2009 Annual Output Statements.

I welcome the Minister for Health and Children, Deputy Mary Harney; the Minister of State with responsibility for children and youth affairs, Deputy Barry Andrews, and their officials. This meeting of the select committee has been convened to consider the Revised Estimates and output statement for Vote 39 — the Department of Health and Children; Vote 40 — the Health Service Executive; and Vote 41 — the Office of the Minister for Children and Youth Affairs. A proposed timetable for this meeting has been circulated. It provides for opening statements to be made by the Minister and Minister of State and the Opposition spokespersons before an open discussion on the Estimates and output statements and, finally, a question and answer session. Is that format agreed? Agreed. I ask the Minister and Minister of State to make their opening statements on the overall Estimates and output statements.

Will the Minister, Deputy Harney, speak before the Minister of State, Deputy Andrews?

Yes, obviously.

My colleague, Deputy Shatter, who will be interested in what the Minister of State has to say, is speaking in the Dáil Chamber at the moment.

I am anxious to facilitate all members.

I understand that copies of my script are about to be circulated. Members will be able to read the statement for themselves. I will go through the main features of it. In debates of this kind, people often get annoyed by the constant references to money. As this is an Estimates debate, we have to focus on money. I am seeking the approval of the committee for the Revised Estimates for 2009. I will deal with Votes 39 and 40 and the Minister of State with responsibility for children and youth affairs will deal with Vote 41. The Revised Estimate for 2009 provides for gross expenditure of €15.957 billion for health services. Of this amount, €15.469 billion is being provided for current funding and €488 million is being provided for capital funding. Vote 39 provides for gross expenditure of €495 million. The gross provision for the HSE under Vote 40 is €15.01 billion, comprising an Exchequer contribution of €11.633 billion and appropriations-in-aid of €3.377 billion. In setting the Estimate for the health group of Votes, the Government took difficult but necessary decisions to secure the economy and jobs and the long-term stabilisation of the public finances.

This year national income will be €144 billion, of which 11.1% will be allocated to health. When compared with expenditure in other OECD and European Union countries, this figure places Ireland at the top of the class. Taking into account the definition of health spending and the age structure of the population, a high level of public resources being generated by the economy is allocated to the public health system. Health expenditure this year will be 30% of gross current expenditure.

The health service has benefited greatly from economic prosperity. Life expectancy is one of the key measurements of health in all countries. In the past decade life expectancy in Ireland has increased faster than in any other country in the OECD and is currently three years higher than it was ten years ago. A child born in Ireland today can expect to live longer than a child born in the United Kingdom, Belgium and many other European countries and as long as a child born in Germany.

Since 2002 current public health expenditure has doubled in nominal terms. During this period Ireland'sper capita expenditure on health has exceeded the European Union and OECD average for the first time. According to OECD figures, growth in expenditure in Ireland was the second fastest among all OECD countries between 2000 and 2006 and 8.8% per annum in real terms. We can also place €16 billion spending in the context of a total of approximately €41 billion in taxation and other current receipts expected this year. This means 39% of revenue will be expended on the public health system.

The challenge for all of us is to achieve more for patients and members of the public with the given level of spending. The underlying increase over the 2008 Estimates provision in gross current funding for the health group of Votes is 0.18% compared to an increase of 11.3% in 2008. Gross current funding for the Health Service Executive is being increased by 1.8%, while current funding for my Department shows a reduction of 5.6%.

In 1999 we spent €220 million on public health capital projects. This year, the figure will be €488 million. The significant increase in the rate of capital investment during the period has modernised health facilities and equipped the health service to be much more responsive in its delivery of services.

We know from international comparisons that there is considerable scope for the health system to become more efficient and, in the process, improve service availability. Greater flexibility, redeployment and new work practices are required to ensure the money being provided delivers better patient care and outcomes.

Even in the challenging financial circumstances in which we are operating, the Government has allocated €193 million for new developments in the Health Service Executive in 2009. There has been some media speculation in recent days that these developments are not proceeding. I am pleased to note that while finalisation of the Revised Estimates and their publication were delayed owing to the necessity for the Government to deal with the critical position in the economy through the supplementary budget, the necessary approval to implement these new developments is being issued by the Department of Finance. An additional provision of €350 million has been made available to meet the increased cost of demand-led schemes which is rising by approximately 15% this year. A further provision of €80 million has been included for the health repayment scheme.

The Estimates for 2009 include an additional €15 million to fund the cancer control programme. This additional funding will allow the programme to concentrate on developing high quality services to combat lung and prostate cancers. It also provides for the creation of an additional 100 posts. The additional funding brings the total allocation for the national cancer control programme to €36.75 million to support the development and reorganisation of cancer services. The target for the reorganisation of breast cancer services was to achieve 60% of the reorganisation by the end of 2008. Some 80% of the target was achieved at that date and 100% will have been achieved by the autumn.

An additional €10 million was provided for the HSE in the 2009 budget for disability services. These moneys will provide for 125 additional therapy posts in disability and mental health services targeted at children of school-going age. Of these, 90 posts, including speech and language therapists, occupational therapists, physiotherapists and psychologists, will be provided for children's disability services. There will be 35 additional posts for the child and adolescent mental health services. A further €10 million was provided in the Vote for the Department of Education and Science for educational services for children with disabilities.

Additional funding of €12 million has been allocated to the Health Service Executive in 2009 to continue with the revised primary childhood immunisation programme and commence the measles eradication programme. The revised immunisation programme continues to be implemented.

In budget 2008 we provided for the creation of a special fund to foster innovative projects in the delivery of health care. This has been continued in budget 2009. The aim of the innovation initiative is to stimulate new and innovative ways of delivering services in a manner that achieves greater efficiency and improved outcomes for patients. The emphasis is on spreading innovative success to other sites through shared learning. Information on best practice and successful experiences could then be extended to other areas and parts of the health service. Projects are designed to encourage integrated working across community and hospital services and foster an integrated approach to planning, implementation and governance. A total of €33 million in funding is available, €12 million from last year and €21 million in additional funding provided in this year's Estimate.

As Deputies will be aware, the legislation giving effect to the fair deal was recently passed by the Dáil and is before the Seanad today. The Government has provided funding of €55 million to commence implementation of the fair deal in September, subject to the approval of the legislation by the Seanad. This will create an equitable and fair system of support for those who require long-term care in the public and private sectors. The legislation is long overdue and will establish a system which will relieve the burden experienced by families trying to meet the care costs of their loved ones. As Deputies will be aware, the State covers 90% of the cost of care for those in public facilities or a bed acquired by the HSE in a private facility. However, where persons must provide their own care, the State pays, on average, only 40% of the cost of care. This is an inequitable and unfair system which imposes a significant financial burden on many families. It will be a good day's work when the Oireachtas finally signs off on the legislation. The National Treatment Purchase Fund will require the summer period to procure beds on behalf of the Health Service Executive.

Public expenditure on drugs provided for patients under the general medical services and other community drugs schemes has increased significantly in the past decade. The year-on-year increase in expenditure on medicines is among the highest in Europe. In 1998 we spent slightly less than €400 million on drugs. By 2008 annual expenditure on drugs had increased to almost €2 billion. The factors driving this increase include: the number of items prescribed has increased in the past decade from 25 million to 65 million; general practitioners are prescribing newer, more expensive products; and greater numbers are eligible for medical cards. My Department and the HSE have taken a number of actions to control expenditure on drugs. Savings are being achieved through off-patent price cuts agreed with pharmaceutical manufacturers. This agreement will conclude in 2010. In addition, the pricing mechanism for new products has been changed and we now have a review mechanism which takes account of price reductions in other countries. However, ongoing efforts are required to control drug expenditure. I am considering changes to the payment structure for pharmacists under the Financial Emergency Measures in the Public Interest Act 2009. Other options are also under consideration by my Department and the HSE.

Under the Health Act 2008, automatic entitlement to a medical card for persons aged 70 years or over ceased on 31 December 2008. The income thresholds for entitlement to a medical card for those aged 70 years and over are €700 gross a week for a single person and €1,400 gross a week for a couple. I welcome the fact that these income guidelines are much higher than those for persons aged less than 70 years, as they reflect that as persons get older, the Government will continue to provide them with support, even within the constraints of the current economic position. I am aware that to date in 2009, 19,954 medical cards for persons aged 70 years and over have been returned or removed from the medical card register. Of these cards, 10,690 were returned to the HSE by persons aged 70 years or over whose weekly income was in excess of the specified thresholds and a further 9,264 medical cards were removed from the medical card register as part of a data quality exercise. It is also worth noting that the vast majority of people in the over 70 age group have retained their medical cards.

Some €80 million has been provided to meet the cost pressures on services arising from demographic changes and new technology. The additional funding will fund service increases in areas where there are unavoidable demographic and other pressures. The health repayment scheme provides a clear legal framework to repay recoverable health charges for publicly-funded, long-term residential care. Approximately 35,000 claims for repayment have been received, of which an estimated 20,800 will result in repayments. The scheme is estimated to cost €80 million in 2009. Approximately 1,100 claims remain to be concluded. A significant amount of those are more complex and may result in higher individual repayments.

The capital funding allocation for my Department is €15.45 million. This will fund the health research projects administered by the Health Research Board, improve infrastructure required by the National Cancer Screening Service and support ICT projects, the Health Information and Quality Authority, the Office of Tobacco Control, the National Cancer Registry and the Health and Social Care Professional Council.

The capital allocation for the Health Service Executive in 2009 is €410.263 million. This represents a reduction of 31% from 2008 levels. This year's allocation will facilitate completion of several major projects currently under way. These include construction on the accident and emergency department and ward block at Letterkenny General Hospital and the cardiac-renal project at Cork University Hospital. Regarding developments at the Mater Hospital, advance works are under way and it is anticipated that construction will begin before year end. The design brief for the National Paediatric Hospital and the Paediatric Ambulatory and Urgent Care Centre at Tallaght will be advanced. Capital projects under this year's allocation include developments to support the transformation in the mid-west, including CT scanning facilities at Ennis General Hospital.

The health service faces a major challenge to live within the budget for 2009. The HSE is required to continue with the value for money initiatives it succeeded in delivering last and to build and develop on them. Centralised procurement, which is now happening within the HSE, should help to drive down costs. The main cost of health care is staff and 70% of the budget is spent accordingly. We must ensure, therefore, that in a modern health system we deliver services with a staff that is motivated to be flexible; I am confident that staff throughout the health service will give this support. Flexibility means members of staff moving from one ward to another and from hospitals to community services, where required. I hope there will be support for more flexible work practices in the context of the voluntary early redundancy scheme, otherwise it will be impossible to implement it.

The output statement has been sent to members of the committee; it is a worthwhile process to examine the output for the previous year. Some 93 primary care teams are now fully functional; 298 members of front-line staff have been appointed and a further 117 teams are at various stages of development. I referred to the childhood immunisation earlier and the roll-out of the national cervical screening programme commenced last September. Nursing home inspections for all nursing homes will begin under the new standards from July of this year. There were some 3.271 million outpatient appointments and this exceeded the target of 2.7 million; the number of day-case discharges also exceeded the target. The National Treatment Purchase Fund exceeded its target and BreastCheck, which dealt with 90,333 women, did likewise. The target for the national cancer control programme was a 60% transition to the eight centres and 80% was achieved. The number of home care packages exceeded the target by 2,000 and the number of home help hours also exceeded the target. The same goes for out of hours GP contacts. In the area of mental health there was a 6% reduction in involuntary admissions to adult psychiatric hospitals.

Notwithstanding the challenges that remain and the individual stories that emerge from time to time when things go wrong and services do not live up to the expectations citizens are entitled to have, our health service performs, by and large, to the standard we are entitled to expect. More importantly, as standards are being implemented and new requirements are laid down in the areas of hygiene, infection control, the inspection of long-stay care facilities and so on, this is the first time Ireland has moved towards the application of objective standards monitored by an independent body. We will continue to meet the standards of excellence people are entitled to expect. Reform of the health service is not being driven by the budgetary situation, important as that is, but by patient outcomes and patient safety which remain the determining factors in where and how things happen. Sometimes we become obsessed with institutions, rather than being concerned with what happens in them and we must all pay attention to this. We must ensure we take the advice of experts — for example, in the area of cancer the plan was devised by cancer experts and is being implemented by them to deliver better patient outcomes.

I welcome the opportunity to address the select committee this afternoon on Vote 41. The total estimate of the funding required in the year ending 31 December 2009 is €442 million. This consists of €379 million in current funding and €63 million in capital funding. It might be noted that the estimate allocation includes funding provisions to support youth work programmes and services which transferred from the Department of Education and Science and the young people's facilities and services fund, which transferred from the Department of Community, Rural and Gaeltacht Affairs to my office with effect from 1 January 2009. In the time available to me I would like to present to committee members an outline of the key funding elements across the individual subheads in the Vote.

The early child care supplement, ECS, has been a source of significant support to families with young children and the Government was glad to have been able to introduce it in 2006. However, in the current economic climate unpopular decisions had to be made and there were no easy options in regard to reducing Exchequer expenditure. In the circumstances, it was announced in the supplementary budget that the payment would be halved to €41.50 per child from 1 May 2009 until the end of the year.

When the ECS was introduced in April 2006, it was criticised in some quarters because it directed resources away from more beneficial investment in early years care and education, in particular, in the form of pre-school education. Many experts in early years care and education argued at the time and since that the funding directed into the ECS was more than twice what would have been needed to implement a free pre-school care and education year targeted at pre-school children. In re-evaluating the ECS, the opportunity has been taken to establish a new child-centred approach to early years policy and provision, and to re-invest €170 million into the early childhood care and education scheme, ECCE, from January 2010. The scheme will be implemented by my office and the necessary arrangements are currently being put in place. We will be supported by the county child care committees. The introduction of the pre-school year in early childhood care and education is an historic step in the development of Ireland's early childhood care and education policy; that this step is being taken at this time of economic crisis and budgetary constraint makes it all the more remarkable.

The national child care investment programme, NCIP, is the successor programme to the equal opportunities child care programme, EOCP, under which almost 40,000 new child care places were created. The NCIP, which is wholly Exchequer-funded, is intended to build on the success of the EOCP. The total allocation to the NCIP was €575 million over five years, of which €358 million was in respect of capital and €217 million was in respect of current expenditure. By the end of 2008, €180 million of the NCIP's capital allocation had been committed, with almost €100 million drawn down. In light of the current economic climate, no further commitments are expected to be made in respect of capital grant funding under the NCIP, with the exception of a number of priority projects. Some €60 million in capital funding has been allocated for 2009 and capital funding to cover the remaining commitments will be allocated in 2010.

The community child care subvention scheme, CCSS, was introduced with effect from January 2008. Approximately €160 million has been allocated to the CCSS over the three years 2008 to 2010. Under the scheme it is possible to ensure that the level of grant aid for which the individual services qualify reflects the actual level of services they provide, and the profile of the parents benefiting from the service. The subvention received by the service is, in turn, reflected in the reduced fees for the parents who qualify as disadvantaged under the scheme. The scheme is designed to be transparent and provides an effective framework for continued targeting of additional resources towards disadvantaged parents and their children.

In subhead C of the Vote, the funding allocation of €6 million is sourced from the dormant accounts fund from which €4.87 million is being made available to support the prevention and early intervention programme for children. This programme is aimed at promoting better outcomes for children through improved planning and integration. The programme uses international evidence of what works to support activities chosen and this requires a range of statutory and non-statutory agencies, working across sectors, to collaborate in both service design and interagency delivery.

The programme is being managed by my office and the administration of funds overseen by it. It will run over five years with a fund amounting to €36 million in total, of which €18 million is being provided by the Government and the balance by Atlantic Philanthropies. Funds have been committed to projects in Ballymun, west Tallaght and Darndale-Belcamp. Priorities for 2009 include the phased roll-out of the small number of remaining interventions and the commencement and continuation of evaluation. The development and commissioning of the final strands of an appropriate evaluation framework is almost complete.

The launch of the national recreation policy in September 2007 highlighted the Government's commitment to the development of youth cafes. The focus is to bring better coherence to the approach taken to date, retaining the strong interagency element and identifying an appropriate model for youth cafes for future developments. Any funding scheme will have as prerequisite interagency collaboration, mainstream funding support and will be based on needs analysis and consultation with local young people as a prerequisite for successful proposals. This fund will not fully fund youth cafes but support their development with the bulk of funding leveraged from existing mainstream programmes. In line with the Government's commitment, €1.5 million will be allocated to the development of a national youth cafe programme over the next two years. The allocation for 2009 from this subhead will amount to €750,000.

Subhead D provides for the costs associated with the national longitudinal study of children in Ireland and a range of other programmed activities by my office to support the implementation of the three goals of the national children's strategy. The funding provision for 2009 amounts to €28 million. My office is fully committed to implementing goal 1 of the strategy which states that children will have a voice in matters which affect them. This is being done through a strategy to develop participation structures and promoting the voice of children and young people by supporting their participation in Dáil na nÓg, Comhairle na nÓg, the Children and Young People's Forum and other initiatives. Approximately €1 million will be made available for these purposes in 2009.

Goal 2 provides that children's lives will be better understood with the aim of achieving a better understanding of how children grow up in Ireland. It includes a commissioned research programme, incorporating the national longitudinal study of children, a capacity-building research programme, based on the award of Masters, PhD and research placement scholarships, and a dissemination of research and information programme, most notably through the report, The State of the Nation's Children. A sum of €5.4 million is being made available in 2009 to support these activities.

Goal 3 provides that children will receive quality supports and services to promote all aspects of their development. My office supports this goal through a range of actions including the Young People's Facilities and Services Fund, the development of evidence-based outcomes, focused planning capacity and the implementation of the national play and recreation policies. A sum of €21 million will be made available in 2009 to support these activities.

The most significant share of the funding under subhead D will support the young people's facilities and services fund which transferred from the Department of Community, Rural and Gaeltacht Affairs to the Vote of my office with effect from 1 January last. The fund was established to assist in the development of preventive strategies and initiatives in a targeted manner through the development of youth facilities and services in disadvantaged areas where a significant drug problem exists. Its aim is to attract at-risk young people in these areas into these facilities. The target group is ten to 21 year olds who have been marginalised though a combination of factors including drug misuse in their families or communities. The fund operates in the 14 local drugs task force areas — 12 in Dublin and the remaining in Bray and Cork — and in Galway, Limerick, Waterford and Carlow. It will also be extended to Arklow, Athlone, Dundalk and Wexford.

In 2009, funding of €19.87 million has been provided to support the fund. The allocation includes a current provision of €17.361 million and a capital allocation of €2.509 million. A small amount of existing funding will be available to support a limited expansion of the fund in 2009. One of its key successes is that it is flexible and encourages innovative approaches to attracting the target group into services and facilities. Some of the other projects funded have developed after-school supports or homework clubs to provide young people with the necessary supports to continue in the formal education system.

Responsibility for youth affairs matters transferred from the Department of Education and Science to my office on 1 January 2009. The integration of youth affairs is providing continuity of service and operational experience, as well as opening up greater opportunities for a more integrated, cohesive and effective approach to addressing the needs of children and young people. The overall purpose of the youth work service is to assist young people to realise their potential and to become active participants in society. In 2008, up to 420,000 young people participated in youth work programmes and services. The 2009 budget is €48.115 million. The allocation for subhead E, which is Exchequer funded, amounts to €8.772 million and includes financial provisions to support certain youth activities and other projects under the young people's facilities and services fund. Youth affairs' main funding line of subhead F is part national lottery funded and totals €39.343 million. Focus of financial support in 2009 will be on the consolidation of existing youth work provision and on the safeguarding of front line programmes.

A priority objective for 2009 is completion of the development of a quality standards for the youth work sector, which is being led by my office's youth work assessor in consultation with youth work partners. It will be rolled out nationally on a phased basis later in 2009. The purpose of this process is to assist staff-led youth work organisations. It is based on self-assessment which will be externally validated to ensure adherence to identified and common standards for quality youth work provision.

A sum of €600,000 has been allocated in 2009 under subhead G to support costs in connection with holding a constitutional referendum on children's rights. The Twenty-eighth Amendment of the Constitution Bill was published in February 2007 and contained the Government's proposal to amend the Constitution on children. The programme for Government of June 2007 committed to deepening consensus on the issue. To this end, the Joint Committee on the Constitutional Amendment on Children was established in November 2007 to report back in four months on the proposals set out in the Bill. However, the work of the committee progressed to include a legal audit and analysis of more than 144 submissions. Given the complexity and sensitivity of the issues raised by the Bill, the committee received Dáil and Seanad approval for an extension of its time frame to 16 October 2009. The committee produced two interim reports on absolute and strict liability and the exchange of soft information. It is now concentrating on the family law aspects of the Bill and the Government awaits the outcome of its deliberations before proceeding further with this issue.

Subhead H includes the sum of approximately €10 million in appropriations-in-aid for the Vote in 2009. This is made up of just under €4 million in EU receipts which stem from the operation of the equal opportunities child care programme. The programme ended in December 2007 and the EU contribution is repaid in arrears by the EU. The balance under the subhead amounts to €6 million that has been provided under subhead C from the dormant accounts fund to support the prevention and early intervention programme for children. A corresponding appropriations-in-aid is recorded in the subhead in accordance with the provisions of the Dormant Accounts Acts.

I thank the Minister of State for presenting the Estimate for his office.

I only received the annual output statement a couple of hours ago which is totally unacceptable as it gives no time to properly examine it in detail.

Much of the performance report published on 14 May has not been sanctioned by the Department of Health and Children, particularly the proposals to initiate new service developments. Has the allocation of €12 million to support the extension of new primary care for childhood immunisation been approved by the Department? Has the allocation of €2.8 million for 35 new posts for child and adolescent mental health services, including clinical psychologists, occupational therapists, speech and language therapist, suicide prevention and progress in the implementation of A Vision for Change, been approved? Has the allocation €7.2 million for the development, enhancement of assessment and intervention services for children of school-going age and the recruitment of 90 full-time posts been approved? Has the €15 million for cancer services comprising rapid access diagnostic clinics for prostate cancer, improved access to lung cancer services, development of a national centre for neurological cancer, a national centre for pancreatic cancer and better patient transport services been approved? The Minister informed the committee she hopes the €55 million for the fair deal for older people to be in place in September. We will take her word on that. Will the Minister give more details on the subhead concerning innovative projects? The €100 million set aside in 2009 for the development of primary care services, suicide prevention and disability services has still not been spent this year, and we are in June. The HSE document shows that it still has not received sanction from the Department to spend the money, more than six months into the year. Perhaps the Minister might confirm whether the Department sanctioned the new service developments. If not, can she give a clear guarantee that the money for new service developments will not be diverted to meet shortfalls in funding in other areas of the health service, as has happened time and again?

Last year we saw millions diverted from palliative care, disability services, A Vision for Change and older people's services. Only some of this money was reinstated, leaving massive gaps in services. According to this performance report the HSE is currently running a deficit of €55 million. What is the projected shortfall for the entire year?

There are 25 nursing vacancies to the Central Mental Hospital, but it has not been given the all-clear to recruit nurses. It seems that the hospital management will be left with no choice but to refuse new admissions from 15 June. Will the Minister please confirm that these posts will be filled? The social work services are in crisis management, with extremely heavy case loads and according to recent reports, of the 21,000 reports of child abuse, or children at risk or neglect to the health authorities last year, more than one third were not allocated a social worker. I understand there are 3,000 social workers in the country, 675 or 695 of whom — I cannot remember the precise figure — are engaged in child care. This seems to be way below international standards. Some 6,500 individual children are known to be at risk and they are not getting the support they need. Perhaps the Minister could confirm whether social workers are exempt from the recruitment ban and if so, how many will be recruited this year?

I made this point before: the consultant contract was agreed in July 2008. Some 108 new posts have been approved, but only 48 have been filled. I am sure not all of those appointees have taken up their posts yet. Perhaps the Minister might give the House the exact figure as to how many new consultants have taken up their posts. When I say "new" I do not mean replacement consultants. What is the situation with the consultant bonuses?

I now turn to the Howard teamwork report on the transfer of all acute services from the Mercy and South Infirmary Victoria University Hospitals, Bantry General Hospital and Mallow General Hospital in Cork to the Cork University Hospital over a five-year period. It talks about the transfer of services at Kerry General Hospital, Tralee in the sixth year of the programme. The HSE has said in the past that no service would be removed without a safe replacement being put in place. Clearly, these words ring rather hollow for the people of the mid-west, where the teamwork report was implemented before many of its stipulations were met with regard to accident and emergency services at Limerick, the number of consultants, the new high dependency unit and so on. The same thing happened in the north-east with enormous pressure being put on staff and services at Our Lady of Lourdes Hospital, Drogheda, and at Cavan General Hospital. I am sure Deputy O'Hanlon will have something to say about that.

The Government would appear, in collusion with the HSE, to have deliberately delayed the publication of the Howard report until after the local elections to minimise the political fall-out. However, the people of Cork and Kerry have a right to know the plans for their hospitals — and they were entitled to know this before the local elections. On first reading the report, it seems that no extra funding will be available to implement the plan, no new beds will be provided at Cork University Hospital and the plan depends on the development of a collocated private hospital, which will clearly not happen. Emergency services will only be operational for 12 hours a day at so-called local centres of excellence. Significant investment is needed in improved emergency services, advanced paramedic ambulance and air ambulance services. Significant investment is needed in developing primary care teams as well as for home care, residential care and rehabilitation.

What is the timeframe for the introduction of these plans? When will services be put in place and when will they be withdrawn from regional centres? What funding is available for these? According to the annual output statement circulated today acute hospitals are receiving 2% less in 2009 than they got in 2008.

On cancer services, the Minister will be aware that a letter has leaked from the manager of Galway University Hospital, where it is stated that with a further €6 million cut the hospital cannot guarantee cancer services there as a centre of excellence or as a specialist centre. Furthermore, surely the people of Sligo, before services are transferred from there, are entitled to know the outcome of an internal audit being carried out in Galway similar to the 48-criteria one done at Waterford — which only met eight of the criteria, incidentally, with 36 not met and four undetermined. Clearly this is a hospital under serious stress and this is not a wise move at all.

Furthermore, I question the wisdom of moving breast surgery from the South Infirmary Victoria in Cork where they do more surgery on breast cancer than anywhere else in the country by a considerable long-shot, to Cork University Hospital, just for the sake of it, when we are facing financial constraint. What is working is working, so can it not be left where it is? The report recommends that the HSE needs to develop a suitable forum to bring all stakeholders together so that there is mutual respect, partnership, collective planning, implementation and sharing of responsibilities. Does the HSE have any plans to set up such a forum and if so, when, and what is the timeframe?

I shall just go through some of the subheads. The Minister mentioned medical cards in her speech. I have serious concerns here. During the year a decision was taken by the HSE to centralise all medical card applications to improve efficiency — but certainly not to improve services to patients. There was serious concern among HSE personnel about the lack of local knowledge and the impact it would have on patients, as well as among patients and clients who find it extremely difficult to deal with remote people with whom they have no chance to interface directly. I will just give an example of what happened in recent days. I was approached by an extremely angry patient in Lusk. When he told me the problem I promised to bring it up in this Chamber in one form or another. Last week he received a medical card for his wife who died nine years ago. That is the result of this centralisation. It does not bring efficiency but rather harm and hurt and inconvenience for people.

I cannot let the opportunity go without remarking on the still very low income threshold for a medical card. Somebody on little more than half the minimum wage is no longer entitled to one, and this seems to be an extraordinary situation which has gone on for years without being addressed. Further, I note the Minister has made provision for changing demographics, but when the ESRI tells us we have passed the 400,000 mark and that there will be 500,000 unemployed by the end of 2009 and possibly 800,000 by the end of next year, is the Minister's provision for medical card demand realistic in terms of the money she has put aside?

I am delighted to see that the NTPF money has dropped, because I do not believe that to be an appropriate use of public funds. However, it puts me in mind of what is happening in Crumlin. A solicitor from Cork rang me today whose child is in need of corrective surgery for scoliosis, and many people will be aware that if this operation is not done in a timely fashion there will need to be further surgery, exposing the child to two serious operations instead of one as well as considerable additional pain and risk from a long general anaesthetic. He is looking to see whether he can enter into litigation on behalf of his child, so cross is he, and with good reason. His view is that if Crumlin hospital will not be funded to allow it to do the work it does so excellently, at least such children should be referred to the UK for treatment so that they do not have to endure two operations where one would suffice.

I will comment on one or two other things and then I will hand over to my colleague. The statement mentions considerable improvements in several areas. Outpatient attendances were recorded at 3.27 million versus a 2.7 million target. The population has risen considerably. Who set these targets for the HSE? On what basis were they set? The number of day discharges was up from the target as well. The National Treatment Purchase Fund refers to treating 23,927 patients as opposed to 23,500. Where is the qualitative analysis? What sorts of operations were being carried out? Are we comparing like with like? It is very easy to organise simple things like hernia operations, but it is much more difficult to organise things like operations for scoliosis and hip operations.

A total of 11,500 people benefitted from the provision of home care packages. What was the quality of those home care packages? Did they change from last year? I am certain about the answer to the next question, which is about the home help hours provided. A total of 53,366 people benefited against a target of 54,000. That is because many people saw their home help hours reduced. Some of the hours were reduced by 50%, while others were reduced by up to 75%, which rendered it virtually useless to the individuals involved. These figures do not reflect the reality on the ground.

While I accept that we are spending more money than ever before on health, we are not getting the value for money that we should get. I hold the Minister and the HSE management responsible for that. We spoke last year about redundancies. The Minister spoke about introducing them, yet when I asked her in the Chamber about this, she said it was a matter for the Minister for Finance. We are no further down the road in getting real reform and real value for money. If we reflect on the fact that we are spending €16 billion through the public service and €4 billion through private service providers, as the Minister has told me, that is €20 billion being spent on health, or nearly €5,000 per man, woman and child in this country. However, less than €4,000 per person is spent and the Dutch have got a health service that delivers without long waiting lists, without trolleys in accident and emergency departments. We should be able to do the same.

I will hand over to Deputy Jan O'Sullivan, but I hope the Minister has taken note of the questions.

I welcome the Minister, the Minister of State and their teams. I thank them for the way in which they made their presentation, as the target outcomes are helpful in seeing what is being achieved. However, I agree with Deputy Reilly that we have had very little time to get a handle on these target outcomes because we only got them an hour before the meeting started.

I will begin with the acute hospitals and the cancer programmes. I am also very concerned at the information that has appeared in the media recently about the cancer control programme. This is one of the Minister's main ambitions. Is she happy with its progress so far? There are several causes for concern, one of them being the information regarding the general manager of University College Hospital in Galway, and the €15 million in savings the hospital management is being asked to achieve. The manager was quoted in the newspapers today as saying that it will have a devastating impact on our ability to deliver cancer services in accordance with the national cancer control programme. The manager also said that these savings will bring the hospital to its knees, the implication being the closure of 60 beds, two theatres for the second half of the year, and one intensive care bed. That is in Galway, yet the Sligo services have not even been moved to Galway. In Waterford, 36 out of the 48 standards set by HIQA were not achieved, according to a recent report. We have not seen the HIQA reports for any of the other centres of excellence. Will they be published? The public should be allowed to see whether these hospitals will be centres of excellence. It is vital that we have the appropriate resources, beds, expert teams and so on that are necessary for these centres.

Another report inThe Irish Times stated that waiting times for breast clinics breach guidelines. More than 1,000 women with concerns about breast cancer had to wait more than three months, which is the aim for the centres. The worst delays were in Limerick and in the Mater Hospital in Dublin. These three press reports referred to at least three different parts of the country, where these targets had not been achieved. When Professor Tom Keane appeared before the committee, one of the assurances that we were given was that all of these appropriate resources would be in place for triple assessment, a multi-faceted approach to the various teams and so on. I have serious concerns if this is not in place, because I believe Professor Keane is going back at the end of the year. He was very prominent when he came first, but we have not seen him lately. I suggest that this committee bring him in and find out if he is satisfied with the progress being made. Is the Minister satisfied? I do not think it is appropriate to move to this if the services are not in place.

The same problem exists with reconfiguration. We have had the report on the south, while the report on the mid west came out recently. This document seems to suggest that the north east is progressing very satisfactorily. It refers to targets being achieved, but if one was to ask people in the north east about targets, there is no satisfaction expressed. As there are such severe cut backs in the health budget across the country, especially in acute hospitals, these transitional arrangements are happening, patients are being moved and services are being closed without being made available elsewhere. In my region, one of the recommendations of the HIQA report into Ennis was that there should be a full audit of the Mid-Western Regional Hospital to ensure that it is ready to take the extra burden, especially when some surgical services are transferred at the end of July.

Has the Minister been given all the information she needs about these things? Has she taken on board the concern expressed? Is there a mechanism to ensure that before services are transferred, she is satisfied that the resources are in the areas where centralisation is taking place?

There is to be one list under the consultants' contract, and we on this side of the House want to see a one-tier system where patients are treated in accordance with need, rather than ability to pay. The Minister told us that there would be one list for diagnostics, including things such as colonoscopies, and that everybody would be treated equally. Is that happening in practice now in our acute hospitals, following the signing of the contract? If it is, I welcome it very much. A total of €1 million was to be assigned this year to begin the colorectal screening programme. Much more money is needed in future years, but is that €1million available? I believe €4 million to €6 million is to be made available next year, and an annual cost of €15 million will occur after that. What is the progress on this?

Like Deputy Reilly, I also wonder at the value for money on the National Treatment Purchase Fund. I received representations from a man who has been waiting more than one year for a heart operation in the Mater Hospital. He approached the National Treatment Purchase Fund, which contacted the Mater Hospital. I also contacted the NTPF, and I got a letter back which stated that the NTPF had contacted the Mater Hospital, asking it to prioritise the people who had been waiting a long time. That was the only action the NTPF took. Is that counted in the figures for the National Treatment Purchase Fund? It asked the Mater to prioritise the people waiting the longest, and that is all it did. I am not sure how this is treated. There are many areas where we are not sure what exactly the National Treatment Purchase Fund does. I agree with Deputy James Reilly. While it tends to do nothing about the more difficult cases that cost money and it does a lot of relatively small procedures that add up in terms of numbers, all of the tough, difficult operations are carried out through the public service. We must bear this in mind when we talk about the National Treatment Purchase Fund.

I want to raise the issue of Crumlin hospital. The amount of money required is relatively small but no one, including the Minister, wants to see children waiting any longer than necessary for any kind of procedure they need, especially very ill children who, for example, are having chemotherapy appointments delayed and operations cancelled. I urge the Minister to give members any update she can on addressing the shortfall in funding for Crumlin hospital.

There is a report in one of the newspapers that 1,300 hospital beds are out of use at present in the public service. The number of beds that were to be created through co-location was less than this figure. What is the position and what will the Minister do about the closure of that number of beds? She may suggest this is a matter of finance but the reason the beds are closed is due to the cutbacks in funding for acute hospitals. At page 29 of the document on targets, under the heading of "Older People", there is an output target for residential care beds for 2008 of 525 beds but the document states that this target was not achieved, with just 306 additional public beds operational. In other words, public beds are closed, the number of residential care beds is not reaching its target and there are more than 800 people in acute hospital beds who are ready to be discharged while accident and emergency departments are blocked up with people on trolleys, others are not able to get into the hospitals, operations are being cancelled and so on. This is a very important figure and an important failure in terms of addressing the problems in acute hospitals. The document puts the output for 2009 at 725 additional beds. Does the Minister expect to reach that target?

With regard to the development of the national paediatric hospital, there do not seem to be any figures for money that is being spent in preparation for that hospital. I believe some people have been appointed. Has the Minister any figures in this regard?

Page 27 of the output document refers to suicide prevention. This committee yesterday published its report on suicide prevention. Under the heading "Targets" in the output document, the targets achieved for 2008 are referred to. If the Minister asks any of the four members of this committee who compiled the report on suicide prevention, they will tell her that targets for suicide prevention have not been achieved. The document refers to the steps taken to reduce suicide and repeated self harm and lists 19 phase 1 actions which have been completed and 11 phase 1 actions which have been progressed. The report this committee produced yesterday would indicate that the majority of the targets for suicide prevention have not been reached. I hope the Minister has received a copy of that report. There are other members of this committee who participated more fully than I did in drawing up that report and they are to be commended. Will the Minister read the report and ensure the recommendations are implemented?

I wish to ask the Minister of State, Deputy Andrews, about the changes to child care. I presume the reduction in the figures relates to the child care payment being reduced and the replacement national care in education programme. I have had representations on the implementation of that programme and the difficulty of some who have child care programmes in fitting into the criteria in terms of applying for and qualifying for funding. Are there difficulties and, if so, will the Minister of State, in so far as he can, address them with those who provide child care? Is there a mechanism to ensure the quality of the service is in accordance with much of the research that has been done on early childhood education, particularly in the context of the value of early intervention for children and especially for those who do not have many social advantages or a tradition of education in their families? Are there standards in place to ensure the quality of what they are given is in accordance with the best outcomes for those children? I will finish at that. If I have other questions, I may come back in later.

As a medical doctor, I believe everything that can improve quality of life should be available for everyone and as soon as possible. As a citizen, a politician and a former Minister for Health, I am well aware this cannot and does not happen in any country of the world, unfortunately. In times that are economically difficult, what we must do is consider how we maintain and develop the service within a very finite resource. Some €16 billion is a lot of money and I was glad the Minister said another €193 million is available this year for the development of services. She referred early in her address to increased efficiency in the service as well as its quality, availability and financial management.

With regard to the acute hospitals, the Minister referred to the question of the number of admissions, the length of stay and how we need to get this reduced. Will the appointment of the new consultants help in this regard? Is there a problem at present in that some very inexperienced non-consultant hospital doctors are responsible for many of the admissions? Can something be done in this regard?

My next question relates to the roll-out of primary care facilities, which we would all welcome. There is no doubt that where one has a good primary care facility, it tends to keep people away from very complex and expensive locations, namely, the acute hospitals.

One of the areas which is a responsibility of the Minister and also the Minister of State, Deputy Andrews, is the question of health promotion, particularly for young people. What progress are we making in tackling the abuse of alcohol, tobacco and drugs?

Deputy Reilly referred to the acute hospitals in the north east. The only parochial comment I wish to make — I probably made it last year as well — is that it should not be necessary to remove the acute medical services from smaller hospitals for low grade pathology for people in their 60s, 70s and 80s with pneumonia, asthma, strokes, mild coronary problems and so on. Where we have very good acute medical services, as we have in Monaghan hospital at present, it should not be necessary to move those services to other hospitals in the region which are not equipped at this point to cater for the increased workload. I was pleased to hear that Professor Keane is ahead of target and hopes to have the cancer strategy 100% in operation by the autumn.

The cost of pharmaceutical medicines is a matter of concern to all of us. The Minister referred to a cost of €2 billion and indicated that an additional €350 million will be provided this year. It begs a question we must address, namely, how to control the cost of pharmaceutical medicines. I note the number of items. Perhaps this could be reviewed, which would be a matter for the medical profession. There is also the question of the use of generic medicines. I always recommend to medical colleagues to use generics where they are satisfied as to their equal efficacy and value, which is the case in respect of practically 100% of medicines. Some drugs will costs hundreds of thousands of euro annually for individual patients. We like to pride ourselves on the fact that we have always been able to provide the medicines patients require. However, there is an issue that must be addressed not only in this State but throughout the world as to how to provide medicines that are particularly costly.

On the question of new technology, are we obtaining the maximum benefit of administrative technological initiatives in terms of increased efficiency in the service? As with the cost of medicines, another issue we must address in this area is the new technological developments in medicine and the high cost of, for example, replacement surgeries as they continue to develop.

I am interested in the progress since last year in the comparative analysis of the type of return we obtain in different regions and particularly in different hospitals in terms of staffing ratios, admissions and so on. Some hospitals, such as St. Luke's General Hospital in Kilkenny, seem to secure a very good return while others are apparently less efficient. There must be a root and branch examination, incorporating an analysis of unit costs and cost benefit indicators, to see where savings can be made. Is there any intention to publish the results of what is happening in the various hospitals throughout the State? Are there services which are redundant? For instance, apart from the acute ambulance service, it may be time to outsource the delivery of transport services, perhaps in association with the school transport system or other forms of subsidised transport throughout the State. I have suggested to some of the Minister's colleagues that a pilot project in a county such as mine to integrate all the transport financed by the State might show a worthwhile return.

I welcome the establishment of the early childhood education initiative. In regard to mental health services for adolescents, there seems to be a lacuna in terms of the co-ordination between services for children and those for adults. Another issue of concern relates to co-ordination with the activities of the Department of Justice, Equality and Law Reform. While we must be extremely careful in safeguarding the rights of children, I am concerned that there is no sufficiently rapid mechanism to deal with cases where young people pose a risk to themselves or others. I understand that where a child needs to go to Oberstown for assessment, he or she must first be brought before the courts which may lead to delays as a decision in this regard is awaited from the Director of Public Prosecutions. This process may need to be streamlined while, as at all times, ensuring we protect the interests of the child.

The adversarial system of politics does not serve the people well. We spend a significant amount of time debating topical issues that come to the fore for one reason or another, some very serious and others not. If we are to provide a comprehensive health service into the future where everybody receives exactly what they need when they need it, we must address not only the fact that we have limited resources but also the massively increasing costs of the provision of health care worldwide. No country will be able to satisfy demand, with even developed countries finding it difficult to satisfy need. It would be useful for the committee to address some of these issues in more detail to see how we might offer a solution.

I thank the Minister, Deputy Harney, the Minister of State, Deputy Barry Andrews, and their officials for attending the meeting. I will begin by dealing with the issue of disability services. It is not clear from the Revised Estimates how many people continue to reside in institutions while waiting for suitable accommodation. A commitment was given some years ago in this regard, which was to be fulfilled by 2006. That has still not been done. In my area, the Grove House facility houses 20 to 30 adults with disabilities, which everybody agrees is completely unsuitable. I see nothing in these figures that will rectify this situation in the coming year.

Another issue that disturbs me is the Minister's indication that the target pertaining to the sectoral plan has not been achieved as a result of the deferral of the further implementation of the Disability Act 2005 and the Education for Persons with Special Educational Needs Act 2004. Moreover, it was decided not to complete a second review of the sectoral plan as provided for in the legislation. That is difficult to accept. We fought long and hard when the legislation was introduced to ensure that such a situation would not arise. Our argument was that making the provisions resource dependent meant that once finances became tight, this was one of the services that would be curtailed. That is precisely what is happening.

Furthermore, as a result of the decision not to complete the sectoral plan review, there is not even a quantification of what is happening. At least if we knew what little was being done, we might be able to keep some type of handle on it. It is very disturbing that this minimal commitment is not being fulfilled. Is this because of a lack of funds, even though money has been found for many other initiatives? People such as those being cared for in Grove House require more suitable accommodation. I accept that this will require substantial funding and personnel resources. However, a commitment was given in this regard and it should be fulfilled as a matter of urgency. We cannot continue to pretend this problem does not exist.

The Dáil is debating the Ryan report today and one wonders whether the House will return in another ten years to ask what the Minister and the Department were doing while this was going on. It horrifies me to think these people are not being treated properly and that their living accommodation is not as good as it could be. Given the correct provision, most of the people concerned could live very good lives in communities. It does not necessarily have to be in the type of enclosed housing in which they live at present.

Another issue I wished to raise with the Minister does not appear as a subject for discussion, namely, paediatric diabetes services in Cork. There has been no movement and I have heard it actually is taking a step backwards. This worries me because we have been at it for two years and I had thought that some progress would have been made. A service, rather than an entirely new service is being sought in this regard. The report on the Minister's desk identifies Cork University Hospital as the black spot in respect of paediatric diabetes nationwide. What is happening in this regard? Where in the Estimates is this included and why has more progress not been seen on it?

While I have received several queries on eye tests, I received one this week that struck me. While it is a fairly small matter for most people, one's eyesight is precious if one is elderly, vulnerable or shaky in any way. At present, there is a waiting list of 12 weeks or three months in Cork for having one's eyes tested under the medical card scheme. I acknowledge one can have a test done immediately in exceptional circumstances. However, the average run of the mill waiting time, even for elderly people, is now three months. When I queried the reason for this, I discovered the person who normally deals with this matter is on maternity leave.

Having a baby is one of the most predictable things one can do. After about two months, one knows one is pregnant and one tells people and seven months thereafter it is a fair bet that one will have a baby. While it may come slightly sooner than that, nevertheless it is a highly predictable event. The Minister of State, Deputy Barry Andrews, should note it is equally predictable that such children will require education four years later but this also appears to come as a surprise to everyone. Although it is a highly predictable event, no one is there to take up that slack. I asked how many women, because at present only women can have babies, were on maternity leave and the answer was 851. Having children is highly predictable and should be encouraged because we all will need them to support us in our old age. Although the circumstances were highly predictable, none of the women concerned has been replaced. This is what used to be called human wastage when people retired. It is about cutting back on staff without actually so doing. The pressure on women in such circumstances must be horrendous because they know they will not be replaced and their colleagues will be obliged to try to pick up the slack. However, one cannot pick up that much slack and something must be done in this regard. People not getting an eye test is one of the minor consequences.

For clarity and to be helpful, is the Deputy referring to a doctor who is on maternity leave or to a clerical person?

The latter. This could affect a social worker or anyone else. My point is that ultimately, these are predictable events. Although having children should be encouraged, no one is being replaced at present and this is causing great hardship both for the women's working colleagues and, as I stated earlier, for elderly people who seek services. It is unfair to put such pressure on women in these circumstances and it is as though this is an event that never happens. I await the Minister's response in this regard and will be particularly interested in her comments on paediatric diabetes in Cork. As there has been a reduction in staff members there again, progress is not being made. As for people with disabilities, when will they all be living in more appropriate accommodation? Is there a timeframe in this regard?

While I am reluctant to hurry members along, four other members have indicated they wish to contribute, namely, Deputies O'Connor, Neville, Aylward and Shatter.

Does the Chairman want me to hurry?

I simply point out that four members wish to contribute.

It will help that I know what I wish to say. Listening to members' excellent contributions has reminded me that both Ministers, who are very welcome, have a huge remit and that members can talk about a wide variety of subjects and priorities. I wish to agree with the point made by the Vice Chairman, who acted on the Chairman's behalf yesterday. I was a member of the group under the chairmanship of my good friend and colleague, Deputy Neville, which produced the suicide report that was published yesterday. I made a point that I am happy to repeat before the Minister and Minister of State, whose support in this regard I seek, namely, the sub-committee strongly determined that these issues are important. While I already have conceded that the Minister and the Minister of State have many health issues on their desks, suicide is a serious issue. The sub-committee is determined that action will be taken and I hope the Minister will consider these issues.

I wish to mention two particular subjects regarding Tallaght.

Where is that?

The Minister must find out because she is due to visit on Friday week and I look forward to that. I wish to raise the issue of cancer services because the Minister faces a question on this subject in the Dáil from one of my colleagues today. As someone who is concerned about the services at my local hospital, I seek assurances from the Minister. I also noticed the Minister's excellent presentation stated the design brief for the new national paediatric hospital and the proposed paediatric ambulatory and urgent care centre at Tallaght will be advanced. The Minister is aware of my interest in these projects and I ask her to tease out the details for me. If the plans are to go ahead, I am particularly anxious for the ambulatory care centre to stay ahead because my understanding is that a clear commitment was given to the effect it would be in place in Tallaght before anything happened on the Mater site. I seek reassurance in this regard.

I also wish to make the point to the Minister that this committee has shown commitment to primary care and has heard a number of presentations in this regard. The Minister must be reminded that progress in primary care nationwide — I refer in particular to Tallaght in Dublin South-West — eases pressure on local hospitals.

I also wish to make a point to the Minister of State with responsibility for children, whom I welcome and wish well. It is appropriate to so do on a day such as this when all members have been affected by the debate in the Dáil, which has highlighted the issues. My point to the Minister of State is that without being flippant, my last real job before being elected to the Dáil involved working in the youth service in the National Youth Federation and in consequence, I have a commitment to and a strong interest in ensuring, even during difficult economic times, that funding will continue to be provided for youth services. The Minister of State will be aware of an issue I have mentioned to him a number of times and have raised in the Dáil. I am a member of the Tallaght drugs task force and local groups are concerned about how the administrative changeover regarding funding and various programmes will take place. Through the Chairman, I seek the assurances of the Minister of State, Deputy Barry Andrews, in this regard. I wish both Ministers well as we deal with the serious issues that are of concern to all.

Like other speakers, I wish to draw attention to the report published yesterday. The previous report, on which the most recent report is based, resulted in a two-hour debate in Dáil Éireann led by the former Minister of State, Tim O'Malley. Hopefully the Taoiseach will at some point grant members the same facility for a full debate on the report that was published yesterday. As for the €1.75 million that has been provided on a once-off basis in 2009 for suicide prevention, the Minister should clarify whether this will go through the National Office for Suicide Prevention. As she is aware, the office's budget was cut by 12.5% of its 2008 allocation. How does this relate to the National Office for Suicide Prevention's budget as originally outlined?

The Minister for Social and Family Affairs, Deputy Hanafin, has allocated €11 million to organisations dealing with family crises, family difficulties and child bereavements because of the recession and its consequential extra pressures on families. Since 1879, research has shown an increase in suicidal ideation and self-harming in periods of recession. However, the Minister, Deputy Harney, has only given one tenth of what her colleague is prepared to give in response to the needs of families in crisis.

Will the Minister confirm that the more than €100 million that was set aside in this year's budget for the new services for children with disabilities and mental health problems has not been spent? I understand that a performance monitoring review recently presented to the HSE's board showed that the majority of money earmarked for new service development has not been spent. Is this the case? The money includes funds for suicide prevention programmes, new services for children with mental health problems, disability assessments for children of school-going age and other programmes. Six months into the year, has the HSE still not received sanction from the Department to spend the money?

Since the HSE has a deficit of €55 million, its expenditure will need to be reduced. As the Minister will recall from 2008, the cut was made in mental health services. Extensive moneys ring-fenced by her for those services were hived off by the HSE to meet deficits elsewhere. There is a concern that, when the HSE needs money for deficits, it raids the mental health services. Therefore, the opportunity to improve those services and to introduce the recommendations of A Vision for Change disappears.

Like other contributors, I welcome the Minister and Minister of State to the meeting and wish them well with their 2009 Estimates. I have been influenced by my colleague to my side, who has referred to Tallaght, since I will also be parochial and speak about the south, particularly the south east. I have written to the Minister and the HSE regarding a report in a national newspaper two weeks ago about the closure of acute services in the south-east's hospitals. The newspaper mentioned Clonmel, Wexford and, of particular interest to me, St. Luke's Hospital in Kilkenny. It stated that their accident and emergency services will be moved to Waterford Regional Hospital. With no disrespect to Waterford, the move would not be a good idea, given the geographical spread and the local need for those services. What is the Minister's opinion in this regard? Was the report factual?

I always raise the matter of primary care. This year or late last year, the Minister opened a fantastic new primary care centre in Kilkenny. However, the south of County Kilkenny is also awaiting primary care facilities, particularly in Callan, Thomastown and a suburb of Waterford, Ferrybank, which is in south County Kilkenny. Until primary care services are in place, none of the hospitals' acute services should be closed down. Only when there are primary care services should the question of centralising acute services in Waterford Regional Hospital be considered.

My next question is for the Minister of State with responsibility for children and concerns the four new drugs centres. Kilkenny's drugs problem is no worse or better than anywhere else's, but the city has no youth or drugs services at all. Four towns — Arklow, Athlone, Dundalk and Wexford — are being considered. Every town needs some type of task force on drugs, which are a growing problem. Kilkenny's problem is not yet major, but it is starting to worsen. The sooner every town has facilities in place to tackle the issue, the better. Currently, the only place where someone can go with a drug problem is the main hospital, St. Luke's Hospital, which does not have the professionals to handle such cases or to address the underlying causes for drug abuse. Rolling out a task force would be a good idea. It would require funding, but will the Minister of State consider including a town like Kilkenny?

These are all local issues and general matters. I welcome the Estimates and hope that we can maintain our health services during the coming year.

I will address child care services and refer to the 2009 annual output statement for the health group of votes. Will the Minister of State clarify some aspects? With some interest, I listened to his speech in the Dáil today on child care services. He made one or two comments that were different from his comments to date. I wanted to raise this matter in the context of the expenditures detailed in the output statement.

A number of problems arise, the first of which is on the 1999 guidelines for the protection of children. In the House today, the Minister of State finally accepted that the guidelines are not working uniformly and that he does not have up-to-date communication systems, which would allow him to know on a real-time basis how many children were at risk and how many reports of children at risk remained to be investigated or assessed. He stated that there would now be some action in this regard. He referred to a further report to be published next month.

What moneys are being allocated to the HSE to address child protection? Will there be a specific allocation to create or put in place a communication system whereby the Minister of State and managers in the HSE could know at any one time the number of child care cases being investigated or handled, the number of reports of children at risk, where there were difficulties and so on? What is being done in this regard? According to the 2008 output statement, approximately 20,000 child abuse reports were responded to and approximately 20,000 children were placed into care.

The output statement also refers to how the 2008 output data and the 2009 target will be available in September 2009. The HSE's report on child care protection services for the year ending 31 December 2007 was only published one week or ten days ago. It is unsatisfactory that reports are being published one and a half years too late. Clearly, the Department is in difficulty because it cannot set a 2009 target. By the time it comes to setting one, only three months will remain in the year. Where do matters stand with regard to the HSE's publication of its annual reports, which it is required to publish under the Child Care Act 1991 but that it has been abysmally slow in publishing?

As the HSE has slowed in its publication, the information contained in those reports continues to decrease to a point at which it is almost meaningless. It is noteworthy that more background information was published in today'sIrish Examiner concerning the problems experienced within the 32 HSE child care offices in 2007 than was published in the HSE’s 2007 report. That is very unsatisfactory. Are resources being allocated to this? Can existing resources be used more effectively?

Regarding child care and the approximate figure of 20,000 child abuse reports in 2008, I presume child abuse is shorthand for reports relating to child abuse, child neglect and concerns about children's welfare. That would transcend the whole area. Without the 2007 report in front of me, my recollection is of in excess of 23,000 children either at risk of abuse or neglect, or with child welfare concerns. In 2007 there were some 15,000 assessments undertaken, meaning approximately 8,000 reports made in respect of which no assessments were undertaken on the validity of the reports. There is no guarantee that a full assessment will be undertaken if someone in this State reports a child at risk to the HSE.

The 2007 report shows that different areas have different perspectives of what an assessment means. This was highlighted by the report published in April 2009, when the HSE surveyed social work services and identified the problem with the use of terminology. It is alarming that there could be 23,000 reports about children to the HSE in 2007, with only 15,000 investigated. I do not know if the position was the same in 2008 and I do not think the Minister of State knows either because of the systems failure. How rapidly will this change?

The HSE has been operating child care services since 2005. If information systems were defective when the health boards were in place, it is no longer tolerable that a body dealing with it in a uniform fashion does not have proper systems. A report is to be published next month on putting a system in place. When will there be change and what will be the cost? When will there be real-time information? If there is a systems change, will the Minister be able to access it to have real-time information?

In some areas social workers are overwhelmed by the amount of work. On occasions, social workers are unfairly criticised. If we have social workers at the coalface of child care services who go on maternity leave with no substitution, this adds to problems and results in children being left at risk through no fault of the social worker. It means we have a defective, broken child care system. The Ryan commission report taught us that this must be given urgent priority but it has not been given it. We have had a plethora of reports. A report commissioned by the Department of Health and Children set out that only 6% of respondents believed child care guidelines would be properly and fully implemented. What is being done to address that?

There is a major problem with out-of-hours services. Children aged over 12 from dysfunctional families are out on the street, given hostel care and then find themselves transferred between different social workers. They are put up in different locations, some are being pimped, others are drug addicts and some are dying on our streets. It is a scandal and it is time for transparency in this area. Has the Minister of State received the report on the death of Tracey Fay, an 18 year old who died in 2002? It took six years for a report to be completed and it remains unpublished. This was a young girl with an intellectual level of eight or nine years of age. A number of social workers tried to provide assistance but because of the corporate approach to dealing with her, decisions were made by corporate managers who were not directly involved in social work support. Wrong decisions were made and this girl died in the care of the State.

David Foley, a 17 year old, died in the care of the State, in theory. At the age of 14 he sought help because of family difficulties. In theory he was taken into care and cared for by the State. At the age of 17 he was dead. A report into his death has not been published. If we are to use the current phrase and learn from the inadequacies and mistakes, we must have greater transparency. We now have the spotlight shining on the tragic barbarism to which children in residential institutions were subjected. We must be open and upfront about the inadequacies of our child care services so the inadequacies can be addressed. There is an obsession with secrecy in the HSE and, with all respect to the Office of the Minister for Children whose establishment I welcomed, the obsession has continued in that new office. We must shine a light on what is going wrong in our child care services so that we can address what needs to be done to make it right. There is no point in internal or private investigations, with recommendations being made but no transparency or accountability or way in which Members of Parliament can assess whether the recommendations made are being implemented.

I refer to the lessons to be learned from the Monageer report. It is the politically correct phrase to refer to portions of it being "redacted". In my view, they were censored. This includes seven recommendations. I stated in the Dáil Chamber that I had never seen recommendations censored in any report. We have entered Kafkaesque territory, when Franz Kafka was writing books such asThe Trial. Recommendations contained in a report given only to a Minister and one other individual in the HSE should be implemented but cannot be communicated to anyone. No one can account for whether they have been implemented. If something goes wrong in the future, no one will know. These recommendations are meaningless.

What is happening with the report? I have already proposed that the full, unredacted report be furnished to the committee. I do not want to be unfair to the Minister but this proposal was made at least four weeks ago. The Government has had adequate time to consider it. It is of major importance that we address where we have gone wrong so that we do not need another commission in the future to investigate the failures of today.

I formally second Deputy Shatter's proposal on the Monageer report.

A number of weeks ago I asked the Minister of State about the total number of children who have died in care in the past ten years. He did not know the answer and said the HSE would communicate with me and that it would take some time. It emerged that 21 children had died since 2000, a fact that was leaked to a newspaper before I was shown the courtesy of having the information provided to me. We do not know the total number of children who have died in care in the past ten years. I would have thought it a sufficiently important matter for the health boards to have maintained that information and certainly by now for the HSE to know it. I was promised the HSE would communicate the information to me but I still have not received that communication. Will the Minister deal with that?

The Ombudsman for Children has quite rightly stated that we should put in place a definitive structure to investigate the deaths of children, particularly the deaths of children in care, which would allow an investigation or inquiry to be conducted, a report to be prepared and published and recommendations to be made to ensure that if something had gone wrong in our child care services it would be addressed and would not be repeated. The Minister of State's office has been engaged in this and it was first proposed two years ago. Will the Minister of State implement this proposal from the Ombudsman for Children?

I thank Deputy Shatter and I thank the Minister and the Minister of State for their presentations. It is very much in the nature of the work we do here that we deal with the issues that are problematic in the health service so it is very useful for the Minister and the Minister of State to come before us and through the output statements indicate the very many positive initiatives throughout the health services. It is important for people working in the services that they realise there is appreciation in the Houses of the Oireachtas and the public that very many positive things are happening, and the Minister and Minister of State have attempted to highlight those in the statements they put before us.

The Minister, Deputy Harney, referred to the almost 20,000 people who are no longer in possession of the over 70s medical card and she stated that 9,264 were removed as part of a data quality exercise. That is an interesting phraseology; does it mean that those people died or left the country? I have one thing in common with Deputy Reilly's constituent in that I recently received an over 70s medical card for my mother who has been dead for three years. Have general practitioners throughout the country been in receipt of payments in respect of these people and will moneys be recouped in those circumstances?

Others referred to scoliosis patients. There seems to be an inordinate waiting time for medical and surgical intervention in these cases. There also seems to be a problem in that the treatment purchase fund, which does superb work, does not seem to pick up patients with scoliosis and there seems to be a breakdown in communication between the general services and the treatment purchase fund.

We heard a very moving case being made by Traveller representatives on Traveller health several months ago. In her opening remarks the Minister rightly pointed out the achievement of the health services in raising the overall life expectancy of people here. It is a very obvious measure of the progress that has been made but there is a sharp contrast between what is happening among the general public and what is happening among the Traveller community where the mortality rates among infants is frighteningly high and life expectancy is frighteningly low. On occasions we have been told that specific funding has been allocated for Traveller health but we have also been told by the Traveller community that on occasion this fund has been raided by the HSE for other purposes. There is a real need to ensure that this dedicated funding is used for the purpose for which it is intended.

With regard to suicide, a report spearheaded by Deputy Neville, who was a bit like John the Baptist crying in the wilderness on the issue for many years, was published yesterday by the committee. It indicates some progress but it behoves us all to give this issue far more priority, and that priority must be matched by investment. The useless loss of young life is frightening and we must prioritise it on the political and health agendas. I appeal to the Minister to respond to us on this issue.

I pay tribute to Deputy Andrews; there has not been full public appreciation of the importance of the early childhood care and education scheme. It will make a major difference and will be of enormous benefit, particularly to children living in disadvantaged areas. He deserves our support and commendation on bringing forward this initiative but I also anticipate problems in the area. Will the Minister of State speak to us about what we are hearing from the providers on the variation in cost between charges in urban and rural areas? I also anticipate Deputies being inundated with calls from parents indicating that they want their child to attend a particular facility. How will the Minister of State match the supply with the demand?

I thank the Chairman and the members of the committee for their observations. I will begin by taking up some general themes. Usually we are criticised for having what is regarded as a bloated and overly bureaucratic health service full of unnecessary bureaucrats. However, we are also criticised when we seek to centralise the application process for medical cards, which has the capacity to free up 300 people to be redeployed elsewhere. I look forward to the day when we have a central facility for means testing for all Government schemes. Everybody is familiar with old age pension applications, which are processed in Sligo, and the fact that the application process centralised there does not cause any undue difficulties.

Centralisation has not taken place and it is precisely for the reasons stated. We want to have centralisation but it has not yet taken place and the correspondence received by the Chairman's late mother was from the current regime. We want to centralise it to have greater efficiency and effectiveness and we want to ensure that the staff who can be freed up, and Professor Drumm has told us that the number would be slightly more than 300, can be redeployed elsewhere. However, that very simple fact is being opposed.

Deputy Kathleen Lynch mentioned a clerical person on maternity leave and I am told by the director of finance, Mr. Woods, that HSE staff produced 6,500 children last year. The health service staff members are young. I doubt many of them had twins, triplets or quads so many people are on maternity leave. It is expensive to replace all of them and there should be scope in the clerical area for redeployment to cover maternity leave, such as the example given by Deputy Lynch. I am not familiar with the case she mentioned but I will investigate it because the service is provided by private opticians and I assume the delay is caused by this clerical issue. To be fair, often when the HSE seeks to redeploy people it is opposed. Industrial relations issues arise at every level and if we cannot resolve them by agreement then quite honestly they will be very damaging to patient care at a time when money is very restricted. There is no doubt about that. If we cannot replace people through redeployment then we will not be able to provide services.

We have very high staff ratios in many sectors in the Irish health care system in comparison with any other country. The number of nurses working in our health care system is the highest in all OECD countries and double the number in France. Perhaps the reason other countries can do more with the same amount of money is that they have better staff ratios, a better skill mix and pay is substantially lower. I stated in the House to Deputy Reilly that it costs €24.80 to see a GP in the Netherlands. If we are to compare the money allocation here with the money allocation elsewhere we must also compare the salary costs here with the salary costs elsewhere and there is a huge difference in salary costs, not only in health but throughout the economy in the public and private sectors.

Several Deputies mentioned the new development and with the exception of the additional money to deal with suicide, which was approved early because it is for a programme aimed at schoolchildren, the remainder of the new development money was not approved. As everybody here is aware, we have been in a very changeable budgetary situation over the past 12 months, which is why we had a supplementary budget in April, and therefore no new additional moneys were approved by the Department of Finance — and rightly so — until it was in a position to ensure that the Revised Estimates were available and that the budget went through.

I understand approval for the expenditure of additional moneys for new services will be forthcoming from the Department of Finance tomorrow, with the exception of the fair deal scheme. We will not approve the latter until August or September because we do not wish for the money to be redirected elsewhere, which as Deputy Neville noted occurred in the mental health area in 2007. We want new moneys to be spent on new developments.

I cannot emphasise enough the importance of the HSE living within its budget. We will introduce a supplementary budget for demand-led schemes such as the additional medical cards to which Deputy Reilly referred. That is the only area in which a supplementary budget will be forthcoming, other than on foot of an unforeseen emergency. The budget within which the HSE must live is 39% of the tax and receipts that the Government will collect this year, or 11% of our national income. Most people would recognise this as being an enormous sum of money. When different divisions of the health service are asked to live within budget, clearly they will face challenges. Sensitive areas are often the ones in which we are told problems will arise. It is incredible that every time somebody is told to stay within budget, lo and behold we are told he or she is responsible for the most sensitive area.

I assure the committee that we have made huge efforts in reorganising cancer services and Professor Keane is doing an outstanding job in this regard. If one asked the cancer clinicians in this country, 95% — not 100% because there are one or two naysayers — would express huge confidence in the implementation programme Professor Keane has put in place. Every time I meet clinicians, they tell me how much things have changed and how motivated and enthused they are by what is happening. Next week I will open the fast-track clinic in Galway for prostate cancer. Another clinic is being developed in St. James's Hospital, Dublin. When we first designated the eight centres on the advice of cancer specialists, none would have met the standards set. They lacked the volume of patients or expertise of a fully dedicated cancer staff. In Galway, for example, 16 staff were appointed last year, just under €1 million was allocated this year towards new equipment and capital expenditure and a new theatre will be commissioned next month for the cancer programme. If Deputies are in any doubt about Galway's success, they need only speak to clinicians in County Mayo, from which services transferred some time ago. Both patients and medical practitioners in that county have confidence in the services in Galway. A motion put before the IMO conference criticising the cancer programme was rejected precisely because those who have experienced the transition are satisfied with the services on offer. We are not acting this way to be unpopular or appear tough but because we want to put patients first. Volume and specialisation go hand in hand in terms of outcomes for patients.

Deputy O'Sullivan referred to colorectal cancer screening. I have held several meetings with my officials in this regard and we are engaging with the national screening service on developing a model for the affordable and innovative roll-out of colorectal screening. The Irish Cancer Society has offered to make money available this year to begin that process. This is a priority in the cancer area because more than 900 people die from bowel cancer annually. Early detection is critically important in ensuring a good outcome. In the context of our challenging financial circumstances, not every new programme requires additional money but where staff have to be employed we must redirect resources from elsewhere to meet priorities. On foot of the dialogue already entered into, I hope over the summer months to develop an innovative and affordable programme which can be rolled out in as short a timeframe as possible. Population screening will be one element of such a programme but 6% of those screened will require follow-up treatment. It would be useful if Professor Keane appeared before the Joint Committee on Health and Children to discuss the cancer programme and I am sure he would be happy to do so.

In regard to paediatric services, Crumlin hospital's budget has increased by 39% over the past five years. Its budgetary challenges are largely due to the fact that it employs more than 100 staff in excess of its ceiling. The three children's hospitals in Dublin have a budget of €250 million between them and we know from the cost-benefit analysis conducted by the HSE that their merger could save a minimum of €20 million per year on administration alone. As part of the new consultancy contract, the three hospitals are required to appoint a single clinical director and this position is in the process of being filled. Professor Drumm and I recently held a meeting with the chairman of Crumlin hospital's medical board, Dr. Doherty, and another clinician from that hospital. The HSE and Crumlin hospital have engaged on the issues that arise not only in respect of the three Dublin hospitals but also for paediatric services generally.

The HSE has appointed a new clinical affairs director, Dr. Barry White, who is a clinical haematologist from St. James's hospital. Part of Dr. White's remit is organising clinical affairs for the regions and paediatrics is important in that context. I hope we will find sufficient administrative savings to increase our emphasis on services for the seriously ill.

In Dublin, the 17 hospitals which provide acute services carry a multiplicity of administrative overheads in terms of CEOs, directors of finances and human resources directors. This figure includes three maternity hospitals, three children's hospitals and the eye and ear clinic. We have been good at establishing stand-alone institutions but the more we bring services together, the more we can reduce non-frontline costs.

The new paediatric hospital has cost €6.3 million to date. The site was donated by the Sisters of Mercy, which I acknowledge in view of the criticism being directed at the religious congregations. It was valued at €90 million at the time, although it is probably worth less now. The donation was made with no strings attached. It will be a State hospital. Mr. Fintan O'Toole recently referred to it inThe Irish Times as a religious hospital and asked why that should be the case. It will not be a religious hospital. The construction of this new state-of-the-art hospital is a priority for capital development. The children’s hospital development will be suitable for the new pension fund initiative for capital projects announced by the Minister for Finance because it is a priority as far as sick children are concerned.

Deputy O'Sullivan asked whether all the new commitments are in place in respect of consultants. Clinical directors have been appointed either between hospitals or for individual hospitals. They have held a number of meetings and I also met them on one occasion. Their job is to ensure the new contracts are implemented on the ground. I cannot put my hand on my heart to say they have been implemented in every situation but I remind members that we have only just agreed to payments under them. The implementation of the changed contracts and the consequences thereof for hospitals are a matter for the clinical directors. The new contracts will fundamentally alter how our public hospital system works by guaranteeing equal access to diagnostics on the basis of medical need rather than preferential treatment for those with insurance or the ability to pay. I am not certain what the question is on bonuses. No bonuses for consultants are included in the contract.

Shall I rephrase it?

We are not paying all the money that was agreed because economic circumstances do not allow us to. The money due on 1 June is not being paid. The Irish Medical Organisation has taken a strong view and sought a meeting with me on that, but in these economic circumstances we could not justify paying that money. The issue will be reviewed in due course when economic circumstances change. We paid the increases due from 1 January.

What about the bonuses being paid to other consultants, such as advisers, to the HSE?

In an organisation that spends €15 billion, and Mr. Woods might be able to tell me the exact sum, Professor Drumm has two or thee advisers. People love to get a great PR headline from some of these issues, but when one is trying to reform and transform the health services in the radical fashion we are seeking to, particularly where patient safety and quality outcomes are concerned, expertise, where it is lacking or necessary, is an important use of public resources. At his last meeting here, Professor Drumm said there has been a major decrease.

In my letter to the HSE I have asked for reductions in the costs of legal services, which are approximately €30 million per year, consultancies and travel and subsistence. All these expenses are being cut to the bone, and that is as it should be. With the major procurement the HSE is involved in, the centralisation of procurement should greatly help to deliver better value for money. In these economic circumstances, the costs of capital projects are down by approximately 25%, so we should be able, with less money, to do almost as much, if not as much.

The NTPF comes up time and again. It treats the longest waiters. Generally, people who require emergency and serious surgery do not fall into that category. It does hips, knees and cataracts. The vast majority of people awaiting a surgical procedure are in these categories. The NTPF's annual report includes only patients it has treated or the pilot project it did with outpatients. It has seen 150,000 patients and spends less than 0.5% of the total budget we spend on public health services. I would love some of the Deputies to come to some of the gatherings where one meets the patients, including people who work in the environs of this facility, and hear how satisfied they are with the high quality treatment. The surgical procedures are overseen by Professor Arthur Tanner, whom many of the Deputies know. He is a highly qualified and experienced former president of the Royal College of Surgeons——

Nobody is questioning the quality of the work. They are questioning the value for money.

Allow the Minister to reply.

The Minister has been replying for 15 minutes.

The Comptroller and Auditor General has examined value for money in the NTPF, and it meets the test applied.

Could the Minister repeat who examined it?

The Comptroller and Auditor General.

That is inaccurate information to give the committee.

Please allow the Minister to continue.

No, this is a point of information, Chairman. This has been meted out before. The Comptroller and Auditor General did a report in 2004 and commented that he could not, with the case mix in the public system, make a fair comparison. He is doing a study which is not finished. For the Minister to say what she has just said is totally misleading.

Perhaps the committee should have Mr. Pat O'Byrne, the CEO of the NTPF in here to talk to members directly before they make such statements. The NTPF can satisfy the requirements examining case-by-case, whether it is a cataract, a hip, knee operation or whatever it might be, and the two follow-up treatments, which everybody gets. Rather than constantly running down a public organisation, I suggest the committee invite the CEO in here to ask him questions.

The Minister made a statement a moment ago that the Comptroller and Auditor General made a finding which he did not make.

Deputy Reilly made a 15 minute statement.

Yes, and the Minister made a 30 minute statement before that.

Many other members have made statements and raised questions. Will Deputy Reilly please allow the Minister to deal with those matters? Deputy Reilly has made his point. The Minister is trying to answer everybody's questions.

The budget of Merlin Park and University College Hospital, Galway, which act as one, is €263 million. With that resource, in these circumstances, the hospital should be able to meet its commitments, notwithstanding the challenge this is for the hospital, like every other hospital. There is no additional money, nor will the Government be in a position, given these financial circumstances, to find additional money for any hospital in the country. The HSE is challenged to live within the budget allocated to it. As I said earlier, the increase is 1.18% on last year, as against 11% the previous year. That poses a major challenge. That is why I have emphasised the importance of changed work practices and greater flexibility.

If the Minister gives them extra work, surely she should give them increased resources to carry out the work.

What about the audit for the people of Sligo? Will the same audit that was done in Waterford be done in Sligo before the service is removed from them, to reassure them? If the Minister would answer the questions I would be happy to hear, but she only part answers and then moves on to her own satisfaction.

We would like to hear the answers. Many of us are here waiting to hear them.

The decision has been made on the cancer control programme. Sligo General Hospital does not meet the volume. Some 15 public patients from that hospital have gone to Galway already this year——

Will the Minister answer the question? I asked about an internal audit to satisfy the people that they are going to a safe service, unlike what happened in Waterford, where the service failed to meet 40 out of 48 criteria.

That is the second time Deputy Reilly has put that question. Will he let the Minister answer?

We know Sligo General Hospital could not meet the standard because it does not have two breast surgeons, two specialised radiologists——

The Minister is not answering my question. That is fine.

I am just telling Deputy Reilly the facts. The problem with Deputy Reilly is he is against everything and for nothing.

I want some information.

He is trying to tell us his universal health plan, which will cost nothing to the taxpayers and the 500,000 people who will be covered, is revolutionary.

I did not say nothing.

As I said yesterday, it is the revolution of the comic, because it does not add up.

That is the answer to the Sligo question. I thank the Minister.

It does not add up. I would expect somebody in Deputy Reilly's position to support the cancer control plan because it delivers best outcomes for patients

If it were being done properly, I would, but it is not.

The Irish Cancer Society supports it. Why does Deputy Reilly not talk to its members?

They are not happy either.

They are very happy with the cancer control plan.

Not with the manner in which it is being implemented.

I met them only three weeks ago.

Are the people of Limerick happy with the way the Minister is dealing with the mid-west?

The members of the committee will not be happy if they do not have their questions answered.

The Minister should be given the opportunity to answer the questions.

Yes, we are most anxious that she respond.

Deputy Kathleen Lynch raised eye testing, which I dealt with. A number of Deputies raised suicide. I have not read the report of the committee yesterday, but I read the coverage of it in today's newspaper. I will be happy to read it. This morning the Minister of State, Deputy Moloney, said he would be very happy to have a debate in the House and I hope we can do so. Yesterday the Minister of State, Deputy Barry Andrews attended a meeting of the North-South Ministerial Council on health, and suicide was one of the issues on the agenda. There is major North-South co-operation. We have similar difficulties and challenges. We have very high levels of suicide, particularly among young males on the island of Ireland, as they do on our neighbouring island. A number of initiatives are on the way in Northern Ireland and there are a number of joint initiatives on awareness. We are determined to work together. The additional money given this year is for a campaign aimed at school children, that is why it was approved earlier.

Deputy O'Hanlon raised a number of issues. He made the very valid point that in no country in the world is there unlimited access to unlimited care. Every country is challenged to meet the needs of its citizens not just for basic health care but for the new innovations, therapies and treatments that are constantly coming onto the market. The moratorium does not apply to social workers, and 17 new social workers have already been employed this year. The Minister of State, Deputy Barry Andrews, who is more familiar with the issue of social workers and child protection, might deal with that issue.

Deputy O'Hanlon asked about comparing one situation with another. If one examines the volumes and nature of patients, some hospitals seem to do much more with less than others. The HSE recently moved into a HealthStat environment where data is published hospital-by-hospital covering approximately 27 targets, including the number of patients seen at outpatients. Knowledge and information is a powerful driver of change. It is good for us to be able to compare ourselves with peers and for hospitals to be compared with each other. It is also good for us to learn best practice.

For example, one neurologist in the city was seeing 95 new patients a month and somebody else had a different number. It is good to have that data, provided we compare like with like. I do not want to be accused of not doing that. The move into the HealthStat environment is a first in the world, and I know other health systems are very interested in it. It will deliver significant change.

On the reconfiguration of hospitals, Professor John Higgins is the clinical lead for the south and he is engaged in the process. I was asked about the forum, which deals in consultation with the various stakeholders. Professor Higgins has had widespread consultation on the matter and I met him two weeks ago. He met many Deputies from the region, if not the spokespersons, and the committee might ask him to come before it at a future date.

Professor Higgins has made the point, which is worth repeating, that in Cork and Kerry we spend €1.4 billion on the public health service. When Deputy O'Hanlon was Minister for Health this was probably close enough to the budget for the whole country.

That €1.4 billion is a considerable sum, and the issue for the reform is how to deliver the best quality of service within that budget. That is the task facing Professor Higgins and he is engaged with clinicians from all the hospitals in the region. The same applies to the south east, where four clinicians are involved in the reform. Engagement is at a much earlier stage in the south east and Dr. Courtney is lead clinician from Kilkenny.

On primary care, 80 agreements to lease have been entered into. Contrary to what Deputy Reilly keeps telling us, there are 350 GPs involved. He told me in the Dáil recently that not a single GP was involved but 350 GPs are involved with the 80 leases. There was a significant response from the private sector to the invitation extended by the HSE for the construction of primary care centres around the country. Besides the benefits to the health system of having new and modern state of the art facilities that will allow health care professionals to work together and deliver significant benefits to service users and patients from that, there will also be major spin-off benefits in terms of employment, as the construction will be very labour-intensive.

Deputy Aylward asked about primary care but I do not have the details on Callan and Ferrybank so perhaps we can revert to the Deputy on those. I am well aware of the Callan project. I cannot go to Kilkenny but I am met by the strong advocates for that project and although I am not certain where it is in the development process at the moment, we will revert to the Deputy on that.

One of the advocates was elected last week on the strength of the issue.

Thomastown should also be included.

We will come back to the Deputy on that. Deputy Lynch mentioned disability, on which we have made much progress, although we have a long way to go. There are 320 persons with a disability in psychiatric institutions so we have a way to go to provide community base facilities for those people.

The sectoral plan will be done this year and we have not been able to trigger the over fives because of the budgetary position and the significant additional costs involved to both the Department of Health and Children and the Department of Education and Science. A decision was made by the Government not to proceed with that during this year.

With regard to paediatric and diabetes services in Cork, I will meet Professor Drumm and the chairperson, Dr. Costigan, to deal with the report mentioned. That meeting will take place in the early afternoon tomorrow. Deputy O'Connor mentioned cancer services in Tallaght and I dealt with the suicide issues. With regard to the cancer services, diagnosis and surgery is to move to St. James's Hospital and follow-up treatments will continue in Tallaght. The new clinical director in Tallaght, Professor Conlon, is doing a fantastic job. The additional money for suicide prevention will be channelled through the suicide prevention office.

We recently began a Traveller health survey, which will take in every Traveller in the South, and I believe it is a North-South project, so the same will be done in Northern Ireland. That will provide good data. Much of the information referring to the reduced life expectancy of Travellers has to do not just with healthper se but with sanitation, living conditions and so on. There are big issues. I cannot remember the life expectancy off the top of my head but it may be 15 or 20 years lower, if not more, than the normal population, which is a shocking indictment. We have put an additional €12 million into specific Traveller health projects. I am not certain of the position this year and perhaps I could revert to the committee on that.

With regard to suicide prevention, anybody who presents at an accident and emergency department with self harm is followed up with counselling and other services rather than how it was dealt with previously, where the incident would have been treated in isolation with no follow-up. A large percentage of people who commit suicide have previously self-harmed and therefore it is very important we work——

I have a brief query on that. There is a significant problem with those between 16 and 18 who are in need of psychiatric help, sometimes threatening suicide. There is a gap in services in that regard so what is happening in the area?

A number of teams for adolescents have been appointed this year. There is a wider issue of whether such people should be taken in by the adult or child service.

That is a big problem.

It arises in the children's hospital as well and the matter has not been totally resolved. I will have to revert to the Deputy, although I know the Minister of State, Deputy Moloney, is involved with quite a few new teams specifically dealing with services for adolescents.

I was made aware of a case of a teenager in the leaving certificate year who was suicidal. The parents and GP were at the end of their tether and a major hospital was persuaded to take her in as there was nowhere else for the poor young woman to go. There is a great need to bring clarity to the area. People should know what to do if they have a young person in that position and it should not require contacting a Deputy to get a 17-year-old who is deeply distressed access to a psychiatric unit where required.

Deputy O'Sullivan's comment is on the same issue.

The Minister indicated that when somebody presents at an accident and emergency department with self harm, they are referred for counselling. Senator Keaveney yesterday contrasted what happens in her area when people go to Derry against Letterkenny or somewhere in Donegal. She seemed to clearly say that in the North, a person would be referred to the Samaritans or somewhere else but that was not the case in the South. The Minister said quite swiftly that people are automatically referred but the reality is that many people are not referred and are instead left out into their community without any follow-up for a month or two months, when they might get an appointment from the local psychiatric team.

I apologise but I will have to leave. Deputy Shatter is correct in this issue and the Minister has acknowledged the problem of 16-year-olds to 18-year-olds, who are children, using the adult service. In Crumlin, a psychiatrist or psychologist is retiring and because of cutbacks, that is the last one in the place. The hospital admits children regularly who are self harming because there is nowhere else for them to go. The issue must be addressed.

There are 55 child and adolescent mental health teams in place and there is provision for a further eight consultant appointments in the area. The point made by Deputy Shatter, as I understand it, regards the acute service and where this person should go.

Yes, as there is a gap in the service as to whether such individuals are admitted as adults or children. Nobody seems to take responsibility for them. It is not a recent problem. It has been evident for some years. I raised it once before and was told it was to be looked at but that was at least 12 months ago. There is an urgent need to address the matter. It is a problem for GPs also, with late teen distressed patients who are quite clearly at risk if they cannot be admitted. There is a real difficulty in finding a place for them.

On the wider issue of when paediatric services stop and adult services click in, we have taken the advice of the Minister of State with responsibility for children. This applies in particular to the new paediatric hospital and the nature of the service provided there, which is that children up to 18 should be treated on the paediatric side. As the new hospital is to be collocated with an adult hospital, it is hoped that some people will remain on the same campus with the same specialist. This can often be an issue.

On the psychiatric side, I accept there are real issues that must be addressed.

Is there a timeframe in this regard?

I will have to come back to the Deputy on that. My colleague is more familiar with the issue.

What about the issue of scoliosis? The Minister has not addressed this, or perhaps she is not able to today.

It seems that when the health service is challenged it always seems to involve sensitive areas in which the financial challenges will have a more severe impact. Several weeks ago I met some medical representatives, including Professor Drumm, the chairman of the medical board of Crumlin hospital and one of his colleagues, with regard not just to the specifics of Crumlin but the wider issues in paediatrics. I hope we will have some good outcomes from that process.

I thank the Chairman and the members for their questions. There are two major issues, namely, the free pre-school year and child protection. Deputy Reilly asked about the number of social workers and recruitment in this area. Social workers are exempt from the moratorium on recruitment and, according to the figures I have to hand, over the next year and a half, within the employment ceiling, up to 270 social workers can be hired, which is a significant figure. There is no question that we need more social workers, as Professor Drumm mentioned a couple of weeks ago. As I mentioned earlier in the Dáil, I met social workers in Dublin and Cork and anecdotally it is evident that we require more social work posts to be filled.

When the Minister of State met the social workers, did he have an opportunity to meet some of those involved in the out-of-hours service? If not, I ask him to meet them as they are under very significant pressure and they are very frustrated.

I am not sure whether some of them were from the out-of-hours service. The invitation was sent out to all social workers.

My understanding is that there may not have been a single representative of the out-of-hours service at that meeting——

I am certainly happy to meet them at any time.

——although I could be mistaken. This is a very important issue.

The standardisation process was mentioned by Deputy Shatter. The task force set up by the HSE about three months ago is due to report this month. The main focus of that task force was to ensure that an initial assessment and referral in one local health office would be considered to be exactly the same in another area. It does not matter whether one is in Donegal, Wexford or Cork, one will be treated and measured in the same way. That standardisation process will be reported on by the task force later this month. It ties into the knowledge management strategy because there is no point in having such a strategy if one has different ways of measuring things in the first place. It does not give any idea of where there are gaps or duplication, thus allowing for deployment of resources. The first step is to standardise all these processes so that the legacy of the old health boards is taken away, something that should have been done, arguably, a long time ago.

The knowledge management strategy includes the installation of an ICT system which will allow us to measure gaps and duplication contemporaneously and determine where resources need to be used. Deputy Shatter asked about the financial situation in that regard. I argued strongly that it be part of the HSE service plan for 2009, which it is. There is a €30 million budget for the HSE with regard to ICT generally. The specific proposal is with CMOD in the Department of Finance and a peer review of the business plan is being conducted. We hope to have significant progress in this regard.

Is it part of the plan, as I believe it should be, that the Department will be able to access the system directly to obtain real-time information——

That is the idea.

——rather than having to contact management in the HSE to look for information?

I will have to get back to the Deputy about the issue of access, but the HSE has statutory responsibility under the Child Care Act for child protection and, as such, it would initially have the information.

The Minister of State is ultimately accountable to the Dáil——

There are many questions I have to answer and I will come to that in a minute.

——and if moneys were spent on a new ICT system, it would be the worst of all worlds if it could not be accessed by the main front-line Minister of State with responsibility for child care.

I will come to that. Another question asked by the Deputy was with regard to the review of adequacy of services for children and families, otherwise known as the section 8 report. In the past 12 months, since I have been Minister of State in this area, we have produced two of these — one for 2006 and one for 2007 — and I am anxious that we produce the report for 2008 as soon as possible. The survey conducted by Pat Dunne of the local health office, LHO, for Dublin north is a more complete assessment of the adequacy of services than the section 8 reports. I am not satisfied with the section 8 report; it is anaemic, to be fair.

The 2007 report, and the section 8 process itself, do not fulfil what they were intended to do. We do not know, for example, where any of the referrals came from, whether they came from teachers, gardaí, local authorities or members of the public. Therefore, we do not know whether one section of the referring community is in need of more training while another sector may make too many referrals. This needs to be dealt with and I intend to talk to the HSE about it. However, the 2008 survey completed in January and being validated at the moment is a much more complete picture because it goes into demographics and measures specific LHOs against all sorts of different indices, giving a much more complete picture than the section 8 reports have been able to provide in recent years. We should replace the section 8 reports with more comprehensive, more contemporary reports such as this. I would like to have that information and be able to provide it to the Dáil as quickly as possible.

With regard to the number of children at risk of abuse, the HSE informs me that all referrals are triaged and priority is accorded appropriately thereafter.

Triage means different things in different areas. Is that not our problem?

Obviously it is impossible to distinguish between what is a priority and what is not. The essential problem in child protection here is that not enough work is being done and there are children who are not allocated a social worker. That is the core of the problem and we are trying to address it. One needs to have the bottom line figures — they need to be up to date and accessible — and then we can zero in on the gaps. However, we know without doing that exercise that we need more social workers anyway.

The out-of-hours service is a topical issue because of the Monageer report. The new place of safety mechanism set up as a protocol between the Garda and the HSE, in which a child is taken out of the family home for his or her own protection, is already up and running and the first reports are that it is working well. There have been several referrals under that protocol. However, that is not the end of the story; we have more to do in that area in terms of an out-of-hours service. I will undertake, as Deputy Shatter has requested, to meet any social workers in that area that have something to add to what I have heard already from social workers.

I have received the reports on Tracey Fay and David Foley. According to my recollection, I believe we are able to publish the recommendations of the David Foley report and we are working with the HSE on that issue.

With regard to Tracey Fay, again from recollection, there are references to her children in that report. If the Deputy wishes to table a parliamentary question I can give him a more comprehensive response.

The Monageer report was not censored. I do not wish to get too political but one can look at this from——

Can we briefly come back to the Tracey Fay——

No. Please allow——

This is very important. It is about two young people.

Of course it is but it is very important that the Minister of State answers all the questions.

It is about two young people who died in care. Surely now it must be acknowledged that the lesson of the Ryan commission is that we must shine a light on where things go wrong. In any democratic society one must have some level of reportage, monitoring and accountability. The Ryan report makes this clear. I am not trying to score political points. This is about the welfare of children. It is of the utmost importance and in the public interest that these two reports should be published. It is known that this poor young girl, Tracey Fay, gave birth to children as a young teenager. To suggest that the reason for not publishing the details of the report is because there is a reference to the fact that she had children——

That is not——

Deputy, please. The Minister of State should——

These reports should be published in full, perhaps with names redacted in circumstances where there are children who should not be named.

Does the Deputy wish me to redact it?

Deputy, excuse me. We are here to discuss the Estimate. This committee intends to meet at an early juncture with the Minister of State, Deputy Barry Andrews, to discuss a range of issues relating to children and children's welfare. It would be much more appropriate on that occasion to discuss the vitally important issues the Deputy is raising.

I raised both matters in the Dáil and so far have got nowhere. This committee is an appropriate format in which to raise them.

The Deputy is using it as a form of writ. I am deciding it is not appropriate.

It is not all right to spend the time in a two-way debate.

I ask all Deputies——

The Deputy should not be so crass.

We are all concerned about the matter. Deputy Shatter does not have a monopoly of concern.

There is a need to know what went wrong and what must be corrected.

We are all concerned but we accept the order of the Chair.

It should not be necessary to have to come into this committee room to look for these reports.

(Interruptions).

It is not fair to see the whole——

I ask the Deputy——

(Interruptions).

I did not interrupt anybody's opening remarks.

The Deputy is speaking all the time.

In a committee meeting a Deputy should be able to have a discussion with a Minister of State rather than have people making speeches at each other.

Order, please, Deputy Shatter.

I am well used to this from the Joint Committee on the Constitutional Amendment on Children. The point I made is that reference was made in the report to Tracey Fay's children. Non-publication is not for that reason but because those children will be adults themselves. Therefore, one must ask whether one wants that information to be in the public domain. However, I will talk to the HSE about publication. As I said, in the David Foley case we can consider publishing those recommendations.

It is interesting to hear that the Deputy will be happy for me to publish the Tracey Fay report in a redacted form considering all he had to say about the Monageer case——

I meant redacted in the sense of removing the names of children.

----otherwise called censorship by the Deputy. Let us be clear about our terminology.

No, she gave birth to——

The Deputy cannot have it every which way.

If Deputy Shatter wishes to have a one-to-one——

A full report concerning the background and circumstances of both these tragic young people should be published.

I ask the Minister of State to continue.

Thank you, Chairman. Deputy Shatter raised a question about children who have died in care. I do not have the exact figure but I believe 21 is the correct number since 2000. The Deputy also raised my ongoing discussions with the HSE. I asked the organisation to prepare a serious incident protocol so that there would be an automatic response in circumstances such as this. I understand some of the children who died in care died for medical reasons rather than for reasons that might be suspicious. Nevertheless, once they are in the care of the State, obviously every step must be taken to satisfy ourselves that nothing untoward happened.

I shall move quickly to the issue of the pre-school year. I thank the Chairman for his comments about this development which I believe is a landmark in education. The idea was to try to ensure equality. We all know that well-off parents provide pre-school education for their children but the disadvantaged do not. It was to answer that gap and give everybody a chance so that once they present themselves at junior infants all children will start from the same beginning and have the same motivation, development in language and socialisation skills, etc. That is what is behind the initiative.

In addition, however, service providers had told me they were going to the wall because of the recession. They said they had to close their doors because of the labour market, that parents were either minding their children at home or were going from the commercial sector towards the community sector. In other words, they were going from private child care facilities to community child care facilities. The question was what we were going to do about this because, as members know, the State has invested huge amounts of money into child care facilities over the past ten years. We did not want to see any of that go to the wall. This was our response and, as the Chairman acknowledged, it is a landmark decision concerning the future of education in our country.

Deputy O'Sullivan asked about flexibility and how we would meet the concerns raised by different organisations. I have met the national voluntary organisations on a number of occasions. First, the reception for this scheme is incredibly positive. Over 80% of people are absolutely delighted with it and see the obvious benefit to them of having a guaranteed income paid three times a year in respect of services they provide. However, because of issues raised, we have made a number of concessions so it is not a one-size-fits-all scheme. There are different ways of responding and different options open to different providers, whether they are in the playschool day care sectors. We will continue to respond to concerns and have until January 2010 to lock this down. My door is open to any ideas but I believe we must stick to the notion that this will be a free service, available to everybody in the way primary education is free and available to everybody. That is a basic principle.

Regarding the workforce, for the first time we will require that people working with children in a pre-school setting will have a minimum qualification. I will launch the workforce development plan tomorrow in the Department of Education and Science. There is a ten-year plan regarding how we will raise the status and standards of people working with children in the pre-school setting. These will make significant impacts in coming years.

Deputy O'Hanlon asked about young people and the mental health area, as did Deputy Shatter. It is not really my area but I take an interest in it because of the participation of my office. When we bring young people in through Dáil na nÓg and the young people's forum they always bring up mental health as an issue they wish discussed as much as possible. Next Monday the Minister of State with responsibility for mental health, Deputy Moloney, and I will launch the conclusion of a public consultation with young people on the issue of mental health.

With regard to the south Dublin area and the child to whom Deputy Shatter referred, there is a project based in Cluain Mhuire services aimed at upskilling general practitioners and teachers to know how to diagnose and recognise these kinds of symptoms rather than have the situation end up in an accident and emergency room. It is well known that the sooner one sees and diagnoses those symptoms, the better the chance of being able to treat the problem without medication. Those facilities exist and are improving all the time.

Youth justice is part of my brief. When it is completed, Oberstown will be the centre in the country for detention schools and assessment. It will take about four or five years. We have moved all such schools from the Department of Justice, Equality and Law Reform to the Department of Health and Children. This acknowledges that the treatment is about rehabilitation and is much more a care analysis of youth justice rather than any kind of punishment. It is a very exciting development. The Department of Justice, Equality and Law Reform has the youth justice brief and will continue to ensure the capital will be provided for that development.

Deputy O'Connor asked about youth services and the changeover from the Department of Education and Science to my office. The changeover gives us an opportunity to create better linkages between the various structures in the childrens sector and the youth affairs sector. There is no question or doubt about that and it is recognised generally.

Deputy Aylward referred to a concern about the provision of youth facilities in Kilkenny, especially to address the drugs scourge that is common in the south east, including such places as Clonmel, Dungarvan and others. I have visited some of the facilities in Kilkenny and they do not have a specific drugs focus but we plan to continue to expand the young people's facilities and services fund. Kilkenny is one of the places we will consider but I cannot make any commitments at this time.

I seek a small clarification from the Minister, Deputy Harney, on new funding for new developments. The Minister said she will not release the fair deal money until the autumn in case it is spent on something else. Does the Minister have a mechanism to ensure the new money for new developments is ring-fenced within the Health Service Executive, HSE?

Yes, there is a separate subhead for it now.

Is it for all of them?

Is the Minister suggesting we no longer need to keep an eye on it as the Minister will be doing so?

The man responsible is present.

Perhaps we will keep an eye on it as well.

I thank the members for attending and the Ministers for briefing us today and answering the Deputies' questions.