Jerry Buttimer (Cork South Central, Fine Gael)
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I remind members and witnesses that mobile telephones should be completely switched off for the duration of the proceedings as they interfere with the broadcast and also are an interference for our staff, which is unfair. As this is also a workplace for members of staff, I would appreciate if all mobile telephones could be switched off rather than put on silent mode.

Our discussion this morning centres around the Health Service Executive Service Plan for 2013 and also issues pertaining to medical cards. I welcome Mr. Tony O'Brien, director general designate, Health Service Executive, and Ms Laverne McGuinness, chief operations officer, Mr. Brian Kirwan, chief operations officer, Mr. Liam Woods, Dr. Áine Carroll and Mr. Patrick Burke from the medical card service. I also welcome Mr. Ray Mitchell and thank him for his co-operation and for facilitating meetings between the committee and the HSE. His co-operation and helpfulness has been most welcome and we thank him.

I remind witnesses that they are protected by absolute privilege in respect of their evidence to the committee. If they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a person or persons or entity by name or in such a way as to make him or her identifiable. I remind members of the long-standing parliamentary practice to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name in such a way as to make him or her identifiable.

I thank everyone for attending and I invite Mr. Tony O'Brien to make his opening remarks.

Mr. Tony O'Brien:

I thank the committee for the invitation; the Chairman has taken care of the introductions.

The HSE national service plan 2013 was submitted to the Minister for Health on 21 December 2012 and approved on 9 January 2013. On 28 February, the national operational plan, regional service plans and hospital group plans were published to ensure that the HSE has a robust planning framework to support the implementation of the national service plan. These reflect the first full year of implementation of Future Health, a Strategic Framework for Reform of the Health Services 2012-2015, which sets out the Government’s priorities for the health services.

The gross current Estimate for the HSE this year is €13.4 billion, a net increase of €71.5 million on the previous year. However, the reduction required of the HSE in 2013 is €721 million which is a total reduction to HSE budgets since 2008 of €3.3 billion or 22%. In addition, staff levels have reduced by over 10,000 whole-time equivalents since 2009.

The scale of the financial challenge continues to be significant in 2013. Taking account of the budgetary reductions borne by hospitals over the past number of years and the challenge to reduce expenditure at the pace required, the 2013 budgetary allocation process has endeavoured to allocate more realistic hospital budgets with targets that are challenging but attainable. This rebalancing of hospital budgets is made possible by driving changes in policy and driving further cost efficiencies of €383 million in primary care schemes.

The budgetary framework seeks increased income targets of €77 million which requires legislative changes, increased non-pay savings of €43 million and a reduced pay bill of €286 million, primarily linked to measures under the public service agreement. The measures include implementing changes in rosters and skill mix.

The 2013 service plan outlines new expenditure of €90 million in respect of demographic pressures experienced by health services and €390 million to address deficits from 2012. The plan also provides for an investment of an additional 1,025 whole-time equivalents in a number of key prioritised areas. It will be necessary to achieve a reduction of almost 4,000 WTEs or 4% of the workforce. The impact of the staff available to deliver front-line services is critical and will be a key issue that will most directly impact on service levels in 2013. Managing the pay reductions under the public service agreement will also be a primary focus in 2013.

Regarding acute hospitals, fundamental to the reform agenda is the need to reorganise our hospital resources to ensure patients access appropriate treatment in the right setting, receive the best possible clinical outcomes and provide sustainability for hospital services into the future. In 2013, specific targets include over 600,000 inpatient activity and over 830,000 day cases; that no adult will wait more than eight months for an elective procedure, either inpatient or day case, by the end of the year; that no child will wait more than 20 weeks for an elective procedure, either inpatient or day case; no person will wait longer than 52 weeks for an outpatient department appointment by the end of year; and 95% of all attendees at emergency departments will be discharged or admitted within six hours of registration. In addition, when the Government concludes it deliberations and publishes the relevant reports, we will establish hospital groups, implement the small hospitals framework and implement new methods of resourcing in hospitals to drive further efficiencies.

Regarding the ambulance service, a significant reform programme has been under way in recent years to reconfigure totally the way we manage and deliver pre-hospital care services. A further €12 million investment will take place in 2013.

With regard to cancer services, the national cancer control programme will continue to focus on maximising timely access to services and the development of a comprehensive national service. A €17 million additional provision has been made in 2013 for the increased costs of cancer drugs. We will see both the launch, which has already occurred, and the continued development of the national colorectal cancer screening programme and the diabetic retinopathy screening programme during 2013. The latter is not a cancer programme but is managed through the cancer programmes.

The primary care team remains the central point for service delivery in the community. Some €20 million will be invested this year to support the recruitment of prioritised front-line primary care team posts and to further develop community intervention teams. In addition, funding has been provided to continue the implementation of the diabetic retinopathy screening and audiology programmes. Some 17 clinical nurse specialists are in the process of being appointed to support the delivery of the integrated diabetes care model. The total budget for the primary care reimbursement services, PCRS, in 2013 is €2.5 billion. Very substantial cost efficiencies are required to support reduction of €383 million which is outlined in the service plan. Provision has been made for growth of up to 100,000 medical cards and up to an additional 130,000 GP visit cards. Policy changes will reduce eligibility for approximately 40,000 people currently in receipt of medical cards, giving an anticipated net growth of 60,000 cards. Ongoing assessment of eligibility will also continue throughout 2013, with a number of people losing eligibility as a result. These will include individuals in all age categories.

In 2013 we will provide almost 23,000 long-stay residential care places for older persons in line with the funding available under the nursing home support scheme. We will provide home help and home care packages at the levels planned for in 2012. Some 10.3 million hours of home help service and 10,870 people will be in receipt of home care packages.

We have made provision of €1.5 billion for disability services in 2013, a 1.2% reduction from the previous year. We will provide 1.68 million hours of personal assistance, which is the same as committed to in 2012. We will also prepare for the implementation of the national HIQA standards for residential care during the year.

In 2012 an additional €35 million was allocated to mental health services with an associated 414 posts. At the 27 February 2013, 307 of these posts were filled and the remaining posts are in the process of being filled. In addition to the completion of the mental health investment programme for 2012, a further €35 million has been allocated for year two, 2013, of this investment programme. Our priorities in 2013 will be to further develop suicide prevention initiatives, forensics and community mental health teams for adults, children, older persons and mental health intellectual disability and to continue to rationalise adult inpatient and continuing care provision.

Children and families services will be disaggregated from the HSE into a new agency, the Child and Family Support Agency. The main priority for the HSE is to plan for this safe transfer during the year.

Funding of €341 million has been allocated to progress our capital plan. The plan prioritises the development of the National Children's Hospital, the replacement of the Central Mental Hospital, the national programme for radiation oncology and the continued roll-out of primary care infrastructure. The commitment to deliver the mental health investment programme in line with A Vision for Change will continue. Provision is also made for the redevelopment of the National Rehabilitation Hospital and improving long-term care facilities to support services for older people.

The 2013 national service plan sets out a very significant financial challenge. Very substantial savings are required in pay and in the primary care schemes as well as increased collection of income. Managing changes to our staff resource will require a lot of management attention. At the same time a number of critical key areas for investment will take place as I have outlined. A robust process has been put in place to monitor and manage the performance of the plan and any deviations from the plan will be identified early and remedial actions put in place.

I, together with my colleagues, look forward to addressing questions from members.

Jerry Buttimer (Cork South Central, Fine Gael)
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I remind members that prior to today's meeting, the Primary Care Reimbursement Service issued a comprehensive report on medical cards which together with the agenda and briefing material were sent to members. Both Ms Laverne McGuinness and Mr. Patrick Burke will answer questions on medical cards.

Deputy Kelleher has seven minutes.

Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the delegation from the HSE. This will be a challenging year. If one looks at the budget overrun last year and the deficit that has been carried forward it certainly puts the HSE in a difficult position.

While we are basing budgets on estimates, there are a number of key issues that we do not know anything about. I do not see anything about the smaller hospital framework and the hospital groupings. Have the estimates and projections been made on reports that nobody else has seen? Has there been a detailed analysis of these reports and have they been taken into account in formulating the estimate of expenditure in 2013? We have seen regional plans and the potential for grouping smaller hospitals, but we have not seen full details of the Smaller Hospital Framework and the funding allocated to it. Is that a central plank of that estimate before us?

May I address the question of medical cards now?

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes.

Billy Kelleher (Cork North Central, Fianna Fail)
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Mr. O'Brien refers in his opening statement to policy change reducing eligibility for approximately 40,000 people who have a medical card. Will somebody outline the policy change in respect of eligibility? The key question is whether the change in eligibility will impact on 40,000 or is that the minimum number of people on whom it will impact? While the policy change may withdraw medical cards from 40,000 people, is that a minimum number or is it the target figure? These are important issues that must be clarified.

What is striking also is the reduction in staff in the services for older people, mental health and community care. There seems to be a disproportionate reduction in staffing number in these three key areas, yet the priorities identified for mental health services, suicide prevention, and care for older persons with mental health and intellectual disabilities.

The decisions were made prior to the Croke Park II deal being finalised. What savings are envisaged under Croke Park II? Some worker representative groups and unions are still outside and are in negotiations outside of the Croke Park II? Can one say definitively the savings will come about under Croke Park II when the deal has not been concluded yet?

With the permission of the Chair, may I be parochial and raise a local issue?

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes, the Deputy can be parochial provided it is within the realm of the discussion.

Mr. Tony O'Brien:

Provided also it does not involve Cork.

Billy Kelleher (Cork North Central, Fianna Fail)
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It does not involve Cork. I can raise it at another stage. I wish to raise in general terms the policy in respect of the smaller hospitals framework.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Smaller Hospital Framework is not part of the HSE service plan in the strictest sense but I will allow some latitude.

Billy Kelleher (Cork North Central, Fianna Fail)
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The smaller hospitals framework document will be published at some stage this year. The hospital groupings will be published as well. We have been told previously by the HSE and the Minister for Health that they are linked and they will form a central policy. Having read Mr. O'Brien's speech and looked at the estimates for the budgets, are some of the savings identified in this national service plan ones that the witnesses see already? They know more about the hospital framework than I do.

That is something I would have difficulty in accepting. For example, in Cork, the accident and emergency department has been closed in Mallow and the one in Bantry has been downgraded, while urgent care centres are being established. Are these savings that are already identified and are they included in this national service plan? We have had no discussion about this and do not know what is in it. We will find it hard to accept the veracity of this document until such time as we see the small hospitals framework and the hospital groupings coming together in an integrated way. Only then will we be able to analyse the impact that will have on both services and on the budget itself.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome our guests. The service plan invites such a broad set of responses and covers such a vast area that I will try to focus in on a few issues and seek clarification on them. We have noted the signalled cut of €721 million to the budget for 2013 and the composite figure of €3.3 billion in cuts since 2008. I note that in the presentation the witnesses indicated a reduction of €383 million in primary care schemes. However, if I recall correctly, the breakdown of the €721 million, when it was first signalled, contained a figure for the reduction in primary care expenditure of €323 million. There seems to be an additional €60 million here. Is my recall muddied or is there an explanation for that? Am I correct in pointing up the difference in those figures? Perhaps I have missed something in the intervening period but it seems that €323 million has grown to €383 million in terms of cuts to primary care schemes. That must cause serious concern to our friends from the primary care reimbursement service.

The witnesses also spoke of the composite figure of a €3.3 billion reduction in budget provision as representing a cut of 22%. They went on to talk about the fact that staff levels have reduced by more than 10,000 whole-time equivalents since 2009, but that obviously does not include the further reduction of 4,000 in the current year. If we are going to spell it out in terms of the euro and cent impact, we should also have the composite figure expected to apply in the course of this year with regard to staffing. A 14,000 reduction in whole-time equivalents is alarming. Is that the full situation? I ask the witnesses to clarify that point.

I understand the specific targets that have been set out and hope they are all realisable. I hope that in looking at this again in 12 months time, we will be looking back and ticking all the boxes, noting that the targets have been achieved. We only have to put ourselves in the shoes of those awaiting elective procedures to accept that a waiting time of no more than eight months is desirable. There is a sense that elective procedures are non-emergency procedures. However, I do not have to go far to come up with real people who were in real pain and anguish but whose treatment was categorised as elective. It is a fact of life and we are talking about human beings. Even the eight month guarantee for elective procedures is too long for someone in protracted agony, and I hope that we can do even better than that. That is not to say I am not mindful of the reality with which the service is contending at this point. I hope all of these targets are achievable but I believe we should be going much further.

On the issue of medical cards, I wish to record the fact that Ms McGuinness had a difficult enough meeting with us on Tuesday, following on from the non-consultant hospital doctors, and I would like to share something positive with her. I acknowledge the continued accessibility and reasonableness of people working in the primary care reimbursement service. While I will not take off on the Minister's statistics, as read into the record of the Dáil yesterday, Ms McGuinness might like to clarify the position. The Minister said, with a smile on his face, that there were only nine outstanding medical card applications in the real, quantifiable backlog category. I am not sure that could be the case because, if it is, they must all be in my back yard and the applicants must all have come to my office. However, I am not slating the effort because I know people are working very hard to cope. The Minister has cited, or put on the record, data that do not link up with what we, as elected representatives, know.

Of the 40,000 people who are signalled to lose their medical cards in the current year, the witnesses have indicated that a certain cohort will be people over 70 years of age. Will the witnesses explain the criteria and what particular body of people over 70 will lose their entitlement to a medical card? I presume it is on the basis of income calculations and perhaps the witnesses would elaborate on that. Will they give us the detail and explain who else, apart from those in the over 70 cohort with a certain income stream, will lose their entitlement to a medical card in the current year? We need that clarification on the alleged, so-called saving of €20 million.

My last point relates to the famous €35 million that has popped up again, which somebody pinched out of the back pocket, as it were, of the Minister of State, Deputy Kathleen Lynch, last year. The €35 million is back again and Mr. O'Brien has indicated to us that 307 of the 414 posts have now been filled between the end of 2012 and the beginning of 2013. Could he indicate what posts he is talking about and give us a breakdown of the roles, responsibilities and so forth? What service providers are we talking about in the profile of the 307 posts? On the €35 million which we all hope will be spent in realising the best prospects for the delivery of A Vision for Change, is that money only for additional posts or is some part of it to be used in some other regard vis-à-vis the roll-out of A Vision for Change?

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I welcome the HSE staff to this meeting. Mr. O'Brien has outlined the figures fairly clearly and we see there has been a reduction of €3.3 billion or 22% in the health budget in recent years. Approximately 10,000 staff have left the health service already. This year there will be a further cut of €721 million to the budget and a net reduction, if I am correct, of around 3,000 staff. That budget is unrealistic and I would be very surprised to find that it is achievable. Cuts of this magnitude are effectively undermining the delivery of health services in this country, particularly to people who are ill and require treatment urgently.

Small hospitals were mentioned in Mr. O'Brien's report and I ask him to clarify exactly what he means by small hospitals. Are there identified small hospitals and, if so, could he name them for the committee? Mr. O'Brien referred to a target of a maximum waiting time of 52 weeks for outpatient appointments.

Perhaps Mr. O'Brien will outline how it is proposed to achieve this, particularly given that in the south east the waiting time for an orthopaedic appointment classified as urgent is 18 months and for non-urgent appointments it is three years. There is a significant waiting list for orthopaedic appointments, as in respect of other specialties, at Waterford Regional Hospital. How is it proposed to reduce these waiting lists to 52 weeks in the current year?

On income, I note that legislative change will be required. How soon is it expected and will it come soon enough to meet the targets set in the plan? On medical cards, in my view there is a continuing difficulty in this area, particularly in respect of medical cards sought on grounds of long-term ill-health. Perhaps the delegates will outline how it is proposed to address these difficulties, in particular in respect of medical card applications by very ill people. In my experience, there are significant delays in processing medical card applications. We have been told that for a person to obtain a medical card urgently his or her GP would have to indicate that he or she is terminally ill, which is a difficult situation in which to place any applicant, his or spouse or representative. What is the structure of the process by which cards are granted on medical grounds? For example, how many doctors are involved in this scheme, what is the timescale for processing applications and can the delegates give a commitment that this process will be streamlined and expedited particularly for people who are very ill?

On medical card income limits, it is my understanding that these have not been increased since January 2006. I would welcome a response from the delegations on that issue also. Last year - it may have been the year prior to that - the Minister announced that those who qualified under the long-term illness scheme would as of right receive a medical card. At what stage is this process and how soon in the delegates' view will it be implemented? Also, was this scheme impacted financially by the recent budget?

As I have previously stated, the manner in which the HSE does its business, in particular in terms of decision-making which affect patients in my area, is, in my view, unacceptable. There is no consultation with staff, patients or stakeholders prior to decisions being made. Last week, a decision was made and announced by the HSE to transfer a rehabilitation unit from St. Patrick's Hospital in Cashel without any consultation with patients, staff or stakeholders. This practice must change. If the HSE does not introduce such change, the Minister must then introduce legislation which will entitle stakeholders, including staff and patients, to be consulted prior to decisions being made.

Jerry Buttimer (Cork South Central, Fine Gael)
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Five other speakers have indicated. I will call Mr. O'Brien at this point to respond to the questions from Deputies Kelleher, Ó Caoláin and Healy, following which I will call the other five speakers in the order in which they indicated.

Mr. Tony O'Brien:

I will respond to questions in the order they were asked. On the hospital group report, we have not substantially taken the financial impact of hospital groupings into account in the service plan because it is not our expectation that there will be significant yield from that this year. Our expectation is that Government will conclude its deliberations on that issue in the coming weeks, make its announcement and then assign responsibility for the implementation of groupings to the HSE. We will take that forward on a group by group basis. It is logical to expect that the different composition of the groups will create the different dynamics around the process and pace at which they will move. There will be significant potential benefits of various kinds arising from the groupings. There is no particular dependency on this in terms of the financial arithmetic for this year.

The small hospitals framework, which arises from the Health Information and Quality Authority, HIQA, report, which we refer to as the Ennis-Mallow report, relates to the following hospitals: Louth County Hospital; Our Lady's Hospital, Navan; St. Colmcille's Hospital, Loughlinstown; Bantry General Hospital; Mallow General Hospital and the Mid-Western Regional Hospital, Ennis; Mid-Western Regional Hospital, Nenagh; St. John's Hospital, Limerick; and Roscommon General Hospital. This is primarily an issue of ensuring patient safety arising from the HIQA report rather than one of cost. There will be other potential benefits arising from full implementation of the small hospitals framework and the groupings, which has a direct bearing on the subject matter discussed by the committee at its meeting on Tuesday, including compliance with the European working time directive, cross-covering in various disciplines and ensuring that the overall resource in a given area, including staff and so on, is used to provide the maximum possible range of services. For example, in Roscommon General Hospital, which is now part of the Galway-Roscommon University Hospital Group, there have been significant performance and operational benefits arising from the creation of this group. We have also seen a significant increase in the level of activity at that hospital following the changes which occurred there the year before last. The hospital is busier in terms of day cases and so on. These are the types of changes we expect to emerge. There are dependencies but these are not service plan financial dependencies. We keenly await the outcome of the deliberations so that we can give effect to these proposals before the end of the year.

On medical cards, I will ask my colleague to address the detailed mechanics of that process. The target is 40,000. There are some policy determinations yet to be made and provided to us, which will cover the detail in that regard. We expect to have those relatively soon.

Jerry Buttimer (Cork South Central, Fine Gael)
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Will that policy determination come from the Minister and Department of Health?

Mr. Tony O'Brien:

Yes. In terms of Croke Park II, the service plan spells out that the financial provision this year will be €150 million which is, in effect, a half year's worth of savings. This finance has not yet been allocated to any area of service. It is being held centrally precisely because the various options that could emerge from Croke Park II will affect how it is distributed. Although what happens will change the gross and net figures for any particular service, it will have a broadly neutral affect on the service itself in that it will be a reduction of cost associated with whatever is ultimately agreed. Obviously, if nothing is agreed we will be faced with a €150 million challenge. Our expectation is that if the package currently on the table is ultimately agreed, we will not have a residual problem.

They would be equal to the €150 million referred to.

Billy Kelleher (Cork North Central, Fianna Fail)
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That money is centrally held.

Mr. Tony O'Brien:

It comes within the HSE Vote but is centrally held and allocated internally.

On staff reductions, members will have seen some illustrations as to what an across-the-board equivalent reduction of staff in existing categories would mean. This is not how we would expect it to turn out. There will be a natural rate of turnover, probably accounting for between 1,000 and 1,400 staff based on a typical cycle. Members will be aware that a voluntary exit scheme is being prepared, which will have an impact on the total numbers leaving. An exit of 4,000 will be required if we are to comply with our employment control framework and create the headroom for the additional posts we need to create. We will have to closely monitor this process, which is in its relatively early days. Some of the matters about which we spoke earlier will have an impact on it.

On Deputy Ó Caoláin's point regarding the difference between the €323 million and €383 million, the figure of €323 million is identified on page 3, table 2 of the service plan. It was an Estimates day issue. At the bottom of page 4, under community demand-led schemes it states: "The HSE board has made a decision to introduce additional cost reductions in PCRS beyond those specified in the Estimates. In so doing, the HSE will seek €60 million of further target reductions in expenditure through a range of efficiency measures detailed in table 5". We believe it is possible to reduce costs in areas such as medicines management and so on and have set a target of €60 million in this regard, which we believe is realisable. The €323 million essentially relates to the impact of the IPHA deal, various eligibility changes and the impact of the increase in co-payments, which impact on the cost rather than level of care provided. On the question of the impact on those aged over 70 years, a policy decision was made by the Government to reduce the income criteria for those aged over 70 years. While previously the qualifying income criteria for a single person was €700 per week and for a couple was €1,400, this has been reduced to €600 and €1,200 per week, respectively. That is how people aged over 70 years will be impacted.

I agree with Deputy Ó Caoláin that an eight month target, while a significant improvement on the two and three year wait evident up to two years ago, is still a lengthy waiting period. This is a target beyond those classified as clinically urgent. Such persons can, left untreated, have significant debilitating and life altering conditions. Clearly, this is another step towards reducing waiting times further. The primary target list which started out at 12 months was reduced to nine months and now stands at eight months. We hope to achieve this year's target and to use it as a platform for reducing the target further so that we get to a normative situation in due course whereby persons could expect to be treated within three or four months, as would be the case in neighbouring jurisdictions. I agree with the Deputy's points in this regard. While it may be classified as elective it does not mean it is in any sense trivial or non-urgent: it is. My colleague will address the Deputy's questions on medical cards.

In terms of mental health, Appendix 3 of the service plan, which is set out on page 3, details the level of expenditure and number of posts, totalling 477, to be allocated this year to different areas of mental health services. It is important to stress that while primarily due to the lag in recruitment last year the €35 million was not spent on development posts, that €35 million has been restored and added to by a further €35 million. As such, in-year additional resources for these developments is €70 million.

Jerry Buttimer (Cork South Central, Fine Gael)
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There will be two tranches of €35 million.

Mr. Tony O'Brien:

Yes, both of which will be spent this year. One of the challenges faced by the HSE this time last year was the interplay between the new posts and the challenge of reducing its overall head count. This led to a delay in seeking to achieve the head count reduction prior to implementation of the service plan and Government priorities for the new development posts. We have turned that around this year. We are proceeding with new development posts in advance of achieving the head count reduction which is, it must be said, a risk but a necessary one if we are to achieve the objectives of the service plan - the risk being that we will put in these new posts and miss the overall reduction target. It is a calculated decision.

On orthopaedic appointments, about which Deputy Healy made a valid point, there is a particular problem in this area. The Deputy referred to Waterford Regional Hospital where the waiting time for an orthopaedic appointment on an outpatient basis is unacceptably high. The hospital is benefiting from the clinical programme relating to orthopaedics, including musculoskeletal physiotherapists, which is having an impact. To reduce the overall quantum, a number of patients have been taken off the back of the waiting list at Waterford Regional Hospital and taken to other hospitals. The reality is that the waiting list for orthopaedic appointments at Waterford Regional Hospital, which had stretched out to four years in some instances, had reached the point where it had become unmanageable. A number of measures have been taken to address this, although the situation is not yet fully under control or where it needs to be. The Deputy's point that such lengthy waiting periods is unacceptable is well made.

Jerry Buttimer (Cork South Central, Fine Gael)
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The point made by Deputy Healy was also made at the briefing in Cork on Monday. It is commendable that there is a plan in the southern region to tackle orthopaedic waiting lists. I commend Mr. Pat Healy and Mr. Ger Reaney on taking the initiative but is what is proposed attainable?

Mr. Tony O'Brien:

I believe it is attainable. Chronological waiting list management if rigidly adhered to, which it must be, will with support from other hospitals reduce the overall waiting list and progressively reduce maximum waiting times. For example, a number of patients from Waterford had their outpatient appointments transferred to Cappagh hospital. The musculoskeletal initiative, which Dr. Carroll will speak to, has a particular impact on ensuring that such waiting lists are not built up in the first instance.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Have all the orthopaedic consultant posts at Waterford Regional Hospital been filled?

Mr. Tony O'Brien:

I will check that for the Deputy. There may be ongoing vacancies, as there often are.

Jerry Buttimer (Cork South Central, Fine Gael)
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I omitted to welcome Mr. Liam Woods and Dr. Áine Carroll, both of whom are most welcome to the meeting.

Dr. Áine Carroll:

With reference to the question about orthopaedic appointments, the orthopaedic and rheumatology clinical care programmes have been working together on the issue of waiting lists. They are also working with the special deliver' unit, SDU, from a scheduled care point of view. The orthopaedics and rheumatology programme has developed a model of care. A number of referrals to orthopaedic clinics do not need to be seen by an orthopaedic surgeon. It is important that there is an appropriate amount of screening to ensure that individuals who do not require to be seen by an orthopaedic surgeon are seen and treated appropriately. The model of care developed a number of musculoskeletal physiotherapy posts. The plan is that in excess of 24,000 individuals will be screened and managed at that level rather than at orthopaedic clinics. This will have a huge impact on outpatient waiting lists at orthopaedic clinics.

Jerry Buttimer (Cork South Central, Fine Gael)
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Will this result in a reduction in waiting time for the person awaiting a hip replacement who is in excruciating pain?

Dr. Áine Carroll:

Yes. The individuals who require to be assessed by an orthopaedic surgeon will be seen in a much more timely fashion. They will get a quality service and access times will be increased significantly.

Jerry Buttimer (Cork South Central, Fine Gael)
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I am currently on a waiting list. If I receive an appointment by way of letter in the post with a specified consultant at, for example, the South Infirmary-Victoria University Hospital in Cork, how quickly, following that appointment, will the process be, in terms of my getting a hip replacement?

Dr. Áine Carroll:

Orthopaedic referrals are a heterogeneous group. Referrals will be screened such that individuals who do not require to be seen by an orthopaedic surgeon will be seen by a musculoskeletal physiotherapist and managed accordingly. Those who require to be seen by an orthopaedic surgeon will be seen in a much more timely fashion and will have access to the services they require.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Are occupational therapists or physiotherapists in place in Waterford?

Dr. Áine Carroll:

I cannot comment specifically on individual hospitals. I understand that the programmes examined the staffing requirements throughout the country and most of those posts are in place.

Mr. Tony O'Brien:

There was a musculoskeletal physiotherapist post, or MSK, for Waterford but I would have to check if they are currently in post.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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My concern is the same as the Chairman.

Jerry Buttimer (Cork South Central, Fine Gael)
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Five other people are offering but I will allow the Deputy to comment at the end.

Mr. Tony O'Brien:

The service plans contain a provision for a significant increase in the number of GP visit cards regarding the long-term illness scheme but we await legislation. It is a matter for the Department of Health rather than the HSE.

A number of questions were on practical issues related to the operation of medical cards. My colleague, Ms McGuinness, will address those questions.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I ask Mr. O'Brien to address my question on consultations with stakeholders.

Mr. Tony O'Brien:

I will come back to that.

Ms Laverne McGuinness:

We have given a detailed paper that sets out the medical card process. There was a difficulty with medical cards a year ago but all of the backlogs have now been cleared. As many as 97% of medical cards are processed within 15 days, even though we had set a lower target of 95%.

There are two other types of medical cards, the emergency medical card and the discretionary medical card. The former can be obtained at very short notice from a local health office, then with the GPs and back at the primary care reimbursement service where there is a terminal illness. However, terminal illness does not include people who have cancer who are going to survive and are undergoing treatment. In cases where the medication will cause a significant financial burden, applications can be put in place under what we call a discretionary medical card. There was a backlog of 3,000 for discretionary cards because we needed medical assessments for them. We have 12 medical officers in place which are five whole-time equivalents. They also do other work such as all of our immunisations. The backlog has been cleared. I can inform Deputy Ó Caoláin that I think that is where the Minister would have used the figure of nine discretionary medical cards being in play.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I bet that the Minister loved using that statistic.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy can believe it.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Perhaps the delegation is not in a position to go further than the over-70s and the income threshold. Where else will the reduction of 40,000 cards have an impact?

Ms Laverne McGuinness:

As the director general designate has pointed out, there are some policy measures that are with the Department of Health and it will advise us on the changes. It is important to focus on the fact that 100,000 new medical cards will also be issued plus 130,000 extra GP visit cards this year. There will also be a reduction of 40,000 cards.

Jerry Buttimer (Cork South Central, Fine Gael)
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I have five other speakers waiting and I give a commitment to members that I will allow them back in.

Mr. Tony O'Brien:

I shall return to the list and the question on the timing of an income legislative change. The relevant income is for the charging of private patients in beds in public hospitals, irrespective of designation. That is factored into our Estimates as a mid-year change. In other words, we need to be able to give effect to that from the beginning of July. The advice that we have from the Department is that it expects the timetable to be met. Legislation will have to come before the Oireachtas after Easter in order for that to be achieved.

With regard to consultation issues, I am not familiar with the details regarding Cashel.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I asked about consultations generally, not just the generalisation of it.

Mr. Tony O'Brien:

Let me break that question into two halves. The Deputy asked about stakeholders, including staff. The HSE seeks to abide by the requirements for consultation and communication with staff regarding workplace changes. There is a general commitment to do that with other stakeholder groups. I heard what the Deputy said and I would be happy to talk to him to find out what happened in the case. I am aware that the rehab unit was relocated to a newly constructed facility across the road but I do not know any further details. I am happy to engage with the Deputy on it.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. O'Brien. I call Deputies Fitzpatrick and Maloney and Senator Crown.

Peter Fitzpatrick (Louth, Fine Gael)
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I welcome the delegation. The director general designate said that the budget for 2013 is €13.4 billion, a net increase of €71.5 million.

Jerry Buttimer (Cork South Central, Fine Gael)
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I wish to remind members that RTE will not cover the proceedings because mobile telephones interfere with the sound quality for members and staff.

Peter Fitzpatrick (Louth, Fine Gael)
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There is also a reduction required for 2013 of €721 million and a deficit of €390 million from 2012. I compliment Mr. O'Brien on his report. It is very easy to understand. He stated that a robust plan has been put in place to monitor and manage the performance of the plan and any deviation from the plan will be identified early and immediate action will be taken.

Mr. O'Brien has stated that 95% of all attendees at emergency departments will be discharged or admitted within six hours of registration. If that goal is achieved it will be a major plus. Most of the complaints that I receive about the HSE are about people having to wait 24 hours or more at a hospital. In the Louth-Meath area there is Our Lady of Lourdes Hospital, Drogheda, Navan Hospital and the Louth County Hospital, Dundalk. Can the delegation give me the details on services that will be transferred from Our Lady of Lourdes Hospital in Drogheda to the Louth County Hospital in Dundalk? The Louth County Hospital is on a site of seven acres so there is plenty of room. A transfer of some services would alleviate the pressure on Our Lady of Lourdes Hospital.

John Crown (Independent)
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I welcome the guests. I also welcome Dr. Carroll and congratulate her on her new role as national clinical director of strategy and programmes. It is timely to have the delegation here. Last year a matter about the health service was brought to my attention. I apologise to Deputy Maloney if I sound like one of the politicians who is always criticising but I am.

John Crown (Independent)
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As it used to be said in military circles, the HSE is a target-rich environment.

The situation with respect to rehabilitation services, in particular, is appalling. The figures I have indicate that we have approximately 60% of the number of rehabilitation consultants per head of population as the United Kingdom. If it was not for Ireland, the United Kingdom would be at the bottom of every metric for patient access in the world's socialised medical systems. It scores dismally in terms of patient access. The United Kingdom has 10% of the number of rehabilitation consultants of a country like France, which would be at the upper end of the scale. We have 60% of what the British have and the British have 10% of what the French have. As a result, we can have up to six months of a wait for access to neurological rehabilitation, which means that somebody who has had some devastating, life-altering injury can be lying in a hospital bed for five or six months before being transferred to rehabilitation services for their specialist rehabilitation to begin. That has all manner of downstream consequences and our health service tends to specialise in the law of unintended consequences. It is harder to rehabilitate someone who has been waiting six months for treatment to begin. As well as that, someone who is lying in a hospital bed for six months is, effectively, bed-blocking, but I do not use that phrase in a pejorative sense. That person is inappropriately using a bed that should be used for other services. We have, according to local representative group estimates, one fifth of the number of consultants that we should have in this area. If the HSE appointed a new clinical director every month from a different specialty we would still be having the same conversation because that is the kind of health service we have. It is the kind of health service we have been given because of years of maladministration and one that we need to fix. While I have the witnesses captive here, I am taking the opportunity to bring this to their attention. I brought it to the attention of the Oireachtas through the Seanad debate system some time ago and I am sure it has been ignored. Now that representatives of the HSE are actually here, I am bringing it to their attention, as well as to the attention of my colleagues on this committee. The issue of rehabilitation is something we should discuss in more detail in this forum.

Sandra McLellan (Cork East, Sinn Fein)
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I welcome the witnesses and thank them for their presentation. Regarding the current control framework and the sharing of data between the HSE, the Revenue Commissioners and the Department of Social Protection, what type of legislation is pending and can the witnesses assure people that they will protected under the Data Protection Act? I am happy to hear that the National Adult Literacy Agency is involved in the revision of application forms and letters and I ask the witnesses to elaborate on how successful the effort to make application forms more user-friendly has been.

According to the presentation, there has been a 74% increase since 2005 in the number of people who are eligible for a range of health services covered by the GP visit cards. How does the HSE plan to address the issue of growing demand at a time of limited funding? The witnesses also mentioned that there will be a reduction of 40,000 in the numbers holding full medical cards. What eligibility criteria will be used? Is the HSE planning to lower the income threshold for qualification, bearing in mind that many people have far less money in their pockets now?

The standard medical cards are relatively easy to get but it is still very difficult to obtain emergency medical cards. There are also enormous problems pertaining to the discretionary medical cards where, for example, people who would have been approved for medical cards on discretionary grounds are quite often only given a GP visit card once their discretionary card comes up for review. They then have to go through the process of applying for a discretionary card all over again. Such people are presenting to our constituency offices and explaining that they are not taking their prescribed medication because they have been issued with GP visit cards and cannot afford to fill their prescriptions. Another concern in this regard is the difficulty for cancer patients in obtaining discretionary medical cards. I have found, through my constituency office, that many such patients are being refused discretionary medical cards. The HSE might argue that their income is above the medical card threshold but that does not take into account the true cost for people of dealing with cancer. People with young children, for example, need to pay for additional child care and in some instances, also need help with cooking and general housework because they are so ill and are in bed for weeks on end. It costs money to buy take-away food on occasion, to travel to and from hospital, to park one's car at hospitals and so forth. Such expenses over a 12-month period can add up and I do not think such issues are being taken into consideration.

On the issue of orthopaedics, I have been told by several people that they have been waiting for up to four years for treatment. People are put on a waiting list for the waiting list, so to speak. When the HSE representatives talk about reducing waiting lists, are they talking about one list or all of the other lists along the way?

Jillian van Turnhout (Independent)
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I welcome Mr. O'Brien and his team. The service plan is essentially about delivery of services. While I welcome what was said about the mental health budget and the ring-fencing of the €35 million, what reassurance can we be given that the service plan for the mental health sector will be implemented this year? Has the recruitment of staff allocated under the service plan started? We will be at the end of the first quarter within a few weeks. Last year many of us asked questions about this throughout the year and were constantly told that the staff would be in place "within the next few months" but they were not in place by year end. I am very concerned about this because the target for the child and adolescent mental health services is that no-one will wait more than 12 months for an appointment. A year is a very long time to wait for a first appointment for a child or an adolescent experiencing mental health difficulties. All too often I am hearing of cases where a child is waiting nine months, is given an appointment but is then told he or she is with the wrong specialty. The child then goes to the back of another queue. So, while the target of less than one year has technically been met, the child's needs have not been met.

I am also very concerned about the waiting lists for those suffering from pre-natal and post-natal depression. The birth of a new baby is supposed to be a time of joy but women are being told they will have to wait nine to 12 months before they can access expert mental health services. The weeks and months following birth are the critical time for bonding with one's child and in that context, I am very concerned about the delays in that area.

We have had good discussions in this committee about the child and family support agency and we await the legislation. However, I am reminded of the warning in tube stations in London to "mind the gap". We are in a "mind the gap" phase now, or a transition period. All of the services are currently under the auspices of the HSE and all of the accountability for them rests with the HSE. I ask the witnesses to clarify whether the CEO designate of the new agency reports to the HSE at present. The main objective listed under the child and family support services is child protection but child and family support is about much more than just child protection. I would like to see references to other outcomes for child and family services. The other mind the gap concern I have relates to the transition period between childhood and adulthood.

On the issue of the money following the patient, the witnesses spoke about hospital groupings but have they considered patient groupings, such as children with life-limiting conditions? This is a very specific grouping of children for whom a money follows the patient model could be initiated very quickly. This is what their parents want, it would be good for the children and could save us money in the longer term. Has any consideration been given to this?

Robert Dowds (Dublin Mid West, Labour)
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Go raibh maith agat. I welcome Mr. O'Brien and the staff from the HSE and acknowledge that significant progress has been made. It is important that I say that before I go ahead and raise various issues of concern. I find it very difficult to communicate with the HSE because it is not clear whether responsibility for certain things lies with the executive or with the Department of Health. In that context, some of my questions might be better directed to the Department of Health than to the witnesses before us but I ask them, in so far as they can, to answer them.

To what extent is progress being made to reduce the cost of drugs, and generic drugs in particular, to the health service? There seems to be enormous room for savings in that area.

To what extent have we moved from the position where ambulances have to wait for many hours outside hospitals because they cannot recall the trolley that has gone into the hospital? The problem was particularly acute at one stage at Beaumont Hospital so to what extent has that issue been addressed?

I hear anecdotal comments from health workers about continued waste. I have more than one example but I know of a person working in a blood clinic in one of the leading Dublin hospitals being asked to take blood from the same patient multiple times when once would do, leading to waste of that person's time, inconvenience to the patient and the cost involved. To what extent have improvements been made in that area?

I am sure the next issue also involves the Department of Health. When I examined the budgetary figures, the hardest Department to follow with regard to spending was the Department of Health. Will there be moves to make the spending of money more transparent? To compare with the Department of Education and Skills, it is much easier to follow in that Department where money is being spent. Such an exercise would be useful.

Regina Doherty (Meath East, Fine Gael)
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I apologise for not being here for the first part of the presentation as I had to be somewhere else. I appreciate the witnesses coming here this morning. I would like to be associated with Deputy Maloney's comments. As politicians both here in committee and in the media we are nearly always very critical and it is really nice to see a change management programme which evolved last year having such a successful outcome. I congratulate the witnesses on that. I am somebody who is genuinely interested in the delivery of health services but I am new to it. Considering the change management done by the wider team in the Department of Health and the HSE over the past year, there have been massively improved outputs, and all while we are losing staff and money. It is a credit to everybody here and I thank the witnesses for that.

The question I have is not about the service plan as the issue is not in the plan. Will the witnesses comment on the umbrella of health and well-being programmes? Do they see any benefit to extending the remit of the pharmacy sector, particularly around proactive measures regarding community services in the health and well-being sector? It would be great news if this was already done. I have a concern that since we increased the dispensing rate - I accept our Government has done this - people are self-medicating and going into pharmacists on a weekly and monthly basis but leaving items off their list without fully recognising what they are doing or the impact on their health. Is there a benefit in employing, empowering, asking, engaging or paying the pharmacy sector to be more involved? Are there any plans afoot in that regard?

Mr. Tony O'Brien:

Deputy Fitzpatrick's questions were specific to the Louth-Meath hospital group. At the end of last year we put in place some change management arrangements for that group of hospitals and in the intervening period, we have seen some significant improvements in the access position of the hospital, particularly with trolleys. Our Lady of Lourdes Hospital was a facility that would keep a person awake at night because of some of the 8 a.m. trolley counts but we have seen significant improvement there. The Louth-Meath hospital group will form part of a wider group in the development plan, and one of the purposes of those groups is to give devolved decision-making around the appropriate distribution of services between hospitals rather than issues always being decided at the centre. I know the hospital or group management team for this are examining the appropriate distribution of services across the available sites. Although that will progress, I do not have any information that I can share today, unfortunately, other than recognising there has been some early benefit and a significant degree of ambition by the local management team to continue that. I am confident that will happen.

There was a question on the ambulance service investment, which is a very important area of development. This is particularly pertinent with regard to intermediate care vehicles, which enable a much more responsive and dynamic flow. There is also the centralisation of control, which has significant benefits. There was a question on the ongoing occasional problem of ambulances being delayed because of issues in accident and emergency departments. It has not yet gone away but one of the reasons for the investment in intermediate care vehicles is that sometimes there are problems of egress and access in the same hospital. Beaumont Hospital was mentioned as an example. At times, it would have ambulances held seeking to get in patients while at the same time being unable to obtain transportation services to get patients out who would be going to a referring hospital or to another place of care. The intermediate care vehicle strategy is a central part of that process and it will, in turn, speed up the general turnover within a hospital and make accident and emergency departments more effective. Investment in ambulances and intermediate care vehicles is vital to the overall efficiency, and it is a particular issue in some of the big Dublin hospitals.

Robert Dowds (Dublin Mid West, Labour)
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Could Mr. O'Brien explain what he means by intermediate care vehicles? Are they simply cars to bring people who can easily get in or out of them?

Mr. Tony O'Brien:

Such a vehicle looks like an ambulance but it is not a first responder ambulance. It would be a slightly larger ambulance vehicle which can take two patients and which is attended by paramedics but not advanced paramedics. It is not a first responder type of vehicle but it is able to provide a good standard of care as patients move between hospital settings.

Robert Dowds (Dublin Mid West, Labour)
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Okay.

Mr. Tony O'Brien:

They will be a feature not just in Dublin but in other places, such as the mid-west and so on.

Jerry Buttimer (Cork South Central, Fine Gael)
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With regard to the centralisation of the ambulance control centre, what is the benefit of that in Cork, for example, where it is currently on Kinsale Road? The despatcher may send an ambulance to Clarke Road or Kent Road, so what sort of technology will help the ambulance, such as Sat Nav or directional operations? Has that been addressed?

Ms Laverne McGuinness:

By the end of the year there will be a centralised control centre nationally, which will be manned from two sites, Tallaght and Ballyshannon. It will be as the Chairman described and like a Sat Nav for the country. The centre will know where every vehicle is at any time, and if a vehicle could be despatched to a location. It will provide visuals to facilitate more efficient use the system. This is in use in the UK and we are at an advanced stage of procurement for that.

Mr. Tony O'Brien:

The primary care posts are spelled out in appendix 2 on page 22 of the service plan, with details of regional distribution, funding and so on. We intend to progress those on the same basis I referred to with regard to mental health. Last year, there would have been challenging interplay between the decreases and increases, and we are setting that to one side this year in order to have them progress.

I will ask my colleagues to come back to the issue of medical cards. I am sure Mr. Burke is grateful for the kind remarks about the response. I will ask Dr. Carroll to respond on the issue of rehabilitation services, as mentioned by Senator Crown. Dr. Carroll is a specialist in rehabilitation medicine. I will ask Ms McGuinness to respond on the issue of the legislation for information sharing, which is part of the medical process.

With regard to the child and family support agency, the position remains that child and family services are currently fully integral to the HSE. Mr. Brian Kirwan is the acting national director for child and family services within the HSE. We took a decision, in consultation with the Department of Children and Youth Affairs, that it would be advantageous to the process of establishing the child and family support agency to allow Mr. Gordon Jeyes to focus on his role as the chief executive designate of that agency while working with and being integral to the HSE services.

Jillian van Turnhout (Independent)
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Who is reporting to the Oireachtas?

Mr. Tony O'Brien:

The form of governance line is from me to Mr. Brian Kirwan and Mr. Gordon Jeyes is available to us as and when needed and is constantly involved in the process. Senator van Turnhout referenced the issue of boundaries. A drawn out process of transition is not as advantageous as a speedy one. In order to assist that, it was thought appropriate that Mr. Gordon Jeyes should have the opportunity to focus on being the CEO designate of the new agency. It gives us a greater opportunity to clear all the many practical issues that have to be dealt with when creating the environment.

Jillian van Turnhout (Independent)
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So he is reporting to the Minister. I am just trying to-----

Mr. Tony O'Brien:

He will report to the Secretary General of the Department of Children and Youth Affairs.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is the witness happy that the negotiations on the new agency are progressing and that the relevant personnel and resources are moving in tandem?

Mr. Tony O'Brien:

There are obviously a number of strands to the process of disaggregating a set of services which were originally imbedded in 11 health boards. As a result there are complexities around identifying personnel and putting in place appropriate systems. The new entity will operate off a number of shared services together with the HSE and we are creating that environment but there is a significant team involved in ensuring these things progress. Does Mr. Brian Kirwan wish to say anything?

Mr. Brian Kirwan:

As Mr. Gordon Jeyes mentioned last week, there is an oversight group which is chaired by the Secretary General of the Department of Children and Youth Affairs. In that respect it is examining all aspects of the project plan to bring about the transition in as simplistic a way as possible.

Mr. Tony O'Brien:

It is also worth stressing that we are conscious that while certain services related to children will migrate to the agency, the HSE will still be a very significant provider of children's services and will need to be fully in compliance with Children First and will need a lead in relation to children. It is a carefully sequenced extraction process. We would not want the view to develop that the HSE is no longer in the child care business because it is. The focus of child protection is appropriately moving to the new agency but the HSE will still provide a vast range of services to the benefit of children and needs to be appropriately organised for that. We have someone working on this process.

At this stage we are preparing for the full roll-out of money follows the patient. In that context we are not piloting any new areas. We will be seeking to move swiftly in line with the publication by the Department of Health two and a half weeks ago of a survey strategy and discussion paper in regard to money follows the patient. We will be seeking to move wholesale towards that in shadow form and then in full form as quickly as practical thereafter and there will be benefits that arise from it. Not every type of health service will be amenable to money follows the patient. That will emerge as we go through the process.

In terms of the cost of drugs, there are a number of key issues here, one of which is legislative in terms of reference pricing, sometimes referred to as reference pricing 1 and 2. The full benefit will flow in due course from reference pricing. At present we have a medicines management programme in place which will address also the issue of how best to interface the pharmacy sector in this issue. We know that our rate of generic prescribing by comparative standards is very low and we also know that there would be a significant economic benefit if that rate were to be increased and the medicines management programme is focused on that. Reference pricing would add to the value of that but there is significant to be obtained even in advance of that legislation.

On the issue of waste, I am sure there is no limit to the number of individual examples of less than ideally efficient practice. The clinical programmes and other measures are in place to draw attention to these. There is a constant focus on it but in an organisation of 100,000 people, unfortunately there will always be instances where there is room for improvement. We will continue to focus on that. I am sure the example used is a clear one.

In terms of clarity of funding flows, there is no doubt that the health sector is by its nature a complex funding flow environment by comparison with any of the other mainline Departments. We are moving towards a governance structure in accordance with the HSE governance Bill, which is currently under discussion, which will see us move to a focus on care groups rather than regions with the appointment of directors for acute, primary, mental health, social care and health and wellbeing. We will be organising our budgets in that way with a view to bringing greater clarity and money follows the patient will also add to that. I will ask Ms Laverne McGuinness to speak to the issue of medical cards.

Ms Laverne McGuinness:

On the of issue medical cards Deputy Sandra McLellan raised a number of queries one of which was in regard to the sharing of information between the Department of Social Protection, the Revenue Commissioners and ourselves. Anything we do will be done in consultation with the Data Protection Commissioner. That office is involved in the process. The National Adult Literacy Agency, NALA, has been involved in the redesign of the medical card application form and continues to be involved to review it.

The Deputy asked about the discretionary medical card. Such cards are issued only for a period of 12 months. They are reviewed after that period and if still warranted they will be reissued. In some circumstances a GP visit card is issued. The full circumstances are taken into account. The medical officers have been put in place to ensure a full medical assessment takes place. A person's finances are also taken into account as it is basis on which a person gets a discretionary medical card. The threshold is much higher than the normal threshold for applications. We have a procedure in place in respect of the discretionary medical card and we have had it analysed and assessed. Our probity and also the Government require us to review the discretionary medical card after a period of 12 months. If warranted, it will be reissued. In some cases a GP visit card is issued where that is considered to be appropriate in line with our governance. We have standardised it by putting it into the HSE Primary Care Reimbursement Service, PCRS, whereas it had been localised prior to that.

Sandra McLellan (Cork East, Sinn Fein)
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On the discretionary medical card, when it comes up for review the person is issued with a GP card and has to go to the trouble of getting all the information together again and it takes weeks to get the discretionary card back.

Ms Laverne McGuinness:

Once we get the application it is processed within 20 days. That is the target we have set. There are nine discretionary medical cards waiting to be dealt with.

Sandra McLellan (Cork East, Sinn Fein)
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With regard to the discretionary medical cards for cancer patients, the whole circumstance of 12 months' human cost, even if one is above the threshold, is certainly not taken into consideration. That is one issue that needs to be examined.

Ms Laverne McGuinness:

There are cases where patients will get it for 12 months and it will be renewed for another 12 months up to a period of three years. There is not a cut-off if the individual circumstances warrant it. That is the reason we have the medical officers involved in the assessment. It is not black and white; a clinical assessment is taken into account, so it can be up to three years, year on year.

Mr. Tony O'Brien:

I can bring in Dr. Carroll and then I will come back to the issue of mental health.

Dr. Áine Carroll:

I thank members for their questions, which show a patient-centred attitude towards health services. I also thank members for their comment on the work being done to implement significant change at a time of financial hardship. I acknowledge the work of the front-line staff in implementing significant change, the benefits of which we are beginning to see. I thank Senator Crown for raising the issue of rehabilitation medicine, a subject very close to my heart. In the rehabilitation medicine programme there is a plan to develop managed clinical networks in the four regions as they currently stand. I am glad to report that five rehabilitation medicine consultant posts have just been approved in the consultant appointments committee and I hope we will soon advertise for those posts. There will be an extra ten beds staffed at the National Rehabilitation Hospital and although in terms of specialist inpatient rehabilitation beds that still falls significantly short of what is required for the population it is a significant development. With the new rehabilitation medicine consultant posts going into the regions the intention is that there will be a development of four inpatient and ambulatory units for the management of neurological and other disabling conditions which will be an excellent development. It is likely with the work being done to look at the development of major trauma centres that there will be an increased need for specialist inpatient and outpatient and, obviously, community services, as the sustaining services are incredibly important.

Moving on to deal with the questions about ambulance waiting times and trolleys, a group of clinical care programmes is looking specifically at the area of unscheduled care. We are working closely with the special delivery unit, SDU, and also with my colleague, Mr. Colm Henry, who is the national lead for the clinical directors.

Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise to the delegates but there is a vote in the House.

Jerry Buttimer (Cork South Central, Fine Gael)
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I apologise to the witnesses for the delay. It is now just a two-hand reel with Deputy Ó Caoláin and myself.

Dr. Áine Carroll:

I had just finished commenting on the developments through the rehabilitation medicine programme and the very welcome development of the regional inpatient and outpatient rehabilitation units. Members asked about ambulances and trolleys. A lot of work is being undertaken to deal with the issue of unscheduled care. Trolleys are just one small component of the patient journey through unscheduled care. The HSE, the special delivery unit, SDU, the clinical directors, the RDOs and the hospital group chief executive officers are working together in an examination of all aspects of unscheduled care. The likelihood is that in the next year or so we will be looking to develop a collaborative approach to the management of patient flow right from front of house to discharge planning and to a plan for maintaining individuals in the community so that they are not readmitted to the acute hospital system.

From the point of view of health and well-being, a new preventative programme to deal with chronic disease is being initiated. I have just signed off on its objectives and aims. It is important to emphasise that prevention is a very important part of all the clinical care programmes. Pharmacists have a very important role to play with regard to unscheduled care and health promotion. It is interesting to note the developing and important role of community pharmacists in unscheduled care in other jurisdictions.

That is certainly a model that we will be exploring in the next 12 months.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Dr. Carroll.

Mr. Tony O'Brien:

On Senator van Turnhout's comments on mental health, I acknowledge the work that Dr. Brendan Doody is doing as director of child and adolescent mental health services and also to recognise that many of our standards relate to graduated improvement rather than the ideal end state. I was reminded the other day, by the Northern Ireland Minister for Health, Social Services and Public Safety, Mr. Poots, that Bevan, founder of the National Health Service in the United Kingdom, stated that health services should always be changing, always be improving and never be satisfied with where they are. At this time, that is a reasonably good point of which to remind ourselves.

There is a clarification on discretionary medical cards and I will ask Ms McGuinness to give it.

Ms Laverne McGuinness:

In clarification of Deputy McLellan's query, the majority of discretionary medical cards are issued for up to three years.

Jerry Buttimer (Cork South Central, Fine Gael)
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We have covered nearly all of the questions.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Is the Chairman on the closing path?

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I would raise two brief points, for fear anyone would think that Deputy Kelleher had a monopoly over matters parochial. I noted when Mr. O'Brien read out the small hospitals framework list that there was a glaring omission, and I am deeply upset. Could he go back on that for a moment? What has happened to the former Monaghan Hospital, the place of my birth? It did not appear on his list and I am deeply concerned.

As a second and last question, regarding the two by €35 million, can we be assured that this €70 million is additional to the budget for mental health services and it will be particular to the ongoing roll-out and underpinning of A Vision for Change?

Mr. Tony O'Brien:

In reply to Deputy Ó Caoláin's last question, the answer is "yes". I can give the Deputy a categoric assurance on that. When Senator van Turnhout asked earlier how we can provide assurance that these posts will be put in place, I should have stated that the assurance comes in the form that we are not waiting to see the relevant number of exits but instead are proceeding in advance of that and are taking a calculated risk that we will fall short of our overall employment control framework, ECF, reduction in order to achieve this. Obviously, we are concluding the recruitment of the outstanding posts from the list for 2012 before commencing the recruitment for 2013 in order to avoid any confusion that might pertain otherwise.

Technically speaking, Monaghan is not part of the list identified under what I referred to as the HIQA Ennis-Mallow recommendations. That is not to say that it is not a small hospital or that we will not seek to develop services there appropriately in the context of the small hospitals framework, but I------

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Recently it had an unannounced HIQA inspection. It clearly comes under its ambit.

Mr. Tony O'Brien:

All hospitals and all services funded by the HSE are subject to HIQA inspection, but the hospital is not one of those encompassed by the Ennis-Mallow recommendations, which is what the small hospitals framework is primarily designed to address. That is not to say that all small hospitals are in that and that other hospitals are, therefore, not classified as small or important. That is the clarification as to why I did not mention Monaghan in that list.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Obviously, it is very important. We all agree on that.

Jerry Buttimer (Cork South Central, Fine Gael)
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I have a question in the context of this week's newspaper reports on dietary requirements and the procurement of foods within the Health Service Executive and hospitals. Having worked in a hospital as a porter while going to college, I am aware of the dietary requirements and the types of meals being provided. Are we driven by cost, nutrition or a combination of both? Apart from patients' dietary requirements, what is the overriding philosophy on the meals provided to them in hospitals?

Mr. Tony O'Brien:

The Chairman mentioned the newspaper reports. If I might use the phrase, I think they themselves made something of a meal of it. Each year the HSE spends approximately €32 million on food product expenditure. Some 73% of that represents fresh food product such as fresh meat, poultry, pork, bacon, fish, etc., fresh fruit, vegetables, dairy products and fresh bread. The standard sought from tenders is that they should reach at a minimum the An Bord Bia quality assurance programme or an equivalent quality assurance scheme. Some 20% of it represents ambient or dried products, which would include cereals, pasta, preserves, beverages such as tea and coffee, cooking products, flour, grains, etc., and 7% represents frozen food products supplementing fresh produce. Some 4% would include products such as ice cream, poultry and frozen vegetables, which also carry nutritional value. The remaining 3% refers to processed food, which would include such products as were the subject of that newspaper report - pizza, sausage rolls, burgers, etc. Therefore, approximately 3% of the total food purchased annually is in that category. The contract that was referenced relates to HSE west and nine counties, and the food there would not only be for patients but for staff and visitors.

In a rounded sense, while the HSE, in common with other health promoting entities, would seek to encourage all to minimise their individual consumption of processed foods for a variety of reasons, it still remains the case that there is a requirement to provide persons with a degree of choice and an ability to make decisions for themselves. To put it in context, while one might have expected that we were force-feeding burgers and sausage rolls to the entire country, the total procurement in HSE west would amount to no more than approximately 30 burgers a day or no more than approximately 18 frozen pizzas a day which, in the context of the numbers we feed, as I think the committee will agree, is very small.

The other point is that many, in a point in their lives, become long-term residents of a HSE facility and we would not wish to be placed in a position of being directed to say to them that they will never again be able to enjoy in an appropriately informed way some of the foods that have been part of their nutritional lives, be that the occasional undesirable battered sausage or battered cod fillet. We seek to provide choice. All resident inpatients have a choice menu. Where it is appropriate for their particular circumstances, dietary advice is given. We seek to promote choices that are healthy and balanced. It is not unreasonable for 3% of the food to be in that category.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. O'Brien for the clarification. If one were to read the article and listen to the commentary, one would be of the view that all one is getting is processed food and undesirable dietary elements.

Regina Doherty (Meath East, Fine Gael)
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What household in the country could attest? I have four children at home and I am embarrassed to say that the processed food that comes into my house makes up a great deal more than 3% of our food.

Jillian van Turnhout (Independent)
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Can I return to the issue of the child and family support agency? I seek clarity. In the absence of legislation, Mr. Brian Kirwan is in charge of child and family services. Does responsibility for addressing the concerns raised in the recent HIQA report lie with Mr. Kirwan and not Mr. Gordon Jeyes? I want to be clear. I am confused on this new agency. I accept it is a transition period but children will fall between this gap. I am concerned that there would be clarity.

Mr. Tony O'Brien:

For unavoidable doubt, until the agency is established, the responsibility lies with the HSE, in legal terms with myself, and that is delegated. The appropriate delegation orders are in place for Mr. Kirwan. Mr. Jeyes remains an important part of the overall architecture-----

Jillian van Turnhout (Independent)
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Absolutely.

Mr. Tony O'Brien:

-----for having been the director in place for a considerable period of time. He will, as requested, deal with issues in the public domain where he is able to bring particular clarity to matters, but the accountability lies with the HSE until the agency is established.

Jillian van Turnhout (Independent)
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I thank Mr. O'Brien.

Jerry Buttimer (Cork South Central, Fine Gael)
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Did Senator Colm Burke want to make a comment?

Colm Burke (Fine Gael)
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No.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank everybody most sincerely for being here. I want to put on record, at a time when we hear a great deal of criticism in the House, on the public airwaves and in commentaries, that the staff of the HSE are always courteous to me, as Chairman and as a Member of the Oireachtas, and everybody here. They are efficient in their replies. We might not like the replies on occasions but the replies, unlike in the case of other agencies, come back promptly. In particular, I thank Mr. Paddy Burke of the medical card section for his replies. He has been courteous to and efficient with members of the committee and the Houses. I thank Mr. O'Brien's staff most sincerely for the work that they do. I thank, in general, the RDOs and hospital management staff and thank most sincerely, if I may, the HSE staff who are not in the public eye and who deal with queries from Members of the Oireachtas and from officials.

The HSE brand gets much bad press and while some of it is justified much of it is not. The staff is a credit to it and I thank sincerely those on the front line who have introduced reform and who work in difficult situations. On behalf of the committee I thank the witnesses for their engagement this morning. I ask them to please convey to their staff at various levels that we are appreciative. We do not have an adversarial and combative role; we are here as legislators and the witnesses have a job to do. I hope the staff recognises that we value the input they make at all levels and in all aspects of the service. I thank Mr. Ray Mitchell for liaising with us.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Do not overdo it.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the members for their patience.