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Select Committee on Health díospóireacht -
Wednesday, 31 Jan 2024

Vote 38 - Health (Revised)

Seán Crowe

An Cathaoirleach

Apologies have been received from Deputies Colm Burke, Gino Kenny and Róisín Shortall.

The purpose of the meeting is to consider the 2024 Revised Estimate on Vote 38 for the Department of Health. I welcome the Minister for Health, Deputy Donnelly and the Minister of State with responsibility for public health, well-being and national drugs strategy, Deputy Naughton. I thank them for the provision of a briefing note on the Estimate. Members will have noted the correction notified by the Department of one figure in that briefing note.

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

Members are also reminded of the long-standing parliamentary practice to the effect that they should not 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 they must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit a member to participate where they are not adhering to this constitutional requirement. Therefore any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any member participating via MS Teams that, prior to making their contribution to the meeting, they confirm they are on the grounds of the Leinster House campus.

To commence consideration of the Revised Estimate, I invite the Minister for Health to make his opening remarks.

Stephen Donnelly

Minister for Health (Deputy Stephen Donnelly)

I am happy to be before the committee to consider the Revised Estimates for the Department of Health for 2024. I will be joined shortly by my colleague, the Minister of State, Deputy Naughton. She sends her apologies. She is taking a Private Member's Bill in the Dáil at the moment. I am joined by officials from my Department, Ms Louise McGirr, Mr. Kevin Colman, Mr. Patrick McGlynn, Ms Aonraid Dunne and Mr. Trevor Moore.

Over the past four years, the Government has delivered record levels of investment to the health service. This has led to a significant increase in the number of healthcare professionals we now have working in our public service. In fact, there are now more than 26,000 more healthcare professionals than there were at the start of 2020, which is a 22% increase. It includes more than 8,000 additional nurses and midwives, more than 4,000 health and social care professionals, and almost 3,000 more doctors and dentists, including approximately 1,000 hospital consultants. We have increased our acute hospital bed capacity by 1,126 beds since the start of 2020. This significant investment was badly needed, and certainly our healthcare professionals are putting it to good use on behalf of patients. In the post-emergency pandemic phase, we, like many other countries, have seen extraordinary increases in demand for services. Unfortunately, we are seeing this against a backdrop of high inflation, especially in the healthcare world. Of this year’s funding allocation, the majority is focused on absorbing price inflation and meeting growing patient demand.

Looking forward to this year, the priorities continue to be the reduction of waiting lists and delivery of ongoing improvements to urgent and emergency care, particularly reducing the number of patients on trolleys. Last year was the second year in a row that hospital waiting lists fell, with 1.74 million patients treated and removed from waiting lists. More than 177,000 more patients were removed from our waiting lists last year compared with the year before, 2022. I fully acknowledge we have a way to go, but important progress is now being made year by year. It is fair to say the figures that matter most to us are the agreed Sláintecare figures, that is, the number of people who are waiting more than the agreed ten to 12 weeks. That is our core focus in all our waiting list activity. We set a target last year for a 10% reduction in the number of people waiting more than ten to 12 weeks. It was an ambitious target and I am pleased to be able to report to the committee that we have exceeded that target. We have had an 11% reduction. It equates to 57,000 fewer men, women and children waiting for hospital care than at the end of 2022. It is great to see. Since the pandemic peak, there has been a 27% reduction in the number of people waiting longer than the agreed Sláintecare targets. That is approximately 170,000 people. I pay tribute to the extraordinary efforts of healthcare workers who have worked extremely hard by working additional sessions, later hours and weekends, innovating to treat people in the community and so much more. We are really seeing the benefits for patients of all the work of our healthcare workers. Significant funding has been allocated this year to further reduce waiting lists. We will also continue to prioritise and invest in reducing the number of patients on trolleys and, more broadly, in building a robust responsive national urgent and emergency care service.

While we face real challenges in some of our hospitals, it is important to acknowledge that many of our hospitals are performing well in reducing the number of patients on trolleys. Nationally, the number of patients on trolleys in the second half of last year was down by 20% compared with the same period in 2022. I am by no means suggesting the job is done. It is not. We see constant pressures in certain hospitals but we are moving quickly in the right direction at a national level and we are focusing more and more on the hospitals that are under the most pressure.

We will continue to invest in our workforce this year, including the full roll-out of safe nurse staffing, the expansion of student nurse and medical education places, and the ongoing roll-out of the public-only consultant contract. The latest figure I got last night is that 1,700 consultants have now signed up to the new contract. I was reporting 1,500 only two weeks ago. There is a lot of appetite early this year, which is great to see.

We will also be prioritising the ongoing expansion of health infrastructure, which is badly needed. As colleagues will be aware, I have committed to funding staff and capital for six new surgical hubs, 162 additional hospital beds, 22 ICU beds, which are of importance, and 160 community beds.

We are increasing our investment in digital health. Ireland is a laggard in digital health. It is an area we need to improve. A new patient app will begin to allow patients to see their information for the first time in this way. We are investing in virtual wards, the use of more telehealth and progressing e-health initiatives such as shared care records. All these projects will have a real impact for patients and healthcare providers in providing the best possible care as quickly as possible.

I am also pleased to announce that we are substantially increasing our investment in mental health services again. I am acutely aware, as are colleagues, of the pressures on our youth mental health services, especially on CAMHS for those who need the widest interventions and deepest supports. This year we have put an additional €44 million into mental health services. The Minister of State, Deputy Butler, and I announced an additional recurrent fund of €10 million specifically for youth mental health with a clear focus on CAMHS and continuing to reduce those waiting lists.

I am funding a range of other measures including: free contraception up to the age of 31, which will bring our significant investment in the free contraception scheme up to around €43 million for 2024; better and wider availability of PrEP; progressing the diabetes patient register; and progressing our genetics capacity with the continued build-out of genetics and genomics in healthcare delivery. This investment prioritises the recruitment of specialist staff and will increase the accessibility of genetic and genomic medicine service for patents across the country. This is a very exciting area of medicine in terms of being able to do more and more for people.

To support the incredible levels of activity and to address some of the financial challenges in 2024, the health service has been allocated additional non-core funding of €1.032 billion. This funding will increase population protection from Covid through vaccination programmes and ongoing monitoring. It will reduce our waiting lists through in-sourcing and the use of additional private capacity and will increase our capacity to help us manage our patient flow. This is going very well in some hospitals but others have a way to go. The additional funding will also support community groups in areas of mental health, older persons, and social inclusion. Approximately €432 million of this money will be allocated to our health resilience fund to provide for the cost of additional goods and services in acute hospitals as well as investment in technology and information systems, particularly the integrated financial management system, IFMS. Despite the provision of a significant amount of additional non-core funding, it is entirely possible that there will be a substantial supplementary Estimate required later this year due to inflation and growing patient demand. We flagged this at budget time and are flagging it again now as we look to the Revised Estimates.

On reform and productivity, I am committed to delivering a significant programme of savings and improved productivity. I recently established a productivity and savings task force, which has started to meet. The purpose of the task force is to ensure the most efficient use of existing funding and to provide as many services to as many patients as possible, while at the same time meeting the needs of a growing and aging population. While we have succeeded in substantially increasing activity in our hospitals, with better outcomes for people, this has come at an increasing cost. Investment in acute hospital care has increased by more than 80% over the past seven years, from €4.4 billion in 2016 to €8.1 billion in 2023 and now makes up over a third of our overall spending. The quality of care has undoubtedly improved. We can see this through improved outcomes and experiences for patients. While activity has increased, the number of patients treated needs to keep up with the additional funding but I am not yet satisfied this is the case. In fact, we have pretty clear information showing that the volume of patient care is not keeping up with the increases in funding. The increase in funding is not matched by increases in the level of patient care, and that will be the core focus of the productivity task force. Even accepting improvements in outcomes, there is a significant divergence between resourcing and activity and this is something we are going to address. Indeed, addressing this productivity puzzle will be a top priority for me, the Government, my Department and the HSE this year.

Seán Crowe

An Cathaoirleach

Thanks very much, Minister. Just before we get into the cut and thrust of the meeting, which is an examination of the Revised Estimates, I want to inform the Minister and his officials that a delegation from this committee travelled to Derry in the last two days. We met representatives of the Western Health and Social Care Trust and visited Altnagelvin Hospital and the Ulster University campus in Derry. We were looking at North-South co-operation and some of the facilities involved, particularly the roll-out of cancer and cardiac care at Altnagelvin Hospital for people in the region. There are lots of positive things happening there. We all welcome the most recent developments in the North and look forward, in particular, to the Northern Ireland Executive being re-established. Of course, a key component of progress will be the continued roll-out of North-South co-operation in the area of health. We look forward to the North South Ministerial Council being reconvened.

One of the issues that arose during our visit was continuity of care for cardiac patients and the committee will probably be submitting recommendations on that to the Minister. The visit was worthwhile, even if we were mainly talking to officials. A lot of positive things are happening in the region for patients, with very good outcomes. One in five of those attending Altnagelvin Hospital for cardiac services were from Donegal. Such patients would previously have had to go to Galway or Sligo for services, but the hospital in Derry is right on their doorstep. It makes sense for everyone that we continue with this co-operation in the area of healthcare. Disease, as we all know, does not recognise borders and we saw that clearly during the pandemic. Whether we are talking about disease in humans or in livestock, it is essential that we continue to co-operate and build on the cross-Border work that has been done to date. The trip was very worthwhile. While there are many issues that might divide us in the context of North-South co-operation, health is one area where we can continue to work on behalf of patients and those seeking healthcare in the Border region. I just wanted to inform the Minister and his officials that the committee might be following up on some of the issues that came up on the trip.

The first speaker is Deputy Durkan.

Bernard Durkan

Deputy Bernard J. Durkan

I thank the Chair, I echo his views and remarks and I acknowledge the benefits of North-South co-operation. Such co-operation is equally beneficial to patients on both sides of the Border. Everyone benefits from it. I offer my congratulations to all involved.

I congratulate the Minister on the delivery of health services over the past two or three very trying years. In what were very difficult circumstances, doctors, nurses and other front-line workers, as well as those in the back line, worked way above and beyond the call of duty in order to maintain services and ensure that the best decisions were taken, in quick time, to protect the health of our community and, as a result, that of our economy. All of those involved can take a bow. While the health service comes in for a lot of criticism, some of it warranted from time to time, it must be acknowledged that a huge job of work was done without demur and that continues. Long may that be the case.

I want to refer to a couple of points the Minister made. He referred to the fact that the delivery of services had not necessary kept step with the significant increases in resources. That has to be the intention and the target into the future. Every effort has to be made to ensure that is seen and recognised by everybody. We spend a lot of time in this House, and elsewhere, criticising the health service. None of us is above criticism and no sector is above criticism. We must endeavour, in so far as we can, to meet those criticisms, whether warranted or not, and deal with them.

The Minister referred to CAMHS. This service, which was the poor relation for many years, has gotten even poorer but that cannot follow. We cannot continue down that road. We need to bring that service up-to-date rapidly and make sure that patients have a safe place to go to receive the appropriate treatment. They should not have to wait an extraordinary length of time for a diagnosis, report, follow-up or the services they cannot access, for reasons we cannot always understand. It is a priority that be done forthwith.

I congratulate those behind the initiative and experiment taking place in Naas whereby the primary care centre has taken over responsibility, on a pilot basis, for carrying out minor operations and dealing with sprains and other minor things that can be effectively dealt with in the community care centre. I saw such an initiative in Northern Ireland 20 or 30 years ago. Primary care centres were able to engage with patients and deal with them in the same way as they would be dealt with in a hospital emergency department. They could do so more quickly and there was no negative impact on the accident and emergency department. That experiment should be looked at carefully to see how it works and, if possible, it should be replicated as quickly as possible.

I recently mentioned in the House the fact that I have, in another capacity, had need to visit two, three or four accident and emergency departments in recent times. What I saw was not ideal from the point of view of the public health services. In particular, I refer to the attitude of some patients who are regular attendees at accident and emergency departments towards staff. They were extremely abusive and used threatening language and gestures. At all times, they engaged in appalling and foul-mouthed abuse. That is not supposed to go on in our accident and emergency services. There are people who go there for attention because they are ill or worried, many of whom have never been in an accident and emergency department before, and who are intimidated by this nonsense. I saw fights break out. People wielding crutches who had already been admitted to the hospital came back out to the emergency department to indulge in warfare. That kind of thing just cannot go on and cannot continue. No accident and emergency department anywhere can be run that way. Staff cannot be expected to put up with that kind of nonsense. First, it is a distraction and, second, it is intimidating. If there are people who are out of their minds with drugs, drink or whatever it is, they should by all means be attended to, but it should not happen in the same accident and emergency department. There should be a different place down the corridor so that they know where to go and do not intimidate other people who have an urgent need to attend a hospital accident and emergency department and who need an early diagnosis. I ask that particular attention be given to that aspect or facility of our health services at the earliest possible time.

The health service, the HSE and the Minister have been criticised lately for a stall, slowdown or pause in recruitment. There has been significant recruitment and a very great increase in personnel in the past 12 months. That is to be welcomed. We need to welcome and acknowledge it where it happens and record our appreciation. It is not all bad news. It might be the thing to do to spread bad news. Maybe it is part of our culture. Maybe we love that kind of thing. However, we have to acknowledge the work that is being done, the basis on which it is being done and the people who do it in difficult and trying circumstances. That is the first general part. Perhaps I could have some replies or responses to that.

Stephen Donnelly

Deputy Stephen Donnelly

I thank the Deputy for that and for the acknowledgement of the work that healthcare workers have done. Every one of us, including every member of the committee and myself, talk to healthcare workers a lot. We in the Oireachtas quite rightly focus on what is not working, as does the media, because those are the areas in which we need to redouble our efforts. However, there is very little discussion of all of the progress being made relative to the very real challenges that exist. It gets to healthcare workers and demoralises them. I used to work with the NHS in the UK and I found the same thing. They are working in a world where all they hear about is the bad. There are challenges and we must not shy away from them but it does get to them and it is important that they hear from the Deputy and from us in the Oireachtas that their efforts are appreciated and, critically, that their efforts are working on behalf of patients. They are not working perfectly or universally, but they are working.

I certainly echo the comments of the Chair and Deputy Durkan regarding the North and the South. If there is any sector where an all-island approach is in the best interests of every man, woman and child on the island, it is the healthcare sector. We had a fantastic announcement recently regarding a North-South initiative, Daisy Lodge. The Altnagelvin Donegal-Derry-Letterkenny partnerships are essential. I echo those comments and look forward to seeing any note that comes through.

Productivity is a core focus. We have done a lot of work on this over the last two years and what we have found is that some areas are doing very well and other areas are not. Some individual clinical teams are doing very well and others are not. There are big differences between hospitals and between specialties. There are some significant differences over time. We now have the information systems in place. Over the past two or three years, we have put in the things we need to enable more productivity, like moving from five days a week to seven days a week, the new public health contract, safe staffing and the beginnings of new IT systems, which are long overdue. We cannot just demand productivity. We have to support our healthcare workers in achieving productivity. In recent years, we have been putting those supports in place. We now have a big focus on it. I will finish on this but I will come back to the other points the Deputy raised if there is time. I have spoken with experienced senior clinicians in the health service about this productivity challenge and they are up for it. They are up for the challenge and up for treating more patients, but we have to help them. We cannot just tell them to work longer and harder. They need the necessary IT systems, outpatient clinics, access to theatres and flexibility in their contracts. We have to help them to do it but those I have spoken to are very much up for the challenge on behalf of patients.

Bernard Durkan

Deputy Bernard J. Durkan

May I ask another question?

Seán Crowe

An Cathaoirleach

The Deputy may go ahead. The floor is his.

Stephen Donnelly

Deputy Stephen Donnelly

I am sorry to cut across but, if we still have time, I can come back to the other questions. Does the Deputy want me to keep going?

Seán Crowe

An Cathaoirleach

I am flexible this morning. We do not have a big attendance so let us get the conversation going.

Stephen Donnelly

Deputy Stephen Donnelly

On CAMHS, I could not agree more. Youth mental health needed significant investment but it needed more than that. CAMHS is what we talk about most but we must bear in mind that it is for one in 50 children and young people who need mental health support. The other community-based supports are for the other 49 in 50. We must invest there as well. Specifically on CAMHS, the services needed more resourcing and investment. That is happening. Even though the new development funding was tighter this year than in previous years, the Minister of State, Deputy Butler, and I made sure that funding was ring-fenced to fully staff up the CAMHS teams around the country. However, that is not enough on its own. The Deputy will be aware that the Minister of State and I were very keen for there to be a national clinical lead and a national operational lead, very much like we have for the national women and infants programme or the national cancer control programme, which work very well. We needed that in CAMHS and a really impressive lady called Dr. Amanda Burke has been appointed clinical lead.

She is a very experienced psychiatrist. We have had several conversations about what needs to be done and she is very clear about the need for capacity but also reform. For example, the teams around the country do not have standardised protocols that are available in many other specialties. They do not have the level of IT systems they badly need. They do not have the joined-up referral pathways they need in the way some other specialties have. The supports for the healthcare professionals to do the job they want to do have not been in place.

On the back of that, Dr. Burke met with the Minister of State, Deputy Butler, and me. I and the Minister of State, Deputy Butler, asked her to come back to us with the programme of work Dr. Burke thinks is needed and we will fund it. So that the committee will be aware, of the €92 million additional new development funding we got in December, I have allocated a full €10 million to youth mental health, but with the main focus being on CAMHS. That is what will fund and grow out those services. If they need capital, obviously, we will give them capital as well.

We supported it through the waiting list action plan last year as well and more than 1,000 children got the treatment they needed and, therefore, were able to be removed from the waiting lists. We need to keep going with that. We need to keep going with the waiting list plan, which are short-term but important solutions, while building up the full service.

Unfortunately, the latest information we have is quite old because the Fórsa staff are refusing to provide waiting list information on the number of children who are waiting, which obviously makes it very difficult to respond to the needs of those children. I do not believe they should be withholding that information but they are.

Bernard Durkan

Deputy Bernard J. Durkan

Can the Minister circumnavigate that?

Stephen Donnelly

Deputy Stephen Donnelly

Not really, no. My view is what they are doing is not right but they are doing it and we do not have the information. What we have is information from last summer which showed a fall from 4,600 people to 3,900. We have to continue that through this year and accelerate it. I am confident the additional funding, along with the Minister of State, Deputy Butler's political leadership and the clinical leadership of Dr. Burke and others - we have a national operational lead in place - will make a big difference. We are fully committed to making sure children and adolescents get the care they need when they need it.

Bernard Durkan

Deputy Bernard J. Durkan

A special appeal should be made to the staff who are not providing the information required, and that appeal should be made on the basis of the vulnerability of the patients who need the services available through CAMHS as a matter of extreme urgency and have never had the services for some years. I mention that particularly.

I should not fail to mention the passing of Dr. Ivor Browne, who majored in that area for many years and was a pioneer in many of the things he did. Unfortunately, the follow-up by others, not by him, was not always there. He led the charge. We should recognise the contribution he made.

Whenever our public hospitals get challenged in an area in terms of waiting lists, accident and emergency or whatever, it has to be possible to select a number of patients who can be referred elsewhere. That is being done already in most cases under the treatment purchase scheme. If there is a private hospital available within 25 miles, 30 miles or 40 miles, as there usually is, I see no reason the public health services cannot contract out the requirements in those cases, alleviating the waiting times in the public hospitals and providing the service of considerable benefit to the patient. That would not in any way cut across the Sláintecare programme. In fact, it complements that programme. For instance, in cataract treatment, there are several hospitals in the country and, in recent years, we have organised coaches bringing people out of the jurisdiction. That is fine, but if we can get the service provided beside the patients, that is of much more benefit than bringing the patient on a tour of the country to get the same service. The expertise and the technology is readily available.

On the question of the availability of a second opinion, the GPs are doing this to a fairly considerable extent and are online and linked up to consultants who can quickly give an opinion on something. Some hospitals still require that. They do not have the same degree of link-up they feel they should have. I would ask that we take a look at the extent to which various hospitals, health centres or primary care centres can avail quickly of that expert opinion online because it may fill a need that is not only urgent but vital. In recognising, for instance, the need to get a quick diagnosis, there is no sense in having the diagnostic elements in public or private hospitals. They do not have them in private hospitals, but in public hospitals it is hugely important. We have spoken previously about the tragic circumstances in two cases whereby the delay in the diagnosis and the diagnostic process was directly the cause of persons losing their lives. That should not be. When a person goes into hospital, he or she is supposed to be in the right place with all the expertise around, but sometimes, for whatever reason, an initial diagnosis or examination is not made with sufficient intensity to identify the seriousness of the condition the patient is in at the time. We need to address that.

Stephen Donnelly

Deputy Stephen Donnelly

I thank the Deputy. I might address his two points together because they are linked, namely, the private hospital capacity and accessing expert opinion. Specifically on accessing beds in private hospitals, there is a new private hospital framework that was put in place in December. It has various protocols in terms of surge and being able to access more beds as needed. Some hospitals are using it very well. I am not convinced it is being used to the fullest extent in all of the hospitals, especially in some of the most pressured areas. There is more private capacity available than is necessarily being used.

There are other things we are doing. We are now sending specialist teams to nursing homes in terms of moving patients out of the hospital. The HSE is extending GP access to community diagnostics to out-of-hours, which will help as well.

I fully agree with the Deputy's points on accessing expert opinion. That is a central piece to this fundamental shift from hospital care to community care, a shift we are in the middle of. The Deputy will be aware of the chronic disease management programme. GPs can now access consultants, nurse specialists and advance nurse practitioners, either online or in the hubs, for exactly this reason. We are seeing it with the three pathways we have under chronic disease management. We are adding a fourth, which is hypertension, which will make a big difference. It is a big killer and one where the mortality rates have not fallen at the rate they have fallen for other things over the past ten to 50 years. That will make a big difference. Diabetes, respiratory and circulatory, essentially, are under CDM. The GPs I have spoken to love it. They are saying they have a patient with a heart problem, they do not quite know what to do but they can have a five-minute call with a cardiologist in St. Vincent's who can advise. It is going very well. In fact, last week I was talking to the St. Vincent's team which has one of these hubs in Bray, in my constituency. They have just surveyed the patients and 96% of the patients said they preferred this model of care rather than having to go to the hospitals for all of the reasons the Deputy laid out.

The big investment in advance nurse practitioners is making a difference. I was in the Royal Victoria Eye and Ear Hospital last week as well, looking at some of the modernised care pathway work.

This particular one is for cataracts. At its core, the point is that consultants do not need to see everyone who is coming in. Advanced nurse practitioner teams can actually see a significant number of those who would otherwise have to wait to see a hospital consultant. Believe it or not - I had to double-check the figures I was being shown in order to ensure I understood them correctly - the waiting time for a cataract appointment has been reduced from several years to several months through this pathway. It has been revolutionary. In Dublin, the children's waiting list through the school-based programme referral or GP referrals has more or less been eradicated. Children who would previously have waited a lengthy period of up to several years to see an ophthalmologist are now being seen in the community by health and social care professionals and advanced nurse practitioners. As the Deputy stated in the context of GPs having access to specialism, it does not have to be a consultant. Sometimes it is a consultant, but clinical nurse specialists, advanced nurse practitioners, optometrists and health and social care professionals can fully handle end to end a very sizeable number of patients who previously had been waiting to see a consultant. The Deputy made reference to the buses of people going from Cork and Kerry up to Northern Ireland for cataract treatment. That will become a thing of the past. In Ballincollig, there is a new state-of-the-art facility which will see a significant number of people. Many of the ophthalmology services are moving from CUH to the South Infirmary hospital. In fact, the Royal Victoria Eye and Ear Hospital is now seeing lots of people who previously would have gone to Northern Ireland. It is exactly the point the Deputy is making. It is access to specialism, be it nursing, health and social care, medical or dental specialism, that previously was not available. The impact this new approach is having is extraordinary. It is one of the pillars of our waiting list action plan which will be rolling into this year.

Bernard Durkan

Deputy Bernard J. Durkan

I thank the Minister. I have a final question but I will come back in on it at a later stage.

David Cullinane

Deputy David Cullinane

I refer to the briefing note we got from the Department. I have a number of issues relating to it. There are two parts to my questions. Obviously, this meeting is about the Estimates and the funding that is available to the health service for 2024. I will not go over the old ground we covered after the budget in respect of the lack of funding for ELS and new measures, the role played by the Department of Public Expenditure, NDP Delivery and Reform and all that. If I were to do so, we would just have the same discussions. We are not going to reach any agreement on it, even though if the Minister were to be honest, he would accept there are funding challenges.

The second element I wish to discuss is service delivery. I recognise the progress that has been made but there are issues I wish to tease out that are not covered in the briefing note but are really important from a reform perspective. The briefing document states that there is a risk the funding provided at the time of the Estimate may be insufficient to meet the actual level of demand.

Stephen Donnelly

Deputy Stephen Donnelly

I ask the Deputy to provide a page reference.

David Cullinane

Deputy David Cullinane

It is on page 5, under "risk". It is basically saying there may be risk of a Supplementary Estimate in 2024. That goes to the heart of it. "Dishonesty" may be too strong a word but it is certainly a gross understatement of reality. There is no doubt whatsoever that there will be a need for a Revised Estimate this year. The briefing document states that there may be a need and an element of risk but, in my contention, it is an absolute certainty that we will have a Supplementary Estimate at the end of this year. Does the Minister accept that?

Stephen Donnelly

Deputy Stephen Donnelly

I accept and have clearly stated right from the off, from the day after the budget announcement, that there is a material risk of a substantial Supplementary Estimate being required.

David Cullinane

Deputy David Cullinane

That is not what it says in the briefing note, however. That is my point. The document refers to a risk and states that a Supplementary Estimate may be required. There are no ifs, buts or maybes about this. It is a reality. We need far more clarity. The Minister was much clearer in his response just now. This is part of the problem. Although the Minister is clear, I had a very robust discussion with the Minister for Public Expenditure, NDP Delivery and Reform just before Christmas at a meeting of the Committee on Budgetary Oversight. As I was the only member left in the room, I had quite a long time to have a discussion with the Minister. It is the same again today. In any event, he did not share that view at all. Rather, he was of the view that there may not be a need for a Supplementary Estimate. If the Minister, the HSE and the Department get their act together and achieve the savings and efficiencies that can be achieved, all will be good and there will not be a Revised Estimate or Supplementary Estimate. We are here to discuss Estimates. There must be a level of reality to it. It is not negative to call out what is reality, namely, that the health service will not have enough money this year to stand still, and very little money for new measures. In that context, it is a racing certainty that a Supplementary Estimate will be needed. The Minister obviously agreed with me in terms of his response. There is no point in any Minister saying "Maybe" or "I do not think so" but then, come September or October, we are having discussions on a very substantial Supplementary Estimate.

Stephen Donnelly

Deputy Stephen Donnelly

I know the Deputy is not trying to put words in my mouth but, to be clear, I am not saying it is a certainty. I am absolutely not saying that. I am saying it is a material risk and there could potentially be a significant Supplementary Estimate. I said that from day one. It is important that we are-----

David Cullinane

Deputy David Cullinane

This goes to the heart of people's credibility. That is what I am saying. The Minister may say it is not a certainty. I am saying it is a certainty. We will see who is right come September and October.

David Cullinane

Deputy David Cullinane

That will then be a matter of record in terms of what people said. I wish to move on from that because-----

Stephen Donnelly

Deputy Stephen Donnelly

I will respond quickly, if I may. For me, the red line is services. We do not cut services but, rather, protect and grow services for patients. The question then is how to do that within the funding available. That is why we have set up a productivity task force. There are potentially significant savings not just for this year, but into future years. That is important. We have just over €1 billion in non-core funding. A very substantial amount has been allocated against inflationary pressures as well. The reason I am saying it is uncertain is that nobody knows what will happen this year in terms of inflation and demand. Last year, we got hit with both at the same time. We got hit with a massive increase in healthcare price inflation, unanticipated by anybody, and we got hit with a surge in patient demand that was also unanticipated. For example, we had a 16% year-on-year increase in GP referrals. There are differing views on what is driving that. One view is that the population is catching up on care that was deferred during Covid. Last year, we went into a year where prices and demand were soaring.

David Cullinane

Deputy David Cullinane

May I come back in on that-----

Stephen Donnelly

Deputy Stephen Donnelly

I will just finish this point. This year, we are coming into a year where prices are falling. The price of medicines may not fall but interest rates will fall, please God, and energy prices are falling. We are coming into a different environment this year from what we went into last year. That is why I am saying we will do everything we can to bring the services in on budget. Where it will end up is uncertain, however, and based on price and demand.

David Cullinane

Deputy David Cullinane

You can never guarantee what inflation or costs will be. They may go down or they may go up in certain areas. Nobody has a crystal ball to predict with 100% accuracy where it will be, but we can estimate and have a fair sense of what it will be. That fair sense was set out in all the asks made by the Department in the bids that were made for budget 2024 and it was made clear by the Secretary General at the Minister's Department and the head of the HSE that there is a guarantee that much of the additional funding last year in the context of those pressures of inflation and additional demand were going to recur this year. Nobody knows to what degree they will recur, but nobody can say with hand on heart or with a straight face that it will be zero. All I am saying is there is a reality to this that is not reflected, and will not be reflected in the national service plan.

I now want to discuss the productivity and savings task force the Minister has established. On one level, it is right to ensure we shine a spotlight on how we spend money on healthcare. We all want value for money. I do not like some of what I heard from some of the Minister's Government colleagues on the narrative on health at the time of the budget. I am referring to statements that it was all a runaway train or black hole into which money was being poured, wasting it all, and so on. A lot is being said to this effect. While efficiencies are being achieved and there is more we can do in terms of performance, I will outline what really struck me. On page 6 of the briefing document the Minister sent, he mentioned the productivity and savings task force that will improve productivity, deliver savings, drive productivity, examine emerging technologies and demographics, and so on. It goes on to state the task force will be chaired by the CEO of the HSE and the Secretary General of the Department of Health. I do not know how many people said to me that we are asking two people to chair a task force to do a job they are already well paid to do. It is their job to ensure we improve productivity, drive productivity, deliver savings, examine emerging technologies and determine how best we should use them to get a bang for our buck. People were flabbergasted that we were setting up what is called a task force. As the Minister knows, people do not love task forces in the real world and ask what they are all about. We are asking two senior people whose job it is to achieve all the aims under discussion to set up a task force to do what they should be doing anyway. Can the Minister see why there is cynicism over this? Essentially, we are setting up a task force and asking the two people heading it up to please do the job they are actually well paid to do.

Stephen Donnelly

Deputy Stephen Donnelly

On this, no. Whoever is saying that to the Deputy-----

David Cullinane

Deputy David Cullinane

I am saying it-----

David Cullinane

Deputy David Cullinane

-----but others are saying it to me as well.

Stephen Donnelly

Deputy Stephen Donnelly

On this, I disagree. The health service, as we all know, is a huge national system. It is incredibly complex and there are thousands of competing priorities in every part of the country. As a Minister, you have to make some calls on the most important points of focus; you just have to do that. For the first year and a half, it was pretty straightforward. It was Covid, and the system responded incredibly well. Consider what I covered this morning in my opening statement. I have a waiting list action plan, because that is a top Government priority. I have an urgent and emergency care plan and a team that meets and that I meet every month, because that is a top priority. I also have a productivity task force in place now. We are escalating its prominence partly because we have a bit of space. For me, the first two priorities are to get the waiting list down and get the number of patients on trolleys down. That has now built momentum. We need to keep a very close eye on it, and we do that through the two action plans. The women's health agenda was really important to me. In this regard, we set up a women's health task force and a women's health action plan. Really, it is a political decision rather than a HSE decision-----

David Cullinane

Deputy David Cullinane

I know it is a political decision.

Stephen Donnelly

Deputy Stephen Donnelly

-----to point to one of the core things the HSE is to focus on.

David Cullinane

Deputy David Cullinane

I accept it is a political decision but it goes to the heart of what the core roles are. All I am saying is that many in the media and the health service who are considering this are saying we should always be examining productivity and savings. In fact, in some areas we have come far too late. To his credit, Mr. Bernard Gloster has shone a spotlight on agency expenditure, management consultancy and some areas that other CEOs might not have shone it on. I welcome the focus but believe people will rightly say that it has taken far too long. The job of work of the two senior people whose job it is to make sure all this is done all the time should not require political focus. It is part and parcel of their job.

Stephen Donnelly

Deputy Stephen Donnelly

Theoretically, the job of the chief executive and Secretary General is to manage productivity, patient safety, services, affordability, waiting lists, the capital plan and everything else, but ultimately one has to be able to specify the top priorities. The reality is that the HSE really does not have a culture of performance management, productivity and savings. In my previous life, before I was appointed three and a half years ago, the most basic management information I would have sought when going into large corporations, including hospitals abroad, to help them to provide more care for the same amount of money just did not exist. Where it did, it was not being used. I was pretty shocked by what I saw. We are not coming to the productivity task force now. Critically, over the past few years we have been systematically putting in place the public-only consulting contract, getting our e-health initiative going, upgrading the capacity of the system and moving to seven days per week. I hear the Deputy but, to be honest, there is a pretty fundamental cultural change required within the HSE in terms of productivity. In my judgment, therefore, we set up the task force to give it the space, time and political direction to say what has got to be pushed.

David Cullinane

Deputy David Cullinane

I agree with some of that. When Paul Reid entered his role and first talked about productivity, one of his first acts was to send out letters to hospital managers on all these things. The Minister might have been a health spokesperson at the time, although I do not believe he was. The letters stated the HSE was to clamp down on bad spending and so on, but it did not happen. Of course, I welcome the fact there is now a focus on this and that the Minister says he will apply more political pressure or heat, but there should have been a focus all the way through. I am just saying that it looks very peculiar that the two people asked to head the task force are the two whose job it should be to do what it is tasked with.

Regarding a cultural shift, the task force's remit should be part and parcel of the daily work of the two senior people who work in the health service. They should not need to be part of a task force. To deliver, they should be cracking the whip, and this should be an obvious part of their work.

I want to move on to service delivery. The Chair mentioned the trip to Altnagelvin Hospital in the North. Staff in its cardiac unit, which has 24-7 PPCI and treats patients from Letterkenny, Donegal and other parts of the South, made the point that without patients from the South, they would provide neither the cancer services nor the cardiac services they provide. They are really grateful for the funding they get from the South through the service level agreement. They stated secondary care for some of their cardiac patients could actually be provided at Altnagelvin but that patients pass the hospital to go to Galway and Letterkenny. The staff presented a very detailed business case a year ago or more to the Taoiseach, who they said was on a visit, but they have not heard anything back. They were not being critical, to be fair to them; they were simply asking whether the committee could follow it up. They said the requirement would be in the region of €700,000 or €800,000, mainly for staff to deal with secondary unrelated illnesses that affect their cancer and cardiac patients. I believe it was the cardiac unit that raised this with us. It stated it would send us the business case and asked us to follow up. It seems the amount of money requested is not huge in the overall scheme of health expenditure. If it improved the services, it would be beneficial. Can the Minister review the business case favourably and ensure the unit will get a response? If the business case was sent to the Taoiseach's office, I assume it was sent to the Department of Health but maybe it was not. Could we just ensure that this is cleared up and clarified, that the unit will get a response and that we will consider the request favourably?

Stephen Donnelly

Deputy Stephen Donnelly

I cannot guarantee the outcome but we will certainly consider it.

David Cullinane

Deputy David Cullinane

I know the Minister cannot do that but I am referring to considering it.

David Cullinane

Deputy David Cullinane

With regard to the recruitment embargo, I accept that there has been a very healthy net increase in staff over the past three years.

This is a good news story. However, we are moving from a good news story to a different space. This year, there will be a net increase of 2,200 under the national service plan. This may well be higher when the service plan comes out. Who knows? It certainly will not be in the region of 6,000, 7,000 or 8,000 as it was in previous years. This is a difficulty. We visited the Magee campus. Some training courses there are being funded by the Irish Government. These are in community services, speech and language therapy and occupational therapy. We saw the training courses being done. These are being funded by the South. The number of training places are being increased. These are areas where we have a shortfall.

I have spoken to many chief officers in community services about the impact of the recruitment freeze, embargo or whatever we want to call it. I know the Department is precious about what it is. Call it what you want but we are hiring fewer staff this year then we were in the past three years. There was some tightening on recruitment at the end of 2023. This will have an impact on those in training places at present. They are looking at this and wondering why there is a recruitment freeze. They want to work in the public system but many of them will not be able to do so.

From speaking to the head of the HSE, my understanding is that since the recruitment embargo was put in place, some hospitals and healthcare facilities have been recruiting for additional posts. These will now have to be funded as part of the 2,200 posts in the service plan. How long will it take for us to reach the ceiling? When we do so, will it be a case that we will not be able to recruit any more staff and it will not matter who comes out of training colleges or who wants to come and work in the public system because the opportunity will not be there. It is important for this to be clarified. What is the current position? Is there still a recruitment freeze in place? How will it shift and change when the service plan is published?

Does the Minister accept that from an optics point of view it does not look good that we cannot recruit the levels of staff we possibly could into the public system? Someone very close to me who is a nurse wanted to work additional hours. The person works one day a week and wanted to work a number of days a week. This nurse is not in a position to do so because of this. The hospital management has said it is not possible. There are a number of examples of it. I hear many personal examples of people who want to work in the public system or do more hours but cannot do so. This is not a good place for us to be in.

Stephen Donnelly

Deputy Stephen Donnelly

I thank Deputy Cullinane. Let us talk about where what is in place does not apply. It does not apply to consultants. There is no pause on consultant recruitment. I made this decision because it can take such a long time. We are in the middle of going from approximately 4,000 to approximately 6,000 hospital consultants. This is going very well. Hundreds more consultants were hired last year and hundreds more will be hired this year. They were funded through the budget.

David Cullinane

Deputy David Cullinane

I know it also does not apply to fourth-year nurses. I should have accepted all of this so that we can cut straight to what it does affect.

Stephen Donnelly

Deputy Stephen Donnelly

It does not affect consultants or fourth-year nurses, as Deputy Cullinane said. It does not affect safe staffing. There are many important areas that are not covered by the pause. There are, however, some areas that are. I accept that it is a blunt instrument. There is no question about that. In some teams throughout the country right now, somebody has retired or left an important role. These people cannot be replaced, which is causing problems. The other area is where teams have been partially filled or not fully filled, such as a community team still waiting to hire a physiotherapist and occupational therapist and cannot do so. It is a blunt instrument but, unfortunately, there had to be a control put in place. It comes back to the point on productivity whereby school principals who hire the full contingent of teachers cannot simply hire more teachers on top of that. They just cannot do so. Any principal who is told that their school can have 30 teachers and then hires 35-----

David Cullinane

Deputy David Cullinane

I want to come back on this point because it is important. The health service is different. We get a large number of staff through international recruitment. There is a world shortage of healthcare staff. When we visited Altnagelvin, people spoke about the NHS coming in to poach a lot of staff who are trained there. We hear the same from training colleges in this State. We are losing some healthcare professionals to emigration. Some of this is because they want to experience different countries. There is no doubt we need more healthcare professionals. Whatever about what we should do when we reach our ceiling, I am in favour of having a job guarantee for all of those coming through. Perhaps this would not be in every role but certainly in key areas in primary care and community care where we have deficits. We should be taking all of the graduates into the public system. The alternative is that they go to the private hospitals or emigrate. This is the reality.

The Minister is selling a good news story and I am accepting as good news story that the net increase on average each and every year for the past three years was somewhere between 6,000 and 7,000 depending on the year.

David Cullinane

Deputy David Cullinane

It depended on the year and sometimes it was a bit more. Let us say it was an average of 6,000. We will now reach one third of this. If the Minister were to say the ceiling is 6,000 or 7,000 and that we would then put a cap on it, people could somewhat understand it. However, that is not what is happening. It happened at the end of last year but it is not happening now. I am putting it to the Minister in the strongest possible terms that it is not only a blunt instrument, it worse than that. People are coming out of training positions who are not fourth-year nurses or consultants but the allied healthcare professionals that we need. They will not be employed in the public system. The question is where will they go. We have trained them and we have paid for their training but they will not be coming to work in the public system. This is a shame.

Stephen Donnelly

Deputy Stephen Donnelly

I thank Deputy Cullinane. Many of them will come to work in the public system. We have covered nurses and doctors. The third big group are the health and social care professionals, as Deputy Cullinane has rightly pointed out. We are hiring health and social care professionals this year. We are hiring them with the new development funding. The individual regions will be given an awful lot of latitude in terms of redeployment. There are retirements and other things going on and the services will want to reallocate these posts. There can be redeployment.

Another point is that we do not train half enough health and social care professionals. Deputy Cullinane is aware that I am looking to double the number of healthcare college places. When we go through some of them in particular we see we have one graduating class of essential health and social care professionals in the country and many of them will still be hired this year. Some of them will be covered in the more than 2,000 staff we will hire this year. Some of them will be covered through replacement staff. There will be plenty of health and social care professionals retiring this year. Once we get back to the funded level, these replacement posts will be authorised.

I take Deputy Cullinane's point that we have had three very strong years in the context of recruitment. It is worth saying, when we look back pre-2020, that what we have this year is what in previous years would have been a normal healthy year of recruitment with 2,000 to 3,000 net additional healthcare professionals coming into the system. Over the past three years we got used to an exceptionally high level. As stated, I take Deputy Cullinane's point . I acknowledge that it probably does cause distress for some people who are graduating in September.

David Cullinane

Deputy David Cullinane

I am not saying we will not be hiring staff. I have acknowledged there will be a level of staff employed. It just will not be at the level it was the past three years.

David Cullinane

Deputy David Cullinane

A bit like the Supplementary Estimate, we will see at the end of the year who was right when it comes to the pressures this will put on the system. In my view, there is no doubt there will be posts in many of these areas where people will not be able to be replaced. There will be people who will want to come and work in the public system or get additional hours who will not be able to do so because of the limitations on recruitment in 2024. I will stand corrected if it is the opposite, but I doubt very much that it will be.

There are several other matters I want to discuss. I will come in during a second round of questioning later. I know committee members are being given a little bit of latitude because there are only two of us here.

I want to ask about the GP visit cards.

It is something I supported for all the right reasons. There is disappointment that the uptake has been so low. We need to understand why this is the case. There certainly does need to be more communication. In his opening statement the Minister said that free GP care was extended to half a million people in 2023. It is funny to re-read this. It was made available but as of yet it is not extended because they do not have the cards. The Minister also said that it increases the number of medical card holders to more than 1.6 million people. It does not yet because they do not hold them. We need to get to a point of funding it and then people getting them. What analysis have the Department and the HSE done around what is the percentage of take-up? Is there any sense as to why the take up is as small as was publicly stated? Maybe that figure is wrong. Maybe it is less than 5%, I do not know. Give us the figures first but it is certainly nowhere near where we want it to be. Is there any analysis as to why that is the case?

Stephen Donnelly

Deputy Stephen Donnelly

I will ask the officials to find the figure. It is very disappointing. The low take-up is very surprising. The card is very valuable. It is free GP care for you and your family into the future, particularly during a cost-of-living crisis with families under so much pressure. This measure really was targeted at those families who were under the most pressure, which is the squeezed middle.

David Cullinane

Deputy David Cullinane

Will I tell the Minister the reasons why?

David Cullinane

Deputy David Cullinane

It is because people do not understand who exactly is covered. It talks about a family median income. We need to break it down more in terms of the income threshold because that is what people understand. It is far too vague. Even while preparing for this meeting if I am looking for information on what people are entitled to I Google it and the Citizens Information Service comes up straight away, which will always have the answers. It is really good. It is, however, very difficult to get one's head around the information for GP visit cards. I was reading it and had to read it again. Then I had to go onto the HSE website. The vast majority of people will not do that. We need to make it much clearer and much simpler. We need to explain that if a person is on income X then he or she qualifies for this card and how to apply. That is part of the problem. There is a clear messaging need here from the HSE and the Department.

Stephen Donnelly

Deputy Stephen Donnelly

Yes I believe that is right. When I saw the low uptake I instructed the Department and the HSE to immediately get under the skin of this and see what it is. Instinctively I believe it is exactly what the Deputy has just said. I will get the figures for the Deputy, but we have seen a much higher uptake of the GP cards for the ages six and seven, and less for the cards for those on the median income. My instinct is the same as the Deputy's. It is too complicated. We are going to figure it out. Some work is being done on that now. It might require some further very clear communications or it might require some changes to the criteria to make sure it is all very easy for people. There is the income criteria and then there are a lot of income disregards that people may not be aware of either. Yes, instinctively I tend to-----

David Cullinane

Deputy David Cullinane

I wish to come back in later in a second round on mental health, and on elective centres and hospitals but I also will raise a last point now. In his opening statement the Minister referred to 160 net additional acute inpatient beds. The Minister might recall that we had some discussion on this subject matter as part of a priority question I tabled last week. As I understand it the majority of those are still the legacy beds coming from funding in 2020, in terms of the 1,147 beds that were funded and an additional 70 or 80 that year the following year as part of the national service plan. It was a round figure of nearly 1,200. There may have been a bit more here in budgets since but nothing substantial. In any event I was asking about the rapid build beds. The Department of Health and the HSE were in here on this very subject. I asked them very bluntly and very directly if it is about funding and they said "Yes". Interestingly enough they said they had done an awful lot of the work and identified the sites. With the huge amount of the work done they said they could actually deliver these quite rapidly. So, we could deliver them in 2024 if we had the funding. The problem is we do not and the funding is not there. I note that when the Minister was in with the health committee last year we had talked about it as well. There were a couple of newspapers spreads about 1,500 rapid-build beds and there was huge excitement in the system that these beds were going to come because we knew we did need more bed capacity. What happened and where is that at? Do we have the funding to start progressing those 1,500 beds for this year? From memory, in response to a priority question I believe the Minister said to me there were lots of expressions of interest and all of that went very well. That is a positive. The Department is saying that sites are identified, so that is not a problem. Is it simply that we have to provide the capital funding and that it is not there yet?

Stephen Donnelly

Deputy Stephen Donnelly

On the Deputy's first point around the total number of beds coming this year and if that was part of the original allocation, the original allocation was 1,228 beds. We are up to 1,126 of that. That is about 102 shy of the 1,228. The beds this year will be to finish that figure and then move beyond it.

It is also important to say that we have had 147 new beds to open this year and there are other beds under development as well, for example the beds in Limerick. There are beds under construction as well as those we will deliver this year. There are a few hundred in the pipeline either being commissioned or in construction to be delivered this year or the following year. On the 1,500 beds we have done the expressions of interest and we got a lot of interest both internationally and from here. We have identified the sites. We have gone for sites that we believe are not complex in terms of planning. Some of them are car parks, some are brownfield or greenfield sites but as part of the core hospitals. We have broadly identified the design, which is not dissimilar to the Kilkenny block the Deputy will have seen. The 72-bed rapid build went up very well there. Yes, ultimately it comes down to funding. It is a big plan: 1,500 hospital beds is a big programme of work. Ultimately it comes down to funding. I am working through this at the moment with Government to see how that might be accommodated.

David Cullinane

Deputy David Cullinane

Okay. I will come back on a second round on other issues. There may have been an expectation built up that now cannot be realised. Going back to what was actually said in this committee from the Department of Health officials when they were pushed on this, if I recall it was the head of capital infrastructure from the Department who talked about some of those beds coming onstream in 2024 and some in 2025. They said they could really deliver on this quickly and it was a two-year project. Funnily enough this is what was covered in the newspaper articles on the same matter, which I could send on to the Minister. I do not believe this will be the reality. I do not see any of those beds coming on stream this year. I might be wrong and the Minister might surprise me. I do not see any of them coming on stream next year. It is important that we move on them.

The Minister is right that it would be a significant investment. At 1,500 beds even rapid build would probably cost in excess of €1 billion in capital at a minimum, or in and around that. Then there is the issue of the staff needed as well. We had an earlier conversation on the recruitment freeze. Again I do not see how we are going to be able to deliver the beds with that in place. It should be a priority.

I do want to come back in on mental health, on elective-only hospitals and on digital transformation in healthcare. These are three areas that have come up this year where we have not really got any satisfaction from officials. In fact they have conceded and acknowledged to us that in all of those areas there is slow progress. I will come back in later to tease out some of those areas. I will leave it at that for now.

Seán Crowe

An Cathaoirleach

I have some questions. I welcome the Minister of State at the Department of Health, Deputy Hildegarde Naughton, to our meeting. I believe it is her first time attending our meeting and we look forward to it as a committee. We are meeting in the next couple of weeks on health awareness. We look forward to that session.

I will do some overviews of some of the challenges within the system. I will not get into the detail of how many millions of euro and so on. I genuinely believe it would be more constructive if we were to talk about some of the challenges we are facing in the system.

I welcome that the Minister is talking in terms of some of the challenges and the waiting lists going down in some areas and so on.

We touched on North-South co-operation at the start of the meeting. One of the issues in the system is capacity and the lack of key personnel in certain areas. Speech and language is one such area. I am conscious that if we do not have people trained up to come into the system, there will be challenges in future. The positive message we heard from Magee was there was capacity in its system. The pattern is, and all the information indicates, that if people are trained in the general area, they normally stay in that system. It is of benefit to both jurisdictions and both areas on the island of Ireland.

One of the areas we looked at in Magee was obesity. We have not touched on it this morning but I raised the matter previously. We met with Professor Alexander Miras, who talked about the co-operation between Magee and Galway at an academic level. He said there were huge challenges within the northern system, not necessarily involving just young people but those of all ages, concerning travelling abroad, for example, to Türkiye. We have heard the horror stories of these stomach bands and so on. People have actually died on these trips. The common agreement was that people were travelling because they could not access services and were waiting for years or whatever. I raised the issue of Loughlinstown and the system there. I talked to a constituent who was told in a letter that they would be waiting between five and seven years for access to the clinic there. I raised this matter with the Minister and the Taoiseach. The answer I am still getting for that patient is that it is still a five-year waiting list. It is something that needs to be looked at. I am conscious that it is not just about stomach bands. It involves appetite suppressants and the reluctance of GPs to go down that road.

There are things we could do within the system. I am just flagging obesity as one of the issues that clearly needs to be addressed as we move forward. We have a huge challenge. It is not just an Irish problem. It is a western-world problem. The figures on obesity are going the wrong way. It affects people from when they are children. We hope to address some of the issues when the Minister of State, Deputy Naughton, comes before us regarding the availability of processed foods, especially in disadvantaged communities, and the role of companies and the State in what we can do in that regard. Maybe that is something the Minister could address.

I realise section 39 workers are voluntary workers but they are doing the same work. The system would collapse without them. I am conscious the Minister of State with responsibility for the drugs strategy is present. Some of those who work in front-line initiatives and groups working at the coalface have talked about not getting an increase for ten years and the challenges that we face. Again, has the Minister any plans or proposals, not necessarily outlined in this Estimate, to address that issue any time soon?

The issue of capacity within the hospital system was touched on by members. One of the proposals is the need for an additional allocation for hospitals. Cork and Galway were two of the hospitals referenced. I am trying to address some of the issues that have come up at the committee over the past 12 months. We asked for a note or an update on what is happening with those hospitals. Is the Department of Public Expenditure, NDP Delivery and Reform involved in the process? When will we see developments in that regard? We all accept they are needed within the system. I accept the budgetary challenges the Department faces but it is a key component. I am talking about elective hospitals in Cork and Galway.

On oral health, the Minister mentioned additional dentists and GPs. This involves two areas. The fact is that it is almost impossible for people on medical cards to get treatment. The Minister will probably suggest that the figures indicate more people on medical cards are accessing services, and there are more people who can get access to a GP and medical services, but the challenge is that in many cases, particularly with young and older patients, it is about accessing a dentist or GP. The committee talked about possibly looking at the Scottish system in respect of the roll-out of rural GPs. Has the Department looked at other jurisdictions regarding how we can encourage GPs, or how the State can hopefully establish GP services in those areas of the country where there are clear gaps, and where people have to travel an excessive distance to try to get basic access to a GP or dentist? There is a crisis for young people within our health system, particularly those who are younger, with regard to the importance of oral health in the health of an individual. Again, the fact is people are waiting years for their child to be treated. In some cases, the child goes through school without getting access to a dentist. We all accept that is unacceptable.

The Minister mentioned 1 in 50 in respect of CAMHS. There are other challenges in the area of adult mental health services. One of the big challenges, particularly for young people who may have an intellectual disability, whether that disability is profound or not, is access to accommodation and supported care. That is a huge problem. The Minister will know that from his constituency but also through his ministerial role. Is there any positive message we can send to families regarding access? We are over-reliant on voluntary and charitable bodies in this area. I will give an example. The daughter of a woman in my constituency has been trying to access a service for a number of years now. This woman wants to go into a senior citizen facility but she cannot do that while her daughter is living with her. Her daughter wants to have some sort of independent life. The big worry for the mother is who will look after her daughter as she gets into increasingly bad health. There are no follow-up services and no way of moving on. Going around all the possible accommodation, it is all full. Even though money has been allocated for this individual, the beds are not there. What can be done about that? There is also a role for local authorities in accommodation for people with disabilities. It is about doing that. What conversations is the Minister having with the Minister for housing on that? All development plans should include something in relation to suitable accommodation for people with disabilities, regardless of whether they are profound or mild. If we are building an inclusive society, it should be about that.

I have outlined a number of issues. I could go on a lot longer but I will not. I touched on capacity, key personnel and speech and language in the context of the visit to Magee. People are waiting years with a child who may not be able to speak. The longer that child waits, the more difficult it is to get that child into a service. There is frustration for both child and parents about that. I acknowledge that positive things are happening but many of those families are under severe pressure.

In many families it is not just one child. It could be a number of children who are on a spectrum and who cannot speak or who need these supports. We need to do more about that. I accept that where key personnel are missing and there are broken teams, multidisciplinary teams can carry out only so much. The difficulty, which we have touched on as a committee, is that you are trying to recruit people into an area where the backlog of a thousand cases faces them when they come into that, so there are big challenges within the system. I would be interested in the Minister's views on that.

Going back to the all-Ireland stuff, specifically the all-Ireland breast milk bank in Enniskillen, there are really positive things there, but people have said there could be tweaks to the system that we could be doing with the roll-out of that.

Organ transplant is a big challenge for anyone in that situation. There is co-operation there, but it is a matter of increasing the number of organs available. I recognise there is legislation on that coming through but I think we all know friends who have been on those waiting lists and who have, unfortunately, passed because there are not enough operations going on.

One of the issues we have tried to address as regards services is the challenge concerning children with scoliosis. I realise the difficulties in that respect and that inquiries are ongoing and so on. We heard there was a field report on one of the metal bands. There were challenges with that in one of the hospitals. What message can the Minister send to those families? There are long waiting lists for scoliosis treatment. There are difficulties now within the system as regards other matters, but for those families who have a child in that system, their conditions are getting worse and they are waiting long times for access to life-changing operations. I have mentioned the metal bands. There are huge challenges as to what to use for children in that situation.

The common theme of the questions I have asked is that, while funding is one issue, they all probably need champions, such as the Minister and the Ministers of State, in moving these issues forward. I would like to think that, collectively, we as a health committee can work with the Minister and Ministers of State and their officials in trying to move many of these issues on.

Stephen Donnelly

Deputy Stephen Donnelly

Thank goodness the clock is not being used today, Chair. Thank you for all that. I will respond to some of it. I will pass over to the Minister of State, Deputy Naughton, on the public health response to obesity and then other public health responses she may want to cover. I will ask Louise McGirr to come in on the section 39 bodies, on which there is progress, and some of the detail there.

The common theme I heard through all the issues the Chair raised is access. We have high-quality services and we must have access, hence the waiting list action plan and the falling waiting lists, while always acknowledging that they are not yet where they need to be. It takes time to get down to the agreed ten- to 12-week targets.

On obesity, the particular patient to whom the Chair referred, and there have been one or two others, did get those letters with the multiyear waiting lists on them. I went directly to the head of acutes within the HSE and said we simply cannot have this. Nobody can stand over this. Professor Donal O'Shea is one of the clinical leads on the new bariatrics programme. I met with him and one of his colleagues who presented to me in 2022. They put a very compelling case forward to the effect that we do not have the bariatric services we need, people are going to Turkey and other places, some of them are getting quite ill, and this is a service we simply need to have in this country. I was convinced and fully funded the national roll-out. I did not think they would be able to spend the money I allocated. They asked for several million in recurrent funding to hire many people throughout the country. Professor O'Shea and his colleagues assured me they had an entire army of people ready to step into the breach. It turns out they did, and the services are now scaling up. They are getting the access they need and hiring the people they need. The service was funded last year, so they hired through last year and will be hiring again this year to build up those services. It will take them a bit of time. Where we need to get to, which is the only reason to fund the services and all these extra healthcare professionals, is to make sure people can get access when they need it. That has been prioritised. In fact, in the waiting list action plan, obesity and bariatrics were one of the three specific priority areas we reported on every month. I am happy to say good progress has been made and we now need to see those waiting lists come right down, not just for Loughlinstown, from where Professor O'Shea and others work, but across the country. That will remain a priority.

Seán Crowe

An Cathaoirleach

Do you have any idea of the waiting list at the moment?

Stephen Donnelly

Deputy Stephen Donnelly

Based on the patient you referred to and the times they were-----

Seán Crowe

An Cathaoirleach

No. That is probably-----

Stephen Donnelly

Deputy Stephen Donnelly

I have asked for a detailed progress update on the back of that. We might share it with the committee when we get it. I will pass over to the Minister of State, Deputy Naughton, on the public health response.

Hildegarde Naughton

Deputy Hildegarde Naughton

I thank the Minister and thank the Chair for his questions.

As regards obesity, from a prevention point of view, Healthy Ireland was established in 2017 and its budget was €5 million. Today, in budget 2024, it is in excess of €16 million, so there is a big emphasis on this. We have many public engagement campaigns on obesity. One is the Healthy Weight campaign. It was rolled out in 2022-23. After every campaign, research is done on the impact it has in raising awareness. The Healthy Weight campaign used a novel approach in targeting 24- to 34-year-olds specifically and focusing on the impact of managing your weight in that period of your life and what that does for the rest of your life. It seeks to do away with some of the easy myths and the advice of simply eating less and exercising more. There are far more areas we need to look at to make sure we all manage our weight, such as the importance of getting sleep and the importance of managing stress. We have behavioural science communicators as part of that campaign on social media. After the campaign was run, post-campaign research showed that 81% of young people found those ads clearly communicated their messages. We then had a second campaign which was run late last year and which was expanded to include radio. Further research is being carried out now to inform us of any changes around those campaigns.

Healthy eating feeds into particular areas throughout the country. I secured an additional €300,000 to facilitate the recruitment of four community food and nutrition workers, which will bring the national complement to 19. Those workers are vital, going into local communities and developing responses to food poverty and insecurity.

Also, the roll-out of our walking trails through the GAA was a huge success. It was oversubscribed with GAA walking trails. In budget 2024, I have secured further funding for that as well as outdoor swimming activities.

That is just a quick overview of what is happening in the area of prevention.

Seán Crowe

An Cathaoirleach

Can you give us a sense as to what the reluctance of GPs is in this regard? A lot of this comes down to appetite suppressants that are needed, so there is a medical response to it as well. The professor we met in Derry said they were looking down the road at a particular hormone that might potentially trigger appetite and so on. There is a lot of very positive work going on, but he was at a loss as to what the reluctance of many GPs across the system was to using medication that clearly works in the majority of cases. There may be side-effects for some people and so on but there seems to be a reluctance to prescribe these medications. Many of them are not new.

Maybe you cannot answer. For a layperson it seems rather strange that that is not one of the options that have been taken up more often in relation to it.

Hildegarde Naughton

Deputy Hildegarde Naughton

I would not be the medical expertise around that but I think these are all areas that certainly need to be considered from a prevention point of view and going into communities to see what they need on the ground right now through healthy eating, and smoking cessation of which there has been a huge uptake. The demand for the Healthy Ireland programmes is very high which is why we have more than trebled the funding to meet demand. We need to continue from the preventive space. Obviously medical interventions will always be required but if we are serious about looking at our overall health, then it is not just about hospitals, GPs and primary care centres. It is about how we live well and have a healthy lifestyle but we need to be able to facilitate people through those initiatives and base it on research, which is what the healthy weight campaign has done. It is also important that we target specific age groups.

Seán Crowe

An Cathaoirleach

Did the Minister say he would ask someone to come in on section 39 bodies?

Stephen Donnelly

Deputy Stephen Donnelly

Yes. I will just make two quick points. First, as the Chai will be aware, we have just finished a really important transition for the remaining hospices to move from section 39 to section 38. It was very expensive. It was many times more than the initial estimate from the hospices. The Government made the funding available and it is making a big difference now. The funding really is putting the remaining hospitals on a sustainable footing. That is one of the things that has been done around section 39s.

As the Chair will be aware, the largest 300 section 39s went through a process some years ago. The question we were then faced with was that there were many more smaller ones. Progress has been made on that and Ms McGirr might give an update.

Ms Louise McGirr

Yes. It was agreed there would be an overall 8% increase for section 39s. That was agreed last year, in 2023, and concerns Building Momentum but I will talk about the new agreement as well. On that, we have provision within the Revised Estimates for over €27 million to pay our portion of it. A lot of this falls to the Department of Children, Equality, Disability, Integration and Youth now because many of those organisations are providing disability services.

As I understand it, and potentially this is what the Chair is talking about, there had been delays with those payments or the payments did not go out immediately. The process is now much more efficient than we had with the 300. Two weeks ago, the HSE was instructed to make advance payments of 70% of the overall estimated cost of those salary increases. That should be with them within the next two weeks. That is the information I have, so those payments, or initial payments, of the 8% can begin to be made. The balance and the auditing piece, etc., will be worked out after the initial payment is made.

The WRC agreement last year also had a commitment that once there was a new pay deal, we would go into further discussions with those sections 39s on the implications of that deal for them. We are reflecting on commencing that after the announcement of the new pay deal. There has been good progress.

Seán Crowe

An Cathaoirleach

I am conscious that it is ten years since many of these people got an increase. It must be an impossible task. They are constantly being recruited by the health service, particularly those involved in community care and in the drugs area. These staff are being headhunted all the time, which is having an impact locally in many areas. Again, I appeal to whoever is involved in negotiations to resolve this as soon as possible. It is impacting on people's lives. People want to stay locally in their communities where they can see that they are having a huge impact and they have buy-in and they have a loyalty to particular areas but loyalty can only go so far. As I have said, waiting ten years to try to get an increase is unacceptable in any system.

Stephen Donnelly

Deputy Stephen Donnelly

The next thing the Chair raised was the elective hospitals for Cork and Galway. The preliminary business case, as he will be aware, was approved just over a year ago for St. Stephen's Hospital as the preferred site in Cork, and Merlin Park as the preferred site in Galway. A lot work has been going on. Since then, the HSE is progressing the procurement for the design team, which will include an architect-led design team and a project control team. We hope to appoint the design team in quarter 2 of this year, which will be an important milestone. That is for the architect-led design team.

Oral health is an issue that we have discussed here in committee and in the Dáil on many occasions. The Chair has raised several issues. One is the difficulty that some people with medical cards have getting through the dental treatment service scheme, DTSS. I am very aware of this. In response, we increased payments by about 50% in 2022, I think. It was a very significant increase. As a result of that, we have seen some dentists rejoin the scheme and we have seen more work from those dentists on it. The amount of work that is going on is on the increase.

I raised this matter recently with the Dental Council and I have raised it with the Irish Dental Association as well. What I said to the Irish Dental Association, and I have made these comments in the Dáil, was that I fully accept, and the Government accepts, the current scheme is out of date. The scheme does not provide the clinical flexibility that dentists need to provide appropriate treatments to their patients and it needs to be updated.

On the amount of money being paid, I accept that in many cases it is less than the dentists can get from their private patients. That is true. However, it is also true that funding had increased by a half, which is very significant. It is also true that the funding is significantly higher than the amounts paid by many comparable countries around Europe and in western Europe. The payments made by the State to dentists under this scheme may, indeed, be less money than the dentist can make through private practice but they compare very favourably internationally. We need to bear that in mind.

What I have said to the representative body and the regulator, which I have put on the record of the Dáil, is that we are engaging with the Irish Dental Association and looking at how we can put a new scheme in place. Obviously, that process takes time. In the meantime, I would call on individual dentists to see people with medical cards. I do not believe it is right ethically to say, "I am not going to see you because I can make more money seeing somebody else." I do not think that is right. I understand it from a profit perspective and maybe there is some amount of that is required in order to protect the financial sustainability of the practice and to pay the bills, which I accept as well.

I think one or two of the Chair's colleagues in the Dáil raised examples of constituents of theirs where their dentist had said, "No, I am not treating you as a medical card patient", but I will treat you but you have got to pay me as a private patient. I do not believe doing so is right or ethical. We do not hear GPs doing that and I do not believe dentists should be doing it, so this has to work both ways. I reiterate my call that I believe dentists should see their medical card patients even though they could make more money in the same period. I am sure GPs could make more money treating just private patients but they do not do that and I think that is something which is worth restating.

Second, one of the areas that I am very aware of is the orthodontic waiting list. It is not acceptable and it has not been acceptable for a very long time. We have funded it through the waiting list action plan. I am happy to say that from 2019 to now, we have seen an almost 50% reduction in the number of patients waiting. We have a way to go but a 50% reduction is important and certain things are moving in the right direction. We want these children to be able to get the specialist orthodontic care they need when they are referred for it.

The number of dentists on the Dental Council is increasing. It is 177 more now compared with March of last year. We now have 3,649 dentists. The number is up significantly on 2019. The number of dentists working in this country is increasing. Members will be aware that we are looking at opening another dental school and we are looking at doubling the number of dental college places in the country as well.

On access to GPs, it is absolutely the case that in some parts of the country, be they more rural areas or in some cases urban areas, it is still difficult to get a GP. I fully accept that. A lot of important progress is being made. We have quite radically increased the number of GP training places. It has gone from around 120 about ten or 11 years ago to 350 this year. It was 285 after the intake in September and it will be 350 after the intake this year. We had a record number of applications from medical graduates for those GP training places. The number of training places is increasing very substantially, and just as importantly, the demand from medical students and graduates to be GPs is growing. It is great to see. The increases over recent years up to the 350 means that, even before we start factoring in the ones going into training now, for every GP who retires there are now about two entering practice, which is very positive. It will obviously take several years for that to fully work through.

In addition, a shorter term measure is the international GP programme, which is done in conjunction with the Irish College of General Practitioners, ICGP. The latter is planning to bring in several hundred more GPs again this year and is targeting the areas where this real demand. For example, there is the Iveragh Peninsula. The Minister, Deputy Foley, and I have been working through this. They had six GPs on the peninsula and they are now down to three. One one of those will be retiring in June. They are going to go from six GPs to two, which is a real problem. I have spoken with the ICGP to see if we can bring some of its international doctors through, and it believes that might be possible. These are some of the short-term measures we are using as well but that is not to detract from the fact that it is still an issue in different parts of the country.

One of the other points the Chair made was around surgical waiting lists, particularly for those who are quite sick. We are approaching this in two ways. The first is just a general reduction in the number of people waiting longer than the agreed targets of ten to 12 weeks. There has been a modest reduction but, in fact, the number of patients being treated and the number of procedures is going up. What is happening is that because there has been so much additional outpatient activity, the number of referrals to the surgical list and the numbers on the inpatient day-case list have both gone up as well. One of the things we have been putting a lot of focus on is the number of people who have been waiting more than a year. I do not have that number to hand. It is probably in the briefing, but I am happy to say that number in last year versus that when Covid was at its peak has fallen substantially. We obviously have a focus on those who are most urgently in need of time-sensitive care.

Supported living for people with disabilities does not fall within my remit. I hear the Chair loud and clear. It comes under the remit of the Minister, Deputy O'Gorman, and the Minister of State, Deputy Rabbitte.

Those with scoliosis comprise one of the groups in respect of which there is a very time-sensitive need for complex surgery. As stated previously, we are failing many of these children in the context of the length of time they are obliged to wait. The level of activity has gone up. Investment in the service has gone way up. We had a €19 million investment fund. Quite a number of resources came on stream in the past few months, including the second MRI machine in Crumlin, the fifth theatre in Temple Street, additional beds and more staff. From memory, 192 staff or thereabouts were hired specifically in the context of that €19 million fund. I am not yet satisfied that everything that can be done needs to be done. What I want is a specialist spinal service for Ireland. If we look at international best practice, this is what the centres that are the very best at this have. They have dedicated theatres, theatre teams and beds, and we do not. That is something that we want to see.

We have been making some significant changes to how this is run by CHI. We now have a dedicated management team in place that is looking at better waiting list management and better communications with patients and families. It has not been where it needs to be for a very long time, and I am not remotely satisfied with it. A highly experienced surgeon, Dr. David Moore, has agreed to lead this from a clinical perspective. I met Dr. Moore recently to discuss what we are going to do. I am not satisfied that the €19 million has been allocated according to my very clear direction on prioritisation for orthopaedics, with a very clear focus on paediatric spinal work. Some of it has. I do not necessarily believe it has all been allocated in the way I intended, and I have asked the Department and the HSE to engage with CHI on that. I want to see dedicated beds and staff. These surgeons cannot be fighting for resources for these children, particularly when the Government has made such a large amount of funding available.

When the transition to the new national children's hospital happens, it will greatly alleviate the situation. Obviously, we cannot wait for that, however, hence the second MRI machine in Crumlin and the fifth theatre in Temple Street. There has been intensive engagement with the families and some of the stakeholder groups are engaging with Mr. Nayagam on that report. Some of them have decided not to. I fully respect their position but I think it is a missed opportunity. It is important their voices are heard as part of that review. Mr. Nayagam will be reporting directly back to me and the chief clinical officer, Dr. Colm Henry. I have no doubt that he will have some important recommendations in the context of improving the service further.

We have a long way to go but there have been some very important changes recently, in terms of both capacity and how that service is being run. Ultimately, I will not be satisfied until we see a dedicated spinal service and children getting the care they need when they need it.

Seán Crowe

An Cathaoirleach

I thank the Minister. I will make a comment before we conclude. The upsetting thing about the waiting lists is that in many of these areas, if someone has money, they can access services. Unfortunately, poor people or those who do not have access to spare cash are being left behind, whether it is in the context of dental care, accessing a doctor or paying for the basic things that are necessary to protect their health and that of their children. The more we can do to eliminate that two-tier system we have, the better we will be.

I am going to take a comfort break now. I am sure the Minister and his officials will be glad of that. We will come back with Deputy Cathal Crowe when we resume.

David Cullinane

Deputy David Cullinane

Will the meeting be finishing at 12.30 p.m.?

Seán Crowe

An Cathaoirleach

Yes, so ten minutes for the sos. Is that okay?

Hildegarde Naughton

Deputy Hildegarde Naughton

I have to go to the Dáil for Leaders' Questions. However, I will be back before the committee in a couple of weeks anyway. I would be happy to deal with any questions at that point.

Seán Crowe

An Cathaoirleach

I thank the Minister of State. I will suspend for ten minutes if that is okay.

Stephen Donnelly

Deputy Stephen Donnelly

I thank the Chair.

Sitting suspended at 11.38 a.m. and resumed at 11.53 a.m.
Seán Crowe

An Cathaoirleach

We will resume our meeting. I call Deputy Crowe to speak. He is very welcome.

Cathal Crowe

Deputy Cathal Crowe

I thank the Chair. I join in welcoming the Minister and his team to our committee and I thank him for his continued engagement.

A few weeks ago we did a whole body of work here at this committee around sepsis. We had Dr. Colm Henry, the chief clinical officer, here and earlier that day families who had lost people through sepsis in the hospital system attended the committee and presented harrowing evidence to us. Dr. Henry outlined the sepsis protocols. They were very clear, sound and positive and they need to be because far too many people lose their lives in hospitals each year. The one thing I want to briefly home in on as we get under way is that prior to going to that meeting, I read a great deal of material because I have no medical training whatsoever. I do not think many of us on this committee have. We rely very much on accurate evidence, information and briefings. I discovered the previous night that if someone has had sepsis, there is a 60% chance of that recurring when they are in a hospital environment and they are at a very high risk if they re-present in a hospital environment.

I asked Dr. Henry about the sepsis protocol when someone is being triaged and if they are asked a simple question as to whether they have ever had sepsis before. He said "No" and that it is not in the protocols. Anybody who has been triaged in the hospital system answers the questions they are asked. We do not have medical training and sometimes people leave out critical information because they are only answering what they are asked. On the simple question I asked, Dr. Henry said he would look at it, and I am sure he is looking at it.

I want the Minister to ask if a simple question can be inserted in those protocols, which could potentially detect many people who are at higher risk, could allow the medical professionals to monitor that person more closely when they are in the hospital system and, very importantly, could save lives. Could the Minister follow up on that issue first, please?

Stephen Donnelly

Deputy Stephen Donnelly

I can, of course.

Cathal Crowe

Deputy Cathal Crowe

In the funding streams I notice the Minister's budget is vast. I see the National Treatment Purchase Fund, NTPF, as being a very positive mechanism. There is space to further elaborate and broaden its scope. At the moment, as I understand it, it is largely around elective surgeries and getting people off long waiting lists and it is doing so very effectively. I know many people who have gone for cataract and varicose vein treatment very successfully and they speak positively of the scheme.

Will the Minister consider - I mentioned this in the Dáil recently - broadening the National Treatment Purchase Fund to include children in the primary and secondary school age cohort, who are in the queue for the National Educational Psychological Service, NEPS, and the child and adolescent mental health services, CAMHS, for critical diagnostic and screening tests? At the moment, they are not allowed to go through the National Treatment Purchase Fund. Many of them are waiting for two or three years. I was a teacher and some of the children we would have referred on may not have been seen by the system until they left the primary school system. Therapeutic supports are continuous but diagnostics are very different. Someone might have a diagnosis only once in their life. To delay a diagnosis is all wrong. Surely, we could acquire private capacity in this regard or even send these children beyond the jurisdiction, so that we know they can have a diagnosis and that a care and support plan can be built around them.

Stephen Donnelly

Deputy Stephen Donnelly

I thank the Deputy for his question. When the Deputy is talking about diagnostics, is he talking about things like magnetic resonance imaging, MRI, ultrasound or X-ray?

Cathal Crowe

Deputy Cathal Crowe

I am talking about educational and psychological reports, screening reports and the types of referrals which would be made to NEPS and CAMHS, which people are typically delayed on, sometimes, for up to several years?

Stephen Donnelly

Deputy Stephen Donnelly

I can certainly ask. That would be quite a departure for the NTPF. The NTPF has been expanding its remit in any event. It has targeted long waiters and inpatient day case hospital lists and has now targeted people who are not waiting that long at all. In more and more high-volume procedures, it is now beginning to contact people who have been waiting for just 12 weeks and is organising care for them. We are expanding into outpatients, which it traditionally stayed away from, as well as other areas. I will certainly raise the issue with the NTPF.

It is a question for the Minister, Deputy O'Gorman, and for the Minister for State, Deputy Rabbitte, rather than me because it falls within disability services. If they want to have the conversation with the NTPF, I would see no reason they could not. In the first instance, I would need to refer to them and the Minister for State, Deputy Rabbitte, has line responsibility obviously for that.

Cathal Crowe

Deputy Cathal Crowe

I have just read the terms of the NTPF. Largely, when we see someone availing of it, it is an adult and they are going off to get positive treatment. I did not see any exclusion clauses which say that young people should not also be going there. I just thought that in the whole realm of cognitive supports, and diagnostics, and perhaps less in the case of therapeutics, I cannot see anything that rules that out and yet it is not practised at the moment. Of course, there would be a major budgetary strain on that but if it dealt with those incredible backlogs we are seeing, I think it deserves some consideration.

Stephen Donnelly

Deputy Stephen Donnelly

I will certainly raise it with the Minister of State, Deputy Rabbitte.

Cathal Crowe

Deputy Cathal Crowe

I thank the Minister. I want to bring up next the incessant issue of University Hospital Limerick, UHL, overcrowding on trolleys.

At the outset, I will mention that I found myself in the accident and emergency department and the Minister was in touch at me when I was in the hospital. I was in there on New Year's Eve with a rumbling appendix which nearly burst but the staff got it out in time. They were incredible. I saw the best and I will not say it was so bad the evening I was in there. The staff made me aware of that. It was one of those quieter nights in the accident and emergency department, which are not that common. On New Year's Eve, it got busier as the night went on. I was on a trolley for two and half days. I was not in pain and I was hooked up to drips and getting good care. I am very grateful to the staff. Yet, I could see the very significant limitations and challenges the staff were facing on the ward.

We, in the mid west, believe - I have had this conversation with the Minister many times - that alleviating that funnelled pressure which UHL experiences day in, day out, not just at peak times of the year but every day of the year, and the solution to that is to unlock the greater potential of Ennis, Nenagh and St. John's Hospital. The medical assessment units and local injuries units there have been very successful. The Minister has been down to visit them and has seen them working to the hilt.

Will the Minister give positive consideration to further increasing the operational hours of the local injury units and the medical assessment units to further unburden some of that pressure felt at UHL? Additionally, when he is on the road throughout the country, he has often given the good example of the Reeves centre at Tallaght University Hospital. Surely, the likes of UHL, or some hospital in the mid-west, could look at decanting a ward or two off the hospital campus, perhaps a little way down the road. There are plenty of commercial properties, similar to what happened with the Reeves centre, in the Limerick area. Will the Minister consider that? Anything that frees up bed space in the hospital ecosystem ensures a better through-flow in accident and emergency.

Stephen Donnelly

Deputy Stephen Donnelly

I thank the Deputy for his questions. I was delighted to hear he got such good care in UHL. When we talk about UHL, we tend to talk about the consistent and unacceptable pressures for patients and staff in the emergency department. It is worth saying the hospital is making very considerable progress on its waiting lists and has been for some time. We need to acknowledge that.

We come back to the question around the trolley situation, put simply, in the ED. The answer to this is capacity and reform. Capacity in the hospital is very substantial. In the lifetime of this Government, there has been an increase in the hospital's workforce, believe it or not, of more than 1,100 staff, which is very substantial. It has gone from approximately 2,800 staff to 3,900 staff. That is a 40% increase in the hospital's workforce in the lifetime of this Government. That gives a sense of how much we have invested in that hospital. We added a lot of extra beds to the hospital. As the Deputy is aware, two 96-bed wards are being built on the site of the hospital. In addition, and the Deputy referenced the Reeves centre, UHL is getting one of the six surgical hubs. We are progressing that as quickly as possible.

As the Deputy quite rightly referenced, the medical assessment units at Ennis, Nenagh and St. John's, and the injury units, are going from strength to strength. The injury unit in the Deputy's local hospital in Ennis opened in 2022. I was very impressed by what I saw there. We are looking to standardise and lengthen the opening hours. When we were there, staff made the point that they were getting additional radiology equipment but they needed more staff and could do more. That is part of it. We have 13 injury units. They are a critical part of our urgent care infrastructure. People do not know about them enough. For example, leaflet drops by the HSE are now going on and there is online advertising and more to make people aware of the injury units. Those units can do more and more. When the Deputy and I were in Ennis, it was said to us that people were driving past the door of the injury unit to sit for hours in an ED at University Hospital Limerick when they could be in and out of the Ennis injury unit in half an hour to an hour.

Cathal Crowe

Deputy Cathal Crowe

Absolutely, and it is incredible. Is the Minister considering 18 hours over seven days or 24-7 local injury units in that region in particular, given the acute pressure it is under?

Stephen Donnelly

Deputy Stephen Donnelly

We are not looking at 24-7 at present but only because the feedback from clinicians is there just would not be enough people coming in. An awful lot of people would be hired to sit there through the night doing very little. However, it is something we should always keep under advisement.

We talked about capacity. It is important to say that a large part of the solution now in UHL is reform. We must have senior decision-makers on site on Saturdays and Sundays and out of normal regular hours. That is what the whole public-only contract is about. We have to have better patient flow in the hospital. The Deputy will be aware that a new regional executive officer has been appointed. She is working on the ground in UHL. I believe there are changes benefiting patients. That can be seen in the data on the number of people in the emergency department versus up the house in the wards. There is a long way to go. The Government will continue to invest but we must see reforms in patient flow and working practices in UHL. To be blunt about it, we are not seeing them yet at the level we need to see them.

Cathal Crowe

Deputy Cathal Crowe

I thank the Minister. I will make a few small points. The fair deal scheme comes under the curtilage of the Department. There are many strands to the Department but many people with houses with defective concrete blocks, and this is in the realm of the Minister for housing, Deputy O'Brien, cannot avail of fair deal to any meaningful effect because those defective concrete blocks affect the value of their homes. I spoke to the Minister of State, Deputy Butler, about this. It is just something the Department needs to advise on. A whole set of data are available to the Government. The Minister for housing has most of it, but many of these people are elderly, are moving on in life, and have health issues. They need to be in a nursing home, yet they are effectively locked out of them. I would love the Minister to scrutinise that and for the Department to look at ways of unlocking that because it is denying many people the care they need in their later years.

There is no time limit, Chair. I have a final issue.

Seán Crowe

An Cathaoirleach

There has to be a limit. We have three more members looking to get in.

Cathal Crowe

Deputy Cathal Crowe

The final issue is quite a sensitive one. At the committee a few months ago, I spoke about psychiatric care given to women who have postnatal depression and-or postpartum psychosis. A woman asked me to represent her case, which was a very delicate and sensitive one. I asked whether she was sure she wanted that and she said "Yes". We went through the whole thing. She watched every minute of that contribution and the ministerial response. She has since passed on. It is a very raw and sensitive case. The point I made that day, which I will reiterate, is that women who have postnatal depression or postpartum psychosis, if they present in an acute psychiatric environment, are in a ward or room system beside a whole plethora of other psychiatric cases. Having given birth to a child is quite apart from someone who may be grappling with addiction or lifelong psychiatric problems. It is quite a different thing.

The ask was that there be somewhere, be it co-located in a maternity hospital or somewhere else or some particular bespoke setting, where women who have just given birth can be reintegrated with the baby, have access to the baby and have family access without being, in this case, in a room next door to somebody who is coming off high-drug dependency. They are at totally different ends of the spectrum of mental health needs. This woman's point, which I reiterate because the poor woman is in the heavens these days, is there needs to be a more sensitive bespoke care realm for people like that. Not everyone on the psychiatric health spectrum can be in the same facility at the same time. If someone has just given birth to a child, there needs to be something bespoke on the maternity hospital campus or elsewhere. I am fighting for that woman still. I hope the Minister can. It is not a massive ask. I ask that there be some facility in different parts of the country that can sensitively care for this.

Stephen Donnelly

Deputy Stephen Donnelly

I thank the Deputy. I will certainly review the situation. As he said, the proposals he made seem very sensible. Let us take a look.

Cathal Crowe

Deputy Cathal Crowe

I thank the Minister.

Seán Crowe

An Cathaoirleach

Deputy Durkan will make a short intervention.

Bernard Durkan

Deputy Bernard J. Durkan

It will be short this time. The point I wanted to make, when the Minister of State was also present, relates to the importance of dealing with eating disorders in the CAMHS system. There are very serious deficiencies in the degree to which patients are dealt with and put on whatever medication is necessary. One of the problems that comes up again and again is that the patient does not follow the required medication and the problem becomes more serious. I would like to see some reform there.

An issue I raised previously is the question of medical card holders, and in one case the holder of a GP-visit card, who, for one reason or another, do not qualify for an upgrade to a full medical card. In one of the cases I dealt with, it was due to misadventure in one of our hospitals. I would have thought it was the primary aim to ensure, insofar as it can be done, that trauma for the patient is alleviated as much as possible. I hope it is not a possibility that nothing is done unless liability is accepted or something. That should not be the case. The trauma was on the patient at the time, in a hospital, as a result of which that patient now has a serious problem.

There may be a case later. I do not know, as I have no indication of that, but there are situations where there were no legal cases at all and it still made no difference. I ask that the Minister consider this matter again. A full medical card could be of help to the patient. Such patients have many worries.

I wish to raise the issue of cataracts. In some cases, people do not need to travel anywhere, as we can deal with them right now if we have to, but there was a patient who had been on a waiting list for a long time and was suddenly going blind. For a person living alone, that was a problem. He was not that old of a patient either. He had his cataracts done by capitalising his pension or something like that, which is something he should not have had to do, and getting help from relatives. The HSE refused to pay for it afterwards despite the fact that we had purchase arrangements in place and services were readily available nearby, although he was not aware of that. I ask that something be done – this is the subject matter of a number of my parliamentary questions – to alleviate the burden on people in such cases. If people are suddenly told they will be blind in a week, it concentrates the mind fairly quickly, especially if they are living alone.

Stephen Donnelly

Deputy Stephen Donnelly

I agree wholeheartedly with the Deputy about eating disorders. We are now recruiting into ten eating disorder teams around the country. We have seen a significant increase in general youth mental health presentations, including for body dysmorphia and eating disorders. Ten specialist teams have been set up, are being staffed and are making a big difference. This was one of the elements of the women’s health action plan for 2022 and 2023.

While we must provide healthcare services for those with eating disorders, we also need to take more action regarding smartphones and social media. I have met parents whose children’s lives have been destroyed by eating disorders in the most serious of ways. When I asked them what kicked it off, they held up their phones and said, “This is what got them.” At a BT Young Scientist and Technology Exhibition, I saw a project concerning a platform where the young scientist had shown that, within seven clicks or likes, the content being provided through the general stream went from the most innocuous and blandest of material to the sinister glamourisation of body dysmorphia and eating disorders. What is happening is poisonous and causing a great deal of damage to young people’s mental health, including through body dysmorphia and eating disorders. We have information and we know this from around the world. I am working with Cabinet colleagues, including the Ministers, Deputies Foley and Catherine Martin, and others on having a robust response to this issue. Coimisiún na Meán is doing good work. The Online Safety Commissioner and the binding rules will help. I note they are being challenged by more than one of the platforms, but it cannot just be about helping people who find themselves in this awful position. We have to be robust.

Regarding cataracts, if people pay for private care in Ireland themselves, the HSE is not in a position to reimburse them. If they do it through the NTPF or the cross-border directive, they can and will be fully reimbursed. Legitimately based on the waiting list or not, though, none of us can elect to say that we will just go into hospital and pay privately.

Bernard Durkan

Deputy Bernard J. Durkan

He was going blind and there was not time. That was unfortunately-----

Stephen Donnelly

Deputy Stephen Donnelly

The Deputy might send me the details of that case.

Stephen Donnelly

Deputy Stephen Donnelly

The answer to this is the innovation that I saw in the eye and ear hospital last Friday, whereby more care is now being provided in the community by optometrists and specialist nurses, leaving the ophthalmologists free to do the most complex cases. The hospital has reduced its waiting list from years to months. We want that approach rolled out across the country.

Bernard Durkan

Deputy Bernard J. Durkan

Do not forget about hospital misadventures and medical card patients.

David Cullinane

Deputy David Cullinane

I was going to pose a number of questions on the elective hospitals or centres, but the Chair already raised the matter. I am not looking for a reply, but the committee had a lengthy discussion on the issue with officials late last year. I believe we will have another session on it this year. We need to identify the site in Dublin and progress the other hospitals. This is important for the reform of our health service. I hope that we see an injection of pace into the delivery of these hospitals.

I will ask questions on another hospital, namely, the national children’s hospital. I know the Minister likes to answer questions on this particular subject, as does every Minister. Given how this is the first time the Minister has been before us in the new year, it is important that we get an update on it. There was a great deal of discussion about the hospital last year. Everyone accepts that, when it is built, it will be world class, add significant value and so on. At the start of last year, the total programme cost of the hospital – there may have been additional costs for the satellite centres at Blanchardstown and Tallaght – was €1.433 billion. At our last session on the matter, the board stated that it had spent approximately €1.35 billion. It was nearing the figure of €1.433 billion and was going to the Cabinet for additional money. What was the additional capital that the board requested? Did it get all of that capital or just a portion of it as a bridging amount? What was the amount? I am still none the wiser about what amount the board requested. That is my first question. I have a number of others. Could I have clarity on the amount?

Stephen Donnelly

Deputy Stephen Donnelly

I brought a memo to the Government in December for a bridging amount. The board was sanctioned for €1.433 billion and was close to that amount, so I brought a memo for €40 million as a bridging amount. There is a significant additional funding requirement. The officials can correct me if I am misremembering, but from memory, the latest programme of works from the developer suggests that we will take full ownership in September. One has to assume that significant payments will need to be made between now and September. I know-----

David Cullinane

Deputy David Cullinane

What we were told was that there had been a specific request from the board. What the Minister gave them was a small amount of that to cover expenditure for that period. Will the Minister say what the requested amount was?

Stephen Donnelly

Deputy Stephen Donnelly

That amount is commercially sensitive because it is what the board believes it will need as part of the negotiations with the contractor. For obvious reasons, we do not want the contractor knowing-----

David Cullinane

Deputy David Cullinane

The board told us something different.

Stephen Donnelly

Deputy Stephen Donnelly

-----how much money we believe we will allocate.

David Cullinane

Deputy David Cullinane

This is where it gets frustrating. The board told us that the request was not related to that, what it needed was money to pay for rising costs, and there would be a separate requirement to deal with outstanding claims and so on. Every time we ask a question about costs, we are told they are commercially sensitive, so answers cannot be given. It strikes me that the hospital will be well built before we know how much it costs. I do not see how the question of how much money the Cabinet was asked for and potentially approved can be commercially sensitive. It beggars belief. In any event, there was a figure of €1.433 billion. The Government gave the board an extra €40 million. The board had asked for more, but the Minister is saying that, for commercially sensitive reasons, he cannot or will not give me the figure. He is leaving this open to speculation, which is not good. There is a great deal of speculation about the numbers. I do not get into that, as I want factual information.

How confident is the Minister that the September date will be met?

Stephen Donnelly

Deputy Stephen Donnelly

It is difficult to say. The project to date has been beset by delays and an acrimonious relationship between the board on behalf of the State and the main contractor.

A significant amount of money is under dispute - many hundreds of millions. To the Deputy's point about not knowing the final cost in September, we will not know the final cost unless there is a full and final agreement, which could happen, but it is entirely possible that a lot of the claims will go on in the courts for-----

David Cullinane

Deputy David Cullinane

If the Minister had said, "Here is the money we have been asked to provide, take out the amount that relates to claims and here is the balance", I could live with that. When he gives us no information, it worries me. I imagine some of the additional money needed to finish this project will be to deal with claims. That is one element. Then, there are other costs. It is not commercially sensitive to be informed of what the other, non-claims cost is.

Stephen Donnelly

Deputy Stephen Donnelly

It is commercially sensitive. The board, on our behalf, is in the middle of an engagement with the contractor involving substantial amounts of money. It is not simply a question of the board saying it needs this amount and then there is a commercially sensitive amount on top of that. It is not in the interest of the taxpayer to signal to the contractor how much money we are considering. I do not believe it is.

David Cullinane

Deputy David Cullinane

Has the Minister formally met the paediatric development board this year so far?

Stephen Donnelly

Deputy Stephen Donnelly

I wish to clarify something. In September last year, it submitted its programme of works.

Stephen Donnelly

Deputy Stephen Donnelly

It is saying quarter 4. It is not necessarily September this year, it was September last year, in quarter 4.

David Cullinane

Deputy David Cullinane

I knew that. Has the Minister formally met the paediatric development board this year so far?

Stephen Donnelly

Deputy Stephen Donnelly

Not so far. I have had conversations with the chair of the board but they probably happened in late December.

David Cullinane

Deputy David Cullinane

I suggest that would be really useful. I had some sharp disagreements with the Minister last year on the role of the Minister versus the role of the board. The board has a clear role in making sure this hospital is built on time. There is a programme of works that the contractor has now submitted. The programme of works determines how quickly the project can be completed. The contractor has to deploy human resources to make sure it can meet that timeframe. The board needs to put pressure on BAM but so too does the Minister. If I was in his shoes, one of the first things I would have done in the new year, given all the controversies around this hospital last year and, I assume - I may be wrong - there will be more this year, would be to meet the board and ask, "Are you confident the programme of works is being delivered? Is it falling back? Is it on time? Where are we with it?" We do not need more shifting deadlines. I suggest, constructively, that needs to be done quickly and urgently.

Stephen Donnelly

Deputy Stephen Donnelly

I had those conversations with the chair of the board in December. I doubt the position changed much between late September and now. I would be amazed if the board said it was fully confident in any timetable the contractor has given it because every single timetable the contractor has given it has proven not to be the case. The board will speak for itself. Based on my conversations with it, it has accepted the programme of works and is working to that programme. I would be astonished if the board said it was confident.

David Cullinane

Deputy David Cullinane

That is why there needs to be accountability. We cannot forever and a day accept that whatever date we are given, we have no hope it will be delivered on time. Every date given and every target is missed. At some point, the State has to say, "Enough is enough. You have given us September, you have a programme of works. Deploy the resources and deliver this". There needs to be really strong political oversight. If September is missed again, we know there is a six-month commissioning period before it is operational.

David Cullinane

Deputy David Cullinane

It will be well into the summer of next year before any patients are seen in that hospital.

Stephen Donnelly

Deputy Stephen Donnelly

I agree with everything the Deputy said with one caveat. I assure him there has been significant senior political involvement in this matter over the past number of years. It is ongoing. BAM Ireland and BAM International are clearly aware of the Irish Government's position and our deep frustration with how this project has unfolded.

Seán Crowe

An Cathaoirleach

For what it is worth, the committee went out and had a look at the site in December. We went to areas we had seen before. I am a layperson but there is no way, under anyone's timetable, that the hospital will be finished by September. I would put my life on it that it will not happen.

Stephen Donnelly

Deputy Stephen Donnelly

Steady on now, Chair.

Seán Crowe

An Cathaoirleach

There is a huge amount of work. There is no way it will be finished by September. That is my personal view. I follow through on what my colleague said, that it would be useful for the Minister to follow up with the board and perhaps have a look himself at what still needs to be done. A huge amount still needs to be done.

Violet-Anne Wynne

Deputy Violet-Anne Wynne

I appreciate the Chair allowing me in as I am not a member of the committee. I am seeking updates on the delivery of a number of things for this year in respect of yesterday's online meeting. We were given the opportunity to discuss ongoing issues at UHL with the new regional health executive officer, Sandra Broderick. I was happy to attend and I wish Ms Broderick the very best in her role. My first question is about revenue to provide the first 96-bed block at UHL. Where are we in terms of capital and revenue for the second 96-bed block at UHL? By extension, 48 of the beds in the 96-bed block are to replace existing nightingale beds, which are not HIQA compliant. Can something be done to maintain and extend the lifespan of those wards rather than just decommissioning them? Four new respite disability houses are needed to support children with complex needs and families. It was mentioned in yesterday's meeting that families who do not have access to necessary respite services are presenting to the emergency department, which is concerning.

In a meeting of this committee before Christmas, Colm Henry told me that extending injury unit hours later into the evening would not make a material difference to presentations at the UHL emergency department. I refute that, considering the high volumes currently presenting at LIUs. It was quite rightly pointed out that a lot of people are still not aware that they exist or whether they can attend the LIU rather than the MAU, for example. The Minister responded to that fact and a leaflet drop will be done. How many people were sitting in an overcrowded accident and emergency department in Limerick all night who were just looking for a patch up or to be looked after following an injury at football training, for example. We voted in the Dáil on a motion to extend the hours. Will the Minister comment on where we are in that regard?

Will the Minister provide an update on the tender process for the satellite haemodialysis unit at Ennis Hospital? It affects around 300 people in County Clare. Are funds available for that to be delivered this year? The Minister mentioned the delivery of the surgical hub at the Scoil Carmel site in Limerick. Currently, theatres in UHL are running at 125% capacity, which is a major concern. Are there any updates on that situation? Are there plans to expand services like stroke, coronary or cancer care at Ennis Hospital in the future?

Stephen Donnelly

Deputy Stephen Donnelly

Regarding specific services in any hospital, be it Ennis or anywhere else, it is a matter for the national service plan, which will shortly be published but has not been brought to the Government yet, and the capital plan, which we will publish. However, I will ask officials to get an update for the Deputy on haemodialysis in Ennis. Regarding University Hospital Limerick, I have a few comments. I fully acknowledge the ongoing distress caused to patients and our healthcare professionals working in that environment.

The solution is not just capacity. For far too long in this country, we listened to individual hospitals that were under pressure say there was nothing they could do about this issue and that the Government just needed to provide them with more staff, beds or other resources. That is absolutely not the entire answer. We must continue to insist on reform within the hospitals. When I met the team from University Hospital Limerick, it quite rightly put the challenge to me and the rest of the Government, saying it needed more staff, beds, non-hospital pathways and other things, but it is fair to say we have responded to that. An additional 1,100 staff have been working in UHL in the lifetime of this Government, believe it or not. The number has risen from 2,800 to 3,900 – a 40% increase in just three and half years, which is huge. The team asked for more beds. It already has 98 more beds and, as has been referred to, there are to be another 192. The first block is under construction and enabling works are being carried out for the second.

With regard to responding to the ask for resources, the injury unit in Ennis opened up in 2022. It is one of the six sites of the surgical hubs. It is fair to say that, in response to the correct demand for more healthcare capacity in the region, not just in UHL, and bearing in mind that there has been a huge upgrade at Croom in terms of orthopaedics, the Government has invested at an unprecedented level in beds, staff and injury units. It has done so at Croom, which has done fantastic work.

It is important to state that, to the great credit of healthcare workers in the mid-west, waiting lists are getting shorter rapidly. We do not talk about that because we are focused on what we can all see, which are the emergency department and the unacceptable situation therein, but we must give credit to the healthcare workers for bringing down the waiting list.

I hope I have addressed the members’ various questions on capacity. On reform, one of the most important things to reduce the number of patients on trolleys is weekend discharge or seven-days-per-week discharge. UHL has the second worst weekend discharge rate of any hospital in the country, in spite of its having had the second biggest increase in staff of any hospital in the country. My information is probably a year old. Certainly as of last year, UHL had more ED consultants than any other hospital in the country. Therefore, in spite of its having had a vast increase in resources, it is not doing what it needs to do in terms of patient flow that other hospitals are doing. It is doing some of it but by no means is it where it needs to be. Therefore, my message – the Government’s message is very clear – is that we have accepted the demand for capacity and are investing in that. This must be reciprocated with senior decision-makers on site at the weekends and weekend discharge. I am referring not only to the hospital but also to the community care services.

Seán Crowe

An Cathaoirleach

I said to the Minister and some of his officials that we would probably finish earlier today, but that was my naivety.

Seán Crowe

An Cathaoirleach

Maybe I am just too optimistic about how these things go. I apologise to the staff for going over time. I apologise to Deputy Violet-Anne Wynne for there not having been more time. That concludes our consideration of the following Revised Estimate for public services for the year ending 31 December 2024: Vote 38 – Department of Health. In accordance with Standing Order 101, a message to that effect will be sent to the Clerk of the Dáil. I thank the Minister, Deputy Donnelly, the Minister of State, Deputy Naughton, and their officials for attending our meeting this morning.

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