Annual Output Statements 2010

I welcome the Minister for Health and Children, Deputy Mary Harney, the Minister of State at the Department of Health and Children, Deputy Barry Andrews, and their officials to the meeting.

The purpose of today's meeting is to consider the Revised Estimates and output statements for the Department of Health and Children: Vote 39 — Department of Health and Children; Vote 40 — Health Service Executive; and Vote 41 — Office of the Minister for Children and Youth Affairs.

Members will be aware that as part of the budgetary process reform initiated by the Minister for Finance in his budget speech of 2006, each Department must publish an output statement for consideration by Oireachtas committees. In line with that reformed budgetary process an output statement has been provided and has been circulated along with the briefing to the members. This is a very important initiative and it is intended to facilitate better parliamentary involvement in the budget and Estimate processes.

In addition, the Minister for Finance, in letters in 2008 and 2009, respectively, requested that the Estimates debates should have a particular focus on the outputs to be achieved for the moneys being voted. We have circulated a proposed time schedule for today's meeting. While we may continue until 4.30 p.m., if we finish by 4 p.m. it would be appreciated on all sides of the House, if that is possible. We will adopt the traditional format whereby the Minister and Minister of State will give an overview followed by contributions from the spokespersons of Fine Gael and the Labour Party and then general questions. If that format is acceptable, I invite the Minister for Health and Children, Deputy Harney, to make her open remarks, to be followed the Minister of State, Deputy Andrews.

I am here to deal with the Estimates and the output statement for the HSE and for the Department. The Minister of State, Deputy Andrews, will deal with the Office of the Minister for Children and Youth Affairs.

The gross expenditure for 2010 is €15.324 billion of which €491 million is capital expenditure. Gross expenditure for the HSE is €14.583 billion, of which the Exchequer contribution is more than €10.5 billion and appropriations-in-aid is €4 billion.

The Estimates for 2010 represent a 12% reduction on the net outturn position for 2009, a reduction of 4% in gross spending over the 2009 outturn. Gross spending represents 11.8% of our national income which is €129 billion which puts Ireland high up in the OECD rankings in terms of national expenditure devoted to health. Our current expenditure will be 27% of all the money the Government will spend, 133% of all income tax raised. We spend substantially more on our public health system than the totality of the tax we raise in this economy.

The tax base has declined to 2003 levels, even though spending has increased by about 65% in that period. Therefore, as part of the Government's budgetary process, it was necessary to stabilise the public finances to reduce the gap between our revenue raising capacity and our expenditure to make reductions across all public sector organisations and particularly health because it represents 27% of spending. The health reductions for 2010 represent €659 million in pay savings and €400 million in non-pay savings. Most people are familiar with the reductions in pay savings. There are general reductions and higher reductions for those on higher pay, on foot of the recent recommendations from the review body, a reduction in fees payable to certain health professions, and savings associated with the moratorium on recruitment and promotion.

The non-pay savings of €400 million is comprised of cost reductions of €283 million, €141 million of which is in the drugs area, €30 million of which is in respect of dental treatment, economies in the HSE in terms of procurement of €106 million, economies in the Department of Health and Children and the national child care investment programme of €2.5 million in 2010, and €7.5 million in a full year.

In regard to income collection and charges, the HSE has committed and is required by its service plan to increase and improve the private income collection by public hospitals. We have put in an additional figure of €75 million for this in 2010. The change in the drugs payment scheme will generate €27 million and prescription charges will generate €15 million in 2010 and €25 million in a full year. We have not yet produced the legislation but it is currently being drafted. It will be introduced into the Oireachtas in the next session.

That national service plan for 2010 was approved by me on 5 February. It has very ambitious targets, particularly to reduce admissions from accident and emergency departments by 33,000 during 2010. In addition to the reductions about which I spoke earlier, an additional €500 million is available to the HSE in 2010 over the 2009 allocation in the following areas: €97 million for the fair deal; €10 million for home care packages; €230 million for medical cards — the medical cards now stand at 1.5 million for full medical cards and 101,000 for doctor-only cards which means that 1.6 million people can see their general practitioner free of charge, an increase of 400,000 over the figure a number of years ago; €55 million for the flu pandemic; €20 million for the cancer control programme; €15 for the implementation of the Ryan report; and €70 million to address various demographic needs.

In acute hospital services in particular there will be major challenges to live within the budgetary framework for 2010. Obviously the pay reductions impact on acute hospitals since their employers have large numbers of people. They will also need to be involved in efficiency gains, including change in practice, more day-case activity in particular, more five-day activity and certainly more access to diagnostics outside admission from an emergency department.

The HSE is focusing on a number of measures including: a range of measures in the quality and clinical care area, including antibiotic consumption rates; the percentage of primary care teams implementing structured diabetes care and structured asthma and prevention programmes; waiting times for assessment following referral of child or elder abuse or neglect; and waiting times for palliative care. These are among the issues that need to be addressed seriously in 2010. We are in the process of putting in place rapid access clinics for lung and prostate cancer. Two clinics are already operational and I believe the other clinics will be operational during the remainder of this year.

As I undertook to keep my opening comments to a minimum to allow members to ask questions, I shall conclude at that point. However, I just want to mention some of the new initiatives. Obviously we are now preparing to roll out a cervical vaccine programme and a colorectal screening programme. The colorectal screening programme will represent the first time that men in Ireland have been involved in any population-based screening programme. An enormous amount of work must be undertaken to ensure we get the maximum uptake of the programme. From the experience in other countries we are told that a 50% participation rate would be regarded as very good, even though it would be only 50% of the targeted population. Significant work will be under way this year with the Irish Cancer Society and others to prepare for the introduction of the colorectal screening programme.

We also want to continue with the roll-out of primary care teams. Some 220 teams are now fully functional with a further 184 teams at various stages of development. Obviously 9,500 people currently avail of home care packages. In the past the choice was between hospital and nursing home care. This is now an option being increasingly availed of, particularly by older people who do not require long-term care or hospitalisation, but require nursing, physiotherapy and other supports in order to remain at home.

The output statement referred to by the Chairman at the opening is an important public sector innovation. Its purpose is to assess the outturn as anticipated with the targets that were set. In many cases members will see the targets far exceed what was set and in other cases we were unable to reach the targets. In 58% of the cases the outputs were either exceeded or achieved and in 42% the targets were either partially achieved or not achieved. If the targets were exceeded from a cost point of view that would obviously be seen as a negative as people need to live within their budgets. The number of day cases exceeded the target as did the cervical check. The cancer control programme considerably exceeded the target as did home care packages. In many areas there were significant positives. The demand for the services exceeded the targets that were set and clearly the output statement greatly informs the approval of the service plan for the following year.

I will try to be as brief as the Minister, Deputy Harney. Vote 41 for 2010 will amount to €351 million, which represents a decrease of 20% on the 2009 provisional outturn. The reduction is mainly associated with changes in child-care programmes. Vote 41 since its inception received a significant level of funding obviously reflecting the Government's commitment to services for children. When the early child care supplement was introduced it was at €1,000 for children under six. In January 2008 it was at €1,100 and its full year cost was due to be €480 million. As a result of the economic downturn in the latter half of 2008 it was obviously necessary to make some changes to that. As a result of the April 2009 budget the cost of the ECS in 2009 was reduced to €231 million, a saving of €260 million. However, as it is paid in arrears an amount of €4.5 is provided for in 2010.

While the changes in the early child care supplement were necessary, the Government took the decision to reinvest a substantial amount of money in the early childhood care and education scheme. Subhead D of the Vote provides for €170 million for this scheme. The scheme is administered by my office and will provide an annual programme of early learning. Some 4,000 services are already taking place, representing 90% of the sector and in excess of 50,000, which is a target we set at the time of the announcement. Each provider in respect of each child receives an annual capitation fee of €2,450 and a higher rate of €2,850 is available reflecting more highly qualified staff in certain playschool services. The eligible cohort comprises children who on 1 September of the qualifying year are aged more than three years and two months and less than four years and seven months. There are exceptions for developmental delay.

Naturally when the scheme was announced some developments occurred to reflect submissions made to my office so that services can charge parents for any additional services provided, such as additional hours and additional activities. There were also various options for the delivery of the service as a result of which full and part-time day-care services can now participate in the scheme. Naturally it has served to assist the sector in very difficult times when many crèches would have experienced severe difficulties as parents withdrew their children from these services as they lost their jobs. It has also ensured the protection of 20,000 child-care workers jobs as a result of the investment.

Vote 41 also had significant funding under subhead B for the national child care investment programme which replaced the equal opportunities childcare programme. The NCIP capital programme closed to new applicants in April 2009 and total expenditure now amounts to €222 million with the creation of approximately 25,000 new child-care places to add to the 40,000 provided under the EOCP. By the end of 2008 approximately €180 million had been committed with almost €100 million drawn down. With the exception of a small number of priority projects, totalling approximately €10 million last year, no further commitments are expected. The NCIP's projected allocation for current expenditure is €217 million, with a substantial amount of this for the community child care subvention scheme, which supports community child care services with a focus on disadvantage. It also provides funding for national voluntary child care organisations such as the NCNA and the IPPA.

The NCIP's current funding allocation is increased from that originally announced to €239 million. The CCS enables community services to charge reduced child care fees to disadvantaged parents. Since its introduction, the number of services supported has increased from 750 to 1,000 and the number of children from 14,000 to 18,000. The scheme was due to end at the end of 2010, but in December's budget a follow-on scheme was announced to commence from September 2010. It will maintain the subvention rate for parents in receipt of social welfare payments of €100 for full-day care. Although parents not in employment or training will be limited to no more than five hours per day, parents in community employment and receiving family income supplement will also qualify for the top rate of subvention. I am also considering introducing a funding strand that will ring-fence free child care places in services for qualifying parents attending FÁS or VEC courses.

Just over €5 million has been made available from the Dormant Accounts Fund under subhead C to support a range of targeted measures for children and young people, including those in disadvantaged areas. These will support the continuation of the prevention and early intervention programme for children and the implementation of the national recreation policy. The prevention and early intervention programme for children will amount to €4.35 million this year, targeted at services in Ballymun, west Tallaght and Darndale-Belcamp. There will be a key evaluation element to that funding during the course of 2010.

Just under €26 million is being made available this year under subhead E, mostly associated with the national longitudinal study of children in Ireland and a range of other programmed activities. The specific measures being undertaken by my office in this area include facilitating the better understanding of how children grow up in Ireland by overseeing the continued implementation of the study, the operation of the research placement programme and the research scholarship programme.

This area also covers the supporting of the development of youth facilities and services under the young people's facilities and services fund in disadvantaged areas of high drugs misuse. We will also be implementing a strategy to develop participation structures to promote the voice of children, who appeared before the committee on behalf of Dáil na nÓg and Comhairle na nÓg earlier this year. We will also provide support and services for the implementation of the national play and recreation policies.

The overall purpose of the youth work service is to assist young people to reach their full potential and to become active participants in a democratic society. The total 2010 funding is just under €47 million. The main body of that, in subhead G, is part funded by the national lottery and includes some €39 million. The key schemes are the youth service grant scheme, the special projects for youth and the youth information centres. The priority objective for 2010 will be the quality standards framework which is already being rolled out and is already applied by some providers.

Under subhead H, €3 million is being made available to support costs in connection with the holding of a constitutional referendum on children's rights. The Twenty-Eighth Amendment to the Constitution Bill was published in February 2007 and contained the Government's proposal to amend the Constitution with regard to children. The Oireachtas Joint Committee on the Constitutional Amendment on Children made its final report a few weeks ago on the substantial issue of children's rights and since then we are committed to making a submission to Government on a possible referendum on children's rights, hopefully this year. That provision is made for that purpose.

I welcome the Minister, the Minister of State and their team.

I note on page 7 that of all the breakdown of total gross expenditure by programme, there is a deficit in all areas except policy and corporate support, which has gone up 3%. That does not add to patient services, it is related to planning at a time when we need more action and less planning.

Apparently the existing medical card eligibility criteria target has been achieved and the review completed. Can we get a copy of that review? What does the Minister think of it? She told us that 1.5 million people are now covered by the medical card but the threshold still remains at just over half the minimum wage, causing people very significant hardship.

The new oral health policy did not have its targets achieved. When might we see that policy? Similarly, I would like the timeline for the cardiovascular health policy.

The number of additional child care places was not achieved. Can the Minister explain that? The target has not been achieved for the number of children for whom payments have been made in respect of the early child care supplement. The Minister alluded to that already.

There are 210 primary care teams in place and 100 in development. The Minister said targets have been exceeded but how many of these are fully staffed? How many do not even have a doctor on them? How many of them have a premises to work out of as opposed to being "virtual" teams?

The target was not achieved for emergency department turn-around times. No one is surprised by that. Why is there no target for the reduction of cancelled operations? Why is there no target for outpatients and outpatient waiting times? Hundreds of thousands of people have been kept waiting. The Comptroller and Auditor General criticised the HSE for its approach to this and confirmed my suspicion that waiting times for operations were being manipulated by controlling the flow through outpatient departments so people could not get on the list.

The Minister claims the national cancer control target was achieved. Where is the target for after-care? We were in Sligo yesterday and people there are very unhappy with the service they are getting. People who have had cancer find they are going for repeat mammograms to BreastCheck, instead of going to the regular mammography service where the previous mammograms can be compared with the current, which is clearly best practice. They are also having trouble with transport to Galway. The transition of services to the designated breast cancer centres is essentially the same issue.

What about child and adolescent beds? There is no target for ending child admissions to adult facilities, something we all agree is wrong and should be addressed in a much more urgent fashion.

The Minister says there will be more access to diagnostics for public patients. How will that happen? How will GPs access diagnostics for patients who do not have insurance? Currently, they have to refer patients into hospital for these tests instead of to other facilities that private patients can attend.

When will the cervical cancer vaccine be administered? We are coming into April and it is unlikely it will happen before Easter. The Minister of State might also confirm when he hopes to have the referendum on children's rights.

Can the Minister comment on the succession stakes for the CEO of the HSE now that Professor Keane has pulled out of the race?

I welcome the Minister, the Minister of State and their teams.

Would the Minister comment on the statements in the media that Professor Keane is not going to take up the post that will be vacated by Professor Drumm, should he be offered it? It must be a disappointment and it was the Minister's preferred option. People would have been confident in him given the work he has done.

It should be pointed out, however, that it is not the case that Professor Keane chose the eight centres, they were chosen before he came and he simply implemented a decision that was already made. It is important people know that. There was a suggestion that the Opposition opposed his choice not to have a centre north of a line between Dublin and Galway. That decision was made by an entirely different group of people, not by Professor Keane. I still believe there should be a centre in the north west.

I have a series of other questions. I refer to the briefing note on the annual output statement, which states that 58% of the outputs for 2009 were either exceeded or achieved but 42% were only partially achieved or were not achieved. That last figure seems a high percentage of unachieved targets. Will the Minister comment on that? Generally, when one sets targets one would expect the great majority to be achieved so that is disappointing.

I have a question about the H1N1 vaccine. Will the Minister tell us whether any money can be recouped on the unused vaccine? We have indications that a large amount of vaccine will not now be needed. Some will be kept in case of emergencies but there will be leftover vaccine. Is there any way of retrieving some of the money concerned?

Regarding the money allocated for the various sections of the HSE, geographical areas and voluntary hospitals, am I right that there is €100 million less available for the voluntary hospitals? Presumably the figure is commensurate for other HSE hospitals. Is this down to reduction in pay or are there other cuts which are not related to pay? Is it true that 1,100 beds will be taken from the system this year? If so, how will the demand on the service be addressed?

What did the Minister mean when she mentioned "demographic needs"? She provided a list of various amounts of money for the fair deal scheme, home care packages, etc., and referred to demographic needs. I seek clarity on the meaning of that term.

With regard to the moratorium, there are some exemptions, one such being social workers. I believe consultants are another. I heard some reports that at senior HSE level there is no difficulty about replacing people who retire. Will the Minister clarify whether the moratorium applies to the senior grades in the HSE?

Is the Minister able to tell us when the group she set up will report on the financing of the health services? I believe it is to be in April but perhaps she will clarify that point.

Does the Minister wish to comment on today's news about the Quinn Group? I do not know if she can clarify whether this applies to its health insurance section or only to other sections of the group.

My question for the Minister of State with responsibility for children and youth affairs, Deputy Andrews, is much the same as Deputy Reilly's, which referred to the referendum. Perhaps he can tell us whether he expects it to take place this year. Obviously, he has set aside funding for this year. Can he clarify the current situation regarding recruitment of social workers? Where will they be allocated? Clearly there is a shortage in the areas of child protection, foster care, children in care and assessment of young people who are considered to be at risk. Perhaps he might clarify what the intention is this year regarding extra social workers and whether funding has been set aside for that purpose. In addition, all children in care should have an allocated social worker and written care plan. Are the resources in place to achieve that in 2010?

I thank both Ministers for their contributions. We have an excellent health service. There are hiccups from time to time and one area that causes concern is the waiting times for outpatients and, occasionally, for admissions. However, when people are admitted to hospital the service is first class. It is important that we stress that point on occasion because the public perception would not always be----

Could Deputy O'Hanlon tell that to people around the country?

Deputy Reilly, please.

I would be glad to deal with that point with Deputy Reilly any day of the week he wishes.

I have some questions for the Minister. First, although I agree fully with her policy of developing a primary care service which should reduce the need for hospital beds, the number of people being admitted to hospital and those being discharged has been increasing. It is very encouraging to see the increase in the percentage who avail of day care services but the numbersin toto are increasing. What conclusions have been drawn from the comparative analyses of the different levels of service being provided in similar situations throughout the hospitals in the State? The number of patients attending out-of-hours general practitioner services is increasing and has been recorded but I wonder if there is a record of the number of patients who attend their general practitioners in surgeries, whether it has increased or what the balance is between trends in hospital visits and doctor visits.

I refer to primary care teams and the question of their geographic distribution, and to home care packages. Are they well distributed throughout the country or have some areas done better than others? Even within certain areas, for example, north-east Dublin, do the services tend to be in the Dublin end or is there an even spread throughout the region?

Regarding the waiting times for appointments, the entire system of making appointments for patients and the duplication in different hospitals, is there any hospital in the State to which the general practitioner or the patient can make appointments on-line and get an instant response? Can people go on-line themselves, make an appointment and learn the date, as with Ticketmaster? It seems to be able place 82,000 people in seats in Croke Park for a concert. I wonder if there is any hospital with this facility and whether there is any intention of introducing a sophisticated IT system whereby appointments might be made and people might know when their next appointment would be available.

Regarding immunisation, I compliment the Minister and her Department on the good work done in respect of swine flu. In Australia and in other parts of the world there were three waves of this epidemic. We had two in this country. Is there is any view concerning whether we might experience a third wave in the current year?

My final question is for the Minister of State, Deputy Andrews. What progress is being made in developing mental health services for young adolescents who find themselves caught between child services and adult services?

I welcome the Ministers and their staff. The Minister, Deputy Harney, referred to a reduction of 30,000 in admissions. Perhaps she might elaborate on that. How does she hope to achieve that figure, what will be the mechanics of achieving it and what are the implications of so doing? She might provide her response to the fact that this will happen, and how, if it has happened already, she can justify it. I do not believe she can justify it. Deputy O'Sullivan asked about social workers. The Minister promised to recruit 270 social workers and that all children in need of a social worker would have one allocated to him or her.

I note from programme 7, mental health, that the allocation last year was €1,076 million while the allocation is €1,056 million for 2010. The outturn for 2009 was €1,058 million. According to figures published recently, there was an increase in suicides last year of the order of 26% which is way more than 100 on the previous year. It is recognised that because of the recession, the level of psychiatric illness and depression has increased, as a result of losing jobs, the financial crisis, the risk of losing homes, the risk of losing jobs. Family difficulties due to financial problems have led to suicide, attempted suicide, self-harm and depression. This is not unexpected given that during every recession throughout the world since the 1920s, there has been an increase in the level of suicide. In times of crisis there is an onus on the State and on the Government to respond. I read in one of today's newspapers that the money for social welfare payments will run out in a few months' time. While social welfare levels were cut, which is unacceptable, the Minister responded to need in that area.

The Minister must respond to another need for an increased allocation in respect psychiatric illness because of the economic problems rather than an effective cutback in the allocation. I assume the HSE performance will be related to the level of outcome. I accept that on the basis of the outturn last year, there is a cut of €2 million. The national suicide prevention office would welcome an extra €2 million with open arms in respect of the work it would do and the NGOs involved, whose allocation is being cut again his year, would welcome €2 million to enhance their work on suicide prevention and in dealing with the bereaved in the aftermath. In times of recession people have to deal with personal crises. The economic crisis will be dealt with later. However, I will concentrate on personal crisis — people who are victims of suicide, the families who have to go through the trauma and so on. There was an 8% increase in the incidence of self-harm last year. People suffer from depression caused by the tension in the home due to loss of employment, the consequent danger of loss of home, loss of home, and interpersonal difficulties created in the family. That should be recognised and responded to in terms of the services available.

I omitted one question on dental and orthodontic services under primary and community health. I cannot imagine the Minister would want to stand over the suggestion that dentists are being encouraged to extract teeth rather than fill them, if filling is appropriate. Has the Minister had any discussions with the Irish Dental Association on its concerns in that regard? There is a reduction from €222 million to €216 million.

That is quite a range of questions. In responding to those I ask the Minister to address the issue of the operation of the National Treatment Purchase Fund which has done superb work since its establishment. However, there appears to be growing waiting lists in some hospitals for orthopaedic procedures. I am aware from a recent contact with the National Treatment Purchase Fund that it may take up to 12 months before a person can be dealt with.

I extend my heartiest congratulations to the Minister and all involved in the colorectal screening programme. It says something about the way society is evolving that it is only at this point that we are trying to do something about screening the male population for cancer. Do we need a particularly focused campaign to ensure an update of this screening programme, given that it is a first attempt? Perhaps the Minister would address those questions and there may be some supplementary questions.

Thank you, Chairman. I will deal with the various issues directed to me. The first issue concerning child care places was raised by Deputy Reilly. One of the fears at the beginning of the early childhood care and education scheme was whether we would have sufficient places to provide for every child in a preschool year. As it happened, we had more than enough places. Initially the national child care investment programme was to provide 50,000 places at a cost of €358 million. We are on target to provide 25,000 places. We have reached almost saturation point and many providers faced closure in the past 18 months. While the labour market shrinks, as it inevitably does in a recession, parents take their children out of these services. We are replacing that investment by programmes that try to support children to get the benefits of the provision rather than the care side. We are on target to provide an appropriate number of additional places under the national child care investment programme. Obviously we want to protect the €1 billion already invested by the Government in capital projects.

Deputies Reilly and O'Sullivan asked about the timing of the referendum. The funding was set aside to reflect that we are ambitious to have this referendum. It has been called for since 1993 and perhaps earlier. We are closer to achieving this than we have ever been before by achieving all-party support on a potential wording, which is being considered by senior officials whom I will meet the week after next. We will incorporate the Attorney General's advice before making a recommendation to Government. There is no specific timing for a referendum that can be committed to at this point but the wording that has come out of the committee is very attractive. The timing is less important than getting it right, especially when dealing with a constitutional provision.

Deputy O'Sullivan asked about social workers. This year we intend to recruit an additional 200 social workers. The funding is provided from the additional €15 million in the supplementary Estimate in respect of the Ryan report implementation plan, of which €8 million is provided for additional social workers. Where will they be allocated? The answer to that question will be a little easier now given that we have some agreement in terms of social partnership over the past 24 hours. One of the key issues is redeployment and, as a legacy of the health boards, we are not sure exactly where redeployment would be most appropriate. We know there are areas where there is duplication and where there are gaps. We are committed to ensuring that every child in care has a social worker. That is an ongoing commitment. Serious shortages have been identified by HIQA in the foster care area, particularly among relative foster care. I am determined to try to close that gap. Ultimately it will be targeted at child welfare and protection. As mentioned by the Deputy social workers benefit from an exemption from the moratorium.

Deputy O'Hanlon raised the issue of mental health for adolescents. This was one of the priority areas for development in A Vision for Change. Last year the HSE almost doubled its allocation for mental health provision for children and adolescents in respect of bed capacity so that the total number of in-patient beds is 30. This is an area we want to grow. I certainly work very closely with the Minister of State, Deputy Moloney, who has direct responsibility for this area to try to enhance developments in the area. As members will know from December's budget, he was able to secure additional funding for this area. It remains a priority for development.

I will begin with the Chairman's question. He asked about waiting times for outpatient appointments which represent a very central part of the commitments the HSE has made for 2010. As members know, Dr. Barry White has taken over as clinical affairs director for the HSE and among the initiatives he will introduce will be care pathways, which will include appropriate care led by consultants across a number of different disease-specific areas but also access to appropriate outpatients, and particularly new referrals. On a number of occasions when he started the cancer control implementation plan, Professor Keane said that his concern was to ensure that general practitioners followed up in the main regarding cancer patients and that consultants were dealing with new referrals. I believe he has made great progress in that area.

The National Treatment Purchase Fund has done well. It has treated 165,000 people to date. At the presentation of the annual report there are normally some very satisfied patients who have been treated in the previous year. The National Treatment Purchase Fund spends less than 0.5% of the total budget spent in the public health service which is a relatively small amount of money. It is there effectively as a universal insurer to procure treatment for those who are waiting longest essentially in a private capacity in this country. A small number have gone to the UK or Northern Ireland. However, more than 90% are treated here in the South. It has been very successful.

The National Treatment Purchase Fund did some useful pioneering work in the area of outpatients, where an outpatient appointment may have led to the need for a procedure. If memory serves me right a very large percentage of those who had their outpatient appointment did not need a procedure. This is particularly true in orthopaedics where up to 70% of those having seen the consultant do not need a procedure. Very often they need referral to a physiotherapist. Among the initiatives Dr. White is interested in putting in place in the area of orthopaedics in particular is ensuring that an adequate number of physiotherapists are available.

That brings me to the issue of the moratorium, which applies to administrative and management staff. There are a large number of exceptions, including doctors, therapists, social workers, physicists, radiation therapists and so on. Outside those categories a case can be made to the regional group that investigates these issues to make a recommendation to fill an appointment, for example a director of nursing appointment, etc. I shall not read out the long list of exceptions, which includes counsellors, emergency medical technicians, clinical psychologists, all the various therapists, physicists, radiation therapists, clinical engineering technicians and so on. Many of those are needed for the cancer control programme.

It would not be appropriate for me to comment on the succession in the HSE. I have spoken publicly on many occasions about my high regard for Professor Keane. However, I equally made it clear that it is a selection process that is overseen by the board by law and it is a matter for the board to make the appointment. Clearly the issue of Professor Keane's candidacy has got into the public domain and he has made a decision for personal and family reasons. I have not spoken to him since that decision was made. However, it is a matter for the HSE to pick the most appropriate person to lead the Health Service Executive over what will be a very challenging period, particularly as far as financial controls and change is concerned. I hope the board of the HSE will be in a position to make a selection in plenty of time for a smooth succession. I understand Professor Drumm finishes in August. I hope we will be able to have a successor in time for a smooth succession from the current CEO to the new CEO.

The agreement reached last night with the public sector unions will have a major positive impact on the health service, in particular in the area of access to diagnostics. The importance of the 8 a.m. to 8 p.m. working day should not be underestimated. Our hospitals need to respond to the needs of patients and clearly a 9 a.m. to 5 p.m. working day, where outside those hours access to radiography, in particular, was so expensive and on a fee per item, has led to many delays in hospitals being able to fund appropriate diagnostics. I believe that will have a major impact.

The HSE has given a commitment that region by region it will reduce the number of admissions from accident and emergency units by 33,000 because it estimates that a large number of them simply require diagnostics, others require outpatient appointments and some can be provided services through the community intervention teams in the home. The VHI is now engaged in a "hospital in the home" pioneering project. I met the group last week and its target for this year is to treat 1,000 people with different chronic illnesses at home as opposed to in a hospital environment. There is great potential to have appropriate treatment at home and in the case of the HSE it is being led by the community intervention teams.

Deputy Reilly asked about the medical card review. It was completed and obviously no change was made in the budget. The McCarthy report had recommended we change downwards from where we are — in other words reduce the financial criteria substantially as far as medical card holders are concerned. The Government did not agree to that recommendation. However, the numbers on medical cards is growing very rapidly as is the cost of medication this year. Some 12,000 full medical cards were issued in January and if that continues through we estimate there will be an extra 140,000 for the entire year. There will be an additional €250 million on drug costs associated with additional medical cards. Clearly in a time of tight financial constraint it is impossible to relax the income criteria. However, I would say that we factor in travel to work costs, rent or mortgage costs, child care costs and so on. Although the nominal income may appear small, it is disposable income and other costs are also factored in. That is why so many additional people over and above the numbers that may be on those kinds of incomes qualify for medical cards or doctor-only cards.

We are preparing eligibility legislation as the Deputies will be aware. It is long overdue. We hope to be taking it to Government this year. It will clarify the items for which people are eligible in the health system. That is particularly important as we move from a hospital model to a community model, particularly regarding therapies. If access is free at a hospital level, but there is a charge associated with it at community level, obviously there are perverse incentives there, so we need clarity on eligibility. It will be a major Bill and will offer a major challenge for this committee to take us through that legislation. We hope to have that this year and it should bring great clarity to the issue of medical cards and other eligibility issues.

Deputy Reilly asked why the Department's Vote had increased by 3% on the policy side. If the Deputy takes a two-year view on the matter he will see that it is less than it was two years ago. Last year there were a number of once-off savings that cannot be factored into 2010. For example in 2009 there was an increase of €5 million, referred to on page 7 of the output statement, which relates to non-pay spending. This was a once-off saving in areas such as legal fees for the Mental Health Commission and the Department, and for the establishment of HIQA. So some once-off matters which reduced in 2009 compared with 2008 could not be counted again in 2010 because they will not recur. However, when 2010 is compared with 2008, there is still a substantial reduction.

One of Dr. Barry White's initiatives is to examine ring-fencing beds for surgical procedures. When there is pressure, particularly from the emergency departments, elective surgery gets postponed or delayed. The only way to avoid that is to ring-fence beds for surgical procedures and his intention is to make that a reality in as many hospitals as possible as part of his initiatives regarding clinical care pathways. That would allow surgeons to manage those beds rather than have patients brought in in advance over concerns that the bed will not be available. In some cases patients come in on Sunday for a procedure on Monday. If surgeons knew they had the beds then patients would come in on Monday. There are many positive reasons for that to happen. I understand that initiative will be put into effect during this year — hopefully soon. It might be a good idea for the committee to invite Dr. White, who is the new clinical affairs director, to engage with the committee.

A new consultant was to be recruited for Sligo — someone retired and that person had to be replaced. I do not know if that is what is affecting the regular mammographies, I will check that, but that was the understanding I got from Professor Keane when the issue arose a couple of weeks ago. However, the intention is that the follow-up will occur in Sligo General Hospital. The reason for going to the specialist centre is for initial diagnosis and surgery and, thereafter, patients were to be managed in the local hospitals. That is what is happening in Mayo and what should happen in Sligo. I will clarify that for Deputy Reilly.

We gave a commitment that the vaccine would be introduced this year for first year girls. The intention is to start after Easter. The Irish Medicines Board has indicated the second dose must be given exactly two months after the first dose, with the third dose being given sixth months later; that will be a challenge. The Chief Medical Officer and public health doctors in the HSE are engaging on this issue. I will repeat our commitment that all first year girls will get the vaccine during 2010.

Deputy Jan O'Sullivan asked about the successor to Professor Drumm. She is right, when Professor Keane came to Ireland, the eight centres had been identified following a recommendation by a group that was composed of 19 clinicians and three others. Professor Keane, however, did not disagree with the identity of those centres. He did not get involved in the issue because it was a project he came to implement but it was project he was happy to implement.

The issue comes down to what is safe and how we can get the volume of patients to guarantee highly skilled clinicians performing surgery — 150 new procedures a year for breast cancer. Other than for breast surgery, and there was one breast surgeon in Sligo, and there could not be a service if that person was not there, all other major cancer surgery went either to Dublin or Galway.

There is a satellite centre in Letterkenny and I have been in discussions with my counterpart in Northern Ireland on the radiation centre for west of the Foyle which the Northern Ireland authorities intend to put in place by 2015 as a satellite for Belfast City Hospital. We have already procured treatments in Belfast City Hospital for some patients from Donegal but a good outcome for the north-west would be to have a radiation centre in the north-west supported by patients from both sides of the Border. Our talks have been successful and the Government has committed to investing in the provision of that facility by way of a capital allocation and ongoing service level agreements related to the number of patients. Minister McGimpsey is positive about this matter.

We have sent some of the H1N1 vaccine back. We had 12 million vaccines either that we did not pay for or do not have to pay for. We are also talking to another manufacturer about some other vaccines.

A large part of the reduction for voluntary and public hospitals is pay. Galway university hospital, for instance, has more than 3,000 staff. Given the cutbacks in public sector pay, a large part of the €16 million reduction would relate to pay. The same applies to voluntary hospitals where the pay scales are in line with public sector pay norms. Not all savings, however, are in the pay area, hospitals must move to more day case activity, which has increased by 4% per year, although there is still some way to go to get to best international practice.

There are demographic issues with regard to dialysis, additional cancer treatments and more people requiring disability services so the €70 million I mentioned earlier is in that space. It has been called the demographic pressure in health but it relates to unavoidable provision of patient services.

I heard about Quinn Insurance this morning. Health insurance is affected but the regulator made it clear that the administrator will ensure the company continues to trade and can take new business. All claims will be honoured. There is an insurance compensation fund that will be applied to meet the gap between the assets of the company and the liabilities, which I understand are considerable. There is no immediate concern about the health insurance element. Quinn has 23% of the private health insurance market and all those policy holders are fully covered. That will continue to be the case.

The resource allocation group had a target of finishing in April. I have not heard of any delay being sought so I expect the report during April. The group was asked to look at how a resource is raised for health, be it through insurance, taxation or a combination of both and how it should be allocated to get the best results for the patients. The group engaged widely. It is made up of key stakeholders and those who have looked at funding models and I look forward to receiving and debating the report.

We had to make reductions in dental services. The cost of the dental service had increased by 50% in one year. I have engaged with the Irish Dental Association recently and it put forward some suggestions. I asked the HSE to come forward with plans for allocating the money on a month by month basis. I do not want the money to run out in June and there to be no service available. We are involved in that engagement process with the HSE. There are different dental schemes, the public scheme, the medical card scheme and the social insurance scheme; in an ideal world we would bring all of that together.

We do not have comparative data but Ireland is at the higher end of the scale for admissions from accident and emergency departments into acute hospitals. Generally, attendance at accident and emergency is higher where there is an accident and emergency unit and where there is not a good out of hours service. We spent €108 million last year on out of hours services for medical card patients — they spent £18 million in Northern Ireland for the same number of people, so we are spending a considerable amount on out of hours services. There are some deficiencies but there have also been wonderful things happening, with areas that did not have out of hours cover now having it.

I do not have data on the number of people visiting their doctors. Given that we make capitation payments, it is not easy to understand that, regardless of the number of visits, the capitation payment remains the same for in-hours consultations. We may be able to get some data from prescribing practices and, if we can, I will make them available to Deputy O'Hanlon.

The HSE is making a better effort at a fairer distribution of home care packages. It does not mean they are allocated on an equitable basis county by county. Obviously it relates to demand. Last year more than 12,000 families benefited from that and at any one time, 9,500 are receiving those packages at home. We get positive feedback from families on the home care packages. An extra €10 million is going into them this year and we must continue to develop the home care package model.

We do not have on-line bookings or the IT system to do that. The HSE is working with GPs and hospitals on messaging between the two. In many cases, hospitals will send patients a text message to remind them of appointments. The physiotherapy department in St. James's has had great results in dramatically reducing the numbers of no-shows as a result of introducing a text message service close to the appointment time. There is scope for the further use of technology. We will bring forward the health information Bill this year, it is almost ready, and that will provide the legal enabling powers to allow us to use technology in a range of areas to develop better health care. It also requires considerable investment in IT systems.

Deputy Neville asked about social workers. They are exempt from the moratorium. Since the HSE was established, we have recruited an additional 3,100 health and social care professionals, a considerable additional increase, across several areas. There are never enough and I do not suggest we will have enough. There will always be a need for more. However, we are making good progress and both Ministers of State, Deputies Andrews and Moloney, who have responsibility for children and disability, respectively, will ensure that commitments made in the budget regarding recruitment of social workers, speech and language therapists and physiotherapists will be honoured.

Deputy Neville referred to suicide. Recently my office engaged with one of the larger voluntary bodies in this area and I tried to encourage, if possible, the coming together of some of the voluntary organisations. There are a large number of these, each with its own chief executive officer and administration, which compete for funds. I do not say this in any negative sense, rather in a positive sense, but I speculate on whether we might make the money go further if there were to be a coming together of some of the organisations.

This does not apply only to suicide-related groups. Laurence Crowley is heading up a committee at the request of the Minister of State, Deputy Moloney, to look at the voluntary sector in general and see how we might have further rationalisation so that the money we can make available can go into actual services rather than have too much of it consumed in administration. There may be scope in the area of suicide. I hear what the Deputy says and I know his commitment. He will find that the Minister of State, Deputy Moloney, is very focused, especially this year, on the implementation of A Vision for Change. Later today, he and I will meet with key officials in the HSE concerning some of the initiatives we need to put in place this year, including in the area of suicide prevention.

How many primary care teams are fully staffed?

In my opening comments I stated there would be 220 primary care teams. The Deputy asked whether they are fully staffed but I do not know the answer to that question. I suspect there will always be a need for more staff in every team, to include therapists, dieticians and others.

I might help the Minister there. It concerns the definition of what is wanted on the team.

I know what is required on the teams. The first thing about such a team is that if we can get all the people who currently work in the public health system working together differently for patients, that in itself, without any additionality, will lead to better results for patients. I have been told the number of general practitioners participating is 840. Is that the case?

There are 840 general practitioners currently participating in primary care teams.

May I ask for clarification on what the Minister means by "participating"? Does it mean actively attending meetings and being involved or does it mean——

That would be my understanding. I would not regard it—

——or does it mean those who sent a letter expressing interest?

In fairness, I would not regard my response to be appropriate if those concerned had merely signed a piece of paper. I would regard it as appropriate only if these people were actively participating.

How many teams mentioned by the Minister have no doctors?

I do not have that information. My very clever official has just told me it cannot be a team if it does not have a doctor. I thank him. I wish I had thought of that myself.

We are told that some do not have a doctor. Perhaps the Minister's clever official might look into this for me.

If Deputy Reilly has any specific example I would like to pursue it for him.

I asked other questions. For example, why do we not have a target to reduce cancelled operations?

I said that part of Dr. Barry White's brief, as I understand it, is to try to do this. The reason so many elective procedures are cancelled is because of pressures within the hospital system, mainly from emergency departments. The way to avoid that is to ring-fence beds for surgery and have the surgeons manage those beds. My understanding is that Dr. White is engaging seriously with the surgical community to make that a reality. That is the way to avoid unnecessary cancellation of surgical procedures.

Does the Minister have a target?

As the Deputy knows, currently we are measuring hospitals every month across 27 different indicators. I am a great fan of measurement and information. That drives change faster than anything else, peer review and so forth. I agree we should have targets in that area.

I apologise for arriving late. I ask about the moratorium on nursing staff. Many nurses have applied for early retirement, disproportionately, one might say, across district hospitals in my region. In one hospital 25% of nursing staff are opting for early retirement. One can imagine the pressure this would put on district hospitals.

At our last meeting with the Minister and Professor Brendan Drumm, I asked about the future role of district hospitals in the rolling out of health care. Professor Drumm said they would have an enhanced role and this makes good sense when one considers that a hospital bed costs €850 per night and a step-down bed in a district hospital costs €1,000 per week.

If the deal done over the weekend is accepted by the unions will there be any prospect of flexibility being introduced in the recruitment of nurses, even on a short-term basis, to alleviate difficulties that would occur in such hospitals? It makes good economic sense that these services should be kept open. Perhaps the Minister might outline whether it is national policy that district hospitals will have an enhanced role in the future.

Are there any other supplementary questions in respect of individual subheads or programmes?

I asked the Minister about the closure of beds in the context of cuts. This is a supplementary question in that she told me the cuts in various hospitals around the country are partially to do with pay and partially with other factors. I presume the closure of some beds relates to the issue referred to by Deputy Flynn, namely, the current shortage of nursing staff to run wards in some areas.

Frankly, I do not know how hospitals will manage, when I consider the number of people I have seen in various hospitals I visited recently, including those on trolleys. Will there be further cutbacks in these hospitals in respect of finance and staffing?

Regarding what the Minister said about Dr. White organising the ring-fencing of beds for surgical procedures, those beds presumably will not be available for people who come through accident and emergency departments. The public needs reassurance from the Minister that hospitals will not end up in a situation where there will be increasing numbers of people on trolleys as the year progresses. As I see it, much of the difficulty does not concern understaffing in accident and emergency departments but has more to do with the fact that people have gone through those departments but cannot get into a ward because no beds are available.

Before we leave the Estimates for 2010 we must address this issue and know exactly how these cutbacks will impact on what I see to be a growing problem, with even more people on trolleys this year.

Is it the Chairman's intention that we should wrap up? I asked why we do not have a target for outpatient department figures. These are the people who are waiting to wait. Will the Minister confirm that there has been an increase in moneys available for those who suffer from thalidomide? I saw a reference to that.

If this is my last opportunity to speak I must respond to the comment made by Deputy O'Hanlon to the effect that we have an excellent health service. I find it very difficult to understand how the Minister will achieve 30,000 fewer emergency admissions because, by definition, these are emergencies and I do not know how she can avoid that. Nor do I know how we will cope with having 1,100 fewer beds. In this excellent health service virtually every day there are 300 people lying on trolleys. On one day in January there were 500.

There was a 70% increase in delayed discharges last year, which resulted in more than 300,000 bed days being lost. There were 9,000 cancelled operations in the first six months of last year — we do not have the figure for the full year. Outpatient appointments are given to people who have waited for more than two years. Very often I am told to send my patients somewhere else. There were unread X-rays in Tallaght and Waterford hospitals. I would like the Minister to tell us what the situation is in other hospitals, such as James Connolly, Cork University and Beaumont hospitals. How long must we wait for the report to come from the HSE?

There are still unread letters in Tallaght hospital though they have all been opened. Dr. Ilona Duffy is standing over what she said about unopened letters in Drogheda hospital.

There is a cancer strategy with no centre north of a line from Dublin to Galway although there are several in Dublin. Children are still being admitted to adult mental health facilities. One third of foster parents are not being vetted by gardaí. Intellectually disabled sufferers are being left in Victorian decay in St. Ita's Hospital while across a field they can see a €14 million new facility they cannot get into because of staff shortages. Acute psychiatric patients are still being admitted to a building that was built as a temporary measure in the 1960s, 50 years ago, because the co-located hospital in Beaumont impinges on the site for the new psychiatric inpatient unit.

That is our excellent health service. I realise we are in financially straitened times but what the Minister proposes to do is not realistic unless patients are to be hurt even further.

I will respond to Deputy Reilly. One of the measurements of health systems around the world is life expectancy. Life expectancy in Ireland has increased by three years in the past ten years and that has not happened anywhere else in the developed world in that timeframe. The Deputy knows that the performance of health systems in countries is examined and issues such as life expectancy and infant mortality are addressed. We are top of the class. That is not to say we do not have problems. We have many good elements but we must deal with issues and that is what our journey of reform is about.

On the question on delayed discharges last year, the fair deal scheme will have a significantly positive impact. The applications under that scheme are being processed and we have provided sufficient money for all the people whom we believe are entitled to avail of it. When the backlog has been addressed — there are some IR and court issues — and we can continue to deal with the flow in a reasonable timeframe, it will have a major impact on older people being able to move into suitable nursing home accommodation.

I am not aware of issues in regard to X-rays in the hospitals named by the Deputy but I had a meeting with Professor Drumm last week and the HSE has sought assurances from every hospital in respect of these issues. I look forward to hearing words of assurance in respect of unread letters and X-rays in the next few days. I know that HIQA is also involved in an exercise on that matter from the patient safety perspective. Serious issues could arise if it were the case that referral letters were not addressed appropriately in a hospital.

I asked the State Claims Agency some time ago to look at the case of the 32 Irish thalidomide victims and I expect that report to be furnished shortly. I will take it to Cabinet and decisions will be made on foot of the suggestions in that report. I look forward to that happening as soon as possible. The provisions in that regard in the Estimates is on a no change policy that is based on matching the monthly allowance paid by the Germans. We pay up to €26,000 a year to thalidomide victims plus they are entitled to medical cards and other medical expenses. I am aware of issues such as housing and other particular needs for some of the victims of thalidomide and I am sure that will be addressed in the report from the State Claims Agency.

District hospitals will have an advanced role as we move to the greater provision of community based services. That is much more effective from the point of view of patients. We have many more community hospitals than acute hospitals and it is clearly less expensive to provide services in a community hospital setting. The arrangement agreed with the public sectors unions, which I hope will be endorsed by their members will greatly help us to provide the skill mix, particularly as far as nursing is concerned. We have a very high proportion of nurses relative to nursing assistants in the workforce when compared to other countries and in particular to the services in Northern Ireland. We need a better mix and the agreement reached last night will allow us to have a better skills mix. Although nurses are not excluded from the moratorium because of the significant number of nurses we have in the health care system, if there are particular deficiencies, they can be addressed as part of the exceptional rules that are in place at a regional and national level.

Hospitals must survive on less. A large proportion of their reduced budget is around pay. The HSE will be allocated €1billion less that in 2009 and faces a reduction of €659 million on the pay side and €400 million is on the non-pay side. Some of the non-pay side will clearly affect hospitals as well. As we procure services more effectively and at less cost at national level, that will have a positive impact on hospitals. I do not want anybody to think that hospitals will not be under pressure this year; they will be under enormous pressure because of the financial constraints. Last night's agreement will help us greatly to be able to meet our service plan requirements within the available resources because it will allow for flexibility, longer working days, redeployment of staff from one place to another, from a hospital to a community setting. All of the agreements reached last night will impact positively on the provision of health services and allow the reform agenda to continue without the additional cost that might be required.

Patients waiting to be admitted from the accident and emergency department are placed on trolleys. The chief medical officer did a full capacity protocol which is implemented in every good health system in the world when there is an issue. Its safety was challenged on the last occasion and Dr. Crowley may perhaps have things to say on that. I believe as a result of last night's agreement that we will be able to implement it in more hospitals than has been the case to date. Clearly it has a positive effect and it is safer for the patient and it also seems to have a very positive effect from what I have seen from other countries on decisions being made up the line in the hospital. In too many hospitals, the accident and emergency service is left to the emergency department and the Comptroller and Auditor General's report drew attention to the fact that key clinical decision makers were not involved in the emergency department. As a result, unnecessary admissions were made for people to get appropriate diagnosis and so on. That is the reason we can reduce the numbers by 33,000 people during 2010 if we have rapid access to diagnostics or outpatient appointments. The new consultant contract requires consultants in our public hospitals to have a one for all access to their outpatients services and for diagnostics. There can be no more cases of what happened to Susie Long, where a person with private health insurance can be admitted within a week, and those with no private health insurance must take their place in the queue. Those days are over and the implementation of the new contract should fundamentally alter access to both outpatients and diagnostics. Many patients end up in emergency departments because they cannot get rapid access to these services.

The Select Committee on Health and Children has completed its consideration of the Revised Estimates and output statements for public services for the year ending 31 December 2010 for Votes Nos. 39 to 41, inclusive. Normally at this stage a message would issue to the Clerk of the Dáil, indicating that the select committee has completed its consideration of the Estimates. However, because of the recent changes to some Departments, the Minister for Finance intends to take back all the Estimates referred and they will be resubmitted to the Dáil for referral to committees in April 2010. For technical reasons, the committee cannot therefore agree to send a message at this stage. When the Estimates are resubmitted the committee can then agree to refer the message to the Dáil.

On behalf of the select committee I thank Deputy Harney, Deputy Andrews and their officials for attending today.

The select committee adjourned at 4 p.m. sine die.