Jerry Buttimer (Cork South Central, Fine Gael)
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We move on to deal with the quarterly meeting. I remind members that the Minister and Mr. O'Brien will make opening remarks, followed by questions from the Opposition spokespersons, and we will then have a question and answer session. I call the Minister, Deputy Reilly. The opening statements have been circulated and the members have them in front of them.

James Reilly (Dublin North, Fine Gael)
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I thank the Chairman and the members of the joint committee for this opportunity to discuss health service issues. Both I and my Ministers of State, Deputies Kathleen Lynch and Alex White, will provide as much information and clarification as possible.

While I propose to keep my opening statement brief to allow more time for discussion, I must refer to a number of landmark developments that have recently come to fruition in the health service. I have no doubt my two Ministers of State will wish to speak to them as well.

The major new deal on the cost of drugs in the State, which was just mentioned, was recently brokered with the Irish Pharmaceutical Healthcare Association, IPHA. It will have a value in excess of €400 million over the next three years and will mean significant reductions for patients in the cost of drugs, a reduction in the drugs bill to the State, greater access to new cutting-edge drugs for certain conditions, which has always been a concern, and an easing of financial pressure on the health service in the future.

The agreement is of major benefit in two broad ways. Approximately half the value is related to reductions in the cost of patent and off-patent drugs. The other half is related to the State securing the provision of new and innovative drugs for the duration of the agreement in the current exceptionally difficult economic climate. We have discussed in the past that the Chief Medical Officer will initiate a new process around this involving not just the pharmaceutical companies, the policy makers, which is the Department, and the service providers through the Health Service Executive, HSE, but also clinicians and patient groups because we must realise there is a finite sum of money and if we are to make room for new drugs, the older drugs have to reduce in cost to allow that to happen. There is always a problem with that dynamic because some of the companies that are producing the drugs are not the same companies that are producing the newer drugs.

In addition to the new agreement with the IPHA, the Department of Health and the HSE have completed discussions with the Association of Pharmaceutical Manufacturers in Ireland, APMI. This group represents the generic drug industry and the agreement represents a significant structural change in generic drug pricing and should lead to an increase in generic drug prescribing.

Savings in 2013 will be in the region of €15 million and that figure will rise in subsequent years. The Minister of State, Deputy White, will want to address that when he makes his contribution, but I would say there may have been a sense that the enthusiasm for substituting for generics was somewhat diminished by the fact that many of the generic drugs were either the same price or a few cent less in price. That has been addressed through this agreement.

These landmark agreements come as legislation aimed at reducing the cost of generic drugs makes its way through the Oireachtas. The Health (Pricing and Supply of Medical Goods) Bill 2012 will introduce a system of reference pricing and generic substitution. I hope it will be enacted before the end of the year and it is currently being passed through under the watchful eye of the Minister of State, Deputy White. It will deliver further significant savings in the cost of medicines for the health service and for the private patient.

Our agreement with the private health insurers on the accelerated payment of €125 million to publicly funded hospitals in 2012 is a major part of our budget control as well. I am delighted it has been possible to reach agreement with the private health insurers in this regard. The arrangement will deliver a once off cashflow benefit in 2012 in the order of €125 million, providing much-needed funds for the hospitals. The money is a once off payment in respect of private patients who have been treated in publicly funded hospitals but where the detailed claims have not yet been received by the insurers. The effect of the arrangement will be to reduce the over-run in the HSE.

I fully acknowledge that the public hospital system has unacceptably long delays in regard to income collection, especially the completion and sign-off of claims by hospital consultants. To address this situation the HSE has instructed hospitals to reduce the value of claims awaiting signing off by consultants and also to target completion of the highest value claims. It is not that they will reduce the value of the claim but they will reduce the number of claims that are outstanding. In fairness, I hope the insurers also will co-operate in this regard.

The recent Cabinet decision to develop the new paediatric hospital on the St. James's Hospital campus activates the most important capital building project in the State. It is a key priority for the Government and no effort will be spared in expediting its completion. The decision to choose the St. James's site was led by clinical considerations. Co-location with St. James's and ultimately tri-location with a maternity hospital on the St. James's campus will provide the excellence in clinical care that our children deserve. The estimated cost of the development in the region of €500 million is considerably less than the projected cost of building the facility on the campus of the Mater Hospital.

Publication of the strategic framework for health reform, which occurred last week, is a very important moment for us because it lays out very clearly the main health care reforms that will be introduced in the coming years as key building blocks for the introduction of universal health insurance. People have sought the plan for a long time and, in many cases, we have mentioned aspects of it but it is now laid out in a clear document with actions to be taken and a timeline around all those actions. It is called Future Health and it contains a set of specific actions that will prepare the way for universal health insurance. Future Health will bring about a major reshaping of the health system by restructuring our delivery service and improving our organisational, financial, governance and accountability systems in the primary, community and hospital care sectors. These changes will be introduced in a step-by-step manner on the basis of good evidence.

A White Paper on universal health insurance to be published in 2013 will provide the basis for more detailed actions. We have already commenced communicating this to those in the system. We had meetings in Cork and Waterford with both service providers and the health forum and yesterday we had similar meetings in Naas, Tullamore and Dr. Steevens' Hospital. We will go to the west later this week to Sligo, Galway and Limerick and the following week to the north east of Dublin to involve all those areas as well. The point of this is that we engage with those in the system. It is a two-way conversation. It does not stop there; they will have an input back to us. This is very important from the point of view of ensuring we do this in the best possible way because while we can see all the road signs, we cannot see all the potholes. The people working on the ground can see them better than us and know best how to deal with them.

From the actions outlined above, the members will note that I am determined to press ahead with the health service reform promised in the programme for Government. Robust governance and management arrangements will be crucial to drive, manage and monitor implementation of the reform programme.

I will therefore establish a programme management office in the Department of Health to act as a central overarching and co-ordinating function for health reform.

These major initiatives which I have outlined are positive developments. However, I must also refer to the serious challenges facing the health system, the scale of which surmounts anything previously experienced. The HSE is facing a serious budget deficit and is still required to make significant savings in the current year. The contributing factors to the overrun include increased hospital activity. While one might complain about certain activities that are elective, one certainly cannot do anything about a 6% increase in emergency department admissions. Those are the most acutely ill people in society.

There is increased expenditure on medical cards and drugs, which is a result of the economic downturn. Although we planned for 105,000 additional medical cards, we have issued in the region of 150,000 so far this year. The income from private health insurance has declined, which is also reflective of the economic downturn. The number of staff who availed of the grace period to retire was much greater than that provided for in the national service plan and that had an impact in terms of lump sums that had to be paid out.

However, a programme of measures has been initiated to address this deficit. In addition, I have put in place a financial improvement and new programme management arrangements which will transform the way financial management is handled across the health system. This will strengthen governance and improve consistency and continuity in financial reporting, performance management and data collection. That is easily said but this is a major area of concern and this is the first time it has been tackled in a serious fashion. It was pretty worrying and astonishing to find when we reviewed the situation that only 10% of the people in charge of the financial end of the service have a finance or accountancy qualification.

It is clear that further savings are required in the health sector and the 2012 health sector action plan prepared under the Croke Park agreement contains a demanding set of measures. They include a comprehensive review of rosters, changes in skill mix, productivity improvements and a focused approach to reducing sick leave levels. Further significant cost reductions will be required in 2013 and 2014, requiring substantial savings to be made to the cost base of the health sector. My Department is working intensively with the HSE on a range of substantive proposals for submission to Government in the context of the 2013 Estimates. Both my ministerial colleagues and I will be happy to answer questions from the committee on these and other issues in greater detail during the course of the meeting.

Putting the patient first in a real way is at the core of what we are doing. Everything we do must be focused on improving the outcomes for patients. In the past there has been far too much focus on inputs – how much money, how many doctors and how many nurses. We need to measure outcomes for patients because that is what the service is about.

Concern has been expressed by several committee members, and we have all expressed our sympathy to the family of the late Savita Halappanavar, but I must inform the committee, as the Taoiseach did, that there have been changes to the membership of the team in Galway investigating the incident. I would like Mr. Tony O’Brien from the HSE to address the issue during the course of his opening contribution.

Mr. Tony O?Brien:

I thank the committee for the invitation to be present. I am joined by Ms Laverne McGuinness, national director for integrated services, Mr. Liam Woods, national director for finance, and Dr. Philip Crowley, national director, quality and patient safety. We will all do our best to respond to the questions of members.

Before I get into the general details of the opening statement I would like to take this opportunity, in common with members of the committee, to extend my deepest sympathy and condolences, and that of the HSE itself, to Ms Halappanavar’s husband, family and friends on their tragic loss. Yesterday, the HSE set out the details of the investigation into the death of Ms Savita Halappanavar. Professor Sir Aralkumaran, an independent expert in obstetrics and gynaecology, is chairing the investigation team. Professor Sir Aralkumaran is head of obstetrics and gynaecology and deputy head of clinical sciences at St. George’s Hospital, University of London. He is also the president of the International Federation of Obstetrics and Gynaecology with more than 40 years’ experience, 30 of which are in clinical and academic obstetrics and gynaecology. Professor Sir Arulkumaran conducted an inquiry at Northwick Park Hospital following ten maternal deaths at that facility.

It is important that the members of the investigation team comprise expertise in the relevant disciplines of anaesthesia, midwifery, obstetrics and gynaecology to review the full range of clinical care provided to Ms Halappanavar. It is also deemed essential that the team includes an independent patient representative, which it does. The HSE announced such an expert, multidisciplinary team yesterday. However, the HSE is taking into account the concerns of Mr. Halappanavar and in that regard the chairman of the investigation team has sought a meeting with Mr. Halappanavar to discuss his concerns.

The HSE is also currently reviewing the membership of the investigation team and members will be aware that the Galway-based members of the team, as announced yesterday, have stood down in the interests of the investigation. Other appropriate experts will be appointed to the team in due course.

On behalf of the HSE I would like to reassure the public, and in particular Mr. Halappanavar and his family, that we are most anxious to expedite the investigation so that we can establish all of the facts and address any possible safety concerns that may arise as a result of the investigation and that could have implications for women attending at our maternity services.

The financial report for the HSE for September shows a deficit of €399 million, 4.4%, against a spend this year to date of €9.543 billion. The main contributors to this are community schemes at €180 million, hospitals at €207 million and community services at €22 million. There are some minor offsetting balances that give a total deficit of €399 million.

September is the first month this year in which there has been a reduction in the deficit reported, which indicates that the cost containment measures in place are having the effect of reducing spend rates. However, the financial situation of the HSE continues to be extremely challenging. The community-based schemes continue to run significant deficits, which increased by an additional €29 million in the month of September. The HSE has a range of measures in place to reduce the year-end deficit.

Activity continues to grow across the majority of HSE services placing considerable demand on resources. The position, as of September, compared to the same period in 2011 shows that. The Minister has already mentioned the 6% increase in emergency attendances. Emergency admissions have increased by an additional 7,091, or 2.5% in the first nine months of 2012 over 2011. The number of inpatient treatments is up by an additional 2.3% or 10,260, and the number of day case treatments is up by 1.8% or 11,257, giving an overall 2% increase in inpatient and day case activity. GP out-of-hours contacts are up by 3.4%, over 24,000 compared to last year. The number of individuals covered by a medical card as of the end of September was 1,838,603; an additional 144,540 individuals were issued with medical cards since December 2011.

The increased service activity levels place considerable pressure on available resources and capacity within the system. The HSE continues to face significant financial challenges to year-end in areas such as child care, acute hospitals and community drugs schemes based upon the demand for services. Health service staff resources at the end of September stand at 101,743 whole time equivalents, a reduction of 11,028 or 9.78% since staff numbers peaked in the health system in 2007. The organisation is currently operating well within its current approved employment ceiling of 102,936. The recruitment embargo remains in place for funding reasons until the end of December 2012.

In recent weeks the HSE, together with the Department of Health, has been involved in negotiations on private health insurance income, consultant contracts and the cost of drugs. The Minister has spoken about the detail of private health insurance income. In addition to that deal, there are a number of initiatives in train to improve income collection. I have emphasised to all hospitals the importance of addressing the issue of income collection in conjunction with the insurers in order that as many resources as possible will be available to the health system. We have set hospital targets for income collection. Hospitals have been instructed to bring down the value of claims awaiting consultant action, and they will also target the highest value claims. This issue was also addressed by health service employers and the two consultant representative bodies at the Labour Relations Commission.

An important feature of the proposals agreed between the parties was a commitment on the part of all consultants to expeditious processing and signing of claims for submission to private health insurance companies. Consultants will be required to complete fully and sign insurance forms within 14 days of receipt of all relevant documentation and to co-operate with the secondary consultant scheme, whereby a secondary consultant involved in a case can sign the claim form if the primary consultant has not signed within a reasonable timeframe. They will also be required to support the implementation of electronic claim preparation. Health service management is proceeding with implementation of this and other measures, having regard to the relevant provisions of the public sector agreement.

We have awarded the contract for the rolling out of an electronic claims management system on 11 HSE sites to replace the current paper-based system. This system is operational at six sites and a further three are expected to be operational shortly. I expect the range of measures outlined will contribute towards improving the collection of income outstanding to the public hospital system.

On 17 September, following detailed engagement between health service management and the consultants' representative organisations, the Labour Relations Commission issued a comprehensive set of proposals regarding the implementation of the Croke Park agreement by consultants. The consultants' organisations are either balloting or have completed the consultation process on the proposals. Rulings on three outstanding issues have been received from the Labour Court. Management will be meeting the parties concerned to make progress on implementation of the recommendations. In the meantime, the HSE and HSE-funded agencies were advised by the HSE's human resources unit to commence implementation of the full scope of the proposed agreement, with effect from Monday, 5 September, under section 1.23 of the public service agreement which provides for employees and unions to co-operate in implementation during the consultation process.

The Minister has spoken about the cost of drugs. Let me refer to the crisis pregnancy counselling services, particularly the issue that has arisen regarding information provided by these services. We provided members with information last week, as requested, but I will provide a further update. Based on the findings in an internal review carried out by the HSE, I have established an independent investigation which will be chaired by Ms Bridget McManus, former Secretary General of the then Department of Education and Science. The terms of reference are being finalised with the chairperson and I expect that the investigation will be concluded as expeditiously as possible.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. O'Brien. Is it possible for committee members to be told the composition of the independent investigation team regarding the crisis pregnancy counselling services? We received correspondence from Mr. O'Brien, but his remarks today have superseded it. Members are to discuss the correspondence in private session on Thursday morning.

Mr. Tony O'Brien:

Ms McManus has been appointed as the sole member.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. O'Brien and the Minister for their presentations. It is important that the people and parliamentarians have confidence in the investigation into the incident in Galway. It is a question of putting the patient at the centre. I welcome the changes announced today. I have two questions for Mr. O'Brien on the investigation. When will it commence? When will the composition of the panel be finalised, given the changes announced today and Mr. O'Brien's opening remarks? It is important that we reassure people about the quality of maternity services. It is a question of focusing on patients and all others concerned.

Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the delegates. I, too, welcome the Taoiseach's announcement of changes to the personnel investigating the tragic death of Ms Savita Halappanavar, as I was very concerned when I heard about the composition of the panel. I do not want to cast aspersions against or question the integrity of the eminent individuals originally appointed to the investigation team, but I believed they were being compromised almost immediately by being put on the panel. It is regrettable that the original decision was made, for a number of reasons. As the Minister rightly stated, we want to get to the truth of the matter in a manner that is completely impartial and independent. We were told there would be discussions with Mr. Praveen Halappanavar on the investigation. If there had been, those appointed to the investigation team would not have been appointed. There have been strong expressions of concern about the composition of the team. Mr. Halappanavar has expressed views publicly through his solicitor.

There are a number of reasons this issue is very important. The first is the tragic death of Savita and our desire to find out exactly what happened. There ought to be absolute independence to give confidence to everybody using or who will use maternity services. By and large, we have an excellent maternity system, staffed by the most highly qualified and eminent individuals, be they consultants, midwives or other nurses. It behoves everybody to ensure there is an impartial, independent investigation for everybody concerned, including the family, service users and service providers.

I was amazed and completely disappointed at the outset that people could compromise the investigation by including in the investigation panel individuals who had close associations with the personnel working in Galway. We must be conscious of the fact that many staff are very upset about what happened. We must take this into account. Therefore, I welcome the change in personnel. We want an expeditious, impartial and independent investigation.

With regard to the opening statements of the Minister and Mr. O'Brien, I have major concerns about some of the issues raised and some of those omitted owing to time constraints. There is an overrun of €399 million and we are asking the insurers to assist with the cash flow of the Department of Health and the HSE in terms of up-front payments for treatments provided. Clearly, there is a major difficulty with respect to the sustainability of the budget and how it is put together in the first instance. A huge budget deficit is to be carried over into next year when savings of an inordinate order have already been identified as necessary. Clearly, this year's HSE budget was unsustainable from the word go.

Reference was made to full cost recoupment for private patients in public beds. This would obviously have placed a considerable burden on insurers and, ultimately, premium holders. Consider the escalating price of private health insurance. There is always price inflation in medicine and it normally runs well ahead of the consumer price index. Clearly, there is a considerable problem. Major difficulties are encountered by ordinary families in that they are simply unable to pay the increasingly higher premiums demanded by insurers.

Reference was made to the next step, namely, the strategic framework for health reform and the move to universal health insurance. What is happening goes against the grain of everything the HSE and the Department of Health should be trying to do, that is, encouraging as many people as possible to take out private health insurance, at a sustainable and affordable rate, according to the principles of risk equalisation and community rating. People are giving up cover all the time. Younger people are dropping out, thus placing the burden of community rating and risk equalisation on older generations. This is simply not sustainable. With regard to the move towards universal health insurance, the Minister must take one step forward to try to address the haemorrhage of people from private health insurance which is placing additional pressure on the public health system. The move towards universal health insurance is aspirational because every day people are downgrading their health insurance plans, thus creating considerable extra difficulty.

The issue of home helps is another area to which reference has not been made. To be clear, there is no relationship between what the Minister and Mr. O'Brien are stating in public and what is happening on the ground. I genuinely mean this as what is happening regarding the withdrawal of services for those who rely on home helps simply does not equate with the press releases being sent out stating no one will be denied a service. Thousands of people are being denied services that would sustain people at home for a longer period. Even at this late stage, the Minister and Mr. O'Brien should try to revisit this issue. I acknowledge the sum involved is €8 million and that the health budget is under significant pressure but there have been repeated cases of people simply not being able to access a home help service they had heretofore. This is putting significant pressure on individuals' ability to remain at home, on their quality of life and on families who are trying to sustain people at home and out of long-term residential care. Clearly, the Minister and Mr. O'Brien must address this issue because what is being stated publicly and what is happening on the ground are at absolute variance.

On the broader issue of the strategic framework for health reform, this could yet be the best seller for Christmas. However, it will be found in the fiction department because there are neither costings nor an outline of precisely how the Minister intends to achieve his goals contained in the strategic framework. For example, the Minister speaks of universal health insurance and in the strategic framework, he already has identified a form of universal health insurance. At the same time, however, members await the White Paper on universal health insurance as to the model on which it will be based. If a major shift is envisaged in how we fund health services and how universal health insurance is to be introduced, it clearly will be desirable for the people, the Department and the Legislature to have a discussion on what form of universal health insurance is being proposed. While a White Paper is forthcoming, at the same time we already have in place a strategic framework for universal health insurance. There is a difficulty with people trying to buy into this particular framework document when they are not even quite sure of the funding model that will be available to fund the move to universal health insurance. The cart certainly is well before the horse for this proposal.

The Minister referred to a move to primary care, investment in primary care and what flows therefrom. How far down the road have we gone regarding the issue of access to GPs and free GP care? As far as I can ascertain, we are no further advanced in providing access to free GP care than was the case two years ago. There were legal problems and complications in respect of the long-term illness scheme but, to date, there has been no major move in that regard other than "Live horse, get grass" in 2013. I fully understand the budgetary constraints on the health services but, clearly, the move to universal free GP care and then to universal health insurance was a very important stated policy on which we have not progressed very much further.

Finally, I again ask who is responsible for the budget? Is the Minister for Health or is Mr. O'Brien responsible in respect of accountability for the budget itself and for ensuring the reining-in of the deficit?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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At the outset, I wish to use this opportunity to again convey my sympathy to the family of the late Mrs. Halappanavar. Perhaps it is too soon to give an answer but with the indication at this meeting of the change in membership of the investigation team, has there been a response from the legal representative of the late Mrs. Halappanavar's husband, Praveen, as to the acceptability of the new composition of the investigation team? I am anxious to learn what Mr. O'Brien has to say on that. It is very important to recognise the investigation team must be seen to be independent and must have the confidence of both the bereaved family, which is of significant importance, and the wider public and this must be addressed.

I have a number of questions. In response to my proposal that we might consider initiating address of some particular areas in the course of the Irish Presidency of the European Union next year, the Minister indicated two such areas. I welcome that the Minister does indeed intend to focus on particular areas. He mentioned autism and went on to speak of the impact on health of financial difficulties domestically and across Europe. While they may not be the exact words the Minister used, that roughly is the representation of it. I absolutely welcome this, particularly in respect of autism. I again ask the Minister to consider the area I had highlighted and to not allow it to fall off the table, that is, the issue of rare diseases. Ireland has more than its fair share of such diseases and per capita across a number of them, quite a high incidence on a comparative basis with other member states of the European Union. It would be very appropriate that Ireland would indeed take up the issue of rare diseases.

As for the second of the two points of which the Minister spoke, namely, the impact on health of financial difficulties, it is against a backdrop of reports that appeared both yesterday and over the weekend that further cuts are anticipated in the health budget, of the order of approximately €900 million. This is more than I had expected we would be obliged to face. Moreover, a further 3,231 staff are set to leave the service. Can the Minister confirm these figures? Can he comment on both these issues? Does he not agree these further cuts will have further devastating consequences on the impact of the delivery of services and on the impact on health of financial difficulties which he hopes to address in the course of Ireland's Presidency in the first six months of 2013?

As for some of the replies the Minister has given to the joint committee in response to various questions posed, I wish to address question No. 8 on the national bowel cancer screening programme. I am particularly concerned there is little hard evidence of readiness in respect of the roll-out, which is supposed to happen before the end of next month or that is what one had been led to believe. As the Minister indicated in his reply, it is anticipated that the first round will take up to three years to complete. Can the Minister outline in detail for members the proposed phases that will lead to full implementation? I again invite the Minister to comment on the case I have highlighted with him previously, with the support of the Irish Cancer Society, of the need to encompass a wider age group from the outset, that is, the 55 to 74 age group, to maximise the potential of this screening programme. In recognising that more than 2,000 cases are diagnosed annually and that this is the cause of approximately 950 deaths annually across this jurisdiction, everyone agrees early detection is hugely important. Moreover, earlier detection leads to more effective and less costly treatment. Can the Minister advise us precisely where the 15 candidate colonoscopy units will be located? The joint committee will understand if he cannot do so this afternoon but I ask him to circulate the information naming the aforementioned units to members. As for the symptomatic service, what state of readiness exists with regard to the anticipated 5% to 6% of those who go through the screening programme and who then will need to have ongoing referral? Can the Minister name the hospitals that are in a position to respond to this additional number of people who will require address of diagnosed issues in respect of bowel cancer?

Bowel cancer has the second highest cancer incidence and is also the second highest death-causing cancer. We can only expect with the advance of the screening programme polyps are going to be identified in an ever greater number of people. What state of readiness is the hospital system in to take this on?

Regarding staffing for mental health and acute psychiatric services, I note with concern that a minimum nursing staff floor, a bottom line, does not apply but ceilings do. The HSE stated in a reply to a parliamentary question to me that total agency staff in Dublin-mid-Leinster mental health services came to 7.5. I must correct that figure; it should be 16.5. Some 11% of the workforce in our mental health services are temporary or agency workers. There is a permanent staff of 465, 16.5 agency staff and 39 temporary staff in Dublin-mid-Leinster mental health services. With the further anticipated reductions in staff and the continuation of the recruitment embargo, will the HSE give us some certainty that it will have adequate staff to cater for future mental health needs in the region?

The €35 million earmarked for the creation of 414 posts in mental health services by the end of this year has been knocked on the head with only 17 posts filled, three in the child and adolescent mental health area and 14 in general adult mental health services. These are statistics I have taken from replies to parliamentary questions. It is a concern that we are not providing adequate staff to carry out these important roles in mental health services.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I also express my condolences to the husband and family of the late Savita Halappanavar whose death at University Hospital Galway was tragic and untimely. The manner in which the HSE inquiry into her death was announced and the composition of the inquiry team has compromised it from the very beginning. Will the Minister establish an independent public inquiry into this matter? I was disappointed to see the composition of the inquiry team but was not surprised. From my contact with the HSE over the past several years, I have found it to be an arrogant body. Whoever took the decision to have three consultants from University Hospital Galway on the inquiry team is certainly not in touch with reality. It is important and essential that the inquiry is in no way compromised.

It is clear now, if it was not clear up to now, that the budget for the health service is totally inadequate. The system is bursting at the seams and a high standard of service is not available to patients despite the best efforts of HSE staff. The health service is simply underfunded. The HSE outlined the growth in admissions to accident and emergency departments and the issuing of medical cards while there are serious cutbacks, bed closures and significant numbers on trolleys in accident and emergency departments. Last Thursday, for example, there were 287 people on hospital trolleys across the country. Up to a 1 million home help hours have been cut this year and elderly people have been badly affected by this. The promise of free general practitioner, GP, care has not materialised. There is the prospect of further cuts amounting to €1 billion next year with a further 3,000 job losses.

Austerity needs to stop and the health budget needs to be increased. People are entitled to a reasonable level of services. In the past I have pointed out there is significant wealth in the country with a top 5% of the population considerably increasing its income and assets during this recession. They do not pay their fair share of taxation. They should be made to pay it so that we can better fund health services.

In a reply to a parliamentary question on hospital network structures, I was informed there has been extensive consultation on this process. What consultations have taken place? Which civic society organisations and patient representative organisations were consulted? Were there requests for submissions from the wider public? In my view there has been a constant lack of consultation by the HSE concerning the services it provides. There is certainly consultation within the HSE and hospitals on services but no wider public consultation.

What is the position on the draft report on the hospital networks? Has the strategic board seen this draft report? Has it been approved by the board? Has it been sent to the Minister? What is the current position?

Finally, I want to raise the question of beds at the Hospital of the Assumption in Thurles. A number of commitments have been made - one by the Minister approximately 12 months ago and one by Deputy Coonan approximately three weeks ago - that these beds would reopen. The reply to my question would suggest that there is no question of these beds being reopened, either this year or in the coming year. The Minister committed to opening those 22 beds. That has not happened. Deputy Coonan stated approximately four weeks ago that in three or four weeks' time eight to ten beds would reopen at the Hospital of the Assumption in Thurles. Is it going to happen? What is the position in that regard?

Jerry Buttimer (Cork South Central, Fine Gael)
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I remind members that 34 questions have been submitted, six members have intimated a desire to speak and Private Members' business, at which Deputies Ó Caoláin and Kelleher and the Minister must be present, is at 7.30 p.m. While I do not want to stop members from questioning and speaking, the desired objective of the Chair is that we finish before 7.30 p.m. The Minister may divide the responses among the Ministers of State and the HSE officials.

James Reilly (Dublin North, Fine Gael)
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I would hope we could finish before 7.30 p.m. to allow us some time to prepare for the Dáil.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will endeavour to do so.

James Reilly (Dublin North, Fine Gael)
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I will be as quick as I can. Deputy Kelleher raised several issues which others have raised. Perhaps the committees will accept a composite reply which will save a great deal of time.

I agree, paraphrasing the old saying, that justice must not alone be done but must be seen to be done. The same can be said of this inquiry. Not only must it be independent; it must be seen to be independent, and there can be no perception of a lack of independence. It is worth spending a little time on this issue because others also raised it. This is a difficult and traumatic time for the family of the late Mrs. Savita Halappanavar. This procedure will be very difficult for them. In so far as I can, I want to accommodate their wishes. Equally, we have a duty of care to the women who use the services in this country to expedite this as quickly as possible to ensure that there are not any unsafe practices at that hospital so that there is no risk. Members have spoken about a public inquiry. A number of persons have called for that. The problem with a public inquiry is that it will certainly take much longer and the answers will be much slower to come. The changes that have taken place, as Mr. O'Brien outlined, allow for a real sense of independence here. Hopefully, we will be able to expedite this as quickly as possible. People have mentioned a timescale of three months. I hope it will be completed much quicker than that. In light of that, we can review the situation.

I must point out that there will be a coroner's court hearing as well, which is also something that takes time. It is really important that we get to the truth in a clear and transparent fashion that stands up to scrutiny, not only the scrutiny of the family of the late Mrs. Halappanavar but also that of the Irish people and of the world. That is our aim. Patient safety must always be to the fore of my conscience. I want to be able to give an assurance that the service is safe, and that is not in any way to be pejorative about the service provided at the hospital. We merely need that reassurance. We need this investigation to be independent and to be seen to be independent, and we must allow the HSE to get on with its business as quickly as possible. Everybody has the height of regard and respect for Professor Sir Arulkumaran, his bona fides and the experience he brings to this.

On the more general issue of the budget and the cost of services, I made it clear that I do not want to cut services to patients or clients who need them and who have been assessed as needing them, but I am determined to cut the cost of services. That is something we must consider, and there are many ways of approaching it. We have examined many efficiencies and we have achieved them through measures such as the clinical programmes, but there comes a point at which we must examine how things are organised in terms of rosters. I believe the new consultant agreement at the LRC is a key part of this, as consultants will now be available any five days out of seven, including in the evenings and at night. This will ensure that senior decision-makers are there so that decisions will be made more quickly and with less regard to and reliance upon tests. The leadership that is shown in this regard will continue throughout the service in other areas where rosters are concerned.

Deputy Kelleher also raised the issue of full cost recoupment for all private patients in public beds. We were quite cognisant of the fact that if we were to introduce this across the board immediately, the system would fall over. One could be looking at a €250 million cost to the insurance sector, and it just could not bear it. The figure of €75 million was always in the budget under this heading. We have more than achieved that, which allows us bring in this measure on an incremental basis.

I want to talk about why private health insurance is so costly in this country. I have instructed the new leadership of VHI, through its new chairman and CEO, to address this under four separate headings. The first of these is more robust auditing. Everybody in this room has heard anecdotal evidence of subscribers looking at the bill paid by the insurer and declaring that he or she did not have this or that done although it has been paid for. We need more robust auditing. Something that has never happened - which in my view is astonishing - is clinical auditing, in which the treating physician is challenged as to whether the treatments given and the tests carried out were necessary. That must be done. Then we must look at how the VHI is billed per day, even by the public sector. I want to change that to billing per procedure so that hospitals that are effective and efficient get their patients in on the day of procedures and home as soon as possible, as long as there is no co-morbidity that needs to be taken into consideration. Those are the hospitals that will thrive. Those which are inefficient and do not do so will not thrive. As a form of quality control, we also will be watching readmission rates. The last area to consider is what we pay consultants for the procedures they carry out. Why are we paying at the same sort of rate for procedures that used take two hours to do but with new technology now only take 20 minutes?

There are a host of areas in which we can save money and reduce costs to the consumer. It is about getting back to that principle of reducing the cost as opposed to reducing the service and focusing on the outcomes for patients, not the inputs. We are always talking about inputs; it is time to talk about outputs for the patient. It is a question of whether the outcome for the patient has improved rather than how many doctors were at the bedside at the time. From memory - I was trying to see if I could get the figures for this - private health insurance costs increased at a much greater rate over the period 2008 to 2011 than they have since.

The Deputy mentioned home help and home care services. He is quite correct. I was concerned about that last week. I had taken soundings from many TDs and Senators who hear about people's problems and there were number of issues arising. When we took the decision that this had to be done, there were certain issues with regard to the process that had to be fulfilled and I was not happy when I heard from many backbenchers that this was the case. I have made it clear to the HSE, which has taken this on board and is redoubling its efforts, that no one's hours should be taken away without a full assessment - not a desktop assessment - of his or her case. No one should be informed of a decision by voicemail; direct contact is vital. Only in exceptional situations should this be carried out by letter. It was suggested that a clear mechanism should be put in place for reviewing individual decisions. This is something that many backbenchers felt they could not get around.

How does one appeal a decision that was seen as absolutely unfair? A designated individual is to be appointed in each integrated service area with responsibility for ensuring such reviews are carried out in as timely a manner as possible and an escalation process to a senior manager will be put in place in order that cases can be properly reviewed. We have already put in place a weekly reporting arrangement to monitor reductions in home help hours and I have directed the HSE to provide more comprehensive reports every Monday. Each integrated service area will nominate a senior official to deal with Oireachtas Members' inquiries about home help and home care packages because Members were experiencing difficulties in contacting an identified person in the HSE to make their case and organise an appeal. Standardised guidelines for the provision of home help and home care packages are to be applied throughout the country. It became clear during the course of our investigation that in some areas of the country home help was, in fact, home care, whereas in others home care is clearly related to more needy cases in terms of assisting people to get dressed, wash or go to the toilet. A standard definition of what constitutes home help and home care will be agreed. Just as we faced difficulties with the fair deal scheme because people were receiving long-term care under differing criteria, even though they were supposed to be using the same assessment tools, we have to introduce uniformity across the system. That is the benefit of having a national organisation. It will slow the process down, but I am more concerned with ensuring people receive the services for which they have been assessed than with meeting our targets for budgetary savings.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is the HSE fully aware of what is supposed to happen? The lack of communication between the HSE and the people who require services has been appalling and does a disservice to all of us. It is not good enough to leave a voice message stating X or Y will happen. It is welcome that the review will not be a desktop exercise, but I hope it will be communicated to the individuals who make decisions at local level that they have to be humane in their approach, as opposed to sending a cold and calculated computer printout.

James Reilly (Dublin North, Fine Gael)
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I think the Chairman will find when Mr. O'Brien has an opportunity to respond that that will be the case. We have discussed the issue on a number of occasions.

The issue of structural reform was raised. This is important. Deputy Billy Kelleher is particularly concerned about universal health insurance and that the report has not yet issued and that the model has not been agreed to. It is described in the programme for Government as a multi-insurer model. The universal health insurance group is advising us on the best way of implementing it. The funding was always going to be a combination of insurance premiums and central funding to allow for community rating and risk equalisation. Legislation on risk equalisation is before the Dáil as one of four separate health related Bills. The Minister of State, Deputy Alex White, will outline the reasons the long-term illness legislation has been delayed. As the Attorney General would point out, this has transpired to be difficult legislation because we are moving from an income threshold assessment of eligibility to disease entity eligibility criteria. This task has proved to be more complex than was originally expected. However, the funding issues can be addressed.

On who is responsible for what, Mr. O'Brien is the Accounting Officer for the HSE and responsible for the budget. I am accountable to the Oireachtas for it.

I will answer the questions from Deputies Caoimhghín Ó Caoláin and Healy before deferring to the Ministers of State, Deputies Alex White and Kathleen Lynch, and Mr. O'Brien. I will refer the questions on the roll-out of bowel cancer screening and the plan to widen age groups to Mr. O'Brien.

In regard to the candidate colonoscopy units, top of the list is Cavan General Hospital. The list also includes Kerry General Hospital; Louth County Hospital, Dundalk; Midland Regional Hospital, Tullamore; Ennis General Hospital; South Tipperary General Hospital; St. James's Hospital, Dublin; Wexford General Hospital; Connolly Hospital, Blanchardstown; Letterkenny General Hospital; Mayo General Hospital; Mercy Hospital, Cork; Sligo General Hospital; St. Vincent's University Hospital, Dublin; and Tallaght hospital, Dublin. Mr. O'Brien will deal with the question in a more comprehensive fashion. He will also speak about our readiness to deal with referrals.

In regard to the issue raised in question No. 21 and the comment that there is no floor for staff, there is, particularly in respect of mental health services. I will refer this question to the Minister of State, Deputy Kathleen Lynch, and Mr. O'Brien.

Deputy Healy asked about a public inquiry. I have dealt with that issue. If I set up an inquiry, I do not think I would have the power to compel witnesses to appear before it, whereas the HSE has such powers because the individuals concerned are its employees and it forms part of their contracts. I would have to pass legislation to give me the requisite powers, which would only create further delay. I ask that the HSE be allowed to get on with its inquiry which I believe is independent and let us see the results and the level of transparency before we make further demands for inquiries.

I am not sure what question the Deputy was asking in regard to the significance of the budget, but he alluded to the number of trolleys. The budget presents a real difficulty for us, but we are meeting the challenge. We have addressed many of the inadequacies in the HSE identified in the Ogden report by implementing the measures it recommended. Mr. O'Brien can speak further about the issue. Notwithstanding reductions in budgets and personnel, the men and women working in the health service have not only maintained a safe service but have improved it, with a 25% reduction in the number of patients on trolleys, an 85% reduction in the number of patients who have to wait one year or longer for inpatient treatment, a 91% reduction in the number waiting nine months or longer and an 18% reduction in the number waiting three months or longer. The number of children on the waiting list for inpatient treatment has also decreased by 1,800. For the first time we have defined the full outpatient waiting list. At 385,000 people, it looks like a staggering, almost overpowering, figure, but it is not. We will deal with it in a fair fashion and the same way as we addressed the issues in emergency departments and inpatient treatment. It should be borne in mind that 200,000 people are seen as outpatients every month.

The report on hospital groups is to come to me through Mr. John Higgins. I have to remind people that the hospital groups will operate for a trial period of a couple of years and that there will be plenty of time to report on problems and find out what works. It will be 2015 before hospital trusts are formed. These are the legally binding institutional arrangements.

I will refer the question on the Hospital of the Assumption in Thurles to the HSE. I know there were plans to make funding available to address issues in the hospital. I made it clear at the meeting that I would seek to have beds reopened on the basis that it was a modern facility and that we needed rehabilitation services. I did not specify the number of beds at the time, but Mr. O'Brien may have something to say about the matter.

I ask the Minister of State, Deputy Alex White, to address the questions on the long-term illness legislation.

Alex White (Dublin South, Labour)
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I welcome the opportunity to meet the committee and look forward to a fruitful engagement with the Chairman and members in the period ahead.

Deputy Billy Kelleher spoke about free GP care. GP care without fees would be a more accurate way of describing it because nothing is free. The intention is to provide care that is free at the point of delivery. It is not true to say we are no further down the road or that major progress has not been made.

The legislation to give effect to the first phase of free GP care is at an advanced stage and since my arrival in the Department six weeks ago, I have had a number of meetings with officials in respect of the legislation. As the Minister said, it is not without complication. Since the last health Bill, our medical card system has been predicated on eligibility, which has to do with income and hardship. The legislation will change the basis on which we provide a GP visit card and that will be predicated on, as the Minister indicated, certain designated or chronic illnesses. It stands to reason that changing the basis on which these cards are awarded will require attention. Despite how complicated it is, I assure Deputy Kelleher and the committee that the legislation is at an advanced stage. I hope to meet officials again later this week. It is close to being ready to be published. There is always frustration, which I share as a new Minister of State at the pace of change. We want to bring forward these changes, including universal health insurance, by the end of this Dáil and we have set the target dates of 2015 and 2016, but it is unrealistic to set specific dates, for example, in 2013 for the delivery of particular projects. We were asked about this last week by journalists. We are pressing on as hard as we can. It will be in earnest of our good faith when the legislation is published. There will be progress and I assure the Deputy that we are working hard to bring it about.

I agree with the Minister regarding universal health insurance. Deputy Kelleher reasonably asked whether there would be a debate. There is no constraint on anybody having a discussion. The Minister said the programme for Government sets out an agreed course and last week's document elaborates on that. It does not purport to be the last word on every aspect but it is consistent with what is in the programme. I hope that document will engender debate and input, including political input, into this important issue. Nobody is saying there cannot be discussion.

Kathleen Lynch (Cork North Central, Labour)
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Deputy Ó Caoláin has always had an active interest in mental health issues. There is a floor for the number of staff employed and the Mental Health Commission makes sure that is the case. We should be grateful to the commission. Ms McGuinness will outline the details of the numbers. We are reviewing the Mental Health Acts because so much of the service will be moved into the community. As Deputy Healy will be aware, significant work has been done in Clonmel and south Tipperary. Deputy Mattie McGrath has told me it has been hugely successful. I have taken notes of everyone's comments and I have written after Deputy Healy's name: "It will all end in tears." That is his general view of the health service. We also hope to get the Mental Health Commission to cast its eye on community-based services, which will ensure the balance between them and acute units is equalised. We want to make sure there is an equality in delivery of services both in the community and in the acute units.

Ms Laverne McGuinness:

With regard to the 416 posts, significant progress has been made. Deputy Ó Caoláin is correct that, at the end of the October, 17 posts had been filled. Another 28.5 candidates have been asked to take up posts and that process is being progressed. In addition, 275 candidates had been given offers and we are currently going through Garda clearance and checks and they will come in, while 67 other positions are being posted by human resources division. Of the 416 posts, 28 are not in active progress. We said in our service plan that we would progress to fill them in the final quarter of the year. We are confident we will have a significant number of them in by the end of the year with some more at the beginning of next year.

Mr. Tony O'Brien:

Deputy Kelleher asked about accountability for budgets. Since 20 August this year, I have assumed all the responsibilities associated with the post of chief executive officer of the HSE, which includes the responsibility as its Accounting Officer, and it is expected that will continue to be my responsibility for the financial year, 2013. In that context, I have an obligation to take all steps necessary to improve the financial position of the HSE. We set about a number of things during the summer to do that. We have talked about the negative consequences of some of those this afternoon.

The Minister made reference to the Ogden report. We have seen the health service take out €2.5 billion over recent years and lose almost 10,000 staff, yet there have been considerable improvements in activity and performance in a number of areas. The financial component of the HSE has also suffered attrition due to the antibodies that developed in the past decade to ICT projects. The HSE is without an enterprise-wide financial solution and I pay tribute to the work done by the relatively small band of financial managers in the executive, recognising as the Minister often says, that while we invest significantly in the training of medical specialists, we have not distinguished ourselves in investment in management training and so on. In response to the Ogden review to work alongside and support the internal cohort of financial managers, we have brought in additional personnel resources through procurement to beef that up in terms of a medium-term financial management turnaround process to work with our existing team of financial staff to build on the strengths they have and develop more robust systems for the future, not just in the context of the work we have to do today, but in the context of what we know from the framework and Government policy more generally are the future organisational arrangements for the health service, which create particular contexts and needs.

It is intended that when the national colorectal screening programme is fully implemented, the programme will offer free screening to men and women aged between 55 and 74 on a two-yearly cycle but as 50% of cancers within this age group are found in people aged between 60 and 69, the programme will begin with this age cohort. That has been the policy for some while. That is a population of approximately 500,000 and it is anticipated that the first round will take up to three years to complete. I was heavily involved with both BreastCheck and CervicalCheck and, typically in all screening programmes, the first round takes longer than the steady stage screening cycle. Over time, the phasing of the programme will allow development of colonoscopy capacity to cater for the full 55 to 74 age cohort but, at the moment, there is no predetermined timetable for that. The Minister has outlined the list of candidate colonoscopy centres and the process of approving those units to go live is under way, the key objective being to ensure the screening programme does not interfere with symptomatic colonoscopy services in these hospitals. The national cancer screening service, NCSS, is confident there will be adequate capacity to provide this important part of the programme and the Deputy may be aware that, under the targets commonly referred to as the special delivery unit targets, although they are HSE targets, significant improvement has been achieved in access to colonoscopy services.

I do not have the figures with me but they are in the performance report and I can supply them.

A key feature of the bowel screening programme is that where a referral for a colonoscopy occurs, which will be to one of the candidate centres, in the vast majority of cases treatment, such as the removal of polyps, can be provided during the course of that colonoscopy. The programme is already in test mode and a limited number of patients have been randomly selected so their samples can validate the processes. It is planned that the first call letters will be issued before the end of the year, which means testing will commence early next year, with regard to the response to these call letters. I spoke to those responsible for the programme recently and they are very confident the roll-out will proceed.

I will ask Ms McGuinness to speak about the position on home helps.

Ms Laverne McGuinness:

It is correct to state guidelines were issued whereby anybody who had a home help and had an assessed medical need would not lose the service; that nobody would lose all of their home help hours; and that the focus would be on personal assistants in the first instance. It is also correct to state this has not been applied appropriately in all cases, and where this has happened the situation has been rectified. We have identified in each local area a person to whom public representatives can go and this list is available and has been circulated. In addition, all managers have been advised that an assessment should be carried out by a public health nurse or a health professional and no reduction should be made in the absence of this assessment. Messages should not be left on answering machines and where possible people should be contacted on a personal basis. This is not always possible.

Jerry Buttimer (Cork South Central, Fine Gael)
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It should be always possible.

Ms Laverne McGuinness:

The person might not be there. It might not always be possible for the public health nurse to make the call. Another health professional may do so but we are clear it must be a member of the multi-disciplinary team. This has been made very clear to managers.

Mr. Tony O'Brien:

Earlier this year the number of beds open in the Hospital of the Assumption was increased from 45 to 50 within existing resources. I can confirm that at present there are no plans to open further beds in the facility before the end of the year. However, the position will be actively reviewed in the context of the 2013 service plan, as with all matters of this type. Perhaps an over-expectation has been created about this location with regard to a Deputy in the area, and I have arranged to meet him to discuss it in the very near future.

I wish to turn to the review under way in Galway and I will ask my colleague, Dr. Philip Crowley, to speak when I conclude. It is very important to stress that while we have an excellent national record with regard to maternal mortality, unfortunately maternal mortality is a fact of our service and as a result of this established protocols are in place for carrying out such reviews. A number of such reviews are conducted each year and others apart from the matter we are discussing are ongoing and incomplete at present.

The typical protocol at first line is that the reviews are carried out by the institution in which the death occurred, so the inclusion of members of staff of an institution is not unusual or aberrant. In this instance, those who saw coverage or read reports of the media event yesterday in which the professor who will chair the review took part will know he made clear that he had asked for persons not involved in the care of Ms Halappanavar but who had significant knowledge of the processes and procedures of the hospital in question to be part of the review. Consequently they were included. I welcome Deputy Kelleher's acknowledgement that their agreement to step aside, which I will discuss, is in no way a reflection on them or their professional integrity. Given the particular circumstances arising we were of the view it would be beneficial to bring in a distinguished international expert with significant experience of carrying out such reviews to chair this review on an independent basis and we did so. People will agree he is an excellent choice for the role. As I stated, he had a particular view about the resources he needed to be available to him. We are very anxious to get to the bottom of what happened in Galway and we recognise the necessity of securing the full co-operation of the family. It is in response to their concerns that we discussed the matter with the chair of the review and the Galway personnel involved, and by mutual consent they have stepped down from the role and will be replaced by others with expertise in the relevant disciplines from outside Galway.

A question was asked about the level of contact we have had with the family. Mr. Halappanavar is represented by Irish-based solicitors whom we have contacted to seek direct contact with Mr. Halappanavar but this has not been made possible at this stage. I understand of course the significant distress Mr. Halappanavar is undergoing and the difficulty that may be presented to him in making himself available to us. It is for this reason that a renewed effort has been made today and the independent chair of the review group has sought a meeting with Mr. Halappanavar.

I have an absolute obligation as the director-general designate of the HSE in any and all circumstances to inquire into an event of this type. It is absolutely in the public interest that we get to the bottom of what happened, particularly in the context of the broader allegations in circulation which are of concern to our population as a whole. Consequently I must make arrangements for this review to proceed. The team is in Galway. I hope Mr. Halappanavar and his legal advisers will come to the view the best course of action now is for him, if he can, to make himself available to the chairman so his evidence and that of other members of his family can be brought to bear so we can get to the bottom of what happened, in particular so we can ensure any lessons that need to be learned can be learned and applied.

We will have to consider how best to proceed with the review in the event this does not happen because, as I stated, I have an obligation to pursue this review. I can absolutely guarantee, for the benefit of anyone who may be listening, including in particular the friends and relatives of Ms Halappanavar, no attempt whatever will be made to avoid getting to the absolute truth. Whatever we find out we will find out, and whatever must follow from that will follow from it. However, we need Mr. Halappanavar's full co-operation and if he is listening to, hearing about or reading my words I hope he will find it possible to meet the chair of the review in his interests, in the interests of the review and in the wider interests of the people of Ireland.

Jerry Buttimer (Cork South Central, Fine Gael)
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If Mr. O'Brien feels it appropriate I encourage him to pick up the telephone and meet or speak to Mr. Halappanavar because it is a matter which requires his complete participation. I accept he may be out of the country but we are all conscious of the trauma he has encountered and the tragedy he has experienced. It behoves all of us to ensure the inquiry is full and thorough and I appreciate the changes that have been made.

Mr. Tony O'Brien:

If Mr. Halappanavar would find it easier to speak to me then I will go wherever I need to go to have that conversation.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. O'Brien.

Dr. Philip Crowley:

Our intention all along with regard to the review was to investigate as properly as possible all of the facts and root causes of what led to the tragic events in Galway. The purpose of this in the first instance is to ensure if any elements arise in the investigation which suggest there could be any potential risk or harm to any other woman attended our maternity services that we address it immediately and that we do not await the end of an investigation or an inquest process which can take longer.

It is our policy to investigate ourselves when adverse events occur. As Mr. O'Brien stated, in many instances this may be done effectively by local staff in a local institution with national incident management team oversight and with our audit and review to ensure that our policies, which are based on evidence and best international practice, are pursued and that the investigations are done in such a way that the root causes are found, addressed and subjected to recommendations. We pursue this process in all instances.

Jerry Buttimer (Cork South Central, Fine Gael)
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Five members have indicated. I am conscious that Deputies Ó Caoláin and Kelleher have Private Member's business to attend to. To be fair to the Minister and members participating, we should try to conclude by 7 p.m. I ask the members to be brief in their questioning. The order will be Deputies Mitchell O'Connor, Naughten and Doherty. They will have two minutes each.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I wish to offer my deepest sympathy to Savita Halappanavar's husband, family and friends on their tragic loss.

It has been of benefit to hear the good news and the bad news today. I was not aware that 1.8 million people had medical cards. Every week, a number of people contact me about availing of medical cards. In most cases, they are successful. I am glad to see that an additional 144,000 medical cards have been introduced to the scheme. Once my constituents enter the system, they are happy with and have trust in the service they receive. The difficulty lies in trying to enter the system. Perhaps we need to promote more the good news story on page 4.

Are there plans to increase the age limit for women availing of BreastCheck?

The committee has held a number of meetings on obesity. One doctor told us that mothers were not breastfeeding and, as a possible result, children were becoming more overweight. Are there plans for an information or education programme? Are there plans for a parental information programme on children's nutrition and preventing obesity?

I wish to ask about specialised not-for-profit charities, in particular the LauraLynn House palliative and respite care service, which does good work but is under pressure, and a body that will interest the Chairman, namely, the organisation that trains guide dogs in Cork. The latter is also under pressure and has needed to withdraw dogs from children with autism who have had them for a number of years. Due to cutbacks, dogs are not being trained and children cannot avail of the service.

Denis Naughten (Roscommon-South Leitrim, Independent)
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As a representative of the communities serviced by the Galway and Roscommon University Hospitals Group, I wish to express my sympathy and that of the communities to the family of Savita Halappanavar. It is a great tragedy. The public, particularly the parts of it serviced by the hospital group, wants the truth about and the facts of the case as soon as possible. An impression is being given that maternity services in this country and the hospital group are unsafe, but that is not the case. The group's standards meet the best international standards. Anything that can be done to facilitate the completion of the investigation and to reveal the facts of the case needs to be encouraged. I hope that the family can participate in the inquiry.

The Minister referred to a 6% increase in emergency department activity and mentioned that admissions from emergency departments had increased by 2.5% in the first nine months of this year. Are the changes to community supports and the failure to fill the community nursing vacancies and so forth having an impact in this regard? Will the Minister focus on this issue during the next year to try to remove some of the pressure? The issue of home help is tied into this matter. From the figures supplied to me by the HSE, an approximate average of 5.68 hours has been taken from individual clients since the beginning of September. Up to 12,500 clients may have had their hours reduced. This puts pressure on emergency services.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy's time has concluded.

Denis Naughten (Roscommon-South Leitrim, Independent)
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I would appreciate it if the Minister could comment.

Regina Doherty (Meath East, Fine Gael)
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I wish to put on record my condolences to Praveen on the recent passing of his beautiful wife.

I will make two comments on the two investigations that have been discussed at this meeting. First, I welcome the independent investigation into the allegations around our crisis pregnancy services. I also welcome the changes that have been made to the investigation into Savita's death.

My second point may seem trivial. I understand the professionalism and the protocols, namely, what must be done to tick boxes from a professional organisation's perspective. Where this type of investigation is held, they are usually into real tragedies involving real human beings. Politicians and organisations such as the HSE are constantly abused for being "desensitised". Can the HSE humanise its press releases or the language used in any investigation that is necessary? Serious offence has been caused, not just to Savita's family, but to the majority of Irish people by yesterday's announcements.

I wish to ask about the financial overview.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy's time has concluded.

Regina Doherty (Meath East, Fine Gael)
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It was mentioned that community-based schemes had overrun by €29 million in September alone. Which specific schemes are overrun and by how much? It was also mentioned that measures are being implemented to address the overruns before the end of the year. What are their details?

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputies Fitzpatrick and Byrne and Senators Crown and MacSharry are next. I will take all questions together.

Peter Fitzpatrick (Louth, Fine Gael)
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I wish to express my sympathy to the husband, family and friends of Savita Halappanavar.

In 2013, savings on generic drugs will be in the region of €15 million. I expected it to be much more. I am delighted that private health insurers have agreed to make a one-off and up-front payment of €125 million. What will be done about the amount of money that remains outstanding?

There is a €400 million overspend. The Minister stated that the HSE's range of measures will reduce that deficit by the year's end. I am being asked about what those measures are.

I have asked the Minister to reduce the attendance fee of €100 at Louth County Hospital. On 29 June 2010, the hospital stopped functioning as an acute hospital. The paediatric, obstetrics and trauma services were transferred to Our Lady of Lourdes Hospital, Drogheda. The hospital's opening hours are 9 a.m. to 8 p.m., but there are rumours in the area that it will close at 5 p.m. seven days per week. If the fee was reduced, many patients would present at Dundalk, thereby helping with the trolley situation at Our Lady of Lourdes Hospital.

Catherine Byrne (Dublin South Central, Fine Gael)
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I thank everyone, particularly the Minister and Ministers of State, for their input into the meeting. I wish to give my condolences on the sad death of a beautiful woman and a lovely unborn child.

I will move straight to question No. 23. I wished to raise many issues, but there is not much that one can ask in two minutes. The question relates to 2008 and 2009 and I have raised it at this committee numerous times during the past 17 months.

It is about the Hollybrook Community Nursing Unit in Inchicore. It has been ready for use for the last couple of months but, unfortunately, it is lying dormant. There is not enough time to deal with many of the questions, but I will ask a few. If the Minister cannot reply now, I would welcome a reply to them as soon as possible. Are the beds in Hollybrook new or replacement beds? What does this mean for the people who are on the waiting list for the beds under the fair deal? If the patients are transferred directly from St. James's Hospital, which has been mentioned, what will happen to the people on the fair deal scheme who are on the list and have expressed their interest in Hollybrook? Can the Minister provide a time frame for the opening of this unit? Will he clarify if there are talks under way with the new chief executive officer of St. James's Hospital to transfer the patients to Hollybrook? Between 2008 and 2009 the community of Inchicore and the surrounding area was given a commitment by the HSE that 18% of the beds would be allocated to people living in the area. Will the Minister or the HSE clarify, if possible, that this will still happen? People in the local area are very worried. We bought into this in 2008 and 2009 and it is crunch time now. It would be most helpful if the Minister would answer those questions.

John Crown (Independent)
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I did not submit questions so I do not wish to catch the Minister on the hop. I wish to make a few general points and put a question about the Halappanavar tragedy. The Minister and our colleagues will be aware that Ireland has extremely low maternal mortality. In some years there are no maternal deaths and in most years there is one or perhaps two. Most western countries that have varying degrees of legalised abortion have similar rates. It is more an index of social issues and of health status than being specifically to do with abortion. When these deaths occur they are incredible tragedies. They are among the worst deaths that any doctor, nurse of family member would ever have to deal with. It means a totally natural and beautiful phenomenon, childbirth, being destroyed by one and sometimes two deaths. It can be argued that very occasionally one would be prevented by termination of pregnancy. For that reason it could also be argued that we need legislation. The rarity of maternal death, which has been quoted as an argument for not legislating, is not a valid argument. Even if we prevent one death every two, three or five years because the appropriate legislation is in place, that is sufficient grounds for having the legislation. We pass legislation on all manner of matters in these Houses that never saves a life. If we can pass a law that might save somebody's life every three or four years, it is critical that we do so.

The committee structure is manifestly unsuitable. Ireland is small and it is well known in medical legal circles that because of the small medical community in the country it is often difficult to get Irish doctors to take part in medical legal disputes. Selecting three people from the consultant cohort of 122 consultants in Galway was ab initio a mistake. It would probably be a good idea to have more of an international presence on this committee. I am not saying we should not have some Irish doctors but it would be important to have a more international presence. Is it appropriate to ask who or at what level or what organisation or structure within the HSE picked that committee? There is a certain degree of accountability implicit in coming to that conclusion.

Marc MacSharry (Fianna Fail)
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I do not wish to cover the same ground but on the home help issue, does the Minister believe there is a link between that and the increase in attendance at accident and emergency departments? Also, at the launch of the Home and Community Care Ireland group in recent weeks, the group reported it could make savings of up to €280 million on home care while creating more hours for home carers. What is the Minister's view on that?

I also have a question for Mr. O'Brien. In respect of the centralised buying conducted by the HSE in its procurement unit or in the individual areas, such as my area in Sligo, Donegal, Leitrim, Cavan and so forth, are any of the procured materials, be they dry goods, food or the like, invoiced to individual hospitals at a margin to the HSE? If there is a margin, how is that calculated? Will Mr. O'Brien comment on that?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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The Minister did not respond to some of my questions. I will remind him of them. With regard to the reports of a €900 million cut in the health budget for 2013 and the projected further loss of more than 3,200 staff across the health service, I was citing the response the Minister gave me when I stated that nursing floors do not apply. That was in the reply I received to question No. 21 relating to mental health.

Again, perhaps the Minister would take on board the proposition relating to rare diseases. It would be a terrible miss given that we only have a chance every 14 years to hold the EU Presidency. It is something that would have a massive impact.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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One question that was not answered related to consultation. When major matters are being dealt with by the HSE, such as the network structure for hospitals-----

Jerry Buttimer (Cork South Central, Fine Gael)
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The Minister replied to that.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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No, there was no reply.

Jerry Buttimer (Cork South Central, Fine Gael)
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He replied.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Perhaps the Minister would clarify it.

James Reilly (Dublin North, Fine Gael)
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I made it clear.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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What is the situation with civil society organisations, the public and patients?

James Reilly (Dublin North, Fine Gael)
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There has been no consultation with any of those groups. I pointed out that this is a temporary arrangement for two years. A report will come to me and it will have to be checked by my Department from the point of view of patient safety, patient services and financial implications. There will be ample opportunity for all those groups to be consulted on the working of the groups as they apply over the period of two years for which they will be in trial before we go to the permanent situation of hospital trusts.

In response to Deputy Ó Caoláin, the €900 million savings that must be made next year are a combination of programme for Government commitments, increased pressure through demographics and the carry forward of the deficit. It is a challenge but it is one we will meet. Regarding the 3,200 staff, or 6,400 over two years, these are proposals from the Department of Public Expenditure and Reform. We are still in negotiation with that Department with regard to how they will impact on health. As I said earlier, I am focused on cutting the cost of service, not cutting the service to people who need it. I wish to maintain as much service as possible so I am looking at how to cut the cost of service.

Senator MacSharry asked about home help and increases in emergency department activity and admissions. That is highly unlikely. The figures we have are up to September-October. The issues surrounding home help and home care have only come to pass since about October, so they could not have any impact. Basically, it is due to demographics. As people get older they tend to get more illnesses and cancer. That is the reality of life. However, we hope to address that through more emphasis on prevention and well-being and more care of chronic illness in the community.

I agree with Senator Crown's comments about the rarity of maternal death in this country. However, that is no argument for delay in addressing the ABC case. This is a tragic incident that occurred in one of our hospitals and it must be investigated expeditiously for the reasons outlined, not just to remove any uncertainty for Mrs. Halappanavar's family but also to assure women, who are expecting a child and will have to use services at a hospital, that the service there is safe. The ABC case is a separate issue. The Government has commissioned a report on it from the expert group.

I will be bringing it to Government next Tuesday and I hope the Cabinet will agree to its immediate publication. There will be time for a long discussion in Dáil Éireann and Seanad Éireann, with no time limits so that everyone has the opportunity to express themselves. In the past, some of the discussions and debates were limited, with two or three minutes per contributor. This issue is too serious to allow that format but we are not holding the debate to delay proceedings. We have Friday sittings so we should use them. We should make sure everyone gets to speak on this, that all political parties have the opportunity to digest it and that the broader public has the opportunity to become engaged through access to the report.

Deputy Catherine Byrne asked about Hollybrook, which was built for the specific purpose of looking after the people from the area of Inchicore. Earlier this year, the HSE proposed to relocate current services, including staff and patients, from St. Brigid's Hospital in Crooksling as it was not compliant with the HIQA standards. This would enable the closure of St. Brigid's Hospital in Crooksling. However, having regard to the wishes of patients at St. Brigid's Hospital and the need to maximise the level of service provision in the region, the services at Crooksling will be maintained and an alternative avenue of opening the Inchicore unit is being explored. Crooksling has been modified in terms of the model of care possible after the reduction from four to three units. In light of the public sector moratorium and the significant additional reduction in staff numbers required over the coming two years, it is essential all possible approaches are considered in respect of how the unit may be opened. One option is through use of a public private partnership agreement. The model has been used successfully by the HSE to open a 100-bed unit for older persons in Ballincollig, Cork. The unit delivers real cost benefits and value to the system, which would not be possible through direct employment. I visited the unit and the patients are happy. There is a great range of services and the Chairman of this committee knows it well. It is operating at a cost of €5.2 million when the estimated cost of the HSE operating it was €7 million. The HSE is also considering the Inchicore unit in light of the recent decision to locate the new children's hospital on the St. James's Hospital site. In these circumstances, the future of the long-term care unit on the St. James's Hospital site must be considered. Many of the people in the unit are from the area and its environs. Any decision on either unit will be taken in the best interests of the existing patients in the local area. I hope that clarifies the situation.

Deputy Peter Fitzpatrick asked about private health insurance and generic drugs. The Minister of State, Deputy Alex White, apologises as he had to go to the Seanad to reply to an Adjournment matter because another Minister of State, Deputy Michael Ring, had to leave and was unable to reply to it. The generic drugs market is quite small in comparison with what it might be. Reference was made to the producers of the drugs and decreasing prices by way of agreement. Generic prescribing legislation and drug reference pricing legislation will allow us to make more savings in this regard. The more generic drugs, rather than branded drugs, that are prescribed, the greater the opportunity for cuts to occur. What saves most money is doctors not prescribing when there is little indication to do so and something is more likely to be a viral illness than a bacterial illness. On Northern Ireland television, there was a great advertisement years ago suggesting one does not need a pill for every ill. People sometimes feel they have wasted their money when they go to a doctor unless they get a prescription. People should remember one has paid for a professional opinion on health and the reassurance that brings. In any event, when free GP care comes in - and it will despite what many people believe - that issue will be easier to address. We now have a new prescribing advisory council, with six new pharmacists gone into the payment board to examine GPs prescribing, to help them be more cost-effective and to advise them if they are out of kilter with their colleagues in various areas of prescribing.

Reference was made to private health insurers and the outstanding moneys. Mr. O'Brien can respond to that. Some of it is insurance money but more of it refers to other fees due to hospitals or overnight stays. Deputy Peter Fitzpatrick also referred to reducing the attendance fee at the Louth County Hospital. Perhaps we can discuss that in a different forum. We do not want people to start heading to Louth County Hospital because it is cost free instead of going to their GPs. Some reduction may be in order but we will have to discuss the technicalities at a later date. Deputy Ó Caoláin referred to mental health.

Kathleen Lynch (Cork North Central, Labour)
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I dealt with that.

Mr. Tony O'Brien:

The strategic framework referenced earlier contains a specific commitment to increase the age range for BreastCheck to encompass the 65 to 69 age range. The framework envisages it happening before 2015. I think it will be in 2014. A number of questions concerned the connectivity between what we might loosely called cutbacks elsewhere and the impact on emergency unit attendances. The number of attendances at the emergency unit reported relate to a period that predates the impact of the recent cuts so it is unlikely there is a direct connection. In other jurisdictions, particularly our neighbouring jurisdictions, there is an increase in emergency unit attendances, presentations and admissions. There is a great challenge for health services in Europe in respect of emergency unit avoidance measures and how to redirect to an appropriate alternative persons whose best care may not be in an emergency unit. That is a priority for us as we examine the resources available to us and the increasing utilisation of emergency units. What is more important is that those who present at emergency units are dealt with expeditiously and appropriately. This is why we have a focus on reducing the number of people recorded on trolleys as awaiting admission. Significant progress has been made this year although we are not satisfied that we are where we need to be. In the coming year, in particular, we will focus on the reduction of the journey time through emergency units in order that the great majority of patients are either sent home or admitted within six hours. In other jurisdictions they managed to reduce it to four hours but they have been working on this for longer than our programme has been under way.

With regard to the questions on financial matters, one question concerned procurement, another referred to cost saving measures and a third referred to the make-up of outstanding insurance claims. I ask Mr. Liam Woods, the director of finance, to address these. The overrun reported in the month of September in community schemes was, in a straightforward manner, the cost of the increased number of medical cards over and above the numbers provided for. The sum of €29 million is part of a cumulative figure of the year to date to the figure of €180 million to the end of September. There are no measures available to us to curtail costs because they are demand-led schemes. The cost containment measures are outside that area and I will ask Mr. Liam Woods to address that also.

James Reilly (Dublin North, Fine Gael)
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That will answer Deputy Regina Doherty's question on the scheme overruns. Perhaps her comment on crisis pregnancy services was to welcome the investigation. The questions put by Deputies Naughten and Mitchell O'Connor relate to Mr. Tony O'Brien rather than me.

Mr. Tony O'Brien:

The questions were all about emergency units and home helps. Ms Laverne McGuinness can address that question.

James Reilly (Dublin North, Fine Gael)
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In my opening statement, I said we would extend BreastCheck to a wider age group further down the line.

Mr. Liam Woods:

I understood one of the questions to refer to the HSE operating centrally, through procurement, negotiating national contracts and the charging of a margin to hospitals in the implementation of those contracts. The answer to that is "No" and if there is any incident the Deputy is aware of, I would be interested to hear about it. There is no such policy. We are a cost-based organisation and there is no attempt to do what is suggested.

In terms of the specific deficits on schemes in the year to date, I do not have the data with me but they are published and available on the website. I can get a copy for the Deputy for all schemes. High-tech schemes and the long-term illness scheme are the biggest single contributors to that.

The data are in our published report and I will send a copy to the Deputy.

At the end of October there was €206 million in outstanding claims due to the HSE. The work under way that the Minister and CEOs referred to in terms of accelerating income is with a view to receiving €125 million of that. The Deputy asked about older claims and the target is to collect the older claims within that €125 million. It is all inclusive. The €125 million target for this was in the service plan and is now being delivered. The entire issue is being addressed.

Ms Laverne McGuinness:

Deputy Naughten asked about reductions in home help services. The national average is about five hours per person and reductions are in the range of half an hour to an hour. Since the reductions commenced, 72,000 hours have been cumulatively reduced across the country. It is important to note the balance of that and where it has been. The majority of hours reduced have been in the south, 59,000 hours, but in Cork alone 82,000 home help hours are delivered over and above what should be delivered according to the service plan. A further 12,000 hours are being delivered in Waterford over and above what should be delivered, and an extra 20,000 in Wexford. That is why the proportion is so high. In the west, the cumulative figure for the reduction is 9,000 hours. There is high level of over-delivery in the west too, particularly around Sligo-Leitrim, where there are 30,000 hours delivered over and above what should be delivered. North Tipperary and east Limerick have 17,000 extra hours, Donegal has an over-provision of 17,000, Limerick has an over-provision of 14,000 and Mayo has an over-provision of 6,000.

Jerry Buttimer (Cork South Central, Fine Gael)
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Does "over-provision" mean the service was not needed?

Ms Laverne McGuinness:

Over and above what was committed and what was written down in the service plan.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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That is very different from not being needed.

Jerry Buttimer (Cork South Central, Fine Gael)
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It is very different.

Ms Laverne McGuinness:

Absolutely.

Mr. Tony O'Brien:

To clarify, that means it is not a cut in hours in the service plan; it is a reduction to bring the figure into line with the service plan. For the individual there is no difference, but there is an important distinction to me made in terms of how it is applied in different regions. That is why Ms McGuinness is going through the details.

Jerry Buttimer (Cork South Central, Fine Gael)
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I am conscious that it has gone past 7 p.m. and the Minister and other Members must go to the House so I will ask for some brief comments.

John Crown (Independent)
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I asked a question about who picked the original committee.

Dr. Philip Crowley:

It is not a secret. I presented the committee in the media yesterday. The director of quality and patient safety picked the committee. As I said before, this can be argued many different ways. We did a review of miscarriage misdiagnosis with national and international representatives. The woman at the source of that described the review as leaving no stone unturned. Our commitment is to achieve exactly the same with this review.

Catherine Byrne (Dublin South Central, Fine Gael)
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I know all about Ballincollig, as I have been told about it for the last nine months every time I have submitted a question, and I have met David Walsh on many occasions. This is not about the people of Inchicore; this is about new beds that were promised in the new unit. That is not going to happen now as these will be replacement beds. I welcome the Minister's commitment that 18% of the beds will be ring-fenced for the people of the local area, not just in Inchicore but in Ballyfermot and Kilmainham. If they are not going to be new beds, we must ensure the people who are in the Fair Deal system at the moment get the chance to stay in the communities where they live. That is all I am asking.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I asked about LauraLynn, guide dogs and a programme for obesity. We have had many meetings about this and I would like to know what the plan is.

Ms Laverne McGuinness:

I am not aware of any reductions for LauraLynn or guide dogs but I will get back to the Deputy.

Jerry Buttimer (Cork South Central, Fine Gael)
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The LauraLynn Foundation has written to members, as has Irish Guide Dogs for the Blind. We could perhaps pick that topic up again at a different meeting.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Since 2008 there has been a 20% cut, a total of €1.1 million.

Ms Laverne McGuinness:

That would be in line with the reductions of 3.5% across all disability agencies this year. There is nothing else involved that would have specifically targeted those bodies.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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We have been talking about a child dying, but I am talking about children who are dying and who are not getting the services they require.

What about the question of obesity?

Ms Laverne McGuinness:

I will come back to the Deputy on that with a written response to her specific queries.

James Reilly (Dublin North, Fine Gael)
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This is the first Government in the history of the State to put in place a principal officer across the Departments of Education and Skills, Children and Youth Affairs and Health to deal with the issue of obesity and to get more co-operation to address the issue of education. I agree with the Deputy that this is a serious issue and we must tackle it at many levels.

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Fitzpatrick is the rapporteur for the committee, which has just concluded hearings on obesity and health.

James Reilly (Dublin North, Fine Gael)
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I acknowledge that.

Peter Fitzpatrick (Louth, Fine Gael)
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Almost 70% of those with diabetes are obese. There is a diabetes clinic in Dundalk so anyone who would like to study obesity should come to Dundalk.

James Reilly (Dublin North, Fine Gael)
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This is a serious issue. There is an epidemic of obesity across the world, including in this country. We must address this and the Department of Health cannot do it on its own. It is also a matter for the Department of Education and Skills, which can allowing for more physical education, and for the Department of the Environment, Community and Local Government, which can make available safe places to exercise. The Departments of Justice and Equality and Transport, Tourism and Sport are also involved.

I thank the committee for their courtesy and for raising issues of concern. I assure members of our continuing commitment to improving the health service.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the Minister, the Minister of State, Deputy Kathleen Lynch, and the officials for being here. I also thank Mr. Ray Mitchell of the parliamentary division of the HSE for his co-operation. We are talking about people - that is what the health service is about - and in framing our budget we must put the patient at the centre of our plans.