Vote 41 — Office of the Minister for Children and Youth Affairs (Supplementary).

I welcome the Minister for Health and Children, Deputy Harney, and her official. Briefing material provided by the Minister has been circulated to all members. We are meeting this afternoon to consider the 2009 Supplementary Estimates for Vote 40 — Health Service Executive, referred by Dáil Éireann on 25 November 2009, and Vote 41 — Office of the Minister for Children and Youth Affairs, referred by the Dáil on 1 December 2009 for the consideration of the select committee. We have scheduled a period up to 3 p.m. for the meeting but we would not be unduly disappointed if it were possible to conclude earlier. I hope that would be to the satisfaction of the Minister. I invite the Minister to make her statement and then I will invite members to make statements and ask questions.

I thank the Chairman. I would be delighted to facilitate the committee in coming to a conclusion earlier than anticipated, if that is possible. The Supplementary Estimate is for €254 million. I am also moving a technical Supplementary Estimate for Vote 41 which is the Office of the Minister for Children under the remit of Deputy Barry Andrews, in order to facilitate the new pre-school programme that will begin on 1 January next. It is a technical sum of €1,000 to provide a subhead for a new programme that is to be introduced.

The sum that is sought for the Health Service Executive, HSE, could not have been anticipated in advance. It is not the case that the HSE is not in a position to manage its budget. In fairness, it is managing its budget incredibly well. The sum of €102 million is accounted for by the shortfall in the health levy as a result of the economic circumstances in which the country finds itself. The sum of €20 million is also as a result of the economic difficulties and the significant rise in the number of medical cards. A total of €18 million is required because of changes in the pension levy for staff in the HSE. A total of €55 million is for the influenza pandemic, of which €7.5 million is for capital spending and the remainder for the revenue implications. The superannuation shortfall of €73 million is due to the higher than anticipated number of people retiring. Savings have to be offset against that. Those are the areas that account for the Supplementary Estimates.

A total of €55 million of expenditure on the influenza pandemic is for the purchase of vaccines, vaccination of the population, the purchase of equipment such as ventilators and increased capital works in intensive care units. It is not for the corporate HSE, contrary to an impression given in one newspaper today by Deputy Reilly, who is not present. I do not wish to be critical of him, but it is not for increased staffing costs in the HSE; it is for the purchase of the vaccine, the payment of GPs, capital works in intensive care units and the purchase of ventilators.

This year we estimate an increase in the number of medical cards of 135,000. That is 54,000 more than we anticipated this time last year. The cost will be €20 million. Superannuation costs will be €73 million. The HSE estimates that there have been more than 2,000 lump sum payments in respect of retirees between January and September of this year at a total cost of €100 million for lump sum payments alone. A higher number of employees with sufficient service are now retiring from the health service, as they are from other areas of the public service.

I had discussions with the VHI this year. Payments by private insurers to public hospitals are much slower than we would wish to see and the Comptroller and Auditor General recently had something to say about this. The main problem arose because in the public service consultants are required to sign off before private insurers can be billed. Next year, I hope to break the link between doctors signing off and hospitals being able to make claims for the money owed to them. The VHI will advance €50 million this year to the Exchequer. It will be off the borrowing requirement but we will make provision for the HSE because it will spend that money. Next year, it will be dealt with by means of appropriations-in-aid. The appropriate treatment is to include the income in a suspense account and bring it to account in appropriations-in-aid next year. This is an accounting issue but the repayment of €50 million received at the end of November will reduce the Exchequer State borrowing requirement.

An additional €25 million is sought towards the costs incurred by the executive of commencing the modernisation of mental health infrastructure in line with A Vision For Change. The €25 million required this year is to meet the mental health contractual commitments entered into. This money was previously surrendered to the Exchequer and is returning to the HSE for development in the mental health area.

I dealt with the pension levy shortfall. The change in the rates and the exemption of the first €15,000 of earnings following the supplementary budget resulted in an annual shortfall of approximately €7 million, and a timing issue has caused a once-off shortfall of €11 million, so supplementary funding of €18 million is sought to address this. I also dealt with the shortfall in the health levy which is €102 million as a result of the economic circumstances in which we find ourselves.

Some of the additional money sought is offset by savings. The fair deal scheme became operational recently and the €55 million provided for in the 2009 Estimates will not be fully expended this year. A timing issue also arises in ICT developments. Next year, notwithstanding the difficult economic circumstances under which we will operate, we will provide not only for the full year cost of the fair deal scheme, but also for the demographic pressures caused by the growth in the number of older people availing of the scheme. That will be a priority for funding during 2010.

I thank the Minister for her overview. Each spokesperson has ten minutes and I would be grateful if members could incorporate questions as well as comments in that ten minutes.

I suggest that we just ask questions. I only want explanations and I am not here to make big long speeches.

Ask away, but the Deputy has ten minutes.

Does that include the Minister's time to respond?

The Deputy has ten minutes and we will go to the Minister for a response at the end.

I apologise for not being here at the outset. I was speaking to the chief medical officer about the swine flu vaccinations, which are causing considerable confusion — I will discuss that in a moment. The projected shortfall in health contributions is €102 million and the Minister explained it as a shortfall in income through unemployment.

Yes; tax receipts generally have decreased. Even though the health levy doubled, the actual contribution is down. Notwithstanding the increase in income tax, receipts have decreased for two reasons; namely, increased unemployment and people not earning as much as they were last year.

The next issue is the projected shortfall in pension levy receipts. Is this similar?

They were the changes made in the supplementary budget where the first €15,000 of income was excluded from the public sector pension levy.

Can we take the questions en bloc and then move on? The cross-table method will keep us here forever.

It will not because I have only a few questions.

If the Deputy has only a few questions he can ask them and the Minister will answer them at the end.

I just want a few explanations. The questions I have asked were quickies and they have already been resolved.

Superannuation increased due to increased retirements; that is fairly straightforward. What is the breakdown of the projected costs of €47.5 million associated with the management of the H1N1 virus, between administration and the actual cost of the vaccine? Earlier, I alluded to the confusion that exists. A constituent contacted me to tell me she had her seven month old baby vaccinated in Ballymun and was told that she did not need to go back while her nephew was vaccinated in a HSE clinic in Lucan and was told to return for a second shot. The HSE website indicates that two shots are required. I know from speaking with the chief medical officer that this may change and that it is being examined, but until it changes and an announcement is made, which is correct? This is causing uncertainly, confusion and anxiety for people, particularly mothers of young children.

The €25 million in respect of the development of mental health facilities is fair enough and is money that was taken by the Exchequer and returned to health. Is the funding of €50 million through payment from the VHI in respect of private and semi-private hospital charges? The funding of a projected excess in the medical card scheme is self-evident.

With regard to the savings of €67 million under certain subheads due to timing factors, the Minister mentioned the fair deal scheme. How much of the €55 million has been spent? What are the other areas that make up the €67 million? We should have a clearer view of that.

We have a higher level of retirements and that is fair enough. Will the Minister confirm whether any of the €25 million to be returned from the Exchequer has been spent on mental health facilities——

——or is it new money for next year?

It is for this year and it has been spent.

I do not know whether the Minister has the information but I understand facilities were purchased by the HSE five years ago which are lying idle and boarded up at considerable expense to the taxpayer and Exchequer. I can provide the Minister with the details after the meeting if she wishes.

A major area which does not appear in this document but appears in another document is an increase for the various health areas of €138 million. Will the Minister provide us with a breakdown of this? The figures do not tell us what the money is for. The amount of €48.5 million for salaries in the HSE corporate will be of serious concern to everybody.

That is due to swine flu. I explained that prior to the Deputy's arrival at the meeting. There is no subhead for swine flu because we did not have a pandemic subhead so it is allocated to HSE corporate.

This shows a figure of €48.54 million but a figure of €47 million is quoted elsewhere.

Why are the figures different?

I am sure the Minister will answer.

A total of €47.5 million is for swine flu and the rest of the higher amount is for superannuation. That is the difference.

I thank Deputy Reilly for being so concise. I ask Deputy Jan O'Sullivan to make her statement and ask her questions.

I will be as concise as I can. In the overall Book of Estimates, health accounts for the biggest chunk of money by far in the Supplementary Estimate. Will the Minister respond to this? The other amounts are very small and most Departments do not need a Supplementary Estimate. Obviously, much of it has to do with the fact that the health budget was affected by the shortage of contributions under the health levy. The growth in superannuation costs and the €73 million associated with unanticipated increases in retirements is sizeable. When people retire, they are paid the fraction of their salary they receive as a pension. Will the Minister indicate to the committee how this will affect income and expenditure for next year? Perhaps it is a question for next year. Will those who retire be replaced? How does the moratorium on recruitment affect services? The figure of €73 million implies that the number of health service staff taking early retirement is much larger than anticipated. This must set alarm bells ringing about the impact on the provision of services. To how many people does the figure of €73 million refer? Will the Minister provide a breakdown of the types of staff involved? How many nurses, doctors, administrators and so forth are taking early retirement? We need to know what will be the effect of this large number of early retirements on the health service.

I do not have a problem with the expenditure required to deal with H1N1 or to cover demand-led schemes. On the issue of private and semi-private hospital charges, the detailed note states that the Comptroller and Auditor General indicated that private health insurers had outstanding debts to the Health Service Executive of €167 million at the end of 2008. It further notes that efforts are under way to speed up the billing and payments process but that, in the interim, VHI has agreed to make a one-off payment of €50 million this year. I am concerned that the HSE is settling for a figure below the full debt from one of the health insurance companies.

What is owed by the other private health insurance companies? How much of the €167 million is recoverable? A certain amount of the debt relates to the 80:20 ratio for the allocation of public and private beds in public hospitals. The public hospitals in my region are exceeding the 20% threshold for private beds, primarily because the region does not have a private hospital. In some cases, therefore, there are valid reasons for hospitals failing to comply with the 20% limit, whereas other hospitals have no reason to exceed the threshold.

Will it be possible for hospitals to be reimbursed by health insurers in circumstances where private patients are in beds allocated for public use — in other words, where a hospital exceeds the 20% limit for private beds in public hospitals? If this is not possible, we must find a way of ensuring the public system is fully recompensed for the use of public beds by private patients. I ask the Minister to clarify the matter.

On the pension levy shortfall, why was the likely revenue from the levy not known in advance? Why is it necessary to have a Supplementary Estimate in this area? It was noted that one of the reasons for the annual shortfall of approximately €7 million in the pension levy is the number of part-time and lower paid staff in the Health Service Executive. One would expect the HSE to know the salaries paid to staff and the number of lower paid and part-time staff it employs. Why was the HSE unable to plan for the levy in advance?

The Minister referred to the fair deal scheme. How much has been allocated for the scheme next year? While I welcome the decision to ring-fence the allocation for the fair deal, I would like to know the current figure. How many people will qualify for the scheme next year? Is the allocation adequate? As it is capped and resource dependent, a person who qualifies for the scheme may be excluded from it on the basis that the allocation has been spent.

Recently, when a matter of serious concern was brought to my attention, I checked the position with my local nursing home subvention unit. I understand that the fair deal scheme will only apply to new residents in nursing homes from the date on which the decision on qualification is taken, as opposed to the date on which the application is received. I also understand the old nursing home subvention will not apply between these two dates. This creates a gap during which funding will not be available for new patients in nursing homes.

It is a cause of serious concern that the person to whom I spoke by telephone in a HSE nursing home subvention unit confirmed this was the case. I have tabled a parliamentary question on the matter. Perhaps the Minister will clarify the position now. I was informed that the nursing home subvention unit had received instructions that the fair deal scheme would apply on the date on which a decision is taken that an applicant qualifies rather than from the date of application, as is customary in the case of applications for social welfare benefits. The matter must be clarified urgently because families are understandably concerned that they will not be able to pay nursing home fees during the period between application and final decision.

The Minister has outlined where the Supplementary Estimate, which I support, arises. On the figure of €73 million associated with the unanticipated increase in retirements, is there a specific reason for the increase in the number of retirements? What impact will this have on the health service?

I compliment the Minister and Chief Medical Officer, Dr. Tony Holohan, on how they handled the swine flu epidemic. The epidemic was potentially serious in itself but also in terms of its potential to create panic. The matter was handled extremely well by the Minister, the Chief Medical Officer and staff involved. It was a massive undertaking to mobilise so many staff and vaccinate so many people. While I accept that the issues raised by Deputy Reilly need to be addressed, I have encountered a minuscule number of incidents relative to the success of the vaccination programme.

On the general medical services scheme, is the Minister satisfied that a standardised system is in place for allocating medical cards? I read recently that it appears to be much more difficult to obtain a medical card in Dublin North-East than elsewhere.

On the figures provided on the collection of money from private insurance companies and hospital contributions, are these estimates or confirmed debts owed? When hospital contributions are investigated it is often found that for one reason or another the person is not eligible to pay.

In the event that the Minister is unable to answer my final question, which relates to United Kingdom dependencies, I ask her to supply a reply after the meeting. I understand that Guernsey and Jersey are no longer entitled to avail of the national health service and that from 1 January 2010 this will also apply in the case of the Isle of Man. Are reciprocal arrangements being put in place for Irish people visiting these UK dependencies andvice versa? Apparently, all three dependencies will no longer be entitled to avail of these facilities under European Union rules. Perhaps the State has an opportunity to sell a service to them, given that two of them no longer have an arrangement with the United Kingdom and the third, the Isle of Man, will no longer have such an arrangement from 2010 onwards.

I welcome the Minister and wish her well. I also support the Supplementary Estimate. Is the recent decision to transfer the administration of the medical card system to Finglas having an impact, including on the Estimates? The Minister will know we are all receiving calls from people who are very concerned about the rumours about possible charges for prescriptions. They are asking me to bring this to her attention. She was in Fettercairn last week and missed a lady in a wheelchair who was looking for her. I told her I would pass on her concerns.

I am sure the Deputy dealt with it swiftly.

I know the Minister took her time and it was great to have her.

Can I ask about the Vote pertaining to the Office of the Minister for Children?

The Minister's opening comments referred to Vote 41.

Like everybody else, I am receiving queries on the implementation of the programme. It is a good programme but there are still issues that various providers must deal with. Has this come to the attention of the Minister? If she does not have information today, I will be happy to wait.

I support the Minister in respect of the Supplementary Estimates. On superannuation, an increasing number of staff seem to be retiring. Will the embargo on recruitment pertain to positions that become available when people retire? I ask this in the context of overstaffing in the HSE for many years.

I thank the Deputy. I want to ask the Minister about the fair deal scheme. The process is now running well. What has been the experience of the HSE in processing the applications? How smoothly is the system operating and have we identified any problems that may need to be resolved?

I will start with the fair deal scheme. We estimated €35 million of €55 million would be spent this year. The Chairman asked whether the scheme is operating smoothly and whether there are any problems. If what is alleged by Deputy Jan O'Sullivan is happening, it is inappropriate and I will take up the matter. I was not aware of it. Processing could be delayed for six months to save money. I will take this up. The benefit should apply from the date of application, as with all other State benefits.

The calculations were based on the number of people who should qualify. We felt €55 million for this year and €110 million in a full year was appropriate. We said we would factor in demographic trends. We need an additional €140 million for the fair deal scheme next year. It is a priority and I intend to make the money available, albeit under enormous financial pressure, as the Deputy can appreciate.

I will deal with the questions in no particular order. If I leave any out, I will be more than happy to return to them. On superannuation, the trend in the HSE is the same as in the Garda and other organisations. While I have not spoken to individuals, I believe the reason for the trend was the Minister for Finance's statement in his last budget speech that he could not guarantee that lump sums would not be taxed from next year. That clearly had an effect in that people close to retirement made a decision to retire early.

The Office of the Revenue Commissioners has a lot of people leaving also.

The main up-front cost is incurred in year one, in which year one and a half times one's salary is paid by way of a lump sum.

Is the Minister trying to scare people out of the system?

We will see. The budget is next week and I cannot anticipate it.

Some 5% of those who have left, or 45 people, were doctors and dentists. The number of health and social care professionals amounted to 110. There were 722 nurses, 141 staff from management and administration, 431 staff from patient and client care, which includes those in community service, and 498 others. The number of support staff amounted to 196. The total is 2,143. The moratorium does not apply to doctors or anyone required by way of professional expertise. However, we would not be replacing managers and administrators, for example, except in exceptional circumstances. The moratorium does apply to the latter but there are exclusions to the moratorium in respect of front line service staff. They would obviously be replaced.

Who were the 431 people?

They were in patient and client care.

Are they social workers?

Are they carers?

They could be people working in primary care centres or health centres, for example.

Will the Minister provide that information later rather than delay the meeting?

How many doctors retired?

Some 45 doctors and dentists. Clearly, anybody with specialist expertise will be replaced. The moratorium does not apply to them but I do not anticipate that managers and administrators will be replaced, except in exceptional circumstances.

With regard to the pension levy shortfall, the Department of Finance originally estimated €345 million would be collected in respect of the HSE. That was based on everybody paying on all their salaries. Subsequently, the first €15,000 was excluded, thus creating a €7 million shortfall. The levy was to apply from 1 March but many of the payments made on 1 March relate to work on 1 February, which should not be subject to the levy. Therefore, the timing issue results in a sum of €11 million.

With regard to the flu pandemic, the cost of the vaccine in 2009 was €25.688 million. The figure for clinical consumables was €2.6 million. There was no ICT cost. The distribution and logistics cost, incurred on foot of getting the vaccine to the doctors and clinics, was €2.159 million. Advertisements and communications by the HSE cost €1.6 million and the cost pertaining to critical care and ventilators was €12.6 million. The cost associated with clinics, including clinic security and the installation of the pod system, was €7.9 million.

Can the Minister explain the pod system?

I will pass the information to the Deputy.

We do not know the names of the officials accompanying the Minister.

I am accompanied by Mr. Jim Breslin and Mr. David Smith.

Mr. Jim Breslin

My understanding is that the HSE placed an order for pods that could be shipped to where the vaccine was being delivered. They contained everything one might need to run a clinic. They contained sutures, plasters, stationery, pens, post-it notes, etc.

Did they contain resuscitation equipment?

Mr. Jim Breslin

That would be sent separately and would not necessarily be in the pod. The pods were to ensure that one would not run short in a clinic with no materials. The materials were purchased and shipped out alongside the vaccines so people would have everything they needed there and then. Anything from the kits that is not utilised will be used after the pandemic to meet other needs.

Can we get a list of the contents of the pods? A lot of money was spent on them.

With regard to the vaccines, which I believed Deputy Reilly would know about, the GSK vaccine requires two doses as of now, while the Baxter vaccine requires one. If a person in Lucan got a Baxter vaccine, one dose would have been required. If a person in north Dublin got the GSK vaccine, two doses would have been required.

Is that for children under five?

It is expected that the GSK vaccine will ultimately require only one dose but this has not happened yet, to the best of my knowledge. Sorry, it is the other way around; the Baxter vaccine requires two doses and the GSK vaccine requires one.

How could I know when the Minister does not know herself?

Deputy Reilly is a doctor; I am not.

She does not know herself.

Deputy Reilly is a doctor; I am not. He is delivering the vaccine.

Like many doctors, I am confused by the disinformation coming our way.

I do not believe so.

CanI make another point?

No. We will let the Minister continue.

The Minister said, in my absence, that my statements in the press were inaccuratevis-à-vis corporate administration. Her own document refers to “salaries, wages and allowances and other administration expenses of corporate HSE”.

I was referring to the swine flu.

It does not state anywhere in the note that the Minister was referring to the swine flu. She should look to herself before she looks to others.

I ask the Minister to continue.

The note the Deputy received states the revenue costs in respect of the A (H1N1) pandemic are being managed by the HSE corporate and are provided for at subhead A1. I will not have a row with the Deputy about it. I simply wanted to——

The Minister took the trouble to make the point earlier.

The Deputy claimed €47 million more would go into Health Service Executive administration, which is not correct.

It was because of the way the Minister presented it.

Allow the Minister to reply.

Chairman, can we hear the Minister? If the Deputy wants to have a one-to-one, he can do so afterwards.

I want this on the record.

The €167 million is for all health insurers but 90% of it will be for the VHI. The majority who end up in the hospital system are older people, many of whom are VHI members. This year, the VHI will lose €170 million on its over-60s members. No deal was done with the VHI. This is an advance and it will get billed for all of this in due course.

We want to break the link with doctors signing off on hospital bills next year. Currently, the consultants must sign off before the hospital can bill the insurer. We want the hospital to be able to bill the insurer for the hospital piece, so to speak, and not have to wait for the doctors to sign off. IT will also have to help the Health Service Executive with its billing system.

It is intended to collect all the moneys involved. Seeing the VHI owed much money, I met with it to explain the budgetary pressures we are under and asked for an advance on the money owed. It is not a deal. It is not €50 million in lieu of €167 million. It is simply an advance of €50 million against what it owes.

Is the VHI losing money on its older members?

Yes, €170 million.

Is that covered by the health levy?

No, the levy only accounts for half the difference in the cost. It is not a full risk equalisation.

Regarding the 20% threshold for private hospital beds, if the hospitals could, they would bill for every bed, making it impossible to get a public patient into a bed. We do not want to incentivise the hospitals in this regard.

All are entitled to universal hospital access. Many people who have health insurance do not even opt to use it when they are in hospital. Some informed patients, when asked, will prefer to go as a public patient. If it were the case that every bed could be charged to the insurers, it would be hard to enforce the new consultant contract and get access for public patients to the public hospital system. It must also be remembered there is a huge amount of private capacity in the country.

I believe the 20% threshold is reasonable. I know the hospitals make the case for increasing that percentage. However, successive Ministers have been committed to the 20% threshold.

All moneys are apportioned across the country. There is nothing more significant in one area than another. For example, if it were on the vaccine side, it is proportioned to where the vaccine money is needed and so on.

The early childhood care and education scheme will begin next year. I have seen some correspondence about the adequacy or otherwise but the Government has provided the moneys for it. The Minister of State, Deputy Barry Andrews, would be more than happy to discuss it further.

Regarding the 50 cent charge on prescriptions, which I suggested, the McCarthy report mentioned a charge per prescription as opposed per item dispensed. The report was referring to a considerably larger sum of money than we may do next year. The budget, however, is not yet finalised so I am not in a position to discuss this.

Much of the debate in this area has been about encouraging some small contribution. During the pharmacy dispute last summer, I kept hearing about waste and the number of items returned. The idea of a charge was advanced even then. I accept people may have changed their minds in the meantime as to using the charge as a possible way of discouraging over-prescribing and over-dispensing.

Ireland has a high level of antibiotic prescribing, for example. A whole host of issues around this will be examined next year including reference pricing which will have to be legislated for in 2010. The State will set the reference price for pharmaceutical products and only reimburse at that level.

We have not yet moved to the centralisation of medical card applications. All offices will still deal with the applications they have on hand. From some date next year, all medical cards will go to a central administration. I have also given an undertaking to Deputies that the Health Service Executive will have a dedicated telephone line for medical card queries for Oireachtas Members. A similar system operates well in the Department of Social and Family Affairs. If the telephone number has not yet been provided, it will be in the next few days.

We were not aware of the matter concerning Guernsey and the other islands raised by Deputy O'Hanlon and we will have to reflect on it. We have reached an agreement with the UK for it to pay €287 million for treatment of its citizens, who benefit from its insurance scheme, in the Irish health care system. We will have to examine the implications for Guernsey, the Isle of Man and other places not covered under EU regulations.

Regarding the early retirement scheme, I am concerned that only 141 of the total retirements for the health service were in the administrative category. In seeking to reform the Health Service Executive, we will be looking to reduce the layers of administration, particularly at senior levels, and the number of people working in administration as opposed to those on the front line. From my figures I understand the figure of 141 is less than 15% of the overall health services staff. Clearly, early retirement is not going to be a way of addressing health service reform. What is the Minister's view on that?

If a private insurance patient enters an accident and emergency department, he or she obviously has a right to a bed. That is not a problem and probably accounts for the overspill of the 20% threshold. Will the Minister clarify whether that is why private insurance patients are occupying more than 20% of hospital beds? What should not happen is that private patients get elective procedures but these are not paid for by their insurers. Clearly, those beds are meant for public patients and often they have to wait longer than private patients for elective procedures.

Can we have a breakdown of the figures of the 2,143 people who got lump sums across the health service?

Yes, I will get Deputy Reilly a breakdown of those figures. The figures I gave are up to the end of September so the final figure will probably be higher.

Support, administration and management staff make up 16% of those that have taken up the early retirement scheme. The Minister for Finance will be dealing with public sector numbers in the forthcoming budget. If we are going to see a reduction in the number of people employed in the public service over the next several years, a large proportion of that reduction will come in the health sector.

We want to be able to reduce but also recruit at the same time. We are anticipating a reduction of 6,000 people overall. This would be achieved by having an 8,000 reduction but at the same time having 2,000 new recruitments. We want to ensure we can recruit front line staff.

Over what period would these reductions be implemented?

Probably between now and 2013.

Will there be savings in that regard?

Yes. The McCarthy report dealt with this but acknowledged that it could not all be done in one year. When the HSE was being established, there were intensive negotiations with the representatives of those who work in the health sector. They were mediated and arbitrated upon and decisions were made in that context. People take one view now, but they assuredly took different views then.

We are anxious to ensure that we have a health system that functions appropriately and, in particular, that a very strong emphasis is placed upon the transformation programme, which means strengthening the primary care side especially regarding health care professionals. As we speak, we are recruiting social workers, because there is a large deficit, particularly in the child protection area, as well as allied health professionals for the primary care teams around the country, and that will continue next year. The same will apply regarding the recruitment of consultants and so on.

Does the Minister expect this to be done through voluntary redundancies, redeployments or otherwise?

Talks are taking place in a different place and I would not like say anything that might have an impact there right now. We know what the country's economic circumstances are and we have to ensure that we deal with a very large number of issues, including the size of payments in the public sector, as most people acknowledge.

Regarding private patients and the question of admissions through accident and emergency departments, we do not allow any distinction between patients at accident and emergency level for the very good reason that we do not want preferential treatment in an emergency situation being given to one patient over another. However, we could have many debates about the levels at which hospitals could charge patients.

For example, under the new consultants' contract, any patient admitted under a category A consultant cannot be charged. We want to arrive at a situation whereby those who need care get it on the basis of medical need and not on any other basis. As the committee knows, however, a working group is examining how resources are allocated in the health care sector and this will be looked at, among other issues, in that context. The resource allocation group, under the chairmanship of Professor Frances Ruane, is due to report next April and most of the experts in this area in Ireland are participating in the process.

I am certainly open to any suggestions from that group on how, in particular, we can ensure that the money continues to follow the patient, as it is termed. No system in the world has unlimited resources for health. The countries that pay on a fee per item basis are now quickly coming to address that issue. In Ireland, we make out of hours payments to general practitioners on a fee per item basis, so out of hours costs in the GMS for 1.4 million people are about €108 million. In Northern Ireland, the figure is about £18 million for 1.8 million people. Therefore, we need to be very careful if we move to a fee per item system because it can entail enormous costs.

I thank the Minister.