people who will qualify for medical cards. In addition, a substantial amount of money from the health levy will be lost. The Department of Social and Family Affairs appears to be receiving funding from across the financial pocket to address the effect on it of unemployment. Will the Minister state whether there are proposals to obtain similar funds from the Exchequer? I acknowledge the Exchequer is under pressure but this is a direct result of unemployment and it seems unfair that the health budget should be obliged to take the brunt. Are there plans to spread the burden across Government funding?

The main issue I wish to tease out further is how the new consultants' contract will work. I understand the Minister may not pay as soon as was originally intended. She should clarify whether there will be a delay in this regard. While there was a delay because she considered the consultants had not complied fully with the agreement, a suggestion was made in one of the medical newspapers today that the back money might also be reduced from what was originally planned. However, I really wish to establish how the common list will work. Will it be a common list for outpatients, diagnostics, tests, investigations, procedures and operations? Members need to know whether this will be the case. If so, will a public patient who has been waiting for a rheumatology outpatient appointment for two years, which is possible, be on the same list as those private patients who heretofore would only have been waiting a short time? If so, will such a public patient be prioritised ahead of them because he or she has been waiting for so long? How will the list work? On the introduction of the new system, will public patients who have been waiting for a long time for operations, tests or colonoscopies be given absolute priority ahead of private patients? When will this happen in the hospitals? Has this matter been discussed and how will the scheme be implemented?

A final and related question is whether the Minister is expecting a reduction in the number of persons taking out private health insurance. Does she expect cancellations of private health insurance policies on the basis that it appears as though in future the service will not differ greatly for private and public patients? Alternatively, does she envisage that private patients will be treated in private hospitals somewhere? There is a great lack of clarity on this issue.

I thank the Minister and Professor Drumm for their attendance. It is important to note that everyone, including the Government, all other Oireachtas Members, Professor Drumm, the Health Service Executive and its 120,000 employees, wishes to provide the best level and highest quality of care possible, given the finite resources available. The latter, which is the problem for everyone, always has obtained. However, the position is worse this year than in the past because of the shortfall in the State's finances which causes problems for us. The shortfall means savings must be made. It is fortunate in one sense but unfortunate in another that health, education and social welfare account for 75% of what we spend. Consequently, one cannot achieve savings in public spending without impinging on these services. It will be important for everyone to put their heads together to ascertain how we can manage within the available resources.

The first item we must seek is greater efficiency and productivity. This applies to all of the 120,000 involved in health services at every level, including at both political and Health Service Executive level, as well as those who work in the service. Because there always will be competing priorities, regardless of how much money is available, and there never will be enough to do everything one would wish, we must seek greater efficiency throughout the service. Certainly, I would like to see the special needs sector protected. As for the need for greater efficiency in that regard, there is a case to be made for close consideration, with the Department of Education and Science, of a more integrated approach to the provision of special needs services. As for the question of transport, while the money may not be significant in the context of the overall budget, I refer to the question of whether the health service should be involved in transport at all, other than the provision of acute ambulance services. It might be possible, by adopting a more integrated approach to transport in conjunction with the Department of Education and Science or rural transport initiatives, to achieve a more efficient use of the resources invested in transport.

The Minister referred to the issue of medicines. Certainly, there are many savings still to be made in that regard. There is an obligation on prescribing doctors to prescribe generic medicines when they are satisfied such products are of similar efficacy to the proprietary brand. Although there had been some concerns in this regard at the time when I started to practice, this is no longer the case and doctors could make a contribution to savings in that way. As for the question of best practice, much work has been done. The Minister's response to some of the questions posed, as well as some of the material provided for members by the Health Service Executive, have pointed to what is happening with regard to best practice. However, we should be examining acute hospitals, in particular, which are extremely expensive, to ascertain how one can ensure what constitutes best practice in one hospital is transferred to another.

I wish to keep general the tenor of my remarks and will not mention Monaghan General Hospital. While I may do so if I get an opportunity to return to it, my constituency colleague undoubtedly will mention it. The final point I wish to make is that the Minister referred to a sum of €13.5 billion. That is ten times what was available to me when I served as Minister for Health. In those days we faced exactly the same problems but simply were obliged to face them and to get on with it. It is important that everyone gets into the boat together and rows in the same direction.

We will move on to the next section of the meeting in which we will deal with the written queries submitted by members to which written responses have issued. We will deal with clarifications or elaborations on these points. Members have four minutes each and I ask them to stick to that time limit. Quite a number already have indicated, beginning with Deputy Conlon.

I welcome the Minister, Professor Drumm and his team. One general point that pertains to the written responses concerns the idea of service efficiencies and trying to save money. I share the view that each person, line of management and layer must come under scrutiny. I am still appalled by anecdotal evidence provided for me about people who do not know what is their job description, as well as by the huge amount of money they receive. There is great scope for examining this and saving money.

I refer to the transformation programme and the north east in response to the answers I have received. I am not convinced about the time line. It is too rushed if we expect such significant and major changes in a short period of two months before transferring services from Monaghan hospital.

I have not received answers on packages of care and what this means. My remarks are addressed to Professor Drumm, who may have the specific information. At a meeting I attended in December, one person asked whether a package of care is a package for one patient or whether every visit is considered to be a new package. There are no specifics in this respect. At this meeting, pre-hospital thrombosis was explained to us. Members raised a query and there was talk about a day of information, with experts attending. The train is moving on and we have not received specific details.

Regarding cuts and the impact on front line services, a press release from a few weeks ago mentioned that Monaghan hospital will be closed in April or June. Such negative spin deflates and demoralises the people working there. It also strikes fear in those who depend on it. Whether the statement is true is something I do not know but I seek clarity. We were told at the meeting by a member of the HSE that this was a policy decision that could be changed. I had been of the opinion that everything the HSE does in the north east was in the best interests of patients. A statement like that gives me no hope that this is in the best interests of the patient, if something can be overturned as easily as that. The patient will always be my number one priority.

I am very concerned by the lack of engagement with the general practitioners in Monaghan. As Deputy O'Hanlon said, we must all row the boat the same way if this is to succeed. If we are not engaging with the GPs in Monaghan we are not rowing the boat the same way. Who is the clinical person leading this? I fear we do not have a medic at the top moving this on. I worry about the concerns of GPs. What is the HSE doing to ensure engagement with the GPs to ensure the best interests of the patient are considered at all times?

Regarding transforming HSE south, Professor John Higgins is due to report in June. Oireachtas Members from south Tipperary met the Minister for Health and Children in February and she said that nothing will be decided until September. What is the view of the delegation on that?

Regarding South Tipperary General Hospital, the medical assessment unit closed without discussion, as did the Warfarin clinic which dealt with my mother-in-law, who is 85 years of age. The gynaecological ward was subsumed into surgery with a ten bed closure. I invite comments on this.

I refer to the ambulance service. The spatial study has been concluded and the HSE awaited the final document. Has it been received? When will there be an ambulance based in Carrick-on-Suir? Regarding changes in the transformation relating to Nenagh hospital and the additional ambulance needs, how is it proposed to deal with those who need an ambulance in south Tipperary? North Tipperary and south Tipperary work together in respect of maternity services. What is the situation with regard to maternity services at South Tipperary General Hospital? Can the delegation comment on the case mix adjustments? There is a negative figure, -1,377. Can the delegation explain the meaning of that?

Regarding disability and mental health funding, the HSE removed €53 million from this sector in 2007. An efficiency saving of 1% was introduced in 2008, with a further 1% cut in the budget in 2008 to come into effect in 2009. In February the HSE introduced a further 1% cut effective from 1 January. The HSE said it was aware of the challenge this would present to service providers in ensuring the needs of service users would continue to be met. My understanding, from a previous meeting here, was that the HSE does not have legal capacity to spend the funding in an area other than disability and mental health.

I welcome the Minister, Professor Drumm and his people. I refer to funding of the National Suicide Prevention Office, a matter I have raised with the Minister previously. A cut of 12.5 % was imposed on the budget of the office this year. The recession is expected to lead to increased rates of suicide, as happened in previous recessions and as international research has shown since 1897. The response to a request for increased funding for the national suicide prevention office in the Dáil by the Labour Party and Fine Gael was a reduction. The availability of services of the office is being curtailed.

I refer to Question No. 4 of the questions sent to the HSE. Has the Minister seen the report on St. Luke's Hospital, Clonmel, which is with the Mental Health Commission? When will it be published? I tabled a Dáil question on that matter and I was informed that it was due to be published shortly, whatever that means.

Can the Minister comment on the up-to-date position of the Central Mental Hospital? With the changes that have taken place, there is no clarification on the necessary provision of modern psychiatric conditions for the patients of the Central Mental Hospital. The Government identified the need for modern mental health facilities and psychiatric inpatient facilities for patients of the Central Mental Hospital as a priority. The report of the Minister indicates that the budget of Limerick regional hospital has been reduced in 2009. Is there a reduction of €1.2 million in the budget for inpatient services and €326,000 for the accident and emergency unit?

I refer to the allocation of €2 million in 2007 and 2008 by the Department of Health and Children for Traveller health development funding. Can the Minister confirm that €1.8 million of these moneys was hived off to balance the HSE books? What the Minister allocated for Traveller health development was used for other purposes by the HSE, despite the fact that this was labelled for Traveller health development. A need has been identified because the levels of health care and longevity within the Traveller community are so far behind those for the settled community. Approximately €2.2 million was allocated in two years but will the Minister confirm that only €200,000 of this was spent?

I raised the issue of palliative care in Newcastle West. My reading of the Minister's reply is that the opening of the unit in St. Ita's, planned for 2008 but postponed to 2009, will not now take place.

I welcome the group. It is good that the process is ongoing.

The questions I have relate to the transfer of the breast care unit from the South Infirmary-Victoria Hospital to Cork University Hospital. The answer provided is extensive and comprehensive. I have great time for centres of excellence. Wherever the best outcome is achieved, that is where people should be. When Professor Keane came to Ireland, he said we would have centres of excellence, including four in Dublin, which is still beyond my comprehension. He did not realise we already had a centre of excellence in Cork and we are now in the process of moving it. The BreastCheck unit was installed at great expense next door to the hospital in order that it could become part of a joined-up service but we are now moving the breast care unit to Cork University Hospital. The BreastCheck unit is to be left where it is. I am told however that in the near future we will close it in order to move it, at great expense, to be located next to the breast care unit. This does not make sense, either to me or the people who will be the direct beneficiaries, the patients. They definitely do not understand the reasoning and have significant concerns.

Another issue relates to standards with regard to people with intellectual disabilities or any disability. When will the relevant report be published and its findings implemented? The majority would not cost a great deal of money to implement, as they involve changes in attitude more than anything else. The report is excellent and demonstrates much common sense but its findings must be implemented.

I have a question I would like to put to both Professor Drumm and the Minister. For this meeting we have probably received more information than we have ever received before. I am looking at three sets of receipts from consultants. On one page I counted 34 lines of a bill which had been paid. I have ten pages with approximately 25 receipts on each page. I am staggered and astonished by them. There is a bill for €3,500 from Anne McMurray Consulting in respect of executive coaching but there are bills in the region of €166,000 or €188,000 coming in year after year.

How many are working in the HSE? If all of the people concerned are working in the service, what are we doing employing this many consultants? There are bright people working in the HSE who have particular skills and we all know they are being paid well. Nevertheless, it seems we have to hire a consultant to tell the chief executive how to present. When will this stop and when will we expect the people whom we have employed to do their job without constantly talking about bringing in consultants? If we were to do this, the only downside would be that our unemployment figures would probably triple if all of the people concerned did not have any work to do in the morning. Is this still ongoing? Why is the job the people concerned are paid significant amounts of money to do not being done by persons working in the HSE?

A total of €1.4 million was set aside for the payment of bonuses to the HSE executive last year. Is this money to be paid out?

I also welcome the Minister, Professor Drumm and their teams.

My questions relate to the two local issues I put down for consideration. The first concerns the oncology unit at Mayo General Hospital. In Professor Drumm's reply he indicates the project is awaiting stage approval to proceed to design stage. The new oncology unit will be an important and integral part in the transfer of the breast care service to Galway. My understanding is that €250,000 to €300,000 was allocated to be spent this year on the design of the new unit. Will the Minister provide an update? I understood the project had been approved; therefore, can the matter be clarified? It was raised at a regional HSE meeting. I am anxious for the project to proceed.

With regard to the transfer of breast care services to Galway, will the Minister provide an update on the numbers since the transfer of the service in November 2008? The anecdotal evidence is that people are very pleased with the service and the way it has operated but will the Minister provide the figures?

Professor Drumm has indicated that with regard to prostate cancer services, planning is well advanced for both services to be transferred this year. Will he elaborate on this and say what exactly will happen this year? In his introductory comments and when we discussed the matter last year, he indicated that when services were transferred from a hospital, others would be moved to acute hospitals that did not necessarily have to be located in a regional hospital. There were comments about the hospital in Ennis with regard to services that had been transferred there. What services have been transferred to Mayo General Hospital since the surgical part of the breast care clinic service was moved to Galway? What additional services are being provided in Mayo General Hospital? The intention, when the idea was mooted, was that services would be transferred. I am very concerned that there might be cuts to front line services in the western region, particularly in Mayo General Hospital. Will Professor Drumm indicate if there is anything planned for the hospital?

I apologise but I had to attend another meeting. I will try to be brief but I am particularly interested in the document given to us on local priority issues. I will raise issues affecting my own town and Tallaght Hospital. I applaud the quality of information being given, particularly on cancer services, which is very important. I have mentioned to Professor Drumm that there is a communications difficulty on some of these issues and that much of the news about Tallaght Hospital recently has been negative rather than positive. It is important that I reflect such concerns.

I have raised the matter of the children's hospital with the Minister before and know the standard answer. A lead article in an edition ofThe Irish Times from several weeks ago reported that the HSE had indicated delays in the schedule being followed for the development on the Mater site. This raises issues for many community organisations in Dublin, including in particular the Tallaght hospital action group, with which members will be familiar. What is the status of this development? The decision must be taken in the context of the current economic climate but people in the Dublin region, and certainly those in Tallaght, want to know whether the project on the Mater site is still being seriously considered. Was The Irish Times correct in reporting that the HSE has reviewed the decision? Can a better site be found and what is the future for the delivery of children’s services? The sands have shifted to some extent and it is important that we press the Minister and the HSE to outline the current position in regard to this project.

I welcome the proposed relocation of the Coombe Women's Hospital to Tallaght. I hope I am not overly enthusiastic when I say that the word from the HSE and hospital appears to be positive in that regard. Does the transfer of this first-class facility to Tallaght not raise the question of what services should be in place to greet the new babies? I thank the Minister, the Department and the HSE for the documents they have given us and I hope I can receive replies on the gaps I have identified.

I welcome the Minister, Professor Drumm and the officials. I ask again when the vaccine programme for cervical cancer will be introduced. Vaccination is the primary preventive measure for cervical cancer, with the second method being screening. I commend the Minister on the tremendous work she has done on screening. In light of the recent death of the celebrity Jade Goody, young women have become much more conscious of cervical cancer. Even in the context of the current economic hardships, it is critical that the Government introduces screening for young people at the earliest opportunity.

I commend the Minister, Professor Drumm and Mrs. Laverne McGuinness on their valiant efforts to fill the outstanding vacancies for suicide prevention officers. International evidence indicates that during recessions greater numbers of people become depressed and die from suicide. As members of the Sub-Committee on the High Level of Suicide in Ireland, Deputy O'Connor, Deputy Neville, Senator Prendergast and I are aware that, while people in the know speak about suicide, it is not on the political radar. It is important that we be told the total amount of money spent on mental health and suicide prevention. We know that the RSA received €43 million but it would be useful if we could be told how much money is spent on mental health, depression and suicide prevention.

When the programme for government was drawn up in June 2007, I made valiant efforts to have a target included on suicide prevention. The public is not aware that more people die each year from suicide than in road accidents.

I am currently reading a very interesting book by two renowned French professors of philosophy which raises the issue of hidden suicide and the thousands of people who are suffering but do not seek their to doctors' help. Dr. Ella Arensman estimates that 60,000 people self-harm each year, of whom 11,500 present to accident and emergency departments. How can we reach these hidden sufferers? As a business person and a Senator, I am aware that many business people are traumatised by their relations with banks. Even the banking officials whom I have contacted report feeling upset about the aggressive manner they have to take with clients. It is a vicious circle. It is critical that all 11 suicide prevention officers are in place. I recently published a newsletter in which I drew attention to the fact that people suffer emotionally as well as economically in times of recession. Even the strongest families will suffer in a recession.

I welcome the Minister and Professor Drumm to the meeting. The response given to issues I raised in regard to polio sufferers has been welcomed and I hope the review of medical cards, which is due to be completed within the next few months, will have a positive outcome for this group of people.

In regard to turnover thresholds for contracts, I recently learned this issue arises across a number of Departments. Has the HSE any leeway in the issue or are the criteria set by the Department of Finance?

I did not intend to raise any local issues until I received correspondence today from a distressed mother regarding public and private appointments with ear, nose and throat consultants. Have criteria been set in the new contracts in regard to situations where a consultant has a waiting list of up to one year for public appointments? A private patient could meet the same consultant within two months. I can supply the Minister with further details on the matter. This woman's child is constantly ill but she does not know whether the child's tonsils have to be removed. It is not right that she will have to wait for one year before finding out.

I welcome the opportunity to engage once again with the Minister and Professor Drumm on these matters. I have tabled three questions for today's meeting and will deal with them as follows.

The response I have received from the Department of Health and Children on the Monaghan General Hospital issue is nothing short of insulting. I have received a paltry written reply from the Department to my question on the fate of the hospital. As we all know, we will see the removal of the last acute in-patient service from this once fine hospital. The Department's response does not even refer to the grave concerns, particularly for patient safety, raised by GPs across counties Cavan and Monaghan, as highlighted in my question. The Department chose to ignore them.

The HSE reply is more detailed and I thank the executive for this. Nevertheless, the reply is no better, as it offers no more hope. We are told the day of execution for Monaghan General Hospital will be some time in early June. I expect it will not be too early in June, as we would hardly expect Professor Drumm to close the hospital in advance of the local and European Parliament elections on 5 June. It is more likely to run a little longer than this. I would not be surprised if it ran into the summer recess when there will be nobody here to question, challenge or raise the matter directly. The signalled date is early June.

The HSE response states, "It is of concern that GPs in Cavan and Monaghan feel it appropriate to withdraw from engagement and involvement in the service changes". If it is of concern to the HSE that GPs should feel it appropriate to withdraw, why is it not of concern that they should express such clear opposition to the axing of acute services in Monaghan and such concern about patient safety? These professionals who provide direct primary care and the first address for service for the people of Cavan and Monaghan have expressed in unequivocal terms their concerns about patient safety in the event of acute medical services being closed at Monaghan General Hospital. Why would the HSE not comment on this? Should this not be a wake up call for the HSE and the Department? What they are continuing to do is an absolute scandal and will put patient safety at risk, as demonstrated all too sadly the last time Monaghan General Hospital was taken off call for acute medical services. We know the litany of unnecessary deaths which occurred as a result of that experience.

It is significant that the GPs have also pointed out to the HSE that attempting to replace 56 acute medical beds in Monaghan General Hospital with a six bed medical assessment unit shortly to be opened in Cavan does not equate to replacement, compensation or an equal situation. Clearly, it amounts to a significant deterioration, not only in the service provided by Monaghan General Hospital but also in overall acute hospital services in the north east.

I ask the Deputy to conclude.

I will conclude on this point. One cannot transfer 3,000 acute in-patients annually from Monaghan to Cavan General Hospital, where there are already significant difficulties with a throughput of 5,000 patients and no additionality. It cannot work. This is a recipe for real and serious problems, not only for the displaced people of County Monaghan but also for the people of County Cavan who also depend on services at Cavan General Hospital.

I had other issues to raise but make no apology for placing Monaghan General Hospital, its future and future access to acute hospital services for the people of my home county at the top of my list. Once again, I say shame on the Department of Health and Children and the HSE for proceeding with this absolutely outrageous and scandalous proposal.

I thank the Deputy.

Members on all sides of the House realise the enormity of the challenges facing the Minister, Professor Drumm and their teams, particularly in the current difficult economic climate. A recurring theme, alluded to by Deputy Neville and others, is the issue of ring-fenced funding. At our last meeting there were lengthy references to the disability sector and we have heard about palliative care. Deputy Neville referred to our recent meeting with the Traveller community at which we heard that €2 million had been allocated to addresss Traveller health care issues but that only €200,000 had been spent. Notwithstanding the enormity of the challenges he faces, does Professor Drumm share the concern of members that public confidence in the HSE is eroded when funding is not used for the purposes for which it was allocated?

I will begin by responding to Deputy Ó Caoláin. We recently published the report of the Commission on Patient Safety and Quality Assurance which was chaired by Dr. Deirdre Madden and included patients' representatives and others with a strong background in safety and quality issues. One of the commission's key recommendations was that we should move to a licensing or accreditation regime in the provision of health services, beginning with a licensing regime for the acute hospital sector. The Government has accepted the report. The framing of legislation is complex because this is a new area. It will take some time, probably most of the next two years, to complete. Even if we were able to pass the legislation tomorrow and begin a licensing regime in the next year, the manner in which we organise services would not meet the patient safety standard required in a licensing regime centred on patient safety. That is a fact. Therefore, the manner in which we seek to reconfigure services — the acute hospital system in particular — is not governed by money. Money is not unimportant because if, through the fragmentation of services, we are wasting money, we do not have it to spend somewhere else. Above all else, what is guiding reform is patient safety. We know, for example, from international and Irish experience that in accident and emergency services where there are properly trained accident and emergency consultants and appropriate volumes, mortality rates improve by up to 25%. On previous occasions the committee has dealt with performance in cancer services. Implementation of the cancer plan by Professor Keane is proceeding very successfully. Patient safety is central to some of the issues raised.

Deputy O'Connor mentioned the children's hospital. In this city tonight we will have three accident and emergency teams on duty throughout the night dealing with very small volumes. That is not a good way to organise paediatric services, either from a safety or value for money point of view. That is why I have become such a strong fan of having a single paediatric hospital in this city, not only for secondary care services in the Dublin area but as a national tertiary centre for sick children. It is not about a physical place but about bringing teams together with as many specialists as possible working in a single centre.

Deputy Reilly mentioned the capital plan. There is a distinction between the capital plan for the HSE and the overall capital plan of the Department of Health and Children. This is because the Department also has responsibility for the Office of the Minister for Children and that office has a capital plan of approximately €60 million for child care facilities. There is also an ICT capital budget of about €30 million. There is lottery money of approximately €2.5 million.

It was envisaged that the budget for the HSE building programme would be €425 million but that has been reduced to €390 million. That is a reduction of €30 million from what was forecast in the budget. Clearly we would like to see no reduction but the evidence is that building costs have reduced by about 25% and we must reprioritise, given the economic situation in which we find ourselves. We must cut our cloth to suit our measure.

I am very conscious that Deputy O'Hanlon said that the budget is ten times bigger than he had when he was Minister. We must be mindful that in straitened economic circumstances we must reprioritise spending in our capital programme. One of the reasons that primary care centres are being provided through the private sector is precisely that it does not involve capital funding from the Exchequer. It does not require any money from the taxpayer. I welcome the deep interest the private sector has expressed in providing the necessary infrastructure to allow the roll-out of primary care teams around the country. We have already selected some but perhaps Professor Drumm will deal with the number. Equally there are other initiatives where we can get private funding for the provision of capital facilities and this must be welcomed. In fact, of the 23,000 older people in long-stay care, under 10,000 are in publicly-funded facilities and the majority are in privately-constructed facilities. If we did not have that additional capacity, we would have a serious deficit in the number of available places.

Some of the issues raised by Deputy Reilly relate to service provision. If we assume that we will only get better service with more money, we will never get the service we require. We will get better service by reorganising the way we provide the services.

There are 12 surgical teams working across four hospitals in the mid-west. If we can bring the 12 surgeons together working as a single team, we can achieve much more than 12 surgeons working individually. The same applies across a whole range of other services. That brings me to the issue mentioned by Deputy Lynch. We are seeking to create cancer centres, not a breast cancer centre, a urology centre and a prostrate cancer centre. We are trying to create centres where there is a critical mass of expert doctors, nurses and other professionals working in the area of cancer.

The issue in Cork is not about the facility but about the service to patients. The objections raised tend to be raised by medics in Cork. I have met them and I do not understand the objection because the distances are short. I can at least understand the concerns of people in Sligo, Donegal and Mayo, but I find it hard to understand that the short distance between one hospital and another causes such concern in Cork.

We are seeking to create eight specialist centres, where every health centre should be a centre of excellence. Professor Keane did not decide on the location of the eight centres, because when he came here, the decision had been made by a group consisting of 16 people, the majority of whom were medics. They decided where the eight centres would be located. I did not decide where the centres would be located. The hospital in my constituency was not one of the chosen centres. There was no political involvement, nor should there be. These centres were recommended by cancer experts and the Irish Cancer Society, among others, was involved. The Government accepted their decision. I am a strong fan of making that happen as quickly as possible.

On the issue of the amended service plan, the HSE must submit a new service plan to the Department and then I have 21 days to consider it. Deputy O'Sullivan asked what was the difference between the €1.1 billion and the €480 to €540 million. In the service plan, the HSE made provision for €530 million of savings, and €280 million — to the best of my memory — was saving the HSE achieved last year. It was not a once-off saving and, therefore, that is achieved again this year. The balance of €270 million is to be saved from further efficiencies that the HSE must achieve this year. In the service plan approval, 3% efficiency must be achieved in the numbers of people in management and administration, a reduction of 540 posts. In the Dáil two weeks ago, I announced the figure of €480 million for the service plan, since then an extra €60 million has been added because of the shortfall in the levy, which brings the figure up to €540 million. This is additional to what was provided in the service plan and the HSE will make submissions on a new service plan.

I cannot say today what the outcome of the budget deliberations of the Government will be. I will be going to a meeting after this to deliberate on the budget and the Minister for Finance will announce the budget on 7 April. What the HSE must do after the budget remains to be seen. As of now we are talking about a shortfall of €540 million and that is why some of the issues I raised earlier on the cost of distribution and dispensing of drugs, which is rising very rapidly, must be addressed together with other efficiencies.

A number of Deputies raised issues around their local area and I will allow Professor Drumm deal with them as many relate to Monaghan hospital and the mid-west area.

In relation to the report into St. Luke's Hospital, that is a matter for the independent Mental Health Commission. It will not be a matter for me to publish the report but I hope it can be published as quickly as possible. I met a group from St. Ita's Hospice recently and I think in the first instance a day service may be provided. There are significant revenue implications in opening the inpatient unit, but I will ask Ms Laverne McGuinness from the HSE to deal with that.

It is a priority to provide a new state-of-the-art central mental hospital. We still expect that can be done on a cost neutral basis because even in the current market, the south Dublin site of the Central Mental Hospital is very valuable. It was always anticipated that we would advance money to build the new hospital and then recoup it through the disposal of the land. That remains the Government's position.

The disability standards are at an advanced stage and we hope to enter into dialogue with HIQA. I agree with Deputy Lynch that it is often a matter of attitude. It is the same perhaps with financial regulation; sometimes it is the culture as much as the law that determines how things are regulated.

I will allow the chief executive officer to comment on cancer services, because together with Professor Keane and others, he advises me.

I very much accept the point being made by Deputy Neville and Senator White. We spend €1.1 billion on specific mental health services and does not include GP services, accident and emergency services and so on. The Office of Suicide Prevention has seen a reduction in its budget from €4.5 million to €4.3 million, but all that is on the non-pay side. I understand that Mr. Geoff Day who heads up the office and engages with all the groups is confident that can be done without affecting front-line services. We have a significant role to play. Senator White makes a valuable point. Very often it is the difference between somebody accessing a service and being unable to. I recently had an opportunity to visit the Cliffs of Moher. Right at the edge there is a sign for the Samaritans which I thought was really appropriate. The big challenge for the office and for many of the groups involved in suicide prevention is trying to target campaigns around young people because young people do not read newspapers in the way the older generation do and perhaps they do not access the same news and advertising messages that we do. That is a major challenge for everybody involved in suicide prevention.

Deputy Blaney raised the issue of polio. As the Deputy knows, a group is examining the issue of medical cards and is due to report later this year. Among the subjects being examined is the long-term illness card. The list of eligible illnesses has not been amended for some time, as the last time an illness was added was in 1978. There are major issues around the long-term illness medical card, which are being examined.

The Deputy made a valid point about contracts. We want to ensure that companies have the capacity to provide the service. The HSE has now moved to central procurement. In the legal services area, while one may go national to procure a service, it is very often devolved to a local level to smaller solicitors in more rural areas. That is an example from the legal area. Perhaps there is a lesson to be learned. I am a strong fan of encouraging small and medium-sized enterprises to compete for State business, particularly in the current climate. In other areas, therefore, one could go national for the procurement but the provision of the service could be done at a local level by smaller contractors.

In response to Deputy Reilly, the revised budget Estimate will be published on budget day, 7 April, when we will see the spending for health services for the remainder of the year. The amended service plan will have to be laid before the Oireachtas and I am awaiting the submission of the HSE. To be fair to the HSE, we will not be able to finalise the service plan for 2009 until we see the budget on 7 April.

I would like to get clarity on the €540 million which has now been reduced to €390 million.

That is not correct.

The Minister states that the €540 million consists of €60 million for the Department of Health and Children——

It is for the National Childcare Investment Programme 2006-2010. There is €30 million for information and communications technology. That is another €90 million.

Is that for the Department or the HSE?

It is for the HSE. If we want to compare like with like, the reduction is from €425 million to €390 million on the building programme. That is the project the Deputy mentioned.

Is there any reduction in those two figures, the €30 million and the €60 million?

Not that I am aware of. Not at this point.

There will be some concluding remarks later. Professor Drumm has 25 minutes.

I have some questions on consultants' contracts. Is the Minister going to deal with those?

Perhaps Professor Drumm will deal with many of them.

During the 25 minutes, Professor Drumm might deal with many of the questions the Deputy has and we will take a few supplementaries if necessary.

I would like my primary question answered. My main question related to consultants' contracts. I would like to know that somebody will answer it.

Will the Minister take that or will Professor Drumm take it?

I am happy to take it. In regard to the new consultant contract, first, there will be for the first time a strict measurement of the public-private mix which does not exist at the moment. Second, in regard to access to diagnostics, there will be one system for all. There will be no question of a private patient getting preferential access to diagnostics in our public hospitals at the expense of a public patient.

In regard to hospital cover, at the moment because consultants do not work as part of a team, they can effectively decide when they will or will not be providing services in the hospital. Under the clinical directorate model, they will be part of a team and it will be the responsibility of the team to provide cover. It will also be the responsibility of the team to deal with seven-day discharges. We know that in this city if one is in hospital on a Friday evening there is more than an 80% chance one will still be there on Monday morning. There is no health reason for that. It relates to discharge policies. The consultant contract is about an entirely different way of working. There are hospital managers who say they must keep junior doctors and other staff on overtime waiting for the consultant to do his or her rounds. Under this new contract, with 85% of doctors signing on for it, all of that changes.

The HealthStat, published yesterday by the HSE, begins a process of measuring what happens in our acute hospitals, including the numbers of new patients seen by consultants in outpatient departments. I gave data to the Dáil recently supplied by Professor Drumm which shows a huge variation both within this city and across the country in the numbers of people seen in a particular area, neurology, from one consultant to another. There are huge variations. The new consultant contract is about changing that, measuring it, monitoring and having a clinical director, one of their peers, rather than a hospital manager, in charge of the implementation of the new way of working.

Professor Drumm has 25 minutes.

Professor Brendan Drumm

I would like to ask Mr. Woods to comment on the financial issues because we need to deal with some of the financial issues raised by Deputy Reilly.

Mr. Liam Woods

On the points on finance that have been raised, the Minister has covered the global position. The HSE is dealing with a global financial issue of just over €1 billion, but €530 million of that was incorporated within the service plan which was prepared late last year.

Deputy Reilly asked about the internal rebalancing of €204 million. That related to the fact that while the HSE delivered a balanced Vote in 2008, it had a deficit on community-based schemes and pension payments and so there was an internal adjustment. We had to move surpluses to cover deficits so that we could start with a balanced position. If the committee would like more information on that I can provide it. Effectively there was an internal rebalancing to make sure we started 2009 in a balanced place.

Deputy Reilly also asked about the €205 million in the break-out between €133 million and €72 million. The HSE already has measures in place to address the €133 million which relates to risks that arose after the year end. The service plan on page 3 identified a number of potential risks. The €205 million in total relates to those risks crystallising in early 2009. We have taken actions and there are already measures under way to the extent of €133 million which are not having an impact on front-line services. We have now to propose to the board of the HSE in the coming days measures to address the €72 million and, as the Minister has already said, that will become part of the deliberation within the 21-day period for the Minister. That €205 million made up of those two components is being dealt with in that way.

What about the €133 million?

The Deputy may not intervene now. He may do so later.

Mr. Liam Woods

There were a couple of other questions on finance. The case mix adjustment figures provided to members give rise to two questions. Senator Prendergast asked about South Tipperary General Hospital and the figure of minus €1,377. That is euro, not millions. The Senator is right that it is a negative adjustment of €1,377. Deputy Neville referenced the position in Dooradoyle in Limerick. There is a negative adjustment of €831,000 in the figures.

That has been removed from the budget.

Mr. Liam Woods

Yes. The two figures the Deputy quoted were the losses. There was a gain in the day case area, so the net figure is €831,000. This is a neutral process nationally. There is no money leaving the hospital system but it is incentivising effective practice through looking at areas of common cost and common activity level. It is quite a complex mechanism but it is right to say, and the Deputy rightly identified, that there is a loss in the case of Dooradoyle in the mechanism. Those are the only questions I picked up on.

I take it Mr. Woods is the man who deals with the money. Were any bonuses paid?

We can take supplementary questions later.

That was not a supplementary question. That was one of my questions.

Professor Brendan Drumm

I will deal with that. I will speak in a moment about some of the capital issues raised by Deputy Reilly of which I can speak. In regard to his question on brain tumours and neurosurgery, one of the cancer control programme's priority areas is looking at the treatment of brain tumours in the same way as it is following up on the BreastCheck programme. There will essentially be a single unitary approach across the Cork and Beaumont sites to start dealing with them in a focused way as in the BreastCheck programme where people will be given fixed and rapid appointments. That is a priority for Professor Tom Keane now in relation to brain tumours, lung tumours and prostate cancer. That work has already begun with the establishment of that process.

The Minister has covered the issue of the children's hospital fairly well. I have been dragged into this for all sorts of reasons but the bottom line in regard to the children's hospital remains that there are essentially two sites in this city on which to locate it, St. James's Hospital or the Mater Hospital.

The children's hospital was never going to be and could never be built on the M50. It could not be built away from an adult hospital because everybody agreed, including the children's hospital, that there should be a maternity hospital with it for high-risk new-born deliveries and no maternity hospital would be built in the future isolated from a general hospital. We certainly are not building another general hospital.

A lot of this has been an amazing argument. Only sites on which general hospitals exist were ever seriously considered. The Mater Hospital and St. James's were the two top ranked hospitals because of their subspecialty development. The cardiovascular unit being in the Mater Hospital and the neurosurgical unit being in Beaumont, which is relatively close, a decision was made to go with the Mater Hospital. This reasoning has been made out to be smoke and mirrors but the position is as simple as I have said. There are documents that anybody may see.

The group that looked at this included a man from the Office of Public Works who did a great deal and is now deceased. It was a remarkably focused group and its work will stand up to rigorous scrutiny. I am glad the Government are fully focused, as am I, because anyone who has seen the children's hospitals in Dublin will agree that it is unthinkable that a person could try to stop this urgently required development. The development is needed not only for Dublin, given the circumstances in which children are cared for, but for children from all over the country who use the services. It is still within our capital programme, unless the Government chooses to change this; I cannot comment on what the Government wishes to do in terms of new developments within the capital programme. I will comment on projects that are already up and running and Ms McGuinness will answer the specific questions on long-stay facilities that are being built.

Ms Laverne McGuinness

Some 483 new long-term care beds will proceed in 2009 and there will be 150 replacement beds; the total will be around 700. Some of these are in places mentioned by the Deputy, including Clonskeagh, St. Joseph's, Galway and Ennis; I have a full list that can be made available. Sometimes delays occur in planning schedules so to cover for this and ensure we provide the same number of beds. We have contracted for 245 extra beds. This will ensure that patients have the full number of beds available for the full year. These will come back as soon as the public fast track beds are established.

Can that be circulated to us?

Ms Laverne McGuinness

I will do that.

Professor Brendan Drumm

Deputy Reilly mentioned HealthStat and it is a huge step forward for Irish health services; it has been a priority of the HSE's for almost three years and it has been running as a pilot for a year. Setting it up is a huge process as much of the information was not collected in that way previously. There has been much co-operation with hospitals and I will now move it into communities, where such information, including detailed performance data, has not been collected before. We will lead internationally in the information and transparency we will have. Our focus on performance has been great. We have been criticised for using figures too much at times but they can be very helpful in identifying where money is spent.

The diabetic retinopathy programme will continue this year to be rolled out along the west coast as planned. The money is being invested, the programme is continuing and we agree that the sooner it covers the whole country the better. It is being rolled out as planned and Limerick to Donegal will be covered after the next stage.

Mr. Woods dealt with Deputy O'Sullivan's questions on finances. Ms Doherty, director of the national hospitals office, may wish to comment on the common list and so on.

Ms Ann Doherty

On the consultants' contract, there are one or two things to be clear about. Inpatient and day case waiting lists are held by the national treatment purchase fund as part of the patient treatment register. The public private mix will be controlled through measurement: ratios will be 70:30 for existing contract holders and 80:20 for new contract holders — this is the important information relating to inpatients and day cases. There is a specific provision in the new contract for a common waiting list for outpatient diagnostics, which is a significant area of access, and we are currently progressing this.

Ms Ann Doherty

The common list in the new contract relates to outpatient diagnostics.

It is not a common list everywhere.

Ms Ann Doherty

The important element of the new contract is the measurement of inpatients and day cases.

Professor Brendan Drumm

New contract holders and existing contract holders will be limited to different degrees. Figures from various areas indicate this will lead to a significant change towards public patients. There should be a significant impact on public activity.

Deputy O'Hanlon is correct about the best-practice approach. HealthStat is concerned with pointing out that things should not be done differently in different places. Figures from across the country indicate that a person who has a heart attack may spend ten days in one place but four and a half days in another. This is evident for many different diagnoses and it is without justification. The appointment of a chief clinical officer and the development of a clinical directorate means the development of a standardised approach to the treatment of patients from primary care to the hospital system will be prioritised. It is essential to treat people in the community. Yesterday it became evident, through HealthStat, that a geriatrician from St. James's Hospital who runs nine clinics per week has practically no inpatients, even among stroke patients. They are dealt with effectively in an outpatient capacity. The same goes for neurologists in St. Vincent's Hospital and for others throughout the country.

Progress on Monaghan General Hospital is a big issue for Deputies O'Hanlon, Ó Caoláin and Conlon and Ms Doherty will address this.

Ms Ann Doherty

We have tried to put as much information in the briefing as possible; there has been much discussion outside this forum. I apologise for and am concerned about the commitment Deputy Conlon mentioned to a meeting with paramedics and I will follow up on that. The medical assessment unit is opening in Cavan and that will be significant in terms of changing how we use existing bed stock. We know from our bed utilisation studies that a change of practice is required and the medical assessment unit is a very important part of that. The unit is due to open next week and we always said that rather than take acute calls away from Monaghan immediately we would let them continue for a couple of weeks. That is where the date in early June came from; it will give bedding-in time and confidence to local general practitioners.

Many comments were made about general practitioners in Monaghan and we are concerned about their lack of engagement. We are making every effort and if Deputies can assist in getting them to engage through Ms McGuinness's service that would be welcome. We have GPs who are trying to work with them to get them involved in the development of the service in Monaghan.

The involvement of clinicians was another significant area that was raised. As part of the north-east transformation teams of clinicians are involved in every aspect of the service. Every part of this has been planned with clinical involvement and engagement.

What about the rumour about Monaghan General Hospital being closed?

Ms Ann Doherty

The service plan for 2009 is being prepared on the basis of the existence of 50 acute hospitals in Ireland. That is a statement of fact; I am not being smart.

Does that mean Monaghan General Hospital will be closed or open?

Is it closed or open?

Ms Ann Doherty

According to the HSE's service plan on acute services, there will be 50 hospitals in Ireland.

How many are there at the moment?

Ms Ann Doherty

There are 50.

Will Monaghan be one of the hospitals in question?

Please contain yourselves.

Hold on, I object to the Chairman's interjection. Deputy Connaughton asked a clear question that required a "Yes" or "No" answer. The answer given went around the house and referred to 50 hospitals in the service plan. I do not think the question was unreasonable.

Ms Ann Doherty

My comment was not meant to be disingenuous; I was trying to be factual. There will be 50 acute hospitals and Monaghan General Hospital is one of them.

Regarding changes in the policy decision, we were told at a meeting with the HSE that the Government could make changes. As far as I am concerned there is a huge question mark over this.

We will conclude on this matter and people can come back with supplementary questions.

Professor Brendan Drumm

I will deal with Senator Prendergast and we can then have follow-up questions.

Has Professor Drumm finished speaking on Monaghan General Hospital?

Professor Brendan Drumm

I think Deputy Ó Caoláin had similar questions on GPs.

Deputy Ó Caoláin is no longer here but he is monitoring the responses.

Professor Brendan Drumm

We have found engagement with GPs in Monaghan difficult.

Can we finalise the question on Monaghan Hospital and move on to other issues?

Deputy Conlon asked whether there could be political interference. In theory there could be, as, under the Health Acts, a direction can be given to the HSE. However, a Minister for Health and Children who valued patient safety would not prevent something which was designed for that purpose as it would be highly irresponsible. The HSE is organising better services for patients, here and in the mid-west, and it deserves the support of the Minister in that task.

I do not wish to be antagonistic but how can the Minister stand over that statement when the people of Drogheda are watching their hospital bursting at the seams but closing its accident and emergency unit which impacted services as far south as Beaumont Hospital?

Professor Brendan Drumm

Our figures show that people are twice as likely to be admitted to a hospital in most areas of the north east as they are in the rest of Ireland. The majority of surgical admissions do not result in surgery so we have to bring about huge changes in practices in north eastern hospitals. There are a huge number of beds and, as we know from the rest of the country, the higher the number the higher the admissions. People living in Cork city or Waterford city are twice as likely to be admitted to accident and emergency units as they would be if they lived in County Cork or County Waterford. However, they are not likely to live a day longer.

Is Professor Drumm saying that if there were no beds nobody would be sick?

Professor Brendan Drumm

There are huge admission rates where there are more beds available, because rates rise in proportion the number of beds.

So half the patients are not sick.

Professor Brendan Drumm


Is Professor Drumm saying people are admitted to hospital who are not sick?

Professor Brendan Drumm

We have made that point on several occasions. We review bed-dependency measures regularly and presented the figures yesterday on HealthStat.

We had an attitudinal problem relating to feasibility but this is the most outrageous thing I have heard in a long time.

Please, Deputy Lynch, allow Professor Drumm to conclude.

Professor Brendan Drumm

I will respond to that because members of the press are present. It is clear that a significant number of people, in this and other countries, are admitted to hospital who do not need to be admitted.

Professor Drumm should take control of the doctors who admit them because they believe their patients are sick.

Professor Brendan Drumm

We need comprehensive services in the community.

That would be better but we do not have them.

Professor Brendan Drumm

Many patients are admitted to hospital for diagnostic tests and their average stay is between four and ten days. If we brought that average down to the mean for similar countries we would free up the equivalent of five 300-bed hospitals immediately. There is no point fooling ourselves that Irish hospitals function at the cutting edge in terms of patient throughput.

If we had a primary care service we would not have such problems but we do not have one.

Professor Brendan Drumm

Nobody has done more than the HSE in that regard.

Can I point out——

I will adjourn the meeting if members do not speak through the Chair and stick to our protocol. Please allow Professor Drumm to conclude. I will go to as many members as possible for comments and supplementary questions.

Professor Brendan Drumm

Senator Prendergast asked about the medical assessment unit in Clonmel. I do not know why it might be closed.

Ms Ann Doherty

My understanding is that it is to be relocated to the medical education unit.

It is my understanding that one trolley cubicle has been given over to the medical assessment unit.

Professor Brendan Drumm

South Tipperary General Hospital has 35 admissions per day and 76 doctors. We should be able to keep the medical assessment unit running in that structure. It pays out €60,000 per week in medical overtime, which is €3.2 million per year. The Senator brought up the question of ambulance services in Carrick-on-Suir and I am not sure if we ever clarified it.

Ms Ann Doherty

We are carrying out a spatial analysis on the ambulance service to determine where the activity is and guide us as to where to locate our response services. The analysis is in draft form at the moment and I expect the full version to be available in early summer.

Professor Brendan Drumm

The cut in disability service money is a significant issue and was raised by a couple of members.

Ms Laverne McGuinness

There was a 1% reduction in funding for disability in the budget day letter. In February 2009 the HSE made an additional 1% reduction, which was the case with all HSE services. The reduction was made so that the disability sector would look at its advertising costs, travel costs, subsistence and general cost efficiencies in line with the HSE's value for money programme. I told the three umbrella organisations what was required and that the cuts should not impact on front-line services. I also told them they should look at the high levels of absenteeism. It does not take away from the commitment that funding for disability services has been ring-fenced from 2008 onwards. As part of the overall service plan, €7.2 million is currently being used to put in place therapist posts and an additional €8.5 million has been made available for emergency funding for disability placements.

Some €19 million is available for mental health in 2009. We have put in place four additional child and adolescent psychiatry beds in Galway, six have opened in recent weeks in St. Vincent's Hospital and the other eight will open in Cork in April. In addition, two new 20-bed units will open in Galway and Cork for child and adolescent psychiatry. There were 47 child and adolescent psychiatry teams at the beginning of the year but 58 will be in place by the end of March 2009 and there will be 64 by the end of the year.

Professor Brendan Drumm

The Chairman asked a question on this subject and I will also answer Deputy Neville's questions on Travellers and funding for social inclusion. Historically, development money has been moved into mental health but, as of last year, we cannot move money anywhere. The amount available this year is €500,000 and it will be spent on the areas for which it is identified, unless we receive an instruction to the contrary.

What allocation is provided by the Minister?

Ms Laverne McGuinness

Some €19 million is provided for A Vision for Change.

Given the time constraints, can Ms Laverne address the principal issues raised by members?

Ms Laverne McGuinness

The report of the Mental Health Commission into St. Luke's Hospital, Clonmel, is due to be published on 30 March or 31 March but a closure plan is currently in train. A project manager is in place to ensure the facility is closed and its patients moved to more appropriate locations. Funding is provided by the proceeds of the sale of lands belonging to mental health facilities.

Can Ms McGuinness answer the question about the Central Mental Hospital?

The Minister has addressed it.

I addressed it in the Deputy's absence. Unlike Deputy Ó Caoláin, Deputy Neville was not monitoring us from afar. The intention is to advance the money and recoup it from the sale of the site at Dundrum. The Minister of State, Deputy John Moloney, is very active on this issue.

Professor Brendan Drumm

Deputy Flynn asked about the new oncology unit in Castlebar. We are awaiting approval for the design and it is part of the capital plan which has been submitted to Government. On the breast cancer services, when we talked of moving services from Limerick to Ennis and to Nenagh and from Cavan to Monaghan in terms of day surgery and so on, it has been in the context of overnight surgery stopping in those centres. That is not our plan for Castlebar and we envisage all the major services in that location continuing. Removing breast surgery would not create much capacity to move in something else. The situation is not the same as obtains in Ennis and Nenagh where significant potential bed capacity is being created so as to remove services from the centre. There will not be much space for people coming from Galway because not much work will move away from Castlebar. The situations are not comparable.

Will there be day services?

Professor Brendan Drumm

Yes. We are working with the people in Galway to move more clinics away from it. I cannot outline the specific plans for Galway and Castlebar, but they are under discussion. We must move work away from Galway for other reasons.

Previously, Professor Drumm stated that certain day surgeries being performed in Galway could be performed at Mayo General Hospital.

Professor Brendan Drumm

Absolutely. For example, we would like to see some urology day surgeries move to Castlebar, but this process has not been finalised.

Assuming that approval for the design stage goes ahead, is it the intention that the oncology unit will be operational by the end of the €7.9 million three-year programme?

Professor Brendan Drumm

As it is part of the capital plan, I presume that we will do it.

It is important, given the consequent transfers.

Professor Brendan Drumm

We do not have any plans for cuts at Mayo General Hospital.

I have answered Deputy O'Connor's question on the children's hospital, in that the plan is being maintained. Regarding the Coombe Hospital's move to Tallaght, it is planned that all maternity hospitals will be moved to acute hospital sites. However, our plans are dependent on what funds can be raised from the sites. That operation would have been easier a couple of years ago. We are working closely with the Coombe Hospital to devise a proposal that we could make to the Government, but the situation is dependent on the moneys that we can free up. It is a work in progress.

I thank Senator Mary White for acknowledging that we took her message on board. Deputy Blaney asked about contracts. After speaking with Mr. Woods, it is my understanding that, under the Government regulation, we have a lee way of two to three times the turnover, which we have decreased to two times overtime. Most people should be allowed, but it is a national regulation.

The ENT appointments, which relate to Deputy O'Sullivan's question, comprise a significant issue. The use or, dare I say it, misuse of outpatient waiting lists — private patients waiting two days while public patients wait two years — is scandalous. Not only are we focusing on it through the consultants' contract, we are engaging in a major project in alignment with our health staff project to measure for the first time how many new patients consultants see in public clinics each week. As the Minister has indicated, we have found some amazing figures since beginning the process. There is no excuse for such performance, but we are in a position to start shining a light. I hope that the information will become publicly available to Members, although this might be challenged.

Deputy Ó Caoláin has left, but we have addressed the issues he raised and I know his concerns about Monaghan General Hospital. It is interesting that, according to Deputy Flynn, people in County Mayo have found their breast services, which were moved, to be satisfactory. Deputy Conlon has been reasonable with the HSE despite her concerns. However, fear is a considerable issue and will not be easily overcome unless something is seen to work. I have answered the Chairman's question on the money for Traveller health development.

Deputy Kathleen Lynch raised an issue. Professor Drumm may have missed it.

Professor Brendan Drumm

Whether PRAs will be paid is subject to a Government decision.

Professor Brendan Drumm

The Deputy asked about performance-related——

Professor Brendan Drumm

Yes. The matter is not specific to the health sector, as no decision has been made in respect of the entire public sector.

No bonuses have been paid in the HSE this year.

Professor Brendan Drumm

That is true.

What about the consultants?

Professor Brendan Drumm

Details of the consultancies have been circulated to the committee. No one present would maintain that these consultancies are unnecessary in an organisation that spends €14.5 billion. In the first six months of 2008, our spend across all of the lists in question was €5.5 million. It would be difficult to find any organisation with so large a budget that spends such a small amount of it on consultancies. I suspect that the situation in the rest of the public service is the same.

Here is one, namely, personalised communications consultancy to the CEO, the monthly charge for which is €83,000.

Professor Brendan Drumm

That is not accurate.

We should revert to Mr. Woods.

Professor Brendan Drumm

It is a half-year figure.

We will depart from the procedure somewhat. A number of people have indicated that they have follow-up questions.

I did not get an answer to my question on the cervical cancer vaccine and maternity services.

This may save us some supplementary questions. Will Professor Drumm respond?

I would prefer the Minister to respond.

I do not mind.

At this point, I cannot say when it will occur. As I have stated, we will accept the health technology assessment, HTA. The Senator used the phrase "screening of young girls", but this is a vaccination programme and not a screening programme. We have rolled out screening for the first time to detect those with pre-cancerous cells. I know of no country that rolled out a vaccination programme before a screening programme.

I am not disputing that. The vaccine——

In an ideal world, one would love to do everything. Ireland also has bad colorectal cancer results. Within the budget available to me, there are a number of priorities. Regarding colorectal screening, I will take advice from the chief medical officer and Professor Keane on how to allocate money during the coming years, recognising that we are in challenging times. However, we remain committed to the speediest introduction of the vaccine.

It is imperative that the vaccine be introduced as quickly as possible.

Senator Prendergast asked a question on maternity services.

Professor Brendan Drumm

Was it regarding Nenagh?

No. I do not know whether the story is rumour-based, but I seek clarification on whether maternity services at South Tipperary General Hospital will be relocated.

I am sorry that I was not present earlier. If I am out of order, the Chairman should tell me.

The Deputy should be brief.

I have been led to believe that assessment centres for medical card applications around the country will be closed and centralised. Is this fact? If so, it is a serious development.

I wish to raise two quick points on the information provided today. While I am delighted that Monaghan General Hospital will be open in 2009, I do not have great hope for 2010.

Professor Drumm referred to fear. The media have behaved irresponsibly, given the stories and negative publicity about hospitals. They have contributed to the public's fear, but the HSE is not blameless either. The goal posts have moved so often that one does not know what to believe.

Professor Drumm discussed private and public patient waiting lists, but I am concerned about the elderly. Sometimes, they do not receive the treatment they require as quickly as they should. It is a case of older versus younger. If one is considered to be at the older end of the spectrum, one might not necessarily be treated as quickly. This matter must be looked at and dealt with.

I call Professor Drumm, briefly, on those three important issues.

Through the Chair——

We are coming to——

My question has not been answered although it was brought up by someone else. I refer to the issue of the redundancies.

Very well. What was the other question?

I thought I was in the next round.

We will come back to the three spokespersons for five minutes each. Who will take those three supplementary questions and the issue of redundancies?

As for redundancies, the Minister for Finance, who is the Minister responsible for the public service, announced in his Budget Statement that he intended to bring forward a redundancy plan. Such a plan of course must also be accompanied by a redeployment plan and that remains the intention of the Government. I stated earlier that the HSE this year must reduce the administrative and management grades by 3%, or 540 people. I wish to put this issue in context because much of what passes for debate in Ireland on the health service is based on myth rather than fact. I have heard people on radio programmes stating that 48% of the budget goes on administration. In 2008, 12% of the budget went on administration, 35% on nursing, 16% on doctors and nurses, 12% on paramedics and superannuation accounted for 7%. When such issues are debated, the facts rather than the myths must be debated. I constantly hear references to figures that are incorrect and on occasions, what is an administrator to one person constitutes an important support staff member in another context. If consultants are to run outpatient clinics, they must be given back-up secretarial or information technology support.

As for a redundancy programme, it will be a matter for the Minister for Finance and the Government and I am sure this matter will be addressed in the context of the forthcoming budget.

I call Professor Drumm on the other matters.

Professor Brendan Drumm

While there is no plan to close maternity services in South Tipperary General Hospital, services in all hospitals are being examined in respect of future reconfiguration. I have made that point at all stages. This applies in the south east, the south, the old mid-west and every site is facing that challenge. However, I have no plan at present regarding the disappearance of South Tipperary General Hospital's maternity status. As for whether the capacity exists to maintain four acute general hospitals in the south east in the future, were Senator Prendergast sitting here in 20 years' time, it would be highly unlikely that there will be four acute general hospitals there. The same challenge exists everywhere.

As for Deputy Connaughton's comments on medical card assessments, it certainly is being centralised. It is a source of significant challenge in respect of industrial relations. With all the reductions of the administrative——

I assure Professor Drumm this will pose a challenge to many of those who seek a medical card, whatever challenge it may pose to the human resources staff.

Professor Brendan Drumm

The HSE is challenged constantly by this joint committee about reducing our administration numbers. This is a central——-

I know those numbers well.

Professor Brendan Drumm

No, I refer to the administrative staff. While we can keep them——

One needs a local sympathetic ear for those who have a problem.

Professor Brendan Drumm

Perhaps that is the point.

That is the point.

Professor Brendan Drumm

Perhaps such people are not administrative but are central to the provision of the service. This is the point about which we must make up our minds.

The problem is that such staff will not be present to help people.

May I intervene? In respect of medical cards and other health services, it is important to have clear national priorities in order that acquisition of a medical card does not depend on where one lives.

No and nor should it.

If that is the issue that is causing concern——

—— it obviously must be addressed.

It is on health grounds and the discretionary element regarding people's entitlement to a medical card. Were Professor Drumm to suggest that people who were obliged to make their case to a central location in Dublin or elsewhere will be well looked after, it would be a bad day's work.

The Deputy's point is well made.

Professor Brendan Drumm

Discretionary medical cards will still be issued.

Is this decided centrally?

Under the 1970 Act, medical cards, with the exception of the over-70s medical cards for which special legislative provisions have been made, are issued on the basis that the chief executive officer, formerly of the health board and now of the HSE, determines that one is not in a position to provide services for oneself. Ireland does not have clear legislative criteria pertaining to medical cards, which constitutes an issue. I have stated previously before this joint committee that the issue of eligibility to services is being addressed within the Department and the Government, because it is patchy.

I guarantee the Minister that the numbers of discretionary medical cards issued will fall dramatically from henceforth and that is what this is about.

One third of the population has a medical card at present.

We will now have five-minute statements from each of the spokespersons, namely, Deputies Reilly, O'Sullivan and O'Hanlon.

Before so doing, I seek a written answer regarding the national strategy for long-term beds. My understanding is that at present, people in County Mayo only pay €595 for a long-term bed, while the equivalent figures in Cork and Dublin are more than €900 and €1,200, respectively. Is this strategy decided regionally or nationally? Moreover, as one cannot get adequate dressings or aids and appliances, why does a national strategy not exist in this regard?

That issue will be dealt with later.

While I will be obliged to leave the meeting shortly, one of the most important issues confronting us at present is that of the two-tier system. I certainly read into the Minister's comments on common lists that the two-tier system would be discarded with regard to access to diagnostics, treatments in hospitals and so on. There are 150,000 public patients on outpatient waiting lists and from what I have heard today, my understanding is that common waiting lists will only operate for diagnostics and for everything else, depending on which contract the relevant consultant has, there will be ratios of 30:70 or 80:20. I seek clarity on this vital issue as consultants will be paid great amounts of additional money. The entire purpose for so doing is to have a fair system in which one is treated on the basis of need, rather than on ability to pay. The responses I have received today give rise to a concern that common waiting lists will only operate in a small area of the entire service. I also seek clarity on whether, for example, public and private patients will sit in the same waiting area in the hospital to see the same consultant and whether they will be treated on the basis of need.

Deputy Reilly has five minutes.

I am happy to listen to the reply to the Deputy's questions before I speak.

The procedure is that the Deputy should make his remarks now and that the Minister and the chief executive officer should respond during the wrap-up.

Clearly, their responses would inform my remarks.

I am willing to answer the question. Deputy O'Sullivan appears to be sceptical about the new contract. Professor Drumm dealt with the Deputy's region and I could comment on my own, in which one can often only access our public hospital if one is a private patient even though the State pays all the staff, for all the diagnostics and so on. Under the new contract, this cannot happen any longer. Access will be on the basis of medical need and I refer, for example, to access to diagnostic facilities. lncidentally, more than 400 consultants have opted for full-time public work only and will no longer have a private practice, which I greatly welcome. The 85% of consultants who have signed on for this new contract will have their public-private mix measured for the first time. If a consultant wants to see one more private patient, he or she will be obliged to see four public patients first. This is a fundamental and radical change to the current contract of employment that exists in which there is no monitoring, measurement or enforcement of an appropriate mix in our hospitals. I believe, contrary to the Deputy's comments, that it will, from the public's——

Will this apply right across the system?

Yes. The Deputy asked about the payment and I apologise for not answering. In some respects, it was due to be paid back in 2007. However, as I have informed this joint committee previously, we did not pay it back because it had not been implemented. The intention is to pay it this year. It is to be paid in different instalments and issues may arise in this regard that will be addressed in the context of the budget. However, I intend that this contract will be honoured because it is fundamental to changing the manner in which our public hospitals operate. Without this change, we will not see improved access for public patients.

I will start with the Minister's last comment. I fail to discern how this contract will result in improved service. We still do not have sufficient capacity in either diagnostics or beds and the consultants who have taken this contract to work longer hours will not have sufficient beds to perform the procedures. Furthermore, can the Minister tell members the age group of the consultants who have taken this contract? What percentage of them are 60 or older? She should exclude geriatricians and psychiatrists from that question.

I will revert to a matter discussed by Professor Drumm earlier. I refer to Deputy Kathleen Lynch, those who should not be in hospital and long stays in beds. I alluded to a letter from the neurosurgical unit of Beaumont Hospital where 12 people acutely and critically ill are waiting on a list for brain surgery. Some are waiting for six weeks and are not fit to be at home so they are in the regional hospital awaiting transfer. That is an example from only one specialty and this is a persistent problem in many of the smaller hospitals that have patients who need referral to larger centres. They cannot get their patients in there and are left with their beds blocked and the figure for bed days appears much worse than it would otherwise be.

The Minister referred to cancer strategy. Can she confirm my understanding of the new Dublin model, which involves Beaumont and Blanchardstown being included with the Royal College of Surgeons, the Mater and Vincent's Hospital included with UCD and Tallaght and St. James's included with Trinity College? If that is so, why would the Minister interfere with the hospital that carries out more breast surgery than any other hospital in the country? As the Minister says, it is a short distance from Cork University Hospital. Why not use the model in Dublin for the hospitals in Cork?

I refer to the inconsistency with regard to private hospitals such as the Beacon Clinic, which is carrying out breast surgery as a satellite of Pittsburgh University Hospital in the US. We have had this argument and no one is for turning. The issue of what will happen at Sligo General Hospital remains. Other private hospitals may engage in breast surgery in Dublin. How does that sit with HIQA, our specialist centres and minimum numbers required to be a centre for breast surgery. The Minister alludes to the HPV vaccine for cervical cancer. I do not accept the argument that we do not need to have the cervical vaccination at the same time because nowhere else has been as slow as us in introducing cervical screening. It is purely spurious. Every other country is so far ahead of us in cervical screening and I do not accept that the three legs of that stool should not be implemented at one time. Dr. Alan Smith urged for the introduction of this on the radio. HIQA has recommended it, the National Immunisation Advisory Committee has recommended it and a Nobel Prize winner, Harald zur Hausen, who received the prize for developing it, says it is key. This argument does not wash. It is a financial consideration and I refer to Professor Drumm's remarks on his consultants and advisors costing €5.5 million. If a tight deal had been done, young girls could have been protected against the scourge of cervical cancer instead of paying this money to consultants.

I asked about cystic fibrosis beds in St. Vincent's Hospital. Will this go ahead? Notwithstanding the information available to Professor Drumm such as HealthStat, information that he had last year when he could tell us about inconsistencies in the manner of how patients are processed, why has this not changed? HealthStat will not change this and Professor Drumm had the information one year ago. What is his plan to change it?

I asked about collocated hospitals but I am still no wiser. When will the first sod be turned? When will a patient get into a bed? This was the solution to our bed shortage but it does not seem to be much of a solution. Which hospitals are closing this year?

I thank the Minister, Professor Drumm and his staff for the answers to the questions. Much good work has been done, as has been reinforced today, but issues of concern remain. One obvious concern is anyone waiting for essential surgery and this must be addressed. I agree with Professor Drumm that many patients do not need to be in hospital but find themselves there for one reason or another. I would like to see primary care facilities, particularly diagnostic facilities, and easier access for GPs to diagnostic facilities. In many instances, GPs are obliged to refer patients to consultants, which takes more time and space. If there was a facility whereby GPs could do more diagnostic work it would be beneficial.

On the question of the public private mix, if people want to spend their disposable income on private health care they should be allowed to do so. It is important that there is equity in the system, not the use of public facilities for private patients to jump the queue. I accept what the Minister is saying about the new common contract. I hope that will improve the situation. I see much merit in the common contract and in more consultant hospital doctors and fewer non-consultant hospital doctors seeing patients at outpatient clinics. Many patients are admitted to hospitals unnecessarily because of the lack of experience of the non-consultant hospital doctors. I hope we get to the situation where everyone who turns up at an outpatient clinic would be seen by a consultant. That would have a major impact on hospital beds.

I was delighted to hear Professor Drumm saying that best practice must be examined to ensure it is introduced uniformly across all hospitals. I am disappointed that GPs in my county have opted out and are not co-operating with the HSE. Everyone, particularly when faced with a challenge in a multi-disciplinary service such as health care, should sit down together and find a solution.

The hospital at Monaghan has a first-class acute medical unit. I have stated that what is put in place in Cavan and Drogheda can cater for the need. We must examine how we can ensure that patients, most of whom are elderly, are cared for as near as possible to their homes. There are some 120,000 members of the health service and, adding the Oireachtas Members, we must all work together to get what the Minister called the best level of quality of service for everyone.

I wish to raise a point for clarification——

The Minister has answered this but I am still confused. She says the figure is not €540 million but €390 million, that there is €60 million for children and €30 million for ICT. The answer we received to Question No. 12 is that the HSE has resubmitted its 2009 capital plan to the Department of Health and Children to reflect the cut in capital allocation from approximately €540 million to €390 million.

I wish to deal with the issue of the consultants. If 85% of the consultants, some 1,800, have signed a new contract, then they cannot all be in their 60s or close to retirement. Deputy Reilly welcomed the consultant contract, on one of the rare occasions when he said something good about it, saying he wished to congratulate the Minister and all involved. I do not know if he used the word "great" but he was very positive about it and today he is sceptical.

I question whether it will achieve what the Minister says it will achieve.

It will. There are cynics out there, who often get a high profile, and who do not want to see any reform work but the vast majority of consultants working in our health care system support this new contract, have signed it and want to see it implemented.

Regarding the centres in Dublin, Blanchardstown and Beaumont are teaching hospitals for the Royal College of Surgeons. The Mater Hospital and St. Vincent's Hospital are for UCD and Tallaght Hospital and St. James's Hospital are also teaching hospitals. There are proposals, mainly driven by the universities, to create academic teaching hospitals. That is a very different matter. It is not proposed that we keep breast cancer services in Tallaght. The specialist centre for those two hospitals for cancer surgery will be St. James's Hospital.

The issue in Cork seems to be medically-oriented rather than patient-oriented. It comes down to whether people are prepared to move down the road to work as far as breast surgery is concerned. There is no model that I have seen or been advised of that would suggest, in a country with our volumes of activity, that some hospitals would do breast surgery and others would carry out other surgeries and so on. That would not bring about the critical mass or specialist centres we require.

With regard to the provision of surgery in private hospitals, in the majority of cases it has stopped. I have discussed this matter with insurers and I know HIQA is engaging with private hospitals with regard to breast surgery. If memory serves me right, the Mater and St. Vincent's hospitals are effectively co-location hospitals so one would combine the figures for both. Until we have a licensing regime — that would be the purpose of licensing — we will be prescribing the requirements for the public and private sector. HIQA is currently engaged with the private hospitals with regard to breast care standards and I have already spoken to the insurers on covering patients. Hospitals could not function in the private sector if they were not supported by the insurers.

On the HPV vaccine, it is not a question of not carrying out a vaccine programme but rather when we can do it. We are behind other countries in the rolling out of a screening programme but it has now begun and it is very successful. Some 1,000 women per day are being screened. We must also consider colorectal screening because we know that today, this year and next, people will die because we have not been able to carry out screening. That is the immediate priority as far as resources are concerned.

I want to see the vaccine introduced as quickly as possible. As members are aware, the nurses who will administer this vaccine are currently involved in the child immunisation programme, the catch-up of which will be completed this year. I hope those nurses will be free to administer this vaccine, as that will be my intention.

With regard to HealthStat, I am a strong fan of audit and information. If we had audited what was going on in the Our Lady of Lourdes maternity hospital 25 years ago we would have known immediately that it had a peripartum hysterectomy rate that was 17 times the rate of Dublin hospitals. The power of information is immense in changing all our performances when we are measured against our peers. Perhaps it is not as easy in politics.

If we had spoken with consultants about the radiology service we might have avoided all those deaths too.

The issue of consultants was dealt with by Professor Drumm. All of us have paid advisers and we must be reasonable and proportionate in the manner in which we address, as serious politicians, some of these issues. We cannot keep spending the consultant money on every new idea that comes here. I have heard of some of the money used in the Dáil for many programmes as well but it can only be used once.

There are 120,000 people working in the HSE and the Minister wants to spend more money on advisers. That is unacceptable.

The Minister would then accuse me of having one parliamentary assistant. How many advisers does the Minister have behind her?

Deputy, please.

All the people here are public servants.

I accept that.

They provide excellent advice.

How many advisers does the Minister have?

I have two advisers, which is not unreasonable given that the health service expends a third of all the money we raise in total taxes in the country.

How many constituency staff does the Minister have?

If the Deputy wants to deal with those matters he should put down a parliamentary question.

The Minister is casting aspersions.

In our Department we have reduced the cost of ministerial offices by somewhere between 10% and 13% for this year. It is right that we should do so and respond to the financial difficulties facing the country and its health services. That was our response to a request by the Taoiseach.

I have dealt with co-location on many occasions. It is based on the principle that we can provide additional capacity and more single rooms by supporting through the taxation system the provision of these services. Deputies know we are in difficult economic circumstances.

The point is they cannot be provided through that mechanism.

It will depend on people being able to raise the finance to meet the criteria set down by our benchmark and by the——

It is a failed policy.

The Deputy cannot hear the answer if he keeps interrupting.

The problem with the Deputy is he does not have any policy in anything except to oppose everything.

The Minister will see it all very shortly.

The day the Deputy supports one single tough measure and stands up to any vested interest in this country in the health area, I will salute him. I ask him to support one.

The Minister did not give us the opportunity.

I ask no more than that. With regard to Deputy O'Hanlon's comments, I agree completely on the need for best practice. As Professor Drumm noted earlier, if everybody could operate to best practice within the country, we could greatly improve our performance.

Beds are an input but we must speak about patients. It comes down to how we use the beds. If we operated like the Australians, people would spend half the length of time in hospitals for 17 of the top 20 procedures. We can greatly improve our performance by moving to more day-case activity, which is in the HSE's service plan for 2009 and which it has been successfully moving to over the last number of years. There is also access to diagnostics, which is a reason many people end up in acute hospital beds. This is what is driving the transformation programme that is currently under way.

I thank the Minister. Professor Drumm has five minutes.

Professor Brendan Drumm

Many of the issues have been dealt with. Deputy Reilly asked what we have been doing with regard to HealthStat, which we have been using for over a year. We gave the hospitals a year without putting the information on the web because we figured people deserved that time to begin to take action.

We have taken significant action in areas such as absenteeism, the rate of which has been driven down through the efforts of people like Seán McGrath, who is here and who works in human resources. We never had clear figures across the country before for absenteeism across different grades. That can be taken all the way through to day of surgery admissions rather than admitting patients a day or two before surgery. We now have a complete focus in hospitals on bringing people in on the day of surgery. Why did people have to come in a day or two before surgery? We are acting on that.

We realised early on that this country had a very low day-case rate and we are now challenging individual hospitals and their clinical leaders in specific areas to ask why patients must come in early for an inguinal hernia or cataract operation in 100% of hospitals in one place and 0% of hospitals in another part of the country. This is a very powerful tool but it cannot be created overnight.

The question of consultants was raised and a significant amount of money in that respect was spent on developing this programme. That money was well spent and it is naive in the extreme to suggest an organisation of this size could ever exist without bringing some external help to it. It would be a failure to look to such sources occasionally, and we do so at a very limited level.

On the cystic fibrosis issue, we gave a detailed answer on this but I do not know if there is other information that should be provided regarding the development of beds in St. Vincent's Hospital or the spend in Beaumont Hospital. There is a very significant spend in tackling cystic fibrosis across the country. We have now developed what are, by international standards, very large multidisciplinary teams right across the country. We hope to see the dependency in bringing young people with cystic fibrosis to hospital diminishing rapidly, as it is the last place they should be because of the risks they are exposed to in hospital.

In Toronto, where there may be 600 cystic fibrosis patients, there are eight beds. The system should be focused on getting people with cystic fibrosis treated in their homes rather than having them coming together at risk. As outlined, the Government, the taxpayer and everybody here has invested quite significantly in this over the past three years.

I dealt with most of the issues raised by Deputy Reilly. To respond to Deputy O'Hanlon's comments, our focus through the HealthStat programme means one of the critical measures is access of GPs to ultrasound, for example. It is pretty dismal. It is amazing that where there is a good personal relationship between the radiologists and local general practitioners, there is excellent access. There are places in this country, such as Kerry and parts of the south east, where access is excellent but in others a decision was made that GPs could not be trusted.

When one asks the people who are given access, they will say there is no problem because a relationship has been developed and people do not abuse it. That measure will be significant as we see it as a major action in keeping people out of hospital. I would be interested to see what the medical assessment unit will do in Cavan and the north east because we see medical assessment units as being critical to giving GPs instant access to a physician's opinion and reducing unnecessary admissions. The proof of the pudding is in the eating and I hope I will be able to come here one year's time to say it is working in members' areas.

On behalf of the joint committee, I thank the Minister and her officials and Professor Drumm and his officials for dealing with our questions and the comprehensive information they have given to us. We look forward to meeting them again in three months' time.

The joint committee adjourned at 5.40 p.m. sine die.