Oireachtas Joint and Select Committees
Wednesday, 18 September 2024
Joint Oireachtas Committee on Health
Productivity and Savings Task Force: Discussion
10:00 am
Seán Crowe (Dublin South West, Sinn Fein)
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Apologies have been received from Deputy Crowe and Senators Kyne, Hoey and Black. The minutes of the committee meeting of 10 July 2024 have been circulated among members for their consideration. Are they agreed? Agreed.
The purpose of today's meeting is to receive an update on progress being made by the productivity and savings task force. The task force was established by the Minister for Health earlier this year to generate savings and efficiencies across the HSE and thereby ensure the maximum amount of patient care is delivered from the funding available. The context for this work is the need to provide an increasing amount of care to a growing and ageing population within a finite budget.
To assist the committee's consideration of this matter, I am pleased to welcome from the Department of Health, Mr. Robert Watt, Secretary General; Ms Louise McGirr, assistant secretary; Mr. Muiris O'Connor, assistant secretary; and Ms Rachel Kenna, chief nursing officer. From the HSE, I welcome Mr. Bernard Gloster, chief executive officer; Mr. Damien McCallion, chief technology and transformation officer; Mr. Stephen Mulvany, chief financial officer; and Ms Martina Queally, regional executive officer for HSE Dublin and south east.
I will read a note on privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity either by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in respect of an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.
Members are reminded of the long-standing parliamentary practice to the effect 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. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex to participate at public meetings. I will not permit a member to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any member participating via Microsoft Teams to confirm, prior to making his or contribution to the meeting, they are on the grounds of the Leinster House campus.
To commence our consideration of the issue of the progress being made by the productivity and savings task force, I invite Mr. Robert Watt to make his opening remarks on behalf of the Department of Health. He is very welcome.
Mr. Robert Watt:
I thank committee members for the invitation to discuss progress of the implementation of our Sláintecare reforms. I am joined today by my colleagues Mr. Muiris O’Connor, Ms Louise McGirr and Ms Rachel Kenna who will be familiar to the committee from previous engagements.
The committee will know from previous discussions that Ireland’s health services are undergoing a most significant programme of reform and expansion. There has been an unprecedented level of investment to support that expansion and reform. There is continued investment in our workforce, in delivering new care pathways, new facilities, new technologies and creating new ways of working that is enabling our health service to respond to the growing health needs of our population.
We are increasingly seeing the patient impacts of this investment. The enhanced community care programme, for example, continues to deliver increased levels of healthcare through general practice, primary care and community care closer to people's homes and away from the acute hospital system. The Minister published a three-year progress report covering the period of 2021 to 2023 in April showing the extensive progress made over this period in respect of that programme.
Work has continued through this year and significant reform programmes continue to build on progress across the service. This is particularly so in areas highlighted in the programme for Government, such as waiting lists, women’s health and digital health. These reforms will aid in our goal of achieving the highest possible standards of affordable, quality health and social care for the people of Ireland when they need it and where they need it. Making this vision a reality for the patient is at the core of our collective efforts in the Department and in the HSE, and we will continue to improve health and social care services to optimise patient outcomes and be responsive to their needs.
Our driving objective remains, as ever, to increase the volume of public activity and to treat more people in the community through improved integrated care. In addition, as I have said here before, healthcare productivity is key to achieving this goal - the more productive we are, the more patients we treat, the less time they must wait and the better health outcomes we can achieve.
As members of the committee are aware, significant investment has been made over the last number of years. To give some examples, staff numbers have risen by almost 40% from 2016 and we have added more than 1,100 acute beds.
As the committee is aware, we are continuing to build more physical beds and we are also putting in place a virtual beds programme. We have invested significant resources in shifting care to the community in line with the recommendations of the Sláintecare report.
We now have in excess of 430,000 people registered with the chronic disease management programme, 91% of whom now have their care fully managed in primary care settings. We have presented various data to the committee in respect of that programme. A recent audit of a sample of such patients revealed a reduction of more than 31% in emergency department attendance, a 25% decrease in inpatient admission and a 33% reduction in the use of GP out-of-hours services. This is a significant programme that focuses on people with particular conditions. The progress we have made is really impacting on the overall efficiency of the system. There is obviously more we need to do and we need to build on it in future years.
The investment we have made has yielded not just better care but also more care. This year, the HSE expects to deliver almost 4 million outpatient appointments, up from 3.2 million in 2021. Emergency department presentations are up by 29% over the period. Day cases are up by 20% and inpatient discharges are up by 17% over the past four years. This year, we are once again likely to see the highest level of activity ever within the public health system. We are doing much more because of the investment we have received and the reforms that have been undertaken. It is a critical message that these things need to go hand in hand.
That said, we need to do more. The demographic challenge we face cannot be underestimated. We have seen growth of 11.4% in our population since 2016. There has been a 20% growth in the population over 37, with this cohort now making up more than 53% of the population. The population ageing is a significant factor. Within 30 years, our population over the age of 65 will grow by more than 1 million. The number of over-85s will almost quadruple. This committee is aware of the challenges this will bring to providing more care to more people over much longer periods. One interesting statistic is that, since 2016, 67% of the increase in inpatient discharges is accounted for by people over 70.
While we continue to expand our service to meet growing demand, we must change how we work in order to deliver ever more care. We are seeing signs of what is possible. I will touch on a few of these data points. This year, we have seen a decrease in the number of patients waiting on trolleys. This is despite an increase in demand of more than 10%. We have seen an improvement in the percentage of people who are waiting less than six months on our waiting lists for scheduled care. This has increased from 41% in 2021 to 62% this year. Some 82% of people are now waiting less than 12 months and the number of those waiting more than 12 months has been reduced significantly. Overall, the average wait for people on the list for outpatient care has fallen from 13.2 months in July 2021 to 7.2 months now. While we are not saying that these improvements necessarily mean the end of our ambition - of course, people are waiting too long - they do show significant progress on waiting lists.
The productivity and savings task force was set up in March and is co-chaired by Bernard Gloster of the HSE and myself. This endeavours to bring a sharp focus and leadership to how our system can respond to ever-increasing demands. We have taken advantage of the digital opportunities available, analytics and the use of data and insight to effect real change for patients. New clinical pathways, moving services to the community, as I have mentioned, and focusing more of our efforts on prevention is yielding results. The task force prioritises both savings in cash terms and productivity measures that can deliver real improvements in services. Cost-cutting is not the overall objective of this group. We are making the budget go further and maximising resources to deliver more with what we have. We are seeking savings across the management consulting budgets, medicine spend and non-pay expenditures. While this is challenging against a backdrop of high demand, these targets are intended to focus the service on where we are spending more in a cost-effective manner. We need to continue to challenge ourselves. There are a number of key questions for us. Are we carrying out procedures across all the regions and sites at the same and best value? Are we ensuring that all diagnostics and tests ordered are needed and not duplicated? Are we maximising our procurement strength as a major purchaser of health goods and services?
It is clear that it is not sustainable over the long term to continue to increase health expenditure in line with demand each year. That is not sustainable from the Exchequer's perspective so we must meet the increase levels of demand in health by reforming how we do things and availing of opportunities to maximise existing infrastructure and resources to meet demand and reduce waiting lists, such as introducing new models of care, care in the community and virtual wards. As the Chair knows, we have introduced two virtual wards at St. Vincent's and Limerick. The early results as to the impact they are having are very positive. We have made good progress and we will continue to focus on these areas. We are very happy to engage with the committee as required.
Mr. Bernard Gloster:
I wish the Chair and members of the committee a good morning. I thank them for the invitation to meet the committee today to discuss the progress in respect of the 2024 focus on productivity in our health service. I am delighted to attend with the Secretary General of the Department of Health and his team. I am joined by my colleagues, who have already been introduced. I am supported by Mr. Ray Mitchell from the parliamentary affairs division and Ms Sara Maxwell. The committee will be aware that in approaching this and the coming years, the Minister requested a specific focus on the issue of productivity at both Department and HSE levels. The following are now in place: the group referred to by the Secretary General, which we jointly chair, and a small dedicated unit in the HSE reporting directly to me. This will remain in place for the next two years. It is essentially the entire driving force between designing and monitoring multiple measures across the HSE aimed at ensuring the best use of the resource we have in the public interest.
It is clear and well set out that demand for services is only going in one direction and in many cases at a faster rate than had been predicted prior to the pandemic. Demand is not only increasing in the number of people seeking services but also in the range of conditions and the ever-growing options for responding, be that in diagnostics, procedures or therapeutics. The work of the task force and the unit is seen in the context of productivity and savings. I will turn to the financial element of that discussion shortly, but it is important to outline what we mean by productivity and savings.
Earlier this month I addressed delegates at the HSE’s integrated care conference, advising those in attendance that productivity and savings in healthcare are about our greatest resource, which is time - a focus not only on staff time but also patients' time as an increasingly supported concept in the emerging literature. The impact of productivity on patients is what this is all about. Increased productivity means getting more out of the time we put in and more activity out of the resources we have, leading to more access. More access not only improves quality of care but it is also safer. The combined efforts of more resources and productivity will enable us to respond to demand, whereas more resource on its own or the corresponding waiting times pending that additional resource, are unsustainable.
The impact to date on waiting times through this combined resource and efficiency can be seen in significant examples. The first is in waiting lists for outpatients, inpatient day cases, and GI Scopes. In 2023 we removed 180,000 people more than in the previous year. The weighted average waiting time for outpatient services has gone from ten to 7.5 months at the start of this year and despite continued unprecedented growth in demand to 7.2 months at the end of August. In our overall policy direction and target, some 30% of people are now waiting inside the Sláintecare timeframe for targets. In unscheduled care, which is trolleys, since the second half of 2023 we have seen improvements in this challenge, which is tracked daily. While 10% more people are turning up in emergency departments this year to date, there is a corresponding decrease in trolleys of up to 20%. Delayed transfers of care, previously discussed at this committee, which is the delay in people waiting to get out of hospitals who are finished the acute episode, has reduced from a running average of 550 to 600 a day to 350 to 400. It is clear that we must continue to adapt our ways of working to build on these improvements and to broaden the focus of productivity to all of the services we have, including both health and social care in the community.
The committee will be aware of the challenges we face as an organisation in managing significant demand for our services and in controlling such a large and at times disparate organisation. The revised structure of the HSE with six new regions and new regional executive officers puts us in a much stronger position to manage our considerable budget, with the ability to make funding and activity decisions much closer to the patient, where they are best informed. In June of this year with the agreement of both the Department of Health and the Department of public expenditure and reform, we have achieved a very strong and certain position for our cash budget that enables us to plan to the end of 2025. Introducing a new control environment for both pay, referred to as the pay and numbers strategy, and non-pay is a critical factor in an overall productivity-centred approach. By the end of 2025, that control environment will have fundamentally altered in its impact and the certainty regarding the resources we have and the value the public gain from them.
Finally, I want to make a note of thanks, if I may. The HSE will be 20 years in existence this coming January. For the majority of that time, our engagement with the Oireachtas, both at committees and with individual Members, through parliamentary questions and representations, has been extensive. There is no doubt that an enormous amount of work goes on behind the scenes to keep that process well oiled. The stand-out name for most of that time has been our head of parliamentary affairs, Ray Mitchell. He joins me today in the last few weeks leading up to his retirement. Owing to his unique relationship with the Houses of the Oireachtas, I thank the committee for affording me the time to pay tribute to him, to thank him for his work, to wish him and his family all the very best into the future and to wish him good health and happiness. That concludes my statement.
Seán Crowe (Dublin South West, Sinn Fein)
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I thank Mr. Gloster. On behalf of the committee, I would like to be associated with the remarks relating to Mr. Ray Mitchell. He has been extremely helpful and courteous to the committee down through the years. He also came back and engaged and has been a vital structure between us and the Department. On behalf of the committee, I thank Mr. Mitchell very much for all his help and support. I wish him well in the next stage of his life.
I welcome Senator Maria Byrne, who is substituting for Senator Martin Conway.
There was mention of emergency departments. Before we go into questions, I want to outline my experience over the summer. Just a week ago, a brother-in-law of mine was brought in for a suspected heart attack. While there were challenges within the emergency department, he is now, thankfully, at home and recovering from that incident. I thank the staff there. I also had a difficult period regarding a brother-in-law's partner who was in an end-of-life situation. We were in St. James's Hospital. As regards the help and support of staff there, many of them went way beyond normal support. We will always be grateful to the staff for the support and help they gave us during that particularly difficult period. He was a short period in accident and emergency, but everything that needed to be done was done. I really thank the staff in St. James's Hospital for all their support and help. That is just a private note from me on that.
I will open up the floor for questions now. Deputy Durkan will lead off.
Bernard Durkan (Kildare North, Fine Gael)
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I welcome our guests and congratulate them on the indicative progress at all levels, which is very welcome. Like the Chairman, I have had personal experience of our hospital services in recent times. I was really impressed with the manner in which everybody, from orderlies to consultants to everybody else involved, fulfilled their duties. We should mention also the number of foreign-born staff who are evident in all our hospitals at present, up to 90%, I would say, in some cases. We need these people with the appropriate qualifications at every level nowadays and we should be very grateful to have them. Our congratulations go to the organisation in general.
The first word I want to mention regarding both addresses this morning is "organisation". Organisation is what counts, as well as the utilisation of what is available and co-ordinating that with what is required. It is coming to pass. It was slowly getting started. There were a number of hiccups and a number of ditches here and there but, generally speaking, it is getting organised now. The demand is greater and will be greater, and that is a fact of life. It is, however, the small things that count, as well as the very small glitches in the supply chain at any given time. Even the lift system going wrong, for example, can mess up the whole day's work for somebody else at a different level.
Something does not happen within ten, 20 or 30 minutes and, the next thing, the entire schedule is knocked back. Those small things, when put together, mean the organisation of services in the hospital or health facility for the day is affected, which leads to another and another, and it goes on and on. Congratulations for identifying those issues in the way that has been done and on the progress. Everybody can see two sides to everything. For some, the glass is half full in some cases and half empty in other cases, depending on whom one talks with at any time. We must progress on the basis of having the glass half full and filling more, because the greater requirement is there.
In the examples that I saw, I think that the organisation on the floor, whatever it is, from the front door to the theatre, makes a huge difference. If the layout is right, the degree to which the staff can respond makes it easier and puts much less strain on them and on the organisation in general. For instance, as mentioned, we have seen a fairly substantial reduction in waiting lists, as we have wanted and called for. Something is really happening now in the sense that it is beginning to progress in a way that a passer-by can see. That is commendable. There are still a couple of stitches that we need to deal with. We want to be aware of the fact that things can go wrong. Things go wrong in all walks of life from time to time. We need to try to avoid it insofar as is humanly possible and to make sure that they do not go wrong.
Given all that, we need to prepare for what happens next if things go wrong. What is the fallback position or plan B, as they say nowadays? When something is likely to go wrong, there is a need to put in place a schedule that will pick up the slack and move on. For example, we still have unacceptable waiting lists for scoliosis. We should be able to get that organised. It is not beyond the bounds of possibility. If we cannot do it in our own hospitals, the treatment purchase system is there and should be utilised. There is no sense saying otherwise to the patient on that waiting list, who is suffering and whose family is suffering, looking at the child or whatever the case may be. They see it as a simple thing to get done. We can do it but we do it too slowly. We wait, have to organise and consult. The organisation and consultation should be done. The provision is there for treatment purchase and has been for some years. For heaven's sake, let us utilise it quickly and put those procedures in operation much more quickly than has been the case heretofore.
I would say the same about any area of services where there is a problem; for instance, cataracts. The treatment for cataracts is very simple. It can be done around the corner anywhere in the country. What are we waiting for, for God's sake? It is so simple to do it. One can get it done in any town or village in the country within a few miles. We make a big hurrah about carting patients almost around the world to get a simple procedure that is well within our reach. If we cannot get it in the public sector, which we can, we can get it through treatment purchase adjacent to the homes of people without any organisational feats at all. It is simple.
The other point, which I have raised before at these meetings, is that people cannot wait, especially people who live on their own who have a need for cataract treatment and whose sight is diminishing at a rapid rate. They are dependent on driving and that is the only way out. They live alone and are isolated entirely. Many of those people's friends have got together to collect the necessary money to have it paid for. I brought this up before as well.
If it was not approved beforehand, the patient was on a waiting list for a couple of years, waiting for something to happen. It should not be that way. It is being dealt with now in the forthcoming scheme, but we should also try to help pensioners who have had to get private treatment even if it is after the event. Nobody is going to look for reimbursement of the full amount, but it would be a very nice gesture to those we could not accommodate on the waiting list within the required timeline to at least make a contribution that takes the sting out of the time they waited and the fact they had to get it done privately. Those are a few of the simple things I have dealt with in respect of patients locally.
I do not want to go on as I have said all of these things before, and I am sure others want to speak, but I refer to accident and emergency departments, and I have experience of two or three of the major hospitals in Dublin. Although they are very good, they are overcrowded and there are a lot of people with addictions in the waiting areas who should be waiting in different outlets. The problem is that older people who go in there who are concerned about two things - first, about getting treatment and the waiting times for that and, second, about unruly behaviour, threats or violence in the accident and emergency departments. We cannot say that does not take place because it does. There is considerable abuse being turfed out to medical staff, nursing staff, orderlies and others who are working in the system, trying to make it work.
Any interference with the smooth running of the system is not on. We can continue as long as we like, but as long as there are people hurling abuse at, threatening or assaulting staff, or attempting to assault one another, in accident and emergency departments up and down the country, the system is not viable. We need to identify these places. By all means, we should treat those who present with alcoholism or drug-related illnesses, but they should not all be in the same place because that is at cross purposes. We must to deliver to everybody, as is required, but at the same time there are those with specific requirements who need to be dealt with differently.
I visited a couple of the drug treatment centres around the area during the break. One of the things I noticed was that I knew most of the people there. These are people who fell by the wayside, who had a bad turn or two, or more, over a short time or a longer time. It is so sad that they have to hesitate to consider the implications for themselves. They need to have the appropriate treatment and it needs to be quickly and readily available, along with counselling and so forth and we do not need the system where I always run into difficulties. Methadone is very important in those situations, and we need it, but it must be a means to an end. If methadone is going to solve the problem, it has to be used to ensure a diminishing reliance on drugs.
We see what has happened in the past few weeks with drug trafficking all over the globe and in a big way in this country in particular. There are many drug barons making an awful lot of money from other people's misery. We need to come to grips with that and recognise that we need to give treatment to patients with a view to reducing their reliance on the drugs now coming into this country.
Seán Crowe (Dublin South West, Sinn Fein)
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The ten minutes is for questions and answers. Deputy Durkan has used up his ten minutes.
Bernard Durkan (Kildare North, Fine Gael)
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They are gone. I could go for another ten minutes if the Chair wants me to.
Seán Crowe (Dublin South West, Sinn Fein)
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I know. I am conscious-----
Bernard Durkan (Kildare North, Fine Gael)
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I know the Chair is anxious that I would-----
Seán Crowe (Dublin South West, Sinn Fein)
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The Deputy has used up his time.
David Cullinane (Waterford, Sinn Fein)
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Can I ask Mr. Gloster about the publication of the review of Mr. Justice Frank Clarke into the death of Aoife Johnston?
The witnesses might have seen reports in the media today that the report might be published next month and that the family has asked for the report to be published by this Friday. It is obviously a really important issue. As well as waiting for the publication of that report, elective procedures in the entire mid-west were cancelled, as our guests will know, over the summer for long periods of time, which is not very productive in terms of healthcare. This is a very serious issue and the family has asked that the report be published at the earliest possible time. When is it intended to publish that report?
Mr. Bernard Gloster:
I thank the Deputy for the opportunity and recognising the sensitivity of the matter. I did say in a brief interview with RTÉ yesterday that within the current two-week period was my intention to do it. I can confirm this morning that I will be publishing the report not later than this coming Monday. I want to establish contact with the solicitor for the family later today, as I have done previously, just to give people fair opportunity and notice of that but the latest it will be published is this coming Monday. It is important in the public interest that the report is published appropriately. I am very conscious of the commentary about the report in the past couple of days. It is important that commentary is addressed and I believe the best way to address it is when the totality of the report is there. I will then be able to comment on the detail of it and explain to people regarding some of the concern being expressed about the report, which I respectfully suggest is misplaced concern. It is a very comprehensive and effective report. It is one that completely fulfilled all of its terms of reference. It is one on which, as a basis of being acted on, is being acted on now, at the present time. Obviously I cannot say a lot about that aspect but it is in the public interest and I intend to publish the report not later than Monday.
David Cullinane (Waterford, Sinn Fein)
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I will move on to performance and outputs. When we are talking about productivity what people will measure is, obviously, what we get at the other end of the investments we make. Since 2019, there has been a 50% increase in health spending, which we all welcome. Of course, additional funding will be needed over the next number of years in areas as well. One of the measurements is waiting lists. The waiting lists have essentially remained static since 2019. I refer to all of the correspondence I have seen. Our guests might recall that we got very extensive correspondence that was exchanged between the Department of public expenditure and reform and the Department of Health in respect of health budgeting. One of the issues raised in that correspondence was that there has been a 50% increase in funding since 2019 but a marginal decrease in the active waiting lists. Mr. Watt outlined that the number of people waiting longer than 12 months has come down, and that is welcome, but the active waiting lists have remained static. In fact, in July they were up by 8,000 people. Can Mr. Gloster explain why we have had a 50% increase in funding but waiting lists have remained static? Can that be described as productive and getting bang for buck for the investments that we are making?
Mr. Bernard Gloster:
I am very happy to address that issue. I thank the Deputy for the opportunity to do so. The number of people on the waiting list on any one day does not tell the story of the activity and the most important metric, which is the length of time people are waiting. It is not the number; it is the length of time. All of the OECD reports evidence that.
In very simple terms I will talk about what the bang for buck is. Up to the end of August this year, we removed 1,184,000 people from waiting lists. That is 4.9% more than we removed in the same period last year. Up to the same period this year, additions to the waiting list, that is, new referrals from general practice to outpatient and other procedural waiting lists, was 1,225,000 people. That is up 6.9% on the same period last year.
The Deputy mentioned the slight difference in the number on given days and that there are marginally more people coming on than going off. Of course, that is what increases the number.
David Cullinane (Waterford, Sinn Fein)
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Can I hold Mr. Gloster on that point?
David Cullinane (Waterford, Sinn Fein)
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It does strike people as a bit bizarre that a country with a population of 5.2 million has 840,000 people on active waiting lists. That is acute waiting lists. We also have 240,000 people on community waiting lists, which do not get published. Members must submit parliamentary questions to get those responses. That is across a whole range of community services. That is a lot of people waiting for access to care.
I accept that the number of long waiters has come down. However, it does not make sense that in a country with a population of 5.2 million, there are 840,000 people on acute waiting lists and 240,000 on community waiting lists at a time when spending has increased by 50%.
Mr. Bernard Gloster:
The waiting lists that are measured include outpatient, inpatient, day cases and general GI scoping. The number of people on waiting lists at the start of this year was 670,000. At the end of August, it was 712,000. That is an increase of 41,000. The target to get to by the end of the year is 632,000. The critical point is that 30% of people on that list are now inside the Sláintecare waiting times. That is a very fast turnaround. The number of people who had been on waiting lists for more than 36 months and who were at risk of becoming the type of four-year waiters that I stated I wanted to eradicate when I came into this job stood at 34,200 at the beginning of the year. At the end of August, that figure was down to 14,000. I call that very high productivity and, to use the phrase the Deputy quoted from the Department of public expenditure and reform, "bang for buck". Last year, we focused on those who had been waiting for more than 48 months, a really outrageously long time, and took the majority of them out. At the start of this year, there were 5,300 of those. At the end of August, that figure was down to 4,500.
All the time we are condensing the time. However, the number of people being referred is an example of the fact that people's health is being attended to and of the advances in diagnostics and other treatments that people are receiving. People rightly want access to those treatments. We have to be able to manage the debate and analysis relating to waiting lists. Certainly, we must talk about the number of people involved-----
David Cullinane (Waterford, Sinn Fein)
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If can come back in-----
David Cullinane (Waterford, Sinn Fein)
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-----I have given Mr. Gloster a lot of time.
David Cullinane (Waterford, Sinn Fein)
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I accept that, and I have given Mr. Gloster a good deal of time to respond. I accept that long waiting times have come down; I acknowledged that twice. I make the point again, however, that there are still many people who are either coming onto waiting lists or who are still on them. I spoke to the head of the Department of Health about this matter a number of times. I want to see more work done on centralised referral systems-----
David Cullinane (Waterford, Sinn Fein)
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-----integrated waiting list management systems and getting a better bang for buck. Those are the outputs we are talking about. When we look at the big numbers of people waiting, they just do not make sense in the context of the size of our population.
One of the issues that has come up in respect of expenditure is that of aids and appliances. Spending in this regard has, again, gone up substantially. My understanding is that approximately €180 million was spent in Dublin alone over a three- or four-year period on crutches, wheelchairs, Zimmer frames, walking sticks, etc. These items cost a great deal of money and are not always returned after use. There is a lot of waste in the system. I want to understand the process here. What follow up is done? There is a great deal of money involved. Hundreds of millions of euro are being spent every year on this. Manufacturers have been saying that they would prefer to be issuing what are referred to as single-use client appliances. That might not be suitable in all areas but it would be suitable in some. Again, are we getting bang for buck here? Are there proper checks and balances within the healthcare system? Culturally, do we need to say to people that they have to bring back the appliances given to them? If we are talking about waste, we have to look at every element of the healthcare system. This is one of the areas where there is a problem. Can Mr. Mulvany indicate how much we are spending and outline the checks and balances the are in place to ensure that we are getting value for money ?
Mr. Stephen Mulvany:
The total expenditure will be approximately €177 million. This relates to people who are receiving every type of aid, appliance or medical equipment at home, such as beds, hoists, aids, nebulisers, sleep apnea machines and continuous positive airway pressure, CPAP, machines. The range of medical appliances and equipment that people are receiving is only going in one direction; it is increasing. They are getting more complex. Much of that is a good thing because it means that people are getting out of and staying out of hospital and being maintained at home. The more we maintain them at home, the more kit that needs to go into the home. It is an ever-increasing piece.
Some €177 million is going to medical card holders under the local demand-led schemes that are administered in our six regions. In addition, another €88 million is going on primary care under a range of initiatives. We have provided significant policy guidance to the system on the need for proper clinical referral.
We have what we call local resource allocation groups which consider the more high-cost materials such as electric wheelchairs. Either through our direct provision in some areas and-or managed services from external providers, we have arrangements in place to distribute, collect, recycle, re-engineer and repair where it makes sense. Again, this is typically for the more high-end aids and appliances. In some cases it is more than aids and appliances and involves medical equipment. In other cases we do not recycle them in the sense of reissuing them for re-use because, as Deputy Cullinane said, they are low-cost, single-use items. Typically we seek to recycle the parts or the product itself at end of life. This is something under constant review given the green agenda. It is an area that needs focus and it is getting that focus, including between ourselves and the Department, in the community schemes. As the Deputy rightly said, it is a significant area for control. It is an expanding area and this is a good thing.
Seán Crowe (Dublin South West, Sinn Fein)
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It might be useful for the committee to be sent a breakdown of where people send something if they want to send it back rather than taking up time at this meeting. Most people listening at home would have some sort of equipment they would like to get rid of or return for it to be recycled or reused. I know a number of elderly people who have quite expensive hearing aids sitting in a drawer. Anecdotally, I know a number of people who have them and do not use them. They are not able to use them or they do not fit. This is one example.
Mr. Bernard Gloster:
With regard to the waste agenda, it is important to recognise and put out there that there is a very strong clinical view and body of evidence that certain appliances are not worth recycling for infection control reasons and with regard to the benefit on return. There are certain things that can only be used by one person. The general point is on the principle.
Two factors are the ageing demographic because of the association of the use of appliances with frailty and the increasing number of physiotherapists and occupational therapists. Every time the number of occupational therapists or physiotherapists is increased, we increase the appliance budget because they are prescribing. That is what they do. They are the tools that people use. It is increasing and it is within this I take Deputy Cullinane's point on where probity and productivity needs to come in.
Róisín Shortall (Dublin North West, Social Democrats)
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I join the Cathaoirleach in thanking Ray Mitchell for all of his work in supporting the committee and supporting Oireachtas Members generally. I wish him very well in his future endeavours.
I thank the witnesses for coming before the committee and for their presentations. Does the productivity and savings task force include the area of value for money specifically? It is strange that it mentions savings rather than value for money.
Róisín Shortall (Dublin North West, Social Democrats)
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Is Mr. Gloster looking at issues such as procurement, outsourcing and other such areas?
Róisín Shortall (Dublin North West, Social Democrats)
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It was not that clear. I have a couple of questions on the action plan from March. It was stated that the task force would be fully staffed from May. Is it the case now that the task force is fully staffed?
Róisín Shortall (Dublin North West, Social Democrats)
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And in the Department?
Róisín Shortall (Dublin North West, Social Democrats)
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How many people from the Department are on the task force?
Róisín Shortall (Dublin North West, Social Democrats)
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How often does it meet?
Róisín Shortall (Dublin North West, Social Democrats)
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There was a report out in June, I think.
Ms Louise McGirr:
We have not published a full report. We published all our minutes, agendas and the documentation at the meeting. We publish productivity data. The HSE has published the outpatient dashboards. There is a report with the Minister, which will be published.
Róisín Shortall (Dublin North West, Social Democrats)
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As a matter of interest, a small section of the action plan has been redacted regarding targeted savings. Why has that been redacted?
Róisín Shortall (Dublin North West, Social Democrats)
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Why did the HSE not include that as a heading? We were not looking for the detail. It seems strange that the Department redacted that. I am particularly interested in knowing the total savings. That figure has been redacted. I am interested in knowing the total savings over pay, medicines and non-paid procurement. What is the target savings figure?
Róisín Shortall (Dublin North West, Social Democrats)
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What is that figure?
Róisín Shortall (Dublin North West, Social Democrats)
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Why has that been redacted?
Róisín Shortall (Dublin North West, Social Democrats)
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Does the Department now have a total target figure for savings?
Ms Louise McGirr:
There was agreement with the Department of public expenditure and the Minister for public expenditure and reform during the summer in terms of the total amount. No additional money has been voted into the health or HSE budget at this point. Those targets will be published.
Róisín Shortall (Dublin North West, Social Democrats)
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It is expected that other organisations set targets, and targets are a good thing generally. How do we know about the HSE's performance if it has not set a target that is publicly available?
Ms Louise McGirr:
Mr. Gloster might want to speak about the limits that are in play in terms of pay limits. Following agreement during the summer with the Department of public expenditure, there are pay limits in place across the HSE around pay budgets and the amount of money that people have to live within.
Róisín Shortall (Dublin North West, Social Democrats)
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That is one element. There are a whole lot of elements in this. I am asking-----
Róisín Shortall (Dublin North West, Social Democrats)
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The Department has all of the target savings across the other headings.
Róisín Shortall (Dublin North West, Social Democrats)
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I look forward to getting that information from the Department as soon as possible. The opening statements were interesting in terms of activity. I did not get a sense of where the HSE had identified areas for productivity improvements and what it was doing about those. Ms McGirr told us about activity but not productivity. Maybe there is a report somewhere which gives us that information, but I thought that was what we were discussing today.
Mr. Bernard Gloster:
It is a fair ask. The point I attempted to demonstrate in my opening statement when I spoke about certain improvements in performance as opposed to activity was that they are enabled by two things, namely additionality of resources or productivity within the resource. We have been increasingly focused on both. Enabling improvement in the unscheduled care trolley position and in delayed transfers of care can include elements of productivity, be it in terms of the spread of availability of staff across the day-----
Róisín Shortall (Dublin North West, Social Democrats)
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That is fine. I do not get a sense that the HSE had identified areas where productivity needed to be improved. What sectors or staff categories need to be addressed? How did the HSE tackle that issue? I have a sense that it is a bit of a blur. This brings us back to the fact that it has never been possible to get a clear line of sight of health funding because the data systems were, and continue to be, weak in many areas. There was no integrated financial management system for a very long time. It was unbelievable that the organisation in the country with the largest budget had no integrated financial management system.
I gather some of the blame for that was down to it not being funded by the Department of Public Expenditure, NDP Delivery and Reform. Funding was provided in recent years. Where are we now with regard to the establishment of a fully functioning integrated financial management system?
Mr. Stephen Mulvany:
The IFMS programme is delivering that financial system. It went live on 1 July in the eastern part of the HSE's directly run services. The aim is to have it live for the full country in HSE directly provided services by 1 July next year. That will mean it will cover approximately 80% of the total health Vote by 1 July next year. We will then need to move on to the larger voluntary organisations to pick up the balance of the final 20%. It is a huge transformation programme and, as the Deputy stated, it has been a long time coming. We are delighted it has been funded in recent years, in particular with the support of the Department. They will be our two next big go-lives - 1 April and 1 July - by when we will have all of the HSE's directly run services. It is both financial management and a procurement system. The procurement piece gives us an opportunity to assist with the productivity discussion around price and volume analysis.
Róisín Shortall (Dublin North West, Social Democrats)
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You would despair, though. It beggars belief that at this stage we do not have an integrated financial management system for a spend of €23 billion. I am not blaming the HSE for that. It should have been funded by the Department of Health and by the Department of public expenditure.
I raise a question with the Department about making the case for an adequate health budget. We know there is a lot of pressure from different sources with regard to health. I welcome that some attention has now been focused on getting better value for money and on productivity because there was always a sense of a black hole there. A huge amount of money was going into this black hole and nobody knew how it was being spent and whether we were getting value for money.
One aspect of the budget I am concerned about is the comments made about this year's budget by IFAC. It talked about demographic changes such as the significantly growing population and the ageing population. IFAC made the point that those demographics were entirely predictable but the budget for health did not take them into consideration. Why is that the case? Was the case not made sufficiently strongly by the Department with regard to costing that huge additional element or was it that the Department of public expenditure was not listening to that? Why did that happen, Mr. Watt?
Mr. Robert Watt:
The Department made the case for additional resources, setting out what we thought the ELS for the service would be this year given what we knew about wages, inflation and projected demand across all the different areas. We came to a number and that formed the process of the bid. That bid did not receive the funding in the budget and that is the political decision that was made. As the Deputy will know, subsequent to that, at mid-year-----
Róisín Shortall (Dublin North West, Social Democrats)
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It was a political decision that was made?
Róisín Shortall (Dublin North West, Social Democrats)
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But that was not adequate.
Róisín Shortall (Dublin North West, Social Democrats)
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It was not adequate to cover the demographic costs. Would Mr. Watt accept that?
Róisín Shortall (Dublin North West, Social Democrats)
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Did Mr. Watt put forward a specific figure to cover the demographic costs?
Róisín Shortall (Dublin North West, Social Democrats)
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Yet IFAC, which criticises the Government all the time for spending too much, said "the health allocation for 2024 [in the budget] is ... [not even] enough to cover [these] demographic and price pressures". Where was the lack of response coming from in terms of ensuring those elements were included in the budget allocation? Was the case not made strongly enough by the Department of Health or was the Department of public expenditure not listening?
Róisín Shortall (Dublin North West, Social Democrats)
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My final question relates to a particular area that stands out, and the witnesses have identified it themselves, where additional money going is into the hospital sector but the results are not being achieved at the other end.
What specifically is the Department doing about that? There is huge money going into the hospital sector. I have put it to Mr. Watt before as to whether a "money follows the patient" type system has been considered, or any other system that would ensure we would have a line of sight of those vast amounts of money. However, it is not happening. The Department is not getting value for money in the hospital sector, so what is it specifically doing on that?
Róisín Shortall (Dublin North West, Social Democrats)
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I ask Mr. O'Connor to give us an example of that, if he does not mind.
Mr. Muiris O'Connor:
We published a lot of detail at each hospital level and speciality on the quantum of resources and the increases in activity between 2016 and 2022, and raised issues and concerns about the deterioration in productivity. We have followed that really closely since and have very encouraging signs of much greater productivity between 2022 and the current year.
Róisín Shortall (Dublin North West, Social Democrats)
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On the part of who?
Seán Crowe (Dublin South West, Sinn Fein)
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Deputy Shortall said it was the last question two questions ago.
Mr. Muiris O'Connor:
The productivity task force was also committed to making regular performance information available at hospital level and speciality level, and there is huge learning available for the system where there is variation in the quantum of service being delivered for a certain amount of money. There will be a lot of learning-----
Róisín Shortall (Dublin North West, Social Democrats)
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Is that publicly available?
Seán Crowe (Dublin South West, Sinn Fein)
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Deputy Shortall will get a second round, hopefully.
Róisín Shortall (Dublin North West, Social Democrats)
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It is the last one.
Róisín Shortall (Dublin North West, Social Democrats)
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Okay. I thank Mr. O'Connor.
Neasa Hourigan (Dublin Central, Green Party)
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I will start by adding my congratulations to Mr. Mitchell, and also by recognising the work that has been completed on the waiting lists, and the effort going into it in the face of increasing demand. I know that is not a small challenge.
I want to follow up on the issue of targets and estimated savings but I want to look back a little bit to the recruitment freeze. My first question is this: do we have an estimate of what the saving was during the time of the recruitment freeze?
Mr. Bernard Gloster:
I do not have a specific estimate because the issue was that by the time we adopted the pause on recruitment across the board, more or less, in October 2023, we were already contractually committed to a significant number of people who kept coming onto the payroll right up to the end of the year. Essentially, it did not save anything. I suppose it stopped the deficit increasing. That is probably the best way to describe it.
Neasa Hourigan (Dublin Central, Green Party)
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Okay but we were increasing at a percentage point and we can track that on a graph somewhere, say what the percentage increase was and estimate what the saving was, can we not?
Neasa Hourigan (Dublin Central, Green Party)
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We will come to staffing ceilings in a moment but I expect we would have a sense of what the recruitment freeze did in terms of savings and efficiencies.
Neasa Hourigan (Dublin Central, Green Party)
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Okay. We can argue whether it is an opportunity cost but we should have a sense of what that number would have been if we had not put the recruitment freeze in place.
Mr. Stephen Mulvany:
For every one WTE, or every one whole staff member, that we did not further exceed, as the CEO said, you can take it that that is about €75,000 or €80,000 saved. For every 100, we stopped it growing when it should not have been growing, that is 100 times that. That is the order-----
Neasa Hourigan (Dublin Central, Green Party)
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Mr. Mulvany has all the calculations so he could do that. He has all the numbers at his fingertips. He could do that calculation and tell us.
Neasa Hourigan (Dublin Central, Green Party)
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An indicative view. An estimate.
Neasa Hourigan (Dublin Central, Green Party)
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Okay, and since, is it mid-July that it was lifted?
Neasa Hourigan (Dublin Central, Green Party)
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Since then, what has been the increase in staffing, or have we tracked that with regard to the data?
Mr. Bernard Gloster:
We did two things, critically, in the strategy. First, we secured funding to retain the unfunded 4,000 posts we were carrying by virtue of both the pandemic and the overshot on recruitment in 2023. We secured the funding for that, and we locked in the control at 31 December of last year, plus new developments for this year, plus a couple of factors like taking over the hospices, section 38 agencies and so on. Essentially, we are now inside our target, and our target WTE for the end of the year is not greater on the health side - I am leaving out disability - than 129,000.
We are inside it now. We now have the control and the measure and therefore do not need to revert to the type of blanket measures we did last year. That control mechanism is now in place. Whatever about still having to deal with agency and overtime, which we are working on, I am very confident that, on the pay and numbers strategy, regardless of the debate about need, which is a different thing, the control environment that is in place as regards full-time employment is working. It allows people like Ms Queally the flexibility to make choices within their numbers but their number is their number. That is working. I have put in place a control mechanism that cannot be breached because there are only ten people in the country who can admit somebody to the payroll system.
Neasa Hourigan (Dublin Central, Green Party)
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I have heard people responding to that. We will come to need in a second but I will first return to agency and overtime, which Mr. Gloster just talked about. Perhaps this is a question for the Department as well. I believe we all generally support this push for savings and productivity. Is what Mr. Gloster just described how the number for the staffing ceiling was arrived at?
Neasa Hourigan (Dublin Central, Green Party)
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I am not sure whether this is a question for the Department or the HSE but will Mr. Gloster outline the policy as it applies to a particular unit, whether a maternity unit, a mental health unit or whatever, when there are new roles coming along and new recruitment happening and where roles have been staffed by an agency staff person for quite a long time? In a world where there are finite resources and finite abilities to staff, what is the procedure or how is the decision made? What is the preference? How is the decision made? Do we make agency staff permanent or do we bring in new roles?
Neasa Hourigan (Dublin Central, Green Party)
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May I ask a follow-up there? What does "reduce" mean? Does it mean to make those people permanent and bring them within the HSE family or does it mean to get rid of them?
Mr. Bernard Gloster:
As to what that means, in the next two weeks, we will issue in excess of 500 whole-time equivalent positions to regional executive officers to allow agency staff to be directly converted into full-time staff. However, we will still allow those officers an agency budget because we recognise that agency staffing is needed for temping and filling shifts, although that dependency must be controlled. You cannot just keep allowing it to drift. It was drifting, understandably, when the moratorium was in place because people had to fill shifts but could not recruit. However, the position is now much more stable. When you put the paid workforce alongside the agency and the dependence on overtime, you get the three legs of the stool of the pay and numbers strategy. The next one is the agency conversion.
Neasa Hourigan (Dublin Central, Green Party)
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Will that agency conversion be a long-term project? It seems we are staffing a significant number of long-term jobs.
Neasa Hourigan (Dublin Central, Green Party)
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My question is not so much about the time it takes to do it. I presume there are more than 500 staff in this position.
Neasa Hourigan (Dublin Central, Green Party)
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That is for the Department to answer, then.
Mr. Bernard Gloster:
Yes. I need additional numbers. Quite frankly, the reason we ended up in the trouble we ended up in last year was that there was no connection or clarity between the numbers, the money and how the control environment operated. We ended up with the pretty severe approach of the blanket pause. Nobody in this room disputes that. We have now put in place a system in which we do not need to rely on that. However, I have been very rigid. I believe the Secretary General will, at times, find tensions coming from his side as well. I have been very clear. We can no longer assign additional pay costs or numbers unless there is a letter with a harp from the Secretary General to me saying my number has increased by a given figure. That is the only way it can be done.
Neasa Hourigan (Dublin Central, Green Party)
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That is very clear. Will the Department respond to that point? Will it also respond as regards its position on the conversion of agency staff?
Ms Louise McGirr:
From the Department's perspective, where we ideally want to go with the HSE is to a safe level of staffing. The chief nurse can give more detail on that. Ultimately, that is an objective measure of the safe number of staff within a service. That includes absence, sick leave, maternity leave and all sorts of other things and provides an objective benchmark as to the staffing requirements in a service.
That is really the gold standard of where we want to be across all our services. It is not yet rolled out across all services. That is what we aim for and that is the appropriate level of staffing. In terms of conversion, we approved a conversion for safe staffing within the budget and there is a further proposal, as Mr. Gloster outlined, to convert more staff where there are high agency costs - front-line staff. We are supportive of that approach to conversion.
Neasa Hourigan (Dublin Central, Green Party)
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The Department of Health is identifying particular posts that have a high cost----
Neasa Hourigan (Dublin Central, Green Party)
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But units that have a high-----
Ms Louise McGirr:
In terms of prioritisation, areas that have high agency costs and areas that have staffing shortages would be prime for conversion of existing agency into permanent posts. We know permanent posts are generally safer in terms of the quality of care and that is a key factor. It is more desirable to have permanent staff, it is more efficient and they know what is going on. However, there will always be a need for agency staff. That is recognised.
Neasa Hourigan (Dublin Central, Green Party)
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We have gone far beyond stepping in for maternity leave or stepping in for sick leave.
Neasa Hourigan (Dublin Central, Green Party)
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We are now in a position where we have people who have been going in and out to work for maybe 18 months, they are fully integrated into the team and they are still on the agency's books.
Neasa Hourigan (Dublin Central, Green Party)
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Okay. Is that tracked into the Department's decision making? Is the Department making a commitment to an ongoing addressing of the issue of converting agency staff to full-time health service staff?
Neasa Hourigan (Dublin Central, Green Party)
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Maybe Ms Kenna can speak to this. Some 500 is great but we are probably talking about thousands at this rate. Is there a recognition and a commitment that this is an ongoing process?
Ms Rachel Kenna:
We are continuing with annual funding for the implementation of safe staffing over the last five years to a total of €56 million. One of the main principles of the safe staffing framework for nursing, which is the largest workforce throughout the whole system, is that we have a sustainable workforce and a stabilised workforce. This means you have to reduce your reliance on agency and overtime. Generally, around 80% is the figure of permanent and whole-time equivalent staff as part of your team that allows for that flexibility for clinical judgment of patient care as and when the need arises. There should be a sustainable approach. We have proved through evidence that this results in better patient outcomes when there is that stabilised workforce.
Neasa Hourigan (Dublin Central, Green Party)
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What would be the highest level of agency use that Ms Kenna has come across in a particular department?
Neasa Hourigan (Dublin Central, Green Party)
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Wow. There was 56% reliance on agency staff.
Neasa Hourigan (Dublin Central, Green Party)
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So that is 900 total?
Neasa Hourigan (Dublin Central, Green Party)
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In the push for productivity and savings which, again, we all support, I would not like to see a slippage in the standards of the working life and workers' rights within the HSE. I noticed that when we removed the recruitment ban, the IMO made comments about the staff ceiling and asked if that was a proxy for a recruitment ban. I thought a lot about the fact that so many non-consultant hospital doctors, NCHDs, are working hours that are unacceptable and very difficult and I do not want to say they definitely put people at risk but they are certainly not ideal. In the push for these savings and productivity increases, how are we ensuring that we are still tackling those issues that were there already and hopefully not exacerbating them but that we are actively working to improve conditions for young doctors, nurses and all those staff?
Mr. Bernard Gloster:
There are a couple of parts to that. The first thing is that we all have to put our hands up and admit and accept that regardless of the pay and numbers strategy, recruitment pauses and inflated recruitment, the working conditions of NCHDs has been very variable and challenged, long before even the European Working Time Directive came in. We all know that. In recent years, the number of NCHDs has exponentially grown.
We do not make an apology for it, but we will not compromise the service or quality of care. We are trying to reduce the number of non-training NCHDs and increase the number of training NCHDs. We have a specific focus in our doctor training programme. I have given specific commitments to the NCHD task force review to make as many improvements as we possibly can. It is a slow-burner, I will be honest, because we have to balance not just the European working time directive but safe care and the quality of training for doctors versus non-training doctors who just move around the system.
Neasa Hourigan (Dublin Central, Green Party)
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I ask the Department to respond.
Ms Rachel Kenna:
It is a good question. We have the NCHD task force, which was established by the Minister. There are about 42 recommendations, of which a significant number are dealing with the issues the Deputy pointed out, such as flexible and fair working conditions. We have the report of the expert review body on nursing and midwifery which, again, deals with the health and well-being issues of staff. We have health and social care professionals. There is much work going on about enhancing roles, expanding roles and advanced practice, all of which have been asked for by the professions in terms of more flexibility and more opportunities. Looking after their health and well-being is all part of that.
Seán Crowe (Dublin South West, Sinn Fein)
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I will bring in Deputy Gino Kenny, after which we will have a comfort break for five minutes.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank the witnesses for the quite upbeat assessments.
I will ask Mr. Watt and Mr. Gloster two general questions. Do they envisage any kind of headwinds blowing things off course over the next six months in the context of this assessment? Do they see anything over the next period where things could fluctuate or go off course? It is a general question but I want to get to specifics.
Mr. Robert Watt:
There are the headwinds of demographic change and what that means for demand, which is, in the main, predictable to anticipate, even though, as Mr. Gloster mentioned earlier, the demand we are seeing is probably ahead of what we thought the demography would lead us to. It is partly a function of the fact that services are now available, more treatments are available for conditions and more drugs are available to treat things which previously were not able to be treated. The demand is steady.
Winter is always the big risk. If respiratory disease-flu is more virulent than previous years, that could lead to such pressure that we may have to cancel more scheduled procedures. That is what we are trying to avoid with winter planning across many different things. It is the winter respiratory season. We know it will happen and it will cause pressure, but if it is worse than the past number of years, that could-----
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Has anything been put in place to mitigate against that?
Mr. Robert Watt:
Yes. We have the vaccination programme, deals with private hospitals and a whole variety of measures around capacity and rostering steps to take. This week, we started the process of winter planning once again. We have planning all year round, but it is a more acute phase. There are many measures. Last year, the system coped very well despite the fact that there was very significant demand. We have seen trolley numbers come down. This year, we need to continue with that. Those are the concerns.
Mr. Bernard Gloster:
That is a fair assessment. Going specifically to the productivity place, the next natural step for us is to further advance the move from what we call the five over seven week to getting six over seven, perhaps. To be fair to the unions, it is a big one to grapple with. If there is a long delay in that, the benefit of the public-only consultant contract will not be fully realised. There are many people around consultants other than consultants themselves who need to be part of that working system. The healthcare system needs to operate on Saturday the way it operates on Friday.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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In Mr. Gloster's view, how is that progress?
Mr. Bernard Gloster:
To be fair to people, it is reasonable. It was accepted in the public sector pay agreement. It is now a question of which prioritised disciplines we want to get to first and engaging with the unions and professional associations on that. In the meantime, people have, by and large, been quite flexible. We now have 2,600 consultants on the public-only consultant contract, which is well over 50% of the consultant workforce.
To be fair to consultants, we can roster as many of them on a Saturday or on a Thursday night as we want but if they are going to function, we have to build the rest of the infrastructure around them to do that. That is the part we are progressing. If the Deputy was to ask me if something could blow us off course, it would be if we overcooked things and it took us too long to get there.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Mr. Gloster is happy that is progressing, largely?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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What does that mean in practical terms for somebody who wants to access a service if they are working on a Saturday?
Mr. Bernard Gloster:
It means we move from an emergency system on Saturdays with the emergency department or on-site or on-call arrangements in diagnostics and other things to a functioning system on Saturdays with outpatient clinics and late Thursday evenings because it suits people who are at work. Something consultants would agree with, as would we, is that theatre utilisation leaves much to be desired in the context of the amount of downtime. It means Saturday being a normal day as opposed to being an emergency or on-call day.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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That will have an effect on people accessing public healthcare and so on.
I have another question that I will direct to Mr. Gloster. It relates to private nursing homes essentially going to the wall. There have been a number of cases this year, including Lucan Lodge and a nursing home in Kerry, I believe. They are care providers that have been there for a period and that lost their licences, via HIQA, for all sorts of reasons. In the case of Lucan Lodge, the company involved went into liquidation. I submitted a parliamentary question over the summer to ask how much it cost the HSE to intervene. The amount involved was colossal. It was €600,000 in the space of three and a half months. The sums are colossal. The HSE has to pick up the tab. How concerned is Mr. Gloster about private nursing home providers going to the wall?
Mr. Bernard Gloster:
I will come back to the systemic piece in a moment because we are the provider of last resort. The person who can best articulate the impact is Ms Queally. She is the regional executive officer. She has had to run counties where nursing homes have literally gone in a day. Perhaps she will comment on that.
Ms Martina Queally:
It is a massive challenge for the team. I acknowledge the capacity within our teams to address that challenge as it occurs. We have to take over when it happens. The HSE becomes the provider of last resort under the legislation. Our teams have to pivot. Frequently, as outlined, it is unexpected. As a result, they have to reorganise their work completely to ensure the safety of the residents. It is always our priority to ensure the safety and dignity of residents who find themselves in that situation and to work with families. A great deal of movement has to happen. One has to ensure that clients are transferred appropriately and maintain good communications with the public, families and residents because it is their home. It is very dramatic for clients. It is not a situation we like to see happen but unfortunately when it does, we have to be able to respond to it. We are fortunate that we have great teams and can work through that arrangement when it occurs but it is challenging.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I can imagine.
Mr. Bernard Gloster:
It is sector-wide. That is an important point because I think it is behind some of what the Deputy said. There are many very good nursing home providers. I would be the first to recognise that. They pay attention to the quality of the service they provide. I have addressed with Nursing Homes Ireland my serious concern about some providers which choose to enter the market and may significantly borrow against the business in capital terms and then find they cannot sustain that. They know going into the business the rates and the projected incomes. When they get into trouble, there is an erosion of quality because they cannot fund staffing or maintenance of the premises. It starts to deteriorate. At a particular point, HIQA will only tolerate a certain level, particularly where something is disimproving.
It is in those circumstances that we have to take over, and we have to-----
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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At a huge cost.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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At an enormous cost.
Mr. Bernard Gloster:
There is not only a huge cost because, apart from that, there is dreadful distress and upset for families. Many years ago when I was a manager down the country, I took over a nursing home late one evening. The impact of uncertainty on the residents to be displaced and on their families is dreadful. Equally, however, it is not the case that the State can simply buy, take over and run every nursing home that fails. That creates a perverse incentive, among other things. I have asked Nursing Homes Ireland, which has many good members, to try to ensure that when people are entering the market or taking over nursing homes, they do so with their eyes open and realise they have a commitment beyond what is just the commercial interest.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I acknowledge the human damage this does. You could not put a price on it. Is there a growing trend of care providers leaving the mess to the HSE, at enormous cost, when private care provision is not profitable enough?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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In how many instances in, say, the past two years has the HSE had to intervene directly?
Mr. Bernard Gloster:
I would have to check. While I would not be across all the detail, I would certainly say to the Deputy that, on any given day, we are worried about five, six or seven situations where we might have to intervene. I am certainly aware that we have intervened in several in the past year.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Ultimately, the HSE has to intervene. We are not arguing against that but it comes at a huge cost, with damage done to the residents. What does the HSE ultimately do? Does the nursing home close down? Can the HSE intervene directly and take over a facility completely, as with Lucan Lodge? Lucan Lodge is a great facility-----
Mr. Bernard Gloster:
I do not want to go into the specifics of any one provider. There are property ownership, property value, staff and capability issues. It is very difficult for us to take over a private nursing home and staff it to a public sector standard when doing so is unplanned. Going in when a nursing home fails and then keeping it running, as is normally expected, does not represent the best way to take a sector or part of a sector into public ownership. The usual position is that when safe intervention is required, we put a person in charge immediately. That person takes control of the nursing home, including the staff paid by the provider, runs it safely and manages it. The person usually helps the provider to wind down and liaise with other providers, nursing homes and families to determine what alternative arrangements can be made. It is rare enough that we would take over a nursing home and permanently keep it ourselves.
Seán Crowe (Dublin South West, Sinn Fein)
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I thank Mr. Gloster. We will take Senator Maria Byrne when we return just after a comfort break.
Maria Byrne (Fine Gael)
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I thank Mr. Gloster and Mr. Watt for their contributions. I also thank everyone attending before the committee today. My questions relate to efficiencies and greater use of resources. I am based in Limerick and therefore most of my questions relate to UHL. There was a report published recently on the recruitment freeze. It stated that, because of that backlog, there would not be sufficient staff in place for the new 96-bed unit that is being built in the first quarter of 2025. That is the first thing I would like a comment on.
Mr. Bernard Gloster:
I can absolutely confirm for the Senator that the recruitment freeze that was in place has gone but in any event had no impact. The Minister made special arrangements and the Department gave me approval this year for, I would say, one of the earliest opportunities ever in a capital development. I have given formal approval to the mid-west to commence recruitment for the 96-bed block to ensure staff are contracted, can come on the payroll any time from 1 January onwards and will be there in time to open that facility. The additional numbers I talked about earlier with Deputy Hourigan are being provided by the Department in 2025 for that.
Maria Byrne (Fine Gael)
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There were a number of surgeries cancelled in mid-August because of trolley numbers. I welcome that there have been improvements within the health system. However, UHL always seems to fall behind. There were surgeries cancelled over a two-week period because of people being on trolleys. There is now a backlog of surgeries. What are the plans? While we are making greater efficiencies to reduce trolley numbers and people waiting for surgeries in UHL, things are going the opposite way.
Mr. Bernard Gloster:
To be fair to the people working in Limerick, they have come in for much focus on the downsides. In commenting on Limerick, I want to balance that by saying that much good work happens in that hospital. I know the Senator agrees with that. She and I both live within the remit of that hospital. The cancellation in August was a planned intervention to essentially de-escalate the hospital and take the heat out of it. I do not want to be disparaging but the hospital had overheated to a point where to allow that to continue would have meant that we would move into the space of being unsafe. First and foremost, we have to ensure we make sure the site is safe on any day.
Last year, despite many of the criticisms, Limerick delivered one of the highest levels of improvement in scheduled care waiting times, including surgeries, so it was well ahead. The two weeks is always discomforting. I do not want to mislead anyone. I suspect that, probably for the next couple of weeks and months, there will be days on which activity on the waiting list side will have to go down to accommodate pressure on the emergency side of the trolley. Equally, we will find every opportunity to balance that. The long-term solution to that in Limerick is the 96-bed block, which is the second block. We had a 16-bed drop just before Christmas. We have had some planning difficulties and other difficulties regarding the surgical hub, but we will have that. As the Senator knows, we use the private sector for waiting lists and Limerick will have a super new private hospital in the coming months. All of that will add to the capacity of the region while we are building those additional blocks. I will not give her any false promises. It is difficult but it is all being done in the best interests of the people.
Maria Byrne (Fine Gael)
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I thank Mr. Gloster. I appreciate how hard the staff work. Everybody is working to try to give a safe experience not only to the staff but to the patients too. I am concerned by the recent report that an open competitive procurement process was not used at the hospital and the senior management then said it did not have that system within the hospital group. I think that sends out the wrong message not only to us as a committee but also to the public. Would Mr. Gloster like to comment on that?
Mr. Bernard Gloster:
I will, of course. I am happy to comment on that. To be fair, that report was not just on Limerick. It was about three hospitals. When I came into this job, I wanted to look at how we manage additional waiting list activity and plans in the best interests of the use of public money. Both the Secretary General and I agree it is important that we look at those things and are transparent about them. Secondly, the report the Senator is referring to, which was published last Monday, was published proactively by us. It was not dragged out of us or anything else. I think that is important. The third thing which is important to say is that while it suggested problems and difficulties, there is nothing illegal or untoward in it. I want to be careful about that. I would be a little critical and push back at my colleagues in Limerick to say that one does not actually have to have a fully operating procurement function to do procurement. Public servants do procurement every day. There is a good action plan response to it. My colleague has gone to Limerick to assist the hospital with that and might want to comment on it.
Mr. Stephen Mulvany:
As the CEO said, the hospital group and regional executive officer accept and have provided the necessary assurance that we are all clear, regardless of the pressure on service and activity, that the basics of probity, including competitive procurement, have to be complied with. They have confirmed that no further non-competitive procurements have been put in place around such initiatives since that happened. It is now a standing item on their agenda and they are working with our national procurement team to bring those current contracts into compliance. As the CEO said, it is an important issue, they have accepted that, and they have provided the necessary assurance.
Maria Byrne (Fine Gael)
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I thank Mr. Mulvany and Mr. Gloster. I want to raise concerns around staffing levels. I was speaking to somebody recently. I know I am confining my questions to just one area. In the high observation unit, unit 5B, I understand there should be four staff on at any one time. In recent weeks, there have only been two. In the last few days, there have been four. If staff are out sick, are there plans for how to replace those people? Does it involve agency people? Sometimes, it just does not happen.
In a high observation unit, I would expect staffing levels to be at full capacity.
I am aware of a patient in the area who was to see a physiotherapist in the past six months, but the physiotherapist has still not materialised. There seem to be discrepancies in certain areas. I had a personal experience in the hospital recently and the service was second to none. It was really good, but there are niche areas where it is falling down.
Mr. Bernard Gloster:
The acute psychiatric unit the Senator spoke about is run by the community service rather than the hospital. The mental health service now has one of the pay numbers we spoke about, as does the entire mid-west, and it has to work and manage within it. The Senator is correct that short-term absences would normally be covered by agency workers. I do not know the specifics of that case, but the issue in mental health nursing is usually to do with availability rather than money or approval. Mental health nursing is a profession in very high-demand.
The one thing I will say about an inpatient waiting for a physiotherapist in such an acute psychiatric unit - again I do not know the circumstances - is against us. I am shocked when I hear those things, because with the number of physiotherapists and occupational therapists in whom we have invested in the country and the mid-west in recent years, it should not be the case that someone we are caring for 24 hours a day cannot access that type of healthcare. There are traditional boundaries that mean primary healthcare physicians will not go into inpatient units. Frankly, however, that is unsustainable. I will certainly pursue that matter. On the broader issue, it should not be occurring.
Seán Crowe (Dublin South West, Sinn Fein)
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We spoke about productivity and savings. Mr. Gloster mentioned occupational therapists, OTs. Recently, I dealt with a case of an 83-year-old man who is trying to get access to a wheelchair. He needs a referral from an OT. He received a letter stating it will take two years or more to see the OT. He was then given a leaflet about the private purchase of equipment such as rails and wheelchairs, private rental of wheelchairs, private purchase of portal ramps and so on. The difficulty is that he is 83. He is not getting any younger. He needs to get access to an OT but he has been told it will take two years or more. Mr. Gloster said that productivity is a big challenge. Is that an unusual case? Is it particular to an area or is it common across the State?
Ms Martina Queally:
I hope it is unusual, but that is hope more than anything else. One of the things we are trying to do in our programme of work is to avoid such scenarios for 83-year-old men. We have integrated care programmes for older people and 96 community health networks across the country. The idea behind and objective of those programmes is to ensure the pathways of care to enable people, such as the person to whom the Cathaoirleach referred, to stay at home and stay active and well within their families by ensuring they have whatever equipment required. An OT assessment is required to get such equipment, but I do not like to see that kind of waiting time for an older person. We have seen improvement in waiting times in the integrated care for older persons. Some areas are extremely challenged when it comes to therapies, but that is not what we are coping with in the overall system.
Mr. Bernard Gloster:
I will add to that. I do not know the individual case and I am sure the staff are trying their best.
We should be called out on that. We should hold a mirror up to ourselves on that. When we are asking an 83-year-old to wait two years for something, we are telling that person to wait beyond life expectancy. That should be to our shame as a healthcare system. I certainly would not stand over that. It is well within the capability of any county in Ireland to respond to an 83-year-old who needs an occupational therapist.
Seán Crowe (Dublin South West, Sinn Fein)
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Again, there was a lot of coverage in the papers regarding children, particularly those with scoliosis and orthopaedic issues. There was a family in touch with me who were a number of weeks in Crumlin hospital waiting on an MRI. There were other supports needed in order to take that MRI, but they were there for weeks. You would think it should not take weeks to get an MRI. I am conscious that there were other supports involved. Again, we are talking about productivity and savings, but the financial cost to the family was huge. The parents were out of work. They were sharing a room with two other children and their parents. I am just giving that as an example. People do not understand. They think that surely an MRI would be prioritised to get that child out of that bed. It did not work. I mention this case as an example. There are many examples out there in this regard.
I spoke earlier about an emergency department and how it worked for members of my family. I am conscious that there are many people listening in for whom it did not work. This puts into context what we are talking about today.
There are a couple of things that could be helpful that we have not touched on in this committee. Could the witnesses go into extra detail about the national electronic patient health records? That is an area where we would save money. I understand a pilot has been completed in conjunction with Maynooth University and is ready to be rolled out. This should provide some additional information and will hopefully eliminate the duplication of diagnostics and so on. That might be one area that we could focus on that is really positive. When will this happen?
Mr. Damien McCallion:
The Digital for Care 2030 framework, which was developed with the Department, sets out a roadmap right up to 2030 for how we can invest in digital because we have a long way to go. We have stood up a number of major projects to advance it. One is the electronic health record. We have many electronic health records. I am familiar with the one the Cathaoirleach has referred to in south Dublin. We have them in our maternity hospitals, some mental health services and other hospitals. The issue is that they cannot all speak to each other and the staff that need to use those systems are typically in hospitals, not just in communities.
One system we have is consistent with other countries. We have looked at Alberta in Canada and at Northern Ireland, which is currently rolling out a system that will be finished in about three years. Some of the UK trusts are also combining. We have worked with them to develop a model around that. This will take time. In parallel with that, we are developing a health app for patients which will start to use what we already have. That will be launched at the end of this year. That will use MyGovID, which over 2 million people are already using, and will give people access to their medical cards, their EHICs and their long-term illness cards. It will also have the option to reimburse medicines, which will develop further over the next few years in terms of other medicines people may have. It will have an ability for people to enter their own. This will be helpful for family members caring for elderly people, like the gentleman that was mentioned earlier. It will also have signposting to services. Many people who come into the country do not know where to go. Those of us living in communities for a long time will know, but many do not. It is important to know where the services are and how they can be accessed. It will also have self-care capacity within it. We see this as being the key development with regard to giving patients access. When we talk about productivity, one of the areas we focused on initially in the first release was women who use maternity services. They will get their appointments directly to the app. We ran a pilot in the summer with about 60 women, and there was really positive feedback around that. We have an electronic health record in some of our maternity hospitals. In those that do not, we are standardising the data, to take a point that was mentioned earlier.
In addition to those big projects, we are also working on diagnostics. There is a national imaging system, bar two hospitals, whereby a child who appears in Letterkenny or Kerry and needs a neurological assessment can have that CT scan or MRI viewed in Beaumont hospital in Dublin. In times gone by, the inefficiencies that would have gone on to try to make that decision, apart from care outcomes, were huge. Beaumont hospital in north Dublin was the first site to go live with our new laboratory system in recent weeks. There were 3,000 people trained in eight weeks. One of the key aspects is electronic ordering for GPs.
There were between eight and ten people involved every day. There were 1,000 samples. I walked the floor with the team, the members of which would have had to enter all of that manually. That is now all electronically scanned and links into their robotic systems. There is a lot of potential on many of those big projects, and we will tender and work through a business case with the Department and the Department of Public Expenditure, NDP Delivery and Reform with regard to the roll-out of that.
We are obviously obliged to tender for the electronic health record. However, my point is that while the electronic health record is important, we can move in many of the other areas at the same time. I will not go on at length, but a great deal of work is going on with robotics and things like that. This is creating efficiencies. We had a robot built in the west last year that resulted in significant savings in the context of a load of administrative processes that are now run overnight. That means waiting list management is more accurate and it saves a couple of hundred hours in that one hospital. That is now being rolled out across the country. There is much scope there, but we need to be aware that we have procurement obligations. We will see companies or people say from time to time that we can use X and get there quicker. We have to follow our procurement rules. At the same time, many other things are happening. That is important. I would be confident that the framework gives us a good basis to move those things forward in a strategic and consistent way across the country.
Seán Crowe (Dublin South West, Sinn Fein)
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Mr. McCallion might touch on the virtual ward system. I think many people get it, particularly as it relates to those specialties. The big concern would be if the person develops complications. Will Mr. McCallion speak to that?
Mr. Damien McCallion:
There is a great deal of virtual care. Ms Kenna may also want to comment on this. We have two wards live at present- in Limerick, and in St. Vincent's. They are at around 25 beds. It is clinically led, so it is only for certain diagnoses, conditions and treatments. It is managed carefully in terms of the nature of the patients who avail of it. We think we can move to larger numbers, both in those two facilities and throughout the country. We are trialling other initiatives in respect of virtual care in the community, between the community and hospitals and self-care for people. There are another 12 projects running behind that. The virtual wards certainly give huge potential. You do not have the capital investment to make, and the time delays, so you can get beds in much quicker. The typical construction cost of a bed is well over €1 million, and you are saving that. However, it is important that it is clinically led and only for certain conditions. It is then managed through.
Ms Rachel Kenna:
As I said, in the first place there are three different models of virtual care being delivered. I turn first to the acute virtual ward, and to the Chair's point about our ability to interact with patients. The care is the same as if the patient were an inpatient in a ward. They are constantly monitored. It is consultant-led and clinician-delivered care across the range and variety of respiratory and cardiac patients at the moment. We are hoping to expand the number of conditions we can look after.
I will give an example of the early impact of that. As Mr. McCallion said, each ward has a capacity of 23 beds. Since they started in July, we have seen 163 patients looked after at home who would previously have been in hospital, saving approximately 800 bed days across the two sites. They have significant potential to look after people in their own homes. The community model is slightly different. It is focused on integrated care and gives great visibility to what Sláintecare has always intended. ICPOP teams and the ECC programme are integrated in this one. It operates on 80 virtual beds in south Dublin city and the west. The St. James's and Cherry Orchard sites operate this virtual model for older people under three pathways. We have crisis management, rehabilitation and palliative care. These patients would all be older people who would be at high-risk of emergency department admission.
I will again give an example of the early impact of this. Some 500 older people are admitted annually through these 80 virtual beds. They averted 414 ED presentations in 2023, saving approximately 1,200 hospital bed days. Those are early indications of that. The virtual ward in the community can prevent 94% of crisis management patients presenting to ED. It is significant for the patient and for the impact on hospital settings. There are also 15 of what we describe as seedling projects in operation around the country, and a variety of conditions where we are delivering digitally-led care for anything from virtual contact clinics to some monitoring telemetry, etc., where it goes back to the clinicians and decisions can be made, but the patient does not have to come into hospital.
Seán Crowe (Dublin South West, Sinn Fein)
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There is one other area. We have talked about it before, and it relates to Pathfinder. I think we all got that it keeps elderly people in particular out of emergency departments. It made more than 10,000 call outs between January and April of this year alone.
It makes sense in the context of the number of acute beds and so on. I submitted a parliamentary question in May and was informed that, again, it was not included in the service plan for 2024. It does not make any provision for long-term funding of the programme. From our discussion this morning, we all accept it seems to work. Is a roll-out of that service being continued or are we cutting back in some areas? I have a particular concerned relating to the National Ambulance Service, which is a key component of the Pathfinder service. One of my colleagues in County Kerry, Councillor Deirdre Ferris, was saying there was a cut in particular to rostered-----
Seán Crowe (Dublin South West, Sinn Fein)
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There was a cut in non-rostered ambulance cover. I am concerned as to whether that will impact on this service. The worry is that if something happens to a person in Tralee and the ambulance is on call in Killarney, it will take a long time for that person to receive assistance. How will this affect the Pathfinder programme? The fact that it is not part of the service plan raises concerns. Maybe it is not included because it is a pilot programme. When we discussed this before, we all accepted it is working and seems to tick all the boxes with regard to keeping vulnerable people out of dangerous places - emergency departments and so on. It also saves beds and saves money. It ticks all the boxes in the context of what we are talking about this morning. The fact that we are not funding the programme into the future worries me.
Mr. Bernard Gloster:
First, it has been not been cut back where it started. I insisted on keeping it where it was. It is quite difficult to staff over the seven days because Pathfinder relies not just on EMT paramedics but also health and social care professionals, particularly physio or occupational therapy. It is not a question of it not being valued. If you take pre-hospital emergency care in its totality, encompassing the ambulance service, the helicopter service, the advanced paramedics and the need to train more paramedics, which we are now doing, we have to scale it. Then there are the alternative pathways, such as emergency department in the home, EDITH, which operates out of St. Vincent's University Hospital, as well as Pathfinder, which is in a number of counties, and what are called community paramedics. We are trying to grow all of those in step. However, in fairness to the Department and the Government, we can only cut the cake so much in any one year's service plan. There certainly is no question but that Pathfinder is a useful part of what we do. Where it will come within the priority of what we have to invest in the ambulance service will probably be the factor that will determine the time it will take us to get there.
Seán Crowe (Dublin South West, Sinn Fein)
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It is common belief among all parties and none that this is clearly a key component if we are talking about saving money. The fact that we are not valuing it by funding it or putting it in our plans for the future is a mistake and a retrograde step. That may be something that can be looked at.
I am going to move back to members now. I call Deputy Durkan, who might give us a few questions this time.
Bernard Durkan (Kildare North, Fine Gael)
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The questions I asked in the first round were seen as comments. I would like to go back to the scoliosis issue, however. We need to deal with that firmly and quickly. We also need a response from this meeting and any other meetings to indicate precisely what it is intended to do. We can come to all the meetings we want and raise the issues again and again. The people expect to see results coming from that. That is what I am looking for. I raise the issues of scoliosis and cataracts and the organisation of the necessary surgery.
I also want to raise the issue of planning for the future. I look at my own constituency as an example. The population is growing quite rapidly.
We have Naas General Hospital there. We need to monitor the extent to which facilities there need to continue to expand in line with demographic trends to ensure we do not come to a spot down the road when somebody says if we had planned it properly, we would have been ready for it now. Now is the time to plan and put it into operation quickly, effectively and efficiently. I would like to a response on that issue.
The other thing I have raised at the previous meetings is primary care centres. There are examples in my constituency. We have already agreed a primary care centre for Maynooth and we expect one for Leixlip too. We have one in Celbridge and we have a very good one in Kilcock, which has the lowest population of all the towns. This is forward planning and a very good idea. Maynooth has a population of 20,000 students plus the town's indigenous population. There is a very strong pull factor and therefore a requirement for a primary care centre in the town in a hurry. The last thing we heard was that somebody was consulting builders concerning where we could get a site. That is not the business of builders, the construction sector or anybody else. It is the responsibility of the policymakers in the Houses, back in the offices and so on and so forth. We need to get progress on these things. We should not be waiting. We should not have to ask a second time. This is necessary and urgent forward planning. It is the same situation in Maynooth and Leixlip. Somebody came up with the idea that we would have mini primary care centres in both towns. We will like hell is the answer to that question. Consulting builders would, of course, be a great consultation. There will be no more of that kind of nonsense. We will have a policy decision and that is where this issue is supposed to rest.
Regarding people who have had cataract examinations, are on waiting lists but whom we cannot facilitate, those people cannot wait for those lists to expire. There are one or two cases I have made representations about repeatedly and the same people keep coming back. They are disappointed because they think that either I am not listening or the people to whom I speak are not listening, so it is Hobson's choice.
I thank the Cathaoirleach. Those are all my questions and I will accept answers to them all, and even written answers if it is not possible to come up with the actual answers.
Mr. Bernard Gloster:
I will certainly attempt to answer those questions I think are relevant to me, and the Secretary General might want to make one or two comments.
On spinal surgery for children, scoliosis being one of the conditions, I know a lot of anxiety has been expressed about this issue over a long time. A lot of work has been done on it and many improvements made. I have spent the past three days meeting with my team and with people from CHI, including Mr. David Moore, the surgeon leading the spinal unit there. It is important that, in the next few days, we communicate clearly to people because there is a lot of narrative about children waiting, how long they are waiting and what they are waiting for. A lot of progress has been made, however, and I hope people will see evidence of it.
Regarding primary care centres, the Deputy raised the issue of Maynooth with me the last time and the mini option of there being two small centres rather than one big centre. If I am not mistaken, I think my regional manager there had a meeting with public representatives to deal with this question.
Bernard Durkan (Kildare North, Fine Gael)
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It must have been a secret meeting.
Bernard Durkan (Kildare North, Fine Gael)
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I am not in favour of secret meetings.
Mr. Bernard Gloster:
I certainly asked for it not to be and I will check it. To be fair to the Deputy, he has raised the issue and it is a very fair question. As to Maynooth, I certainly do not have a principle or policy position that the town should not have a primary care centre. We have struggled to get people to come into the market to take up the lease option for primary care centres because of the rate we were paying. Additionally, the costs of construction and inflation meant it was not viable for some parties. I do not think, however, there is any principle or policy position about not having a primary care centre in Maynooth.
Bernard Durkan (Kildare North, Fine Gael)
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I do not want to interrupt, and I know Mr. Gloster is trying to be helpful, but the site was already available. Somebody decided, "No, we will have a consultation with builders", and so on. There is only so much of that kind of nonsense that can be tolerated.
Mr. Bernard Gloster:
That is very fair. I did say the last time I was here that there would have to be an engagement with the public representatives regarding the total position of primary care centres in Kildare. I had thought that happened, but if it did not, I will make sure it happens quickly. The Deputy will appreciate I do not know all the local details.
I do not have the ophthalmic waiting lists with me, but on the ophthalmic, we have made a lot of improvements. The Secretary General might want to comment. He visited the improved pathways in the eye and ear hospital and they are quite substantial. There was a furore a few weeks ago as to whether we changed the rate we were willing to pay in Northern Ireland and whether that was affecting people going there. I think we explained that reasonably well. There is plenty of opportunity there for our own ophthalmic services to continue to increase their response to people who are waiting. We have not been found wanting in making either the funding or the additional supports available to do that. I hope that will improve, but it is an increasing demand, so the Deputy is right.
On the planning for the future, a lot of what we are doing around the capital programme and, in particular, the technology programme and digital is the planning for the future. That is what we are trying to put in place, rather than just responding to the problems-----
Bernard Durkan (Kildare North, Fine Gael)
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And Naas General Hospital in that context.
Bernard Durkan (Kildare North, Fine Gael)
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Yes, there has to be.
Mr. Bernard Gloster:
I visited Naas hospital after the last time the Deputy raised it with me. It is a fantastic hospital. It is an outstanding hospital. They deserve enormous credit for what they have done with what they have, but there is the population growth there and the clinical connections between that and Tallaght and so on. We need to invest further in Naas, and I would not argue that with the Deputy at all. We have done some; we have to do that everywhere.
I do not know if the Secretary General wants to comment on cataract care in particular.
Mr. Robert Watt:
I will do so briefly, Chair, because I know you are short of time. As regards the primary care centres in Maynooth and Leixlip, we will come back to the Deputy with a note, if that is okay. I am not exactly sure what the latest position is, but we will come back to him on the timelines for that. They are in the plans, as I understand it, but we will establish where they are within the procurement process.
As regards cataracts, there is an issue in Cork and Kerry. There have been improvements recently in the integrated care. The clinic in Ballincollig was opened this summer, which will make a difference. There has been a programme there that has been implemented over a number of years. It was derailed, unfortunately, by Covid, but we are starting to see the numbers improve. Across the rest of the country, the services are improving. Waiting lists are down. It is unacceptable that people in Cork and Kerry have to get a bus up to Belfast to get their cataracts treated. As the best option available now, however, it is good that people are accessing that service. Clearly, we want people to be able to access those services where they live. That is the priority, and I am hopeful, with the reforms put in place and the investment, that we should see the service improve in the period ahead.
Seán Crowe (Dublin South West, Sinn Fein)
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I am conscious that we got a briefing. The committee asked for an update on this and it is on the system there.
Seán Crowe (Dublin South West, Sinn Fein)
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I call David Cullinane. I will take Róisín Shortall then, and I presume John Lahart is looking in. Is five minutes each okay?
Neasa Hourigan (Dublin Central, Green Party)
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I thought it was ten.
Róisín Shortall (Dublin North West, Social Democrats)
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Ten minutes.
Seán Crowe (Dublin South West, Sinn Fein)
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Yes, I know, but I did not know John was coming in.
David Cullinane (Waterford, Sinn Fein)
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I will start; we will not waste any time. As regards the productivity and savings task force action plan that was published, one of the areas that was key to identifying savings was agency spend - overtime, obviously. As part of the pay and numbers strategy that was published, there were a number of pillars to it setting a ceiling for staff recruitment. The ceiling is too low. We have had that argument in the past but, be that as it may, there is a ceiling there and Mr. Gloster's objective is to stay within that ceiling. I refer to agency spend, converting it into whole-time equivalents and then looking at overtime. Agency spend is enormous. I think it is approximately €500 million, which is a huge amount of money. How many whole-time equivalents does the agency spend equate to?
What is the number?
David Cullinane (Waterford, Sinn Fein)
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What progress are we making? My partner is a nurse looking for extra hours in the public system, by the way, and she cannot get them. Her only option was to use the agency which was not what she wanted to do. There are a lot of nurses in the same position. The HSE has set a target for itself which is to achieve savings. I am not sure we are anywhere near that target or will achieve that target this year, and we can maybe come back on that, but the volume of the money we are spending would tell me there are a lot of whole-time equivalents we could convert. That may take time. I am interested in a number, if Mr. Mulvany has it,because I would say it is very substantial.
David Cullinane (Waterford, Sinn Fein)
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I would say it is more than that.
David Cullinane (Waterford, Sinn Fein)
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Could Mr. Gloster outline what progress has been made?
Mr. Bernard Gloster:
The first step to progress, whatever the number is, is that this year we are aiming to convert almost 1,000 of those agency staff. We are aiming for 416 in nursing for safe staffing levels and 500 for general conversion. I hope, with the agreement of my colleagues in the Department, to allocate those out to the regions next week. That is the second part of the pay and numbers strategy. Once we allocate those and convert those, we will then be able to arrive at the more sensible cap and control we need for future use of agency staffing.
Whether or not coming into next year the additional new developments will allow us to convert further is obviously a matter for the budget day announcement. This year, we are targeting to commence the conversion of just under a thousand.
David Cullinane (Waterford, Sinn Fein)
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There is still a long way to go. If it is somewhere just under 10,000 we have a long road to the travel here.
David Cullinane (Waterford, Sinn Fein)
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I know, but we should be aiming to convert at least half of it.
Mr. Bernard Gloster:
The issue is why do we need them in the first place and we are always going to need a level of agency staff for shift filling when you are running a 24-7 system. There is always going to be a level of agency staff, but the question is what is that level? As we have increased our workforce, some would say we should reduce our agency staff but-----
David Cullinane (Waterford, Sinn Fein)
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Mr. Gloster has answered that one. We have had a number of very good and constructive meetings on the roll out of the regional health areas and in fairness to Mr. O'Connor and his team and Mr. Woods, they have been very helpful in departmental meetings. The regional health areas are going to be a key part of driving reform, productivity, population based budgeting and so on. There has been an issue that has arisen that I have to put to Mr. Gloster that is a serious one where health and social care professionals are not represented at management level and regional level. That is a mistake. I have raised it directly with Mr. Gloster privately and I am raising it publicly. I am putting it on the record that this should happen. The Department should be renamed the Department of Health and Social Care because social care and health and social care professionals do not get the recognition they deserve. Mr. Gloster worked in this space so he knows how important it is.
Will that issue be resolved? I have met with SIPTU and Fórsa and I know they are trying to engage with the HSE and the Department on this. We want to get the regional health areas right but we have to make sure that all grades are fairly and properly represented at management level. That is something I ask Mr. Gloster to seriously look at.
Mr. Bernard Gloster:
It is a very fair ask. Fórsa is not inappropriate in raising it. There is only place where I would part company with the argument and that is nobody sits on a management team to run a regional service to represent their own profession. You sit on a management team to be part of the management team decision-making and take collective responsibility-----
David Cullinane (Waterford, Sinn Fein)
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That is what they want. They want to be part of that decision-making.
Mr. Bernard Gloster:
I would bore the Deputy to death with structural design if I was to tell him how they do fit in. It is not that they have been cast aside. It is a fair issue. It is one that has not gone away and therefore it is one we will have to reflect on and see how we can resolve it. I believe it will be resolved.
David Cullinane (Waterford, Sinn Fein)
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My last question is to Mr. Watt and I have given him a heads up on this. I refer to publication of the cardiac review. That was commissioned in 2019. I was at a meeting of Oireachtas Members from the south-east region when the Taoiseach, Deputy Simon Harris, who signed off on this, was Minister for Health. I know Covid interrupted it because Professor Nolan was seconded to NPHET.
The report has been sitting on the Minister's desk for six months. When is that report going to be published? I have been asking this of the Minister, Mr. Watt and others. We need to see the report. My understanding is that failing to publish the report is having an impact on developing a new national cardiac strategy, which is more on the acute side. When will the report be published?
David Cullinane (Waterford, Sinn Fein)
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Does it need Cabinet sign-off or does he just make the decision?
David Cullinane (Waterford, Sinn Fein)
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Will Mr. Watt come back to us on that?
Róisín Shortall (Dublin North West, Social Democrats)
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I raised the HSCP issue with Mr. Gloster at the break. I endorse the campaign that is under way at the moment. We had a situation in the Department where it was doctors who were represented on management and we had a battle to get nurses represented and to have a director of nursing. Then we had a battle to get HSCPs represented in management in the Department. Finally, that was achieved. That has to be mirrored then in the regions. Health and social care professionals are a key component of our health and social care and they must have high-level representation.
On the nurses, Ms Kenna mentioned earlier the percentage of nurses who are agency nurses. She talked about a very high percentage in small units. Does she have an overall figure for what percentage of nurses are agency nurses?
Róisín Shortall (Dublin North West, Social Democrats)
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Does Ms Kenna have a ballpark figure on that?
Róisín Shortall (Dublin North West, Social Democrats)
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I would appreciate that because not only are some existing nurses looking for additional hours but a number of nurses who were on career break are finding it difficult to get taken back in, although they were guaranteed they could return to their job. Again, that is very hard to understand in the context of so many agency staff.
Róisín Shortall (Dublin North West, Social Democrats)
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It seems to be an issue.
Róisín Shortall (Dublin North West, Social Democrats)
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Mr. Gloster spoke earlier about utilising equipment, operating theatres and so on to the max. When we compare what is happening in the HSE with the private sector, there is a significant amount of unused time in the week, and that is not even going into the night-time. It does not make sense from a productivity perspective to have expensive equipment lying idle. Has Mr. Gloster looked at the possibility of introducing a four-over-seven working week to incentivise staff to work evenings, Saturdays and Sundays? Most people in the health service and in other places are looking for a better work-life balance. Could he do that on the basis of a four-day week?
Mr. Bernard Gloster:
To be honest with the Deputy, I have not targeted it or put it up there as a specific initiative. It would require public sector approval from the unions and the Department of Public Expenditure, National Development Plan Delivery and Reform because it would be a change to public pay policy but I say "Why not?".
Róisín Shortall (Dublin North West, Social Democrats)
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Most of the unions support the principle of a four-day week. It can be very attractive for staff.
Róisín Shortall (Dublin North West, Social Democrats)
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Right. Sure.
Róisín Shortall (Dublin North West, Social Democrats)
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Could I ask one more question about clinical placements?
Seán Crowe (Dublin South West, Sinn Fein)
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Deputy Shortall's colleague wants to come in.
Róisín Shortall (Dublin North West, Social Democrats)
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Perhaps Mr. Gloster would come back to me about clinical placements for radiation therapists.
Róisín Shortall (Dublin North West, Social Democrats)
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Thank you, Chair.
Seán Crowe (Dublin South West, Sinn Fein)
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I apologise to Deputy Lahart. He can come in now.
John Lahart (Dublin South West, Fianna Fail)
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I had 12 questions but I will put the rest of them in writing as I am trying to prioritise one question. I thank both witnesses. In my experience on the health committee, they are the most progressive pair of witnesses leading their teams in here.
Despite what people say, clearly there are challenges but there has been a lot of progress. I am particularly interested in the digital aspect, as the Secretary General is aware.
I wish to say the following to Mr. Gloster. I have availed of the Swiftcare model a few times and found it exceptional. If one ran some numbers, one would discover the amount of overcrowding it prevents in emergency departments. I do not know if the HSE has ever run figures on it. He said there is a kind of HSE model of it but one never hears people talk about it. I used to think that part of the primary care model was to replicate some of that but, clearly, it is not. Does Mr. Gloster ever think about replicating it? I ask that because, in the context of the emergency departments piece, notwithstanding that positive impacts have been made, we should not leave it exclusively up to the private sector or even buying time in some of these spaces to relieve it. I have more questions but I will put them in writing.
Mr. Bernard Gloster:
There are three forms of that which we try to use and develop. One is the local injury units, which are now seeing significant numbers of people. In fact, they are seeing very high numbers of people and we are expanding those injury units. Second, there is the medical assessment units, which is less on the injury side and more on the medical side. They are not, unfortunately, at the seven-day scale that you would want them to be at. The third is the model on which most of the GP out-of-hours services now work, which is a co-op based surgery. I am meeting with one of the health insurance providers that run some of those services in the next two weeks to look at the possibilities to further assist the public sector to avail of what opportunities are there. In simple terms, it is a very rapid and very good form of access for people who do not need urgent care but need to be attended to. I do not dispute their value.
Seán Crowe (Dublin South West, Sinn Fein)
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I thank the officials from the Department of Health and the HSE for their assistance on this important matter of the progress being made by the productivity and savings task force. Given the ongoing importance of this matter, the committee will continue to monitor the progress being made in this regard and looks forward to future updates.
Before we finish the meeting, I again wish Mr. Ray Mitchell well in his retirement and offer him many thanks from the committee.
The meeting is now adjourned. Our next meeting will be in private session on Tuesday, 24th of September at 4 p.m..