Select Committee on Health díospóireacht -
Wednesday, 19 Apr 2023

Vote 38 - Health (Further Revised)

An Cathaoirleach

The purpose of today's meeting is to consider Further Revised Estimate for Vote 38 - Health. I welcome the Minister of Health and officials from the Department of Health to today's meeting. I also thank the Minister for the provision of a briefing note on the Revised Estimate.

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

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

I know invite the Minister to make his opening statement.

Minister for Health (Deputy Stephen Donnelly)

I welcome this opportunity to address the committee to discuss Further Revised Estimate for 2023 for my Department - Vote 38. I thank the committee for agreeing to defer this appearance until after the transfer of specialist community-based disability services from my Department to the Department of Children, Equality, Disability, Integration and Youth. This transfer took effect from 1 March this year and involves the transfer of approximately €2.650 million of funding from Vote 38 to Vote 40 - essentially the transfer of disability services.

Notwithstanding this transfer, the gross health Vote for 2023 is €21.358 million. This allocation is made up of €20.197 million in current expenditure and €1.161 million in capital expenditure. When compared on a like-with-like basis to the 2022 estimate, excluding disability services and one-off funding provided by means of a Supplementary Estimate, I am very happy to have secured an increase of 7.8% over last year's original allocation. This is an additional €1.454 billion over last year's allocation of €18.743 billion. This allocation reinforces the ongoing commitment of Government to the provision of a health service that seeks to improve the health and well-being people across the country.

In line with our programme for Government commitment to universal healthcare and in line with Sláintecare, budgets 2021, 2022 and now 2023 have provided an unprecedented level of investment. So far this decade, we have seen record levels of recruitment with nearly 20,000 extra staff since Covid arrived. That includes about 6,200 nurses and midwives, more 3,000 health and social care professionals and over 1,800 doctors and dentists. The HSE has opened an additional 970 permanent hospital beds. This does not include critical care beds, which have increased very significantly as well by 25%.

The level of funding provided will enable the advancement of a number of priorities in 2023. These include tackling waiting lists, which are now falling; rolling out ongoing women’s healthcare services, which is going from strength to strength; continuing with patient access and more beds being delivered; extending free contraception scheme to all women aged between 16 and 30; extending State-funded GP care to those on or below the median household income and children aged six and seven; maintaining the drug payment threshold at €80 per month; and abolishing hospital in-patient charges and many other issues that really matter to patients around the country.

Given the success of the vaccine programme, and the movement from pandemic to the endemic phase of Covid-19, I am planning to scale back the emergency Covid-19 expenditure to €757 million. This is to combat the disease and the effects it has had on our healthcare service for patients.

The programme for Government, of course, reaffirms its support for Sláintecare. It is being funded and is on track to improve access, expand eligibility, improve the patient experience and bring care closer to the home and further into the community. The move to a public-only health system is a major priority for Government, and I was very happy to be able to introduce the new public-only consultant contract. It is a really important step forward in the implementation of universal healthcare and of Sláintecare.

A central tenet is that health services will move to being provided free or affordably at the point of delivery. To this end, I am expanding access to State-funded GP care to those on or below the median household income, and maintaining the drug payment scheme at €80 per month. As colleagues will be aware, from 1 April, we have abolished all inpatient hospital charges, which is a really important step.

Regarding women's health, which this Government has put front and centre, the Revised Estimate provides funding for women’s health issues across the board. This includes the extension of the free contraception scheme to women aged 16 to 30; increased investment in a new approach to menopause care, including specialist menopause clinics, more training and service provision by GPs; nearly €5 million towards women’s health hubs, cervical screening and morning sickness drug reimbursement; and the introduction, for the first time, of a State-funded in vitro fertilisation, IVF assisted human reproduction scheme.

We have put a lot of focus as well on clinical excellence and national strategy. Very significant funding has been provided for the continued implementation of a number of national strategies, including the national cancer strategy, the national maternity strategy, and the national trauma strategy, and many other strategies as well. We have five new strategies which are being funded this year, including stroke, diabetes, genetics, neurorehabilitation and obesity. These are really going to help, and my understanding is they are already helping, to provide patients with the care they need, both in hospital and in the community. I know many members of this committee have advocated for a long time around various services, for example, the community-based neurorehabilitation nurses.

There is much focus on capacity. We are in the middle of probably the greatest expansion of infrastructure and workforce capacity within our public health services in a long time. The budget for this year makes funding available for an additional 6,000 people working in the HSE. This continued growth will bring the health sector up to an estimated 143,000 people this year. If we add 6,000 people this year, and more than 1,000 have already been added of that 6,000, we would be looking at an increase from the start of Covid-19 of about 24,000 or 25,000 whole-time equivalent people.

Improving access for patients obviously requires us to continue to grow bed capacity. Around 250 further beds will be delivered this year, and that is before we look at the plans we have in progress for an additional 1,500 beds, which will be delivered through an accelerated building programme.

The capital funding for this year will contribute to the delivery of modern healthcare facilities and equipment. It will improve and expand service provision and capacity right across the country, and some of the many priority projects are: progressing the new national children's hospital; progressing the new national maternity hospital; continuing with the opening of primary care centres. I think I am opening three more later this week. It has been really successful; a very extensive national equipment replacement programme, which I know members of this committee have, for a long time, quite rightly called for; and progressing the elective hospitals.

I will turn now to the financial position. The final gross provision for the health Vote for last year was €23.585 billion, which comprises €22.435 billion for current expenditure, and €1.15 billion for capital expenditure. It includes additional funding of €1.392 billion made available in supplementary funding for one-off expenditure last year. The outturn for last year also included €2.549 billion for specialist, community-based disability services, which my Department was responsible for last year, but, as was said, has now been transferred to the Minister for Children, Equality, Disability, Integration and Youth, Deputy Roderic O'Gorman's Department.

The initial 2022 capital allocation was €1.06 billion. In response to Covid-19, an additional €90 million, which was held in contingency, was made available, bringing the total for last year to €1.15 billion. The total funding provided by Government to the health service last year for Covid-19 was €1.878 billion.

I will now turn to this year's budget and the framing for the budget. In the framing, the Oireachtas has allocated significant additional Exchequer funding for the health sector. I would like to thank committee members for their support for that. This year, gross health funding is €21.358 billion, and that is €20.197 billion current, and €1.161 billion capital. It represents an increase of nearly 8%, or €1.454 billion, on last year's current expenditure, which obviously does not include disability and the one-off supplementary. It recognises the Government's commitment to providing a health service that works for everybody in the country.

The capital allocation for this year is just over €100 million above the original figure for last year, which represents a very significant increase on the pre-Covid-19 allocations. Again, that is before any agreement may be reached around the additional 1,500 beds through a rapid build programme. The capital funding for this year is already contributing to the delivery of the type of modern health infrastructure that we really need to see.

In conclusion, essentially what I and the Government have been trying to do in the budget for this year and over the last two years is to mobilise the resources of the State, and mobilise reform, investment and activity across the health services to achieve our goal of universal healthcare. What colleagues will see is funding allocation this year building on that over the last three years, and aimed primarily at achieving three things: reducing costs for patients and families; increasing speed of access for patients and families; and rolling out more services, always at a higher quality. These are the three tests of universal healthcare. We are doing that in many different ways, partly through a very significant expansion in capacity, and through much reform, integrated care, community-based care, bringing any health measures, moving to the regional health areas, and so forth.

Between doing all of that, what we are achieving in Ireland right now is not unique internationally but is rare internationally. What we are seeing, at the same time the country is dealing with the after-effects of Covid-19 and its additional health burden, is that Ireland is reducing costs for patients. We are rolling out additional infrastructure, and critically, the waiting lists are now falling. Last year saw the waiting lists fall for the first time since 2015. This will be the second year, and in fact I am very happy to report to colleagues that just in the last month, the number of patients waiting longer than the agreed Sláintecare targets has fallen by 5%. That is around 55,000 fewer people than even a month ago. Good progress is being made this year on that core goal of having nobody waiting longer than the Sláintecare targets. I thank the committee.

An Cathaoirleach

I thank the Minister, Deputy Donnelly, for his opening statement. Before I open up the debate to members, I would like to say that we have had a number of witnesses at different meetings over the last couple of months, coming in and expressing frustration regarding the goodwill pandemic payment. We got a note from the Minister back in March regarding those who had been paid, but there is a significant number of people who have not been paid. Rather than having individual members coming in on the issue, could we start off by finding out who has been paid, and who has not been paid?

What are the problems in regard to the payments? We have had Fórsa and some other trade unions in and they all expressed frustration at the fact that their members had not been paid. It is a significant amount of money. It is a recognition of the extra work and commitment that they made during the pandemic and it is unforgivable at this stage, when we are talking about winding down pandemic services, that people have not been paid. Is there anything the Minister can say to those people this morning that will reassure them that they will get paid sooner rather than later? Has it been going on for a long time?

Deputy Bernard J. Durkan

If I could add to that, could we have a list of those who have not been paid made available to the committee as a matter of urgency, with a view to addressing the issues involved at the earliest possible date?

An Cathaoirleach

One of the difficulties with giving us a list was that the situation is ongoing. The letter we got back in March outlined that a significant number of people had been paid but we do not know who has not been paid. That is the big problem. Just this week, I heard that those who were giving people vaccines in Citywest have still not been paid. We had firefighters in and they were complaining that many of their members still had not been paid. Many front-line workers, those who were delivering services and putting their lives at risk, have still not been paid. Perhaps the Minister could give us some good news or tell us when they will be paid.

Deputy Stephen Donnelly

It is good news. There is now a very small percentage waiting to be paid. It is the nature of these things that we do not tend to hear from the many who have been paid; we tend to hear from those who have not been paid because, quite rightly, there is a small number and they deserve to be paid.

It is very good news. Some €208 million has been distributed. That is a huge amount of money. I asked the Minister, Deputy Donohoe, for it to be a tax repayment and the Minister agreed. Colleagues will be aware that it is a rare thing indeed for a Minister for Finance to agree to agree to anything being tax free, but in this case he did. If we look around the world at similar recognition payments that have been made, Ireland's recognition payment is very favourable by international standards. The sum of €1,000 was given tax free to a very wide group of people.

I am very happy to say that the HSE has distributed €88 million. The section 38 organisations have received €52 million and the section 39 organisations have received €67 million. A total of €208 million has been distributed. Within the HSE, 142,250 staff have been paid. That breaks down to nearly 90,000 HSE staff and a little over 52,000 section 38 staff. If there are people left who have not been paid, they are local anomalies and there is a mechanism in place for them to be paid.

In terms of the non-public sector, that did take longer. As we discussed previously, I intervened directly with the HSE after one of the committee meetings we had here. The HSE was taking a cautious approach. None of us complained about it taking a cautious approach because if the HSE got anything wrong, we would be calling for it to come in to the Committee of Public Accounts or this committee to account for the fact that it had given some organisation too much money or it had done something wrong. The HSE was looking to do a very detailed validation of the amount of money these organisations were meant to get before it paid it out. I intervened, because I shared with you, Chair, and with colleagues my frustration at how long it was taking. What I said to the HSE is that it should ask the organisations to do it on a self-assessment basis and then to validate afterwards. Essentially, the HSE should tell all of the organisations what the rules are and ask them to come back indicating how many people qualify at which point the HSE would send them the money. In doing that, we have to accept that errors will be made but then the HSE is going to validate the payments afterwards. That is why the process accelerated towards the end of last year. To date, 727 funding applications have been received and 655 of those have been processed. There are still some left, but very few in the context of the number of people who are being paid.

Some 90% of the submissions that came back had errors in them that the HSE then needed time to go back and work through with the organisations. That is where it is at. The Dublin Fire Brigade and the prison nurses were the other groups that I asked to be included. The money was sent to those line Departments some time ago, certainly last year. To the best of my knowledge, we are no longer involved in the payment of members of the Dublin Fire Brigade and the prison nurses. I have not heard anything back about that money not being allocated. I would imagine it has been allocated but if there are issues, members should by all means bring them to me or the line Departments. The money certainly left the Department of Health some time ago.

An Cathaoirleach

Does the Minister have a rough idea of how many people are still outstanding?

Deputy Stephen Donnelly

The Dublin Fire Brigade was allocated €1.265 million. Dublin City Council was allocated €840,000. The note I have is that the payment of these staff is a matter for the bodies involved but it is understood to be substantially complete.

An Cathaoirleach

Do we have a rough overall figure at this stage? Are we talking about thousands or tens of thousands of people?

Deputy Stephen Donnelly

No, it is small at this stage.

An Cathaoirleach

As public representatives, we have all been contacted. There have been countless meeting and concern has been raised by practically the majority of the groups that have come in. The unions in particular were frustrated that there was no direct interaction with them on the issue.

Deputy David Cullinane

The process is that as Oireachtas Members, we can get clarity. Just this morning, I received an email from somebody who works for an organisation called KOSI, which provides cleaning and security staff. It is saying the staff have not been paid and there is real frustration. In the first instance, I do not know if they are entitled to the payment but I assume they are. If so, what is the problem? Is there a mechanism whereby we can get clarity on issues like that? It is frustrating for them and they are coming to us and we do not have the information. We are being told by the Minister that issues are being resolved but then we get these emails from people who have not been paid, whom I accept are a minority.

Deputy Stephen Donnelly

There certainly is. To be honest, I encountered it myself. I think it was University Hospital Galway that I was in, where some of the contract cleaning staff and catering staff approached me and said they were told they were out of scope. I assured them that they are in scope. The payments got processed. In that sense, it did not roll out perfectly. What I will do is ask the Department to send an updated note to the committee outlining exactly what the criteria are for qualification. To be honest, the criteria are fairly straightforward. The note will outline the criteria and the progress made that I have just read out. If there are any outstanding issues or questions-----

Deputy David Cullinane

If there is an organisation that is not paying, or there is a problem, the reverse is also important. I refer to a reverse information flow. We can give the information to the Minister or his officials and they can tell us if people are entitled to the payment. If they are entitled to it, they should be paid. There is a problem as to why they are not being paid. It is a different story if they are not entitled to it but from what the Minister just said, I suspect if they are cleaning or security staff they are entitled.

Deputy Bernard J. Durkan

Although the number is small, it is felt more acutely by those directly affected because they feel that we have forgotten about them.

Deputy Stephen Donnelly

Yes, I hear Deputy Durkan.

An Cathaoirleach

The goodwill is gone out of the payment for those who have not been paid.

Deputy Stephen Donnelly

I hear you, a Chathaoirligh. I would just re-emphasise that people tend to contact us as elected representatives when things are not going right. The reality is that €208 million in tax-free payments-----

Deputy David Cullinane

We know that.

Deputy Stephen Donnelly

-----has been successfully sent out, quite rightly, in recognition. In terms of KOSI, the HSE has established a portal for employees who do not have an employer to claim on their behalf. There is also an appeals mechanism in place. Colleagues can contact me any time, and regularly do. I feed individual queries back to the Department regularly. Members should feel free to give the details to me.

An Cathaoirleach

It seems obvious that if the unions have a concern, the Minister should deal directly with them. They represent the majority of these workers and will know what difficulties are arising within the system. It would make sense for him to arrange those meetings with the people concerned and their representatives. I apologise for going on so long on that issue but it is important.

Deputy Bernard J. Durkan

I welcome the Minister and congratulate all those involved in making the strides that have been made over the past three years through the lockdowns and the pandemic. Trojan work was done by all sectors of the health service despite the magnitude of obstacles thrown in their path, but this work must continue apace. Issues remain that are not within the capacity of the staff to deal with and they will need the guidance of management throughout the process. They include the shortage of spaces in various hospitals, in the south west in particular, such as in Limerick, as well as issues relating to capital versus current costs. A debate takes place every year in every Department in advance of every budget regarding capital versus current expenditure, the theory being the capital can be delayed in favour of current. There are reasons for that, of course, as we well know, but it is not a good idea to postpone capital investment for any prolonged period. In that regard, could emphasis be placed on the delivery of capital projects in the near future? I do not want to start naming places in my constituency or anyone else's, but Naas hospital comes to mind. I raised it on a couple of occasions recently but I did not get any feedback, which always makes me suspicious, and suspicion regarding a Department is a dangerous condition for a politician to have.

I welcome the additional expenditure in the health services and the additional staff being provided. The next question the general public will have relates to what the benefit will be. What will be the visible impact for patients or the family members of a patient? How will they see it in the future development of the health services and the incorporation of Sláintecare? The public want to see progress, and they measure progress through their level of access to the services when they need them, and particularly the public health service. It is essential now to emphasise the various ways and means that can be used to move forward the project at all levels, bearing in mind a crisis is looming in respect of GPs throughout the country but especially in areas with a rapidly growing population. It has been brought to our attention that this applies in particular where large numbers of refugees, for good reason, have to be located. Some people see this as a negative issue but I see it as a positive one. It is positive in the sense there may be a need to augment the back-up health services, such as GPs, access to community care and so on, and now is the time to do it. When the necessity arises, we should by all means do that to meet the needs of both the current and incoming population.

Another issue concerns extending schemes for women and various GP care schemes for those on or below the median household income, retaining the drugs payment scheme threshold and so on. All that is welcome and will be welcomed by the people at whom it is directed. In particular, women's health, and men's case as the case may be, will come into sharper focus in the years to come, having regard to the experience of various schemes that did not go the way we wanted them to go. Tests were taking place both outside and inside the country and in the case of some mistakes that were made, it would have been better if they had not been made, if I can put it that way. I am talking about CervicalCheck and so on. We need to keep an eye on all cancer tests. Whether they relate to health services for men or women, we need to keep a close eye on them.

Funding provided for building capacity is important. There is no use crying about the lack of hospital beds if there is nowhere to put them or no additional buildings in which to locate them. The same is true of all the other services. There has been much criticism of the children's hospital regarding the number of beds and rooms. I had occasion to visit one or two of these institutions in recent times. There is an absolute need for all the accommodation provided in these hospitals, including consulting rooms and additional beds. There is a revolving door because the patient is moved from one place to another as necessary and it is not appropriate to cart patients, say, a quarter of a mile within a hospital when accommodation can be made readily available. The national children's hospital is a fine project. It has been going well and services continue to be provided on the rest of that site while the building has been taking shape, although, obviously, they have been restricted. One impedes the other, to a certain extent, but it has been going well. I am not a critic of the end cost. I have never believed there are grounds of criticism, as the Minister will recall from his attendance at these committee meetings. We need to continue apace to bring the process to a satisfactory conclusion as soon as possible and to allow the development of the rest of the health services, such as the new national maternity hospital, to continue as well. The lesson to be learned from all this is that we cannot take the steps we need to take without spending and providing the money that needs to be spent. There will always be those who say something is too expensive or that we cannot afford it. That is fine; let us just accept second-grade services. In any sphere of life, whether broadband, the health services or anything else, we cannot achieve our targets without spending and investing in the infrastructure.

Deputy Stephen Donnelly

There was a lot there but I agree with everything the Deputy said. Essentially, we have one goal, which is universal healthcare, and there are three elements to that. The first is cost, which is largely a Department of Health and Government issue. The HSE does not need to be overly involved in that. It is about reducing costs to patients and a lot of progress is being made in that regard.

The second and third elements are speeding up access, and strengthening services and rolling out new ones. We are doing that, as the Deputy alluded to, through two big steps, namely, increasing capacity and, just as important, reform. We are adding beds, building new hospitals and growing the workforce and we have put in place an entire new community healthcare service through enhanced community care. There is a massive investment in capacity, but capacity is not enough. At the same time, we have to change the way we run our health services. We need significant investment in e-health. We need the Sláintecare, public-only contract to be taken up in order that we can extend rostering hours, which will make more services in hospitals available to patients in the evenings and throughout the weekend, as needed. We saw the big impact it had on trolley numbers at the start of this year and we know it will have a big impact on waiting lists as well.

The Estimates before us are for exactly that.

Many line items relate to reducing costs for patients, such as eliminating hospital charges and free contraception, which has been received very well by people who can avail of it. It is expensive and a lot of money has been allocated in the Estimates for that. They also include State funding for IVF and other means of assisted human reproduction services and so forth. Many line items relate to building capacity, such as 6,000 additional doctors, nurses, health and social care professionals and increasing the workforce across the board; building the hospitals, adding hundreds more beds; and critically at the same time pursuing reform. There is funding for the consultant contract, for improving the lot of non-consultant hospital doctors, NCHDs, and for broadening supports for GPs. I fully agree that there is a problem with access in certain areas. We do not have enough GPs in certain parts of the country. I spent most of the weekend with the Irish Medical Organisation, IMO, at its conference where we spent a lot of time discussing short-term and long-term solutions to that issue.

Deputy David Cullinane

I have a lot of questions. I will probably come in twice. I will not cover them all in the first session.

I will raise one issue before I move on to some more substantial issues relating to the Estimates. We must ensure there is good governance and accountability with respect to the spending of taxpayers' money. We know health research funding was the subject of a report the Minister published this week about a proposed secondment that did not go ahead. That report states that the Minister made a submission, after June 2022, as did the Secretary General of his Department, the Chief Medical Officer and the head of strategic HR in the Department of Health. An email was also sent by the Taoiseach's chief of staff. What was the substance of the Minister's submission?

It is bizarre to say the least and it is unseemly that the Minister's Secretary General, through the Department, states that he told the Taoiseach's chief of staff, Ms Deirdre Gillane, about the secondment and that:

the facts indicate that the Secretary to the Government knew all the critical details regarding the proposed secondment and the proposal to increase funding. And that the Chief of Staff was informed".

He stated, "Based on these facts" - which were not his opinions; he is stating they are facts - "it is not accurate to suggest that Government or key players were not told". He then stated, "I was subsequently instructed to finalise arrangements to give effect to this." We then see in Mr. Fraser's response when he was asked whether he instructed the Secretary General, his first word was "No". Then when he was asked whether he informed the Taoiseach's chief of staff, he says he did not. Both cannot be right. That is a problem. Who is right?

Deputy Stephen Donnelly

My submission was fairly short. I do not have it to hand but the main point I believe I was making was to draw the reviewers' attention to the fact that notwithstanding the letter of intent having been written, several procedures and processes were still to be gone through before the allocation of any funding, in this case the allocation of the €2 million per year. It would have come to me in a detailed submission. It would have formed part of the Estimates process. It would have been discussed with the then Department of Public Expenditure and Reform as part of that and then ultimately it would have been agreed or not by the Government and the Oireachtas. That was the main-----

Deputy David Cullinane

I understand that but my point is that the Minister's Secretary General is stating what he sees as facts, which are completely at odds with what the Secretary to the Government is saying. He says that these are not facts. Does the Minister see that as problematic from our perspective when we are talking about spending taxpayers' money? It seems that the Minister for Health was kept in the dark until late in this process, which is a problem for me and it should certainly be a problem for the Minister as well. The Secretary General in the Department of Health is saying these are facts and other senior civil servants are not only saying they are not facts, but that what the Secretary General said was inaccurate.

Deputy Stephen Donnelly

The reason I said that was in answer to the Deputy's first question, in which he asked what was in my submission.

Deputy David Cullinane

I understand that.

Deputy Stephen Donnelly

I was answering that first.

On the Deputy's second point, the report is quite clear. It looked at the timelines and showed that the then Taoiseach's chief of staff found out about the detail of this very late in the day, after it had come to public light through the original announcement of the move and then the subsequent announcement of the secondment. I do not know, but I imagine that the Secretary General's comments might have been a misunderstanding of testimony given by the Secretary General in the Department of the Taoiseach to the committee-----

Deputy David Cullinane

That is not the case because in his submission, he had asked that sections of the report be taken out. He felt strongly enough to ask for sections of the report to be taken out. I imagine the Minister understands that and that he understands exactly what he was saying. It is problematic. All I am saying is that it is unseemly. It should not happen again. It cannot happen again. We must ensure this type of secondment and any spend of taxpayers' money is done correctly. I said at the time, as many people in this room did - and we were vindicated - that established processes were not followed. This was informal and that informality has led to a lot of problems. Let us ensure this does not happen again.

I will move on to other issues.

Deputy Stephen Donnelly

Can I respond briefly to that?

I do not disagree with any of that. It is important that we are all open to feedback and to getting better at things. We have to be open to learning and we always have to strive to improve at everything we do. Having spent a lot of time on it, I believe that everyone involved was acting in good faith. I believe the proposed secondment - most of us here probably believe - would have been valuable, that is, to have Dr. Holohan with his unique experience leading academic research.

Deputy David Cullinane

I need to move on.

Deputy Stephen Donnelly

I will finish this if I may because I know it has been the topic of a lot of discussion. We must be open to learning lessons. My clear view is that everyone involved was acting in good faith and trying to do the right thing.

Deputy David Cullinane

Whether they were acting in good faith is a matter of opinion but established processes were certainly not followed. To me, that is not good faith and that must be accepted.

I will move on to another important issue. In the last budget, in the Minister's opening statement and in the budget booklet, the roll-out of free GP visits to an expected further 400,000 people was rightly announced. I commended it. The Minister stated it would be delivered from 1 April 2023. That was the date the Minister set. I did not set that date. However, 1 April has come and gone. At the time, I sought a breakdown of costs and it never came. A number of measures were lumped into one additional funding allocation of €107.1 million for hospital charges - which we know have been abolished - GP visit cards, contraception, and fertility treatment, including IVF. We have not had any progress on many of these issues although funding was allocated. How much was allocated for free GP-visit cards? As we are dealing with the Estimates we need to get the details. Specifically, how much was allocated to funding GP-visit cards? How much was allocated to additional capacity and supports for GPs? How much was allocated to fertility treatment? Why has the date 1 April come and gone with it not being delivered? The Minister and his Government have announced the extension of free GP care to six- and seven-year-olds three or four times at this point and they are still waiting. It is beyond a joke. Those who would have been entitled to it have gone past the age of entitlement since it was announced. When will we see it delivered? Will the Minister give the committee any timeframe today given that he has missed his deadline of 1 April, the target he set? Will he give the committee any indication of when that proposal will be delivered and give us the breakdown of costs?

Deputy Stephen Donnelly

It is an important measure. The IMO, on behalf of GPs, came to me and the Department and raised - I have no doubt they came to members of this committee as well - genuine concerns about our plan.

Deputy David Cullinane

I have to stop the Minister there because, this is the problem. I said it to the Minister at the time. They raised concerns before the Government made its announcement. Their concerns were well known. There was no consultation with them. When representatives of the Irish College of General Practitioners, ICGP, were before the committee, I asked whether there had been any consultation with their organisation by the Minister for Health prior to the announcement at budget time and they said that there was not. It seems that the Minister went off half-cocked and made an announcement, giving a date that cannot be delivered. Now he is telling us that he only realised the IMO had concerns subsequent to that. They were well rehearsed and in the public domain.

This was something that also emerged when we were trying to roll out free GP care for children aged six and seven years. My point is that the Minister failed to plan. He set a target that could not be met in order to have a big announcement on budget day. Here we are with 1 April gone by and it has not been delivered. I do not accept that as an excuse. What I am looking for now is the new date. When is this going to be delivered? When will the Minister deliver it?

Deputy Stephen Donnelly

I thank Deputy Cullinane. It will not surprise him that I do not accept that characterisation at all. To be clear, the ICGP would not normally be involved. It would be the IMO.

Deputy David Cullinane

But it is important.

Deputy Stephen Donnelly

It is but it is the IMO that would be raising the concerns rather than the professional body. I was well aware of the concerns, as we all were, on budget day. The IMO and GPs have been raising capacity concerns. They had been raising concerns even about doing something much more modest, which was adding six- and seven-year-olds, which is approximately 70,000 children. We were well aware that announcing an additional 430,000 would not necessarily be well received by GPs or the IMO. We were well aware of that. What we had been asked to do at the start of this was to wait until the strategic review had happened, there was a new GP contract in place and there were many more GPs in situ. I took a view that we should not wait. I took a view that the Oireachtas as a whole called for this in 2017-----

Deputy David Cullinane

People are still waiting. I am still waiting to hear when it will be done. When will it be delivered? The Minister might get to the point.

An Cathaoirleach

Can we let the Minister finish?

Deputy Stephen Donnelly

I appreciate that, but I am saying that I took a call and made a recommendation to the Government that we should move ahead anyway. That was the right thing to do. Six years after the Oireachtas agreed that this would be the approach is long enough to wait. I allocated a substantial amount of money into this year's Estimates to support GPs. I hope the committee does not mind, but there is a substantial amount of money involved. On the basis that we are in the middle of very intensive negotiations with the IMO, it is not be the right time for me to give an exact number. I hope colleagues will appreciate this. We are literally negotiating it at present. I share the Deputy's frustration. I wanted this in place on 1 April. The IMO asked us to pause and we did so. We need to do this and we need to do it soon. We need to do it right. Ideally, we need to do it with the support and agreement of GPs throughout the country.

Deputy David Cullinane

Does the Minister have a timeframe? I have asked for a timeframe. The Minister set the date of 1 April.

Deputy Stephen Donnelly

The date set was 1 April. I fully accept that.

Deputy David Cullinane

What about a new time?

Deputy Stephen Donnelly

What I can tell Deputy Cullinane now is that I was with the IMO at the weekend. We will be in intensive discussions with the IMO in the coming weeks. I do not want to give a date, but I want this in place and agreed very shortly.

Deputy David Cullinane

That does not answer my question.

Deputy Stephen Donnelly

I know. It is as much as I can answer at this point.

Deputy Cathal Crowe

I thank the Minister. A few moments ago I was in a Zoom meeting with representatives of MS Ireland. They are watching this meeting. The representatives in question are Susan Coote, who is a physiotherapist from Killaloe in County Clare, and Alison Cotter. They have a business case before the Department. I understand the numbers are probably being crunched. Essentially, they are looking for a senior physiotherapist in each CHO to deliver Sláintecare and, in particular, the integration fund project.

The Minister is probably aware of the active neuro project that is fully up and running in CHO 3 in the mid-west. There is a pilot scheme operational in the Galway region but it does not exist anywhere else in the country. The argument that MS Ireland is putting forward is that when we have specialised physiotherapy care we avoid a lot of falls among people with MS and we avoid them having to present in an acute hospital setting. At present there is a €19 million cost to the Department per annum in terms of progressing disabilities associated with MS. Ms Coote and Ms Cotter see the hiring being done by means of a service level agreement with MS Ireland. This is already in place with Enable Ireland. There are models where there are special MS-trained physiotherapists who can deliver this and, hopefully, intercept the pathway that inevitably leads to somebody to an acute setting. Has the Minister seen the business case? Is it being considered? What light at the end of the tunnel can the Minister give to people following the meeting today?

Deputy Stephen Donnelly

I thank Deputy Crowe. Given that he is asking about such a specific service I do not have a note with me on it. I am very happy to revert to the Deputy with a detailed note. It sounds like the type of proposal that would work its way through consideration in the Estimates process coming up this year. It might be a good time to be speaking about it. If Deputy Crowe has something I will be very happy to meet him and discuss it with him. The Deputy was one of many who quite rightly advocated for neurorehabilitation nurses. This is different to the specialist physiotherapy service he is speaking about now, which I will be very happy to take a look at. The neurorehabilitation service is new. We are rolling it out throughout the country. It has a modest beginning with approximately 28 whole-time equivalents. Those involved say it is very welcome but they need more. They are right but we have to find them, hire them and train them up.

When it comes to the physiotherapy proposal, it may be something to be done through a service level agreement with MS Ireland. Perhaps it is something we could work in as part of enhanced community care. As the Deputy is aware, we have 91 of the 96 community healthcare networks up and running throughout the country, many in his constituency and many in these new fantastic primary care services. I can certainly undertake to ask for a clinical view from the Department and the HSE on the business case for the specialist physiotherapists. Another question would be where should they sit. Perhaps they should sit with one of the voluntary organisations, as the Deputy said. Perhaps it is a skill that should be brought into the primary care centres as part of a multidisciplinary approach.

Deputy Cathal Crowe

I thank the Minister. I would appreciate it if he could give the matter further consideration. The model to examine would be in CHO 3 where this has been fully rolled out on a multi-annual basis. This is probably me viewing it through the lens of a teacher, because teachers are either full-time or part-time and there is no in-between. I am perplexed that the physiotherapist in CHO 3 is 0.7 of a role. I know it is HR jargon, but I never understand these things. If a position is given to a CHO, region or healthcare system it should be a full-time equivalent position. This is the case that MS Ireland presented but it goes beyond MS Ireland. There is some HR guru who will justify this but I can never understand why a position would be 0.7 when it is that close to being a full-time equivalent position. I ask the Minister to lead on this. It is giving the sweets but taking them back before the bag is empty. It is a real bummer for the people trying to deliver public health care.

Over the Easter period, I became aware that child psychiatrists are not very common. People speak about children's mental health. The joint committee has certainly looked at his matter, as has the Joint Committee on Education, Further and Higher Education, Research, Innovation and Science, of which I am also a member. Children usually go through CAMHS, and that has its own complications. Occasionally, there is a need for a referral to a psychiatrist specialising in children. There are very few of them in the country. The only one we have access to in CHO 3 comes on a locum basis. We are lucky if he is in the county one day month. Children are not being seen. Is any strategy built into Sláintecare or the Department's budget to recruit, hire and have whole-time equivalent child psychiatrists? When contacted, many psychiatrists will say that they do not specialise in it and cannot take people younger than adolescent. There is definitely a deficiency.

Deputy Stephen Donnelly

I thank the Deputy. There is. As we are all aware CAMHS has been under sustained pressure for some time. There are a great number of CAMHS teams throughout the country. They are multidisciplinary teams. There are definitely improvements that must be made. The Deputy will be aware that we have just appointed an assistant national director specifically for CAMHS. There is an assistant national director for mental health. These roles are badly needed. I was speaking to some of the psychiatrists involved and they pointed out that as the lead clinician in their area they work with a multidisciplinary team, quite rightly, but that multidisciplinary team does not actually report to them. It reports to the CHO. If they are the lead psychiatrists on a team and they have other fantastic healthcare professionals working with them, arguably, they should all be part of the same team. There are issues such as this. There are issues with national protocols and guidelines. Essentially the paediatric psychiatrists that we have throughout the country are doing very good work, but neither I nor the Minister of State, Deputy Butler, believe they have had the level of national back-up that they need.

That involves bringing them together for training and learning, ensuring the protocols are in place so that they know where to refer to, and ensuring they have the resources they need. The number of training places in child psychiatry, in the higher specialist training posts, has been increased.

There is probably something of a role for us all here. For reasons we can all understand, the child and adolescent mental health service, CAMHS, has attracted a great deal of negative attention. Some of it is deserved when, for example, we look at what happened in Kerry. This has had a knock-on effect on the number of people training in psychiatry who want to specialise in CAMHS in that it makes it less attractive. Certainly, what has been reported back to me is that while the number of training posts in child psychiatry has been increased this year for the first time in a long time, not all were filled. Part of my job is to ensure those looking at coming into the field of CAMHS and paediatric psychiatry know that we acknowledge there are deficits in support for psychiatrists and that we are very serious about building those supports and putting them in place.

The Deputy has identified that, while a great many very good things are happening across the health service, it is nonetheless not universal. CAMHS is an area where the Minister of State, Deputy Butler, is spending a great amount of her time and is completely dedicated to getting this done, because we need these permanent psychiatry posts filled. The new consultant contract will help with that. Many psychiatrists are on the A contract and it is quite attractive for them to move across to the new contract.

Deputy Cathal Crowe

I thank the Minister for his detailed response. I have one final question. Over the Easter recess, much of the public discourse was dominated by nurses and teachers saying they cannot live in Ireland’s largest cities. They graduate and cannot afford to live there. Will the Minister give serious consideration to having some financial support provided to graduate nurses to remain close to the hospital environment and perhaps to live, like they did until the 1980s, in the nurses' home, which was co-located with the hospital? Is the Minister, in the first instance, looking at anything like that?

The other issue is the brain drain, because any person who has been in any of our acute hospital systems lately will notice that while it is very obvious the staff are very welcome and valued, many of the staff a person will encounter are from Asian and African countries providing fabulous, fantastic healthcare. It is very striking then to see our nurses and our doctors graduate through the Irish system, and weeks after having graduated, they are boarding a plane and heading to Australia. This is a revolving door, and while the level of investment the Minister and his Department are committing is very admirable and significant and is making impacts, that does not matter unless all of these people can be recruited within the acute system. Will the Minister consider supports at any point to keep these medical personnel here or, indeed, some carrot-and-stick mechanism, with more carrot than stick, to ensure these people remain in the country after graduating? This might perhaps be, in particular, by supporting them through their final year with some of the costs associated with training. The brain drain, certainly, is a major factor.

Deputy Stephen Donnelly

I thank the Deputy for those questions. There is quite a good deal to unpack in those questions. The first question the Deputy asked was in respect of the cost of housing, essentially. I believe there is a case to be made and I have discussed this with various hospitals. As the Deputy quite rightly says, it used to be the case that hospitals generally had nursing accommodation. In Galway, for example, it is still there but it has been turned into office blocks. I believe there is a case within individual hospitals and I have spoken to individual hospital managers about it and they are quite interested in it and in buying or retrofitting existing apartments for whomever it might be. It might be visiting or non-consultant hospital doctors, NCHDs, on their rotation, graduate nurses, or international clinicians coming in and providing accommodation for them for the first time. It is something we have to be open to and that would need to be discussed at length with the Department of Public Expenditure National Development Plan Delivery and Reform, which would be concerned with potential knock-on effects into the rest of the workforce. This is something we used to have and need to keep an open mind to.

When it comes to the issue of clinicians leaving the country, the reality is somewhat different from the narrative. The narrative, if we are to believe it, is that there is not a single healthcare graduate in the country who is interested in staying in Ireland. In fact, for the vast majority of nursing graduates, for example, every one of them is offered a job in the HSE and the vast majority of them take those jobs.

A great number of medical students and health and social care professionals, when they graduate, stay in Ireland. There is nothing wrong with any healthcare professional going abroad after college. I went after three years and had a great time. In medicine, to go abroad is seen as an important part of the role. I have no issue with this and I believe it is quite a healthy thing for Irish graduates and healthcare professionals to go abroad to get international experience. The key is that we want them to come back.

We are approaching this in different ways for different groups. The Deputy will be aware we are putting a big focus on NCHDs. The current work-life balance for NCHDs and how they are treated is completely unacceptable and has been unacceptable for a very long time. We have a very important piece of work going on in making things better for them. The Deputy will be aware that in the budget before us today, we have allocated an additional €5.5 million, for example, to student nurses in the increase of supports for them. As I said, the majority of graduates actually do stay here in the HSE.

Similarly, we need to look at the health and social care professionals, who tend to get a lesser share of the voice but are just as important as the nursing, midwifery and medical students. Ultimately, the solution is where the Deputy quite rightly says we have an unusually high level of international healthcare professionals in the country. That is not because our graduates leave but because we do not have enough graduates. One thing I want to see is a doubling of healthcare college places in the country. This is something the Minister, Deputy Harris, and I are engaged in. There was already a big expansion last September and there will be another material expansion this coming September. We will keep going with this. We have approximately 2,000 entry nursing places in the country and I believe we need approximately 4,000. We have now started on the journey of expanding that throughout the country.

Deputy Cathal Crowe

I thank the Minister for that reply.

Deputy Róisín Shortall

I thank the Chair and the Minister for his presentation. At the outset, it would be remiss of us not to revert to the Maura Quinn report which was published this week, given we are discussing expenditure within the Minister’s Department at this meeting. I have to say I was concerned about the approach the Minister took to that report and the statement he issued on its eventual publication. The Minister talked about the future and about learnings and lessons for the future. Would he accept, however, that he cannot move ahead and cannot learn lessons unless there is accountability for what has already happened? We are looking at a situation where the most senior official in the Minister’s Department, his Secretary General, took a decision to spend a substantial amount of public money without going through the proper protocols or approvals.

We know from the report that the Minister’s Secretary General’s account of events is at complete variance with the account of events from the then Taoiseach’s chef de cabinet as well as that of the Secretary General to the Government. Deirdre Gillane’s comments were very trenchant. She did not hold back at all and she talked about the Minister’s Secretary General’s account being grossly inaccurate, and she used the word "fatuous". She said the claims were wholly without foundation.

Surely, the Minister cannot allow that situation just to sit. This is a situation where the Taoiseach’s senior adviser is saying quite clearly that the account provided by the Minister’s Secretary General is not accurate. Whose accounts of events does the Minister believe?

Deputy Stephen Donnelly

I thank Deputy Shortall for this question. I believe the report, which is very clear.

Deputy Róisín Shortall

The report sets out the contrasting accounts of what happened. Whose account does the Minister believe?

Deputy Stephen Donnelly

The report is clear and it does not just set out the two accounts. The report is very clear in stating, and I fully agree, that the then Taoiseach’s chief of staff did not have the details on this until the time she indicated she did, which was much later in the day.

Deputy Róisín Shortall

I am talking about Ms Gillane’s comments in respect of the Minister’s Secretary General’s claims, where she says they were grossly inaccurate.

Deputy Stephen Donnelly

I say that I agree with the report and the report is very clear that Ms Gillane’s account of the timing is correct.

Deputy Róisín Shortall

If the Minister believes Ms Gillane’s account is correct, then that account is totally at variance with the claims being made by the Minister’s Secretary General.

Surely that is a situation that he cannot just move on from. There needs to be some accounting for that huge disparity in the two people's account of the situation. I again ask the Minister, whose account of events does he actually believe?

Deputy Stephen Donnelly

I think I have answered but-----

Deputy Róisín Shortall

No. The Minister has not.

Deputy Stephen Donnelly

-----in case there is any -----

Deputy Róisín Shortall

No. We have an account of events from the Minister’s Secretary General. We have a conflicting account from Ms Gillane. I am asking whose account of events does the Minister believe?

Deputy Stephen Donnelly

What I am saying very clearly is that I agree with the position in the report, which is that Ms Gillane’s account is correct.

Deputy Róisín Shortall

Okay. That is entirely contrary to the account that was provided by the Secretary General. Does the Minster intend to take any action about that?

Deputy Stephen Donnelly

No, I do not. The Secretary General is before the Joint Committee on Finance, Public Expenditure and Reform, and Taoiseach today and I have no doubt that he will be asked this. In terms of accountability, he will be before that committee for several hours today. That is a senior civil servant accounting to the Oireachtas through that mechanism. He will be asked this question. He will be able to answer this question. My understanding of it is that there may have been a misunderstanding in terms of testimony given by the Secretary General at the Department of the Taoiseach as to when Ms Gillane was told. It is clear to me that Ms Gillane was told late in the day.

Deputy Róisín Shortall

Surely the accountability has to be to Deputy Donnelly, as the Minister in the relevant Department. Surely, he should be establishing accountability on the part of his Secretary General.

Deputy Stephen Donnelly

We are talking about a proposed secondment -----

Deputy Róisín Shortall

I know what we are talking about-----

Deputy Stephen Donnelly

Let me answer the question.

Deputy Róisín Shortall

-----but the bottom line is-----

Deputy Stephen Donnelly

Chair, can I -----

Deputy Róisín Shortall

-----we are talking about the spending of a substantial amount of public money without going through the normal protocols.

Deputy Stephen Donnelly

The Deputy is asking a different question. She asked a separate question, which I am more than happy to come to, in terms of the research funding. On accountability, let us look at what has happened here. There was a proposed secondment which people agreed at the time broadly was something that-----

Deputy Róisín Shortall

Sorry, we know what it was.

Deputy Stephen Donnelly

Chair, I need to be able to answer the question.

Deputy Róisín Shortall

Sorry Chair, we know what the situation is. I am asking the Minister a direct question about this and about the accountability. Is the Minister insisting on accountability of his Secretary General? Because the Minister has just said that he accepts the evidence provided by Ms Gillane in this regard. That evidence is in direct conflict with the claims made by the Minister’s Secretary General.

Deputy Stephen Donnelly

Chair, I am going to have to rely on you. I have tried three times to answer the question.

An Cathaoirleach

I am also conscious that the individual we are talking about is before another committee at the moment. There may be a situation in the future where we may be able to ask him the questions directly. If it is in the context of the Estimates, I will allow it.

Deputy Róisín Shortall

I am going to stop at this point in relation to that issue.

Deputy Stephen Donnelly

Chair, can I answer the question?

Deputy Róisín Shortall

I wanted to know what action, if any, this Minister is going to take in relation to his Secretary General.

An Cathaoirleach

Can we go back to the Minister and let the Minister finish his reply?

Deputy Stephen Donnelly

I thank the Chair.

Deputy Róisín Shortall

He can do it briefly.

Deputy Stephen Donnelly

I thank the Deputy. To be clear, the question is in the context of a proposed secondment that did not happen. Nothing actually happened in terms of any spending of money. Several things were done on the back of that to ensure transparency and to ensure that lessons are learned. The first is that a detailed report was put together by the Secretary General at the time and the second is that I commissioned an independent report by Ms Quinn into this matter and she has provided that. Third, I am here today; the Secretary General is before a committee; the Secretary General at the Department of the Taoiseach was before a committee last year; the Secretary General at the Department of Health was before the committees last year. I would argue that is a substantial amount of accountability and transparency based on a secondment that never actually happened.

Deputy Róisín Shortall

Okay. I am going to leave it at that. I just want to make one final point, which is that the terms of reference did not provide for any attempt to establish accountability and as long as that looseness exists, we will have people going off doing solo runs. I want to pursue that in relation to the accountability board that the Government is supposed to have in place but I will leave it for today.

To return to the Estimates, an ongoing concern many of us have is the amount of money that is being siphoned off from the Department of Health to independent agencies, charities and so on. That seems to be increasing in line with the difficulties in recruiting HSE staff. Where within the Estimates can I find the figure that is being spent on outside agencies and the outsourcing of work which, in my view, should be core HSE or Department work? Where can I find that figure for how much is being spent on charities and various outside agencies?

Deputy Stephen Donnelly

Does that include contract cleaning, catering, security in hospitals and all of that as well?

Deputy Róisín Shortall

No, not that.

Deputy Stephen Donnelly

Is it section 38 and 39 organisations? Or section 39 organisations?

Deputy Róisín Shortall

Section 39 organisations.

Deputy Stephen Donnelly

Bear with me for one second.

An Cathaoirleach

While we are waiting, the committee wrote seeking detail of the amount of money that is going to outsourced services and this whole area. I believe we are awaiting a reply on that. It has been discussed by the committee and particularly in private session. It is a concern of the committee overall.

Deputy Stephen Donnelly

The accounts do not have a specific line item because the section 39 organisations involved are across mental health, disabilities and lots of other things. I will revert with a note bringing it all together.

Deputy Róisín Shortall

Okay. I thank the Minister. May I ask about older people’s care? An excess of €1 billion is being spent on older people’s care. Over recent years, concern has been expressed about the definite trend towards very large congregated settings for older people, which I think most people agree are not ideal by any means. On the one hand, there is a business kind of approach and support for that it seems within the Government and on the other, from the perspective of quality of care, we know that those kinds of large congregated settings are not desirable in any way at all. Yet the development of those centres seems to be going ahead apace. Has the Minister had discussions or is he examining developing new policies in light of the lessons learned from Covid, not least because of the problem of infection control in large settings but also because it is in older people’s interests to stay in their own homes or to have supported housing? What approach is the Minister taking? Is a new approach being taken on the basis of the experience of Covid in particular?

An Cathaoirleach

That is the last question.

Deputy Stephen Donnelly

Yes, there is. An important report has already been done. The Deputy will be aware that the expert review was done and a lot of money has been allocated in this budget to implementing its recommendations. It was done specifically in the context of Covid where there were lessons we could learn really quickly. It is a really good report.

Deputy Róisín Shortall

I know, yes.

Deputy Stephen Donnelly

That is the first thing. Second, the Minister of State, Deputy Butler, who is leading in this area, is spending a lot of time on home care and the interRAI system. We have pilots all over the country. We will be moving to a position where home care will be on a much more standardised basis and standardised to the needs of the person at home. HIQA will be beginning to look at regulation within home care, which is another important change. The Estimates before us contain a lot of money around the decongregated settings move. A huge amount of work has been done and I can ask the Department to revert with the numbers this year and in recent years around getting rid of those large centres and moving to the much smaller houses.

Deputy Róisín Shortall

But would that not be the case around disability services in particular, not older people services and not the private sector ones?

Deputy Stephen Donnelly

Yes, it would. But in terms of large congregated settings it is another one of the things that is happening.

On the final point, the answer is yes. The commission on care will be set up in the coming months. Myself and the Minister of State, Deputy Butler are very involved in that and have been looking at its terms of reference. It is to address exactly the points that the Deputy is raising. For example, there are no architectural or planning guidelines for nursing homes in this country so anyone building a nursing home can do what they want. The Minister of State was at one a while ago where they had glass balconies that were up quite high, which were not appropriate.

It was not the fault of the construction company. It had no guidelines. The commission on care is going to look at these exact questions. For example, what is an appropriate size? Something that I want to see, and I know the Deputy and the Minister of State, Deputy Butler, are keen on, is more public provision. We have moved to a very privatised model. It is about pulling that back. We want to reduce the amount of time people spend in nursing homes. As a result, we want to focus on home care and supporting people to remain at home more. One of the ideas we need to explore is whether we can expand the fair deal scheme to home care rather, than just funding people when they are in nursing homes.

Deputy Róisín Shortall

That was committed to a few years ago.

Deputy Stephen Donnelly

Right.

Deputy Róisín Shortall

There is a queue for that to happen.

Deputy Stephen Donnelly

That is fair. On home support, 21 million hours were provided last year.

Deputy Róisín Shortall

When will the commission be up and running?

Deputy Stephen Donnelly

By the summer.

An Cathaoirleach

Deputy Shortall has gone way over time. I have been very lenient. Other members wish to contribute.

Deputy Gino Kenny

I thank the Minister for furnishing the Estimates. My first question relates to the capital spend of €1.1 billion. Can the minister give us a breakdown of how that money will be spent in the context of the overall budget?

Deputy Stephen Donnelly

I can, but I must locate the page and revert to the Deputy. While one of my officials searches for the page, I suggest that the Deputy ask another question.

Deputy Gino Kenny

There is no shortage of money for the overall health budget, which is good. As we have seen, however, we can have all the money that we want but it is extremely important that we recruit and retain staff. Deputy Cathal Crowe alluded to the introduction of additional payments and premia for specialist healthcare staff. If there was additional pay, nursing and other front-line staff could stay in the State and remain in healthcare settings. Will the Minister give serious consideration to providing additional payments over the next two years while he is at the helm of the Department, particularly in view of the cost-of-living and housing crises?

Deputy Stephen Donnelly

There are different layers to the proposal. We discussed the first layer when Deputy Cathal Crowe asked whether consideration could be given to localised housing. In other words, accommodation attached to hospitals. That option used to exist. It would make a great deal of sense now, particularly for healthcare professionals who move around quite a lot. The Irish Nurses and Midwives Organisation, INMO, has sought the provision of specific housing supports for clinical staff. My view of that is it is a societal challenge rather than just a healthcare challenge. That option exists for nurses and midwives, but not for hospital porters, security officers, health and social care professionals and people working right across the country in different sectors other than health. There is an whole-of-government approach to that. For example, rent subsidies and various other supports have been put in place for renters. There are also supports for people to buy their own homes. That is broadly how we would do it.

On specialist payments, the Deputy may have only linked them to the cost-of-living crisis. He raised the issue of additional payments for specialist workers, and I think there is something to that.

Deputy Gino Kenny

Yes.

Deputy Stephen Donnelly

I have to be careful about what I say because there is nothing in place with the Department of Public Expenditure, National Development Plan Delivery and Reform. Anything of that nature would have to be done by means of a public sector pay agreement. Broadly speaking, there have never been more people in the HSE. I know we talk about a recruitment crisis but, in fact, we have just had three years in a row of record recruitment. At an all-of-system level, there absolutely is not a recruitment crisis, but parts of the system really struggle. One of those parts is that relating to children's disability services. Clinicians say to me that complex children's services are more difficult to work in. There is precedence for an additional payment being paid to emergency department nurses because emergency departments are simply harder places to work. Working in an emergency department takes a greater toll. There is an argument to be made for those who work in the more difficult areas. These are the areas, like complex children's services, that the clinicians say are more difficult and in respect of which additional remuneration could be looked at. I reiterate that can only be done after an awful lot of consultation with the Department of Public Expenditure, National Development Plan Delivery and Reform, and as part of a public sector pay agreement.

Deputy Gino Kenny

There is precedent because specific workers in other jurisdictions are given additional payments to work in healthcare settings.

Deputy Stephen Donnelly

Yes, and we do it here.

Deputy Gino Kenny

It would not be out of the ordinary for this State to do so.

Deputy Stephen Donnelly

No. We pay advance nurse practitioners more. Although I do not have the figures, I understand that there is a recognition that critical care nursing and emergency department nursing are some of the most difficult parts of the health service in which to work.

Deputy Gino Kenny

Is the Minister in a position to answer my initial question about capital expenditure?

Deputy Stephen Donnelly

Yes. I will get the Deputy a more detailed breakdown. The capital provision for construction and equipment is €967 million, and there is more involved to bring it up to the total amount. Some of the big projects are as follows: the national children's hospital; the national maternity hospital; the new elective hospitals; the additional critical care beds; the additional acute or hospital beds; the radiation oncology programme; the primary care programme, which has been a huge success; and the enhanced community care projects. To answer the point made by Deputy Shortall, there is the replacement and refurbishment of nursing home units so we end up with fewer beds because people get more appropriate space, more space and single-room occupancy. The projects in this regard include those relating to the expansion and upgrading of mental health facilities. There is a general investment in making things Covid-proof. There has been a very significant investment in the budget for the National Ambulance Service in terms of its fleet and bases. There are climate action projects. Finally, there are also equipment replacement programmes.

Deputy Gino Kenny

That is good. It is very welcome that 970 extra beds have been included in the public health system, but that figure excludes critical care beds. How many critical care beds have been provided since the start of this decade or over the past three years?

Deputy Stephen Donnelly

I can give the figure that applies to the start of 2020 so that is pre Covid. We have got an extra 65 beds. That is an increase of 25%, from 258 to 323 beds. We will provide another 29 beds this year, which will give us a total increase of 94 beds or a 36% increase.

Deputy Gino Kenny

Can I presume that the number of critical care beds will increase incrementally over the next couple of years?

Deputy Stephen Donnelly

That is right. We are moving now from phase 1 to phase 2. Phase 1 put extra critical care capacity in many different places as quickly as possible. Phase 2 is more strategic. It is in line with the national strategy whereby we are creating centres of excellence or critical care hubs and building them out.

Deputy Gino Kenny

It is welcome that a lot of good work has been done to improve women's health services. Again, the funding for endometriosis services is welcome. Endometriosis is very prevalent. One of the criticisms levelled by women who suffer with the condition is that GPs are unable to diagnose it and thus provide care. Some women have had to wait many years before being diagnosed. Others have had to go abroad for treatment and so forth. Those who suffer with endometriosis have criticised the fact that GPs who work in the primary care system have a poor knowledge of the condition. I know that because a number of weeks ago there was a presentation on endometriosis in the audiovisual Room at which we heard from women with endometriosis. I found it hard to hear that women have had to suffer for many years without a diagnosis. One of the criticisms levelled by these women relates to the lack of knowledge of the condition among GPs.

Deputy Stephen Donnelly

I fully agree. There is funding in the budget here before us to expand the service.

Up until now, there has been very limited clinical access for women. As the Deputy quite rightly says, there has been limited knowledge in general practice. The GPs have not had the kind of specialist support they need. There have been very limited specialist services available for referral from the GPs. Even if the GP did know what was going on they did not have many options for referring their patients. That is now fundamentally changing. We are funding the ICGP to produce a quick reference guide for GPs and to do training much like has been done for menopause. The quick reference guide for GPs which was launched last year has been really successful. There is now specialist training for GPs. The ICGP has really taken this on board. We funded a women's healthcare post for a fantastic doctor, Dr. McCarthy, who is working with the ICGP on GP training and supports. We now have referral pathways for the GPs into centres around the country for secondary care. We have also set up the highly specialist units as well. I was with the one in Tallaght recently and it was just amazing to see this new team of experts' multidisciplinary approach. They say this is having an enormous impact on women's lives. They have been doing fantastic work. We are rolling out the service and it really is going from strength to strength.

Deputy Gino Kenny

Will that expand over time?

Deputy Stephen Donnelly

It can. We have now put in place a lot of infrastructure for these three layers. The view of the clinicians is to re-examine the matter once we have the supports in place for the GPs and fully staffed teams for the secondary care and really specialist care. We also have the 21 one-stop see-and-treat and gynaecology clinics. There is a whole new network of support and expertise in place which is having a big impact already. I can assure the Deputy that if we find in a year or two that more specialist resources are required we will put them in place.

Deputy Colm Burke

I thank the Minister for his presentation. Regarding recruitment, in overall terms since December 2014 there are now 40,000 more people working in the HSE. That is a substantial increase and it is about delivering services now.

I want to focus on capital expenditure. We are talking about current expenditure of €21.197 million and capital expenditure of €1.161 million. The Minister raised the issue of the refurbishment of community facilities, as a result of which there are fewer beds. My understanding is that in the Cork-Kerry region there are 240 fewer beds. The reason I am raising this issue now and why I raised it two weeks ago is that I was speaking to a person this morning who has a family member in CUH for over 15 months. The person could have been discharged 13 months ago. It will be the first of June before they are discharged because we cannot get a step-down facility. The person has complex needs, I fully accept that.

I know of two other people who have been in CUH three months longer than necessary because we do not appear to have step-down facilities for them. I know there was a meeting yesterday in relation to one of them. There appears to be a standoff going on within the HSE where the hospital wants to discharge but somewhere on the administration side, the nursing homes are not prepared to take them because the fair deal funding is not adequate and they are looking for additional funding so that that extra staff can be deployed to give these people the care they need. Why does it take three months to make a decision like that? A hospital bed costs €8,000 per bed per week. A nursing home bed, even with additional support would probably cost at most €2,000 per bed per week. What can we do especially in the Cork-Kerry region to deal with this issue? Beds are unnecessarily occupied in CUH and people who need to be hospitalised are complaining about not be able to get in and others are complaining about not being able to get out. This issue needs to be tackled by the Department asking serious questions about why there is such a delay.

Deputy Stephen Donnelly

Nobody should be waiting in hospital for that length of time unless there is a clinical reason for them to require ongoing acute care. There has been a very significant increase in hospital beds but there has also been a very significant increase in community beds.

Deputy Colm Burke

Not in the Cork-Kerry region which is why I am saying that there is a need now to engage with the HSE locally to see if we can get more contracted beds. I accept that there are 60 extra beds built in Heather House which are being brought into use which are very much welcomed and the Minister was down there recently with me. There are also an extra 50 beds in the new facility in Blarney. I understand that will not open until perhaps early next year. Can that opening be brought forward so that we can deal with congestion in both the Mercy University Hospital, MUH, and in CUH?

On the radio on Sunday we heard the tragic case of Vivienne Murphy, a young girl of ten who had to be transferred to Dublin because CUH does not have an ICU facility for children. There is planning for a new paediatric unit in Cork. When will the funding be allocated for it so that what happened to the Murphy family will not happen to another family?

An Cathaoirleach

Minister, I am conscious that some of the questions are very localised and you might have insufficient detail. I suggest that you come back with a note on some of the things and perhaps address the broader issues. It is very difficult for you and your staff if the issue is a very localised one.

Deputy Colm Burke

These questions are about the spending of money for infrastructure.

An Cathaoirleach

I know, but some of the questions are very localised and I think even the backup staff that the Minister has here would not necessarily have that information to hand.

Deputy Colm Burke

I am simply asking whether the paediatric unit is in the budget or not for this year.

Deputy Stephen Donnelly

Thank you Deputy. I want to express my own sympathies to the Murphy family. It was heartbreaking listening to Vivienne's family and what happened to her. My sincere sympathies are with her family and friends. It was just an awful situation. As the Taoiseach said in the Chamber yesterday, there might be some additional training we can look at regarding the recognition of strep A and the prescribing of antibiotics. It was a heartbreaking situation.

I will be led by the clinicians on paediatric ICU care. There is a clinical view that we have a national centre of excellence in the national children's hospital and at the moment in the existing children's hospitals in Dublin. If there is a clinical case to be made for a second centre in Cork or elsewhere, I will consider it very seriously. The Taoiseach made the point yesterday that it could have unintended consequences of us perhaps not being able to find the specialists required to fully staff two centres but I will certainly be led by the clinicians on that.

Deputy Colm Burke

There is planning in place for the new paediatric unit in Cork. Can funding be allocated for it and when can it be allocated?

Deputy Stephen Donnelly

We will be providing a lot more detail in the coming days about various projects, including the paediatric unit. I fully support the project. I have met with the team at CUH several times on this. I can tell you that it will be an appendix 2 of the capital plan meaning there is funding there to progress detailed design and so forth. There is planning as the Deputy says, which CUH rightly has secured but the funding still has to be lined up regarding signing off, final detail design, going to tender and building it. I fully support the paediatric unit in CUH but the hospital needs a lot more than that. It needs a substantial additional number of beds. The oncology unit needs to be upgraded. A new trauma centre with a helipad is required. A very significant amount of investment is needed in CUH and I am working on it with the Department and the HSE

Deputy Colm Burke

I want to move on to the issue of the timeframe for the elective hospital.

As I have raised with the Minister, Bons Secours is building a new hospital in Limerick which will take 23 months from start to finish. In fairness to both Mercy University Hospital and Cork University Hospital, CUH, the staff are working under enormous pressure. There is also the issue of trying to get people out of hospital and trying to get step-down facilities in place. There is also the question of the new elective hospitals to avoid waiting lists getting longer.

Deputy Stephen Donnelly

I had a suspicion Deputy Burke would ask me about this so I very specifically asked for the most up-to-date information on the matter. As the Deputy will be aware, in December, the Government approved the preliminary business case, the site was selected, the procurement strategy was put in place and the pre-tender process was carried out in line with the revised public spending code. The Deputy will be very happy to hear that a design team has been appointed. It is in place, it is taking forward the planning permission and it is now working on the detailed design. I expect that we will be able to move to tender by the final quarter of this year. That means planning will be secured, it is hoped, and the detailed design will be done and signed off on. It is going to be a game changer for the region, as the Deputy and I agree. This is some really positive news. It has been a long time coming. It is expected that, by the fourth quarter of this year, we will move to the tender stage.

Deputy Colm Burke

I appreciate that because I know there is a lot of work involved in getting any project like this up and running. It is a very detailed project. I fully understand that. However, I will come back to the issue of step-down facilities. This really needs to be looked at. How can we get people out of hospital faster? How can we get the HSE to engage with the private nursing homes that have beds? The private nursing homes are saying that, in some cases, because of the challenges they face with people being discharged, they require extra support and what they get under the fair deal scheme is not adequate to support the care that people need.

Deputy Stephen Donnelly

There are a few different aspects to this. The first is that, as the Deputy said earlier, new capacity is being put in place. For example, he and I were at the new facility that is going to be used for dementia patients. The view is that there are many dementia patients stuck in beds in CUH and this will be a much more appropriate and modern facility for them. That kind of thing is happening. The Deputy will be aware of the agreement that is in place with Stick River. Is that what it is called?

Deputy Colm Burke

It is Riverstick.

Deputy Stephen Donnelly

Riverstick nursing home is now taking patients from both Mercy hospital and CUH. That is helping. The clinicians in CUH are certainly saying it has been a great help. More needs to be done. If there are integration issues between acute and community facilities, I will take that up with the new chief executive. It is not something we can have. Obviously, one of the reasons we are moving to the regions is to have that more seamless and integrated care. However, if there are difficulties in that relationship or in the movement of patients who should be transitioned out of the hospitals, I will certainly take that up with the chief executive.

Deputy Colm Burke

The three cases I am aware of are genuine cases. I have been working with the families in all three instances.

Deputy Stephen Donnelly

Perhaps the Deputy would send me on the details. I will ask the HSE for a review.

An Cathaoirleach

This is again something we discussed in yesterday's private meeting. The Minister is coming in again to discuss the issue of acute beds. We have suggested that the matter of step-down beds form part of that discussion. We may be revisiting this again. I just wished to give the Minister some notice.

I call Deputy Colm Ward, who is not a member of the committee but who is welcome.

Deputy Mark Ward

I am in the Cathaoirleach's party; my name is Mark.

An Cathaoirleach

I am sorry.

Deputy Mark Ward

The Cathaoirleach is calling me by the name of the head of housing in South Dublin County Council. I thank the Chair, Deputy Crowe, and the Minister. I was listening to the Minister's opening statement. I had to listen to it in the office because I was speaking in the Dáil and cannot be in two places at the same time. I notice there was no mention of mental health in the opening statement. I have a couple of questions.

What resources are in place to tackle the long waiting lists we have in child and adolescent mental health services, CAMHS? Looking at the figures, since this Government came into office in 2020, the waiting list for a first-time assessment for CAMHS has almost doubled. Figures I got yesterday show that 434 children are currently waiting for a first-time assessment in CAMHS. That figure has gone up 3% in a month. The figures seem to be just going up and up. I listened to the Minister of State, Deputy Butler, and to the Minister himself and they both say they are going to tackle these waiting lists but I have not seen the evidence. We all know early intervention is key. There are 682 children waiting longer than a year for an appointment. I know the Minister will agree that is not good enough. That is my first question. How is the Government going to tackle these waiting lists and what resources are in place to do so?

Deputy Stephen Donnelly

I fully agree with the Deputy that the current situation is not acceptable. It was not acceptable before Covid and Covid made it worse. In answering the question about CAMHS, we have to broaden out to mental health. I know the Deputy focuses on this area, so he will be aware that CAMHS is for children facing the most acute problems. As the psychiatrists point out to me, part of the solution to difficulties with CAMHS is more psychiatrists, although many are in place, better supports for the psychiatrists we have, and better integration of the multidisciplinary teams. The Deputy has supported the appointment of the assistant national director for youth mental health. Those protocols are now going to start being put in place, but that is only one of the issues. Another is that we need to hire a lot more people. I do not have the exact numbers with me and I hope the Deputy will forgive me if they are wrong but, from memory, the mental health workforce increased by in excess of 400 people last year. I believe that is what the increase was. If I may say so, this is partly because the Minister of State, Deputy Butler, and I made it known that an awful lot of funded positions had not been filled for a very long time and that, if we did not start seeing some action on that, we were going to move the funding to other parts of the service where people could be hired. Astoundingly, we saw an awful lot of recruitment activity happening very quickly after that. That is welcome. There are hundreds more staff in place around the country.

An idea the Deputy has talked about a lot and on which the Minister of State, Deputy Butler, is very keen is that, while we need CAMHS to be bigger and while we need to support it more, a lot of the solution lies in youth mental health. In my constituency, there are referral pathways for things like counselling and other mental health supports before a young person needs psychiatric support, which is obviously for the most severe cases.

Deputy Mark Ward

May I cut in there? I agree with the Minister that early intervention is key. Children should get the care they need at primary level. The waiting list for psychology in primary care is in excess of 11,000 at this stage. In some places, there are waiting lists of 30 weeks for Jigsaw services. There are different waiting lists in different parts of the country. There is no counselling in primary care for children. There are bits and pieces that should be there that are not and there are things that are there that could be working better but are not, which means that many more children are going to need the care of CAMHS because they are not getting their needs met at an earlier stage. I am hoping I will hear about something that will start bringing these waiting lists down so that children can get the care they need.

Deputy Stephen Donnelly

That is right. I fully agree. The Deputy will be aware that only 2% of young people referred for mental health supports actually need CAMHS. We spend 90% of our time talking about CAMHS but it is actually for only 2% of the population. There is some good news in that more than 90% of urgent referrals are seen within three days. That is important. However, as we have discussed, more is needed to hit the targets. Much quicker referral is needed. The answer is in youth mental health and in expanding psychology and counselling within primary care teams, disability teams and CAMHS. Significant money has been allocated within this budget. A portion of the 6,000 staff are specifically allocated to youth mental health. The Minister of State, Deputy Butler, is determined that the new assistant national director roles, the focus on youth mental health and the several hundred additional staff hired towards the end of last year will result in us seeing some of that. We also have some longer term solutions in place. Something the Deputy has called for before is for some of the PhD psychology posts to get proper supports. That is also happening in respect of counselling psychology.

Deputy Mark Ward

Can I ask a question? The Maskey report highlighted the shocking mistreatment of children in Kerry and community healthcare organisation, CHO, area 4 and, at the time, the Government said it was going to put an emphasis on CHO area 4 and fixing the problems in that area. The Government promised action but the statistics are the statistics and are not open to being seen as anything other than what they are.

The figures for March, which I got yesterday, show that 340 children have been waiting more than a year for an appointment in CHO 4. The national figure is 682 so nearly 50% of all the children who have been waiting for more than a year are in CHO 4. It is the one area where the Government promised action. It promised to put emphasis on the area but I do not see that taking place. Why is that happening in this particular CHO area? Almost 50% of all children who have been waiting for more than a year are in CHO 4.

Deputy Stephen Donnelly

There is clearly an issue in that CHO. The Minister of State, Deputy Butler, has been involved in that. Rather than saying something on the public record that might be unfair to some of the people involved, I might ask her to revert to the Deputy or meet with him to discuss the specific issues and, most importantly, the solutions in CHO 4. There is a long-standing issue there. The number of people waiting is completely unacceptable. The problem is not for a lack of allocated funding. A lot of funding and many posts have been allocated. There are many issues there, as the Deputy rightly said, and I know he is aware of some of the specifics. I might ask the Minister of State to revert specifically on that CHO.

Deputy Mark Ward

Okay. I will move to discuss early intervention in psychosis. I have asked questions a number of times about the national programme for the early intervention in psychosis to see what budget was allocated and when funds would be released. The answer I keep getting is that the national service plan is not finished yet. Will these Estimates feed into the national service plan or what is the procedure? When will the money for early intervention in psychosis be released? The Minister said that early intervention is key.

Deputy Stephen Donnelly

I thank the Deputy. The national service plan is live and has been signed off. These are the Revised Estimates behind the national service plan. I will ask the officials to get the specifics for the Deputy. We might get those specifics during this session or if not, we will revert to him with the exact numbers.

Deputy Mark Ward

That is grand. The Minister mentioned the National Maternity Hospital at St. Vincent's Hospital in his opening statement. There are two other facilities that I understand were due to open in St. Vincent's Hospital, one of which was an eating disorder service. At the moment, there are only three adult beds in the State for eating disorders. Adults are going onto paediatric wards. They are getting their body mass index increased, being released and later going back in. It is a vicious circle. I understand the inpatient perinatal service was also due to go into St. Vincent's Hospital. Does the Minister have an update on those two services?

Deputy Stephen Donnelly

Those are very specific service areas. May I revert to the Deputy with a detailed briefing?

Deputy Mark Ward

Okay.

Deputy Stephen Donnelly

I thank the Deputy.

Chairman

Before I bring in Deputy Cullinane, I will make a couple of points. The Minister spoke in his opening statement about addressing unacceptably long waiting lists. I could go through the different sectors but he is probably aware of them. I will highlight a couple of cases of unacceptably high waiting lists that have come across my desk. These are not cases that involve my constituents. I am talking in broad strokes. A man from County Donegal needs his jaw realigned. He was supposed to get an appointment for an operation in 2020. It is now 2023 and he still does not have a date. Is that unusual in the Minister's experience? It seems a very simple operation. That man was waiting years before he got a date for an appointment, which was cancelled due to the pandemic. Three years later, he is still waiting. He has problems. He cannot get dental care. His jaw is locked. He finds it hard to eat. I am giving an example of the human figures behind some of the waiting lists. That is just one case. The man also needs his tonsils removed but cannot have that done because of his jaw issue.

In another case, a man was looking to get into an obesity clinic. The man has lost a leg. He is a farmer who lives on his own. Because of an inherited disease, he lost one leg. The other leg was then removed. He was trying to lose weight so he would be able to get another prosthetic. He was told he would be waiting for between five and six years to get an appointment for treatment.

Deputy Stephen Donnelly

Is that for gastric band surgery?

Chairman

It is not even that. That waiting time is just to get an appointment to see someone. There may be other avenues down which he could go. I am giving an example. That man was told by his doctor that he could be waiting for between five and six years.

There are treatments that jump out in respect of the waiting lists, including dental care and oral hygiene, particularly for children. Psychological services have been mentioned. There are delays for access to speech and language therapy and other additional supports. There are problems within the system. We are talking about existing services but there are also problems in respect of services that people cannot access in this State. I am aware of a case of a child who went into hospital in Tallaght at the age of 17. The child had enormous problems. The child has neurodevelopmental disorder, mental illness and a visual impairment. The setting is unsuitable for the child. The option for the child, who is now 21, is probably to travel abroad. I am looking at the figures in respect of children and adults for whom there are no facilities in Ireland. The total number of people travelling abroad to North of Ireland or Britain for treatment where no treatment is available in Ireland is 33. Some €25 million was spent on that. Between 2014 and 2023, €4.355 million was spent on 12 children and 17 adults. I am trying to focus on that. An huge amount is being spent on services that are not available to people within the State. Is there a plan for the children, in particular? There is an added problem of parents trying to visit and so on if their children are outside the State.

There are also difficulties in getting reimbursement for patients who have travelled abroad for treatment because they were waiting years to get treatment in Ireland. Perhaps the Minister will touch on that issue. All these issues are related to the Estimates. I have spoken in broad strokes about the real challenges that are facing real people within the system.

Deputy Stephen Donnelly

I thank the Chair. He has cut to the chase about the areas where our focus is and must be. We must prioritise the long waiters, particularly children who are waiting a long time. Let me go through some of the things we are doing that are in the Estimates. Some of the Chairman's questions fall outside the Estimates and I will come to them.

He spoke about a gentleman in need of prosthetics. If the situation is that the wait is part of that, what he needs is access to obesity services. Those services have been funded for the first time in this budget. We have a fantastic endocrinologist in Loughlinstown, near my own area. He and a colleague are leading on this. I have allocated a lot of money, millions of euro, for this year. I was told they would be able to hire a lot of people quickly. I was not entirely sure if that was true but it turned out it was and they have been hiring at an amazing pace. Ireland has been a complete outlier in terms of gastric band surgery and obesity services. We are going to start coming more in line now. We will all be aware of people travelling to, for example, Türkiye and coming back with all sorts of complications. Those patients will be treated in Ireland as services are rolled out. There are long waiting lists and there should not be. This new service is directly aimed at helping those patients.

I have asked the HSE not just to look at the waiting lists but to look at the long waiters as two groups. To its credit, the HSE is doing that and it is having an impact.

The first group is those who are waiting far too long – more than, say, 12 months. The second group is those waiting longer than the agreed Sláintecare targets of ten and 12 weeks. The HSE is working hospital by hospital and clinical group by clinical group to go through them and point out, for example, that there may be 500 patients waiting to be seen, 450 of whom have been waiting less than 12 months but there is a small group of patients who appear to be waiting for surgery for two, three or four years. In most cases, those patients have been seen by somebody else. However, in some cases, as per the example given, we have people waiting years. One of the priority areas at the moment is exactly that - finding those people who have been waiting far too long and prioritising them, not based necessarily on clinical need but the fact that they have just been waiting for far too long. We need to make sure they all get access as a priority.

The second issue is around treatment abroad. There are three schemes. There is the treatment abroad scheme, which is for services that we do not provide in Ireland. The patient or patient's family do not need to pay for such services, which are paid for by the State. The second scheme falls under the cross-border directive, where services are available in Ireland but, as the Deputy said, the wait is too long and people elect to go to another member state. In that case, the patient pays upfront and is reimbursed by the HSE. The Ombudsman’s report was welcome. It was an important piece of work. I am comforted that the Ombudsman has met the new HSE chief executive, Bernard Gloster. The Department and HSE have accepted all of the recommendations. The Ombudsman’s response was very positive in terms of the chief executive’s engagement with him on the issue of reimbursement. All legitimate reimbursement should happen very quickly. The Deputy will be aware that we have a third scheme for Northern Ireland, which is on an administrative level. It is essentially the cross-border directive for Northern Ireland. The UK came out of it, obviously, post Brexit.

On paediatric surgery, there is undoubtedly some very rare surgery for which children may need to go to London or wherever the case may be. For example, there is a charity in my constituency in Wicklow that helps children with cancer to get proton therapy, which is not provided here. There are, however, other cases where we provide the service. In the areas of scoliosis and spina bifida, for example, children are waiting too long. That is one of the areas of focus in the Estimates. We have allocated substantial moneys to reaching the agreed service level under which no child should wait more than four months unless clinically indicated. Significant progress is being made. The level of activity has increased considerably but waiting lists are still far too long. The HSE and Children’s Health Ireland did not meet the targets we set despite their best efforts, partly because of a very large number of additional referrals. I will meet Children’s Health Ireland again in the next week or two on that precise issue. I will meet clinicians and management to make sure everything that can be done is done, particularly at the moment. Once the national children’s hospital is open, the level of resources available will expand significantly. However, we cannot wait for that. In the 18 to 24 months or thereabouts before the children’s hospital opens, will Crumlin, Temple Street and Cappagh hospitals have the resources they need? Significant investment has gone into that area as well.

Deputy David Cullinane

I will ask a number of questions on capital funding and the delivery of capital projects at pace, which we do not seem to get right both in respect of housing and healthcare. On a more positive note, I commend Derek Tierney on his work in this area. He has brought a new sharpness to the area of capital funding and has ideas on how we can progress projects more quickly.

Speeding up the delivery of bed capacity has been spoken about. I will start with beds. I also wish to raise a number of other local capital projects in Waterford and get some information on them. In October 2020, as part of budget 2021, 1,146 acute inpatient beds were announced, with another 70 or more provided for in the service plan. We discussed this several times with the head of the HSE in recent weeks. It took a bit longer to deliver those beds than we had hoped. It was hoped they would all be delivered in 2021 but they may not all be delivered this year, so it certainly took an awful lot longer. We need to fast-track that process. There is absolutely no doubt about that.

That brings me to the recent announcement, which I welcome, of the delivery of 1,500 beds across a number of hospital sites. Will the Minister provide us with more information on the timeframe for that? When are we likely to see those beds delivered and operational? Second, will those beds be fast-tracked and delivered at pace and as quickly as possible? What is the anticipated capital cost for those beds? Will there be a current revenue stream for them? I imagine that if we are putting 1,500 more beds into the system, we will need more nurses, doctors and so on. I appreciate, as I am sure the Minister will, that this will be a challenge, given that we already have difficulty recruiting staff. Will staff come with those beds? When will we see the beds and will they be fast-tracked?

I will give a local example. I received an email yesterday from the manager of the hospital in Waterford on a project and I would like to know whether it will be one of the projects that will fall under the 1,500 beds. The hospital made a submission in April 2022 for 160 additional beds. A capital projects lead is in place and is progressing the business case. She stated the progression of capital projects is now a lengthy process that has several stages. There is no clarity on any timeframes of when they might be delivered. Will this project for a 160-bed unit in Waterford form part of those 1,500 beds the Minister said he wants to see delivered as quickly as possible? In addition, I ask about the timeframes and cost if the Minister has that information.

Deputy Stephen Donnelly

The 1,500-bed accelerated plan is still working its way through Government. This is an additional project that is not included in the Estimates before us. It requires a lot of extra money. I fully agree with the Deputy’s statement that it takes too long to build things in this country when we have to adhere to the public spending code. The public spending code has, I think, 17 stages to it. We have tried to do a few things in our approach. We are looking at where it is possible to get a derogation on planning. I have taken the Attorney General’s advice on that. We are looking at areas where an environmental impact assessment, EIA, is not required. Sometimes they are needed and sometimes they are not. As the Deputy will be aware, we have issued an expression of interest internationally, specifically around modular build. We are also looking at using modular or rapid-build technology. The quality is just as good but it is much quicker, with fewer or no wet trades on site, for example. We will do batch jobs, have derogations on planning, where possible, including in areas where an EIA is not needed, use rapid build and have a limited number of tenders. My thinking is that there will be batch jobs of several hundred beds each, rather than having to go out to tender for every 50, 70 or 90 beds.

Deputy David Cullinane

Do we have to wait until budget 2024 for the funding for that or is that being progressed?

Deputy Stephen Donnelly

That has not been decided. My ask is that the relatively modest amount of enabling capital required be found this year. The much more substantial amount would have to form part of the Estimates process. That is the plan and it has been well received in Government but it is an ongoing process.

Deputy David Cullinane

On that, we have to prepare and do our job of holding the Minister to account and also put forward our alternatives, which can be quite difficult if we do not get information. I have asked the Department to come back to me with a note on how many beds were delivered over the last five years, which I would imagine should be fairly easy to get. How many beds were delivered and what was the cost of delivering those beds? That information was requested six weeks ago and I am still waiting for an answer. I got a document that did not answer the question. That is basic information. Could the Minister make sure that note is provided to me? It is not too much to ask for. How many beds were provided in the last five years and how much did they cost, in current and capital funding? That is not a big ask and it would give us a sense of how much this will cost. Given that this has to work its way through Cabinet, I am assuming the cost has not been finalised. Is there an estimated current and capital cost for these beds?

Deputy Stephen Donnelly

There is an estimated ballpark capital figure of €800 million to €1 billion. Then, as the Deputy quite rightly said-----

Deputy David Cullinane

Will all of that have to go into one budget or could it be staggered over a number of budgets?

Deputy Stephen Donnelly

In theory, we would love to see it in one budget because that would mean we would build all 1,500 beds next year but-----

Deputy David Cullinane

I am not saying it should be in one budget. I am just asking if it is more likely that it will be multi-annual.

Deputy Stephen Donnelly

Yes. It is more likely to be over several years. I would be very surprised if it were possible to do it one year. In the last three years, we have put in place about 970 beds. That is the fastest that beds have been put in place in a long time. Even with rapid build, dropping 1,500 beds in during one year would be a lot.

Deputy David Cullinane

In how many years would the Minister hope to do it?

Deputy Stephen Donnelly

We are working through that but we have to keep the focus on the fact that this is not meant to be a long-term or five-year project.

Deputy David Cullinane

I understand that.

Deputy Stephen Donnelly

This is not meant to be a five-year project. I acknowledge University Hospital Waterford's outstanding lobbying ability on beds there. That will be considered, which is all I can say at this point. I know University Hospital Waterford is looking for more beds and a lot of hospitals around the country are saying they would love to get some of those. The Department and HSE have already done a preliminary assessment and I will have a report on it within the next two weeks.

Deputy David Cullinane

I imagine the 160-bed unit would be separate from those 150 beds.

Deputy Stephen Donnelly

Which 150 beds?

Deputy David Cullinane

I meant to say the 1,500 beds.

Deputy Stephen Donnelly

No. It would potentially be part of that. We are looking at all of these asks from University Hospital Waterford, University Hospital Kerry, University Hospital Limerick and Wexford General Hospital. We want to try to find the ones that can be put in place quickly. For example, the Department might come back to me and say that this project probably requires planning and an environmental impact assessment and that it may not fit within the rapid build or that a specific build might be required to integrate the beds into an existing hospital structure.

Deputy David Cullinane

I will get back to the hospital management and make sure it is alert to all of that.

Deputy Stephen Donnelly

I think it already is; it is well aware of it. The proposal from University Hospital Waterford is being actively considered as part of the 1,500 beds but no decisions have been made on that yet.

Deputy David Cullinane

I want to ask the Minister about two separate local issues. I do not often use my opportunity to raise local issues but they are obviously important. There was a proposal to build an orthopaedic unit, a new stand-alone centre of excellence for University Hospital Waterford. This was announced a long time ago and the former CEO of the hospital group briefed Oireachtas Members in the south east on it about four years ago. Where is that in the capital approval process? Will we see it?

Comments were made by the Taoiseach recently, as the Minister knows, about the potential for 24-7 emergency cardiac services for Waterford. It was since clarified that this is still subject to review. I imagine the review the Taoiseach was talking about is the national review that was in train and was interrupted to some extent by Covid. We still have no sense of when that will be published. Given that this is an emotive and important issue, when are we likely to get some clarity on that? If the policy is that delivery of 24-7 emergency cardiac care for Waterford and the south east is under review, what does that mean? What is the review process and when will we see the outcome of that review?

Deputy Stephen Donnelly

The outcome of the review is the national work that Professor Nolan was doing. I have not received it yet. We were meant to get it some time ago but Professor Nolan ended up leading the Covid analytics work, which unfortunately delayed the cardiac work. However, I am expecting it soon and I agree with the Taoiseach’s position that any consideration of 24-7 care will be in the context of that report, which we do not have yet. The immediate focus is on getting the new lab open. The Deputy has been in it. It is state-of-the-art and an incredible facility with many of the staff are in place. There is an ongoing discussion around additional recovery beds for people who have been-----

Deputy David Cullinane

There are at least six if not eight who have been-----

Deputy Stephen Donnelly

-----through it. I have raised this directly with the chief executive of the HSE in recent days. We cannot have a situation whereby the new cath lab remains closed on the basis of additional beds. University Hospital Waterford got about 100 extra beds just before Covid arrived so whatever needs to be done locally needs to be done in order to get that lab open. I am supportive of adding the extra beds. There is no problem with that but we will not have a situation whereby the cath lab remains closed, even though it is fully staffed and ready to go, until these six or eight beds are fully in place. We need to move on and do it in parallel.

Deputy David Cullinane

What about the orthopaedic unit?

Deputy Stephen Donnelly

I will come back to the Deputy with a briefing on that.

Deputy David Cullinane

The Minister did not answer this point but I am assuming it is not unreasonable to ask how many beds were delivered and what the capital and current cost of those were over five years.

Deputy Stephen Donnelly

That is no problem.

Deputy David Cullinane

It strikes me as bizarre that we have to keep pushing and asking and then getting half answers. Surely it is reasonable for the Opposition to ask for simple information that should be provided quickly.

Deputy Stephen Donnelly

I am pretty sure we have that information.

Deputy David Cullinane

I have asked for it and I have not got it so if it could be forwarded to me, I would appreciate it.

Deputy Stephen Donnelly

I am pretty sure we have that information for additional beds. I am not sure if we have the information for mapping the exact cost of each of those beds. We certainly have the numbers for beds so we will get that to the Deputy.

Deputy David Cullinane

Surely the Department would know how much it cost. There is a problem if it does not. It is not about what we will do in the future but about what we have done. How many beds were delivered over the last five years and how much did they cost?

Deputy Stephen Donnelly

We will get that information for the Deputy.

An Cathaoirleach

It is on money spent. When Mr. Gloster and Mr. Watt were before the committee the general consensus was that additional beds are needed. The political will is there, including on the part of the Minister, to try to speed up this process. We all expressed a general frustration with the slow pace of the process. The Minister mentioned planning and so on but we all know of projects where there will be no problem with planning or impacts on the hospital footprint and so on. It is just a question of whether we can go from that agreement to the next step of giving those projects the go-ahead. At that meeting, general frustration was expressed by everyone. Collectively, we need to get this sorted. I therefore welcome the Minister’s statement that he is seriously looking at trying to address the issue. Does Deputy Durkan want to contribute again?

Deputy Bernard J. Durkan

I do because this morning's discussion would see the need for setting up a new department of frustration where public representatives who have raised questions, such as those we have been listening to this morning, including those raised by the Minister, could vent their frustration rather than allow it to affect their health. We have dealt with an important issue this morning. I am not joking about this because all of these issues have been raised again and again and it is like dragging a donkey through a bog. It is so slow getting to the nub of the conversation and the person who might be responsible.

For example, I mentioned reimbursements earlier, as did other members, and we saw in recent days how certain reimbursements in respect of treatment outside the State were not made at all, even though they are due and are entitled to be made or else the patient should not have been sent abroad in the first place. It is extremely trying for public representatives and Ministers to tell the public that a matter is on the long finger but that they do not know how long the finger is and when a resolution to it will be reached. The time has come to cut to the chase and let people know that they should not have to go to the Ombudsman to get paid. First, it is important from the point of view of the standing and good name of the State. To get the reputation of not paying one's bills is not something we should be into.

I mentioned reimbursements - I spoke to the Minister privately regarding this - in respect of people who have had life-threatening or life-changing conditions and have looked for a full medical card but have been refused again and again. I would love to know what the people who make these decisions do for recreation because what they are doing is tormenting people unnecessarily. In those situations, what is needed is to look beyond the income of the household. That income may be above the income guidelines, which, incidentally, are not very high either. We should look beyond that and look at the hardship side of it.

The hardship area covers a multitude, including medical cards and particular, specific issues, but it is impossible to find somebody to answer a question straight. We can table all the parliamentary questions we like, and I raised some of these questions under Topical Issue Matters as well, to try to concentrate on a particular issue, but nobody cares. Nobody bothers and nobody tries to go down to the individual patient and say he or she is suffering from a very serious illness or an accident that occurred in hospital. He or she may have complied with all the issues, including providing a GP report, a hospital report and every possible piece of information that could be necessary. What is the answer? He or she to make a new application. Appalling carry-on like that is going on. It is repeating the dose again and again and sending the person around in circles. I am beginning to get very angry about it. I am not blaming the Minister or any individual for it but I will tell him one thing: it will come to an end very quickly. There needs to be a direct address of that issue in the short term.

I will finish on one other matter, that of primary care centres. We need to know more about the roll-out of primary care centres throughout the country. We also need to know more about the extent of the facilities in the individual primary care centres and how well they are working. Are they all of a modular construction so that, for example, in later years, if it is necessary to add on to a particular centre, it can be done without having to wait four or five years to do it? Some of the primary care centres I know are very successful and do a great job. The original intention was they would replace accident and emergency departments, to some extent, and GPs could work from them and provide a greater level of care as a result. I recall being in a primary care centre equivalent in Northern Ireland some years ago. I was very impressed. All services were provided, including out-of-hours services on a Sunday afternoon. There was no question of having to find a hospital for someone to go to at that stage of the day. There was none of that kind of nonsense. The patients were attended to straightaway. These were simple issues that could be simply dealt with. I know all primary care centres are not similarly designed. I believe they should be, within reason and within site constraints and so on but, for example, there should not be a vast difference between them. Someone should not have to climb a ladder, or go up a long stairs or lift or something, to gain access to the place. The patient has to be considered. How do the patients feel when they come on-site? The patient may be in a wheelchair or on crutches, whatever the case may be. We need to consider the point of view of the patient.

The Minister raised the issue of scoliosis, spina bifida and so on and so forth. We have talked about that subject many times at this committee over the past number of years. We had a consultant who did some experimental work and carried out the services, to a great extent, for a limited period. However, for whatever reason we do not know, it was decided to again put this on a waiting list. It is the old long-finger stuff, as far as I can see. Again, we do not even know how long that finger is. There is a necessity to ask whether we have the facilities, people and personnel ready, willing and able to carry out this very much sought facility for quite a large number of patients and children who require the service now and not in some far-off distant future that nobody considers. To a patient who has a severe illness, six months is a long time. A year is a long, long time and it goes on for longer than that as well. I ask the Minister to call in those responsible to say we have had enough of this nonsense. Let us do it now. Let us show the public that we can do this in the way we should do it in the shortest possible time.

An Cathaoirleach

The scoliosis issue, for instance, is not a financial problem. The waiting lists are not due to a lack of finance.

Deputy Stephen Donnelly

No. I allocated a very substantial amount to scoliosis. I met all concerned towards the start of last year. There is a very dedicated team there and we allocated a hell of a lot of money. The waiting lists have not come down in the way we were told they would and the way we all want them to come down. However, it is important to acknowledge what has happened. In 2019, which is the comparable pre-Covid year, 380 scoliosis procedures were done. Last year, 509 were done. That is approximately a one third increase. It is almost a 50% increase versus the previous year but that was a Covid year so it does not really count. In fairness to the people involved, they took the money, put in more resources and funded it over time. Cappagh hospital was brought in and it has done a fantastic job through its Cappagh Kids department, for example. The total number of children being seen has gone up by a third. That matters. The extra challenge we have is almost that number again came in through additional unexpected referrals and, therefore, the waiting lists did not fall to the level they should have.

A few extra things are happening this year. The fifth theatre in Temple Street hospital got delayed. It was meant to be up and running and open by the end of last year. It was not. It got delayed but I intervened and it is back on track. That is being put in place. My numbers will be slightly wrong so forgive me but approximately 20 additional beds were to be put into Children's Health Ireland, CHI, as well. From memory, approximately half of them, either eight or 12, are in place, while the other eight or 12 are being put in now, and more healthcare professionals are being recruited. I fully expect to see, and I will have this conversation with the teams involved in the next few weeks, is that number of 509, which is an important increase, going up a good bit again. Critically, however, we will then see the length of time these children are waiting going down. We are fully committed to children not waiting more than four months. That is what has been agreed with the scoliosis advocacy groups and that is what we must achieve. It is nothing to do with money as there is more money there than can be spent.

Primary care centres are another good news story. We now have 165 primary care centres throughout the country, 18 of which became operational last year while 12 more are scheduled to become operational this year. I am opening three before Friday evening. I opened two others last week. It is a great news story because, to the Deputy's point, these are not old bockedy community healthcare centres. These are state-of-the-art facilities, many of which have diagnostics that have down really well. There are diagnostics in Bray in my constituency, for example, and patients cannot believe they are now being referred for a scan by their GP. That is now free whether someone is a medical card or private patient. The State is paying the full cost and, in more and more cases now, patients are going down the road to their local primary care centre and getting their X-rays, which are going straight back to the GP.

I opened a primary care centre last week. It was amazing to see and the incredible passion among the community care teams can be seen in all of them. They told me, in what was quite a rural setting, they had come from an almost dilapidated single room to this modern, big, state-of-the-art multidisciplinary facility.

That has been happening all over the country. In terms of the staff, as the Deputy will be aware, we allocated 3,500. Most of those are now in place and the advice I have is that the rest of them will be in place this year. Nearly 3,500 staff will be in place and this is already making a big difference in respect of bedding and to the GPs.

Turning to the Deputy's question on the primary care reimbursement service, PCRS, or medical cards, we must always strive to get better. No more than the Deputy himself, I have numerous examples of constituents who have been trying in good faith to get medical cards and they might get something back telling them the documents cannot be returned or that they were out of the statutory number of days. Even if it was one bit of information that was left out, people get a letter back apologising, pointing out they did not provide a certain bit of information, the X number of days has now passed and the applicant needs to reapply. The staff members in the PCRS team are not trying to be difficult, rather they are implementing the rules. It is, then, up to us to change the rules. I would be open to an audit being done to ensure this system works better for patients. As we all know, much of the time when people are applying for these medical cards it is happening when they are already under great pressure. It might be a case of someone in the family having got very sick or whatever it might be. Anything we can do to make it easier for patients, we must consider.

Deputy Bernard J. Durkan

I thank the Minister.

An Cathaoirleach

On that point, regarding the challenge for many people who are seriously ill, I will give the Minister an example. One person with long Covid-19 is on oxygen 24 hours a day. His medical card is running out. He has been asked to get bank statements and information in respect of his income. He needs to get a letter from his doctor and this means trying to visit his doctor. It is also necessary to try to get letters from the consultants and so on. This is a man who is on oxygen 24 hours a day. He has to get a taxi everywhere and he must pay for the cost. This is just one example of someone who is seriously ill and is trying to comply with the challenges he has been faced with in dealing with the system. This man has tried everywhere in respect of his application. In many instances, when people are ringing hospitals and trying to get letters etc., it is not possible to get through. There is not even a system for us as elected representatives to assist. If we could get those letters, then we could put them in the system. Even trying to go online to upload documents is a challenge in itself for many people, especially for those seriously ill. If it were possible to have a system that would simplify this process, then we would all be very supportive of it.

Deputy Stephen Donnelly

Yes. This is one of the many examples of where we are a lot better than the narrative would have us believe. The public and political narrative around healthcare, for all the reasons we understand, is all around what is not working. We would be forgiven sometimes for believing we have a terrible healthcare system that does not work for anybody. In fact, notwithstanding the issues of access, which are hugely challenging for patients, the quality of the clinical care provided is second to none. We have the highest life expectancy now in Europe and we do very well in perinatal mortality rates, infant mortality rates and increases in survivorship rates. One of the areas, however, where we really are laggards is in e-health. I refer not just to systems within the HSE where one's GP, the hospital doctor and the practice nurse can all see what is going on but, as the Cathaoirleach and Deputy Durkan referred to, the ability of citizens to be able to access their health information, be that eligibility information or their own health information. We are laggards in this area.

We are doing major work in respect of putting together a proper e-health strategy and focusing on not just the big complicated stuff that takes many years to put in place, such as the major integrated systems, but also on shorter-term, basic improvements for patients to allow them to see their own basic information. The committee will be aware that yesterday, I got agreement to get the proposed health information Bill fully drafted. We will then send that proposed legislation to this committee as soon as possible for pre-legislative scrutiny. We are not waiting for that proposed Bill. In the meantime, and in parallel, we are going to be funding and building the system. It is certainly, though, an area where we are behind. It is one we are taking seriously and there is a great deal of work to be done. In time, patients will see real improvements in exactly some of those areas referred to.

An Cathaoirleach

I apologise to the Minister and his officials because I know we are drifting off the Estimates.

Deputy Stephen Donnelly

The Estimates contain several hundred million euro for e-health. There is a lot of money in there.

Deputy Colm Burke

It was in fact this very issue that I wished to raise with the Minister. I refer to the computerisation. To give an example, I think four or five of the maternity units have become fully computerised but another 14 of those units have not. Can all this work in this area be fast-tracked now? The computerisation has worked in four or five of the units, so why can we not do it in all the remaining units of the 19 in total?

I accept what the Minister is telling us regarding several hundred million euro going into this work this year, but can we set out a clear programme through which we can try to achieve an end result where everything within the health service will be computerised? I remember raising this issue eight to ten years ago in the context of the Danish system, which dates back to 1996. That country ended up with about 25 different systems and now it is working down to having five systems. We have a long ways to go to even get down to 25 systems. I am wondering about the timescale in this regard and if we can set out a clear plan, whether that might be a three, four or five year plan. We should at least have targets in place and try to get this reform implemented.

Deputy Stephen Donnelly

The answer is "Yes". I fully agree. There was a 2013 strategy. It did not really happen because it never got funded, to be honest. It should have been funded. We would probably all agree, with the benefit of hindsight, that the project should have happened but it did not, for whatever reasons. A new strategy is now being finalised and we are looking at the period from 2023 to 2030. The HSE and the Department have done a great deal of work. They have engaged with international experts on this endeavour. As I was saying, I have asked them, first and foremost, to build this undertaking around the patients. The question to be asked is whether this will make things easier for the patients. Most things to be tracked back to this point. Equally, let us not hang our hat on some ten-year megaproject. Let us ensure we can deliver incrementally to make things better. Taking the example of the maternity hospitals, the aim is by the end of next year to have 70% of babies born covered by the maternity electronic health record service. We will then be moving on from there.

Deputy Colm Burke

Okay. The Minister is talking about a plan to 2030. It is very spread out. The best example I can give about Cork is if people go into Cork University Hospital, CUH, they will get a paper file. If they were to end up in the Mercy hospital 12 months later, they will then get a paper file there. If they were to be in the South Infirmary two years later again, another paper file will be created for them. It is just so difficult for medical practitioners to find out exactly what is the medical history of a patient whereas with a computerised system, all the information could be retrieved by pressing a button. I know there is a lot of work involved in achieving that ability, but is there any way we can shorten the timeline of this implementation of computerisation? I know there is no point in thinking in the short term and then not achieving anything. This undertaking is something we must prioritise, though, because in Denmark and all the other European countries major savings are made by having an e-health system. Significant savings were made in staff time and other efficiencies. This is, then, something we really need to prioritise.

Deputy Stephen Donnelly

I could not agree more. Probably the single greatest frustration raised with me by NCHDs are the IT systems. They cannot get their heads around having to queue up to use laptops to access patient files. It makes no sense and it is deeply frustrating for them. It is also frustrating for patients. I was in Canada recently for the St. Patrick's Day period and I spent a good deal of time talking to IT and e-health experts there to see what was being done in the various provinces in that country. The Department has been looking around Europe and the world to see who is the best at this. Turning to the Deputy's point as to whether we can get things done quickly, yes we can. The way we can get things done quickly is to break this up into different projects. There is a big project where we would choose the likes of Epic or Cerner, the big electronic health records platforms that are all singing and all dancing and go across community and acute healthcare settings.

That takes time. Those projects take several years. In the short term, there are things we can do. We can have summary care records. We should be able to give patients even preliminary or basic access to their own healthcare information. We have to get electronic summary care records into community care. They are still carrying around paper files. We will then roll out the maternity service, the National Integrated Medical Imaging System, NIMIS, and other services and, critically, begin to integrate those services. NIMIS carries the scans. The maternity record might carry something else and the GP records, most of which are on the system called Clanwilliam, carry something else. The question is: how do we bring all of that together and start to integrate all of that information, first and foremost for the patient, and second, for the healthcare providers?

Deputy Colm Burke

I believe the Minister accepts there is a huge saving if we have this in place. It is already working in the maternity service. Where it is place, there is a huge saving. It is extremely helpful for medical practitioners, for nurses and for administrators where the system is up and running in the four or five maternity hospitals.

Deputy Stephen Donnelly

I fully agree.

An Cathaoirleach

I thank the Minister, Deputy Donnelly, and his officials for attending our meeting this morning. It was very useful. I apologise if we drifted off the main issues but I believe the issues were relevant to the Estimate.