Brian Stanley (Laois-Offaly, Sinn Fein)
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I welcome everyone to the meeting. No apologies have been received. Please note that in order to limit the risk of spreading Covid-19, the service encourages all members, visitors and witnesses to continue to wear face masks when moving around the campus or when in close proximity to others, be respectful of other people's physical space and adhere to public health advice.

Members of the committee attending remotely must continue to do so from within the precincts of the Parliament. This is due to the constitutional requirement that to participate in public meetings, members must be physically present within the confines of Leinster House. The Comptroller and Auditor General, Mr. Seamus McCarthy, is a permanent witness to the committee. He is accompanied by Mr. John Crean, deputy director of audit, from the Office of the Comptroller and Auditor General.

This morning we are engaging with officials from the Department of Health and the Health Service Executive, HSE, in resuming examination of the following matters. Those are the 2020 appropriation accounts, Vote 38 - Health, and the HSE's financial statements for 2020. Both organisations have been advised in advance that the committee may also wish to examine the following matters that arise mainly from reports in the public domain. They are redeployment of HSE nursing home staff and value for money; the temporary assistance payment scheme for nursing homes; oversight and governance by the Department of HSE expenditure, including supplementary budgets; HSE recruitment targets, budgeting, delivery and departmental oversight; consultant salary scales; departmental oversight of Exchequer funding carried forward by the HSE; HSE treasury management; and requests for additional funding for mental health services and subsequent delivery.

We are joined in the committee room by the following officials from the Department of Health, Mr. Robert Watt, Secretary General, Mr. John O'Grady, principal officer, and Mr. Kevin Colman, principal officer. From the HSE we are joined by Mr. Paul Reid, chief executive officer, Ms Anne O’Connor, chief operations officer, Mr. Stephen Mulvany, chief financial officer, and Mr. Liam Woods, national director of acute operations.

We are also joined remotely from within the precincts of Leinster House by the following officials from the Department, Ms Fiona Larthwell, principal officer, and Mr. Seamus Hempenstall, principal officer. From the HSE, we are also joined by Ms Mairéad Dolan, assistant chief financial officer, and Ms Anne Marie Hoey, national director, human resources. Finally, from the health Vote section at the Department of Public Expenditure and Reform, we are joined by Mr. Daniel O'Callaghan and Mr. Eoin Dormer.

As usual, I remind all those in attendance to ensure mobile phones are on silent mode or switched off. Before we start, I will explain some limitations to parliamentary privilege and the practice of the Houses as regards reference witnesses may make to other persons in evidence. As they are within the precincts of Leinster House, witnesses are protected by absolute privilege in respect of the presentation made to the committee. This means witnesses have an absolute defence against any defamation action for anything they say at the meeting. However, witnesses are expected not to abuse this privilege and it is my duty as Cathaoirleach to ensure this privilege is not abused. Therefore, if the statements are potentially defamatory of an identifiable person or entity, witnesses will be directed to discontinue the remarks. It is imperative they comply with any such direction.

Members are reminded of the provisions within Standing Order 218 that the committee shall refrain from inquiring into the merits of a policy or policies of the Government, or a Minister of the Government or the merits of the objectives of such policies. Members are also reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

The Comptroller and Auditor General, Mr. Seamus McCarthy, delivered his opening statements on the HSE's financial statements and the Department's Appropriation Accounts last September and December respectively. These were circulated to the committee before this meeting. Unless the Comptroller and Auditor General wishes to address the accounts, we will move straight to Mr. Watt's opening statement.

Mr. Seamus McCarthy:

I have nothing further to add.

Mr. Robert Watt:

Good morning. I am very pleased to be here today to deal with the 2020 annual report, the appropriation accounts and the specific issues raised by the committee, as articulated. The Chairman mentioned the colleagues from the Department who are with me. Ms Louise McGirr cannot be here as she is at the Labour Court and the Workplace Relations Commission dealing with various industrial relations matters. She sends her apologies.

I have previously set out to this committee the main points of the 2020 accounts. I will not go through that again and it is already on the record. I know the committee has asked for information on the governance and oversight role of the Department. We have provided briefing detail on this and I look forward to discussing these issues. It would be helpful at this stage if I set out broadly how the Department conducts its oversight role in respect of our colleagues in the HSE.

As well as providing leadership and policy direction for the health sector, the Department has a key role in governance and performance oversight in the delivery of health and social services. The oversight arrangements for State agencies, including the HSE, are set out in the 2016 code of practice for the governance of State bodies. Reflecting the requirements in the code, the starting point for accountability between the Minister and the HSE is our oversight agreement. This written statement between the Minister for Health and the HSE sets out the terms of the relationship between us and the respective responsibilities of each party.

The Department conducts its oversight role through our Department of Health-HSE performance engagement model and I have provided the committee with more detailed briefing on how the model works in practice. Our oversight model is operational and working well. A key area of focus of our performance engagement model is on the financial performance of the HSE. I know the committee has a specific interest in the financial oversight role of the Department.

On the question of Exchequer funding for health expenditure, the Department of Health co-ordinates the Estimates process for all voted expenditure within current and capital subheads of the health Vote. This includes expenditure by the HSE and other funded agencies, as well as the requirements of the Department of Health itself. The Department works closely with the HSE to determine the level of new services and the associated levels of funding as part of the Estimates process. Based on this, the Minister negotiates a settlement, which is ultimately voted upon by the Oireachtas. This provides the basis of HSE's national service plan, which is submitted to the Minister for approval. The key performance indicators and targets set in the national service plan and the associated expenditure are then monitored by the Department during the year.

On the question of HSE financial performance, the Department is conducting its oversight role on a near daily basis throughout the year, both in a structured way and through more collaborative and informal channels. We have a formal detailed engagement between the Department and the HSE monthly, informed by a suite of reports to assess financial performance against targets and to identify any actions required. Where additional expenditure is incurred outside of the service plan process, such as during the Covid-19 pandemic, we have specific and detailed sanctioning and monitoring arrangements to ensure additional funding is required and that it is spent as intended. The Department of Public Expenditure and Reform also plays a significant role in monitoring financial performance through the health budget oversight group, which meets monthly.

There are strong oversight and governance systems in place to manage expenditure in the health sector throughout the budgetary cycle. Of course, as part of normal business in the Department of Health, we continuously seek to strengthen and improve the insight we have on HSE financial performance. It is widely understood that the current financial systems within the HSE need to be modernised. Delivering a new integrated financial management system, which will give better information on financial performance, is a very high priority for the HSE. Although this project will take several years to fully implement, new reporting capabilities have been introduced by the HSE in the interim, for example relating to Covid-19 expenditure and its working capital position.

In addition, the Department will address recommendations from the Parliamentary Budget Office and the OECD to restructure the health Vote to move to a programme budgeting model from 2024. This will support the implementation of regional health areas, RHAs.

I assure the committee that my Department continuously works with the HSE and other key stakeholders to improve the availability of information and data on financial and non-financial performance. This is a key focus of our day-to-day business in the Department and will be centre stage as we design and implement the new RHAs. The introduction of the RHAs gives us the opportunity to reform the way in which we fund the health service, including a pathway to implement population-based funding and multi-annual budgeting.

I look forward to working with and engaging with the committee on this.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I thank Mr. Watt. I welcome Mr. Reid back to the committee and he has five minutes.

Mr. Paul Reid:

I welcome again the members. I thank the Chairperson and members for the invitation. The Chairperson has introduced my colleagues so I will not do that again. He has also referenced a number of papers that we have submitted in advance so I will confine my remarks to a few key areas.

First, there is the annual financial statements 2020 and the financial outturn. The Covid-19 pandemic placed significant pressure on funding and expenditure during 2020. The HSE's overall reported income for 2020 is just over €20.2 billion and includes a once-off net additional funding allocation of €2.3 billion, of which just over €2.1 billion was in respect of 2020 Covid-19 costs with the remaining €200 million allocated to winter plan funding. The HSE's annual financial statements for 2020 record a final audited revenue income and expenditure surplus of just over €200 million.

Next is the annual financial statements 2021 and financial outturn. The HSE's 2021 annual financial statements were prepared and submitted in line with the required timelines to the Comptroller and Auditor General for audit. I understand that the audit process is nearing finalisation and is expected to be complete around the end of May in time for inclusion in the published 2021 HSE annual report. Subject to the finalisation of the audit, it is expected that the 2021 annual financial statements will record a revenue income and expenditure deficit of about €195 million. The deficit is entirely due to an excess of Covid-19-related costs, including vaccination, and test and trace costs, over available Covid funding.

In arriving at the net deficit of €195 million, the excess of Covid costs over the Covid budget was substantially offset by a surplus on core spending, which was due to the regrettable suppression of some core activity and knock-on delays in progressing new developments largely driven by the pandemic and our need to respond effectively to it.

Over the two years of the pandemic, from 2020 through to 2021, the HSE will have recorded a combined revenue surplus of €5 million or a combined surplus of €65 million over the three years of 2019 to 2022.

The national service plan for 2022 outlines the health and social care services that will be provided to the people of Ireland in 2022 within the allocated budget of €20.7 billion, which included the following. Additional investment in new measures, including the winter plan, of €310 million. Additional existing level of service funding €727 million, including: €286 million pay cost pressures which includes funding increments of €39 million; just over €364.4 million existing level of service and demographic pressures; and €77 million in terms of 2022 full-year costs related to Table 4 of the national service plan 2021. Additional once-off investment for Covid-19 costs of €697 million, including: €497 million for Covid-19 responses, including but not limited to, vaccination, and testing and tracing, personal protective equipment, PPE, and hospital and community Covid-19 responses; and €200 million to cover acute and community scheduled care access, including the use of public and private hospitals.

The national service plan focuses on the delivery, improvement and reform of healthcare services while continuing to manage a Covid-19 environment and is prepared within the strategic context of Sláintecare, the HSE corporate plan and the Minister for Health's annual statement of priorities and the winter plan.

I shall outline the financial position as of the end of March 2022, the draft revenue income and expenditure financial position at the end of March shows a year-to-date deficit of just over €250 million or less than 4.96%, with a significant element of this being driven by the direct impact of Covid-19, as reflected in the €224 million adverse variance in Covid-19 reported costs and €26.8 million or 0.6% adverse variance on core-related costs. However, from an overall perspective, it is expected over the coming weeks and months that our core, which is non COVID-19 activities, will naturally increase and the impact of delayed care will also increase demand for core services.

Finally, I will mention recruitment. The HSE has seen unparalleled growth in both 2020 and 2021 of an increase of 12,506 whole-time equivalents. This is in addition to recruitment via third party for staff in our Covid testing, tracing and vaccination services.  In 2022, the resourcing strategy approach is underpinned by a resourcing delivery range. The minimum point of the range sets out the minimum resourcing target at a net increase of over 5,500 whole-time equivalents, upon which the HSE will be monitored against, in addition to a higher target to allow for our commitment to maximising our recruitment and retention efforts. This level of recruitment is a net increase when recruitment to vacancies that arise are backfilled. This requirement, on an annual basis, is just over 9,500 posts.

In the past two years, the HSE has increased its recruitment capacity and capability through investment in national and local recruitment services. This has secured further resources and skills thereby removing potential barriers to domestic recruitment capacity and capability.

In recognition of the increased global competition for health and social care professionals, together with the ambitious recruitment targets, the HSE is supplementing its already robust recruitment strategies to maximise the national market with comprehensive international recruitment across clinical grades. I thank the Chairperson and members.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I thank Mr. Reid. Before we get into the meeting proper I ask him to address the news that we got yesterday. It was stated in a reply to a parliamentary question yesterday that the average waiting time in accident and emergency units is 14 hours for people over 75 years and in other cases they must wait over 21 hours.

The HSE receives a substantial amount of funding. As I have said to Mr. Reid before, I am the last person who would argue against that funding but it seems that no headway has been made with waiting times. What will the HSE do to address this issue in the next two or three months? I hope that everybody in this room will reach 75 years of age and well beyond that and it is wrong to wind up in the intolerable situation of having to wait 14 hours plus on a trolley or in a chair for medical attention. The Irish Fiscal Advisory Council, the OECD and other bodies have said that our health system is well funded, in particular the acute hospital system. What will the HSE do in the next two or three months to address the current intolerable situation and what actions will be taken?

Mr. Paul Reid:

I will address the question from three points.

First, in terms of extra funding that has been committed to the health service, it is very welcome. There has been a significant major element of that extra funding, over the past two years, related to Covid. By international standards, The Lancetreports and many other international reports, the response of the Irish health service to Covid is unmatched.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I accept that, yes.

Mr. Paul Reid:

I wish to make a general point about the extra funding.

Brian Stanley (Laois-Offaly, Sinn Fein)
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We are only halfway through the year. What will the HSE do in the next three months of June, July and August, and before we get into the winter period, to remedy this sad situation in accident and emergency units that are well funded?

Mr. Paul Reid:

I know, Chair. I did say that I was going to address his question from three points. The first point was that extra funding has gone in and what has been delivered for it, and Covid is one aspect of that.

Specifically related to waiting times, we have seen the experience of what has happened in the first quarter of this year, which has been a major impact on hospital services in particular in terms of Covid. Although the impact on the community, thankfully, is in a much better place now but our hospitals experienced one of the worst quarters that we have seen throughout Covid. That has also resulted in, as we have come through the last quarter, a higher presentation of people to emergency departments with a particular higher presentation of people over 75 years of age.

Specifically related to the information in the response yesterday to the parliamentary question, what we are seeing is increased levels of presentation for people over-75. Obviously these are people who have more complex needs and more care both in the emergency department and progressing through. That is one of the reasons. There is also a higher admission rate versus those under 75 years.

Specifically the third point of the question relates to what will we do over the coming weeks and months. First, we will continuously commit to the Sláintecare strategy, which is a major investment in community services to relieve the pressure on acute services.

I have given a number of examples and I shall cite a few. First, there are multidisciplinary response teams that operate in community services. There are 30 teams that are now funded to care for older persons and 30 teams are being resourced to care for people with chronic disease illnesses. Community health networks are largely trying to shift the pressures away from the acute hospital system and emergency departments to give people care in the community, and that also involves the National Ambulance Service to provide services in the community.

Specifically to the third point of the question, which is what actions will be taken over the coming weeks and months. We are working with each of the hospital sites on an individual and group basis, responding to us and, indeed, in conjunction with the Minister, about a range of actions to be taken over the coming weeks, and particularly as we head into winter months again. That will involve some elements of doing things differently. Thankfully, we hope that with where Covid is at the minute we would be able to reduce the need for dual pathways in emergency departments, which puts significant pressure on resourcing.

Finally, to answer the question. A major element of our approach to capacity and capability is our resourcing strategy, which is all about strengthening and increasing the resourcing.

We are working in a competitive market, which I will be happy to talk about later on.

In summary, it is a combination of strengthening the capacity in the community, the redesign of pathways in our emergency healthcare, and the increase of our capacity in resourcing. My colleagues will-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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We ask that the HSE give this absolute priority and to knock heads together on it. I also understand, although I do not know much about it, that a system has been put in place in St. Luke’s General Hospital, Kilkenny-----

Mr. Paul Reid:

That is streaming.

Brian Stanley (Laois-Offaly, Sinn Fein)
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It is working fairly well. I ask that perhaps the learning from that might be replicated throughout the country.

Mr. Paul Reid:

The Chairman is correct. This is a very good example of what we are trying and aiming to do, which is to pick up the best practices that operate in some emergency departments, and streaming is a very good example of this. I have seen it in operation were GPs directly refer in.

Verona Murphy (Wexford, Independent)
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I welcome everyone and I notice our guests are here in force, both virtually and physically, which is a sign that Covid-19, in particular, has moved on.

What I have to say concerns budgets. To be fair to the Government, we certainly have an input of funding from it that depicts a first-class health service. Some would say that, although we are investing €21 billion in the health service, we are getting a Third World service. I understand and accept health is a massive area and cannot be easy to manage. I am directing this question to Mr. Watt, but if we take what Mr. Reid has said in response to the Chairman’s query, that we have over-75s going to accident and emergency departments and having to wait 14 hours, that would probably be reflective of the home care package support scheme not working. The Government, in fairness, as I have said, has allocated an extra 1 million hours to the home care support scheme but there is no delivery on those hours. We are now seeing the results of that in our accident and emergency departments.

Mr. Watt is top dog now. What specific actions has he taken to ensure that vast allocation of funds results in the delivery of a First World health service?

Mr. Robert Watt:

I thank the Deputy for the question, which is the critical one, which how can we collectively-----

Verona Murphy (Wexford, Independent)
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You. How can you?

Mr. Robert Watt:

-----me, the Department, the Minister and the Government, collectively, along with Mr. Reid’s team, ensure we are getting value for money and we are getting impact for the spending. There are many different dimensions to the Deputy’s question. In very straightforward terms, the agenda is to deliver on Sláintecare and the reforms to ensure the increased capacity to deliver on extra activity in the hospital across all of the different areas of responsibility. It is also to ensure there is a shift to the left and, as Mr. Reid has mentioned, that more care is provided in the community and closer to people’s homes. It is to deliver on Sláintecare and the reforms, and to enhance the overall value for money, productivity, effectiveness and efficiency of the system. That is what our Department is doing in terms of working with Mr. Reid and his team in driving the reform agenda across the health system.

I agree with the Deputy that the health system is well funded and there are resources there. We need to ensure these resources deliver better for citizens. The Deputy mentioned the issue around emergency departments, as did the Chairman, and everybody acknowledges that is not acceptable. There are also issues around waiting lists that are too long and where people waiting too long for treatment.

Everybody shares the analysis and the answer is we are implementing Sláintecare and driving the reforms. Everybody supports those reforms and it is welcome we have a clear consensus on that. Our job is with the Minister, the Government and the various teams we have in the Department to deliver on that reform agenda.

Verona Murphy (Wexford, Independent)
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Okay. The question was what actions has Mr. Watt taken to ensure the implementation and that there is an efficient use of the allocation of funding?

Let me be clearer and we will move on to the issue of mental health. Some €23 million was allocated. This has been widely reported in the newspapers but I do not want to go there. Where I want to go is that, at €23 million, we have growing waiting lists in our health service, particularly in the area of child and adolescent mental health services, CAMHS. Mr. Watt mentioned the leadership, policy and direction in his opening statement. I can only see the direction going one way: backwards. I ask in relation to that €23 million, if Mr. Watt can tell me what actions he has taken as the Secretary General, on a huge salary, and that is as much as I am going to say, to ensure that allocation of €23 million extra delivers the service that reflects a First World mental health service.

Mr. Robert Watt:

I thank the Deputy. The €23 million refers to the new service development, and the increase in mental health spending for next year is €55 million to €56 million, so there is an increase across the board. In effect, that goes to improve services and a large part of it is devoted to the recruitment of staff. It is our job in the Department, as part of the Estimates process, ultimately to negotiate and finalise the settlement on each of the budget lines, including mental health. That money is then allocated to the HSE and distributed to the different service entities within the HSE. Our role in the Department is to negotiate the budget, set the overall policy, and then to engage in oversight of how that money is spent and the services are delivered. Our role is one of oversight and the HSE is in the business of actually delivering the services.

Verona Murphy (Wexford, Independent)
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Just to be clear, the oversight role as stated by Mr. Watt does not include the fact that, once the money is allocated, it is his job to see that the money is spent efficiently and delivers a service. That is not his role. Am I wrong?

Mr. Robert Watt:

The services-----

Verona Murphy (Wexford, Independent)
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We do not have time, Mr. Watt, and I have limited time. That question has a “yes” or “no” answer. Is it his role to ensure that once the money is allocated, it delivers an efficient, First World health service?

Mr. Robert Watt:

It is our job to ensure-----

Verona Murphy (Wexford, Independent)
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Mr. Watt’s job as Secretary General is what I am asking. Is that a description of his role?

Mr. Robert Watt:

Our role in the Department is twofold. It is to set overall policy across the health system, which we endeavour to do, and to put in place then the mechanisms for oversight of delivery of the services.

Verona Murphy (Wexford, Independent)
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Will Mr. Watt tell me, and again I ask the question, what actions he has taken since he took up the position of Secretary General more than 18 months ago to ensure the implementation of the funding to deliver the health service?

Which of these best describes his actions? A, would Mr. Watt say he has identified the problem and he does not know what to do about it? B, would he say he has not identified the problem? C, would he say he is on a large salary, gets paid regardless and just does not care, because we are seeing no improvement in the health service? I have asked Mr. Watt about two areas, CAMHS and the home care support scheme, and what actions he has taken to implement the 1 million extra hours that have been granted by the Government. To be fair, the Government is doing its bit. We are not starved of funding but we seem to have a Third World health service with growing waiting lists. Is it A, B, or C?

Mr. Robert Watt:

Sorry-----

Verona Murphy (Wexford, Independent)
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A was had he identified the problem and does not know what to do about it. B asked if he had not identified a problem, in which case it is getting worse. C asked if Mr. Watt is paid a large salary, which he receives regardless, and just does not care?

Brian Stanley (Laois-Offaly, Sinn Fein)
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Deputy, I ask you to treat the witnesses with respect.

Verona Murphy (Wexford, Independent)
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But that is-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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No, by all means the Deputy is entitled to engage in robust questioning. Continue, please.

Verona Murphy (Wexford, Independent)
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Sorry. Is Mr. Watt just paid regardless and it does not bother him?

Mr. Robert Watt:

I thank the Deputy for her questions. The challenge within the health system, as we all know, is that there are increasing demands every year on foot of demographic change, primarily, technological change, and the greater availability of procedures and options for people to improve their health and well-being. Our role in the Department, along with our colleagues in the HSE, is to improve the services, and that is what we are trying to do.

I contend, and we can discuss it this morning, that very significant improvements in services are taking place this year. On waiting lists, it is proposed there will be more activity in this area than we have ever had where funding has been allocated. The hope and expectation is that we will start to see waiting lists coming down, notwithstanding the difficulties caused by Covid-19 in the first quarter of the year.

Our job is to work with the Minister in driving change and reform within the health system.

That is what I and my colleagues do daily.

Verona Murphy (Wexford, Independent)
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Regarding the 1 million hours allocated for home care support, what actions have been put in place to ensure their delivery? In the Dáil, when I question the Minister for Health, or the Taoiseach during Leaders' Questions, and I say we have increased the number of people waiting on home care support by more than 100 since an extra 1 million hours were provided, the Taoiseach responds by telling me these 1 million hours have been given. Mr. Watt is the Secretary General of the Department of Health. Will he tell me what actions he has taken to ensure the delivery of these 1 million hours? If not, I suppose we could just regard whatever is said when the Minister or the Taoiseach stand up, or even whatever is outlined during the delivery of the Budget Statement, as complete and utter spin. I am making this simple for Mr. Watt. What action has he taken in this regard?

Mr. Robert Watt:

Regarding home care, more than 20 million hours were delivered last year, which I think is the largest total of home care hours ever provided. There is a challenge this year in delivering on the targets set out, and this is primarily a recruitment issue. It is about recruiting staff into the area to deliver the services. A group has been set up to explore how we can improve recruitment. We and the HSE are involved with that undertaking. Concerning the issue of home care, then, there is a commitment and the Government has allocated money. Last year’s provision was the highest ever and there has been an increase in the hours again this year, and we are delivering on that.

Verona Murphy (Wexford, Independent)
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I thank Mr. Watt.

Mr. Robert Watt:

The challenge is to try to ensure we can get the staff to deliver the service and this is constraint.

Verona Murphy (Wexford, Independent)
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Does Mr. Watt regard himself as a problem-solver?

Mr. Robert Watt:

What we all try to do is to address-----

Verona Murphy (Wexford, Independent)
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I am sorry, this is a binary question. Is Mr. Watt saying "Yes" or "No"? Does he regard himself as a problem-solver? This is a question requiring a "Yes" or "No" answer.

Mr. Robert Watt:

Yes, it is my job to solve problems. Of course, yes.

Verona Murphy (Wexford, Independent)
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I appreciate that. I have heard about the problems, but what I am not getting from Mr. Watt are the solutions. I say that because I believe the expectation of this committee, and of the public, is that we appoint people to positions to solve problems and not to be telling us what the problems are all the time. We appoint people to come up with solutions that reflect the fact that we have doubled the health budget and we now have the fourth richest health budget per capitain the world. There is no other way to put it. I thought that statistic referred to Europe. It is worse, however, because it is global; yet we are probably reflective of a Third World service. I again ask Mr. Watt, as the problem-solver and Secretary General of the Department of Health, what actions he has taken or what has he brought to the table? I must ask if he feels that he is in the appropriate position. Will Mr. Watt tell me the actions he has taken that will deliver on the 1 million hours and the 23 million hours it was widely reported-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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This home care issue is a particular concern, but would it be helpful if we got a brief outline of what hours are being provided and by how much it is falling short?

Verona Murphy (Wexford, Independent)
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Not really. I am only using that as an example. This is reflective of the situation across the service. If the Chair wishes, I could go into the issue of the children’s disability network teams, CDNTs, and the debacle regarding the child disability network. We do not have a full child and adolescent mental health services, CAMHS, team anywhere in the country that is reflective of the budget. The concept of the child disability network teams is a joke. I had a case concerning a child aged nine whose application for a wheelchair sat on a desk for nine weeks. I have also dealt with anorexic patients, of whom there are some 23 in Wexford, and a paediatric dietician has not been added to the CAMHS service. I was also contacted by a clinical nurse specialist with 13 years' experience and who was moved from one CAMHS unit to another. There was no explanation. That clinical nurse specialist sat for two weeks with no handover process, no files and no computer and it was impossible to see patients. He was then escorted out by a security guard when he returned to get his belongings.

These are the questions the public wants answered. This committee and Mr. Watt should be working together to get the answers. The only difference is that Mr. Watt is paid a large salary. This is not to be derogatory; it is just a fact. It is a salary that got much publicity. Therefore, I am asking Mr. Watt what actions he has brought to the table to ensure delivery of all these things. I am asking this because if I was given €1 million to go from A to B, and, having received that money at A, I arrived at B with no money, I would want to be able to give an explanation, rather than just saying it went down a black hole. This is what I am asking. On behalf of the public, represented here by the members of this committee, what actions has Mr. Watt taken to ensure delivery of the service that warrants €21 billion?

Brian Stanley (Laois-Offaly, Sinn Fein)
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The Deputy has one minute left.

Mr. Robert Watt:

As I mentioned earlier, my job is to run the Department and to set out, with the Minister, the policies, to agree the budgets, to allocate those budgets and to engage in the oversight mechanisms. We have reformed the oversight mechanisms in the Department, working with our colleagues in the HSE. The budget settlement for this year has seen one of the largest increases we have ever had. There is significant change and improvement in the system across a variety of areas, which I think we can all acknowledge. Of course, our health system, like every other health system, has ongoing challenges and our job is to do what we can with the money we are allocated to address those challenges. My leadership role is to run the Department and to manage it to ensure we can do the best in the context of policy and then delivery.

Brian Stanley (Laois-Offaly, Sinn Fein)
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In fairness to Deputy Verona Murphy, she raised two issues. Regarding the CAMHS teams, we all know there are gaps in the system. I saw the figures recently. I know it is not possible to flick a light switch and fix the problems in this context, but in a few sentences will either Mr. Watt or Mr. Reid outline, for the benefit of the Deputy and the other members of the committee, what is being done on this issue? I ask this to ensure that Deputy Murphy will have some idea in respect of progress being made. Would that be helpful to the Deputy?

Verona Murphy (Wexford, Independent)
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Well, Mr. Watt is the head of the Department.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Whomever wishes can take this question.

Verona Murphy (Wexford, Independent)
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It is for Mr. Watt, as far as I am concerned.

Mr. Paul Reid:

I will comment briefly because this is important from the public's perspective. With my colleagues, I will try to address the mental health and home supports issues as well. First, however, it is important, from the public’s perspective, to state that I disagree that Ireland has a Third World service.

Verona Murphy (Wexford, Independent)
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I did say “some would say”.

Mr. Paul Reid:

If I can, Chair, I disagree. This is important from a public perspective. Sometimes, tired old clichés are not right.

Verona Murphy (Wexford, Independent)
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Now, I disagree with that.

Mr. Paul Reid:

I am sorry, but if I can say this, I spent many years in Third World services in developing countries in a previous role I had with Trócaire. I know what a Third World service is like. We are recognised as having the longest life expectancy by any OECD measure. It is important for the record to state this in the context of public perceptions. We are trying to recruit and to retain people in a public service. It is a health service that has many challenges, but some of the references to us having a Third World service are not correct. They are not borne out by life expectancy and or by cancer care or cardio care. We accept we have radical challenges-----

Verona Murphy (Wexford, Independent)
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They are borne out by the waiting lists challenge.

Mr. Paul Reid:

That is a shared issue, I agree. I just wished to make that statement regarding the situation.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I know. Hold on for one second, though, Mr. Reid. I have to try to chair this meeting and there are several speakers to fit in. I wish to be fair to the witnesses too. We all know this is a challenge. Everyone in this room wishes things to go in the one direction, namely, to improve our health system. There is no argument about that. Whether it is the members, the witnesses or their officials, there is no disagreement in this regard. Concerning specifics, however, I refer to what we wish to know about the CAMHS teams, for example. Deputy Verona Murphy did focus on this aspect and she did not get an answer.

Mr. Paul Reid:

I will ask my colleagues to address it. In fairness to the Department-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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Regarding the specific efforts being made, and I do not wish to be speaking for the Deputy, because she is well able to speak for herself-----

Verona Murphy (Wexford, Independent)
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No, I-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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-----but I have observed what has been going on in this area and what is being done to fill these existing gaps. I know it is a pipeline issue. That is what it appears like. I refer to issues in respect of workforce planning and long-term planning, etc. Therefore, I ask Mr. Reid or Mr. Watt to respond to Deputy Verona Murphy to ensure she will have some idea of the situation in this regard going away from this meeting. I am sorry for interrupting her.

Verona Murphy (Wexford, Independent)
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There is no brief answer. I asked the question several times and I did not get an answer. It is important-----

Mr. Paul Reid:

We are willing to give an answer.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Let us try to get one answer to this question.

Verona Murphy (Wexford, Independent)
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My time is up and I do not wish to take from anyone's time-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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I am trying to be fair to the Deputy.

Verona Murphy (Wexford, Independent)
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-----but someone else can ask the question. I cannot help but feel, however, regarding our health sector, that there is a need for a restatement and reaffirmation of the constitutional structures that underpin the workings of this committee and Dáil Éireann. The Dáil and this committee are not some ad hocforums to be tolerated or suffered by civil or public servants who come in and duck and dive when it comes to answers. I want to see a restatement and a rebalancing of the roles and functions-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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That is a big-----

Verona Murphy (Wexford, Independent)
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-----of the Accounting Officers and this committee, as well as a recognition and appreciation of the role of this committee. That is what I wish to see.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Okay.

Verona Murphy (Wexford, Independent)
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Then we might get somewhere in the health service.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I understand it is frustrating for the Deputy.

That is why I want to try to get the Deputy an answer. I want to get some answer in relation to the child and adolescent mental health services, CAMHS, teams.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I know that. The Deputy-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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If this is acceptable, I would ask that the officials would come back to the Deputy with a written answer on what is being done specifically in relation to CAMHS. I am mindful of that, but I am also mindful of the fact that the Deputy will not be back because she has parliamentary duties that she cannot avoid. I am mindful of that and watching that. We will get everyone in.

Alan Dillon (Mayo, Fine Gael)
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I welcome our guests from the HSE and the Department of Health who are joining us this morning.

As I have a short window, I will jump straight into it. I will focus first just on the redeployment of HSE nursing home staff. Back in December 2021, the Department of Health published the value for money review on nursing home care costs and its corresponding response to the recommendations. I think there were nine recommendations outlined. Recommendations Nos. 4, 5 and 6 are related to the examination around operations, agency staff and costs within the public nursing service. The rationale around recommendation No. 5 stated that the biggest driver to cost differentials is staffing levels, and public nursing homes have approximately 2.5 times as many nurses to residents as private nursing homes. Recommendation No. 6 outlined that an extensive review, an audit process, would be established and the HSE care staff are not contracted to specific nursing homes, but instead to community healthcare organisations, CHOs. It was agreed by the Department of Health and the HSE that the recommendations would be reviewed and combined with the deployment of the single assessment tool and other existing work streams to inform the development of any new service models. My first question is directed to Mr. Reid around the HSE care staff being contracted to CHOs rather than individual nursing homes. Is there a system to allow for staff to be easily transferred among public health nursing homes?

Mr. Paul Reid:

I will ask my colleague, Ms O'Connor, to take that.

Ms Anne O'Connor:

In terms of how people are employed within the HSE, they can be employed by a CHO. The reality is, we are not awash with staff in our community nursing units in general. In terms of that part of our services, we are challenged much of the time. People often want to work close to home, so our community units are in local areas. Generally, we have a mix of people who are employed directly within facilities and, in more recent times, we may have employed them within a CHO. However, people can move. They can be called upon within an area. In terms of nursing homes in the private sector, the HSE does not deploy staff in that way.

Alan Dillon (Mayo, Fine Gael)
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In terms of the public nursing homes, it states there is 2.5 times the level of nursing currently in the public nursing system. Ms O'Connor said that there are actually constraints around staffing numbers.

Ms Anne O'Connor:

Yes.

Alan Dillon (Mayo, Fine Gael)
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Is that something that Ms O'Connor has looked at?

Ms Anne O'Connor:

Yes. There are two different things going on there. In terms of the ratio of nursing, which is what the Deputy is referring to in the first point, we have a higher ratio. Historically, we have seen that within our public units, we often take a different type of person. We will often take people who are more complex. We are looking at that in terms of the investment that has been made that has been referenced in terms of what has happened within the health service in the past two years as we contract beds elsewhere and look at how we actually manage the different types of needs. People now are living longer, have more complex needs and multi-morbidities. We have a need for different types of skilled staff. We certainly learned this during Covid in terms of our Covid response teams and we are trying to ensure we can support the broader area through our specialist staff. Generally, within the HSE, be it older persons' or other services, we try to focus on the higher acuity. We have higher nursing and staffing ratios. That is confirmed and there is no dispute around that.

Alan Dillon (Mayo, Fine Gael)
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On the staffing deficits in each CHO, can Ms O'Connor give us an indication of what they currently are?

Ms Anne O'Connor:

I do not have the detail in front of me, but I know within some areas it tends to be a geographical issue. Within certain areas and certain parts of the country, be it older persons' services or, indeed, any services, it is much harder to recruit. It depends on the service. I would also note that in terms of carers, as everywhere, we are very challenged in getting the care staff, either within the community or in community nursing units.

Alan Dillon (Mayo, Fine Gael)
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In terms of the review, audit, the examination of operations costs, staffing and rostering and the use of agency staff, has the Department of Health or the HSE conducted a review into the public nursing services?

Ms Anne O'Connor:

We are looking absolutely at the use of agency staff. We are reliant on agency staff in some areas, there is no doubt about it.

Alan Dillon (Mayo, Fine Gael)
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My question is whether the HSE has done that.

Ms Anne O'Connor:

We are looking. I might ask Mr. Mulvany to come in.

Mr. Stephen Mulvany:

The exercise referred to is ongoing. Effectively, we have looked at all of our approximately 7,000 beds in the public nursing homes, be they long-stay or short-stay beds, in terms of what is open, closed and whether they are closed temporarily or permanently. As Ms O'Connor said, the value for money, VFM, report was very clear. For every 100 beds in the public sector, there are more staff overall. The mix of nurses is higher. While we pay our nurses the same as the private sector, the salaries for healthcare assistant staff who tend to have higher education qualifications are higher in the public system. That is not necessarily a bad thing. The report also looked at the-----

Alan Dillon (Mayo, Fine Gael)
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I apologise for interrupting. The HSE knows there is a problem and there is a value for money report that has been published by the HSE itself and it has accepted the recommendations. It is five months now since the publication of that report. Have we seen progress?

Mr. Stephen Mulvany:

Absolutely. I apologise. I am getting there. The first step in looking at that is obviously to examine the beds. We then have to do two key pieces that the VFM report outlines. One is that we need to introduce the interRAI assessment tool across the health sector, which is a standard assessment tool. We have plans to recruit 128 assessors by the end of the year, with the first 26 being recruited in July. So far, we are on track for that. The other piece is we need to close out with the Department is a longer piece of work to do, within the safe staffing framework, including figuring out the right mix of staff between healthcare assistants and nurses for different complexities of patient. That is a big issue that came up in the expert panel report on nursing homes in mid-2020 and it was picked up again in the VFM report. There is nothing in the VFM report that necessarily says that the level of staffing in the HSE is inappropriate. If anything, it is likely the private sector nursing home staff will have risen and need to rise-----

Alan Dillon (Mayo, Fine Gael)
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We certainly have deficiencies in other elements of CHO staffing levels in where we actually need to rebalance within each CHO. On the implementation of the report, will a report be published? When does Mr. Mulvany envisage this work to be completed?

Mr. Stephen Mulvany:

Our plan is to have set out a roadmap or framework for a more viable public nursing home sector by the end of the year.

Alan Dillon (Mayo, Fine Gael)
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Can this committee get an update or an interim report on work to date? It is important that we actually follow this.

Mr. Stephen Mulvany:

No doubt we can.

Mr. Paul Reid:

There is a joint oversight between ourselves and the Department and, indeed, on operation level from ourselves within the HSE of all of the actions and we are tracking progress. At some stage, we can give a progress update on the actions.

Alan Dillon (Mayo, Fine Gael)
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I want to move on to the second point I want to raise. On the HSE treasury management, the cash balance held by the HSE at the end of December 2020 was in the region of €812 million, which was an increase of €458 million on the 2019 balance of €354 million. The HSE states that this is equivalent to holding 13 days' cash for its normal day-to-day operations. I certainly find that figure astonishing. The HSE also stated in its advanced briefing, which we thank the witnesses for, that it would typically hold, on average, three to four days' cash for the year. The above balance was due to the final drawdown from the Exchequer based on the estimated year-to-year cash requirements. Can Mr. Reid outline the reasons behind the large increase in the HSE cash balance at the end of 2020?

Mr. Paul Reid:

I will ask Mr. Mulvany to answer that.

Mr. Stephen Mulvany:

Typically, the increase is well correlated with the total budget and the total creditors. As the total budget goes up, particular as it did in Covid, where it accelerated rapidly and necessarily so, there was also a significant move to make payments through non-pay. In other words, many more suppliers were engaged. The HSE has been very clear that it has no desire to hold more cash than it needs, as long as we have enough cash to meet our liabilities. Those ten to 13 day cash figures, the €600 million and €800 million, they are at the end of the year, literally for one or two banking days. For the rest of year, as I said, we average about three and a half days, which is just under €200 million. That is the figure agreed with the Department and the Department of Public Expenditure and Reform.

It is of no benefit to the HSE. We do not earn interest on it, nor do we pay negative interest, which is very important.

Alan Dillon (Mayo, Fine Gael)
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My next question was on the negative interest rate.

Mr. Stephen Mulvany:

I can confirm that we do not pay negative interest on our current contract.

Mr. Paul Reid:

The Secretary General, Mr. Watt and I, and our teams, have monthly and regular oversight over this, including up until yesterday, where we look at cash balances and get agreement at a departmental level.

Alan Dillon (Mayo, Fine Gael)
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What is the cash balance that will be transferred over for 2021? Do you have that figure?

Mr. Stephen Mulvany:

At the end of 2021 the cash balance is €608 million, which is the figure DEPR and the Department of Health agreed and of which they advise the HSE. It is approximately three and a half days cash.

Alan Dillon (Mayo, Fine Gael)
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The agreed figure is €608 million. This is €812 million.

Mr. Stephen Mulvany:

It is €608 million at the end of 2021 for one or two banking days and then it returns to the norm of approximately €200 million, or three or four days cash.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I will allow Deputy Dillon back in for a second round if we have time

Mr. Robert Watt:

I do not think that is a fair characterisation. The Minister of State, Deputy Butler, and other Ministers make their case for money. That is their job and what they are there to do. As part of the cut and thrust of Estimates, the Minister of State, Deputy Butler, defends her corner as one would expect and argues for her case. In terms of the nature of the engagements, the way the Minister of State, Deputy Butler, went about her business was perfectly fine.

Mr. Robert Watt:

It is unacceptable to record private conversations in any setting.

Mr. Robert Watt:

There has been follow-up to that.

Mr. Robert Watt:

It is a HR issue, yes.

Mr. Robert Watt:

Our IT people are involved now in terms of future meetings. Staff have been reminded again of their obligations towards their colleagues because, ultimately, it is the obligation towards their colleagues that they have to respect. We all have to be in a position to have private meetings and private conversations. An integral part of work is that we can express our views in a respectful, thorough and constructive way. It is very important to have that challenge function in any organisation. We have reminded-----

Mr. Paul Reid:

I thank the Deputy for his opening remarks which are always appreciated by our teams on the front line. In terms of mental health services, CAMHS and budgets overall, we have certainly seen increased funding in the period 2012 to 2021. There has been increased funding of €452 million extra in that period. In that time, we have recruited 1,500 extra staff into mental health services. I know the Deputy is asking specifically about the focus on outcomes. We have been specifically focused. We are seeing increased numbers of teams in CAMHS across the board. Yes, there is a challenge in recruitment, which I am happy to take separately. We have seen, as part of that over that period, reduced admissions to both CAMHS and mental health services. We have built capacity over the past few years in mental health overall. It is about shifting the delivery of services and the future vision away from congregated settings. A major part of our investment funding goes into moving people more into supported care services.

Ms Anne O'Connor:

The Deputy is right about the situation. Part of the challenge is the numbers in terms of having people available on call and rostering of consultants. The reality is that we are trying to grow that model in terms of crisis support. Our goal is to try to keep people away from the acute services. Some of the investment in mental health has gone into that in terms of supporting other agencies to provide services. Our role is very much at the specialist end in terms of secondary and tertiary care by our community teams. We know that we have young people turning up at emergency departments and the paediatric hospitals. We see more of that post-Covid than we ever have. We are looking at how to respond in a far more integrated way. The reality for us is that we are very challenged in terms of recruiting consultants into CAMHS. We have some gaps and this has been well-aired previously. We have locum consultants coming in-----

Ms Anne O'Connor:

Absolutely. We need to have a service that can respond to people out of hours, as well as in hours. If one responds out of hours at present, it will be a paediatric response in terms of paediatric hospitals. Clearly, the preference would be to have that specialist support available but it is about being able to get sufficient numbers of people. The reality is that the numbers out of hours are very low. When it happens, it is very serious, but it does not happen very often. Our priority is to be able to staff our teams during the day.

Mr. Paul Reid:

Our capital planning process is multi-annual with the Department and the Minister. It is generally a three-year cycle of plans which has brought on the likes of primary care centres throughout the country. It is designed based on a three-year plan. If we commit to the design of something, we can complete the execution of it. That is the case for the primary care centre.

Mr. Paul Reid:

Yes, that is our intention. We have a schedule of primary care centres to go through implementation over the coming three years.

I cannot comment on that specifically. Generally, if we commit to designing something, we mean to execute it too. Some major constructions have been done multi-annually rather than just annually. I am happy to come back to the Deputy about it.

Mr. Paul Reid:

I am happy to come back to the Deputy with a note on it. I do not have it to hand, but we have a good summary note of the rationale for the purchase.

Catherine Murphy (Kildare North, Social Democrats)
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I welcome the witnesses. Time is short, so I would appreciate succinct responses. How many of the 73 CAMHS units are fully staffed?

Ms Anne O'Connor:

I know Linn Dara is not. We have closed beds there. There are two, at St. Vincent's Hospital, Fairview, and Eist Linn, which are not fully staffed. I am not aware of significant challenges elsewhere. I know there are issues in Galway and at Linn Dara.

Catherine Murphy (Kildare North, Social Democrats)
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Will Ms O'Connor provide a note on the gaps and what disciplines are required to fill them? The closure of Linn Dara puts even more pressure on the community. Where there are gaps, we are likely to see patients turning up at acute or paediatric hospitals. We are told that Linn Dara will be open again in September. Can Ms O'Connor guarantee that?

Ms Anne O'Connor:

No. That is what we are aiming for. I cannot give a guarantee because it is reliant on recruitment. We hope that we will have graduates come through our system over the summer. The Deputy will be aware that we have previously closed some of those beds during the summer. The demand for CAMHS beds in the summer months is 40% lower every year. The number of beds in Linn Dara has decreased by 11. We are recruiting and trying to get those beds open again for September.

Catherine Murphy (Kildare North, Social Democrats)
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Regarding how services are accounted for, there is not segregation between adult and child mental health services in the budget. Is it intended to change that?

Ms Anne O'Connor:

The Deputy is right that there is a mental health budget and it is hard to isolate the costs. I think Mr. Mulvany has plans for accounting in the future. When the systems improve, we will have greater visibility of line-by-line costs in CAMHS and adult mental health services.

Catherine Murphy (Kildare North, Social Democrats)
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When are we likely to see that?

Mr. Stephen Mulvany:

There is full visibility of mental health costs and exactly what the money is spent on. The challenge is the specific sub-discipline teams, such as general adult services, CAMHS, and so on. That will be in place when we have the integrated financial management system, IFMS, which we have talked about.

Catherine Murphy (Kildare North, Social Democrats)
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I am struggling to hear Mr. Mulvany.

Mr. Stephen Mulvany:

When we introduce the single national financial management system-----

Catherine Murphy (Kildare North, Social Democrats)
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Will that be in the future?

Mr. Stephen Mulvany:

From next year, that system will be live for the entire eastern area of the country. At that level, reporting on individual teams will be possible.

Catherine Murphy (Kildare North, Social Democrats)
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Services cannot be provided without staffing. We constantly hear about difficulty recruiting, which is mentioned in the HSE document. The Taoiseach stated in response to parliamentary questions that there is not a resourcing issue but that it is a management and recruitment issue. I am reading the document the witnesses provided. There is monthly reporting of staffing. They would have had knowledge of an issue well in advance. I imagine a mental health service is a highly stressful environment to work in when under-resourced. The national service plan bases its estimate on 10,000 staff for 2022, yet the HSE resourcing plan sets a target of 5,500. Do the witnesses comprehend why people would see those as fake targets? I know there are challenges with recruitment. They do not receive the service that they expect to receive.

Mr. Paul Reid:

We do not see them as that. We see them as real commitments relating to funding and resourcing that we want to live up to. I addressed the issue of 5,500 or 10,000. Since January 2020, the staffing level in the HSE has increased by 14,700 to 134,500. That is a 12.3% increase.

Catherine Murphy (Kildare North, Social Democrats)
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There is an estimate of 10,000 staff, but the resourcing plan sets recruiting at 5,500. Why is that?

Mr. Paul Reid:

The funding for the national service plan provides a budget for up to 10,000 staff. In the discussions with the Department, as we were formulating the plan and knowing what is happening in the competitive national and international market, we put in place a number of strategies to forecast what level we see ourselves getting to. Our view is that it was best to state what the market was telling us at the start of the year. The market was telling us that all the disciplines would probably require about 5,500. We are still striving to achieve more than that. Thankfully, as of the end of March and April, we were above the 5,500 mark, recruiting just over 600 per month. We would like to reach 10,000 but we are reflecting on what is happening in the market.

Catherine Murphy (Kildare North, Social Democrats)
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How are the funds reconciled? If there is an allocation for the recruitment of 10,000 staff, which is not reached, how is that reconciled?

Mr. Paul Reid:

Our chief financial officer might say something. We engage with the Department regularly, using the oversight arrangements referred to, and look at the recruitment profile. We will make an assessment at the end of May and in the early weeks of June of just what that looks like as we plan for the rest of the year. There will be a dialogue and discussion about the appropriate use of those funds. The CFO might give a technical example, but that is what we are doing in practical terms.

Mr. Stephen Mulvany:

We track that money every month. The key point is that we do not allocate money to services until they confirm that the post has actually been recruited for. If the post is not recruited for, we hold the money, which is recurring and available for the next year. If it is put to a once-off use in agreement with the Department, that does not take it away from being available once staff are recruited.

Mr. Paul Reid:

To stand still every year, we have to recruit 9,500, due to what I would call churn. Before we even increase the number of staff by 5,500, we need to recruit 9,500.

Catherine Murphy (Kildare North, Social Democrats)
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Deputy McAuliffe referred to the issue of recording and people needing to have respect for others in work. There was substance in some of what was said. Is Mr. Watt concerned about that?

Mr. Robert Watt:

Am I concerned about the-----

Catherine Murphy (Kildare North, Social Democrats)
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The substance of what was said, rather than the fact that a recording took place.

Mr. Robert Watt:

No. The substance involved a robust discussion. As Mr. Reid mentioned regarding the targets, there is an ambition to recruit 10,000 staff and the budget is based on that. The service plan provides for 5,500. A better approach to budgeting and planning in future would probably be a multi-annual approach to the recruitment and wage bill. It is probably too ambitious to have a point estimate for each year. It is probably best to state that we will recruit 15,000 over the next three years and money that is not spent this year can then be allocated to 2023, but there is still a commitment to increase the numbers.

Catherine Murphy (Kildare North, Social Democrats)
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Is Mr. Watt concerned about the kind of conversations that took place and their substance? Does he pay attention to that as opposed to, for example, trying to put systems in place so that recordings cannot happen? I understand that. Is he concerned about the content?

Mr. Robert Watt:

I would be concerned about the nature of engagement and ensuring that they are respectful. When it comes to the substantive points that people make, I would want to see concerns being addressed.

If there are issues of disagreement between ourselves and the HSE, for example, we would obviously address those and we have a way of working together that delivers on the objectives. I take the substantive comments as important. It is something we have to reflect on and learn from.

On the recruitment issue, there are significant lessons to be learned reflecting the reality of the labour market in which the HSE operates. In many cases, the staff are not available or there is uncertainty about our ability. As Mr. Reid mentioned, it is quite a startling number. Before we add any additional people to the system there has to be 9,000 replacements so that is the first thing to do.

Catherine Murphy (Kildare North, Social Democrats)
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What is the staffing whole-time equivalent in the Department of Health? We have a briefing note on the HSE.

Mr. Robert Watt:

The staffing level is about 750. I can get the exact number for the Deputy.

Catherine Murphy (Kildare North, Social Democrats)
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Has the Department honed in on what the prior year adjustment amount is and how that arose?

Mr. Robert Watt:

We are almost there. Mr. O'Grady might touch on that.

Mr. John O'Grady:

We have not yet received the final annual financial statements from the HSE. They are due in the coming days. We have had interim reports from HSE colleagues.

Catherine Murphy (Kildare North, Social Democrats)
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Roughly how much is it?

Mr. John O'Grady:

Mr. Mulvany is probably better qualified to answer.

Mr. Stephen Mulvany:

The figure will be €71.4 million subject to the finalisation of the audit by the Comptroller and Auditor General.

Catherine Murphy (Kildare North, Social Democrats)
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And how did it arise?

Mr. Stephen Mulvany:

It arose because we sought to do an assurance review of about €1 billion worth of our non-pay accruals at the end of 2020. We took a sample of about €783 million and we got in documents relating to €760 million. Of that €760 million, €56 million did not have sufficient information for us to deem it to be a valid ongoing accrual and a further €28 million was identified as well. Those two figures, less what was relevant to that particular year in 2021 is what leaves you with the €71.4 million there.

Catherine Murphy (Kildare North, Social Democrats)
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Has the Department moved to a different accounting standard?

Mr. Stephen Mulvany:

The reference to a different accounting standard is to a move that happened in 2015 to 2017 between what was FRS 3 and FRS 102. The issue of fundamental errors and what exactly is a prior year adjustment was in that discussion. The key point to note is that since that change happened some years ago the making of prior year adjustments has been more common because it is not only for fundamental errors, which these errors were not. These are not fundamental errors. In the past you only did a prior year adjustment if the error was so gross as to destroy the truth and fairness of your accounts. This prior adjustment does not fall in any way into that category.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I call Deputy James O'Connor.

Mr. Paul Reid:

May I just the point -----

Brian Stanley (Laois-Offaly, Sinn Fein)
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Very briefly.

Mr. Paul Reid:

It is not cash impacting. It does not impact on service and it does not need extra funds.

James O'Connor (Cork East, Fianna Fail)
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I welcome everyone to the meeting. I join others' comments in acknowledging the very hard work that was done by many people within the Department of Health and the HSE and those on the front line of our health service during the pandemic. It has been extraordinarily difficult.

My first question is to the Secretary General. On the managerial structures and work undertaken within the Department, I understand the ministerial-management advisory committee, min-MAC, meetings are quite significant in the decision-making process, and briefing junior Ministers and Cabinet Ministers on work in every Department. Since Mr. Watt became Secretary General, how many of those meetings have taken place?

Mr. Robert Watt:

We have a management board meeting every week, which takes place at noon. The Minister, Deputy Donnelly joins that meeting on occasion, on a monthly basis. During Covid, given the issues in relation to Covid we had a meeting at 12 noon on Monday and then myself, the Minister and Dr. Holohan and Dr. Glynn and other management board members, including Fergal Goodman, would have had a meeting at 3 in the afternoon. We had what was basically a rolling min-MAC, you could describe it.

James O'Connor (Cork East, Fianna Fail)
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Specifically on min-MAC, how many meetings have taken place with the Cabinet Minister and the two junior Ministers?

Mr. Robert Watt:

The meetings that I am referring to ----

James O'Connor (Cork East, Fianna Fail)
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But the ones I am referring to, if that is okay?

Mr. Robert Watt:

So I can be clear, there were min-MAC meetings that involve myself, the Minister and other members of the management team as appropriate meet formally on a Monday afternoon until quite recently. In the post-Covid situation we have changed our working patterns and obviously the Minister's working patterns have evolved. The Minister then has meetings with the Ministers of State as appropriate. The assistant secretary or principal officer in those policy areas for which the Ministers of State are responsible would join in those discussions. They would take place as necessary.

James O'Connor (Cork East, Fianna Fail)
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Who would make the decision about who would be appropriate to be present at those meetings? Would that be Mr. Watt, as in he is in charge of HR matters, or would it be someone else?

Mr. Robert Watt:

It is quite informal really. If the Minister would like to discuss a particular issue, then the appropriate officer in the Department, who could be at any level but primarily principal officers and assistant secretary, would apply. I do not get in the business of deciding who goes to meetings in the main. That is the Minister and his private secretary would organise that.

James O'Connor (Cork East, Fianna Fail)
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The reason I highlight that is it is important for collegiality in the work that the Department and the HSE does that all Ministers would be present and that briefings would be provided.

All of us present are reasonable people. We accept that during Covid decisions had to be taken. Some turned out to be the wrong decisions and we have to ask the questions. The Irish Examiner did a lot of work on the story about the €450 million of unused PPE. What safeguards did the Department put in place when trying to acquire that? I appreciate that there was a rush and that a lot of difficult work had to be done very rapidly, and we did not know where things were going with Covid but it is an unmerciful amount. A sum of €450 million is by no means a small amount. I want to get an insight into what actually happened there.

Mr. Paul Reid:

I might take that. It is more an operational issue. We had commissioned a review because we wanted to look back and see what were the learnings in relation to that. The review was published by KPMG. I think we circulated previously the outcomes of that.

We do have to go back and take a bit of context. What had happened all across Europe was that the EU procurement rules were suspended or put in abeyance. Manufacturing plants across the world were closed, particularly in China. The market had collapsed. Forces were at play that I have referred to previously, which accommodated piracy where when you secured an order someone else came in and paid multiples of that order. Things like surgical masks went from about 67 cent each to over €11. That was the context in which the market was operating. We used the Irish international agencies, including IDA Ireland and our ambassadors all over the world, to help us secure orders. As a nation and as a health service, we performed extremely well by comparison with even some of our very close neighbours in Europe and beyond to the extent that other countries were coming to us about PPE. However, the Deputy is absolutely correct. We had to pay a price in multiples. A small amount of supplied kit had to be exchanged back to China and there was other PPE distributed to the system that was not fit for purpose but had not necessarily been procured through our own procurement processes. They were done through other people with best intentions for donations. We have set out our learnings. This was a market in which people were working 24-7 to secure PPE. Relatively -----

James O'Connor (Cork East, Fianna Fail)
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I apologise for cutting across Mr. Reid but time is very limited. We await the outcome of that work. It might be something that the committee will look at again. I am sure we will.

Returning to some degree of normality outside of the context of the pandemic, I refer to cross-border initiatives and schemes. Many things in our health service are not working and, unfortunately, people are forced to travel. It is shameful that in 2022 that people are still crossing to the UK and other countries in their droves for healthcare. I particularly refer to cataracts. What is the HSE going to do to reduce the number of procedures required? We get many calls in our office. Unfortunately if they want to go through the public system, the waiting times are ludicrous. It is something that I feel ashamed of and I would like to see a lot more work being done.

Can Mr. Reid give us any update or reassurance about what is being done in that regard?

Mr. Paul Reid:

I share the Deputy's concern, particularly on some of the procedures he spoke about. There is a dual pathway from other administrations that avail of some of our services in terms of healthcare. We have, with the Department and through the Minister, secured €200 million of funding for the HSE this year. That is an access to care fund that is primarily focused on increasing the capacity in the public system, utilising some extra capacity in the private system and developing new pathways to make it more efficient and effective, get more people through and get them their care. That is a published plan with ourselves and the Minister. It is extra funding to increase capacity across outpatient waiting lists, inpatients and day cases, GIs and scopes. That is our approach to it. We would like to see this addressed but we do have to avail of that capacity in the interim.

James O'Connor (Cork East, Fianna Fail)
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If I may raise another issue of concern with the Department, is any work being done to shorten the turnaround time and waiting lists for emergency medical cards? One person was in contact with us who is waiting quite a number of months now and undergoing intensive cancer treatment. It is outrageous there would be people waiting months for that type of urgent help. What work is being undertaken in the Department to deal with that?

Mr. Paul Reid:

The Deputy's question is probably more appropriate for ourselves in the HSE than the Department. The primary care reimbursement service, PCRS, is based in Finglas in north Dublin and that is where they are processing those. I am very happy to take up the particular case the Deputy has raised. There is an emergency acceleration system. We generally have increased resourcing significantly over the past few years in the PCRS centre. The turnaround times have been good. They would process lots of other issues in terms of GP and pharmacy claims. I am very happy to take up the particular case the Deputy raised. There has been significant extra resourcing built up to a very strong capacity in our PCRS centre and quite good performance levels and turnaround on medical cards.

James O'Connor (Cork East, Fianna Fail)
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That is okay. I will finish with some questions about the National Ambulance Service. It is coming up repeatedly. I am a rural Deputy for a rural constituency, like many other committee members. The wait times for ambulances are increasingly worrying. We are getting reports into our office of people having to wait in excess of an hour and in some cases much longer. It is deeply concerning considering the budget of the HSE and the health service is approximately €20 billion. I do not feel we are getting good value for taxpayers' money in that regard. Is work being undertaken to improve that particular matter?

Mr. Paul Reid:

The Chair has also raised this issue. Yes, we have a particular focus on the National Ambulance Service to bring forward to the Minister an overall capacity strategy to strengthen our capacity both in terms of capital funding that we are doing for extra fleet but also resourcing, which is part of our key plan this year, to put extra resources into it. There are significant challenges because of our emergency departments, which have a knock-on effect on our ambulance availability, especially with some of the challenges we have in the acute hospital system and the wider demands our National Ambulance Service has taken on in the community as well. In summer, we are finalising and have seen a couple of drafts already of a strategy that will seek to put extra capacity into our National Ambulance Service. We will be presenting that to the Minister very soon.

Colm Burke (Cork North Central, Fine Gael)
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I welcome the witnesses and thank them for their work over the past two years in very difficult times. I refer to figures for community care and public nursing jobs. I have raised this previously. I note that the exit figures out of the HSE were 3,722 to December 2022. I presume the exits out of community services are part of this 3,722. That figure is 3,305. Has any real analysis been done as to why there is that level of exit by people from the community services?

We still are not making any significant progress on nurses working out in the community, although I know there are plans for this year. I have raised the fact we will have a far larger elderly population, which is increasing as we speak and will increase dramatically in the next eight years. I am not sure whether we are doing long-term planning for having more people working in the community. Compared with the figures for December 2014, the real increase in public health nurses has been minimal compared with the increases across all other sectors. I have raised this at previous meetings and will continue to raise it. The HSE might give some idea of the planning on this issue.

Ms Anne O'Connor:

I am not too sure what date the Deputy's data on exits is from. We are certainly seeing more people leaving now in terms of our public health nursing workforce, and that is a concern for us. On community services, one of the things that is shifting with enhanced community care, ECC, is the development of an approach around nursing teams. We are challenged and are having considerable work to recruit clinical specialists for the community.

Colm Burke (Cork North Central, Fine Gael)
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Are we doing exit surveys in our hospitals? Someone else raised this. I have come across HSE staff who have raised concerns that no one is asking the questions as to why people are leaving. Is it because they have young families and the appropriate hours they require are not being given to them? I have heard that people who have young families are not being accommodated at all. These are really well-trained nurses who suddenly find they are being given hours they cannot be available for. There is no adjustment being given at all. Why are we not doing detailed exit surveys?

Mr. Paul Reid:

I will call on the national HR director, who is actively involved in all of this and recruitment. Just to make a couple of points on strategic recruitment and to reassure the Deputy, as he asked us, that we are very much looking at our recruitment. Our figure of 5,500 for this year has put a particular focus on community resourcing and trying to get that shift into community resourcing. We have our annual staff survey that picks up a lot of the issues we might pick up in exit surveys. I will ask our HR director to make a comment on how we are trying to track some of these issues.

Ms Anne Marie Hoey:

We can certainly see that our nursing workforce has increased substantially over the past couple of years. We have more than 42,000 nurses employed across the HSE at the moment. In the area of public health nursing, the number of public health nurses in training has also increased in recent years. That trajectory will continue. There is work under way between the HSE and the higher education institutions in terms of increasing the number of sponsorship-----

Colm Burke (Cork North Central, Fine Gael)
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I know that, but Ms Hoey is still not dealing with the issue I have raised about the exit surveys. Where have we done exit surveys? What has been the outcome of them? If they are not being done, why are they not being done?

Ms Anne Marie Hoey:

Exit surveys are done in some parts of the organisation. I cannot say they are done across the organisation. As the CEO has mentioned, the staff survey also picks up issues in respect of our staff and staff retention issues.

Colm Burke (Cork North Central, Fine Gael)
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I have raised this with a number of sections of the HSE and I do not know of any place or any hospital where exit surveys are being done.

Ms Anne Marie Hoey:

Exit surveys are done in some locations, but as I said, they are not done routinely across the organisation.

Colm Burke (Cork North Central, Fine Gael)
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If we want to cater for people's circumstances as they change, if we want to try to keep numbers, is it not extremely important we find out why people are leaving and particularly why numbers of people in specific areas are leaving?

Ms Anne Marie Hoey:

I agree. There are a number of things to mention there. On our retention strategies, as I mentioned, we have 42,000 whole-time equivalent nurses but many more in terms of actual employees. We are very keen to offer flexible working, to the point the Deputy made about working hours that suit individual. We have been very keen to that fact over the past couple of years. At the moment, over 30% of our workforce have part-time or flexible working hours to meet their needs at certain times during their career when that is appropriate.

We do offer those strategies and initiatives in an effort to retain and grow our workforce.

Colm Burke (Cork North Central, Fine Gael)
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Moving on, another area that I want to touch on is the use of operating theatres in hospitals. I know of a number of HSE hospitals where the use of theatres is limited. There is one hospital where patients are not allowed into theatre after 4 p.m. A consultant in the north-west region advised me that she had been told that if a patient is not in theatre by 4 p.m., that is it, and the operation has to be cancelled. Has that issue been looked at? If we have a situation where a theatre is closed from 4 p.m. right through until 8 a.m. the following morning, that is not a good use of the space.

I want to raise another issue in relation to operating theatres. I am aware that some private hospitals are now using theatre assistants, in other words, people who are specifically trained up to provide back-up support in theatres. Is the HSE going to look at that with a view to ensuring that we have an adequate number of staff to man our operating theatres?

Mr. Paul Reid:

A piece of work was done by the Royal College of Surgeons in Ireland, RCSI, primarily within its own group of hospitals, around theatre utilisation and effectiveness. Generally, the findings of that were that it is all about looking at the whole process throughout the hospital and how theatres can be utilised more effectively, including in respect of the hours of use. We are currently in discussions with the RCSI about running an equivalent process across a number of hospital sites with a view to rolling it out further across the whole system. That will involve, for example, getting process engineers in to look at the whole flow of the hospital system, with a view to increasing hospital utilisation, and to look at the work practices associated with theatre utilisation that can strengthen their efficiency. As part of the access to care plan, funding of €200 million has been provided this year. It looks at new pathways for care, which-----

Colm Burke (Cork North Central, Fine Gael)
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I was asking about theatres.

Mr. Paul Reid:

The plan looks specifically at theatres.

Colm Burke (Cork North Central, Fine Gael)
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If there are staff in who are finishing work at 5 p.m., would it not be appropriate to look at manning theatres with staff available until 8 p.m., so that theatres are not closed down at 4 p.m? Why has that not been put in place in hospitals?

Mr. Paul Reid:

I might refer to my colleague, Mr. Woods to respond to that.

Mr. Liam Woods:

The Deputy's point about theatre utilisation is clearly a very important one for us. As Mr. Reid said, we are doing a piece of work looking at theatre efficiency generally. Trauma theatres run well past 8 p.m. We are funding the use of elective theatres as best we can through the access to care programme, to drive as much activity as we can to catch up on backlogs. I hear the example that the Deputy has referenced. I would be interested in getting more detail. However, I am not aware that that is a general situation. In fact, I am aware that there is a strong demand for additional theatre capacity and a great desire on the part of our surgeons to use it. The Deputy raised a point about theatre assistants. The HSE has looked at that. The process was somewhat interrupted by the duration of Covid, but it is an area that clinically we would like to develop. As the Deputy has stated, it would be a sensible addition to drive more throughput through theatre. There has been some work done recently looking at utilisation and the possibility of further enhancing theatre utilisation. That piece of work is being supported at the moment.

Colm Burke (Cork North Central, Fine Gael)
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I wish to raise an issue in relation to nursing homes.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Very briefly, Deputy.

Colm Burke (Cork North Central, Fine Gael)
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I am aware that the HSE's capital plan 2022 has been announced. I welcome that. There are two issues that I wish to raise. One concerns the amount of funding going into public nursing homes. Such funding is most welcome. I am wondering if we are looking at efficiency in public nursing homes and the cost of running them, compared with what it costs to place a patient in a private nursing home, for instance, under the fair deal scheme. In a private nursing home it costs around €1,000 per bed per week, whereas a public nursing home, it costs around €1,650 per bed per week. While I welcome the provision of funding, I think we also need to look at efficiency. The second point I wish to raise concerns-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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I will let the Deputy back in to raise his point in the second round of questions.

Mr. Stephen Mulvany:

To respond to the Deputy's question, we are looking at that issue. The Department published the report of the Value for Money and Policy Review of Nursing Home Care Costs at the end of 2021. That included a comparison of costs in public and private nursing homes. There is a programme of work flowing from that, including in our service plan, which looks at precisely what the Deputy highlighted. As we know, having more nursing staff correlates well with delivering better quality care. The fact that the public system has more staff and a richer mix of nursing is not necessarily a bad thing. However, getting the right balance between the two is absolutely part of that piece of work. We are looking at the issue.

Colm Burke (Cork North Central, Fine Gael)
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Does Mr. Mulvany accept that we are putting a huge amount of money into public nursing homes, and yet the cost per week is still extremely high? I understand that huge demands are being placed on public nursing homes because the buildings are not up to standard. As we are bringing the buildings up to standard, should there not be savings made at the same time?

Mr. Stephen Mulvany:

We accept that there is a substantial difference and the cost is higher in the public sector. We only reimburse our public units up to a certain cap. If there are costs beyond that, we do not reimburse them. We are very mindful that if we are over-reimbursing in the public system, we are potentially taking resources from the private care system, where we could get more patients into beds. We are very mindful of the issue.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I only want to discuss therapeutic services for autistic children. What will be done to try to make sure that people are getting assessments of need and the therapeutic services that they need? In my constituency, I have one child whose parents were told by the HSE that there was an assessment of need done on 10 May 2021. I questioned the parents about this and they were confused because no assessment had been done. However, I appreciate the letter I received from the HSE on 18 May that acknowledges that disability services acknowledged the error in the previous response that stated an assessment of need was completed on 10 May 2021. This assessment did not take place and disability services apologised for the error. The parents know the assessment did not take place because they are the parents of the child. They are looking for the assessment to get a diagnosis in order that they can get therapeutic services and get the child into a school where the child will get the support that they need, as well as all of the therapeutic services that might make the child and the parents' lives easier as they try to navigate life with autism. That is a problem which I hope Mr. Reid will acknowledge.

Mr. Paul Reid:

I fully acknowledge the issue around assessment of need and the big challenge we have. A recent court case set out very clearly that our process was not complying with the legislation. Some 10,000 assessments need to be reassessed based on that. We have very significant issues to deal with. We are working very closely with the Minister and have been doing so for the past few weeks on how we will approach it. This includes an engagement he and I kicked off last week with a range of stakeholders about how we will do this very differently. It involves extra recruitment which is a challenge. We are looking at recruitment profiles and how we can look at the qualifications for people needed to come into the system. However, I fully accept it is a significant challenge. We will have to redesign the whole process around assessment of need.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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What is the timeline for that? What are the HSE's interim solutions?

Mr. Paul Reid:

We are working with the Minister on the timeline on both the assessment of need redesign, which my colleague, Ms O'Connor, will talk about, and the wider disability issues with which we have a challenge. We will all work with him in the coming weeks and likely into September around a range of initiatives in terms of disabilities that we are approaching, to put together an agreed plan around the wider issues around disability.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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What does that mean? I ask Mr. Reid to speak to me in practical terms. I have a child who is waiting 26 months for an assessment. When is he likely to get an assessment under the new plan? If a child is born today down the road in Holles Street Hospital and an issue becomes apparent in the first year of his or her life, under the timeline for the interim solutions and new plan, when will that child get an assessment of need?

Mr. Paul Reid:

I reassure the Deputy that the assessment of need process does not stall where a person needs access to particular services. If that happens and it can happen-----

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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That is not the experience of the breadth of my constituents. I appreciate that it may be so, but I assure Mr. Reid that it is not so on the ground.

Mr. Paul Reid:

I fully accept that, but it is not that the assessment of need is the starting point. People can access the services while a wider assessment is done.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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My point is that people do not get the services in a universal way. I am sorry to cut across Ms O'Connor. That may be so in some community healthcare organisation, CHO, areas. The witnesses will be aware that the Ombudsman for Children is doing a report on the consistency across CHO areas, which is due to be published in 2022. Certainly, in my own area of CHO 6, it is not so for the volume of parents who are contacting me. I am involved with Ballyowen Meadows Special School in Loughlinstown. It is a very interesting place to get an assessment more broadly, because children are coming from a range of CHO areas.

I met the parents, teachers and the principal some weeks ago. Clearly, there are very different experiences for children and families depending on the CHO area they are in. Therefore, while I appreciate that what Mr. Reid might be saying is accurate at a macro level, I assure him it absolutely it is not so.

Mr. Paul Reid:

No.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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Then there is the additional complication of an intellectual disability being brought in with an assessment of need in respect of autism and how that can be an additional complicating and delaying factor.

Ms Anne O'Connor:

There are a couple of things on assessment of needs. The reason we went down the road of the preliminary team assessments, PTA, was to try to do a shorter assessment. The challenge we have with assessment of need, AON, is we have different durations of assessment. For some children the assessment goes on for a very long time. Our resources get tied up in assessing and we cannot provide any intervention. It was an attempt to try to rectify that and to be able to provide intervention. The Deputy spoke of the challenge being about a child getting into school to get the necessary supports. We are very challenged in carrying out assessments that relate to children's education. In our discussions with the Minister, it is about trying to square that circle somewhat. We have our staff working in disability services assessing all the time, not providing sufficient intervention, which is actually the bit that matters to the families, and teeing them up for educational supports. We would argue our role in education needs to be looked at a bit and how we work with the National Educational Psychological Service, NEPS, system in providing those supports.

What we know from the PTA is that we focus on the child's needs. There is a big emphasis on diagnosis to be able to access supports, but the important bit is how we address the needs. They are slightly different.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I could not agree more. It is not an either-or thing. It is very much both and they do not need to contradict each other and there is no need to have a stream that delays or impedes the delivery of therapeutic services, which is all that parents want.

Ms Anne O'Connor:

The streaming of children into services is what we are trying to achieve through the PTA, but as Mr. Reid said, given the High Court ruling, we have to go back and look at it in a different way. Our priority is to get children into intervention and to be able to provide supports to them and their families as early as possible because, as the Deputy knows, the earlier the intervention, the better for everybody.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I do know indeed. I have another case in my constituency of a child who is 17 and is about to age out of the process but is yet to receive an assessment.

Ms Anne O'Connor:

I do not know the area but there are variations around areas, as the Deputy noted, depending on capacity. We know the availability of speech and language therapy and psychology is a huge issue in some areas, particularly for children with autism diagnosis. You might go to a service where they have a physio, but that potentially will not be as significant for someone with autism. We are looking at that in terms of how we can recruit. We are challenged in recruiting in some of those disciplines. It is also part of the work we are doing to try to level the playing field a bit. There is no doubt we have a challenge in bringing health and social care professionals in for disability sector. The reality is the disability sector is a hard place in which to work. When we try to recruit young staff, they do not always want to go there. They will want to go to primary care, hospitals or whatever. Our recruitment for disabilities is tied up in the broader recruitment challenges we experience.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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The Department has a substantially increased budget for this. The Minister announced an additional 100 posts and then another 80 posts, 24 of which were to be allocated to my area. I appreciate Ms O'Connor cannot speak about the 24 posts but how many of the 180 have been filled?

Ms Anne O'Connor:

I am sorry. I do not have the detail, but funding is not the issue.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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Funding is not the issue.

Ms Anne O'Connor:

Funding is not the issue in recruitment for staff for disabilities. It is the availability of the workforce.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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Assistant psychologists were going to be attempted to be used to try to help. Will Ms O'Connor tell me more about that?

Ms Anne O'Connor:

We have assistant psychologists in place in mental health. That was an effort to improve the waiting list in respect of young people and come in under the primary care banner. We are looking to roll-out the model across our enhanced community care programme and primary care. It is not straightforward. Not everyone is for it. We are reviewing how it is working in mental health. It is a way of trying to get more capacity in and we are working on the system based on what we have learned on mental health.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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How quickly can that be done?

Ms Anne O'Connor:

I do not know how long it will take us to get them in. I will have to come back to the Deputy on that because I cannot say specifically for disabilities, if that is what she is asking.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I appreciate the recruitment challenge but there is a sense of ongoing drift. Again, on the timely assessment for the child who is five years and has waited 26 months for assessment or the child born today who will be identified as having a difficulty, under the new process Mr. Reid is developing with the Minister now, what is the interim solution and when will we have a timeline for the new system?

Ms Anne O'Connor:

We do not have the timeline. We are working through what that model will look like. We have had to rebuild what we do in the assessment of need-----

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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Will Ms O'Connor give me a ballpark? Is it a year, three years or three months?

Ms Anne O'Connor:

Our priority is to go back. We have had to contact the children who have been assessed under the PTA to see if they want to go for assessments. They do not have to go for assessments. There are priorities to reassess those people if that is what the parents want. On working through a new model, as Mr. Reid said, we only kicked-off that engagement last week or the week before with the Minister and stakeholders across our statutory services and, equally, some of the organisations we work with. That work is under way and I would have to come back to the Deputy with a timeframe.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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Why would the priority be to reassess children under that system rather than prioritise children who are growing up with difficulties not being addressed?

Ms Anne O'Connor:

That would be because of the standing of their assessment. There is a view those children have not received an AON under the Act.

Mr. Paul Reid:

It is the nature of the court finding.

Ms Anne O'Connor:

Therefore they must be given the option of an assessment.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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And that is a priority because of what exactly? What is the pressure there making it more of a priority than assessing children?

Ms Anne O'Connor:

The High Court ruling.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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Yes, fine, but what is it in the court ruling that says that must be prioritised over other things, or is that the HSE's interpretation of it?

Ms Anne O'Connor:

It is in terms of their entitlement under the Act. They are people who were brought forward for a PTA. As the PTA is considered not to be an assessment of need under the Act, they now have to be offered an assessment of need.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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What about those other children who have not yet had an assessment of need who also have an entitlement and who did not fall under the category of the High Court ruling?

Mr. Paul Reid:

It is both that we have to capture.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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It is both. That is exactly my point.

Ms Anne O'Connor:

It is chronological. Where children are brought forward, it will be based on a chronological date.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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My difficulty with the chronological approach is that it just creates further delay for the children at an early stage now and creates more difficulties for them. Again, does this have to be either-or? Can this be both?

Ms Anne O'Connor:

That is what is being looked at in the model we now implement. We were doing the PTA in an effort to try to reduce the time.

Mr. Paul Reid:

To reassure the Deputy, that is exactly what we are trying to do: to capture both. The court finding said those 10,000 were not compliant. We have to address it but we also need to meet the pipeline that is coming through. It will not be a short fix. This will take time but we are looking at processes, recruitment and the qualifications of people coming through. We want to go back to the Minister with a wider plan. As Ms O'Connor said, I cannot put a timeframe on it right now but the process has started.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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When a parent points out that an assessment has not taken place and the HSE says it has, do the officials think we can respond in a cultural way in future to what parents are saying?

Mr. Paul Reid:

The Deputy makes a very real point. We have inconsistencies across our CHO areas in resourcing, communications and culture. We have to make real difference in changes. I personally have acknowledged that with the team to the Minister. We have to make a cultural difference. That is the challenge the whole system is working on daily. It is a very challenging environment and I want to show my support for staff who do work in the area because we want to retain them and we want to secure more people in. Like many aspects of our service, however, we have real cultural issues that we have to change in communications and patient experience and then going back.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I will let the Deputy in for a second round. A few people will not show up. Deputy Carthy is taking Leaders' Questions, Deputy Munster has a bereavement and there are a few other gaps. I will try to get people in a second time.

Will Mr. Reid focus on the dental scheme? I will deal with the dental treatment services scheme, DTSS, first. The scheme does not exist in many counties. Nothing I will say is meant personally. I realise there are problems. We have a system that grew up from a certain place. That is what we have and we have to change it. Only 660 dentists were active in the scheme in March. That is 1,000 fewer than four years ago. Of those who are active, it is very difficult. It does not exist in some places. In Laois we have given up on it completely. Will Mr. Reid clarify this briefly? I ask him to keep his answers short, please, as I do not want to cut across him. In Laois and Offaly and across the country, if a medical card patient cannot get in under the DTSS, can he or she go to the health centre? Is the HSE obliged to provide emergency treatment for them? Yes or no?

Mr. Paul Reid:

I cannot comment on the Laois experience.

Brian Stanley (Laois-Offaly, Sinn Fein)
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No, just throughout the country in general.

Ms Anne O'Connor:

It would be for children. We do not necessarily provide adult services in our public services.

Brian Stanley (Laois-Offaly, Sinn Fein)
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That is okay. It was just to clarify that. There are negotiations going on and I do not want the officials to announce what is going on but we are dealing with thousands of private businesses because each dental practice is a private business. That is fair enough. I am not hung up on that. It is the business they are in. They have all come together and they have an association with substantial leverage. They have the HSE, the Department of Health and us where nothing will move until they decide to move.

They will say they have justice on their side and they are not getting enough money and perhaps there is some merit in all that but it has been a problematic as long as I can remember and now it has reached the point where it has collapsed. We can accept that. I am not blaming anyone here for that but the system is not working. Maybe Mr. Watt can come in on this. Has the Department considered recruiting directly employed salaried dentists to work in the HSE to provide emergency services or services to medical card patients? Is that happening or has any consideration been given to it? I am thinking about Sláintecare in particular.

Mr. Robert Watt:

We did have consultations with the Irish Dental Association and the Minister on 12 April. It approved a substantial increase including the reintroduction of the scale and polish and an increase in fees which I understand have come in from 1 May. There is significant extra funding but there clearly is a problem which is two-fold. There is a shortage of dentists more generally. We have been in discussions on how we can increase the number of dentists and train more dentists. The Chairman's question about salary is interesting. That has not been the approach that we have taken heretofore.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Is it being discussed?

Mr. Robert Watt:

I do not think it has been discussed but it is certainly worthy of consideration. We would have to think about how we could make the salaries attractive and make sure that people who had a career in dentistry could choose the public system over the alternatives. There is a shortage of dentists and we need to address that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Is the dispute still unresolved?

Mr. Robert Watt:

No. We had consultations. The Minister made decisions about polish and scale and an increase in fees.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Has the Irish Dental Association accepted that?

Mr. Robert Watt:

A further engagement review of the scheme must take place. That decision was in respect of the additional money that the Minister was able to allocate to the scheme and how it would be spent. From that consultation the Minister has made a decision. However, there are more fundamental questions about the scheme and its attractiveness and how we can ensure that medical card patients get treatment.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Will that be back before us in two or three years time? That is what I am concerned about. The system has been problematic going back years. It is about Government policy but Government policy is now to move to Sláintecare. Mr. Watt and I know what Sláintecare is about: it is a public health system. I do not want to be too ideological about it but it generally means that we would directly employ dentists who would be obliged to see patients. It is also about where graduates come out of training that it would be attractive and they would see a career in dentistry within the public system. Not all of them want to be running a business. It is the same with GPs. Not all GPs coming out of training want to run their own practice.

Mr. Robert Watt:

But there is further review and as part of that we can put that question into it. There is no reason we should preclude looking at it.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I now turn to the school dental scheme. I apologise for moving quickly. What is the budget for the school dental scheme this year or last year if the officials do not have the figures for this year?

Mr. Stephen Mulvany:

We do not have them with us today but we can get them for the Chair.

Brian Stanley (Laois-Offaly, Sinn Fein)
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How much would it be going back over the years? Mr. Mulvany must have some idea as financial officer.

Mr. Stephen Mulvany:

If the Chair had asked me about DTSS I could have answered that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Is it €10 million, €20 million? What are we looking at for school dentistry?

Mr. Stephen Mulvany:

I do not have a figure in my head for that. Apologies.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Okay. Here is where I have the problem. As I have said here before, I saw a dentist when I was eight or nine years old. My grandchild is 16 years and has not seen a school dentist. I am not here to fight her battle but I am trying to illustrate that the system is not working when it comes to primary school dentistry. Health professionals and common sense tell us that it is about a stitch in time and early intervention. Failure can mean bad dental health and general health further down the line. Can Mr. Reid say what the problem is? Is it a shortage of money or dentists? Briefly, what is happening?

Ms Anne O'Connor:

It is a severe shortage of dentists.

Brian Stanley (Laois-Offaly, Sinn Fein)
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It is a shortage of dentists.

Ms Anne O'Connor:

That is in the public sector and private. Even the private dentists are struggling to get dentists.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I am thinking of the example of retrofitting houses. Some of us would have known that was coming and said that we needed to start training apprentices on how to retrofit. I have observed this morning how many of the answers come down to the lack of recruits and then, obviously, retention is an issue. If people come into a system that is overloaded they are not inclined to stay because they are overworked.

So, with dentists, at this point, at Secretary General in the Department and CEO level of the HSE what is being done? What is being said to the Government? The Minister for Further and Higher Education Research Innovation and Science comes in to this too. We need to train more dentists. Are we only offering them short-term contracts when they come out of training and they say "Get lost with that, I'm off to Australia where I can get a permanent job"? What is happening there? Are they not going into the system? Are we telling people in the universities that there is a career path here for them? Are we saying that we need good dentists in the country and it is a good, solid, rewarding job with plenty of work?

Mr. Paul Reid:

We work very closely with the Department across all the professions to look at the colleges and the academic profile that is coming through with doctors, nurses and dentists. We talk with the colleges, and are doing so, about how we can increase the pipeline in the coming years. Unfortunately it is not a short-term fix -----

Brian Stanley (Laois-Offaly, Sinn Fein)
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I know that but what if you want them in five years time?

Mr. Paul Reid:

To reassure the Chair at a general level, across all the professions we talk to and with the Department and the policy-makers about the pipeline of health professionals including health and social care professionals. In the interim, we are looking overseas for many professions as part of an international recruitment campaign. Again, we are fishing in a big pool or, rather, it is a much smaller pool.

Brian Stanley (Laois-Offaly, Sinn Fein)
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How many dentists are in the school dentist scheme?

Mr. Stephen Mulvany:

There are 254.

Brian Stanley (Laois-Offaly, Sinn Fein)
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How many are on short-term contracts?

Mr. Stephen Mulvany:

That number has been the same since at least 2019.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I know but those 254 are across the State.

Mr. Stephen Mulvany:

I am not saying it is enough. To answer the Chair's earlier question there are 800 staff in total in the child dental service. I would estimate that it is about a €100 million budget.

Brian Stanley (Laois-Offaly, Sinn Fein)
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There is 800 staff and only 250 are dentists?

Mr. Paul Reid:

There are also orthodontists, dental hygienists, dental nurses and so on.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Have we half the number we need, a quarter of the number?

Mr. Stephen Mulvany:

I have a statistic here that the percentage who did not receive an appointment was north of 50%. That would indicate, as colleagues have said, that there is a substantial shortage.

Brian Stanley (Laois-Offaly, Sinn Fein)
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So we have fewer than half the dentists we need.

Mr. Stephen Mulvany:

I could not say that is the exact figure but there is definitely a shortage.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I am asking because dentistry is something I get asked about. The public ask me what has happened to the system. People in the midlands raise it with me but it is replicated across many counties. There is a budget that comes across from the Oireachtas and the Department of Health and it goes to the HSE. I know there is no sticking plaster and it is about the pipeline. We have identified that we have fewer than half the school dentists that we need. Is there resistance from the Department of Further and Higher Education, Research, Innovation and Science about training? Is there resistance from colleges? Yes or no?

Mr. Paul Reid:

No, on the contrary. I assure the Chair that we have had very good engagement. My colleagues from the Department might want to comment on it but across all the professions we have had engagement to look at solutions and do so differently including what qualifications may be required.

Mr. Stephen Mulvany:

Can I clarify the figures I gave the Chair are for the child service which includes special needs adults as well?

Brian Stanley (Laois-Offaly, Sinn Fein)
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That really is paper thin. It is very thinly spread across the State. Again, it is a pipeline issue. It is up to us to highlight these things and try to get them addressed. That is why I am raising them this morning because unless you have the staff you cannot provide the service.

Mr. Robert Watt:

If I may add to what the Chair said, it is fair to say that there has historically been a disconnect between the training in a number of these disciplines -----

Brian Stanley (Laois-Offaly, Sinn Fein)
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So I have noticed.

Mr. Robert Watt:

-----and the likely or prospective demand based on any reasonable assessment of demand given our demography. Many of the areas the Chair has spoken about this morning can be driven by demography and other factors can impact on the demand. Something that I have focused on, and Mr. Reid is very much aware of this as we have had many conversations about this, is for us to have better workforce planning and align the educational attainment and the number of people doing undergraduate training and then placements after their undergraduate training in the hospital system. I know the committee is stuck for time so we can circulate a note showing the different areas where we have increased and are increasing the numbers. For example, from September, the number of medical undergraduates will be increased by about 60 and there are plans to increase it further.

The Minister for Health and the Minister, Deputy Harris, are working on this. We have engaged with the medical schools. We are now thinking of what to do about the dentistry schools and a proposal is with us. It is an historical issue and we can start to address it now to improve the situation in four, five or six years. As Mr. Reid mentioned earlier, in the interim, we have to retain the people in the system.

Brian Stanley (Laois-Offaly, Sinn Fein)
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That was already mentioned.

Mr. Robert Watt:

We have to keep those who are graduating now in the system and get those who have gone abroad back. There are multiple aspects.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Are they being offered short-term contracts? Is that why many choose to go abroad? Are they offered the chance for a year's probation and then to get a job or are they just being offered short-term contracts in dentistry?

Mr. Paul Reid:

We offer significant full-time contracts across all the professions. That is our primary model. As to why people are going abroad, we have a significant young workforce, including doctors, nurses and other professions. They have had two years where they could not travel. We see a trend where younger people in particular want to travel. They want to get experience abroad and then come back.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Mr. Reid is saying that is a good thing.

Mr. Paul Reid:

We have done some early analysis of doctors and nurses who travel abroad but come back to the service after a period.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I am trying to highlight that we will never get Sláintecare and a public health system. The people who will be sitting in this room in 15 years will be talking about the same thing if we are not able to collectively get the pipeline of skills and qualified professionals producing something at the far end. This requires joined-up thinking between the Oireachtas, the Department, the HSE and the other Departments involved, such as the Department of Further and Higher Education, Research, Innovation and Science. That needs to be rocking and rolling.

Mr. Paul Reid:

Mr. Watt has qualified some of the engagements that we have had. The people who were sitting here ten years ago would not have seen the recruitment levels we are seeing right now. Some 14,500 people have come in, which is the highest number on record.

Brian Stanley (Laois-Offaly, Sinn Fein)
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The school dental system has gone backwards. Children are seen in third year in secondary school instead of third class in primary school, which is six or seven years later.

Mr. Paul Reid:

I was just making a general point.

Brian Stanley (Laois-Offaly, Sinn Fein)
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It is a failure. The system has collapsed. If Ms O'Connor or the staff can do anything about that, it needs urgent attention.

Mr. Robert Watt:

This is a strategic focus for us. We are trying to address these shortages. It is a function of the pipeline of people who are currently doing training. They will be available in four or five years. It is about our ability to retain people and bring them back. A variety of issues are involved. We need to provide more opportunities, particularly for young people who have completed the leaving certificate, to go into medicine, dentistry and a variety of specialties. The Minister, Deputy Donnelly, is committed to that and he and the Minister, Deputy Harris, are working intensively on that, particularly on initiatives for this September and September 2023.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Will Mr. Watt send us a note on the figures for dentistry? How many dentists are there for the school system? What has the budget been over the last three years? Will the witnesses send a note on the dental treatment services scheme, DTSS, and its progress?

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I thank the witnesses for their opening remarks. I would like to touch on a number of areas. I will be brief in order to get through them in the limited time available to me. To touch on the issue of assessment of needs that we were discussing a little while ago, the redesign in the HSE that is being spoken of is welcome, but a definitive timeframe for when that will be published would also be welcome. I heard Ms O'Connor's remarks about the focus on the child's needs, which is right and proper. Does she have a timeline for when that will be complete?

Ms Anne O'Connor:

No. I will have to come back to the Deputy about that. The event was last week or the week before. I know work was going on to determine the best way forward. Until we know what that is, we will not have the timeline.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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We can touch on that when we meet again.

Ms Anne O'Connor:

Absolutely.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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A constituency colleague, Deputy Carroll MacNeill, raised disability services too. We are fortunate that we have services in CHO 6, with St. John of God, St. Michael's House and a number of other service providers. That is excellent but there are delays in simple resources and facilities. One involves a child who has been waiting for over six months for a wheelchair. It is not anything bespoke. It is a standard wheelchair. There has to be a better turnaround time. I assume there was a good tendering process, with these being brought in and delivered to families who need them. Is there a reason for such an inordinate delay for something as simple as a wheelchair?

Ms Anne O'Connor:

It depends. The Deputy says it is a straightforward wheelchair. I do not know what the story is there. There has been an avalanche of requests for aids and appliances recently. That massive demand may be a factor. I would have to check out the specific case. We have some issues with supplies. It depends on the specifics of the wheelchair. We have some issues with supplies and a challenge with the volume of requests and assessing people for equipment. I would need to know the details.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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From the perspective of a family of children or adults with disabilities, there is no clear pathway. It seems to be a maze for those families. We need to clear a pathway. There should be a helpline to ring and information about the services and entitlements that people will be afforded. If something niche or bespoke is required, people understand that there will be a delay. I cannot understand such a delay for such a basic necessity as a wheelchair. The answers I have got about why there is a delay have not been clear. I will liaise further with Ms O'Connor about that. To me, it points to a bigger problem.

We have an issue with residential care and respite places in CHO 6, which I understand happens nationwide. How are we progressing with purchasing and staffing properties for residential places? I understand the issue with staffing extends across the country. Mr. Reid said that resources are not an issue for staffing and recruitment, but getting people into those positions is the challenge. How are we faring with residential and respite care?

Ms Anne O'Connor:

I am glad the Deputy raised that. We often focus on assessments of needs and often do not focus on the other end of disabilities, which can be serious. We have seen a significant increase in demand for residential placements. Critically from our perspective, post pandemic we see that some families have just had enough. Many people are coming forward, having gone through potentially two years of day services being closed and struggling with challenging behaviours at home. We know that it is often a severe challenge for ageing parents. We see some difficult situations for people with high complexity cases. We are struggling to get residential places. It is easier in some areas than others. We are completely reliant on all those funded agencies that the Deputy referred to. Regarding the cost of placements, we know we have to provide for many people. If I think back to many years ago, if a placement cost more than €100,000, it was a big news story. Many of our placements now cost between €500,000 and €1 million. We are challenged to find places that have sufficient staffing. Like the HSE, those voluntary providers and funded agencies are equally as challenged.

One challenge and discussion we have had with the Minister is about developing houses. We are looking at how to do that better as part of decongregation and as part of respite. In theory, the HSE should be building houses. We are looking at how we can work with local authorities. It is working well where we provide them with support. It is a mixed bag, to be honest. We are very challenged in Dublin, especially in south Dublin, with regard to anything to do with property, even for providing accommodation for staff to attract them. It is a different picture around the country.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Ms O'Connor might send a note about that. As she said, respite and residential care are not aired enough. I would appreciate an update on that.

Ms Anne O'Connor:

It is challenging for everybody, especially families.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I am chair of the all-party Oireachtas committee on diabetes. I am aware of a framework being discussed by the HSE and providers of certain continuous glucose monitors, CGM. It is taking a long time. There was a previous attempt in 2017 and 2018 to get approval for a particular monitor.

That has an impact on those with diabetes. I do not expect Ms O'Connor to have the information right now but if she could come back to me on that, we need to have a definitive timeframe, given the fact that it is at least four years in discussions with the HSE, and also on the LTI list. The supports and adaptations for the CGM monitors also need to be included on the LTI list.

As I am conscious of time I will turn to the value for money aspect for nursing homes. In the documentation it states the cost of providing service in a public nursing home was two-and-a-half times the cost in a public nursing home. What is the update now that report has been published? What will we see in changes of the funding model? What is the thinking within the HSE on the Value for Money report?

Mr. Stephen Mulvany:

The report was published at the end of December. It indicated that the average cost in a private nursing home was about €900 a week and we are reimbursing public nursing homes with about €1,600 whereas the costs are more like €2,000. Specific recommendations flow from that Value for Money report some of which feed back into two other reports, the Expert Panel on Nursing Homes and also the NTB Price Review. As we said earlier, there is no mystery as to why the HSE's public cost of care is higher. That is not necessarily a bad thing in terms of the richer mix of nursing staff and so on. However we are doing a bed census at the moment which is nearly finished on all of our 7,000 public nursing home beds, long-term and short-stay care. Some of them are closed. We have to see which ones we can reopen, which need to stay closed and so on. The aim is to set out a national framework by the end of the year for what the appropriate level of cost should be for public nursing homes, how beds should operate and the overall model.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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That is by the end of the year.

Mr. Stephen Mulvany:

By the end of year we aim to have a national framework around that and then we will have to implement it. Because the cost of the public sector is higher than the private, that report looked at costs from 2019. It made it clear that those private nursing home costs were likely to have increased during Covid-19. The Expert Panel Report indicated that perhaps they need to increase staffing levels to some extent, in some cases. The gap will narrow between the units. Some units are particularly challenged because beds were closed and the number of staff cannot be reduced just because beds are closed. It depends on where the beds are closed. The same cost gets spread over a smaller number of beds and the cost per bed goes up.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I have one minute remaining for three questions. In regard to the waiting lists and the national treatment purchase fund, NTPF, in April a total of 7,221 patients were on some form of public waiting list to be treated or assessed by a consultant. How is the NTPF assisting in those figures or is it not assisting with those numbers? Also, the last time the HSE was in, we spoke about the cyberattack. It is obviously of huge interest to everybody that we would be well prepared and resourced to head off any other such incident. However, the recruitment of the head of the national cybersecurity centre, NCSC, was outstanding at the time. I understand that the salary had to be changed and another offer made. Where does that stand now?

Finally I notice in Vote 38(F)(1) on page 9 of the appropriation accounts for 2020 there was a reduction in expenditure in regard to the payments for those affected by thalidomide. Why was there a reduction in that? Hopefully that issue and the cause for those thalidomide sufferers is coming to a resolution after, not years, but many decades.

Mr. Paul Reid:

I will comment on the NTPF. We are working jointly with the NTPF. That is part of the incremental extra funding with a total of €350 million extra in this year's service plan, €200 million to the HSE and a proportion to the NTPF. It is working jointly with us on the reduction of waiting lists which we committed to reduce this year. Just to say that first, if I have not fully addressed it.

On the cyberattack, I need to differentiate. I am assuming the Deputy's question relate to roles to be recruited within the HSE? I know he said the NCSC was-----

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Yes.

Mr. Paul Reid:

So, I understand the NCSC role has been appointed but Mr. Watts will clarify that. In particular the cyber report related to senior roles within the HSE for which we are in the process of finalising an external recruitment. In the interim we put a contract for services out to address a whole range of the actions on the cybersecurity plan. We are about to finalise that and appoint the procurement team which will in the interim give us those two specialist roles on a contract for service basis along with the wider supports for the actions to set up. Finally on cyber issues, I can assure the Deputy that we were not just waiting on those roles. We have taken a whole suite of actions on security and protection. I always try not to say them publicly but I want to reassure members that we have taken a whole set of actions on it.

On the third question about thalidomide, I cannot comment on that but will try to come back on it.

Mr. Robert Watt:

To add to what Mr. Reid has said, in regard to waiting lists and the NTPF, overall there are some 1.7 million planned removals from waiting lists for this year. The NTPF is allocated €150 million which is an increase on previous years. The expectation is it will contribute to around 280,000 cases. If that number on removals from its contribution is not correct, I will come back to the Deputy.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I thank Mr. Watt.

Mr. Robert Watt:

There is €200 million in the access to care fund which is to fund additional activity, mostly insourced within the public system and then reform of pathways and other initiatives. As part of the waiting list initiative we are looking at driving additional activities. Like all parts of the system, the NTPF was affected by Covid-19 in the early part of the year. We are back up thanks to the efforts of people in the public system in referring patients and because of capacity now available in the private system we are back up to the weekly targets of removals, working with the NTPF.

On the thalidomide issue, that had to do with slower than expected drawdown due to the mediation process being slower because of Covid-19. It is €15,000 lower than was projected for the actual spend in 2020.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I welcome Mr. Reid's-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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I will allow the Deputy back in a for second round of questions but I want to be fair to the others.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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It was just on the issue of cybersecurity from the Department's perspective, that is all. I hear what Mr. Reid is saying about the HSE internal situation which is welcome. Does Mr. Watt have any further update in terms of the NCSC?

Mr. Robert Watt:

The Department of Environment, Climate and Communications is responsible for that. We contribute to that as do all Departments in terms of improving our preparedness and investing significant investment now required to increase our resilience. Given what happened to our system in the HSE obviously across the system we are more concerned about the impact of these attacks, their frequency and severity. That is being led by the Department of Environment, Climate and Communications.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I thank the witnesses.

Brian Stanley (Laois-Offaly, Sinn Fein)
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It is a very important issue for society at the moment with the ongoing conflict.

Alan Dillon (Mayo, Fine Gael)
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In my second round of questioning I will focus on the HSE capital and estates division responsible for the delivery of projects included in the HSE capital plan. One of the issues is the delay in the delivery of projects. In 2020 there was €833 million to deliver what is a substantial annual capital programme. On current staffing, if we take for instance the CHO 2, the Galway estates team and the technical team that is there to deliver projects, there are only seven technical staff. Do the witnesses believe the number of consultancy services we use and HSE staff within the estates and the building division is adequate to deliver on the annual capital plan?

Mr. Paul Reid:

Our capital plan is increasing thankfully, as is funding this year. Our estates project teams, and I do not have the numbers to hand, have delivered internally within the HSE very significant projects in particular over the past year or so including the National Forensic Mental Health Services Hospital, the National Rehabilitation Hospital with 120 extra bed units and a number of other big strategic projects.

They have a good track record in delivering.

Specifically on resourcing, yes, we are resourcing them further. They do need it. There will always be the balance between in-house expertise and what we can recruit internally and the use of contracted agencies, which we are doing. I am very familiar with the demands particularly on the Galway team. I have been chairing a call for the last few weeks with the Galway national and local teams on some of the significant projects that we have in Galway.

Alan Dillon (Mayo, Fine Gael)
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On the capital design consultancy expenditure for 2020, €34.749 million was spent on non-capital estates expenditure on external consultancy related to €833 million of capital projects. In order to get faster delivery on projects, for instance the emergency department, ED, in University Hospital Galway or in Mayo University Hospital, why are we not using external consultancies to deliver on these projects? If you look at detailed appraisal, planning and design, appointment of project managers, procurement, construction commissioning, we are getting timelines of over 60 months to deliver projects.

Mr. Paul Reid:

Sorry, I may have interpreted the Deputy's question wrongly. We do use significant external expertise and are doing so in Galway. It is expertise that we could not build up within the health system ourselves. That is not unusual for a public service. We are a health service. Our core model is health delivery. We do have expertise in-house and we are strengthening it but we will always use significant external expertise.

On the pipeline delays and particularly with Galway, which I am very familiar with, there are significant planning issues that we have to work through. Highly significant objections emerged at early stages of planning. That can be part of the -----

Alan Dillon (Mayo, Fine Gael)
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Has that project gone to planning yet?

Mr. Paul Reid:

No, we are just finalising the business case on that and in parallel we are having some pre-planning discussions with Galway City Council.

Alan Dillon (Mayo, Fine Gael)
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I am thinking of the delivery of smaller-scale projects. For the Department of Health, anything over €100 million goes to Cabinet for approval. Anything below €20 million seems to fall off the radar altogether. How does the Department of Health get oversight over smaller-scale projects that are equally important in each of the CHOs?

Mr. Robert Watt:

The scale of the project does not mean that in some way they fall of the radar. There is an extra assurance process for projects over €100 million. They have to go through the external assurance process set out by Department of Public Expenditure and Reform. The Department of Public Expenditure and Reform officials can explain how it works in more detail. The Government would have to sign off on it as well, because of the scale of the project. We have a list of projects set out in the plan. The HSE has published it. We, along with the HSE, then monitor the delivery of those plans. There are allocations this year for projects that started two years ago, ones that started last year and ones that are commencing this year. It is a multi-annual plan.

Alan Dillon (Mayo, Fine Gael)
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Is there a carry-over of projects from 2021 to 2022, say? Do we have visibility on that?

Mr. Robert Watt:

We do.

Alan Dillon (Mayo, Fine Gael)
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What does the Department of Health do if multiple projects are being carried over?

Mr. Robert Watt:

Most projects go over one year. Those of them that take sufficient time to -----

Alan Dillon (Mayo, Fine Gael)
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Is that acceptable?

Mr. Robert Watt:

Yes. The timeframe to deliver the project will go over many calendar years.

Alan Dillon (Mayo, Fine Gael)
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Has the Department ever allocated additional staff to expedite projects?

Mr. Robert Watt:

We have, yes. We reorganised the capital side in the Department of Health to better support the capital estates in the HSE so that we can-----

Alan Dillon (Mayo, Fine Gael)
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Will Mr. Watt give us an example of a project?

Mr. Robert Watt:

Yes, the electives for Cork, Galway and Dublin that we are working on. On getting the business case, getting the insurance and getting the detailed planning, that has been reorganised in terms of the Department's new assistant secretary who joined the Department and is responsible mostly for capital now. He is driving that. He is trying to push through the different gates faster. The people in Department of Public Expenditure and Reform can explain how that works in more detail. There is a delay from the time that we can say something is a good idea, and there is a concept to build something to then develop the business case, go through the assurance process and so on before you actually get to the procurement. We are trying to accelerate all those stages so that once it is decided that something is a good idea and we go through the cost-benefit analysis and have a clear view of the benefits and costs, that we can then get to procurement as quickly as possible.

Brian Stanley (Laois-Offaly, Sinn Fein)
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There is huge frustration. It would be helpful if the Department could come back with a note on the process and how it is worked through.

Mr. Robert Watt:

We share the frustration about the time it takes to get things done. We share that. There is a whole variety of issues involved here around procurement, which is set by directives transposed into Irish law, the planning system - which others know more about or even could do more about than I could - on how we plan and judicial reviews, objections to planning and so forth and then there are the challenges in the construction sector. Those are only getting worse. There is pressure now about getting competitive bids -----

Brian Stanley (Laois-Offaly, Sinn Fein)
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Okay. Sorry. Mr. Watt has outlined fairly well some of the difficulties. It would be helpful if Mr. Watt could come back to the committee with a note about the process and how it works through. Deputy Catherine Murphy has five minutes.

Catherine Murphy (Kildare North, Social Democrats)
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I will return to recruitment and workforce planning. When there is an allocation at budget time, the public expects a better service. I return to the whistleblower who recorded. We do not concern ourselves with how we get information, just the substance of the information. The recruitment targets were described as "batshit" by officials in the Department. What was Mr. Reid's reaction? Was he surprised at the nature of that conversation? What was the reaction? We all know that big organisations circle wagons. Did Mr. Reid satisfy himself about the substance? The other thing was about the sloppiness of the financial reporting. We did see a prior year adjustment announced after that. How did Mr. Reid deal with that?

Mr. Paul Reid:

To look at some of the specifics, my role as leader and CEO of the HSE is ultimately to remain calm in such situations. Some of the remarks would not go down very well and would be uncomfortable for many of my team who are here and who had to experience it. We had dialogue with the Department. Whether recorded or not, we always have very robust challenges both within our own team and the Department. It is always very respectful, I should say. So, yes, some of the commentary hurt but on the substantive issue, I believe that what happened this year in process for forecasting 5,500 people was actually the right process to say upfront, so the Minister is informed and the national service planning process is informed in order that we can make the right decisions earlier in the year rather than at the end of the year. The intent of the process was to say what was happening in the market and the likely outturn that we would all review that which we are doing at the moment. So I think the process was the right one.

Catherine Murphy (Kildare North, Social Democrats)
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I am concerned. Not everyone who blows the whistle is right but take Kerry child and adolescent mental health services, CAMHS, and the treatment of the person who subsequently left the HSE. That is a concerning indication for me. What is Mr. Reid's approach when people raise significant issues? I was less than impressed. There is a real serious issue of accountability. There were media reports about the State Claims Agency in recent days. The damage to the child and his or her potential is the key thing. But there is concern about accountability, oversight and management. What is Mr. Reid's attitude? How does he deal with it?

Mr. Paul Reid:

First, on Kerry CAMHS, my response was to go down there. I met staff, in all the teams down there. There have been some changes. I met the parents of some of the children affected. It was quite an emotional moment for them to feed back their experiences. I met the look-back team involved, which will carry out the look-back review. That was for me to get a deeper personal understanding.

Catherine Murphy (Kildare North, Social Democrats)
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What engagement did Mr. Reid have with the person who identified the problem?

Mr. Paul Reid:

I was going to come to that. Specifically, in relation to the person who raised the issues, they are of very significant concern to me. There is a process in place for people to come forward with those issues and we encourage that. That is the subject of a very formal process under the relevant legislation that we are continuing. That process has commenced and the person who relayed those concerns is directly engaged as part of the process.

That is a very formal process that we triggered and I cannot comment on that in any particular detail but I did comment.

The Deputy, like many other Deputies at this Oireachtas committee and others, has quite rightly raised the issue of accountability. She asked me what we have done about it. In the very early stages of my tenure in this role, we brought a paper to the HSE board and looked at the issue of accountability. There are a few strands to what happened that we must strengthen. First, when we carry out significant reviews into what happened, or into the harm that happened to some people using our services, we tend to go into a cycle that involves carrying out the review and assessing whether somebody was at fault for what happened. We go about it sequentially. We are looking at that process to make sure we do it.

Very briefly, accountability in the HSE and the public service is a function of a range of issues. First, is the performance management process in place? We have to strengthen our game in that regard. Second, are there very clear lines, roles and responsibilities across the service? We are doing very significant work on that. Third, when incidents go wrong, what is our process if a discipline process has to be taken? Fourth, there is the whole issue around regulation. This involves working through the regulatory health grades that we have and the right regulatory bodies when things go wrong. There are a range of issues that tackle accountability. I know that publicly it comes down to whether someone is fired or held responsible, but we have to take a very multidisciplinary approach.

Catherine Murphy (Kildare North, Social Democrats)
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It often happens that people emerge from the courts and the HSE issues an apology. There is supposed to be an open disclosure approach. Obviously the State Claims Agency is the one that deals with it. On the financial side, where are the settlements referenced when they are made? I presume they are referenced in the budget of the Department of Health. In terms of the last ten years, can the HSE give us a report on when the claims crystalised, the amount concerned and any learnings? People do not want financial settlements and did not want the injury to happen in the first place.

Mr. Stephen Mulvany:

As the Deputy will appreciate, the State Claims Agency publishes its own accounts that detail a lot of the information she has sought. In terms of the HSE and the health sector, the amounts that we reimburse the State Claims Agency for claims it settles on our behalf, under two main schemes, are reported in the HSE's annual accounts every year, and there is a note to the accounts.

Catherine Murphy (Kildare North, Social Democrats)
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Can the officials isolate them and give them to us-----

Mr. Stephen Mulvany:

Of course,.

Catherine Murphy (Kildare North, Social Democrats)
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-----along with the learnings and what is being done to ensure these things do not happen again?

Mr. Stephen Mulvany:

Yes.

Mr. Paul Reid:

There is a very formal process around learnings feeding back from the HSE and how we embed them.

James O'Connor (Cork East, Fianna Fail)
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Today, the HSE has discussed the ongoing work on the decongregation of certain health settings. Obviously, Mr. Reid is very aware of the decision to close the Owenacurra centre. Much of that work probably took place during 2020. I wish to raise this issue with him A number of anomalies were evident in the process of making decisions on what was planned for the patients who resided at the facility. Nine people remain in the centre. Unfortunately, following the decision to close, there is no pathway forward for the current residents in terms of relocation. How does the HSE plan to decongregate? Following what has happened at the Owenacurra centre, I am quite concerned about the provisions that have been to provide more suitable accommodation and meet needs in the mental healthcare settings that are operated by the HSE. Does the CEO think the HSE failed in terms of how it went about making the decision to close the Owenacurra centre? For future reference, when decisions are being made to close down mental healthcare facilities, I urge the HSE to plan properly and invest in more suitable settings as it sees fit. I say that because the HSE decided to close the Owenacurra centre but it did no work on the relocation of the service users. Unfortunately, the remaining nine residents do not know where they will reside in a year's time, which is an unacceptable situation that needs to be addressed.

Mr. Paul Reid:

I will respond to the second part of the Deputy's question that relates to the Owenacurra centre and wider decongregation. I know the Deputy is very familiar with the issues concerning the Owenacurra centre. The assessment that our teams made found very significant issues around fire, asbestos, mechanical and electrical issues and space issues. The biggest issue was the whole structure of the facility around daycare and residential services. The rooms and the space that people had were not fit for purpose. People who visited the facility or attended for day services had to practically go through residential areas or people's homes. So the facility was completely unfit for purpose. On the first part of the question, regarding the HSE's commitment to the Government policy of decongregating and securing sufficient facilities and accommodation, I have seen some of the residential facilities and one knows what good looks like when one visits some of these facilities. We are actively and anxiously working with the remaining residents and their families to secure appropriate accommodation that suits and facilitates their needs. We will continue to work very closely with the remaining nine residents and their families. Very good progress has been made with other residents.

James O'Connor (Cork East, Fianna Fail)
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My point relates to the decision-making process. There are many facilities around the country that are similar to the Owenacurra centre. These are HSE-owned and HSE-operated mental healthcare residential facilities. Each facility is different and provides different levels of clinical care. A decision was taken to close the centre, but no decision was made on what should happen to the residents. Some residents have been moved to nursing home care. We have had a lot of engagement with the families involved and, unfortunately, there are degrees of disagreement between public representatives and the families involved. I think the HSE failed to plan where to locate the residents and did not put in proper work to engage with families. Before the HSE's decision was made public, people discovered in July 2021 that the facility would be closed. People were left in limbo for a number of months. The HSE has changed its story on multiple occasions, which has made it very difficult for me, as a Government Deputy, to explain the situation to people. For future reference and for the remaining residents, the HSE needs to plan properly when facilities are being closed. In this particular case, there is still no concrete plan - many months later - for what will happen to the existing residents. I believe they should be allowed to remain. The number of patients at the facility has been reduced. The remaining residents should be allowed to stay on until the HSE brings forward a concrete and decent plan.

Mr. Paul Reid:

I would disagree with some of what the Deputy has just said. It may be his view and I respect that, but I disagree with what he has said about the engagement with families. I very fundamentally disagree with his claim that we changed our story, and with what he said about the process that was put in place, the assessment that was made of Owenacurra and the follow-through and detailed engagement with families. Many families and many residents have progressed very well. We will continue to work with the remaining residents in terms of finding suitable and appropriate accommodation. We are looking in the locality in terms of the potential purchase of suitable accommodation and residential space. It is difficult but we are working very locally to, potentially and hopefully, secure appropriate accommodation for the remaining residents. I assure the Deputy that our local teams have very significantly engaged, and will continue to engage significantly, with the families of the remaining nine residents. It is not an appropriate setting. The Deputy is correct that many other settings are not appropriate, and the future is decongregation.

James O'Connor (Cork East, Fianna Fail)
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It is unfortunate that I am out of time.

Colm Burke (Cork North Central, Fine Gael)
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Has a report been done that assessed the introduction of the HSE grade of theatre assistant? If the report exists, I ask that it be made available to the committee.

Mr. Paul Reid:

Sorry, Deputy, I am not familiar with the issue of theatre assistants.

Mr. Liam Woods:

There was a process of engagement around that. It is also a recommendation within the model of care for orthopaedics. We can certainly make that available and give an update on any work ongoing. As I said, it was paused during the pandemic.

Colm Burke (Cork North Central, Fine Gael)
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Have targets been set? Is it the case that a decision still has not been made?

Mr. Liam Woods:

No. The implementation of theatre assistants generally across the country is still under deliberation. There is not yet a programme of implementation but I can make available the progress that has been made to date.

Colm Burke (Cork North Central, Fine Gael)
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I would appreciate that.

I would like to move on to the issue of capital spending in the Cork area.

I very much welcome the money being spent on Heather House on the north side of Cork city and the new residential facility in Blarney, where a recently-built hotel has been purchased and is now being converted. I will raise the issue of the elective hospital. I note than only €200,000 has been put into the capital expenditure for 2022 in this regard. It still has not been signed off on. We are still waiting for decisions on it. According to the emergency department figures in Cork University Hospital, CUH, and Mercy University Hospital, it took twice as long for people to get access to services as it did for people in any other hospital facility in the country. This highlights the urgent need for a new elective hospital.

The second issue I will raise is the time period we are talking about. Will the Department give consideration to engaging in a public-private partnership, PPP, on the basis that the hospital would be delivered in a faster timeframe? This is an emergency situation. There has not been a new bed opened in the Cork and Kerry region in the past 30 years. This is something we need to prioritise, particularly in light of the figures released today with regard to the emergency departments in Mercy University Hospital and CUH.

Mr. Robert Watt:

On the elective hospital, the preliminary business case has been shared with the Department of Public Expenditure and Reform and is now being finalised. The final business case will go through the assurance process. It is expected that it will be cleared with Government before the summer recess. Significant work has already been done with regard to design. The project will go for procurement in the autumn.

The project has not been considered for a public-private partnership. I understand that it is to be a fully Exchequer-funded project. In my experience, there is no evidence that PPPs enable projects to be procured faster than traditional Exchequer funding. In actual fact, it may make matters more complex and further delay the project. It is our view and the current view of the Government, which may, of course, change, that this will be funded purely by upfront funding from the Exchequer.

Colm Burke (Cork North Central, Fine Gael)
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With regard to the timeframe, there is no question or doubt but that there are major challenges in Cork. Should private hospital facilities be lease or otherwise acquired to deal with the long waiting lists in the Cork and Kerry region? Should consideration be given to that?

Mr. Robert Watt:

Is the Deputy asking whether we should lease a hospital?

Colm Burke (Cork North Central, Fine Gael)
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I am asking whether we should either buy a private hospital or lease one for a number of years until the elective hospital is built because we have great demands, consultants cannot get access to a theatre and there is not a sufficient number of beds. There is a great number of people working but they are feeling frustrated because they cannot get their lists dealt with. Can we look at that issue and at acquiring a facility in a private hospital?

Mr. Robert Watt:

Absolutely. If there are options available to increase capacity in the short run, we would of course look at those. There is capacity through the NTPF to access private beds through the fourth safety net agreement. We have recently been accessing an average of 1,500 to 1,700 beds in the private sector every week. There are also NTPF purchases on top of that. There is very significant purchasing from the private sector. With regard to beds, there have been beds added in the Cork area. Some 56 beds were added in CUH in 2021 and more beds are planned for this winter. Mr. Woods might be able to add to that. Another 42 beds were added in Mercy University Hospital.

Mr. Liam Woods:

We are already looking at options to take space in private facilities in addition to service, including in Cork. That is a possibility within the arrangements under the NTPF the Secretary General has described.

Colm Burke (Cork North Central, Fine Gael)
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Mr. Woods would accept that if we are building a new elective hospital, we are talking about a certain period. Some projects have taken eight years. What are we going to do in the meantime? When are we going to decide to make additional capacity available for the people employed by the HSE who have the expertise but cannot get to do the work they want to do?

Mr. Liam Woods:

I take the Deputy's general premise regarding the need for capacity. It is clearly beneficial to have additional capacity, particularly for the planned activity that needs to be done to address access to care. It is with that in mind that those dialogues are ongoing. That is built into the access to care plan and the resources available for that. We are in dialogue on that and we will use any space that can be made available through that process.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I will ask Mr. Reid about the claims that, in 2019, €392 million worth of health-related claims were made. I refer to awards made by courts and those paid out without going to court. In 2020, this figure reduced to €272 million, which is a significant sum. At the moment, there is something in the region of €3.7 billion outstanding. Unfortunately, situations like this will arise in a health system but we have to work towards reducing them. Will Mr. Reid confirm the amount outstanding at the moment? I understand that figure of €3.7 billion dates from 2020. What is the figure now?

Mr. Paul Reid:

That figure is the estimate for future liability, that is, the future cost of those claims if they are all settled. It is now north of €4 billion so it has gone up.

Mr. Stephen Mulvany:

The payments dropping was simply a product of the effects of the Covid pandemic on the Courts Service and cases simply not closing quickly enough.

Brian Stanley (Laois-Offaly, Sinn Fein)
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What is the annual spend? I do not expect the current figure but perhaps I could be given the figure for 2021.

Mr. Stephen Mulvany:

Our annual reimbursements of State claims-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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I am asking about the spend on legal services by the HSE. Mr. Mulvany will have seen the overall figure. What was it for 2019 and 2020?

Mr. Stephen Mulvany:

I will come back to the Deputy with a figure. Our direct legal services cost would be north of €40 million but it could be more than that. There is obviously a substantial legal costs element to the reimbursements system. We will send a note on our actual figures.

Brian Stanley (Laois-Offaly, Sinn Fein)
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So in 2019, between claims paid out and legal services, we could be looking at €440 million.

Mr. Stephen Mulvany:

Absolutely.

Brian Stanley (Laois-Offaly, Sinn Fein)
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That is significant.

Mr. Stephen Mulvany:

It is very significant. To clarify, a substantial part of the figure for overall clinical claims relates to catastrophic cases in the maternity area. We are taking steps to improve that but the evidence suggests that the greatest issues there relate to the operation of the Courts Service rather than to the incidence of claims. The Irish maternity service is as safe as any other in the world and safer than some. The issue is the cost of claims under the legal system and the legal process rather than the piece that is within the control of the HSE or the health sector.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I visit the issue of the integrated financial management system each time Mr. Watt is before us. I mentioned earlier that we are a high spender on health. That is good but we need to find out where money is going. As I mentioned to the witnesses from Department of Public Expenditure and Reform, Mr. Watt's former Department, last week, what matters to us and to the public is what happens in between the money going in - perhaps it is sent up to Miesian Plaza in an articulated lorry as it is a significant amount - and services coming out the other end. That is the puzzle. I know it is not simple, that there must be management systems and that there are processes in place. If you go to a meeting with HSE managers, you will hear all about it. There is a budget and then there are the services. I focused particularly on dental services. The witnesses might provide me with a detailed note on that.

On this integrated financial management system, at a meeting of this committee on Thursday, 12 June 2014, the Secretary General of the Department said: "I am pleased to advise members that a detailed business case for a new finance operating model, including the procurement of a new integrated financial management system, IFMS, for the wider health service has recently been submitted to my Department." He went on to say that it had to go to the Department of Public Expenditure and Reform which, as I understand it, rejected it. I do not want to go back over that too much. Dr. Ambrose McLoughlin went on to say: "Finance reform is the highest non-clinical priority of the HSE", and on the same day the former CEO, Tony O'Brien, said: "As the Secretary General noted, the finance reform programme is a key element of overall system reform in the health service." The Comptroller and Auditor General's office recommended this in 2014.

Mr. Robert Watt:

Mr. Mulvany and Mr. Reid might answer in terms of-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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I want to hear from Mr. Watt, as Secretary General of the Department.

Mr. Robert Watt:

I think Mr. Mulvany knows more of the detail. In terms of the overall question the Chairman put, money is allocated, money is decided upon.

Brian Stanley (Laois-Offaly, Sinn Fein)
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How much?

Mr. Robert Watt:

I am just talking about the generality of health. Mr. Mulvany will deal with the detail of the project itself. We have good linkages between the money allocated, the money spent and the outputs and outcomes. That is something we are striving to do all the time. We can do that. We can improve that relationship-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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Straight lines.

Mr. Robert Watt:

-----and provide information in advance of the system being developed. I just want to mention that because sometimes I think we assume that the difficult business of allocating and delivery will somehow be made markedly easier or better when we have the new financial system; it will not. The new financial system will provide us with more timely information on an I and E basis to align better with the cash position each month and provide more granular detail on what is happening. However, the central challenge still remains. We are improving it in advance of the financial system. I do not I want it to give the impression - I am not saying that the Chairman does - that in some way we do not know where the money is going, we are not getting value for money or we cannot link money inputs and outputs. We can, but we need to get better. The system may help but it will not be a panacea in addressing that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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The road between the budget and the services is a road with many twists and turns.

Mr. Robert Watt:

Yes.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I am not inside the system but outside the system looking at it, meeting middle management, meeting the witnesses present and looking at accounts. It seems like a very twisted road and we need to straighten that road out a bit. An integrated financial management system should help to capture that.

Mr. Robert Watt:

It can help to straighten the road, but I am saying that there will still be that challenge which is a delivery and leadership challenge and also a political challenge regarding the relationship between spending inputs, outputs and ultimately outcomes. I am cautioning that the financial management system will not solve all those problems but it will certainly help. Mr. Mulvany might have the detail.

Brian Stanley (Laois-Offaly, Sinn Fein)
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What is the budget for it? When will we see it?

Mr. Stephen Mulvany:

The budget is €82 million capital. May I just take ten seconds-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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Has it increased?

Mr. Stephen Mulvany:

No, that is what it always was. It is the same as when I last told the Chairman. I will just take ten seconds to be clear. This is one of the largest SAP transformation projects in Europe at this time.

Brian Stanley (Laois-Offaly, Sinn Fein)
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The other health systems have it now. Where are we at with it? Are we 50% of the way there?

Mr. Stephen Mulvany:

No. By next year we will start actually going live in the eastern part of the directly run HSE services. By 2025, if we take that the overall health sector encompasses the HSE directly run and the voluntary hospitals, by the end of 2025 it will be at just under 90% of the overall-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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It will be 90%.

Mr. Stephen Mulvany:

I would like to deal with comments about what we said in the past. In talking about the-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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We do not have time.

Mr. Stephen Mulvany:

I would just like one second if I could, to be fair.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Go on.

Mr. Stephen Mulvany:

We have never given a figure in relation to that 80% of the overall health sector that was ever any earlier than 16 January 2024. We will hit that 80% by about the end of March or April 2025. So, it is about 13 months behind. It was never ever going to be earlier than that. That 13-month delay has been caused by Covid, the cyberattack, problems with recruiting and actually having to procure a whole new systems integrator.

Brian Stanley (Laois-Offaly, Sinn Fein)
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It is important.

Mr. Stephen Mulvany:

It is very important. It is only one component, as the Secretary General has said. We are very committed to it, but it is not a simple project. It involves more than 2 million invoices a year. It will involve 100,000 material codes being set up and about 5 million debtor accounts to be cleaned up. It is a very complex project.

Mr. Paul Reid:

May I come in very briefly?

Brian Stanley (Laois-Offaly, Sinn Fein)
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Just very briefly because I have one important question for Mr. Watt before he goes.

Mr. Paul Reid:

The analogy or simile of the tipper truck and the black hole was used. I just want to go beyond what Mr. Watt said. We are not waiting for the IMF test. We can draw a linear line right now on the breakdown of our operational spending. Some 32% of it is on acutes we can follow through. Some 17% of it is on PCRS and reimbursements. We can follow through with really good metrics. About 5% of it is nursing, NHS, schemes and home supports - about 8% to 10% in total on screening. For about 92% of our activity, we can follow through and demonstrate a linear follow through. Yes, there are some that are more complex.

Regarding whether we are seeing any extra services for all this money, I made a comment to a Deputy earlier that we can certainly demonstrate all of the Covid benefits because Lancethas recognised it. Equally, we can show we are having more AD presentations. There is more help going into the system. There are more supports for GPs. There is more access to GP diagnostics in the system. There are more public health nurses. There is more recruitment. There are more older persons schemes. There is more community intervention.

Brian Stanley (Laois-Offaly, Sinn Fein)
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That is welcome.

Mr. Paul Reid:

I know, Chairman, but I just think sometimes when things are said they land with the public. I think it is important and incumbent on me as CEO to say that money has come in and we can trace most of it in a linear way. There has been very significant benefit to the public. We have big challenges, but we can demonstrate a lot of extra activity for that funding. We have massive challenges still.

Brian Stanley (Laois-Offaly, Sinn Fein)
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That is the one. It is the services we get confronted with.

I do not want to go into too much detail on the national children's hospital. Mr. Watt mentioned the figure of €1.7 billion the last time we met back in December. It has cost just over €1.7 billion. I know there are claims and that is a moveable feast. There is also construction inflation of over 4%. If construction inflation and claims are excluded, has a figure been settled upon for the national children's hospital?

Mr. Robert Watt:

If those two factors are excluded, €1.43 billion is the-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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It is €1.42 billion.

Mr. Robert Watt:

It is then €1.7 billion when the other elements are added in.

Brian Stanley (Laois-Offaly, Sinn Fein)
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How much has been spent at this point?

Mr. Robert Watt:

I do not have the number to hand.

Brian Stanley (Laois-Offaly, Sinn Fein)
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What is the latest figure?

Mr. Robert Watt:

I think it is about €700 million or €800 million, but I will check that for the Chairman.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Mr. Watt will come back to us on that.

That wraps up the questioning. I thank the witnesses and the staff from the Department for joining us today. I acknowledge the work done in the past two years. Hopefully, for all our sakes, we are out the other end of that and can get back to more normalised things, giving people in the health system the opportunity to make the reforms that are needed. I acknowledge the work that has been done. I thank the Comptroller and Auditor General and his staff is for attending and assisting the committee today. Is it agreed to request the clerk to seek any follow-up information and to carry out any agreed actions arising from the meeting? Agreed. Is it also agreed that we note and publish the opening statements and briefings provided for today's meeting? Agreed.

With the agreement of the committee, we will resume in private session after lunch to deal with housekeeping matters before moving into public session to consider correspondence and any other business of the committee. Is that agreed? Agreed.