SELECT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Tuesday, 19 Jul 2011

Vote 43 - Children and Youth Affairs (Revised)

Acting Chairman (Deputy Jerry Buttimer)

I remind everybody that all mobile phones should be switched off. I thank everybody for being here and I welcome the Minister for Health and the Minister for Children and Youth Affairs and their officials. Today's meeting is being held to consider the 2011 Revised Estimates: Vote 39 - Health; Vote 40 - Health Service Executive; Vote 41 - Office of the Minister for Children and Youth Affairs; and Vote 43 - Children and Youth Affairs, which have been referred to this select committee by order of the Dáil of 6 and 12 July.

I welcome the Ministers and their staff and officials. A timetable for today's meeting has been circulated to all members. This allows for opening statements by the Minister for Health and the Minister for Children and Youth Affairs and by Opposition spokespersons. This will be followed by open discussion in the form of a question and answer session on the Estimates. Are the timetable and procedure to be followed agreed? Agreed. I invite the Minister, Deputy Reilly, to make his presentation.

Minister for Health (Deputy James Reilly)

I am pleased to have the opportunity to address the committee on the Revised Estimates for 2011 for my Department, Vote 39, and for the Health Service Executive, Vote 40. Following the establishment of the new Department of Children and Youth Affairs, the Minister, Deputy Frances Fitzgerald, will address the committee on that Department and on the previous Office of the Minister for Children and Youth Affairs, Vote 34. Today's meeting is the first of two committee meetings this week focusing on the work of the Departments with responsibility for health and children. On Thursday, there will also be a meeting of the Oireachtas Joint Committee on Health and Children and on Thursday Deputy Fitzgerald and I will be very happy to deal with any outstanding issues which cannot be addressed at today's select committee meeting, which will focus on the Estimates.

Before looking at the Estimates in detail, I would like to make some general observations on the overall budgetary situation facing this area. As members of the committee are fully aware, the Government is committed to tackling Ireland's very serious deficit problem in accordance with the broad fiscal framework of the EU-IMF bailout deal. As both the Taoiseach and Tánaiste have made clear, this will require the Government to take many hard decisions over the next few years. No Department - this includes both the Department of Health and the Department of Children and Youth Affairs - can be exempted from this process. As members will also be aware, the recent performance report from the HSE for May shows an overrun of €195 million, or €170 million after adjustments. In his letter of 17 June to Cathal Magee, CEO of the HSE, the Secretary General emphasised that the HSE must meet its budget targets and that this will result in difficult decisions being made by hospitals and local services alike. The Secretary General also stressed that individual hospitals and services must be ready to explain and defend decisions.

Let me be clear about one thing. While all hospitals, including the smaller ones, will have to take difficult decisions to stay on budget, including the temporary closure or reduction of some services, there will be no hospital closures, either as part of reconfiguration or as part of budgetary measures. I am fully committed to ensuring that smaller hospitals have a strong and secure future. It is vital that they are safe and this work must continue.

It is also vital that smaller hospitals are allowed to do more work in areas where they are best suited. The debate over smaller hospitals has been dominated for far too long by what they cannot do rather than what they can do safely. We need to move the debate on and focus on those things that they can do safely and efficiently. This will require the transfer of certain procedures and programmes from larger to smaller hospitals, an issue to which I will be happy to return at the joint committee meeting on Thursday.

The extent of the financial crisis facing Ireland and the challenges this poses for health in particular at a time of growing demand means that the Government must press ahead with major health sector reform. Only in this way can we deal with the lack of equity in the health system and the very significant waiting lists. The Government is determined to create a single-tier health care system in Ireland. We are also determined to change the way in which the system is financed even before the introduction of universal health insurance. The current system of allocating block grants to hospitals is simply not working. We must move to a sophisticated "money follows the patient" system, which pays hospitals and doctors on the basis of what they do, while putting in measures to ensure that budgetary discipline is maintained.

The establishment of the special delivery unit, SDU, is a core element of the Government's plan to radically reform the health system and make it more efficient. The SDU will work to unblock access to acute services by improving the flow of patients through the system and by streamlining waiting lists, including referrals from GPs. It will also focus on reducing trolley waits in emergency departments and will develop a range of initiatives to ensure that our hospitals can cope better with the increased demand for emergency department services next winter and in the years to come.

Before outlining these issues in more detail, I will directly address the Estimates for health. The Revised Estimate for 2011 for the health group of Votes, excluding the Department of Children and Youth Affairs which the Minister, Deputy Fitzgerald, will discuss with the committee, provides for gross expenditure of €14.142 billion for health services. Of this amount, some €13.748 billion is for current funding and €394 million for capital funding.

Comparisons with previous years' Estimates are complicated by the transfer of functions between the Departments of Health, Children and Youth Affairs and Community, Equality and Gaeltacht Affairs. However, it is important to note that significant reductions were applied to the Estimates for 2011. A reduction of some €26 million was applied to the Department's Vote, with reductions of nearly €1 billion applying to the HSE.

In regard to the HSE, the main areas of savings are as follows: demand led schemes, including drug and professional fees - €449 million; the moratorium - €93 million; other procurement and non-core pay cost savings - €221 million; administrative and other savings in Votes 39 and 41 - €38 million; and the exit package, early retirement and redundancy scheme - €123 million. There were some other technical adjustments which yielded €111 million. The total was €1.035 billion.

Within the overall expenditure reduction, some additional funding was provided to address unavoidable cost pressures and key policy objectives. The main cost pressures are: €115 million for an estimated 120,000 additional medical cards; €57 million for additional superannuation costs; and €36 million for the State Claims Agency. It also provides some additional funding for the following key priority services: €14 million for older people, comprising €6 million for the fair deal and €8 million for home care packages; €10 million for disability; €10 million for cancer services; €9 million for child protection arsing from the Ryan report; and €1 million for suicide prevention measures.

The savings and additional allocations have been incorporated in the HSE service plan which was approved on 21 December 2010 and are recognised in the revised Estimates before the committee today. The funding for Vote 39 provides for gross expenditure of €348 million.

Following the establishment of the Department of Children and Youth Affairs and the transfer of certain functions, funding of some €14 million transferred from my Department to the new Department. This comprised €6.5 million in administrative budget costs, which my Department previously administered on behalf of the Office of the Minister for Children and Youth Affairs, €6 million for agencies which now are under the aegis of the new Department and €1.5 million to cover legal costs and lottery grant applications.

In addition, my Department took over responsibility for the drugs initiative following the transfer of the functions of the former Department of Community, Equality and Gaeltacht Affairs in regard to the national drugs strategy to the Department of Health on 1 May 2011. The Government is committed to addressing problem drug use in a comprehensive way.

Our overall strategic objective is to tackle the harm caused to individuals and society through a concerted focus on the five pillars of supply reduction, prevention, treatment, rehabilitation and research. Some €33.7 million has been allocated to the drugs initiative this year to further the aims of the national drugs strategy. The majority of this expenditure is allocated to local and regional drugs task forces, with the drugs initiative also funding the work of the National Advisory Committee on Drugs.

This allocation is only part of a much bigger expenditure programme on drugs services by the other bodies involved in tackling problem drug use. I am monitoring progress achieved across the strategy through the oversight forum on drugs and am determined that we will make real headway during the term of office of this Government. The Minister of State, Deputy Shortall, had particular responsibility and interest in this area.

Notwithstanding these transfers of functions, the Vote of the Department of Health was significantly reduced in 2011. All health agencies funded by my Department were required to achieve further savings this year of at least 5%, with the Department's administrative budget being reduced in line with the moratorium on recruitment and the provision for legal costs and statutory inquiries also being reduced. In the case of the Department's administrative budget, once account is taken of all transfers the reduction in the provision is some 11% less than the provision in 2010.

Vote 40 concerns the HSE. The gross provision for the HSE is €13.794 billion, comprising an Exchequer contribution of €12.312 billion plus appropriations-in-aid, or charges that raise funds for the service, of €1.482 billion. Up to 2010, receipts from health contributions amounting to approximately €2 billion were attributable to the health Vote. However, following the introduction of the universal social charge this year, these receipts no longer fall to be assigned to health.

In setting the Estimate for the HSE, tough decisions were taken in the context of the need to take corrective action on public spending. The reduction in gross current funding for the HSE is €727 million on the 2010 provision. The underlying reduction is somewhat greater because of the need to provide for a number of key policy priorities and a projected increase in the number of medical cards.

The health service must, of necessity, contribute to the expenditure reductions required in 2011, but the Government's objective has always been to ensure that these reductions are achieved in a way that secures the best possible outcomes for those in receipt of services, with a particular focus on protecting services for the most vulnerable. To protect services, we need to reduce costs and improve productivity.

Acting Chairman (Deputy Jerry Buttimer)

The Minister's allocated time is up. Is it agreed to extend his allocated time? Agreed.

Deputy James Reilly

One of the areas where costs were increasing exponentially was in the area of drugs and medicines. Public expenditure on drugs provided to patients under the GMS and other community drugs schemes has increased significantly over the past decade in Ireland. The year on year increase in spending on medicines is among the highest in Europe. In 1998 we spent just under €400 million but by 2010 our annual expenditure on drugs had increased to just under €2 billion.

There are a number of factors driving this increase. The number of items prescribed has increased in the past decade from 32 million items to 68 million items; doctors are prescribing newer, more expensive products; and, greater numbers of people are eligible for medical cards.

My Department and the HSE have taken a number of actions to control expenditure on drugs. Savings are being achieved through ongoing off-patent price cuts agreed with pharmaceutical manufacturers; the pricing mechanism for new products has been changed; and we have a review mechanism which takes account of price reductions in other countries. However, further efforts are required to control drug expenditure.

Last month I signed new regulations under the Financial Emergency Measures in the Public Interest Act to give effect to a reduction in the wholesale mark-up rate from 10% to 8% on most drugs and a reduction in the retail mark-up on non-drug items from 50% to 20%. Savings from these measures have been estimated at €14.3 million for 2011 and €34.4 million on a full year basis. The Irish Pharmaceutical Healthcare Association, IPHA, has agreed to a range of measures to deliver savings of €200 million in the State's drugs bill this year. Measures include price reductions and efficiency savings.

My Department is also finalising draft heads of a Bill to provide for the introduction of a system of reference pricing and generic substitution. This will allow pharmacists to substitute lower cost generic medicines when branded products are prescribed. The HSE will set the reference price for groups of medicines designated as interchangeable or generic equivalents. Further savings of €44 million will be achieved this year as a result of reductions in a range of fees and allowances paid to GPs.

However the cost of generics themselves must be addressed and this will yield even greater savings. My Department is working on this at present.

I will be carrying out a review of the operation, effectiveness and impact of the various financial emergency measures in the public interest regulations in accordance with the Financial Emergency Measures in the Public Interest Act 2009 later in the year. This will involve full consultation with stakeholders. In setting savings measures, my priority and that of the Government is to sustain services to patients and to match key health priorities with available funding. Notwithstanding this, it is clear that the financial challenges underpinning the HSE's delivery of its national service plan continue to be very substantial. My Department and the HSE are working closely to manage those challenges in this difficult economic climate.

As I am sure members are all aware, a decision to suspend approvals under the Nursing Homes Support Scheme Act 2009, otherwise known as fair deal, was made by the HSE in May causing considerable worry for old people and their families. I immediately requested a full examination of the funding situation and the sustainability of the scheme going forward, which was completed jointly by the Department and the HSE on 3 June 2011.

The fair deal scheme is a system of financial support for individuals who require long-term nursing home care and applies to people entering public and private nursing home care. The scheme is available to anyone assessed as needing long-term nursing home care. Under the scheme, individuals make a contribution to the cost of their nursing home care based on their means. Subject to the availability of resources, the HSE meets the full balance of cost over and above the individual's contribution in public or private nursing homes approved for the purpose of the scheme.

The examination of the funding situation highlighted a number of factors giving rise to the funding difficulties. These include an increase in the average length of stay for nursing home patients, with a resultant higher net demand for nursing home places. An increase in nursing home costs was also a factor, as was the practice of providing ancillary services, such as physiotherapy, occupational therapy, speech and language therapy and drugs services in some care settings, which should have been accounted for in other budgets and not the fair deal budget. We are still examining the full extent of this situation.

I am pleased to inform the committee that the processing of approvals for financial support under the nursing homes support scheme re-commenced on the week beginning 13 June. In June almost 500 applications were approved in chronological order. By 6 July a further 504 approvals had issued.

My key focus is to ensure that those who require nursing home care will be able to access it and, to this end, the Department estimates that almost 24,000 people will be receiving financial support by the end of 2011. In order to fund this increase, and to offset the other pressures on the budget that I have referred to, I identified a range of savings and income sources, one of which is a potential saving of up to €30 million in non-service related spending.

I have also taken a number of measures to help ensure the sustainability of the scheme. I have instructed the National Treatment Purchase Fund, which has statutory responsibility for negotiating prices with private and voluntary homes, to renegotiate prices with a view to achieving price decreases. I have asked the HSE to put in more rigorous governance and reporting measures. I have also asked the HSE to undertake a clinical audit of the appropriateness of care and admission to nursing homes. I have informed the HSE that only agreed cost components for long-term residential care can be charged to the budget and finally I have asked it to look at creating efficiencies in the cost of delivery of public beds. These measures should ensure that the scheme continues in a fair transparent and sustainable fashion.

Clearly, there is a need to ensure that in delivering services to a higher quality they are also delivered in the most cost effective and efficient manner. Given that approximately 70% of costs relate to the employment of staff, this will continue to be a focus in 2011. The numbers employed in the publicly funded health service have already fallen, some 1,600 of which is as a result of the voluntary exit schemes approved by the previous Government. I believe further savings in payroll costs can be achieved through reductions in the volume of overtime and agency staff. The challenge to management and staff alike will be to make maximum use of the Croke Park agreement to ensure services can continue to be provided with fewer staff and lower payroll costs. The employment control framework for the health sector, including the moratorium, is necessary to meet the Government's fiscal targets, and this year's Estimates provide for a reduction of €93 million in savings this year from the application of the moratorium.

Much progress has been made on reducing employment numbers. Employment at May 2011 stood at 105,410 wholetime equivalents. This represents a reduction of 6% since the introduction of the moratorium on recruitment at the end of March 2009. At the same time the framework provides the flexibility to the HSE to grow numbers in certain exempted grades. The HSE can also make other exceptional appointments to maintain essential services and meet priority service change and reconfiguration requirements. Nevertheless, the overall target reduction in numbers must be met and this will undoubtedly pose a significant challenge.

The shortage of non-consultant hospital doctors in Ireland is not related to funding, any recruitment embargo, moratorium or reorganisation of hospitals but to an inability to attract enough doctors to work in our hospitals. Much of Europe, including the United Kingdom, is encountering the same problems. The substantial decrease reflects a trend that has been evident for some time, with the HSE and the voluntary hospitals having encountered increasing difficulties over the past two years in filling posts. Since 2009, the HSE has progressively moved to address the growing shortages through a range of innovations. These include the centralisation of recruitment, the development of additional training posts and the offer of two-year contracts for those taking up service posts.

The HSE coped with an ongoing vacancy level of approximately 150 over the past two years. Services during that time were maintained in many places by the use of locums, amended rosters, cross cover and redeployment. We now have, as a result of the recent initiative, in co-operation with the colleges and the Medical Council and the urgent legislation recently passed, significant numbers of doctors from India and Pakistan arriving in the country. They will in a position to fill vacancies as they become registered. It is envisaged that 30 of these doctors will be registered within a few weeks and a further 60 soon after. This would leave us in a favourable position compared with the past 18 months, though certain specialties including emergency medicine continue to pose difficulties. The recruitment process will continue so that we can attract more doctors and will have less reliance on locums and agencies and, through this initiative, we could save ourselves a further €10 million per year.

There has been much reference in the news recently to the reconfiguration of our smaller hospitals. In this regard, I am on record many times as saying that I will not stand over unsafe services. The changes we are implementing, though difficult, must be implemented to ensure the best possible outcome for patients. I will not confuse the issue of safety with the issue of cost containment. There will be changes later in the year as a result of cost containment but that will be clearly flagged and clearly identified. There will be no question of confusing the two.

However, it is important to point out that the recent changes are not the death knell for smaller hospitals. I have repeatedly emphasised the extremely important role they have to play in providing services for their community. The smaller hospitals can and should provide as wide as possible a range of services, as close as possible to the local community. They should be the corner-stone of locally based services, and should have strong links both to the local community based services, and to the larger hospitals in their region. The services they provide should include a range of diagnostics and an expanded proportion of elective day surgery, not just 9 a.m. to 5 p.m. surgery but 23 1/2 hours surgery which allows a far greater range to take place, and more elective medical procedures. These should transfer from the larger hospitals, freeing up those facilities for more complex work.

I intend to prepare a framework for the development of smaller hospitals, which will set out how they will develop to reach their full true potential. That will specify the services that are transferring to them from the larger hospitals. Too often we have focused on what we are taking away rather than what we can add to services in those hospitals.

All of this will be done with full regard to the safety issues highlighted by the Health Information and Quality Authority, HIQA, in its reports on Ennis and Mallow hospitals. When implemented, smaller hospitals will have a vibrant role, doing more work – not less – and meeting as many as possible of the needs of their local community.

As Minister for Health, I am committed to major reform of the health system. My objective is to ensure access to health care on the basis of need, not income. I firmly believe that can only be achieved by establishing a single tier health system, supported by universal health insurance for the whole population.

There are various important initiatives across the health sector that will need to be undertaken in advance of and to pave the way for the introduction of universal health insurance. Work on key aspects has already commenced. For example, I announced the establishment of the special delivery unit, SDU, headed up by Dr. Martin Connor, at the beginning of June. That unit will tackle hospital system inefficiencies and work towards reducing hospital waiting times and waiting lists. In addition, the resources of the National Treatment Purchase Fund will be refocused to align with the work of the SDU and to allow for progressive improvement in the performance of the nation's hospitals.

A fundamental element in the reform process involves significant strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients. This commitment will be achieved on a phased basis to allow for the recruitment of additional doctors, nurses and other primary care professionals.

I do not want to delay the meeting further. I will make a copy of my full speech available to the committee.

Thehealth services have had a great deal of investment of taxpayers' money but there have not been the improvements the people have a right to expect. This Government fully intends to correct that, even in these difficult economic times. Our reform agenda, while ambitious, will be delivered. Health must lead the way in creating a fairer and more equal society.

I thank the committee and the Chairman for their forbearance. I am sorry for running way over time but I commend the Estimates for the health group of Votes to the committee and am more than happy to answer questions.

Acting Chairman (Deputy Jerry Buttimer)

I thank the Minister for his contribution. Would the Minister's officials e-mail a transcript of the Minister's speech? We will put it on our committee's website and make it available to the public.

Deputy James Reilly

Yes.

Acting Chairman (Deputy Jerry Buttimer)

I call on the Minister for Children and Youth Affairs, Deputy Frances Fitzgerald, to address the meeting.

Minister for Children and Youth Affairs (Deputy Frances Fitzgerald)

Two weeks ago I addressed the joint committee on the establishment of the new Department of Children and Youth Affairs, the range of policy areas and programmes coming under the Department, and my priorities as Minister. I thank members of the committee for their interest and contributions on that day.

I am happy to be here to outline to members of the Select Committee on Health and Children the Revised Estimates 2011 provision which it is proposed will be made in respect of Vote 43 for the Department of Children and Youth Affairs.

On Vote 41 in respect of the former Office of the Minister for Children and Youth Affairs, with the setting up of the new Department of Children and Youth Affairs Vote 41 is being retired. However, expenditure was incurred under this Vote for the first five months of the year and, consequently, the formal approval of the committee and the Dáil is required.

It is proposed that Vote 43 will have a total allocation in 2011 of €221,863,000. It is clear from the framework of Vote 43 that it brings together a range of functions which were previously located in a number of Departments as I explained to the committee when I was here previously. The bringing together of these functions and agencies into one Department for children and young people will provide clarity of purpose and coherence in structures, both of which will be essential to achieving the priority outcomes which I have set for the next five years and which we discussed also.

I will give members the technical background on the way the Votes are being organised. Vote 43 has been prepared under the guidance of the Department of Public Expenditure and Reform. Government accounting conventions mean the period for which provision is included is determined by whether the Votes, from which functions and associated expenditure are transferring into the new Department, are being retired.

Expenditure is therefore transferring from two Votes that are being retired, namely, Vote 41, which is the former Office of the Minister for Children and Youth Affairs, and Vote 27, which was under the former Department of Community, Equality and Gaeltacht Affairs. In both cases, the 2011 provision in Vote 43 relates to the period from June to end December 2011, that is the period from which the Department was formally established following the transfer of functions order. Expenditure for the first five months of this year is shown in Votes 27 and 41. This means the figures in respect of the relevant subheads in Vote 43 relate to a partial year, equivalent to seven months of expenditure. The 2010 provisional outturn figures are not included in Vote 43. Again, that expenditure is shown in the two Votes being retired.

The position in regard to functions transferring from Votes not being retired is simpler. The two Votes concerned are Vote 26, which is the Department of Education and Skills, and Vote 39, the Department of Health. A full 2011 provision is included in Vote 43 in respect of expenditure transferring from these two Votes. In addition, an Estimate for the 2010 provisional outturn related to these activities is included in Vote 43 for the relevant subheads.

I acknowledge that these differences in treatment introduce complexity in the presentation and interpretation of the figures. However, the footnotes to the Vote set out the position in regard to each subhead. I want to explain to members that the approach has been dictated by Government accounting conventions and is consistent with the approach adopted across all departmental Estimates where there are changes on foot of the redrawing of ministerial responsibilities. That is the explanation for the particular presentation on the figures.

I can confirm that the amounts being transferred to the Department of Children and Youth Affairs from other Departments take into account the movement of staff, the associated non-pay costs and the cost of agencies, schemes and other expenditure being transferred.

I must also point out that there will be further functions transferring to the Department, for example, the Irish Youth Justice Service, IYJS, later this year and pending completion of that process, the funding allocated in respect of that area remains within Vote 19, the Department of Justice and Equality. In addition, and this is an important point, responsibility for child welfare and protection services, which currently rests with the Health Service Executive, Vote 40, will transfer in due course to a new statutory agency to be established under the Department of Children and Youth Affairs, as set out in the programme for Government.

Transfer of these functions will be facilitated by further legislation and subsequent Government transfer of functions orders, beginning with the Child Care (Amendment) Bill, which was re-introduced to the Dáil on Report Stage last week, is due to go back before the Seanad tomorrow and will finish in the Dáil this week.

On the Irish Youth Justice Service, it will be a priority for me to oversee the development of a follow-up national youth justice strategy in tandem with the new national children's strategy. All of the civil servants currently working in the Irish Youth Justice Service will relocate to my Department. I believe there is considerable scope to develop better policy and operational arrangements with other areas falling under my Department related to children at risk, in particular the HSE child welfare services.

I envisage continued reform of detention schools with further improvements in service delivery, operational arrangements and support services across the three schools. For the information of the committee, there are 100 Garda youth diversion projects in place as community-based, multi-agency crime prevention initiatives which seek to divert young people from becoming involved in anti-social or criminal behaviour. These are central to the youth justice strategy. The Irish Youth Justice Service has undertaken an analysis of youth diversion projects, evaluating them in the context of local youth crime patterns, the profile of young people who offend and the available evidence regarding best practice and improvements sought by the projects. Work is under way to implement the recommendations of this report.

On the child and family support agency, I have initiated planning for the establishment of a dedicated new child and family support agency. In due course legislation will be brought before the House to establish this agency. The agency will take over the child welfare and protection services of the HSE and will be allocated an appropriate amount of funding, staff and resources from within the HSE.

I am also considering what other operational responsibilities from within those assigned to my Department might complement the HSE's child welfare and protection services. Work has begun to define the exact service scope and corresponding resource requirements for the agency. This is quite a big task and will take some time to complete but it is estimated that up to €600 million of the HSE's current allocation will be examined in this exercise. The establishment of the new child and family support agency, which will report directly to my Department, through its chief executive officer, will be a key objective for the Department and I hope to see progress towards this goal over the coming months. In the meantime, these resources continue to be located within Vote 40 as part of the health group of Votes and I continue to work closely with my colleague, the Minister for Health, in the context of his overall responsibility at this point for this Vote.

Today I will lay the second progress report on the Ryan report implementation plan before the Houses of the Oireachtas. It will be available in the Library. The rate of progress is increasing and, in line with the programme for Government, I am committed to delivering on all the commitments over the timeframe of the implementation plan. As I said to the committee previously, I have invited the Children's Rights Alliance to have an outside member on that committee and I will chair the committee.

I can advise the committee that additional funding of €24 million has been provided to date to implement the plan. The initial allocation of €15 million remains in the allocations of the HSE and HIQA in the current year. A further allocation of €9 million has also been made to provide for the implementation of actions specified for 2011

I advise the committee that 260 of the 270 proposed additional social workers will be recruited by the end of this year and I emphasise that these are additional posts. Recruitment to back-fill other vacancies as they arise is proceeding separately. The allocation for the recruitment of these social workers is outside any moratorium and their recruitment will proceed. The HSE, in line with Ryan report recommendations, is currently filling 29 posts to deliver assessment and therapeutic services for children in high support and special care units, and for children in detention. It is essential that we have proper assessment facilities available for the vulnerable children in these services. The posts are a combination of psychology, speech and language, social work and psychiatry. These professionals will play a very valuable role in assessing the therapeutic needs and facilitating the best interventions for these most vulnerable children.

Another recommendation of the Ryan report implementation plan relates to aftercare. As I have often said, and I am aware members of the committee have also made this point, young people in care do not suddenly cease needing support on their 18th birthday. I am happy to report that work is under way on the development of a national aftercare service in line with the new national aftercare policy developed by the HSE. That work is currently being planned and organised by an aftercare implementation group. Ten additional aftercare worker posts are also now in the process of being filled and their contracts will identify a need for flexible working hours. That should make a real difference along with action on the ground to ensure there is proper implementation, which will ensure we have a better national aftercare service than was previously available to young people leaving care. A number of other actions are being taken under the Ryan report implementation plan, which will be available to colleagues later today.

Another area covered in the Estimates before the members is that of early childhood education. My Department has responsibility for a number of major early childhood care and education programmes which are provided for under subhead B. Such provision represents high quality investment in child care and there is also a programme to help low income parents with the costs of quality child care. We also have the early childhood care and education, ECCE, scheme in which 95% of children participate in the year before they commence primary school. That is a major area of policy development and support for social and education equality.

I discussed with members of the committee previously how I would like the ECCE scheme to develop. There is considerable scope for developing it and the Government is committed to maintaining it. I would like it to be developed whereby, for example, we could work more with children with special needs. As a universal programme, it is providing a very important support to children and to their parents. It is also a place where work on the Government's new literacy and numeracy can be done, and there can be joined-up thinking between the Departments of Education and Skills and my Department on that.

Education welfare provision, which comes under subheads E and I, has an allocation of €40 million. To save time I will not go into the detail of that entire subhead. We are committed to breaking the cycle of disadvantage for children who have problems with school attendance, non-school attendance or school refusal. The work done by the education welfare section of the Department follows up those issues.

The Family Support Agency has an allocation of €32 million and operates at community level to support children and their families. Early family support is extremely important and we are committed to early intervention. It makes a difference to children's lives and it can ensure that children do not come into care. We have to intervene to support families at the right time. There is a substantial allocation for that work and a commitment to maintaining it.

The area of youth affairs has an allocation of €60 million to provide non-formal education and developmental opportunities for young people. The focus is particularly on young people between the ages of ten and 21 and on those who are socially or economically disadvantaged. I have already said to the committee that we will be evaluating those programmes and streamlining some of the funding subheads.

Another area that receives funding from the Department is that of adoption. The Adoption Authority receives funding to allow it to do its work. It is an independent statutory body charged with implementing the Adoption Act 2010, which commenced in November 2010 when Ireland's ratified the Hague Convention on the Protection of Children and Co-operation in Respect of Inter-country Adoption.

Vote 43 includes provision for a broad range of functions and programmes which include early intervention projects and a programme of children's research. It is very important that we are doing this research. It is the first time there has been a longitudinal study on Irish children and the kind of data available to us from that will enable to plan our policies and programmes based on more accurate information on the needs of Irish children.

Certainly cross-agency co-operation will be necessary to promote the work of the Department and to give the best service. We are working to establish children's services committees and four pilot committees in Dublin city, south Dublin and Limerick city have been established since 2007 and there are also additional ones. I want to roll out children's services committees across the country. They have a critical role to play at local level in bringing those who provide services for children together.

I have addressed the issue of the children's referendum at the committee previously. If members want to ask me any questions, I would be very happy to reply to them.

I hope my presentation demonstrates the range of policy functions coming under the new Department. The creation of a new Department is a challenging task. We have a major reform programme and we have made significant progress together. The creation of this Department is an opportunity to bring together the agencies and policies in regard to children to enable us to transform the way we plan, design and deliver services for children, young people and families and move on to better inter-agency work.

There is no room for complacency, as we have seen from the Cloyne report this week and from the appalling case in Donegal where Mr. Justice Paul Carney rightly raised questions yesterday as to how this situation could have arisen. I have received a preliminary report on it. The case raises the most serious questions and it demands full answers and full details. I will be asking for a full report. The Minister for Justice and Equality has also asked for a full report from the Garda.

Acting Chairman (Deputy Jerry Buttimer)

With the permission of the members of the committee, I ask the Minister to arrange for a copy of her speech to be e-mailed to the committee to enable us to put it on the Oireachtas committee's website.

Deputy Frances Fitzgerald

Certainly.

Deputy Charlie McConalogue

I thank the Minister for Health, Deputy James Reilly, the Minister for Children and Youth Affairs, Deputy Frances Fitzgerald, and their staff for coming here today to go through this with the committee. With regard to the Minister for Health's presentation and the Vote for the Department of Health, there has been a reduction in health spending from last year. Specifically, there was a reduction of €1 billion in the HSE spend. None of the headings covers the reduction in services we are seeing as a result of that cut. It comes across as administrative but in hospitals it will amount to real cuts in services.

The Minister alluded to the fact that has been in the media that hospitals across the country are running over budget. To the end of May the excessive spending was €170 million. If those hospitals must stick to the budgets allocated at the start of the year, there will be severe cuts in the services available to patients. Most of the health spending goes on staff and fixed costs, which we cannot address over the course of the next six months. I do not know if "discretionary" can be used to describe health treatments but it is elective treatments that will be hit. Ultimately, services to patients are to be affected.

As a result of an approach requiring hospitals to stick to their budgets we will face a very difficult scenario in many hospitals across the country in the second six months of the year. Patients requiring services will not be able to get them. I will give one example of a constituent I met yesterday who is waiting for a hip operation. That person is in severe pain, having been on a waiting list for a year to see a consultant. The person in question got to see a consultant three months ago only to be told it would at least be another year before he could get his hip operation. He is aware that if he could pay up to €8,000 he could have the operation within two months. The man is in severe pain and cannot sleep at night; he cannot wait another year for the operation.

That kind of procedure will be hit by the cuts and restrictions in budgets over the next six months. What can we say to such patients? I know that is only an example of what many people are going through.

Deputy Eric Byrne

That is down to Fianna Fáil.

Deputy Charlie McConalogue

Every one of us will come across similar cases in time. The closest hospital to me is in Letterkenny and it had a budget last year of €103 million. This year that is down to €95 million. Last year the overrun was approximately €4 million, and the issues which caused that still exist. The hospital is expected to keep to €95 million this year, which will lead to drastic cuts in services.

Acting Chairman (Deputy Jerry Buttimer)

We are talking about Estimates now. The Deputy will have an opportunity to discuss specific health matters with representatives of the HSE and the Minister.

Deputy Charlie McConalogue

I accept that but the Estimates will have key effects. I have some other points on non-consultant hospital doctors. We appear to be losing many of these now because they are going abroad. It is inexplicable and unjustifiable that this country pays third level fees to educate doctors to that level only to see many of them head off, although they have their reasons for doing so. When we invest in resources and people, bringing doctors to a certain level of training, it does not add up for us to lose them and have to bring in other personnel. I know the key element will be to reform the system and health service in order to retain talent but we may need to consider some type of requirement on students going through the system for a certain level of service to the health system once qualified if we are to pay for their education. Another option could lead to reimbursement of the cost of the education to the State as part of that package.

The Minister commented on unsafe hospitals. I will not discuss the issue in detail but when a hospital is unsafe, there are two ways to deal with the problem. We can close down the service, as happens in some cases, or the points outlined by HIQA can be addressed so the hospital can be made safe.

I thank the Minister for Children and Youth Affairs, Deputy Fitzgerald, for coming before the committee. Some €3 million had been set aside for the children's referendum in the initial Estimates. As that referendum will not happen until next year, where will that €3 million go? I welcome the updated report on the implementation of the Ryan recommendations, which was laid before the Dáil. Some €24 million has been included in the Estimate to cover the cost of the implementation plan. Is it the Minister's intention to continue to provide that €24 million in following years?

With regard to the Murphy report into Cloyne, which was published last week, what resources, if any, are being included in the Estimates this year to deal with the measures proposed to address the lessons being learned? I am particularly interested in the move from a voluntary code of reporting child abuse to mandatory reporting. The experience internationally has been that when such a practice is adopted, it leads to an increase in reporting and extra demands on the system. I cannot see how that can be done without additional resources but I do not see anything included in the Estimates today. There is €24 million allocated for the Ryan report measures and if we are to properly learn lessons from the Murphy report into Cloyne, we need resources for that as well.

Deputy Caoimhghín Ó Caoláin

I welcome the Minister for Health and the Minister for Children and Youth Affairs. It is the first opportunity we have had as a committee to engage directly with both Ministers on the current state of our health and child care delivery systems, as well as the financing of those systems. It merits some consideration as to whether it is appropriate to take both Ministers together as the formula for the future. I ask people to give this question some consideration as there is so much within the health area that we wish to address that there is always a risk that the focus on children could become secondary. That is a fault line that must be observed and addressed. My preference, even if it creates additional meeting responsibilities on us as a committee, is to take the Ministers separately in future.

Acting Chairman (Deputy Jerry Buttimer)

A new Government was elected earlier this year and a new Department was created. The Department responsible for health was formulating the budget at that stage but it is expected that in future, both Departments will be taken separately, as the Deputy referenced in his remarks.

Deputy Caoimhghín Ó Caoláin

I welcome that and it is a sensible way to proceed for the reasons I explained. We are meeting today in very difficult times, particularly for health care delivery systems. This is not just in acute hospital care but right across the areas of responsibility. There can be no doubt that there are ever-growing difficulties for people seeking access to health care in this State. There are widespread cuts in services and front-line providers of health and child care needs face very difficult times in their respective professional responsibilities.

I will deal with the Revised Estimates as provided to us. I only had receipt of all the detail we must discuss - a significant body of paper - at 4.30 p.m. yesterday evening, and I did not have direct sight of it until this morning because I was involved in another day-long meeting yesterday. These are meant to be constructive observations. At the outset we must give members of the committee a little more time in order to digest all that is involved with Estimates and Revised Estimates. That is vital as we want the best possible analysis and consideration of what is involved, rather than a rushed process. Inviting both Ministers to attend the committee simultaneously, as I pointed out, will lead to an impossible demand on members. I have certainly found it difficult to prepare for this afternoon's engagement with only a small number of hours this morning to do so. There was much reading and preparation to do.

Last week's emergency legislation was passed to prevent a meltdown in the hospital system arising from the crisis involving non-consultant hospital doctor supply within the system. I have no doubt that given the cuts imposed in this year's budget, reflected in these Estimates, and the overall disastrous economic strategy of this Government, we will face further crises in our health services, especially in hospitals, in the months to come.

I will ask a number of questions. The Minister for Health indicated in his own notes that we now have a significant number of doctors from India and Pakistan arriving in the country who will be in a position to fill vacancies and become registered. He indicated that it is envisaged that 30 of these doctors will be registered within a few weeks, with a further 60 registered soon after. He argues that this would leave us in a favourable position compared to the past 18 months.

We have not had an opportunity to engage with the Minister directly on the floor of the Dáil and I have a real concern that this will not be accommodated before the end of this week. Will he indicate if he will come before the Dáil so we can have a proper address and scrutiny of the position applying as of 11 July? No report on the success or otherwise of the recruitment project relating to Indian and Pakistani non-consultant hospital doctors has been given to the Dáil or this committee. The Minister's preamble gives very little information, merely noting that 30 doctors will be registered within a few weeks and 60 to be registered soon after. We were in the business of trying to recruit 450 non-consultant hospital doctors to fill such a number of vacancies-----

Acting Chairman (Deputy Jerry Buttimer)

With respect to the learned Deputy and his experience, we are discussing the Estimates. We are not discussing the hospital doctor issue per se.

Deputy Caoimhghín Ó Caoláin

I am responding to what the Minister has put on the record. This is about funding but it is also about service provision. I would like the Minister to elaborate in that respect and if there are other opportunities to discuss it. Are we confined to an opportunity to address the matter in committee on Thursday or will he come before the Dáil and make a statement on the issue? I will deal specifically with the Estimates, as the Chairman is settling into his new role.

Acting Chairman (Deputy Jerry Buttimer)

We are not there yet.

Deputy Caoimhghín Ó Caoláin

The 2011 budget imposed cuts of €756 million to our health care system. We made the point in committee and repeatedly on the floor of the Dáil that if the Government had refused to make payments to the unguaranteed Anglo Irish Bank bondholders, it would have saved a comparable figure of €770 million. That would have been an infinitely preferable route rather than seeing further cuts in funding the Department and the Health Service Executive, which is entrusted with the delivery of health care needs. I strongly disagree with the Government's position in that respect but that is already well known.

We are discussing the funding of hospitals. I note that on Saturday the Taoiseach blamed the "overspend", as it is described, of €120 million by hospitals on either incompetence or mismanagement by hospital management. I strongly disagree with such referencing, which is grossly unfair and fails to take on board the reality with which front-line providers of services in hospitals, along with management, must contend. It was no surprise that the regional hospital in Limerick was among the number referred to, with in excess of €7 million overspent in the first five months to the end of May, when one takes on board the displacement of patients from Nenagh and Ennis.

The HSE Estimate document was circulated before the meeting. In appendix 2 we see the outturn for 2010 in the National Hospitals Office Services and grants to hospitals was €5.4 billion but the Estimate for 2011 is €5.2 billion. Grants to hospitals and other bodies go from €2.38 billion in 2010 to €2.24 billion 2011. All these cuts are having seriously negative effects on the delivery systems.

The HSE, in response to the so-called overspend, will as an immediate corrective measure pause recruitment of all but critical vacancies in light of the trends in basic pay cuts. The Minister made reference to the embargo on recruitment and we can only ask him to elaborate. He spoke about a reduction of 6% since the introduction of the moratorium on recruitment at the end of March 2009. Will he elaborate on the impact of the 6% reduction with regard to overall numbers employed within the HSE? I would like the percentage broken down as we need assurances, clarity and detail. Will there be an impact on front-line service providers and where will the 6% reduction have an effect across the board?

Acting Chairman (Deputy Jerry Buttimer)

The Deputy has one minute.

Deputy Caoimhghín Ó Caoláin

I am referring to the Minister's address this afternoon. IMPACT has criticised the HSE for not raising the 2011 budget overrun in a meeting with unions last week. There has been a change in the approach this year, as such matters were discussed in previous years. The HSE would previously formulate ways in tandem with the union to cut costs by agreement but it was not addressed in the current engagement. How does the Minister intend to address the issue because it is only by working together and recognising the critical role of unions in addressing overruns and costs that we will see any real and considerable progress.

Time will beat me and I do not want to conclude my contribution without referencing the portfolio of the Minister for Children and Youth Affairs, Deputy Fitzgerald. This is a less than satisfactory opportunity for us. I welcome the establishment of the Department. The clock is ticking and the Chairman is anxious to ring the bell.

I want to ask about after care services and the issue on which we strongly differed regarding the Child Care (Amendment) Bill last week. In the Minister's address to the committee she states:

I am happy to report that work is under way on the development of a national aftercare service in line with the new national aftercare policy developed by the HSE. That work is currently being planned and organised by an aftercare implementation group. Ten additional aftercare worker posts are also now in the process of being filled.

Can we have that information provided against the backdrop of the profile of what is in situ? How does the after care service engage with the identified areas of need, where it is geographically placed and how it is accessed? Is it intended that the ten additional after care worker posts, which do not come under the embargo referred to by the Minister for Health, come under the aegis of the HSE? Can the Minister give us a sense of where the ten additional after care worker posts, with flexible weekend working hours, will be located? I would welcome an elaboration by the Minister.

Deputy Seamus Healy

I welcome the two Ministers to this meeting. At the outset, the Minister for Health made a critical point when placing the Estimates and the health service in the framework of the EU-IMF deal. The implementation of the deal will be detrimental to health services and children's services. There is an alternative and I have said it many times on the floor of the House. There are significantly wealthy people in this country who pay little or no tax. They are not paying their fair share of taxation. A wealth tax should be introduced to ensure they pay their fair share towards the provision of vital services in the areas of health and children.

The Minister said the reduction on last year is €1.35 billion, on top of significant cuts in 2009 and 2010. In those years, cuts of 10-15% were made in the hospital area. The reductions mean there are severe difficulties across health services, in community services and in hospital-based services. In the autumn and winter it will be even more difficult in light of figures issued by the HSE to the effect that there is already an overrun of €170 million. In the current circumstances, and taking the Estimates in the framework of the EU-IMF deal, there will be further bed and unit closures and severe difficulties for people trying to access services in the autumn and winter.

I welcome the Minister's statement that there will be no hospital closures but I hope this extends to not closing units. In my area, there was an announcement that acute psychiatric services will be closed and, as late as last week, two HSE representatives arrived on the ward of a high-support unit in Tipperary Town to announce the unit would be closed before the end of the year. There was no consultation.

The policy pursued by the HSE in respect of hospitals, specialisation and centralisation is flawed. Independent, professional and international studies prove that smaller hospitals provide better quality of care, better access and are more cost effective. That must be borne in mind in respect of the delivery of services, which should be delivered to local people as close as possible to their home areas.

I welcome the establishment of the Department of Children and Youth Affairs. It is a vital Department and it should have been established long before now. It is a major area of responsibility and is a key area for the development of society. The investment in children's services is a cost-saving measure because the downside of not investing in these services is a major cost when children become adults. This may arise in residential care, court services and prison services. Many of the areas mentioned by the Minister, including the youth justice programme and the family support services, are key services. I ask the Minister to carefully consider an extension to the excellent early childhood care and education scheme, which I am involved in. I hope it can be expanded because it is vital for young people in disadvantaged areas. The Minister might also consider the request by Foróige for support for the big brother big sister programmes, which are operated at very little cost and which had positive outcomes.

Acting Chairman (Deputy Jerry Buttimer)

We will now address Vote 39, dealing with health, and subhead A, which deals with salaries, travel, training and development, post and telecommunications, office equipment and external IT services, office premises expenses, consultancy services, value for money and policy reviews.

Deputy Eamonn Maloney

Are we only addressing this?

Acting Chairman (Deputy Jerry Buttimer)

Yes.

Deputy Eamonn Maloney

I will contribute later.

Acting Chairman (Deputy Jerry Buttimer)

Deputy Eric Byrne also indicated he wants to speak. Will you contribute on this subhead or on another?

Deputy Eric Byrne

I need the guidance of the Acting Chairman. I am substituting for Deputy Ciara Conway.

Acting Chairman (Deputy Jerry Buttimer)

We are dealing with Vote 39, which deals with administration.

Deputy Eric Byrne

Perhaps the Acting Chairman can come back to me as I try to brief myself.

Deputy Michael Colreavy

Regarding subhead E3-----

Acting Chairman (Deputy Jerry Buttimer)

We are dealing with subhead A - A for alpha.

Deputy Derek Keating

Are we dealing with each subhead separately?

Acting Chairman (Deputy Jerry Buttimer)

Yes.

Deputy Caoimhghín Ó Caoláin

I think the Acting Chairman is not right. Deputy Colreavy was referring to line E3 which comes under Vote 39. This deals with administration, grants and other services. Is it not permissible to focus on this?

Acting Chairman (Deputy Jerry Buttimer)

Yes, I will allow him in to speak.

Deputy Michael Colreavy

I refer to subhead E.3, the National Treatment Purchase Fund, the special delivery unit and the €85.5 million. The Minister said the special delivery unit will make all the difference in terms of sorting out our hospitals. In these Estimates, it is listed with the National Treatment Purchase Fund which sees a 5% drop in funding this year.

The National Treatment Purchase Fund was a misconception from the very start because it encouraged consultants to do the wrong thing. If I was a consultant and created long waiting lists by reducing activity in my day-to-day work, I would get paid more because patients must wait longer. It is the very antithesis of encouraging people to do the right thing. It was a totally incorrect approach. It would be far better to abolish the wasteful National Treatment Purchase Fund and devote that funding to the direct provision of care in the public system and to manage the throughput of work in the theatres in our hospitals in the public system.

Acting Chairman (Deputy Jerry Buttimer)

I would prefer if we went through each subhead in order rather than jump all over the place. To be fair to members who have been here and have listened attentively, it is important we go through each subhead and allow members to speak on each rather than jump back and forth.

Deputy Caoimhghín Ó Caoláin

I refer to subhead A under Vote 39. A number of things need to be observed. When we look at the change between the provisional outturn in 2010 and the 2011 Estimate, we can see there are increases in a significant number of the subheads - the make-up of administration. First and foremost, travel and subsistence is almost double from €340,000 to €654,000. We see increases in regard to incidental expenses and increases in regard to post and telecommunications services. Very important - and it is worth noting - there are also increases in regard to office premises expenses from €699,000 to €925,000.

The biggest jump of all is in consultancy services and so-called "value for money and policy reviews". This jumps from €735,000 to €2.194 million. How many reviews do we need? The Minister made this very point and so did the Taoiseach only recently in regard to the number of reports and reviews commissioned by the former Government. One would populate a library with so much of it and yet we are trebling the provision in this situation as against the 2010 provisional outturn. That merits an explanation at the very least because it is inordinate. I have always had a great and a healthy suspicion of reports and reviews because they are all intent on a particular purpose once commissioned.

Deputy James Reilly

Perhaps the Acting Chairman might direct me. Questions were asked and issues were raised in the opening statements. Now specific issues have been raised under subhead A. Will I address the issues raised by the-----

Acting Chairman (Deputy Jerry Buttimer)

The Minister can do that in his closing remarks if he would prefer or if it is relevant to subhead A, he can do so now.

Deputy James Reilly

I will do both.

Deputy Eric Byrne

On a point of information, what I really wanted to raise were some of the points raised in the Minister's statement. Now I feel I am restricted to Votes on these subheads. Am I reading it right? For example, I would like to have talked-----

Acting Chairman (Deputy Jerry Buttimer)

I refer to the clár for today's meeting. In the timetable for the passing of the Estimates, a half an hour is allocated to each of the subheads. We will go through each subhead under Votes 39, 40, 41 and 43.

Deputy James Reilly

I will just deal with subhead A. Deputy Colreavy referred to the Estimates for the National Purchase Treatment Fund. This was done last year by the previous Government. In any event, I concur with Deputy Colreavy in that I do not buy into the ideology of the NTPF, as currently construed, buying additional services from private hospitals and that this 10% can only be purchased from public hospitals. It is not something that will continue. The NTPF funding is important to us as a fund we can put to one side to use for specific initiatives around our public hospitals. That is not to say we cannot use some of it in the traditional fashion. For instance, we have heard of a situation in regard to scoliosis treatment in Our Lady's hospital in Crumlin where Mr. Kiely said that with the addition of 0.4 of a whole-time equivalent of a nurse on the ward and starting operations earlier in the day at 6.30 a.m., he could double the number of children being treated for scoliosis. They are the sort of initiatives in which we are interested - in that sort of thinking outside the box and putting key people into places where the output can be increased in a much more effective fashion than hitherto. We are looking at the special delivery unit in the NTPF as the agent of change and at the funding there to be used in a myriad of ways to effect change throughout the system.

I raised the same point as Deputy Ó Caoláin in regard to the outturn. The explanation is simple enough. The Deputy is comparing an outturn for last year with the Estimate for this year. What we should do for the purpose of clarity is compare the Estimate for last year with the Estimate for this year. There is very little difference.

In regard to the other issue to which he referred, I am happy to tell him that when the outturn comes, he will see there is not a major increase. This was provisional funding put aside for reports, in particular in regard to the private health insurance market and how the VHI might be prepared for privatisation and for sale. There were three components to that. The first component was to examine how the dominance of the VHI in the marketplace could be addressed. There were two other components which will not be proceeded with because we are not interested in them and, therefore, those moneys will not be spent.

The money for the first component was originally €338,000 but in any event, we got it reduced to €250,000, with Goodbody winning the contract to examine and recommend how to deal with the VHI's dominance in the market. That is an issue for us because in the past, it has lead to a situation where hospitals, if they do get approval from the VHI, go out of business such is its dominance. If it was not so dominant, that would not be the case. We must examine that but I am happy to say the €250,000 is the limit of it. More than €1 million was put aside for the full reports to be done but that will not happen.

Acting Chairman (Deputy Jerry Buttimer)

We will move on to subhead B, grants to religious bodies, health agencies and drugs initiatives.

Deputy Robert Dowds

Could we get this information earlier the next time because it is quite difficult to get through it? Even if we had received it three days earlier, it would still have been difficult to get through it. As a new Deputy, it is extremely difficult, especially if one has two committee meetings on the same day, as I do. I welcome both Ministers and wish them well in their important and onerous jobs. I very much welcome the fact we now have a Minister with specific responsibility for children.

I wish to raise the question of the drugs initiative. I am a bit concerned about the reduction of 13%. Will that impact on services and if so, in what way?

Deputy James Reilly

On a point of clarification, is the Deputy alluding to the HSE Vote? I beg your pardon, it is the national lottery. There is no reduction.

Deputy Caoimhghín Ó Caoláin

I wanted to refer to the 13% reduction. Will the Minister elaborate on how the external organisations that are entrusted with specific functions but funded by the HSE will be affected by this significant reduction? I understand the national lottery makes a contribution but what is the ratio of national lottery to Department of Health funding? Is there any way the national lottery could make up some of the shortfall in the partial funding by the Department of external organisations?

Deputy Eamonn Maloney

I join in extending a welcome to both Ministers and commend them for their baptism of fire, in particular the Minister for Children and Youth Affairs, Deputy Francis Fitzgerald, who in a short time has done great work which is well illustrated in the contribution she has made.

On the previous item, the Minister confirmed the €34 million contribution to the National Drugs Task Force, which covers so called illegal drugs. That does not take into consideration the cost to the State of the effects of our national drug, alcohol, but it is an interesting figure in terms of the battle against illegal drugs. In the Estimates there is a figure of €68 million for prescribed drug items. We are fond of drugs, for such a small population our spend on drugs is staggering - not only on illegal but prescribed drugs. I note from the Minister's report that our spending on drugs is the highest in Europe. What would German and British taxpayers say if they got their hands on this figure? Is there anyone who is not in the clouds? The taxpayer is being hurt. The increase in the cost of prescribed drugs in the past decade is staggering and is costing €2 billion.

I was more than delighted to hear that given our present economic situation, the Minister will not close any hospital. I am surprised, but delighted. This will be a difficult portfolio but it must be faced.

Deputy Robert Dowds

May I correct something?

Acting Chairman (Deputy Jerry Buttimer)

Yes.

Deputy Robert Dowds

I apologise to the Minister because on looking again at the figures, there is an increase for the drugs initiative.

Deputy Peter Fitzpatrick

I agree with Deputy Maloney. In 1998 we spent €400 million on prescribed drugs and in 2010, we spent €2 billion. The number of items has risen from 32 million to 68 million items. There must be duplication. The way things have moved on in the past number of year, there must be cheaper drugs available. If we want to save money, we must save it in this area.

The increasing number of elderly people who are eligible for a medical care is a major positive. The Minister is doing an outstanding job under very difficult circumstances. Of all the Members of the Dáil he is the right person to look after the Department of Health. I wish him the best of luck.

Deputy Eric Byrne

I am convinced that all members will support the Minister in his attempts to get greater value for money from the wholesale drug suppliers. The cost of drugs in Ireland is outrageous. There is nothing as educational as having personal experience of it. I take a drug called Crestor, for cholesterol, and my prescription was honoured when I was in France. The saving per tablet was 52 cent. Each morning when I took that tiny tablet, I was saving 52 cent on the cost of each tablet in Ireland. People who fall outside the medical card system, and are in the GMS scheme must pay an additional €180 a year on top of what French people spend to fill their prescription. That is outrageous. I wish the Minister and his officials every success in tackling these drug companies who are marketing the drugs at extortionate rates.

Deputy Catherine Byrne

I agree with the members who suggested it would be helpful to be supplied with the information earlier.

I wish to comment briefly on subhead B.3, the allocation of €33.7 million for the drugs strategy. At the bottom of the page, there is provision of €100 million for capital funding to develop facilities in order to meet accommodation. I believe that much of the money that goes to the particular task forces is tied up in providing offices, infrastructure for the drugs task force teams and is not routed back to the community to the users.

The real issue I face every day of the week in my community is that the people who need services on the ground are not getting them because the money is funding office buildings and staff. We need to look at the administration of the national drugs task force, particularly the regional and local drugs task forces and how the funds are allocated. It is very important that we identify the people who really need the funding, the addicts. The money should not be allocated for the provision of buildings in which the drugs task force operates.

Drugs, including hard drugs, are more prevalent than ever before in the community and they are falling into the hands of younger people. The money that is invested in the National Drugs Task Force, particularly into communities, is not reaching the people but is being used to buy offices, setting up websites, provides computers and so on. I want to know how much is going back into the community and helping people who cannot get into programmes. That is where the difficulty lies.

Deputy James Reilly

There is a little mix-up between drugs under this category and drug spend generally, which comes under the HSE Vote, but I will deal with all the queries now because, in fairness, the committee has been indulgent of me and, therefore, I have no problem.

Deputy Catherine Byrne's comments on the task forces are well made and I have been aware of her concerns in this area for some time. I also have concerns about the practices under the drugs initiatives relating to the incentives within the system for the prescribers of methadone and those who care for recipients. It will be controversial but I am prepared to pursue this because it is not correct that people who are on a maintenance dose of methadone for many years should attract the same payment to the physician looking after him or her as somebody who is being stabilised in his or her first year and represents a challenge. That issue will be addressed.

The broader issue raised by the Deputy relates to spending and we are reviewing that. However, of the €33.7 million allocated, €15.33 million had been spent by the Department of Community, Equality and Gaeltacht Affairs and €1 million is capital. The Deputy is correct that we need to review the spend and the task forces in the context of the way they operate and the flow of money and ensure as much money as possible arrives at the doorstep of the drug addict.

Deputy Eric Byrne raised an issue close to my heart, which I alluded to in my opening contribution. IPHA has brought down the cost of drugs by €200 million, which is a considerable quantum, but some generic drugs are still more expensive than the brand leader and they are 20 times more expensive than elsewhere. One does not have to get a boat to the south of France; one could just go to Northern Ireland where they are significantly cheaper. We are examining this issue and we intend to tackle it aggressively. There are huge savings to be made not only for the taxpayer under the GMS but also for those who have to pay for their medicines, as the Deputy rightly pointed out.

This also addresses much of Deputy Fitzpatrick's contribution. Deputy Maloney and he referred to the high number of prescriptions. This needs to be examined. The administrators of the GMS will print information for doctors, in particular, GPs, in order that they can see their prescribing pattern. For example, if a doctor is a high prescriber of painkillers and antibiotics and a low prescriber of drugs for high blood pressure, cholesterol and diabetes, a question must be asked because he or she is treating symptoms rather than diseases. It should be the other way round. They should be low prescribers of painkillers and antibiotics and higher prescribers of disease specific medication. That has been acknowledged as a sign of a quality practice. We need to educate and inform doctors about their prescribing pattern. An initiative will be introduced towards the end of the year to help them recognise what they are doing and perhaps refocus their prescribing habits.

I remind Deputy Maloney that nice and all as our German and French counterparts in Europe are, they are not paying our bills. They are lending us money in order that we can pay our bills and they are charging us handsomely for that.

Deputy Ó Caoláin referred to the use of national lottery money for one-off initiatives. That is what the money is for and we have been allocated €3.3 million by the Department of Public Expenditure and Reform. It is not about giving out €300,000 here and €500,000 there. The intention is to support minor initiatives related to health and local communities and, usually, the amounts awarded range from €5,000 to €50,000. Equally, the HSE is allocated €7.5 million in national lottery funding for the same purpose. It cannot be used as revenue or for repeated support for a service; it can only be used for one-off initiatives.

Deputy Michael Colreavy

I welcome the Minister's comments about thinking outside the box in the context of changing how the National Treatment Purchase Fund works. Significant revenue is expended on premises, although this does not only apply to his Department. Given many vacant premises are being funded by the taxpayer through NAMA, is there not scope for the Government to take them over rent free rather than putting the taxpayer to further expense by occupying another unoccupied building?

Deputy Regina Doherty

I welcome both Ministers. I hope this question is not ill-advised but I am concerned about something the previous Minister said regarding the wild difference between last year's outturn and this year's Estimates. While I accept what she said then, it does not make sense looking at subhead H.

Acting Chairman (Deputy Jerry Buttimer)

We are discussing subhead B.

Deputy Regina Doherty

This is a general question. No subhead covers the difference between the outturn for last year and the Estimates for this year. Vote 40, which deals with the HSE's budget, provides for a reduction under every subhead. However, there is no reduction under most of the subheads in this Vote with many of them subject to a generous increase. While I understand the Estimates last year and this year are similar, in most budgetary practices, one takes the spend from last year, not the Estimate,and bases the following year's budget on that. I am confused but this is my first Estimates meeting. Forgive me if it is a stupid question but it is screaming at me.

Deputy James Reilly

The capital budget under subhead H in the 2010 Estimate was €15 million, the outturn was €10 million and the Estimate for this year is €15 million again because some of it was not spent. I have made the same point as the Deputy and Deputy Ó Caoláin previously. The Vote should outline the outturn and Estimate for 2010 and the Estimate for 2011 together with an explanation for the difference in order that the three lines can be compared. That is what will be done next year. Several members have asked why they did not get the information sooner. On this occasion, the internal changes in the Department with the transfer for the children portfolio and so on have complicated matters but from now on members will get much earlier notice and sight of the documents because that is only fair and right. I acknowledge members have research staff who must examine them as well. It is only proper to have a good debate and I fully support that.

Acting Chairman (Deputy Jerry Buttimer)

We will move on to subhead C.

Deputy Caoimhghín Ó Caoláin

I welcome the additional provision for payments in respect of disablement caused by Thalidomide and I presume a token figure has been provided just to maintain the reference to people damaged by vaccination. There is ongoing provision for Hepatitis C sufferers and the compensation arising therefrom. Subhead D, which is part of other services, refers to statutory and non-statutory inquiries and miscellaneous legal fees and settlements. I do not know whether settlements apply to court proceedings. In the programme for Government, both Fine Gael and the Labour Party made a commitment to carry through on a commitment the Minister himself gave only last January in the precincts of this House to the remaining cohort of victims of Michael Neary at Our Lady of Lourdes Hospital, Drogheda. There were 35 women for whom provision had not been made under the previous redress scheme and whose cases were outstanding and at that time, the Minister, the then Labour Party spokesperson, Deputy Jan O'Sullivan, and I, gave a commitment as the three Opposition health spokespersons that this body of people, namely, those women who had not been provided for under Ms Justice Maureen Harding Clark's recommended redress scheme, would be provided for within the first year of taking office. As this commitment was included in the programme for Government, is the Minister providing for it in the Department's Revised Estimate? He will recall the estimated figure was approximately €3 million and I noticed this is the difference in provision in the subhead to which I have just referred. However, as it may not be the provision about which I hope to hear, the Minister should indicate whether this commitment is being provided for and followed through.

Deputy James Reilly

First, there is no link between the amounts of €3 million; it is pure coincidence. Second, in a more substantive point the Government gave a commitment it would address this issue and will do so but must take legal advice on how best to so do. This is being discussed at present within the Department and the advice of the Attorney General will be sought. However, in deference to natural justice, the commitment remains and will be dealt with. I refer in particular to one case in which the person was due to have the procedure carried out in one week but it was delayed by a week and her 40th birthday intervened. There is no justice in that and this issue must be addressed.

Deputy Caoimhghín Ó Caoláin

I welcome the Minister's comments. As we have addressed this matter together a number of times, he will appreciate the earliest address is the most fair because people are moving on in age. As the age profile is increasing, we wish to see justice for that final group of women.

Deputy James Reilly

While I accept that, I am sure the Deputy opposite also can acknowledge the vast tsunami of difficulties facing health at present, as well as the amount of demands on time to deal with what are huge looming problems. It has not been possible at this early stage to devote the time and energy to this issue I would have wished but it will be done within the first year of Government.

Acting Chairman (Deputy Jerry Buttimer)

As the half hour allocated to the subhead has elapsed, are members happy to move on to Vote 40?

Deputy Caoimhghín Ó Caoláin

Yes.

Acting Chairman (Deputy Jerry Buttimer)

Vote 40 deals with the HSE and I invite questions on subhead A. If that is okay, subhead B deals with the regions, other health agencies and other services.

Deputy Caoimhghín Ó Caoláin

The Chairman has moved on from subhead A and the committee now is dealing with subhead B on HSE regions and other health agencies. These are significant reductions that are signalled right across the regions. I refer to a 4% common reduction and the impact of this will be absolutely vast. People should not be deflected in expressing concern regarding a 4% reduction. Moreover, this is no longer just a reflection on the outturn as the percentages in the final column representing changes in 2011 over 2010 constitute definite reductions in the provision. The Dublin mid-Leinster, Dublin north east, south and west regions all face 4% reductions at a time when there quite clearly is increased demand. The provision was compiled at a time when the population was understood to be 100,000 fewer than it transpired to be post the census taken this year. One must take into account the real position in this regard and these deplorable reductions will have a serious impact on patient care and patient confidence in the health care services. Cuts are the only thing that will come from this and I am strongly opposed to cuts, as they have presented under the Government and its predecessor, which are giving rise to major problems for individuals and entire communities, as well as creating real concern that of itself contributes to health issues.

Deputy James Reilly

There is a 4% reduction in this regard and that is the reality within which the Department must live. This is the budgetary reality within which we must live and everyone in this country is aware of that. It is known there is no more money and the old ways of simply carrying on as before on the assumption that one will be looked after at the end of the year will not pertain any more. There is no cavalry and no one is coming over the hill with more money as it is not there. The Government has inherited an economy that has been fairly well decimated and must do its best to get its balance of payments back on line. It is trying to achieve this in a fair way and is asking people to change the manner in which they work and to be more clever about how they work.

We are analysing systems within hospitals to ascertain how processes can be made more efficient and I assure the Deputy there is lots of room for efficiency. Someone made a comment earlier about management and the Taoiseach's comments thereon but in the case of hospital management, the coincidence of hospitals that are seriously over budget and have poor management is quite extraordinary. For instance, Galway regional hospital has neither a chief operations officer nor a chief financial officer. It has an acting up chief executive officer who is doing a great job but acting up is not quite the same thing as having in place a full management team to deal with these issues.

There is no question or doubt but there is a gross inefficiency in hospitals in respect of how things happen or are delivered. What sort of system allows the highest-paid person in the hospital, namely, the surgeon, to not work because through one reason or other of organisation, either a bed is not available in an intensive care unit, ICU, or a staff nurse is not available in theatre, etc? That pertains to management and organisation and although I am not the greatest fan of private medicine as such - I have no ideological problem with it either - what private entity would allow a situation pertain in which the most expensive element of the operation was left redundant due to inadequate organisation supporting it? It simply would not happen. However, it is happening within our hospitals and happens every single week right across the system. This is what is crucifying us as much as anything else and it must be addressed and will be addressed and changed.

This is not to move away from the harsh reality that there must be budgetary constraint and this is the reality in which we all must live. Had money been the element that would fix the health service, surely to God it would be well fixed by now. Although we have moved from providing €4 billion to health less than ten years ago to providing €14 billion at present, where are we? It is not all about money but is about how we deliver the service, how we work and how we organise and roster ourselves. This issue must be addressed.

Many of the savings that will be made will be achieved through procurement, that is, by getting better value for money through the HSE doing what it should, which, as one of the biggest consumers in the country, is doing better deals. I mentioned earlier the issue of scoliosis implants. The variation in price is between €15,000 and €25,000, which constitutes a huge difference. If we can get the surgeons who do this sort of work to come together, agree on a single implant and then go to the market and procure it, we could save ourselves hundreds of thousands and probably millions of euro in that single area alone. This is just one of many areas in which savings can be made. In addition, apart from that, there will be an initiative from the Government regarding central procurement of resources, such as energy and electricity. This is where savings will be made. The moratorium also is necessary. There has been some reduction in the number of nurses, yet many nurses have been employed. Let me give an example, some 9,000 patients attend an outpatients clinic for diabetes, if 7,500 of them were to be treated by their GPs at 20% of the cost of the clinic, why would the nursing resource remain in the hospital, it should move too. We must be serious about reforming the system, moving care for those suffering chronic illness to the community and, as opposed to paying lip service, we should fund and pay more attention to health promotion and preventive programmes. It has never been politically sexy, as it were, to spend money on a new preventive programme, it is always much nicer to open a new ICU unit or present a new CT scanner, but this is the direction the Government is taking. Having been at an informal meeting of Ministers in Hungary earlier this year, I am happy to say that is the direction the whole of Europe is taking. Everybody realises the demographics are changing, that we will have a greater number of older people, and a higher rate of dependants in society. If we do not change the way we deliver health care, even without this inherited economic disaster, we would still be forced to change. Two years ago we spent the entire PAYE tax take on health care and we could not continue to do that, no society could. We must provide health care in different ways and be aggressive in examining the way we deliver it.

Deputy Caoimhghín Ó Caoláin

It is welcome that the Minister will address management failures. What I find offensive, and I believe it is inaccurate, is to ascribe overruns to "incompetence and mismanagement", to use the Taoiseach's words, which I think was over the top and I still hold that view. It is also important if one is addressing the real costs of health care, that one addresses the piggybacking by private care in our public hospital system. One addresses the situation where not everyone, but a significant number, of consultants are not adhering to their contractual arrangements as to what they must do. Some 300, at least, have had to be written to by hospital management to remind them that they are contractually obliged to carry out a specific percentage performance in the public health care system. That has not been happening. That needs to be addressed as well as consultants' fees. We will hold a referendum to deal with judges' pay but what about consultants' pay? We need more frontline providers of services, including consultants, it does not have to cost more money. There is less money all round, but we need more consultants at the coalface. There are other answers.

Deputy James Reilly

Absolutely. I could respond but I do not want to start a two way conversation. I stand over my comments on the management issue. We are supportive of management. There are people in the system who never had the opportunity to train as managers, they moved up through the administrative grades to become managers and they need support. There are three elements: bringing in outside expertise; training the people we have; and helping those who are in trouble to retrain. That is how it has to be done. In some instances there may be individuals who are not just up to it and other measures will be offered to move to an area where they would be more comfortable or competent.

I am quite prepared to take on the issue around the 80:20 split. I want to make it very clear because some consultants and certain elements think this a consultant bashing exercise. It is not. Out of the 2,400 consultants, very few are serious offenders but there is a small number who are seeing one private patient for every public patient instead of four public patients for every private patient. There are others who, through no fault of their own, may be over the 4:1 ratio because if 50% of the people have private insurance would it be unusual to expect that 50% of the people coming through the hospital system would not be private patients? There is a need to address that issue and it will be addressed. There is very little point in having transparency, which we are getting now, unless there is accountability. There will be accountability and those consultants who are the most serious offenders will be dealt with.

To address the Deputy's final point, we need more senior clinicians, rather than consultants, at the coalface. The non-consultant hospital doctors, NCHD issue which was raised earlier, is a case in point. Why are Irish doctors going abroad? Why can we not attract younger doctors? The reason is that we do not have a clear career path for them, they are not treated with respect and have not been for quite some time. That must change. The special delivery unit, SDU, will change that by bringing in protocols on behaviour regarding one's peers, juniors and patients. I want to see a situation where there is a five or six year training programme, devised by the colleges, and then when one finishes one's specialist registrar training, one is then an associate specialist capable of independent clinical practice and should be employed in our public service to so do and to become a full consultant a few years later, subject to peer review and so on.

Deputy Caoimhghín Ó Caoláin

It cannot happen quickly enough.

Deputy Catherine Byrne

On subhead B6, it would be wrong of me not to comment because as a public representative, I believe we have to climb a mountain and I do not envy the Minister and his officials in that job. Every member of the community is faced with making lifestyle changes.

Under the heading primary, community and continuing care for older people, I wish to address the home-help services. In my constituency, the home-help service is a lifeline to retaining people in the community. I want to stress that if we intend to keep people out of hospital on a long-term basis, we need to look at the way we support families in communities and a big part of supporting people in the community, whether a young child or an elderly person, is to provide the service in the community. One of the most significant services in the community where I live is home help. I understand there is a reduction of €57 million in that service. I ask the Minister to review the home-help service in communities and try to invest in them rather than taking money from them. If we take away these services, I guarantee we will not have enough spaces either in hospitals or nursing homes to deal with the number of people. I know it is a very broad reflection on that subhead, but it is my simple way of describing it.

Deputy Michael Colreavy

I am a little confused. When we considered the estimated expenditure for administration and general management and we pointed out the major increase in some of the figures, we were informed that is not what we expect to spend in 2011, which makes me wonder why we are looking at the figures. I agree with Deputy Catherine Byrne, now that we are down to the cutting edge of the health services, the people who are getting the services. When I see reductions in the provision for home-help services, and a reduction of €80 million in other services for older people, the story has changed because we are being told that these are accurate figures for estimated expenditure in 2011. The home-help service is probably the most undervalued service in the range of services provided by the HSE and it is counterproductive to cut it. What will happen in my area if the home-help service is cut? As sure as night follows day, these people will end up in acute care, residential care, step-down facilities or perhaps all three. From an economic point of view it is counter productive, and from a humanitarian point of view it is wrong.

The home help service should be the last service to be cut. It is doubly wrong to cut services delivered to older people and people with disabilities. I would not support any reduction in these services.

Deputy Caoimhghín Ó Caoláin

Are we dealing with subhead B?

Acting Chairman (Deputy Jerry Buttimer)

Yes.

Deputy Caoimhghín Ó Caoláin

In the Minister's introductory remarks, he indicated there will be an estimated 120,000 additional medical cards. However, the provision for medical card services and community schemes shows an 11% reduction. This warrants some explanation as it is a significant drop of €2.419 billion. This is an accurate reflection of the expected demand given the number of people being forced into unemployment and facing significant reductions in their pay. Despite the very low threshold for qualification for a medical card, more people will certainly qualify. How will the Minister get more from so much less? It seems to be running contrary to the stated expected need. I would like an explanation for this.

Deputy James Reilly

I will deal with the final question first, which is a bit of a habit. The explanation for having 120,000 more medical cards than anticipated while making savings of approximately €400 million is savings in drug costs and fees paid to doctors and pharmacists. This is how it will be achieved. That is how we get more for less. We will have to do more of this elsewhere, and it is the continuing theme of the Government because of the reality we face. We know we can get more out of what we do if we change how we deliver and examine how we resource.

The issue of home help is extremely important-----

Deputy Caoimhghín Ó Caoláin

May I ask-----

Deputy James Reilly

I will deal with the issue of home help and then come back to the Deputy if he has another issue. Deputies Byrne and Colreavy raised the issue of home help. This year, there is €8 million of new money for home help and the same number of home help hours will be provided. Home help is the last service we want to see cut. Other issues are raised and I will ask Mr. Liam Woods to address the committee on where cuts will occur in home help services. Services such as home help are where we want to spend our money and support people. Home is where people want to be and it is most cost-effective for them to be there.

A more general point is raised because during the first two hours of this conversation we spoke about hospitals. However, we need to focus on primary care and community services. We need to focus on keeping people well and intervene and detect illness earlier. We need to keep people with chronic illnesses well and prevent complications so they do not end up in hospital at great cost to the State and, even worse, in great pain and distress. We must ensure that when we move services from the hospital sector back to the community that the resources move with them. This has not happened in the past but it will happen in the future. I have no doubt there will be rows about it and resistance to it but it will happen and the Government is determined that it will happen.

Deputy Caoimhghín Ó Caoláin

The Minister has laid down specific figures on the reduced return for general practitioners operating the GMS. Has he a clear intent on the reduction and what general practitioners will be paid for operating the GMS? Will it be a per capita reduction? Will the Minister specify what will be the impact?

Yesterday, the Minister met the Irish Pharmacy Union, IPU. I welcome the Minister's proposal-----

Acting Chairman (Deputy Jerry Buttimer)

We are dealing with the Estimates.

Deputy Caoimhghín Ó Caoláin

It is within the scope because it is about the delivery of community services. I agree with the Minister there is an enhanced role for pharmacists to play in primary care and in the provision of the flu vaccine, which was signalled in recent days. Will the Minister indicate whether this is on track for the coming winter? Will pharmacists deliver this additional service even though they will be paid less?

Deputy James Reilly

To address the issue of GP fees, there have already been two reductions through the Financial Emergency Measures in the Public Interest Act of approximately 8%.

Deputy Caoimhghín Ó Caoláin

No further cuts are intended.

Deputy James Reilly

That is supposition. That is not the point. The point, if the Deputy will let me finish, is that there is a new contract to be negotiated with a new method of paying GPs and a new range of services to be provided by GPs. It would be a most unwise general who would lay out his battle plan before he goes on the field. The Deputy will forgive me for not being more specific.

Deputy Caoimhghín Ó Caoláin

I understand.

Deputy James Reilly

With regard to the IPU and vaccinations, this is a welcome initiative and will lead to more people being vaccinated. It is better value for the taxpayer and it will keep our people healthy, and this is a hugely important part of what we are about. This goes back to what I stated about not merely paying lip service to prevention but spending money on funding it and ensuring it is done in the most cost-effective fashion, which is as near as home to possible and at the lowest level of complexity. The Royal College of Surgeons has trained 800 pharmacists to deliver vaccinations and we should avail of these services. There will be considerable savings to the taxpayer.

The enhanced role of pharmacists to which the Deputy alluded is something in which we are very interested and when we met them yesterday we discussed it and the Department will engage with them more fully. The GP negotiations are linked with this because if we move towards a community-based health service more focused on prevention and chronic illness care in the community we need to line up all the players available to deliver the service, so co-operation between them is evident. We should not create one contract which precludes another section of health care workers being able to deliver the level of service we want.

With the committee's indulgence I will give one more example. In England, physiotherapy screening was introduced for people referred by their GP to the orthopaedic service. This led to 40% of those patients not needing to see a surgeon as the problem could be dealt with by a physiotherapist. This was reproduced here. These are the types of initiatives that exist to be availed of but physiotherapists, having achieved 550 points in their leaving certificate before studying for four years, cannot get jobs and cannot work independently in the community because they do not have sufficient experience. They end up working in McDonald's or going abroad.

This is the lack of joined-up thinking there has been heretofore. We intend to address this, and the Department and HSE will work with the Minister for Social Protection, Deputy Joan Burton, and that Department to create an intern program to allow physiotherapists take up posts to allow them progress to a point where they can work independently and we can avail of their services in the community where we are screaming out for them.

Deputy Catherine Byrne

I thank the Minister for his explanation on the extra €8 million for home help. Did I hear him state the number of hours would be the same?

Deputy James Reilly

Mr. Liam Woods will address this matter.

Mr. Liam Woods

The service plan of the HSE says that we will deliver the same home help hours as last year plus the €8 million, which has gone out to the services. Subhead B13, which is service developments, includes the additional €8 million. A figure of roughly 12 million hours was contracted in the service plan, so we have contracted to maintain last year's figure and add to it by €8 million.

Acting Chairman (Deputy Jerry Buttimer)

Are there any questions on subhead C? No. Are there any questions on subhead D?

Deputy Caoimhghín Ó Caoláin

If I could have a chance-----

Acting Chairman (Deputy Jerry Buttimer)

Sorry, Deputy Ó Caoláin.

Deputy Caoimhghín Ó Caoláin

The Chairman is on the fast track.

I have a question on subhead C under the heading of buildings and equipment. With regard to mental health and other health facilities funded from the disposal of surplus assets, the previous Minister of State with responsibility for mental health, former Deputy John Moloney, had given a clear commitment that moneys realised from the disposal of properties that are historically within the mental health domain would be ring-fenced for capital projects in accordance with current mental health service needs. Could the Minister reaffirm that this is the Government's position? With regard to buildings in general, will the Minister indicate his intention with regard to the example recently - I think it was in Carlow, and we had an exchange on this on the floor of the Dáil - in which, under the PPP, sorry, I am not sure if the Minister is with me.

Deputy James Reilly

Sorry. The Deputy was asking-----

Deputy Caoimhghín Ó Caoláin

The Minister will recall we had an exchange in the Dáil Chamber recently about the fact that public private partnerships are part of the requirement in the provision of accommodation for primary care facilities. We had an example, in Carlow town, in which the HSE is expending €1,000 per day to house a primary care facility, which comes to €365,000 per annum, when there is an available, idle HSE-owned space within that area. This is wasteful in a big way and is due to the notion that we must have public private partnership arrangements in providing accommodation in the roll-out of primary care facilities. Can the Minister comment on that? He did indicate some concern when this was flagged in a recent parliamentary question. Has he been able to pursue it in the interim? What are his intentions regarding this example of waste?

Deputy James Reilly

Let us deal with the mental health issue first. It is my position that all the funds raised from the sale of psychiatric institutions should be ring-fenced for the provision of further mental health care, in the community or otherwise. With regard to new capital projects that have not begun, the comprehensive spending review of capital projects that is to take place later this year must be a consideration. For my part, however, I can tell the Deputy that the proceeds of all sales of psychiatric institutions will be reinvested in the care of those with psychiatric illnesses and mental health issues.

With regard to the Deputy's example in Carlow, I must comment on his general statement that public private partnership is a hook that we hang on. That is absolutely not the case. We are quite happy if people go ahead and build facilities themselves. That is a model that is often used, with the HSE renting space. There may be areas in which we need to fund it, for example in areas of particular urban or rural deprivation. There may also be areas, such as the Aran Islands, in which, because of the geographical location, it would never be financially viable to build as part of a public private partnership. In such instances we would have to do it ourselves.

Concerns were raised about the situation in Carlow by several Deputies, including Deputy Pat Deering. I have said I will provide information to that Deputy and I will provide it to Deputy Ó Caoláin too. The Department is investigating this further. I am told there were issues with the suitability of the premises in question, which I believe was St. Dympna's Hospital. However, I appreciate the Deputy's concern and I will pursue the issue.

Deputy Catherine Byrne

I offer my apologies, through the Chair, for raising this here, but there does not seem to be anywhere else I can raise this issue on the subject of buildings. If I am wrong, the Chairman can reel me back in. Is that all right?

Under the heading of buildings, equipment and so on, I want to raise the issue of services for older people. The Minister mentioned the fair deal scheme in his opening statement and spoke about how applications are being dealt with more swiftly. I compliment him on the fact that he put a stop to what was going on previously with regard to the €30 million in non-service-related spending. That is important.

In the community in which I live, a new 50-bed unit has been built to provide long-term care services for older people. It was originally proposed, in the regeneration of St. Michael's estate, that we would have a community-based long-term respite care centre for people who lived in the area. The CBS school had at the time been vacated by the Christian Brothers, and on my own initiative I asked them whether they could offer the building to the health board as a community-based facility, which they agreed to. It is finished and ready to go into action and I am delighted it is there. Yesterday I spoke to the community care manager in the area, who told me the unit could not be opened because of the moratorium on recruitment in the health service. However, on the back of the new facility, the care facility at Brú Chaoimhín, which had been in our community in Cork Street since the 19th century was closed. We were promised a 50-bed unit as part of the regeneration project and that the community would have 7% of the beds. It now looks as though the community will not get any beds at all. All of the patients left in Brú Chaoimhín are being transferred to Inchicore, although I do not know when.

I know the Minister cannot be blamed for what happened in the past, but the previous Government said it would provide extra beds in communities to help people stay within their parishes and near their families. Yesterday I asked the HSE about this and received a verbal reply from the area manager, which was that under the fair deal scheme anybody can be placed anywhere in the community; a person does not have to be from Inchicore or Kilmainham to be placed there. I understand that. However, there are many elderly people living in this community who are being asked to go out to Blessington or Crooksling. I was told yesterday that people from Dún Laoghaire or even further away could be placed in the new community care unit in Inchicore. If our aim is to keep people in the communities in which they live, that is what we should do.

I know this is a long way of getting to the question, and it is probably not relevant to this section because it is about money. I need somebody to answer this question and I was told yesterday it could not be answered by anybody in the HSE. Maybe the Minister will have an answer. Will this unit open? When will it open? Will it be just a transfer of the services in Brú Chaoimhín, as was said to me yesterday, to Inchicore? In the regeneration of St. Michael's estate, 7% of the beds in this facility were promised to the community.

Acting Chairman (Deputy Jerry Buttimer)

The Deputy may receive a better answer from the HSE on Thursday.

Deputy Catherine Byrne

I just want to raise it under the heading of buildings because it is important. There is a beautiful building sitting there. What in God's name are we doing? We need to be able to place people in these units. I feel very strongly about this and so does the community where I live. We were promised 7% of the beds and I was told yesterday that the person in the HSE who made the commitment to the St. Michael's estate regeneration board can no longer hold the commitment and it has been changed. It is wrong on the part of the HSE to agree to something and then overturn it. The facility is needed.

We are not getting any extra beds. There were 110 beds in Brookhaven and we are getting 50. I wanted to raise the issue because I did not know where else to do so. I will raise the issue again next week and I think the committee for its time.

Acting Chairman (Deputy Jerry Buttimer)

The Deputy will be welcome to raise that point with the HSE on Thursday.

Deputy James Reilly

I will address the broader issue. The question is tabled for Thursday and I will have an answer for the Deputy. I would like to take the opportunity to address the issue she raised, which is very important.

For most people a nursing home is the last place they want to be. Everybody values their independence and wants to stay at home for as long as possible. It does not matter how nice any institution is, the sense of autonomy that one has when one is in one's own home can never be reproduced in institution. It is very important that when people have to go into a nursing home it is a place that is local, convenient and where one's friends and family can continue to visit, otherwise people are many miles away.

I have referred to a man from Rush who, after much persuasion on the part of his family, agreed to go into a nursing home. He waited for a number of months and then the great news came through that there was a bed for him. Everybody was delighted but the bed was in Portlaoise. It is a wonderful place but it is 50 miles from Rush. The man was being sent away to wither on the vine and die, which was not acceptable to any of us.

I agree with the comments of the Deputy. We would be very cognisant of the fact that people need to have facilities near their communities in order that their friends and families can continue to visit. It is not always possible but in the main it ought to be done.

Acting Chairman (Deputy Jerry Buttimer)

We will deal with subhead D.

Deputy Michael Colreavy

I want an answer to my question on the use of buildings that are already being funded by the taxpayer through NAMA. I realise it is a Government issue but perhaps we could use the lateral thinking to which the Minister referred. Perhaps it should be considered at Government level.

Deputy James Reilly

The Government has discussed this. We are constrained by certain legalities around NAMA which is charged with ensuring that the taxpayer gets a return on these properties. That is not to say that it is completely deaf to the idea of the community gain that can be achieved through particular arrangements.

Sometimes from the HSE's point of view it is not financially viable to do things the way NAMA would like us to. It is not particularly interested in disposing of properties at knockdown prices in today's market. It is concerned with the value of the loans that it has on its books and, from the taxpayer's point of view, that it realises that value. It does not always suit.

I understand the point made by the Deputy. We have identified a number of buildings that we would like to make use of from a health point of view if we could get the right deal from NAMA. We did not succeed with one building but that does not mean that there are not other properties and we will continue to try to see if we can negotiate a deal with NAMA that is favourable and keeps everybody happy.

Deputy Michael Colreavy

I encourage the Minister to point out to NAMA that it does not own these properties. The taxpayers are currently paying for them and will have to incur additional expenditure if we cannot get access to these buildings. It is a case of double jeopardy for taxpayers.

Acting Chairman (Deputy Jerry Buttimer)

That concludes the consideration of Vote 40. We will proceed to Vote 41 - Office of the Minister for Children and Youth Affairs. There are a number of duplications regarding different topics and I ask speakers to confine their comments to them. I thank the Minister and officials for waiting.

Deputy Caoimhghín Ó Caoláin

Is it possible to address the subheads in general?

Acting Chairman (Deputy Jerry Buttimer)

Yes.

Deputy Caoimhghín Ó Caoláin

The clock is moving on. I understand the situation regarding early child care payments. I am shocked at the situation as spelled out here, in terms of the provision under all of the various subheads.

There is a total reduction of 48% across all of the subheads as against the previous Estimate. There is a 41% reduction in the national child care investment programme and a 75% reduction in the early intervention programme for children which is part funded by dormant accounts. We noted that in regard to another situation in the HSE.

Deputy Frances Fitzgerald

I will explain the situation. The Deputy is misinterpreting the information. It refers to five months. This Vote has been retired and has to be taken in conjunction with Vote 43. The Deputy is looking at the five month out turn. As I explained during my introduction, this Vote is being retired. This is the way we were asked to deal with it by the Department of Public Expenditure and Reform as we are transferring the Vote from one Department to another. It is not a reduction.

Deputy Caoimhghín Ó Caoláin

Does this go to the end of the calendar year?

Deputy Frances Fitzgerald

No, it refers to expenditure to the end of May.

Deputy Caoimhghín Ó Caoláin

This refers to the first five months of the year and not the remainder.

Deputy Frances Fitzgerald

No, the Deputy needs to look at Vote 43. These figures only refer to the end of May. It is an accounting procedure, as I explained at the beginning.

Acting Chairman (Deputy Jerry Buttimer)

The Minister referred to it in her opening speech.

Deputy Caoimhghín Ó Caoláin

I appreciate that. I accept the Minister's explanation.

Deputy Frances Fitzgerald

It is expenditure that was incurred under the Vote for the first five months of the year. Therefore, the formal approval of the committee is required. It refers to Vote 43.

Deputy Caoimhghín Ó Caoláin

Vote 43 deals with-----

Acting Chairman (Deputy Jerry Buttimer)

The Minister's speech also referred to the articles for the provision of Estimates.

Deputy Caoimhghín Ó Caoláin

The difficulty here is that we have no comparisons with the new Department vis-à-vis all of the various subheads.

Deputy Frances Fitzgerald

It is difficult. In terms of administration, where there has been an increase, part of that refers to the new staff coming into the Department. Under subhead A that is allowed for in the 2011 Vote 43 Estimate, which refers to salaries, wages and allowances for some of the new staff who have joined the Department from the areas I outlined. I agree with the Deputy that it is difficult because a new Department has been created. There is no comparison.

Deputy Caoimhghín Ó Caoláin

Is the Minister in a position to tell us, under the various subheads, what is the real situation? Under administration no percentage change is noted compared to the previous year. That is taking into account the remainder of the year under the aegis of the new Department. No exercise appears to have been done to flag what changes have actually occurred under the respective subheads.

It is all very well to say it is redundant in terms of Vote 41 and what has gone before but those were the 2011 Estimates. We are being asked to nod this through. I am not sure this is a fair way to present the information for Deputies. We only saw the information this morning and the meeting began at 1.30 p.m. I do not know what sort of resources we would need-----

Deputy Frances Fitzgerald

Vote 41 refers to expenditure that has taken place in the first five months. If we move on to Vote 43 under each of the subheads there is a clear indication of the full Estimates for 2011.

Deputy Caoimhghín Ó Caoláin

There are no comparisons on the specific subheads as formerly applied under the Department of Health and Children. That is critical information.

Deputy Frances Fitzgerald

They are contained in Vote 41.

Deputy Caoimhghín Ó Caoláin

The Minister is saying those only reflect figures for the first five months and yet the percentage change is not over a five-month period.

Deputy Frances Fitzgerald

This is inevitable, to some degree, because we have taken functions from four different Departments which are now included in the Estimates for the new Department.

Deputy Caoimhghín Ó Caoláin

I find this totally unsatisfactory. I believe the people responsible for the preparation of this information, with respect, have had any amount of time to prepare it. It is not good enough just to present us with gobbledegook which is what it amounts to. Within a couple of hours of this meeting commencing was the time available to any of the members to go through the information. I find it unacceptable to proceed to deal with this when we have already dealt with Votes 39 and 40. Is the 41% reduction over five months as against a 12-month provision or a 12-month Estimate in the previous year? The Minister's commentary does not adequately-----

Deputy Frances Fitzgerald

There are comparisons in a number of cases. I draw the Deputy's attention to Vote 43 and to the footnotes. For example, there is a full comparison under subhead E regarding the school completion programme. I accept it is not there in all of them for the reasons I have outlined.

Deputy Caoimhghín Ó Caoláin

The school completion programme-----

Deputy Frances Fitzgerald

It is complicated because where it is not there it is explained which Vote it is under. As I said already, some of the functions have not yet transferred so some of the allocation for the Department remains under the health Vote and some remains under the justice Vote because certain orders for transfer of functions still remain to be processed. It is a complex situation from an accounting point of view but it will be different next year. As the Chairman said and I explained earlier, we will be examining the Department separately and all functions will have transferred at that point. From an accounting point of view and from a presentation point of view the comparatives will be clearer. In so far as possible, we have some comparatives available and I have explained the reasons the others are not available.

Deputy Caoimhghín Ó Caoláin

The Minister stated in her preamble to the discussion that it is proposed that Vote 43 will have a total allocation in 2011 of €221,863,000. What I wish to ask and what is not contained in the document nor in the figures presented to the committee, is the situation that applied previously across all of the respective subheads, to have an understanding of the reduction in provision. I would prefer to see none at all. We need to have an understanding of where there is likely to be contraction of provision under the new Department as against what applied in the previous year under the Department of Health and Children. If this is not within the gift of the Minister and her colleagues here this evening, I record my disappointment and there is no point in pursuing the matter further. The information is not there. I would have liked to know precisely what the comparative figures are under the national child care investment programme, for instance, between 2010 and 2011. That would not have been an unreasonable expectation, I believe.

Deputy Frances Fitzgerald

I wish to make the point that there is no contraction across the subheads. The Deputy's point is that from a presentation point of view he would have preferred to have seen it more clearly but there is no contraction, for example, on the ECCE programme, the programme just mentioned by the Deputy.

Deputy Caoimhghín Ó Caoláin

Then I welcome that information at least.

Deputy Frances Fitzgerald

There is no contraction on any of the subheads.

Acting Chairman (Deputy Jerry Buttimer)

I understand the Deputy's point. As I said in my remarks, it is the intention to hold separate Estimates. The footnote is also contained in it.

Deputy Frances Fitzgerald

If I may make a point. I refer Deputy Ó Caoláin to the briefing note that was circulated to members. It contains a reply to the questions he raised. With regard to subhead B4 and the ECCE preschool year programme, the figures for last year, 2010, are clearly shown as is the full Estimate for this year. Information is provided in the briefing notes for quite a number of cases. The comparisons, in so far as we have been able to provide them, are available.

Deputy Catherine Byrne

I have two comments and I hope they are to do with this Vote 41. I am pleased to see the youth grant-in-aid is still available for the Girls' Friendly Society and the other organisations mentioned. Sometimes many small voluntary groups such as this miss out on funding. I compliment the Minister and her staff. I am delighted we have a Minister for Children and Youth Affairs and a separate Department to look after children. I agree with Deputy Ó Caoláin when he suggested that both Ministers would attend separately at meetings of the committee as we spent a lot of time on the other Votes.

I have two questions for the Minister, one of which I may have raised on a previous occasion. I have just heard about the early child care payment. I thought this had been abolished in 2009. Forgive me if I am a fool but I cannot understand why we still need money to be paid into this scheme in 2011 if it was abolished in 2009. I understand somewhat the system of payment in arrears but for most people this scheme was discontinued yet €1 million is being sought to finish off payments. I do not understand it.

My second question is on a topic I raised with the Minister previously, namely, the preschool programme. I welcome the €166 million allocated to this programme as it is an essential programme. I have been listening to people who work in and who use community creches and I ask the Department to look again at the regulations. Children are being excluded from the programme depending on date of birth. In some cases, the date of birth can invalidate a child's inclusion in the programme for the sake of three or four days. This is very wrong and the rule needs to be examined. I welcome the funding for the programme but there is a hiccup that needs to be sorted out. As I said at the last meeting, some local community playschools have been forced to close because they do not have a sufficient number of children in the relevant age groups.

I have a question relevant to youth affairs. I think the Minister is aware of my views in this regard. I welcome the funding of €60 million but I have a real problem regarding the provision of the services. Is there a listing available of the non-formal education and development opportunities for young people? Who decides which people are to be involved in these developmental opportunities? I notice that many young people are not informed as to what services are available for them and how they might apply for these development opportunities programmes. Many youth work programmes in communities are missing certain age groups.

Deputy Frances Fitzgerald

I will get that information for the Deputy. On the question as to provision in subhead B for the early child care payment which was abolished at the end of 2009, the Deputy has hinted at the reason which is that the ECS was paid in arrears to parents. In addition, in 2010, residual payments arise where cases have been under consideration or are on appeal. As a result, almost €11 million of these payments arose in 2010 and €1 million are expected to arise in 2011, which equates to 5% of the 2009 payment rate. This is the last year in which it will be in the Estimate. I take the Deputy's point about the ECCE scheme. A number of people have raised this issue and I have looked at it very carefully. The matter has been referred to the Ombudsman who has supported the decisions of the Department. I understand the frustration of parents when their child is outside of the dates in terms of the scheme. There is a period of 17 months allowed. The problem here is in terms of creating a precedent and the number of cases that would arise on foot of that. I know that each parent wants their child to participate in the scheme. In a case where it is a question of a number of days involved, we have had to decide on a particular period. It is rather long - some 17 months. The ombudsman has examined it and supported the approach we are taking. If the ECCE scheme was of two years duration, this would not arise. Certainly, I would like to see that happen but that would involve financial implications. As the Minister, Deputy Reilly, said in regard to his Department, given the economic situation we have inherited, it is very difficult to develop the programmes in the way we would like. That certainly would be one way of dealing with this issue. In the meantime we have this window of opportunity of 17 months and, unfortunately, some children will be outside it by a couple of days.

Deputy Catherine Byrne

I appreciate it is a difficult situation and it is related to funding. When some children in a community can get access to a free child care space but others cannot because they were born on a certain day in a certain month in an interim period, the scheme is not what it says on the tin. This free child care scheme should be available to every child and not only for children of an age that fall within certain dates in terms of the scheme. I do not agree with the Ombudsman on that.

Deputy Frances Fitzgerald

They can avail of the ECCE year the following year but sometimes parents want to start their children at school very early at four years of age. Parents can avail of the scheme for the children the following year if they so choose.

Deputy Catherine Byrne

I understand that.

Deputy Frances Fitzgerald

Parents may make the decision not to avail of it in order to start their child at school at the age of four or five but the scheme is available to everyone and 95% of parents take it up.

Deputy Catherine Byrne

I want to stress again that the scheme is not working in the community as it says on the tin. I want to emphasise that point to the Minister.

Deputy Caoimhghín Ó Caoláin

I seek further clarification on a matter because it is very important. The Minister referred to the briefing note on Vote 43. On the second page after the opening comment the subhead analysis is given. All we are given is the provisional outturn for 2010 and then the 2011 Estimate allocation is given. Is that for the year, the remainder of the year, or for the first five months because if it is one or other of those, that should be indicated? If it is for 2011, as against 2010, I do not have an Estimate for the outturn for health. This is not the way to do business. There is a clear difference between what is shown under the ECCE scheme and under the national child care investment programme. Will the Minister take a further shot at explaining it to me? I apologise if the explanation is flying past me.

Deputy Frances Fitzgerald

The Deputy must refer to the Estimates and the footnotes to get the information he requires. As one goes into each subhead and notes how the subheads are laid out and the briefing, the information is there.

I take the Deputy's point in this respect. The information is in the footnote, it is not in the subhead analysis but as the Deputy goes further into the brief for each subhead, the information is there.

Deputy Caoimhghín Ó Caoláin

The time we were given to peruse all of this was totally inadequate. Given the importance of it and the establishment of a new Department, it is most regrettable. It is an unfortunate start to proper scrutiny which is our role and function as Opposition voices. It is most regrettable.

Deputy Frances Fitzgerald

Government accounting demands that this is the way it is done. It is not something peculiar to the Department of Children and Youth Affairs. This is the case with the establishment of any new Department. The same is the case with the establishment of the Department of Public Expenditure and Reform. We are conforming to Government accounting in this regard.

Deputy Caoimhghín Ó Caoláin

The conforming that I require is not the methodology employed, it is to have the opportunity to properly question what is before me. I could have done that, rather than depending on this opportunity this afternoon, in preparing for this engagement. I rest my case.

Acting Chairman (Deputy Jerry Buttimer)

The Deputy's points are well made but to be fair to the Minister, given the restructuring of the Departments and the delay in producing the Revised Estimates, the Minister has come here and has been here previously to answer questions. The Deputy's point regarding information was well made.

Deputy Catherine Byrne

On a housekeeping matter, when Department officials come before the committee in future, would it be possible to have their names displayed? A sign could be displayed indicating their names. That was done at previous meetings and it was helpful.

Acting Chairman (Deputy Jerry Buttimer)

They do have signs indicating their names.

Deputy Catherine Byrne

We did not see them. They used to be displayed on the front of the desks.

Acting Chairman (Deputy Jerry Buttimer)

It is not the norm to have officials' names displayed when Ministers are present. For the information of the members, the officials present are: Michael Scanlan, Secretary General at the Department of Health; Liam Woods from the HSE; Jim Breslin, Secretary General of the Department of Children and Youth Affairs; and Moira O'Mara, principal officer in that Department.

Deputy Frances Fitzgerald

I point out that members cannot vote for the same money on different Estimates. That is why this is laid out the way it is.

Acting Chairman (Deputy Jerry Buttimer)

We will convey Deputy Ó Caoláin's points to the Departments.

Deputy James Reilly

I am conscious that there are only 5 minutes remaining and I have not addressed the opening statement or questions raised by Deputy McConalogue. It is not that I am avoiding them.

Acting Chairman (Deputy Jerry Buttimer)

We will conclude on the Estimates for the Department of Children and Youth Affairs first. Have members any further comments or questions for the Minister because we have jumped back and forth on issues and I did not hold people to account in terms of sections. Are members happy to conclude Votes 41 and 43?

Deputy Caoimhghín Ó Caoláin

What does "conclude" mean in this respect? Is the Acting Chairman not going to put the question on each of these to the committee?

Acting Chairman (Deputy Jerry Buttimer)

I understand no vote is to be taken. Am I correct on that?

Deputy Frances Fitzgerald

That is correct.

Acting Chairman (Deputy Jerry Buttimer)

Yes.

Deputy Caoimhghín Ó Caoláin

The Acting Chairman might give the reason for that.

Acting Chairman (Deputy Jerry Buttimer)

The committee cannot recommend or make an increase or a decrease in the Estimates and we must send a message to the Dáil. That is what I have been informed.

Deputy Caoimhghín Ó Caoláin

We cannot-----

Acting Chairman (Deputy Jerry Buttimer)

This is only a consideration of the Estimates.

Deputy Caoimhghín Ó Caoláin

Therefore, the use of the "vote" does not translate into a vótail here?

Acting Chairman (Deputy Jerry Buttimer)

The Estimates were voted in the budget and we are having a further review or consideration of them now. I take the Deputy's point.

Deputy Caoimhghín Ó Caoláin

That is fine. The Minister, Deputy Reilly, might respond to the opening comments made.

Acting Chairman (Deputy Jerry Buttimer)

As the Deputy is the only Opposition member present, does he wish to make any concluding remarks?

Deputy Caoimhghín Ó Caoláin

I thank the Minister for a number of points he made. It is important to recognise that Opposition voices do not choose to be opponents of everything. I indicated where I believe the Minister is most certainly pointing in the right direction. There are matters on which we will disagree. I wish him good luck with what he is undertaking in a number of areas and I strongly disagree with him on some areas. I would not have supported votes on the Estimates had they been allowed. I will not repeat what I have said. We will have the opportunity to deal with these again. I hope the Minister will clarify the situation in regard to the NCHDs, as I am anxious to know about that. Does he intend to have this matter addressed on the floor of the Dáil, as the Taoiseach indicated last week? That is on the record. With business concluding on Thursday, there is very little time left.

I look forward to having a more informed opportunity to discuss the Estimates with the Minister for Children next year when the figures will be more easily followed.

Acting Chairman (Deputy Jerry Buttimer)

I note Deputy Healy is indicating he does not wish to comment further and there is no Fianna Fáil spokesperson present, therefore, I call the Minister, Deputy Reilly.

Deputy James Reilly

I wish to respond to Deputy McConalogue's earlier comments. He said hospitals are running over budget and if they stick to their budgets, there will be cuts. The reality is that there is a number of elements to this. First, the budgets they were given were Fianna Fail-led Government budgets and, second, it does not have to be that way. They signed up to a service level agreement and to a budget and they are duty bound to keep to their budget and to keep to the service level agreement to which they signed up. They need to focus more on day cases and on increasing efficiency. For example, 39% of one orthopaedic hospital's patients are admitted on the day of surgery. The international standard in this regard is 75%.

Deputy McConalogue referred to a constituent of his who is awaiting a hip replacement and who is in severe pain. A new initiative is in place in respect of orthopaedic surgery. This is actually quite similar to our system whereby the money follows the patient it is based on the principle that if hospitals do not deliver the number of hip replacements they have committed to delivering, the relevant funding will be withdrawn and given to another hospital in order that additional procedures may be performed there.

There is a great deal of waste and inefficiency and it will not be dealt with through the allocation of more money. If money were the answer, this problem would have been dealt with long before now. As already stated, the necessary reforms have been introduced. However, even with these reforms, our current financial position and the expected increase in our population mean that we are going to be faced with a serious challenge. I am not trying to minimise the seriousness of this matter.

I have already addressed the fact that the subject of NCHDs relates to the career path they are expected to follow, their working hours, the teaching they require and the need for them to be treated with respect. Reference was made to indenture. It costs approximately €150,000 to train a medical student to become a doctor. However, it costs almost €1 million to train a medical student to become a fully qualified specialist. If we are going to have indenture, we should not limit our focus to the NCHDs who are emerging from medical schools. I am of the view that it is far better to use the carrot rather than the stick. If we give people a clear career path, treat them with respect, ensure they have proper working hours and provide them with proper teaching, then we will not encounter the problems that arose in the past.

Deputy McConalogue referred to HIQA and stated that there are two options open to us in respect of hospitals that are unsafe, namely, that we either fix the problem or close down the service. We are of a mind to fix the problems that exist. However, sometimes it is not possible to fix a specific service if the throughput is particularly low. As a result, the service must be modified and changed.

I have already acknowledged Deputy Ó Caoláin's request that members be given early sight of the relevant documentation for meetings of this nature. That will certainly happen in respect of next year's Estimates and the information provided will be laid out much more clearly. A discussion took place at Cabinet earlier today in the context of making budgets across the board more comprehensible.

I reject utterly the Deputy's claim that there was going to be a meltdown in respect of NCHDs. It might have appeared that way but no meltdown occurred. I accept that a serious difficulty arose in respect of NCHDs but this has been addressed. As stated earlier, it will continue to be addressed on an ongoing basis and there will be a supply of doctors available in order that we will not be obliged to depend on agency doctors and pay through the nose for their services. We could save approximately €10 million in this regard. In the context of engaging in a debate on this matter in the Dáil, there is no time available for it on today's schedule and tomorrow I am due to attend a meeting of the North-South Ministerial Council. I am due to come before the joint committee for a three-hour session on Thursday next. I humbly suggest that three hours will be more than adequate for the purposes of debating and asking questions about the various issues. I can reply to any questions I have not answered today - including those relating to NCHDs and other matters - at Thursday's meeting.

Mr. Woods will deal with the impact of the 6% reduction in numbers since the introduction of the moratorium on recruitment on the HSE. He will also comment on why the matter relating to the unions, and the apparent breakdown, was not dealt with in quite the way Deputy Ó Caoláin might have anticipated.

In respect of what Deputy Seamus Healy said, there is no doubt that the economy is having a huge effect on people's health. When people are fully employed, there is less depression, less stress and fewer medical conditions such as ulcers, heart attacks, strokes, etc. All the statistics show that, as a group, the unemployed have worse health outcomes than those who are employed. Unfortunately, we must continue to work within the parameters of the deal the previous Government reached with the EU and the IMF. I assure the Deputy that we are absolutely committed to achieving efficiencies and bringing about reform.

I will ask Mr. Woods to comment on the issue relating to the unions to which Deputy Ó Caoláin referred.

Mr. Liam Woods

We frequently meet representatives from 13 unions at the health service national joint council. I missed the most recent meeting last week because I was before the Committee of Public Accounts. We have a very comprehensive engagement with the unions and we share all our performance information with them at a high level. We discuss matters with them quite thoroughly and I was, therefore, surprised to hear it stated that any kind of breakdown had occurred because the relevant information is freely available to the unions. Typically, we are in contact with the unions after our board meeting. The most recent of these occurred on Thursday last. We have a process and it does work. We are quite interactive with the unions in the context of the information we share.

Acting Chairman (Deputy Jerry Buttimer)

I thank Mr. Woods and call the Minister for Children and Youth Affairs, Deputy Fitzgerald.

Deputy Frances Fitzgerald

I thank members for their interest in respect of matters relating to my portfolio and for the questions they posed. Deputy McConalogue made a number of points in respect of the implementation of policy, particularly in the context of the Ryan and Cloyne reports. It has been the policy of every political party and of all Governments since 1999 to place the Children First guidelines on a statutory footing. That is what we will proceed to do. It is important to focus on the national implementation plan and that is what the director of child and family services in the HSE has been doing. I am pleased to inform the committee that training courses will be offered in respect of the implementation plan. All frontline staff will be invited to attend seminars and training courses in September in respect of Children First: New Guidance for the Protection and Welfare of Children. The HSE has made provision for this in both its Estimates and its plans. It is important now to consider the standards that exist and the implementation and monitoring relating thereto in order to ensure that there is consistency of practice throughout the country. Such consistency will ensure that the statistics we receive in respect of child protection are accurate and that they reflect the position as it obtains in different parts of the country. That is extremely important.

Deputy Ó Caoláin inquired about aftercare services. At present, some 55 people are employed in the area of aftercare services. As already stated, there is a plan in place to recruit ten more. I will obtain additional details for the Deputy in respect of where those after-care professionals are currently based. Obviously, they would be focusing their efforts on young people who have been in residential care as opposed to those who have been in foster care. The needs of those who have been in residential care are generally greater than those of people who have been the subject of ongoing fostering arrangements. I will communicate further with the Deputy in respect of that matter.

Deputy Catherine Byrne inquired about the ECCE scheme. We will be focusing on some of the issues relating to the ongoing improvement of this scheme. I refer, for example, to the qualifications of preschool leaders and the training available to them and bedding down the Aistear and Síolta frameworks for early learning, which relate to standards and support for workers in the front line.

Deputy Seamus Healy referred to the importance of early intervention. I am of the view that we must engage in a closer consideration of the economics of early intervention. The Deputy is correct that early intervention leads to great savings with regard to the costs that can accrue at a later date in the context of residential care and the demands on services. Much work is being done throughout the country with regard to evaluating what is happening in the area of early intervention and discovering what the research reveals in respect of what actually works. I look forward to discussing that matter further with the committee.

Deputy James Reilly

I do not want to be accused of trying to get the last word in. I would always leave that to the Acting Chairman. However, I wish to thank members of the committee for the courtesy they have shown me today. I also thank the officials from the Department and the HSE who accompanied me. I wish the Acting Chairman well in his new role as Chairman of the joint committee.

Acting Chairman (Deputy Jerry Buttimer)

I am not there yet.

Deputy James Reilly

The Acting Chairman is nearly there. I hope this has been the first of many meetings to be chaired by the Acting Chairman.

Acting Chairman (Deputy Jerry Buttimer)

I thank the Minister. Perhaps the Minister for Children and Youth Affairs, Deputy Fitzgerald, will give consideration to the heads of the Bill to which reference was made earlier being submitted to the committee.

Deputy Frances Fitzgerald

I will do so. In the context of getting the last word in, I wish to state that my Department supplied all of the relevant material in line with the timeframe provided.

Acting Chairman (Deputy Jerry Buttimer)

On behalf of the select committee I wish to thank the Minister for Children and Youth Affairs, Deputy Fitzgerald, the Minister for Health, Deputy Reilly, and the staff and officials from the Departments and the HSE for coming before us. I also thank members for attending and for taking a cross-party approach to dealing with these proceedings. I particularly wish to thank Deputy Ó Caoláin for staying the course on behalf of the Opposition.