Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)

I thank the Chair. I am delighted to be here with my colleagues, the Ministers of State, Deputies Butler, O'Donnell and Murnane O'Connor. I am joined by the following officials from my Department: Mr. Derek Tierney, assistant secretary; Ms Rachel Kenna, chief nursing officer; Ms Tracey Conroy, assistant secretary; Mr. Daniel Curry, principal officer; and Mr. Patrick McGlynn, principal officer. We are here to consider the Revised Estimate for the Department of Health for 2025.

This my first time meeting this committee. I want to speak to the members honestly about the performance of our health service and some of the key challenges we face. We have an opportunity to work together to make the health service better for patients and their families.

There have been unparalleled increases in investment over the past five years. Since January 2020, the overall increase in expenditure has been €6.71 billion. This is a 35.3% increase, excluding disability funding, which was part of the Vote in 2020. The budget has increased from €19.04 billion in 2020 to €25.75 billion in 2025. At the end of April 2025, there were 25,661 more staff working in our health service than there were at the beginning of 2020. This represents a 25% increase, which includes additional front-line staff of 9,837 nurses and midwives, 4,084 health and social care professionals, 1,416 consultants and 2,280 doctors and dentists.

In moving towards universal access to healthcare, we have rolled out free contraception for women between the ages of 17 and 35, free hormone replacement therapy, HRT, at the point of delivery, State-funded IVF, and hundreds of thousands of GP referred diagnostic scans are now being paid for by the State.

I have introduced direct referral to diagnostics by physiotherapists as well, in an effort to expedite the processes. Through medical cards and GP visit cards, about 2.3 million people have access to free GP care. When the income thresholds were increased to the median income, we estimated 430,000 people to be newly eligible. However, take-up has been only 72,500, and I encourage members of the committee to spread this story while there are people who have access to free GP care who are not availing of it. There are different reasons but let us try to encourage people to do that.

The key point I want to make today and want to work with the committee on over the next number of months and years is that investment has moved ahead of activity levels. Our investment in health is very high. In 2022, Ireland ranked as having the third highest spend as a percentage of GDP-GNI* out of 27 EU member states. Nonetheless, activity is not keeping pace with the levels of investment. The recent IMF efficiency benchmark review found that Ireland's health system is inefficient compared with other countries, producing good outcomes but at high costs. It estimates that up to 15% of expenditure could be saved while maintaining life expectancy. That is borne out by our own repeated analysis.

I sent the committee last night an invite to see a demo of a new interactive hospital productivity dashboard, which will be made public very shortly. It was developed under the productivity and savings task force as part of our commitment to have objective performance data that is open and transparent. The insight from the dashboard is excellent. It shines a light on the difference in performance across hospital sites, between specialisms and even within sites. For example, it shows us that over the past five years, we have increased real expenditure in our hospitals by approximately 36% above inflation, and that includes an average increase of 18% more staff on the ground.

At the same time, activity in our hospitals as regards inpatients, day cases, outpatients and emergency department presentations has increased by on average 12% over the same period. Therefore, activity is falling behind investment. That average also shows considerable variation in performance between hospitals. For example, one of our model 4 hospitals saw only a 3% increase in overall activity, from a 36% in workforce and a real expenditure increase of 42%. That is clearly anomalous. In contrast, another model 4 hospital saw a 22% increase in overall activity, from a 40% increase in workforce and a 46% increase in real expenditure, which is considerably better than the other model 4 hospital but still not quite where we want to be. What is crucial is that we can differentiate between hospital activity, and it will be very telling.

Obviously, we all have a higher expectation of performance in return for public investment because every cent invested by the taxpayer must produce a result that responds to the demands we face and will continue to face. This is not about efficiency for the sake of metrics. It is not a maths challenge we need to win. It is about making people's lives easier, better patient outcomes, safety and dignity and ensuring that when a person needs an appointment, they have a better chance of getting it and getting it quickly within the Sláintecare model. We are living longer and it is projected our population will reach 6.3 million people by 2040, depending on future migration. We must respond, therefore, but we must do so more efficiently and effectively.

Focusing on 2025, this marks a very significant increase in investment and it has to be targeted in a way that improves access for patients to services and enables productivity. This year has seen one of the largest single-year increases in core health funding outside of the height of the pandemic. Gross funding increased by €2.9 billion, from €22.8 billion to €25.75 billion, an overall increase of 12.8%. That investment is heavily targeted towards increasing capacity to improve patient experience and access to health services.

I recognise the progress that has been made, but also wish to highlight where we need to do more. On waiting lists and waiting times, again, over the past year the health service has achieved a 12% reduction in patients on waiting lists exceeding 12 months and a reduction, crucially, in average waiting times from 7.2 months to 6.5 months at the end of 2024. That is against a backdrop of a 9% increase in outpatients and a 5% increase in inpatient and day case attendances. There is, however, much more to be done to achieve our goal of ten- to 12-week waiting times with Sláintecare. To continue progress into 2025, funding has been allocated to further reduce waiting lists and times. The waiting list action plan was published in February 2025 with a total funding of €420 million, between the NTPF and the HSE. Approximately €100 million of that funding is to be invested in developing HSE capacity, staffing modernised care pathways. The scale of the funding overall shows that we have developed an over-reliance on insourcing and private work to deal with our waiting lists. We need to move away from our dependency on that model to fully utilise the underutilised internal capacity we still have within the core health system. That is how we safely reduce reliance on that model of additional funding to manage our waiting lists, doing so in a way that protects patient outcomes as we transition.

Because of my concerns about the insourcing model, which I am sure committee members share, a number of weeks into my position as Minister, in early April. I requested that the CEO of the HSE carry out a review of insourcing across the system. I expect that to be completed shortly. I would like to come back to the committee when I have that to discuss it in good detail and look to see how we can reduce our reliance on insourcing while, at the same time, not negatively impacting on patient waiting times and patient waiting outcomes. That is going to be a fine balance we will have to figure out together how to do correctly.

In respect of urgent and emergency care, that really is a priority. We have made good progress on reducing our trolley numbers over two different ways. At the end of 2024, there was an 11% reduction in the number of patients waiting on trolleys at 8 a.m. for a hospital bed compared with 2023, despite an additional 130,000 patient presentations to emergency departments nationally, but this year, we have seen an additional reduction, though it has not been as consistent as I would like. One of the key reasons for that has been the weekend rostering of consultants on site. The proper implementation of the public-only consultant contract is absolutely key in improving patient flow through the hospital and ensuring the safety, experience and dignity of our patients. Through the relentless focus of the CEO of the HSE, Bernard Gloster, and hospital managers in different ways, changes are being implemented at local level and we are seeing improvements, though not consistently. There are local nuances everywhere, which we can discuss.

It really is not only about consultants, though it cannot happen without them. Many other staff and community throughout hospitals are also needed to operate our services on a seven-day basis. That has been a key reform goal for me, and I really am absolutely delighted to see the agreement between the HSE and staff representatives on moving towards working across seven days. That was initiated by Bernard Gloster on 12 February, and I am delighted to see agreement now in June. The key challenge is going to be around implementation. What that means is that up to 10% of staff, in addition to consultants, will now be rostered over weekends. I am focused on ensuring the HSE delivers those changes and that people can access services they need at the time they need them. As everybody here knows, people get ill seven days a week and better seven days a week. They need to access services and be discharged from those services on a seven-day week basis. I want us together to deliver this reform to reduce our trolley numbers and the time patients spend unnecessarily in hospital and to speed up access to care in less stressful settings, closer to home. Working over the full week will also mean we use our currently limited infrastructure and resources more effectively.

We can deliver more services, for example, in outpatient departments, appointments and theatre rather than the majority vying for space Monday to Friday between 9 a.m. and 5 p.m. It is not logical or a good use of the assets that the taxpayer has already paid for. To improve access to services and additional capacity through capital investment is also a really key challenge for all of us together over the next number of years. A key limiting factor on improving access even further is our physical and digital infrastructure. We do have a legacy challenge; that is a factor, so we have a lot to do. For example, in 2022, Ireland had 291 hospital beds per 100,000 people, excluding nursing home beds, while the EU average is 516. In Germany, there are 766 beds per 100,000.

The 2025 budget prioritised additional staffing and associated funding to expand our health infrastructure to improve access to services and increase capacity. Funding has been committed to staff two new surgical hubs in Galway and Swords, 335 net additional acute beds, four new virtual community wards, 615 community beds, 455 of which are replacement, obviously, and 160 new beds and six injury units for Carlow, Athlone, Dungarvan, Kerry, Ballina and Tallaght.

Rebalancing our investment towards capital is a key priority for me in 2025 and I am quite sure for the committee as well. It is absolutely key to help unlock some of our productivity and access challenges and I would so appreciate the committee's support in making the best case for the maximum possible infrastructure investment through the NDP review. As the committee is aware, the NDP review is taking place at the moment. I do accept, of course, that there are strong demands in areas of housing, energy and water, but health infrastructure is something that impacts every single community and county in this country, and the Department of Health is keen to invest and invest strongly.

A key area of focus in 2025 underpinning increased efficiency and performance is the digitisation of our services. It is no exaggeration to say that staff have been trapped in a work environment of pen and paper for many years, which is frustrating, difficult and inefficient. We are increasing our investment in digital health in 2025 by €100 million to progress and expand investment in virtual wards, which are quite exciting and the committee should come see them, for example, ehealth initiatives like national e-prescribing and national shared care record to avoid duplication of record collection, national electronic health records to streamline clinical workflows, and the use of AI-assisted diagnostic and triage tools in clinical and administrative services to improve and speed up decision-making.

The HSE’s digital health app, which I hope everybody has downloaded, is one of the main ways patients manage their health information across services in Ireland. The app, which has recently won two awards, allows you to store your medical cards, track medications including self-declared information, view vaccination records and manage maternity and hospital appointments. Crucially, its functionality will continue to increase. By the end of 2025 it will have appointments and communications for BreastCheck, quit smoking support and prostate cancer self-care pathway support. It is really part of building a connected, patient-first digital health system and will continuously improve functionality and continue to evolve. I hope the health app provides a modern, easy-to-use platform for health information and the HSE remains committed to ensuring everyone can access services through multiple channels. This is one of them, but an important one.

We will continue to implement and integrate new and existing HSE IT systems. Our financial management system, IFMS, will have 80% budget coverage later in the year. We have to quickly implement that now, crucially in our voluntary health sector as most of the remaining 20% of health Vote spend. It must absolutely be implemented in the voluntary hospitals. The national hospital management system, an electronic logistics and stocking system within hospital pharmacies, is also important. All of those projects will have a better and positive impact on how patients experience health services and health information.

I turn to workforce expansion. Over the past five years, we have invested significantly to increase our current healthcare workforce. Recruitment in 2025 has been lower than I would like. We have committed funding to increase our healthcare workforce by a further 6,100 to 133,305. We are increasing the supply of trained health and social professionals. We have expanded student training places across medical, nursing and health and social care professions by 762 additional places since 2022. An additional 430 student places will be provided in academic year 2025-26, including 25 medicine places in Northern Ireland. In addition, 389 student places were provided in Northern Ireland across medicine, nursing, midwifery and allied health professions in 2023 and 2024. Crucially, we are trying everything we can to enable professionals to work at the top of their licence and expertise. As I mentioned, physiotherapists will soon refer directly for scans. Pharmacists will prescribe for common conditions and advanced practitioners in nursing and social care are stepping into diagnostic and treatment roles. Alongside expansion of our workforce, I am keen to ensure that regulatory processes in registration are as fast and efficient as they can be without diluting the need to ensure professionals are sufficiently trained to practise in a safe manner. I have recently met with the Medical Council and will be meeting with CORU and the NMBI in the coming weeks. I have reiterated the absolute necessity for the Medical Council to approach its work in the most efficient and logical way to make sure there are not doctors in Ireland who are qualified to work in our system who are prevented from doing so for too long.

There are many challenges for people accessing services in primary care, mental health and in our hospitals. My focus as Minister for Health is to reduce those access barriers. I want to work with the committee to do that. However, it is also important to set out the backdrop of a real cause for optimism. The reforms we are starting to deliver, like a seven-day service, transparency on productivity and performance, the new systems like the app, surgical hubs, virtual wards, AI and many more, offer us opportunities to have a better and safer health service. It is already the case that our health outcomes are good. Our challenge is access and many of these projects are about enabling access and getting better productivity from the resources we have and continue to invest in. We have a lot of work to do. I look forward to working with the committee and I hope the members can see that the Minister and three Ministers of State are ambitious to build accessible, affordable and high quality healthcare for all.