Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)

I thank the Chair and members of the committee. I am very pleased to be here with my departmental officials Tracey Conroy, assistant secretary for acute hospitals, Derek Tierney, assistant secretary for health infrastructure, Louise McGirr, assistant secretary for resources, and Rachel Kenna, chief nursing officer, along with our HSE colleagues Bernard Gloster, CEO, Stephen Mulvany, CFO, Sandra Broderick, regional executive officer for the mid-west, and Sheila McGuinness and Joe Duggan.

I thank the committee for this opportunity to discuss the important topic of waiting times for hospital care. This is something we signalled together we should look at, having had a review of insourcing. I am very glad to be able to do that now.

Let me begin by reaffirming this Government's commitment to ensuring timely access to high-quality healthcare for all patients, regardless of income or geography. As we continue to implement Sláintecare and move towards universal access, we must also confront the operational realities of our current health service, and particularly the pressures for patients waiting for care and the capacity constraints that exist to date in our public hospitals. Even with those pressures, we are improving access to hospital care and reducing waiting times for patients through a range of different measures. Since 2020, the health budget has increased from €19 billion to just under €26 billion in 2025. That is a 35% increase, and it highlights the Government's commitment to improving our health services. Our focus now together is on making sure that expanded health budget delivers for more patients and taxpayers, because it is clear from the purposes of the State that we cannot continue to grow the health budget or any budget at that rate and also maintain security in our public finances. We must make sure we are getting value from that investment by the taxpayer in the health system.

At the end of July 2025, there were 25,492 more staff working in the public health service than there were at the beginning of 2020, which is a 25% increase. That increase includes additional front-line staff of 9,721 nurses and midwives, 4,044 health and social care professionals, 1,427 consultants and 2,389 doctors and dentists.

The significant additional funding over the past five years was weighted in favour of current spending, which was the optimal balance following the Covid years. Now, I am focused on prioritising current funding to leverage our capital investment in order to build and open more capacity. It is through the delivery of our new surgical hubs, physical and virtual beds combined with increasing productivity and ensuring all our resources are maximised, that we will continue to widen access and reduce waiting times for patients. For example, funding for this year has been committed to staff additional beds in hospitals and the community, to open new and progress the construction of surgical hubs in all regions and to open six more injury units around the country. It is clear that digital health will play a powerful role in widening access to healthcare and reducing waiting times.

Our focus for this year and is in driving priorities aimed at delivering better outcomes for patients. Some examples of that include widening the use of the HSE app, which, I hope, everybody in the room is using, to empower patients to take charge of their own healthcare, confirm hospital appointments and so forth. We are also close to launching the first phase of the national shared care record later this year, which will be foundational in enabling integrated care while we plan for the national electronic health record, and expanding virtual wards, virtual care in the community and telehealth. That allows patients to receive care closer to home. I am sure everybody in this room has seen how that works and the benefit it has given to patients already. It helps reduce pressure on hospital beds for those who need them most while reducing waiting times for appointments. We are harnessing the opportunities of intelligent automation to improve how we manage our waiting lists and free up time and resources that can be used in other parts of the health service. As well as delivering patient benefits and improving patient experiences, crucially, these and other digital initiatives also support more efficient use of time and resources across our health services and for our healthcare professionals.

As of July 2025, there were 149,099 whole-time equivalents, WTEs, directly employed in the provision of health and social care services by the HSE and section 38 voluntary hospitals and agencies. Guaranteeing access to an adequate supply of trained professionals to meet the needs of patients has required focused investment to maximise the capacity of our workforce. Significant progress has been made, working in collaboration with the Department of further and higher education and the higher education sector, to increase the number of student training places for the health sector, with up to 1,000 additional student places provided in health and social care programmes in Irish universities since 2022. Furthermore, an agreement in respect of once-off healthcare college places at the Ulster University and Queen's University Belfast for the period 2023 to 2025, inclusive, is in place. We are progressing and implementing initiatives that involve empowering nurses, physiotherapists and, more recently, pharmacists, through the community pharmacy agreement - we have a lot to discuss in that regard later in the week - to support the delivery of safe, equitable, and efficient healthcare.

Advanced practice is an important tool for optimising the capacity of the existing health workforce. Advanced practice for nurses and midwives is well established with 2.6% of the nursing and midwifery workforce now working at that level. Our target is 3%, and we want to drive that further. Building on this evidence, we are extending advanced practice for health and social care professionals for the first time. For example, key steps have been taken to enable physiotherapists working in relevant roles across the health service to refer patients for diagnostic investigations such as X-rays. That is a new initiative. It is something physiotherapists sought. It helps them to work at the top of their expertise. Crucially, it also results in fewer steps in the care of patients who require diagnostics. All of these developments support enhanced performance in our health service and, I hope, improve things for our patients and workforce.

The crucial point is that activity levels in the health system are not keeping pace with the level of our investment. We need to continue to harness the investment we have made with the taxpayers - our people - to improve productivity and performance in our health service. While there are good examples of productivity within the health service, which we will discuss, there is still too much variation in performance. That is really clear from the analysis given to us by the interactive and publicly available hospital productivity dashboard. It shows and confirms variations in performance across hospital sites, between specialties and even within sites and specialties. For example, Tallaght and Naas hospitals are national examples of outpatient department, OPD, productivity. In Tallaght, outpatient attendances increased 59% year on year in 2024, and the appointments per consultant in the OPD increased 44%. Naas Hospital has the most OPD appointments per consultant in all of the model 3 and 4 hospitals, at 2,081. This is way ahead of the second best, Navan, at 1,775. There is scope to learn from those examples of excellence and recent performance improvement and for that to be driven out across the rest of the system.

In terms of our approach to the waiting list, or waiting time, action plan, we are committed to improving access through reforms and by building capacity in the public sector. However, until that capacity is in place to meet the increased demand - and even when it is - we need to use all available options in the public and private systems to ensure that patients have access to the care they need. That is until we get the capacity in the public system. Accordingly, the waiting list action plan approach has consistently targeted the delivery of additional capacity for patients in the public and private systems, using insourcing and outsourcing through a co-ordinated approach by the HSE and the NTPF. This year's action plan is no different, with insourcing and outsourcing being utilised to bolster core HSE activity to help deliver on the action plan's four key waiting time reduction targets.

Insourcing and outsourcing have been used as tactical responses to waiting list pressures. Insourcing allows public hospitals to deliver additional care, often outside of core hours and using their own facilities and staff. Outsourcing enables patients to be treated in private hospitals under both HSE and NTPF arrangements. Of course, this is not where we want to be or where we want to end up, but what it does is providing the care people in our communities and constituencies need now while we build the public capacity we are driving towards. These mechanisms have delivered real benefits. However, they are transitional tools as opposed to permanent fixtures. I firmly believe that we are becoming overly reliant on insourcing and private sector outsourcing to deal with our waiting lists. We must transition that and recognise that it will be difficult and that we must do it together.

The longer term goal remains to build sustainable internal capacity within the public system and ensure that this is maximised to the greatest extent through greater productivity and efficiencies. Given concerns about the operation of the insourcing model in particular, earlier this year I asked the CEO of the HSE to conduct a review of insourcing and outsourcing. This is something we have discussed in the committee before. The review report, which was published on 1 July, highlighted a couple of important points. The first is that healthcare demand continues to increase in both volume and complexity. The current capacity gap in public services is driving the reliance on insourcing and outsourcing. While reform programmes are under way, short-term reliance on supplementary capacity remains.

Having considered the review with my officials and the HSE, I wrote to the CEO in August authorising him to introduce a number of control measures to specifically restrict the use of third-party insourcing. Those enhanced safeguards require other capacity to be fully utilised before third-party insourcing could be considered, including all core capacity, standard overtime and agency staffing for specialist clinics, which is traditional insourcing, and approved off-site outsourcing. Any proposal for third-party insourcing must now be approved by the hospital CEO, kept under review by the IHA manager or REO and can only be used to reduce patient waiting times. We have to move away from any dependency, regardless of how small it is, within the system.

The CEO will speak to the number of instances of patient care delivered through that measure compared with the rest of the system, but the trend was going in the wrong direction and it was working against the incentives we are trying to create in hospitals to do things within the public health capacity. We must arrest that trend and arrest those incentives that may have been building up. That is the important thing about making these changes now. What it does mean is that productivity in the HSE must improve. We are taking action. We have this opportunity because of the public-only consultant contract, POCC, which must be fully implemented. It will allow for: the efficient rostering of services across six out of seven days instead of five out of seven days; better scheduling of outpatient appointments to maximise existing resource utilisation; improved benchmarking and standardisation of scheduled care, and maximising the physical assets the State has already paid for, including diagnostics, new surgical hubs and virtual wards ,where appropriate. That opportunity is maximised by the fact that for the first time we have the agreement of the rest of the health system to work five over seven in a scheduled and rostered way, which is very important.

In terms of the current waiting list position and scheduled care performance, important progress has been made under the waiting list action plan in reducing the number of patients on waiting lists and, crucially, the length of time patients have been waiting. It is really important that we maintain focus on this year's targets and take appropriate actions to address the ongoing challenge of hospital waiting times. The HSE anticipates that activity and performance will improve as we move into the final quarter, as we have seen in previous years. I will allow the CEO to comment more specifically on that.

The HSE has identified specific targeted actions and interventions that can be taken to help improve waiting list and time performance over the remainder of this year, which is very important. Those actions include: utilising the POCC and associated levers to extend weekend and evening working; expanding deployment of the outpatient productivity toolkit that has been utilised very effectively in Naas and Mercy hospital in Cork; optimising the patient pathway by improving the new to return ratio for outpatients, which is clearly visible on the hospital productive dashboard for anybody who wants to see; reducing the "did not attend" rates; the pooling of referrals within specific consultant cohorts and specialties, especially for longer waiting patients. so it is not consultant specific but a pooling mechanism; and, crucially, increasing theatre efficiency and utilisation, recognising that the taxpayer has already paid for these assets and they must be used.

The REOs have a key leadership role in engaging with their senior teams to drive and oversee these productivity and performance improvements to year end across each region. My Department and the HSE will continue to work closely to make sure that the measures bear fruit and have a positive impact on waiting times between now and year end.

There is another piece that I want to highlight to the committee. We have, together, rightly placed a major focus on waiting times for hospital care but we absolutely cannot lose sight of the access challenges in the wider range of important healthcare services. I am very conscious, in particular, of the vital role that primary care therapies play for children and adults. I am acutely aware of the central role that these services play in offering the opportunity for earlier, cost-effective and important impactful interventions for children and young people, in particular. It is important to recognise that overall activity within the eight core primary care therapies is significant. Some 1.4 million patients were seen in 2024 but I fully acknowledge that waiting lists for primary care therapies have increased significantly. Those increases are related to an increase in referrals and the greater complexity of presentations, coupled with some recruitment and retention challenges for healthcare professionals.

Building on some successful local initiatives, I have now asked the CEO of the HSE to put measures in place to scale up those initiatives at a national level to address physiotherapy, occupational therapy, and speech and language therapy waiting times and lists. Beginning immediately, I am asking the HSE to reduce the waiting times for these three therapies to less than ten months. That would be a massive improvement on where we are now, as approximately one third of patients are currently waiting over a year for a service. This is an important target, and it is important that we set this target, but I recognise that this is a challenging target, having regard to where people are now but if we are not ambitious and set a target, then we will not see progress. The measure, if successful, would remove 60,000 people from the waiting lists across the three therapies. I will ask the HSE's CEO to speak more to that. I reiterate that it is important we set this target and identify that there is a very particular problem and that we must be proactive in relation to it.

Due to our growing and ageing population, there are many challenges for people in accessing services, not only in the hospital sector but in primary care, community services and wider healthcare. There are too many people waiting too long for care but the tide is turning and we are using tools that I think will make a difference in the medium term. These reforms offer us a huge opportunity to have a better, more accessible and safer health service for us all. What we are discussing today is not just about funding and delivery mechanisms. It speaks to trust, fairness and the integrity of the public health service. It really is our responsibility, together, to ensure that every euro spent delivers real value and that every initiative is grounded in transparency and accountability. I look forward to working with the committee to ensure that the reforms that we are implementing deliver for patients together across our area.