Jerry Buttimer (Cork South Central, Fine Gael)
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I welcome everybody and thank members for attending. I remind all Ministers, members, guests and officials that mobile phones should be switched off as they interfere with the broadcasting equipment and the work of staff even if they are turned to silent mode. I welcome to our quarterly meeting the Minister for Health, Deputy James Reilly; the Ministers of State, Deputies Kathleen Lynch and Alex White; Dr. Fergal Lynch, Mr. Paul Barron, Ms Bairbre Nic Aongusa, Mr. Paul Howard and Mr. Larry Reilly from the Department of Health; and from the HSE, Mr. Tony O'Brien, deputy chief executive and director general designate, Ms Laverne McGuinness, Mr. Stephen Mulvany, Mr. Barry O'Brien, Dr. Aine Carroll, Mr. Ray Mitchell, Mr. Paul Connors and Mr. Thomas Byrne. They are all very welcome and I apologise for the delay at the beginning, as we had some private business to be attended to and it was important for us to sort it out. I do not propose to give an opening address as it is important for us to get to the heart of the matter.

Before commencing I remind witnesses and members that witnesses are protected by absolute privilege in respect of their evidence to the committee. If witnesses 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 given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice and ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

Members have expressed concern about the situation with regard to non-consultant hospital doctors, and I know Mr. O'Brien has a briefing note on the matter and may reference it in his opening remarks. The Minister and Mr. O'Brien will have five minutes to speak and Opposition spokespersons will have five minutes-ish. Non-spokespersons will have four minutes.

James Reilly (Dublin North, Fine Gael)
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I might take advantage of an "ish" as well, if the Chairman does not mind.

Jerry Buttimer (Cork South Central, Fine Gael)
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I was hoping people would be fatigued after three days of public hearings, but I guess they are not.

James Reilly (Dublin North, Fine Gael)
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You energise us all.

I thank the Chairman and members of the Oireachtas Joint Committee on Health and Children for the invitation to discuss health service issues. I am accompanied by the Ministers of State, Deputies Kathleen Lynch and Alex White, and together with my senior officials we will provide as much information and clarification as possible. I welcome Dr. Fergal Lynch, the deputy Secretary General at the Department, and Mr. Tony O'Brien, the director general-designate at the HSE.

At the outset, I thank the Chairman and committee for their hard work, dedication and commitment to progressing the protection of life during pregnancy Bill 2013. The committee has just completed its oral hearings and will now submit its report to the Government on the content of the Bill. This new legislation takes account of our obligations under the judgment of the European Court of Human Rights, with due regard to our Constitution and to the Supreme Court ruling in the X case. It is still the hope of the Government that the protection of life during pregnancy Bill 2013 will be enacted before the Dáil rises for the summer.

I take this opportunity to update the committee on significant developments in the health services since I last attended in November 2012. Members may recall that I briefed the committee on the publication of Future Health - A Strategic Framework for Health Reform 2012-2015, which sets out the major health care reforms that will be introduced by 2015 as the key building blocks for the launch of universal health insurance in 2016. The new structures are already being established and the actions being delivered in 2013 involve governance changes, the establishment of hospital groups, reforms of the private health insurance market, establishment of a health and well-being framework and the development of a money-follows-the-patient funding model. Newly enacted legislation underpins a permanent risk equalisation scheme which commenced from 1 January 2013. The scheme protects our system of community rating, whereby older and sicker people can buy health insurance for the same price as younger and healthier customers.

Despite significant challenges, especially in scheduled care - primarily, the extended flu season, leading to increased admissions - the implementation of programmes by the special delivery unit resulted in significant progress in improving hospital access targets. By December 2012 there were 20,352 fewer patients on trolleys, with a reduction of 23.6% since 2011; 3,620 fewer adults waiting more than nine months for inpatient and day surgery, a reduction of 98% since 2011; 1,670 fewer children waiting over 20 weeks, a reduction of 95% since 2011; and 4,554 fewer patients waiting over 13 weeks for routine endoscopy procedures, a reduction of 99% since 2011. There has been some rebound because of the extraordinary and prolonged winter. That has seen not so much an increase in attendance at accident and emergency departments but rather an increase in admission rates, up to 17% among the older person demographic. These people were really sick, as intensive care units were full, with all ventilators in use. This was not an experience that was unique to the Republic of Ireland, as it was also evident in the North and in Manchester in the north of England. In order to address this, an allocation of €18 million has been approved by the Department and the HSE to create an intervention fund to aid hospitals in reaching Government targets in scheduled and unscheduled care. The priority is to unblock access and improve the flow of patients through the health system. The Department of Health is preparing a White Paper on universal health insurance, UHI, which will set out details of the UHI model in addition to the estimated costs and financing mechanisms associated with its introduction. A preliminary document on UHI was published last February, setting out progress to date and the major tasks and projects that stand to be addressed throughout 2013 and beyond.

A hospital financing sub-group, established under the auspices of the UHI implementation group, has developed policy proposals on the money-follows-the-patient model. Stakeholder consultation will now be undertaken, followed by the implementation of money-follows-the-patient shadow funding during 2013 in advance of phased implementation of the new arrangements from 2014. The objectives of the new funding model are to achieve a fairer system of resource allocation, drive efficiency in the provision of high-quality hospital services, increase transparency in the provision of hospital services, and ultimately support the move to an equitable single-tier system.

Earlier this month I announced a reorganisation of public hospitals into more efficient and accountable hospital groups that will deliver improved outcomes for patients. This Government decision was informed by two reports, The Establishment of Hospital Groups as a Transition to Independent Hospital Trusts, or the Higgins report, and The Framework for Development - Securing the Future of Smaller Hospitals. The establishment of hospital groups signals a fundamental modernisation of our health system organisation in line with best international practice.

The new hospital groups, each with its own governance and management, have been designed to provide the optimum configuration for hospitals to deliver high quality, safe patient care which is cost effective and guarantees better outcomes for patients. I take this opportunity to thank Professor John Higgins again for all the work he did. I also thank the group that supported him. The framework for hospitals outlines the need for smaller and larger hospitals to operate together, which is intrinsically linked to the formation of sustainable groups. Better co-operation between hospitals will help to maximise the amount of care delivered locally. Hospital groups will secure the future of our smaller hospitals. When the new groups are established, services can be exchanged between sites. This will result in the maintenance of activity in smaller hospitals and will allow them to focus on the provision of care that is safe and appropriate.

Work on the roll-out of hospital groups will begin immediately and will be overseen by a national strategic advisory group and driven by the HSE. Following a rigorous evaluation of each group to ensure it is fit for purpose to function as a hospital trust, legislation will be put in place in 2015 to enable independent hospital trusts to be established, taking account of any changes to groups which may emerge from the review process.

I acknowledge that the Minister of State, Deputy Alex White, and he will expand on this, has successfully put the drug reference pricing legislation through the Dáil. It completed its passage yesterday.

Equally, I wish to mention the Croke Park II agreement. I will not speak in great detail but it is obviously important that a ballot by health care workers is to take place regarding new arrangements that will yield real savings and, we hope, more services for patients. Mr. Barry O'Brien is present and he will address that in a fuller fashion. However, I take this opportunity to thank Mr. Barry O'Brien, Frances Spillane and Fergal Goodman, who were the health team that attended those negotiations on our behalf, on doing such a good job.

Turning to legislation, the legislation to abolish the HSE is complex but will be done sequentially. As a transitional measure, the Health Service Executive (Governance) Bill 2012 abolishes the current board and chief executive officer structure and provides for the establishment of a new governance structure. The Bill is intended to bring greater focus on service delivery and ensure more accountability to the Minister for Health. The national directors will be responsible at national level for the delivery of services in their relevant service areas, such as hospitals, primary care, mental health, social care and health and well-being. They will lead the development of national service plans associated with their sector, manage performance and, in time, develop strategic commissioning frameworks for their areas, as appropriate. The chief financial officer will be accountable for the financial management and performance and for ensuring that the HSE operates within its annual allocation as well as achieving the stipulated income targets. Indeed, due to calendar scheduling, we were due to take that Bill today but could not because this committee was meeting. It has been put back to later in June.

The preparations are proceeding for the development of the new national children's hospital on the campus of St. James's Hospital. New governance arrangements have been put in place to advance the new phase of the project. The National Paediatric Hospital Development Board has been restructured to focus on the core functions of planning, designing, building and equipping the new hospital. A strategic advisory group is being established to provide external advice and expertise to the project. This project will be progressed as speedily as possible, recognising the urgency and priority attached to it together with its scale and complexity.

It is important to reflect on certain key trends within the health sector. Given the continuing severe economic constraints facing the country, increasing numbers of the population are eligible for medical cards and decreasing numbers are opting for private health insurance. Key challenges will be to continue to ensure that resources secured are carefully and appropriately targeted to deliver more efficient and effective ways of providing services. This can be seen in the acute hospital sector where a gradual decline in inpatient admissions is being more than offset by a rapid rise in day cases. Further improved treatment models are leading to better outcomes, as evidenced by continuing improvements in cancer survival. In the case of stroke, the new stroke programme has resulted in saving one life every week and pre-empting the need for three people per week to go into long-term care.

Over the last decade Ireland has achieved a rapid improvement in life expectancy, increasing from nearly one year below the EU average to just above it. Much of this increase is due to significant reductions in major causes of death, such as circulatory system disease. The number of people in older age groups is beginning to increase significantly. Approximately 20,000 more people are being added to the over 65 year old age group each year. The numbers will double in the next 25 years to over 1 million people, with the largest proportional increase in the over 85 year old category. This is good news. However, it will have implications for our health service.

In the area of health determinants, lifestyle factors such as smoking, drinking, obesity and lack of exercise continue to be issues which have the potential to jeopardise many of the health gains achieved in recent years. The type and volume of services that must be delivered by the HSE across all health areas and through a variety of demand-led schemes and preventative services will increase in cost and complexity in tandem with the factors that affect the health of the population and the performance of the health system.

Healthy Ireland, a new Government framework for action to improve the health and well-being of people living in Ireland over the coming generation, was launched in March 2013. This framework sets out a broad range of actions that will be undertaken by Government Departments, public sector organisations, businesses, communities and individuals to improve health and well-being and reduce the risks posed to future generations. Healthy Ireland has been developed in response to rising levels of chronic illness, lifestyle trends that threaten health and persistent health inequalities. The framework is based on evidence and experience from around the world which shows that in order to create positive change in population health and well-being a whole of government approach and the involvement of local communities as well as all of society are required. The Department of Health will be leading across the Government on this national agenda.

I will bring regular progress reports to the Cabinet committee on social policy and I will also keep the Oireachtas Joint Committee on Health and Children fully informed. The Cabinet committee on social policy will oversee progress on Healthy Ireland and provide leadership and accountability for its implementation. Implementation of the framework's 64 actions will be subject to rigorous planning, reporting and evaluation. Healthy Ireland is designed to bring about real, measurable change and is based on an understanding of the determinants of health and well-being in a person's life - economic status, education, housing, transport and their physical environment. It is about each individual sector helping to improve health and well-being, multiplying all efforts and delivering better results. It will result in people living in Ireland being supported to make healthier choices in their daily lives in health promotion and sustainable environments.

The core of everything we are doing is evidence-based to improve outcomes for patients. As long as that remains to the fore of our minds in all we do I believe we will do right by patients. If we veer from that, we will lose our way. I and my ministerial colleagues will be happy to answer the committee's questions on these and other issues.

Jerry Buttimer (Cork South Central, Fine Gael)
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Thank you. I also thank the Minister's officials for their courtesy to our committee. We have received apologies from Deputies Mary Mitchell O'Connor, Regina Doherty, Ciara Conway and Peter Fitzpatrick. I invite the Ministers of State, Deputy Kathleen Lynch and Deputy Alex White, to feel free to intervene and make a contribution should they wish.

On the scheduling issue, I apologise to the Minister and to the Opposition spokespeople. It is unfortunate there is a scheduling clash between our committee meetings and the Department of Health's Bills in the Dáil on a Thursday. I propose that we write to the Chief Whip again to inform him that on a Thursday morning this committee deals with health and children issues at 9.30 a.m. and that any scheduling of Bills dealing with health and children should be for a Tuesday and a Wednesday. Is that agreed? Agreed.

I call Dr. Tony O'Brien, director general designate of the HSE. I thank his staff and officials for their courtesy to all Members of the Houses of the Oireachtas and I thank the staff who work on the front line for their tremendous work in challenging times. It is important to put that in context when one hears unfair criticism of people who work in the health sector. The people who work in our hospitals, in the front-line services and, indeed, people who work in back offices and are not seen, are working in challenging times. I thank them for that. I also thank those who engaged in the labour relations process last week. I thank Mr. Barry O'Brien and the unions for engaging and for putting our health system at the core of what we are doing. I call Dr. Tony O'Brien.

Mr. Tony O'Brien:

For the avoidance of doubt, Chairman, I am not a doctor.

Jerry Buttimer (Cork South Central, Fine Gael)
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My apologies. I promoted you.

Mr. Tony O'Brien:

I thank the Chairman and members for the invitation. The committee requested information and replies on a number of specific issues prior to the meeting and it will have received a written response to these issues from the HSE and the Department of Health together with briefing material on the HSE March performance management report, the April Vote return, medical cards and NCHDs.

I would like to update the committee on a number of key issues, the first being service plan activity. At the end of March, there were 100,740 emergency admissions in the acute system which is 3,518, or 3.6%, higher compared to the equivalent period in 2012. Some 62.6% of all attendances at emergency departments were discharged or admitted within six hours and 77.5% within nine hours. Up the end of March, 41,050 elective inpatients admissions and 202,425 day case procedures were provided - a total of 243,475 compared with 247,682 for the same period in 2012 which represents a 1.7% downward variance.

Some 90.7% of all adults on the elective waiting lists are waiting less than eight months and it is intended that no adult would be waiting for more than eight months for an elective procedure by the end of this year. Some 85.1% of all children on the elective waiting list are waiting less than 20 weeks. Again, it is intended that no child will wait more than 20 weeks for an elective procedure by year end.

The number of people covered by medical cards by the end of March was 1,864,320, an increase of 6% on the same time last year. The number with GP visit cards was 128,589, an increase of 1.7% on the same time last year. Some 96% of properly and fully completed medical card applications have been processed within the 15-day turnaround time, which is ahead of the service plan target of 90%.

Turning to finance, the HSE is reporting a year to date gross deficit of €26.7 million to the end of March 2013. In Vote terms, the largely cash based Government accounting basis, to the end of April, there was a €5 million surplus on net current Vote expenditure which obviously is quite a different picture to this time last year. Based on the first quarter data, the HSE is not flagging any new concerns or risks beyond those which were clearly set out in the national service plan for this year, as approved by the Minister on 9 January, and within the regional and hospital group service plans, which were published in February. These risks remain and principally include the overall scale of savings required in PCRS at €353 million. First quarter performance against cost saving plans in this area has been very positive but there will be a need for us to be vigilant on this and to develop contingency measures in the event that they are needed to address potential shortfalls which would otherwise occur. These contingencies are currently being scoped.

We have discussed the Croke Park agreement before and we have a reliance on Croke Park II for €150 million. The need for validation of the budget reduction assigned to the HSE once there is a definitive outcome to the Croke Park II process to which it relates remains. It is also important to note that anything which would jeopardise the current flexibility which is available under Croke Park I would create risks across most of the areas of cost saving set out in the service plan.

In terms of private health insurance income, both the €104 million accelerated income and the €60 million assigned in the service plan against new legislation, the plan references the need for us to work closely with our colleagues in the Department to ensure the accelerated income does not reverse in 2013 coupled with ensuring that the new private income legislation is enacted by July. The HSE's plan addressed €20 million of accelerated income via improvements in our collection performance and that is being progressed. There is current ongoing engagement at senior level in regard to the proposed legislation and the balance of the accelerated income.

The general scale of the overall challenge within the remainder of our community and, in particular, hospital services is also an issue. The rebalancing of hospital budgets in 2013 has ensured that hospitals have been given budgets which are related more closely to their costs in 2012. However, as indicated in the plan, it has not been possible to provide for the full amount of 2012 costs and hospitals are, therefore, required to safely deliver cost savings of an average 3.5% in addition to further cost savings to offset any emerging or additional cost pressures in 2013 and that is being closely monitored.

However, it is clear that the end of March deficit of €27 million, in the absence of significant delivery on our cost containment measures and the expected additional control activities, could give rise to a significant level of deficit to year end. The message is that while things are improving, we need to remain constantly vigilant.

Initial control actions in regard to the risks outlined above have been commenced. On the scale of the risk and challenge in achieving financial break even by year end remains significant and will increase in the unlikely event there is an absence of continued and improved flexibility under the Croke Park agreement.

In terms of the fair deal scheme during the months of March and April, the hospital system experienced increased wait times and congestion in emergency departments, mainly due to a significant increase respiratory illness among older patients and an extended outbreak of influenza which came later in the season than would be typical. In the interest of patient safety and quality of care, we took a decision in March to release an additional 400 fair deal beds to assist with the hospital pressures. Usually, 120 long-term care beds are released on a weekly basis for the whole country.

Sunday counts of emergency department trolleys provide a strong indication of the pressures in emergency care likely to be experienced the following week and, therefore, are used as a point in time sentinel, as it were, to make intervention decisions. On Sunday, 14 April, the number of patients awaiting admission in our emergency departments at the 8 p.m. count was so high at 243 that there was significant concern for the safety and quality of care of our patients in emergency departments. Given this situation, it was deemed necessary to immediately move to temporarily pause the normal chronological fair deal placement process and to direct the prioritisation of long-term care beds for qualifying patients in the six Dublin academic teaching hospitals and Cork University Hospital, the hospitals which had the highest number of patients waiting for long-term care at that point. With effect from 9 May, we have reverted to the normal chronological placement in respect of 100 of the 120 fair deals beds released on a weekly basis and full chronological placement will resume on 30 May - in other words relating to the full 120 on a weekly basis.

I will turn briefly to the ambulance service. Members will be aware of the recent tragic death of Vakaris Martinaitis in Midleton, County Cork. On behalf of the HSE, I would like to reiterate and extend our deepest sympathy to the family of Vakaris on their very sad loss. On Friday, 10 May, following a preliminary examination of the facts surrounding this tragic accident, the medical director of the national ambulance service, in line with the HSE incident management policy, commissioned a formal incident review into the manner in which the 999 call received from Midleton, County Cork, at 2 p.m. on Monday, 6 May was managed. The make-up of the review team includes experts in pre-hospital emergency care and primary care from both Ireland and the UK, namely, Mr. David McManus, medical director of the Northern Ireland Ambulance Service, who is the chairperson, Ms Tracey Barron, clinical studies officer at the International Academy of Emergency Dispatch in the UK, Mr. Pat Mooney, the control manager of the national ambulance service in north Leinster, Dr. Mel Bates, medical director, GP out-of-hours service, north Dublin, and Ms Deirdre O'Keeffe, quality and safety directorate, who will support the investigation process.

The review team and the terms of reference have been agreed and NAS representative will liaise with the family on behalf of the review team to keep them informed of progress and ensure they are provided with ongoing support. This formal review, which will be concluded as expeditiously as possible, will fully establish all the facts surrounding the management of this emergency call, including why an available emergency ambulance was initially assigned to the call and then stood down as well as the level of information available to ambulance control about the patient's injuries.

Turning to the medicines management programme recently established by the HSE as a first step to increasing quality access and value in medicines management, the programme has identified preferred drugs for prescribers when prescribing proton pump inhibitors, PPIs, and statins, cholesterol lowering medication for patients. This is the first time the State has introduced a preferred drug initiative. The preferred PPI is Lansoprazole and the preferred statin is Simvastatin. The HSE is asking doctors to prescribe these preferred drugs in order to save money both for patients who pay for their medication and to deliver savings of an estimate €15 million for the taxpayer this year. PPIs and statins account for up to 20% of the HSE's drugs budget.

By switching existing patients to the preferred drug, and by prescribing these drugs for new patients, significant savings can be achieved. Although the initiative was launched only in mid-April, there was positive feedback from prescribers.

The Public Appointments Service, on behalf of the HSE, has recently concluded a recruitment process to complete the new HSE directorate and leadership team. The process leads to a revised HSE management structure, planned in conjunction with a new governance arrangement provided for in the Health Service Executive Governance Bill 2012. Five new posts have been established following a confined Public Appointments Service competition which commenced earlier this year. The following senior health managers have been appointed to the five posts: Mr. Ian Carter, acute hospitals; Mr. John Hennessy, primary care; Mr. Stephen Mulvany, director of finance to mental health; Mr. Pat Healy, social care; and Dr. Stephanie O'Keeffe, health and well-being. They will take up the new posts when the Government's legislation is enacted. The five directors are now directors designate and will participate in the process of designing new structures prior to taking up the posts. In addition, Mr. Thomas Byrne will join the senior management team as chief finance officer, following an open competition conducted by the Public Appointments Service. He takes up his post on Monday, 27 May. The current director of integrated services, Ms Laverne McGuinness, takes up the post of chief operating officer and will assist in safely managing our system through this period of transition. Mr. Liam Woods has taken up the post of national director of shared services. These changes are an important step in the reshaping of the health service and an important part of the journey towards the post HSE era. The make-up of the new team is indicative of the importance of clinical pathways, patient and client care and outcomes to the process of reform in the health service. I and my colleagues are very happy to respond to any questions.

Jerry Buttimer (Cork South Central, Fine Gael)
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I welcome the remarks of Mr. Tony O'Brien and I thank him for the inclusion of the Midleton issue in his remarks. On behalf of committee members, I extend our sympathy to the Martinaitis family on the tragic death of Vakaris and we hope the family will receive answers to its questions.

I congratulate the five senior managers on their appointments. I congratulate Mr. Stephen Mulvany in particular as it is very good that mental health is included. The committee has always made that point and I commend Mr. O'Brien on that. I ask Mr. Barry O'Brien and Ms Laverne McGuinness to make some remarks on the NCHD report briefing document. This was a major issue we discussed at the committee and we were concerned about it.

Mr. Barry O'Brien:

The note sets out the overall approach to NCHD recruitment. It highlights the fact that the HSE recruits approximately 15% of the NCHDs, with all others part of the training programmes. As of 14 May, the vast majority of NCHD posts - more than 90% - are filled normally. We are satisfied that where staffing issues exist, there remain sufficient numbers of agency staff to meet the service needs. In the context of training posts being filled, in the main, service posts that remain unfilled will be met by doctors provided by an agency. We are involved with the postgraduate training bodies and we manage the central recruitment of applications. We advise local hospitals that they can proceed. The committee has previously raised the issue, particularly Senator Colm Burke, with regard to local capacity to recruit. Local recruitment fills approximately 70% of service posts, so that capacity continues to exist. A number of initiatives are ongoing to ensure we have the required number of NCHDs. The specific question of Senator Colm Burke is answered in respect of contractual arrangements. I reassure the committee that we are taking the necessary steps.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will return to the issue during questions.

Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the presentations. At the outset, I congratulate the people who have been appointed to the positions of directors, even though in my contribution during the debate on legislation I said it should have been an open competition. I am definite the successful candidates would have come through the process anyway. I wish them well in their positions, which will be quite challenging.

The following point struck me when Mr. Tony O'Brien was speaking about patient safety on 14 April. We know that seasonal factors cause pressures and pinches in accident and emergency units and admissions to hospitals. It is very alarming when another process must kick into gear because of patient safety to address difficulties in getting people to hospital. I refer to the change in the designation of beds under the Fair Deal scheme. There are major concerns that the Fair Deal system and the provision of beds for people in long-stay facilities is under major pressure and stress. It must be dealt with in the short term and the medium term. Looking at the demographic profile and the ageing population, it will be a major challenge in the years ahead. We are now in a delicate position in which accident and emergency units are dependent on another section giving up its bed designations, which are for vulnerable people, elderly people and those in the later stages of life. They are being shifted sideways for a period until the pressure is off the accident and emergency unit.

Comparing the profile of waiting lists by month and year makes the reduction seem successful. However, looking at December to April, it is clear that the pressure is significant in terms of admissions and treating patients in hospitals. It is a worrying development and the trends are not improving. From December 2012 to April 2013, in every single category, there was an increase in waiting lists. We can take account of seasonal factors such as influenza, but the bottom line is that the trend is beginning to go the wrong way. Major advances were made last year, which I am not disputing, but the alarm bells should be ringing in the HSE and the Department of Health in dealing with this worrying and continuing trend. I know €80 million extra has been put into the special delivery unit to try to deal with it but the fundamentals are very worrying. Perhaps this point can be discussed and elaborated on with regard to what can be done at this early stage of the year to address it.

With regard to the broader debate on the health service and funding, we have had the changes in the development of hospital groupings and the transition to trusts. We talk about free GP care, on which the Minister of State, Deputy White, will bring forward proposals in the next couple of weeks. We are still waiting to discuss how to fund this. While the universal health insurance model will be adopted, we are still waiting more than two years for the White Paper. There is increasing concern that the private health insurance market in the country is in a state of collapse. That will be an underpinning factor in any universal health insurance model. Mr. Colm McCarthy recently published a report on the pressures on private health insurance and we have also been raising the point consistently. There seems to be a view in the Department of Health that the VHI is dictating Government policy on private health insurance. The witnesses can correct me if I am wrong. The Health Insurance Authority, HIA, has made recommendations that have been either summarily dismissed or ignored and certainly not implemented. How long more can we sustain talking about hospital groups, hospital trusts, funding reform and governance structure changes when the basic fundamental that will underpin all of this is universal health insurance? The universal health insurance model proposed by the Minister is based on private health insurance companies providing a suite of care for citizens and competing with hospital trusts to do so. There is no point in beating around the bush; it is in crisis. We need the publication of the White Paper and a mature debate on the private health insurance market and how we will fund the system we are all talking about.

In the Dáil many other Members and I call for more medical cards, swifter action in accident and emergency departments and so forth. However, the one fundamental issue not being discussed, because we have no White Paper, is universal health insurance and how it will be funded. This issue is of particular concern because of the fact that the private health insurance market is in crisis and it is not only me who is saying this. It is a simple fact. The statistics and figures show this clearly in terms of the numbers reducing their premium payments and cover and the numbers who have left the private health insurance market entirely. That profile is increasing, as opposed to decreasing. We talk about stabilisation in the economy and the unemployment figures, but there is no stabilisation in the numbers leaving the private health insurance market. That will have an enormous impact in placing further pressure on the public hospital system prior to implementation of any universal health insurance model.

On the issue of VHI, a recent report states the more the cost of private health insurance cover increases, the bigger the hole in the company's balance sheet and because of the capital and solvency ratio requirements, that hole will have to be filled by the taxpayer at some stage in the near future. This issue must be addressed as soon as possible. As premiums go up, the balance sheet of VHI deteriorates and it will be up to the taxpayer to invest in the company, regardless of what model of universal health insurance is eventually adopted.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy has spoken for seven minutes.

Billy Kelleher (Cork North Central, Fianna Fail)
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My apologies.

Jerry Buttimer (Cork South Central, Fine Gael)
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I am being nice to the Deputy.

Billy Kelleher (Cork North Central, Fianna Fail)
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There are two issues on which I wish to touch before finishing. The issue in east Cork is a very emotive one and I do not want to add to anyone's anguish, as I also know an investigation is ongoing. However, there is genuine concern in communities all over the country about ambulance cover. There is no point in not saying this and I am not just raising the issue because of the tragedies in east Cork where there have been two tragedies and there is concern about the despatching of ambulances. In the context of hospital trusts or groupings, the issue of ambulance cover will have to be examined. People will need to be given comfort because 24 hour cover is being taken away from some hospitals. There is genuine concern in communities, particularly in peripheral and rural areas, about ambulance cover and I ask the HSE to take it on board.

On the issue of medical cards, there was an announcement in the budget that 40,000 cards would be withdrawn from circulation. I must draw attention to the fact that the facility for people to qualify for a medical card on medical grounds is being rapidly withdrawn. There is almost no one qualifying for a medical card on such grounds. I am meeting people who find themselves in this situation on a daily basis and I am sure other Members can say the same. The stated policy, statistics and figures are not reflecting what is happening. Let me give two examples. I met a woman recently who had had a double mastectomy and had been refused a medical card on medical grounds. I also met a person with colon cancer who had been refused on the same grounds. There is a problem in this regard which the Minister must address. I understand the country is under financial pressure, but it is now almost impossible for people to qualify for a medical card on medical grounds.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I will table supplementary questions on the three priority issues I raised, namely, questions Nos. 7, 8 and 9 in the pack, dealing with dental, mental health and audiology services. I also wish to make reference to the non-consultant hospital doctor recruitment process.

Regarding question No.7 and what I believe to be a crisis in dental treatment services, it is very disappointing that in the reply I received to the aforementioned question there is not a single word of acknowledgment that there is any difficulty in dental treatment services, let alone a crisis. It must be acknowledged that we saw advances in dental health and dental treatment services in the early 2000s when there was a marked improvement in services. However, these improvements have been steadily eroded by cutbacks. The Irish Dental Association reports a rapid reversal. I cite from its recent commentary in this regard: "We do not believe the cuts to dental care make sense and will ultimately cost the State more in the long term". How does the Minister respond to the position taken by the Irish Dental Association? We are told that primary care is crucial and cost effective. If so, will the Minister restore the dental treatments previously available to PRSI patients and medical card holders? When one looks at the range of services previously available to these groups, it is alarming to see what has actually been cut.

On mental health services, I refer to an article published in The Irish Times last Friday in which the mental health reform group stated that in 2013 mental health services were still staffed at 24% below the level recommended in A Vision for Change. That is very alarming. I commend the group for its work.

In the context of the commitment to an investment of €35 million last year and this year, I have no hesitation in acknowledging progress in the filling of the promised 414 additional posts. It is very welcome. However, these posts were promised in 2012, with further posts promised to be filled this year. What is the net position in this regard? The reply from the Minister contains a tabular outline of the recruitment of the promised 414 additional staff. However, in the same period, staff have left the service through retirement and for other reasons. I want to know what is the net position, taking into account those who have left the service. According to the HSE's health service personnel census in December 2012, mental health service staffing levels dropped by 12.1% between 2009 and 2012. I welcome the appointment of a new national director of mental health and wish Mr. Stephen Mulvany well in his new role.

Regarding audiology services, I wish to focus on the bilateral cochlear implant service which we still do not enjoy in this jurisdiction. I understand the Minister of State at the Department of Health, Deputy Kathleen Lynch, yesterday met representatives of parents coping with children with severe hearing challenges. The introduction at Beaumont Hospital of the bilateral cochlear implant programme is absolutely essential. When is it expected that the expert report, sought from Professor Gerry O'Donoghue of the University of Nottingham, will be available? When will the Department be in a position to agree to the business plan? Will the Minister commit today to the provision of the required funding? I know that initially it will cost a little more because there will be a backlog to address in terms of those who will require sequential introduction of their entitlement to a second implant. Of course, we will then want to see work commencing on the bilateral approach in terms of the introduction of both implants at the same time. There is an estimated additional initial outlay of some €7 million. Will the Minister indicate that it is his intention to introduce the programme in the context of the budgetary provision for 2014? I appeal to him to do this. I have met many of the parents and some of the children affected and it is tragic that their lives are being impaired because their hearing issues are not being fulled addressed, something children in other jurisdictions enjoy.

On the recruitment of non-consultant hospital doctors, I have heard the reply from Mr. O'Brien, but I wish to know what the position will be in July. I raised this issue at the committee some months ago, at which point I was reflecting concerns already expressed by a number of hospitals.

Is he in a position to tell us what the shortfall will be? How will this affect patient care? I was concerned that the five-page report that we received in addition to the replies did not mention patient care once across the five pages. There are hospitals in which the predicted deficit of NCHD manpower for July will be in the region of 20% to 40%, not 2% as indicated in the response. Maintenance of services in the worst-affected hospitals will be extremely difficult and there is a real and genuine fear among management and lead clinicians in some hospital sites that some services will be impossible to sustain and will, at least for a period, cease.

The HSE centralised applications process does not have the confidence of all hospitals across this jurisdiction. This is a simple fact. The late indiction that local recruitment could get under way, something that had been forbidden up to sometime in the middle of last month, April 2013, was much too late. Remember the doctors who were recruited from India and Pakistan in 2011, when we introduced the emergency legislation; the great majority were not in a position to take up their posts until the month of December, some five months after the shortfall presented. We could be looking at a similar situation, although perhaps not as catastrophic in terms of scale and numbers, but most certainly a number of hospitals, particularly those that do not enjoy the allocation of trainees, experience traditional recruitment challenges. Hospitals such as those in Drogheda and Letterkenny are excluded from the allocation of trainees by the training bodies, which is leaving them at a distinct disadvantage.

Will the Minister address the scandalous issue of the training posts in private hospitals? Will he ensure that large regional hospitals receive a minimum? The regional designation is not a necessity. They are performing the role of a major general facility and have a minimum of 50% trainees, given that 80% of all NCHDs in the country are now said to be in training programmes.

Will the Minister undertake to publish the service level agreements so there is an opportunity for public scrutiny? The members of this committee will have sight of them and will have a understanding of what is involved.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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The presentations this morning were welcome. I welcome also the publication of the hospital group's report last week and I wish to raise a number of questions on it. What is the timescale for the appointment of the chairman of the board in each case? Does the Minister have the dates for the appointment of board members? Will he ensure there is geographical as well as specialist representation on the boards of these groupings? It will be vital to create trust for the boards to operate across the geographical areas of these hospital groups. It would be possible for geographical and specialist representation to dovetail and I hope the Minister will confirm that he will bear this in mind and make appointments on that basis.

The Minister gave a briefing last Tuesday week, but after he left, unfortunately, Professor Higgins was very strong on the question of consultation with stakeholders on this process, including consultation with local communities. This will play an important role in the success of these hospital groups and trusts. Will the Minister outline his position on consultation?

I acknowledge the significant pressures on the fair deal scheme. Mr. O'Brien referred to the recent difficulties. There is a perception of geographical discrimination against applicants outside Dublin and Cork, who are effectively denied access to this scheme for some time. I request an assurance that the scheme is run on a fair basis across the country and that applicants outside Dublin and Cork are not disadvantaged.

The issue of outpatient waiting lists was not covered in any of the presentations, but this is an area that is giving rise to major difficulties, particularly in orthopaedic and ear, nose and throat specialties. There are really long waiting lists for outpatient clinics in regional hospitals, particularly for the initial outpatient appointment. Will the Minister outline the current position and the proposals to deal with the difficulties?

There are 350 children with one cochlear implant who require a second implant. It is hoped that all newborns will get simultaneous implants. Will the Minister confirm that he will make €7 million available to Beaumont Hospital to deal with the backlog in this area? It is very upsetting for parents and the children involved.

Will the Minister give an update on the proposed new children's hospital? Are there indicative construction, commencement and completion dates?

I agree with the point made by Deputy Kelleher on medical cards. I am sure that all Deputies and Senators are aware of the difficulties in respect of medical cards being granted on medical grounds. It is very difficult, if not impossible, to have a medical card granted on medical grounds. This seems to be feeding into the current large number of reviews to be carried out. It is indicated in the review covering letter that the review is by random selection, but it appears to me that those in the 65 to 69 age group are being targeted. This is a group of whom many are marginally over the income limit because of occupational pensions, in some cases very small occupational pensions, but who were granted medical cards on medical grounds for long periods. Many hold cards that are in date up to 2020.

I have had numerous inquiries of late from people who have been requested to provide transport for their relatives.

The relatives of patients who are normally transferred by ambulance, and who actually require ambulance transportation, are now being asked to transfer those patients to regional and Dublin-based hospitals, in particular.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will allow Deputy Catherine Byrne in at this stage because she has to leave shortly.

Catherine Byrne (Dublin South Central, Fine Gael)
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I thank the Chairman and whoever was before me for facilitating me. I will go straight to the questions. I thank the Minister, the Ministers of State and the officials for being here.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy has three minutes rather than ten minutes.

Catherine Byrne (Dublin South Central, Fine Gael)
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I know I do. That is why I am going straight to the questions. I do not waffle.

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

Catherine Byrne (Dublin South Central, Fine Gael)
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I want to follow up on the replies to the questions about the senior officials who have been appointed to the interim national paediatric hospital development board. Is there any chance we could get a list of who they are and what kind of expertise they have? Do they have any plans to meet local public representatives, including Deputies and councillors? The only briefing we have received on the hospital so far was from the CEO of St. James's Hospital, who has met us twice. I would like to make the Minister aware that last night, I received a political newsletter through my door that featured a photograph of the CEO of the hospital with public representatives from a certain party.

Jerry Buttimer (Cork South Central, Fine Gael)
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I ask the Deputy not to name them.

Catherine Byrne (Dublin South Central, Fine Gael)
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I am not going to name them. A footnote mentioned that the assistance of the public representatives in question in the hospital's submission for the national paediatric and maternity hospital was much appreciated. The person who circulated the newsletter claims to have made the case for St. James's Hospital to decision makers, Ministers and the media. My understanding was that there was to be no lobbying from any representatives regarding the development of the national paediatric hospital. I would like an answer in this regard. It is very offensive that a political party has hijacked the hospital.

The committee has been told today that it is hoped to secure planning permission for the hospital by 2014. Does that mean we have a commencement date? We will be finished by 2018 or before then? Has a budget been agreed for bringing the project to the planning stage?

I would also like to ask about the Hollybrook long-term care unit in Inchicore. I feel like I am on a rollercoaster in a theme park at this stage. I received replies regarding this matter in 2008, 2009, 2011, 2012 and 2013. According to the most recent reply I received, on 23 April last, a consultation process will last six months up to the end of November 2013. Hollybrook is a beautiful place, but it is still sitting there and nobody is able to avail of it. Most of the people who were on my list three years ago have since died. They have all passed away, God love them. Can the Minister confirm that Hollybrook will be run by a public private partnership? It is now rumoured that it will be used as a transition place for patients from the local national hospital who are waiting for long-term care under the fair deal. I have to say I would be concerned about that. These beds were not supposed to be transition beds. They were supposed to be new beds for people in the community. Some 18% of them were to be given to local people. I do not believe this facility was developed to provide transition beds. I would like to know whether any agency staff will be employed if that happens.

I will move on to my last question.

Jerry Buttimer (Cork South Central, Fine Gael)
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Very quickly. The Deputy has been speaking for three minutes.

Catherine Byrne (Dublin South Central, Fine Gael)
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I will be finished in a minute. I understand there are 16 general ICU beds, four HDU beds and three new HDU beds in St. James's Hospital. In line with the hospital's complement, it should have another four ICU beds. If I have counted correctly, there would be 27 beds in total. How does our national hospital compare with hospitals in Northern Ireland and England when it comes to ICU and HDU beds? I am constantly being lobbied by people regarding the intensive care and high dependency facilities in that hospital. I have been told of operations that could not be done because no ICU beds were available. I would like an answer to the question I asked about the individual in the hospital who has over-stepped the mark by allowing his or her photograph to be put on a political leaflet.

Jerry Buttimer (Cork South Central, Fine Gael)
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The person in question is not here to defend himself or herself.

Catherine Byrne (Dublin South Central, Fine Gael)
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I did not name him or her. I am making it very clear I think it is wrong that a person working in a high position in a hospital should put his or her name on a political leaflet.

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

Catherine Byrne (Dublin South Central, Fine Gael)
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It is very wrong.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy has made her point.

James Reilly (Dublin North, Fine Gael)
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Many of the questions asked by members of the committee relate to officials who are in attendance. I will touch on the questions that are appropriate to me and pass the other questions on.

Deputy Kelleher asked about the temporary suspension of the fair deal scheme. Mr. Tony O'Brien went into that in some detail, in fairness. I would like to comment on it in the overall context of the Deputy's concern that the trend is going in the wrong direction and his comments about the pressure on our emergency departments from December to April. The special delivery unit, which has received tremendous co-operation from the clinical programmes, has been successful. I am pleased that Dr. Áine Carroll, who is leading those programmes, is here today. There have been tremendous savings in bed days. Over 120,000 bed days have been saved since we started. Substantial moneys have been saved. I reiterate that the money we save in the primary care reimbursement service, elsewhere in the hospital system or in any other part of the health service, goes back to making sure more patients are seen more quickly.

I would like to touch on what was said about increased pressure in December. The special delivery unit, the clinical programmes and the front-line staff have managed to create a new flexibility within the health service that allows us to deal with the surges and the waxing and waning of demand that we know is there. When we are under pressure in our emergency departments, of course elective surgery slows down to allow for the admissions that need to come in. These are the most acutely ill people in our society and they need urgent care. As the director general designate, Mr. Tony O'Brien, has said, it was reaching the stage where we felt patient safety was being compromised. As I said at the outset, outcomes for patients and patient safety are our absolute priority. We are very keen to stay within our budget, but we will always put patient safety first.

I will address some particular aspects of this issue. The suspension of the normal chronological order allowed for people who were in the delayed discharge category to be moved to long-term care from the hospitals. It is not just a question of the patient in the community waiting on a bed and the patient in the hospital waiting on a bed. There is a third patient involved here, namely, the critically ill patient, often an older person, who is lying on a trolley in the emergency department. We know that the outcomes for patients who are left in that scenario are far worse than the outcomes for patients on hospital beds in wards, even if there are more people in those wards than would normally be the case. That is why this flexibility was used to suspend some elective surgery. It allowed for acute admissions to take place and it enabled a greater emphasis to be put on outpatients. We will catch up on our elective surgery as the year progresses. The demand is easing. It can be seen that trolley counts are much lower than they were earlier in the year. We always get a rebound in January, February and March after the hyperactivity associated with the end of the year. We plan for that. I am quite happy that we have the wherewithal and the resources within the intervention fund to deal with those targets and waiting times in a focused fashion. The numbers of people who are waiting for forms of surgery and procedures that would make huge difference to their quality of life are not targets. I think I have covered what the Deputy said about the trend going in the wrong direction. It is coming back now and we are heading in the other direction.

Deputy Kelleher also spoke about how to fund universal health insurance. Dr. Fergal Lynch will speak about that in more detail. The Deputy argued that we are basing our approach to universal health insurance on private health insurance. That is not the case. It is made clear in the programme for Government that the VHI will be kept as a public option. There is no doubt that more people have opted out of private health insurance. Part of that might relate to increased premiums. Much of is relates to the fact that 450,000 people are unemployed and the country is in the state it is in. I do not intend to trade political brickbats with the Deputy about why that is the case. We know the reasons. The high level of unemployment is one of the reasons for the increase in the number of people on medical cards. The Minister of State, Deputy White, will deal with the issues raised around medical card eligibility. The bottom line and the inescapable fact is that there are more people with medical cards now than at any time in the history of the State. There will always be hard cases.

Jerry Buttimer (Cork South Central, Fine Gael)
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This committee has had a number of meetings on the subject of private health insurance. All of us know from our clinics and offices that people are concerned that health insurance does not seem to be coming down. It is going up.

There are now more health insurance plans than one has fingers and toes. While it is necessary to find the correct plan, people are genuinely concerned about the cost and number of plans and would like them to be more user friendly, convenient and affordable.

James Reilly (Dublin North, Fine Gael)
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As I have stated on a number of occasions, it is unacceptable that the cost of private health insurance continues to increase. It is also unacceptable that the number of health insurance claims increased by 14% in 2012, given that the number of people insured declined last year. There is no proper audit of the sector. For example, there is no clinical audit, in other words, treating physicians are not challenged to explain the reason procedures have been carried out. This is a major gap, one that I have insisted VHI, as the largest insurance provider, address. The company may have only 57% of the market, but it is responsible for 80% of the money paid out on claims.

Another issue that must be addressed is the practice of paying the same amount for procedures that may have attracted a large fee previously because they took two hours to complete but now take 20 minutes as a result of advances in technology. Health insurers must also shift from paying per diem charges to paying per procedure. I have raised this issue in my Department as it would allow those hospitals that are efficient, perform day procedures and have reduced numbers of readmissions to thrive. I have informed the joint committee previously of a case in which I was approached by a man whose MRI scans had cost VHI more than €6,000. He travelled from the country to Dublin on a Sunday to have an MRI scan done on the Monday, only to be told that it would be postponed until the following Wednesday because of an emergency. He was told not to go home and remained in hospital throughout. Such farcical practices must stop. Much work remains to be done and I am not satisfied that progress is being made quickly enough. I have had numerous meetings with VHI and I am putting the company under the cosh. The Department will engage in further actions to address VHI's costs in the near future.

The Minister of State, Deputy Alex White, will address the issues raised concerning dentistry, while the Minister of State, Deputy Kathleen Lynch, will address mental health services and cochlear implants. I assure members that the budget for next year includes funding to enable Beaumont Hospital to do work on cochlear implants. The hospital must perform a balancing act. First, it must catch up in respect of those who received single cochlear implants and thereafter must commence a double implant service. It is obviously cheaper to do two implants at once.

The position on non-consultant hospital doctors, NCHDs, in Drogheda and Letterkenny will be addressed through hospital groups. Once these are established, NCHDs will be employed by hospital groups as opposed to individual hospitals. Mr. Barry O'Brien will provide some more detail on this issue.

The issue of publishing service level agreements is one for the Health Service Executive. While the agreements are large, I do not see any reason they should not be published, as they are a matter of public record.

Deputy Seamus Healy asked about having specialist representation on the boards of hospitals. I presume he is not referring to medical specialists. While the boards will have some clinical input, no members of staff will appointed to boards. This is in line with a recommendation issued by the Health Information and Quality Authority as part of its investigation into practices at Tallaght Hospital. We want people who have specific capabilities or competencies to be on the boards of hospitals. These include competence in accountancy, human resources, the financial and legal fields and information technology. We also want to ensure the regions are represented.

Billy Kelleher (Cork North Central, Fianna Fail)
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Is party membership a criterion?

James Reilly (Dublin North, Fine Gael)
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The nursing homes support scheme is run fairly. As discussed with Mr. Tony O'Brien and the Minister of State, Deputy Kathleen Lynch, we will revert to the normal course once the pressure point has been addressed, as it has been. Mr. O'Brien will provide further detail. Nobody was disadvantaged because anybody who had been on the list was allocated a bed. We will catch up and make it fair by the end of the year.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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People have been disadvantaged, for example, patients in nursing homes who have been waiting for three or four weeks.

James Reilly (Dublin North, Fine Gael)
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If the Deputy has a specific case in mind, he should provide me with the details. As I stated, we will catch up and there will be fairness and equity across the system by the end of the year. We will also catch up with our inpatient elective procedures by the end of the year.

Deputy Seamus Healy also referred to the outpatients list. This was an unintentional oversight. This is the first Government that has been determined to expose this problem to the light of day. It is astonishing that no previous Government ever counted the numbers on outpatient waiting lists. The real scandal is not the 386,000 people on the waiting lists but the 16,000 who have been waiting for longer than four years. We have undertaken that by the end of this year no one will have to wait longer than one year. We will deal with this problem in the same way as we dealt with the problems of inpatient waiting times.

Jerry Buttimer (Cork South Central, Fine Gael)
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Will that include orthopaedics?

James Reilly (Dublin North, Fine Gael)
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Yes; it will also include ear, nose and throat procedures.

Jerry Buttimer (Cork South Central, Fine Gael)
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There is a massive problem with orthopaedic procedures in the south.

James Reilly (Dublin North, Fine Gael)
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Yes, there are reasons for that and we can deal with that issue also.

The Minister of State, Deputy Kathleen Lynch, will discuss the issue of cochlear implants. I am grateful to her for meeting yesterday with concerned parents who have formed the Happy New Ear group.

On the national paediatric hospital, we have a project timeline to have a cleared, brownfield site ready for building to commence on 1 January 2015. We intend to have the hospital completed in 2018, rather than 2019. It is a massive project, the biggest undertaking in terms of capital outlay in the Government's term and probably the biggest building undertaken since the Ardnacrusha plant was built. Even in the face of a deep recession, the Government has given commitments to compete the national paediatric hospital and the Central Mental Hospital because it has prioritised the most vulnerable, namely, those with mental health issues and newborns and children.

The Minister of State, Deputy Alex White, will address in detail the issue of medical cards. There is, however, no question that there are many more people than ever with medical cards.

I answered some of Deputy Catherine Byrne's questions about the national paediatric hospital. Lobbying is part of the process, but if she wishes, we can have a quiet chat about the specific issue she raised. I can also speak to various people about the matter she highlighted because it is not appropriate. Having said that, I assure members that an international, well run team decided, in conjunction with the Department, that St. James's Hospital was the best site for the new hospital. I have no hesitation in saying this.

On the nursing home in Hollybrook, I accept the Deputy's point. There has been a back and forth discussion on this matter for some time. Perhaps Ms Laverne McGuinness might address the issue before dealing with the Deputy's question on the number of intensive care beds and how it compares internationally.

Dr. Lynch will now discuss some of the points raised.

Dr. Fergal Lynch:

The Minister referred to the private health insurance sector. Deputies and Senators are concerned about the rising cost of premiums. As the Minister noted, one major and obvious issue is the increase in claims costs. The Health Insurance Authority's latest report indicates that claims costs increased by 14% last year, of which approximately 4% was for actual costs and the remaining 10% was accounted for by an increase in volume. The critical issue to address is the volume of claims. As the Minister stated, the number of people covered by private health insurance has decreased, whereas the number of claims has increased. This is a critical issue which must be addressed.

Last year the Minister appointed a consultative forum on health insurance which I chair. The forum comprises representatives of the four health insurers, the Health Insurance Authority and the Department. We have been working intensively on issues related to the cost and affordability of health insurance. While this is not an easy issue to address, we remain fully focused on doing so. Some of the issues on which progress has been made include data sharing and, more importantly, the risk equalisation scheme. Risk equalisation goes to the heart of the issue of the segmentation of the market and the targeting by insurers of younger people. The Minister enacted legislation at the beginning of this year for a new risk equalisation scheme. He has also pointed out that what we need to address the proliferation of plans - as we heard, there are more than 200 plans on the market - is a single standard plan against which everything else could be benchmarked. We are working with the industry on this and all those involved have signed up to the concept of a single standard plan. This would allow people to compare like with like, as every insurer would have one standard plan and costs could then be compared across the board. Consumers would find this much easier. This not to say there would not be other plans, but the standard plan would be the critical one against which everyone could make comparisons.

Equally, the focus on costs could be directed towards that and we would only risk equalise to the extent of that standard plan. That is an important set of issues which we need to deal with in this context.

We are also keen to deal with measures that would encourage greater participation of younger healthier people in the health insurance market. The difficulty we face at the moment is that more older people are joining and more younger people are leaving. The more we can encourage something in the opposite direction, the better. One possible scope is lifetime community rating although that will become irrelevant when we go to universal health insurance. Anyway, perhaps there is a case for introducing it in the meantime at a basic level because it sends a certain message.

The critical concern we have relates to agreeing measures throughout the industry to address costs. We have to be careful about competition law as well. There is no question of cartels or price fixing but there are things we can do at departmental level and throughout the industry to address those costs. The Minister has stated that he is particularly concerned about the costs in VHI. The company has submitted a plan. We are seeking a more ambitious approach to it and I believe that will be possible in the coming while.

Alex White (Dublin South, Labour)
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There are two areas I wish to address. First, I will address the question of dental services and then I will say something about the medical cards issue which has been raised by several members.

Deputy Ó Caoláin raised the issue of dental services and I wish to give some context to my reply. It is worth pointing out that in the year to date, that is, to April 2013, of the 1.4 million people eligible for care, some 170,684 patients have received care, an increase of 10,000 on this time last year. That is an important context. Having said that, I agree with Deputy Ó Caoláin that this area of dentistry, which includes primary care, preventive care, early checks and all these important areas of care in dentistry, is vital.

I have met the Irish Dental Association on more than one occasion. They are very good about this and they are dedicated professionals. The organisation is fully engaged in this process and I am keen to engage with those involved. Let us be straight: it is an area where we have seen the impact of the financial constraints we are under. We have be unable to move on with initiatives as quickly as we would have wished. However, I am seized of the importance of dentistry and of proper and well-developed dentistry services and I will continue to engage with the Irish Dental Association in this regard.

The HSE has commissioned an independent review of the services and this has been referred to in the response to Deputy Ó Caoláin's comments. The outcome of that review will give us guidance on what changes are desirable to provide the best model of care that we can provide, regrettably, I must say again to the committee, within the constraints of the resources available to us. It is regrettable that we have been unable to do more although we have done a good deal in recent years, as Deputy Ó Caoláin has fairly acknowledged. We want to do more and I see it as a priority area for attention once we move on from the stringent financial constraints we are currently under. I wish to give the committee the assurance that it will be a priority because I am fully convinced of the importance of dentistry not only in terms of its direct impact but for broader health care. It is a highly important area in health care. There are synergies between what dentists do, what they can advise on, the way they can assist, treat and care for their patients, and other areas of primary care. I regard this as important and I agree with Deputy Ó Caoláin in this regard.

Deputy Kelleher raised the issue of medical cards initially and Deputy Healy referred to it as well. A written response to Deputy McLellan deals with the issue of medical cards being granted to people on medical grounds. At the risk of annoying the committee or irritating people, I believe it is important to point out that our system awards medical cards on the basis of material circumstances. That is the system we have had since 1970. The entitlement to a medical card is based on an assessment of whether the individual can provide for his care other than with undue hardship, the phrase used in the Act. Sometimes it sounds rather harsh when I give the response that it is all to do with material circumstances. Naturally, there is a concern for people who become ill quickly and people who get cancer or other illnesses and there is a concern that they should be cared for and dealt with in a sensitive way. However, the system we have awards medical cards on the basis of material circumstances and income. That is the position. There is, however, a discretionary medical card application system. I wish to respectfully disagree with Deputy Kelleher, who suggested that it has ground to a halt or that it is not working. That is not so. There are more than 59,000 or almost 60,000 live discretionary medical cards in the system at the moment and approximately 20,000 general practitioner visit cards granted on discretionary grounds live in the system.

It is a difficult area. There has been some debate about this in the media in recent days. Sometimes in the debate on this issue there is a public expectation or belief that medical cards are habitually granted on the basis of medical condition but they are not. Perhaps there could be a debate on whether that should be so, but that is the system we have. We have a centralised system, the primary care reimbursement service. I am a Deputy as well as a Minister of State. We all hear responses to particular cases, including some particular and genuine hard cases, but the fact is that the system is working well. It has become a little more technocratic and sometimes bureaucracies appear harsh but I believe it is working rather well.

In circumstances where there is an application for a discretionary medical card, as we indicated to Deputy McLellan in the written response, the medical officer considers the medical condition and the financial circumstances of the applicant on a case-by-base basis. Great care is taken in these applications and I believe it is done in a sensitive way.

Deputy Healy asked a question about where an assessment is being made for continued eligibility for a medical card and he said that people were being written to. I support the HSE in doing this and I will explain why. I want to ensure we maintain the resources we have for the people who need them and for the people who qualify for them, a view shared, I imagine, by everyone in this room. We have constraints on resources. The Minister for Health, Deputy Reilly, is absolutely right. We have extended tens of thousands more medical cards in recent years and I have no quibble with that. People have found themselves in particular circumstances in which they need a medical card and they get a medical card, but the resources we have should be kept and preserved for when they are needed. There are circumstances in which people qualified for a medical card for a period but then their circumstances changed. If that is the case then-----

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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They have not changed.

Alex White (Dublin South, Labour)
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They have changed in many circumstances. People are written to and are given three months' notice. There are many anecdotes going around which are not true. People are written to and given three months' notice. They are written to again within one month. If people engage with the service and engage genuinely with the letter they receive and answer the request being made for further information, they will not have the medical card removed willy-nilly or taken from them by a doctor, pharmacist or anyone else, as has been suggested. That does not happen. I appeal to people who receive a letter to respond to it. If people continue to qualify they will be left with their medical card.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Minister of State is correct. The problem is that it instills fear in many people who are concerned that they will lose their medical card. I agree with the Minister of State, I support the HSE and I thank the staff in the PCRS and Mr. Paddy Burke for the work they do, but if the language used could be changed in some way it might help because it frightens people. I know from people who come to my office that elderly people in particular are petrified of losing the medical card.

Alex White (Dublin South, Labour)
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I believe this issue is dealt with in a sensitive way. If there are issues about the language in letters-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I am referring to the initial letter issued.

Alex White (Dublin South, Labour)
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There is always room for examining such issues if particular words are used, but there is no question of a targeting of individuals or groups of people. That is not happening. I support the process.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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On a point of order, why are they bringing reviews?

Alex White (Dublin South, Labour)
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Let me finish the point. I have one more sentence to add. I did not hear what Deputy Healy said but I will address it. If there is a question about lack of sensitivity or clarity about what is happening we will deal with it and address it if there is a problem.

James Reilly (Dublin North, Fine Gael)
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In response to Deputy Healy's point, as somebody who worked in the system for 25 years I find it very strange that someone would get a discretionary medical card with an expiry date seven or eight years out. Discretionary medical cards on the basis of medical need are for people who find themselves in an acute situation - very often, sadly, those who are terminally ill. This is where the discretion is shown. If this was raised under the heading of probity I would be investigating it, because I find it weird that someone would get a medical card for seven years on a discretionary basis.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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These are people who have current medical cards. Is the HSE legally entitled to withdraw those cards? These people are marginally over the limit and have medical conditions. They are aged between 65 and 69 and will get the medical card anyway when they reach 70. If it is taken from them now it will be reissued to them after they reach 70.

Jerry Buttimer (Cork South Central, Fine Gael)
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There are five other members who wish to speak. I want to bring them in too in a minute. Then I will bring in the Minister of State, Deputy Kathleen Lynch.

Mr. Tony O'Brien:

On this specific point, irrespective of the expiry date that may be printed on a card that was issued some time ago, the person must continue to be eligible for it in order to retain it. On other occasions we are in the room next door to this one meeting the Committee of Public Accounts, and the issue it would wish to talk about is the extent to which we do random checks to ensure that only those entitled to a medical card are in receipt of them. While I understand the Deputy's point about someone being marginally over the limit, they are still over the limit and the discretion of the HSE to issue medical cards to people who are over the limit, unless there is a clear medical ground, does not exist. The rules are not made by the HSE but we are obliged to enforce them.

Dr. Fergal Lynch:

There are two other issues I want to deal with: the publication of the White Paper on universal health insurance, UHI, and, in response to some of Deputy Byrne's questions, the national children's hospital. We are working intensively on the publication of the White Paper. Much of this type of work has to be done under the radar before one produces the paper because of its technical nature. At the moment we are looking at different models for delivery of a UHI system. The Minister has made clear that it is not simply a case of grafting the Dutch system or any other onto the Irish system. We are examining the legal and financial implications of that at the moment. That is the first stream of work under the White Paper. The second is the basket of services - that is, precisely what services will be covered and at what cost - and the third is the exact approach to financing. Someone asked if this is to be covered by universal health insurance, general taxation or a combination of both. We are working intensively on those issues and will produce that White Paper as rapidly as we possibly can.

Billy Kelleher (Cork North Central, Fianna Fail)
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Can Dr. Lynch give us an idea of the timeframe for this? I am not holding him to days or weeks.

Dr. Fergal Lynch:

The Minister has given a commitment to have it done by the end of the year. We will do our very best to produce it by then. It is a very challenging timetable because of the nature of the work involved, but we are working intensively on it at the moment.

To answer Deputy Byrne's questions about the current board of the national children's hospital, the Minister appointed an interim board to make sure that work continued on the project. The current members are officials of the Department of Health and the HSE: I chair it, my colleague Bairbre Nic Aonghusa is assistant secretary general at the Department with responsibility for finance, and my other colleagues, Mr. Charlie Hardy and Ms Fionnuala Duffy, are principal officers in the acute hospital services, Mr. Jim Curran is director of estates in the HSE and Mr. Gerry O'Dwyer is a regional director of operations in the HSE. We will be replaced by a new board with the necessary technical, financial and planning expertise shortly, when the Minister decides on that. We are working as hard as we can to move things on as much as we possibly can. For example, we had a useful engagement with Dublin City Council earlier this week to begin the planning application and we are working intensively to move that project forward as quickly as we possibly can.

Kathleen Lynch (Cork North Central, Labour)
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I will be as brief as possible. I will deal first with the cochlear implants. We had a very good meeting with the Happy New Ear group and the HSE staff members who are charged with putting the business plan together on how we would do this. That business plan will be completed by the end of June. It is a good timetable because the budgetary process will begin shortly after that. With the roll-out of the newborn screening programme, we will pick up children's hearing impairments at an earlier stage. I heard yesterday that these can be detected as early as three weeks. There are approximately 60 children born each year who have a hearing difficulty - maybe not profound, but nevertheless, something that could be helped by a cochlear implant. Those numbers will not go up; we are simply detecting them earlier. At present this is detected at between two and four years of age. We hope the numbers will not increase, but such conditions will be detected earlier.

There is an emotional and practical case being made for the benefits of having two implants in respect of balance and sound sensitivity. That was all taken on board. It would be in our best interest to wait for the business case to be made and, as well as the children we are picking up at an earlier stage and with whom we are now dealing on an ongoing basis, there is a waiting list for the second implant. It cannot just be for the people we are picking up now. We need to start dealing with the backlog of people who could benefit from two implants. Not everyone will opt for, or benefit from, it. We need to wait for the business case that is being put together. There may be different mechanisms to deal with the problem. We will need additional posts if we go with it. There may also be a mechanism to bring people in on a short-term basis. That expertise is being considered. We are moving on it. The group was very happy with the meeting yesterday, which was very open and honest. No commitments were given. Everyone here knows I am not in the business of doing that, but we are preparing a business plan which needs to deal with the two sides of the equation - the people who have one implant and need a second, and the people we are picking up at a much earlier stage. We will have that business plan in June and it will be well-placed for next year's budget.

Deputy Ó Caoláin asked about the mental health posts. We are above the recommended numbers of staff in the mental health sector - not much above, but we are above. The difficulty is that there are deficits in some areas and not in other areas. We are trying to deal with that and we have to take it into account too. We have almost completed filling the 414 posts. There are 42 posts unfilled, for a variety of reasons. They have been accepted by candidates who are going through the clearing process, but a few posts are difficult to fill for geographical reasons. People do not want to go to particular areas because their families are in other areas and some who are abroad want to complete the jobs they are in. Thankfully, very few posts remain unfilled.

In respect of the 470 posts this year, what we did about the first €35 million was different and took a little bit longer. I am very conscious of where I am saying this: we did not automatically divide it into four and send it into the regions. We told the four regions to tell us where the gaps were and to send in their business cases for those posts and then we would employ. That is what we have done with the 470.

One area has not sent in its business case in regard to what the service needs. It is not the same service. There is a different cohort this year, including old age psychiatry, intellectual disabilities psychiatry and forensics.

In the future where the service is delivered will be as important as who delivers it. We are building a new central mental hospital, which is long overdue, and four regional rehabilitation units which will ensure that people who are in the Central Mental Hospital but could live closer to their homes can be accommodated. Significant progress is being made. More than anything else, there has been progress on attitudes and where we are delivering services. The numbers are ahead of, rather than below, target, but not by much. There is still more to be done.

Mr. Tony O'Brien:

If we break the demographic profile down between immediate and longer-term issues, Deputy Kelleher was correct to say that the changing demographic profile presents a long-term challenge for the entirety of the spectrum of health and social care services. The needs and intensity of our population will change. The challenge of providing the right resources in the right place, in particular for the increasing cohort of older people, is enormous. We will have to face up to it in the coming years.

What has happened in the recent flu season is not unique to Ireland. It is true for the whole island of Ireland, our nearest neighbour and European countries. The relatively late onset of the flu season and its sustained nature had a particular impact on elderly people. When flu season happens later in the year the potency of the vaccine programme is lessened. There is, therefore, more incidence and often people are much sicker. One of the characteristics we experienced was the substantial number of people presenting in the elderly age range, a much greater percentage of whom needed hospital admission. Many needed intensive care and respiratory assistance, which led us, in a phased way, to step back on elective admissions, to accelerate 400 additional places in the fair deal and, ultimately, to temporarily step away from chronological management. As the first step in the fair deal was to accelerate the number of places by 400, at no point in time did anybody who would otherwise have been in receipt of funding approval for the fair deal get one later than he or she otherwise would have done.

When one takes the two measures together, persons who would ordinarily have received their approval during the period when chronology was suspended had already received their approvals by virtue of the accelerated 400 places. There is no instance of an individual having been directly disadvantaged by the temporary pause in chronology. Interestingly, during the chronology pause periods we instituted a procedure whereby anyone in the community who was experiencing a particular need could be accelerated, which would not normally happen. A number of persons whose personal situations were deteriorating were accelerated on medical grounds.

On geography, the reality is that those who were treated and in need of long-term care in the six major hospitals in Dublin and Cork University Hospital, which is a major academic teaching hospital providing tertiary and quaternary services, do not come from those regions alone, rather, they come from around the country. In the best interests of the totality of care we can provide to older persons, because many of those would otherwise have been waiting on trolleys and would have arrived into emergency departments from long-term care, it was the appropriate thing to do.

With regard to the ambulance service, I will ask Ms McGuinness to speak to the non-emergency patient transport issue and the Hollybrook Inchicore issue. The Deputy referred to two tragedies. In the first case, the issue was not ambulance response times. The newspaper that reported that it was subsequently retracted it and apologised for the story. I recognise, however, that it gives rise to a generality of concern. Some people saw the story but not the apology.

To be clear, the ambulance response in that tragic situation in which a child sadly died as a result of the initial drowning incident was appropriate. In the case of the second, we have questions and I have outlined what they are. The review will proceed. This year significant investment in the ambulance service is taking place, in terms of additional intermediate care vehicles and personnel, in order that emergency ambulances are freed up and reserved for that purpose. We are also bringing our ambulance control system into line with international standards. There will be a significant investment with a progressive centralisation of ambulance control functions that will enable the totality of our emergency ambulance fleet to be used much more effectively and in a much more controlled way.

I will briefly address one of the issues raised by Deputy Byrne. She did not name an individual, but by telling us what he does and where he does it she has identified him fairly comprehensively. It is important that I speak up on his behalf. He is a distinguished and committed public servant. Like many of us, we often find ourselves being photographed with delegations of various kinds from all parties and none and various groups. Where those photographs subsequently end up is something over which we have limited control.

While I can see from what she described that it would not seem to be the most appropriate use of his image, I suspect he had no control over it whatsoever. I recall when I was director of BreastCheck that every time a mobile unit rolled into a place for the first time many stories would appear in the name of various local politicians, councillors or mayors, explaining in great detail the meetings they had with me and the extent to which they had lobbied me, but frankly I had never heard of them. The rush to claim credit for various things is a particular phenomenon and I do not think the individual should or can be held accountable for it. I understand the concern the Deputy had.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will not name Deputies.

Mr. Tony O'Brien:

I did not intend to provoke-----

Jerry Buttimer (Cork South Central, Fine Gael)
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People are getting enough publicity; I would not say any more.

Mr. Tony O'Brien:

I will ask Mr. Barry O'Brien to comment further on the NCHD issue.

Jerry Buttimer (Cork South Central, Fine Gael)
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We have seven members who wish to speak.

Ms Laverne McGuinness:

I will deal with Deputy Byrne's question on Hollybrook and the CNU. She is correct; it has taken a period of time to open it. We hope it will be open in six months. The reason it has taken time is because there is a question about whether the service will delivered by the HSE staff, which would require new staff, or through a public-private partnership initiative. Our plan is that it is done through a public private partnership initiative.

A specification is currently being concluded and we hope that will happen within a four week period. Under the public service agreement we also have to engage in an extensive consultation process with unions. That will be concluded in the next six to eight weeks. Thereafter, we hope to open the unit within six months. The specification has to be done because is very important to define what type of residents and patients will be treated in the unit, whether they will be complex, etc. It will take six months for us to complete a HIQA inspection process and have the unit fitted out.

Deputy Byrne also raised the issue of critical care and the importance of critical care beds. This year, working with the clinical lead, Dr. Michael Power, we have identified the areas of greatest priority. St. James's Hospital requires four critical care beds, Tallaght Hospital requires three and Our Lady of Lourdes Hospital requires one, a total of eight. St. James's Hospital has received funding of €900,000 on a full-year basis and will open the critical care beds in June because it needs to recruit 11 staff, two of whom will be involved in intensive care. I understand there was a lag of one week for cancelled operative procedures and those patients have been dealt with within that timeframe.

With regard to the ambulance service and non-emergency and non-urgent transport, it is correct to say that in order to improve response times and ensure that our ambulance fleet can get to emergency situations within our target of 18 minutes 59 seconds, we are very considered in terms of to what we will respond. That is why we use intermediate care vehicles to transfer patients from one hospital to another. We ask people at home to travel with relatives or ask somebody to bring them to hospital rather than engage in the traditional use of ambulance services.

Mr. Barry O'Brien:

Deputy Caoimhghín Ó Caoláin referred to non-consultant hospital doctors. In the context of our overall plan for self-sufficiency in terms of the projection for consultant numbers, general practitioners and other medical specialties, we are increasing the number of intern places year on year, with an overall increase to 740 by 2014. The note for the committee clearly sets out the preparation that has been done to deal specifically with the July intake. There has been a number of distinct approaches to this. As the Minister said, the introduction of the hospital groups will bring a fundamental change in that all resources will be group resources, with the capacity of the chief executive officer and clinical director of those groups to redeploy key personnel in order to meet service needs where they arise. This structure will afford a greater flexibility to deliver services where they are needed, including the deployment of medical personnel. There are several areas in which issues have arisen, but we are dealing with them by way of a number of recruitment initiatives. The hospital groups will bring a changed dynamic in terms of how we use our manpower resources in meeting service needs.

Catherine Byrne (Dublin South Central, Fine Gael)
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Dr. Fergal Lynch referred to the transitional board at St. James's Hospital. Will he clarify whether meetings will be held within the hospital complex with residents and public representatives? Will the chief executive officer of the hospital have a role within the new national children's hospital or on the transition board?

Dr. Fergal Lynch:

My understanding is that the meetings the chief executive officer has held took place specifically in the context of arrangements on the site. Our immediate engagement with St. James's Hospital is to do with decanting. Management needs to plan to clear the site so that the new hospital can be put in place. My understanding is that this is the context in which those types of discussions have taken place to date.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I have another question, if the Chairman will oblige me.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy must be very brief as there are several members waiting to speak.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I understand the potential of the hospital groupings in terms of addressing some of the concerns I have raised. However, in the context of the short timeframe that presents between now and the July date, does Mr. O'Brien accept that particular hospital sites have a more acute problem in regard to the recruitment of non-consultant hospital doctors to cover their needs as and from the second half of this year? What can and will be done in this regard?

James Reilly (Dublin North, Fine Gael)
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If I may, Chairman, I would like, before Mr. O'Brien responds to Deputy Ó Caoláin's question, to make a point in regard to the work that has been going on at St. James's Hospital. As we have said, a project team in the hospital is looking after the decanting project, with a clear plan set out to deliver a brownfield site. I commend the hospital's chief executive officer on the meetings he has held with staff, public representatives and local residents to keep them informed. By communicating with people on an ongoing basis, we can avoid many problems that might otherwise arise, such as concerns about how the building work could interfere with individuals' day-to-day life, the running of their businesses and so on.

I take this opportunity to make two quick points which I omitted to cover earlier. Deputy Seamus Healy asked about consultation in regard to the roll-out of hospital groups. There will be further consultation beginning on 31 May in this regard, which follows the more than 70 official meetings and 50 or 60 unofficial meetings that have already taken place. In all, therefore, well over 100 meetings have taken place with staff and others in the various hospitals throughout the country.

My final point, which deserves to be made repeatedly, relates to the tendency in nursing homes in the past to refer patients who are dying to hospital emergency departments. Speaking for myself, I would prefer to die at home, as did both my parents, rather than in hospital. For long-term nursing home residents, the facility in which they have been cared for, sometimes for many years, is in every sense their home. The tendency to transfer gravely ill residents to emergency departments seems to arise out of concerns and perhaps a lack of confidence in dealing with the terminally ill patient. It is a dreadful tragedy and affliction for such people that the last hours of their life are spent in unfamiliar surroundings. It is utterly inappropriate. To address that issue, the Health Service Executive has begun, through its clinical programmes, sending specialist gerontologists out to nursing homes to support them in dealing with these situations, which are emotionally difficult for all concerned. It is not in the interest of patients who are coming to the end of their days to have to spend those last days and hours in an emergency department. They should be allowed to see out their time in the facilities that have become their homes while receiving all the proper care and attention they require.

Mr. Barry O'Brien:

In regard to Deputy Ó Caoláin's question, many of the staff recruited under the 2011 initiative did not start their two-year contracts until September or October of that year, which means they will continue to be with us post 1 July. In fact, a number of them are taking the necessary steps to transfer their medical registration requirement from the supervised to the general division. That is an ongoing process. In addition, we have undertaken a specific recruitment initiative with the College of Physicians and Surgeons in Pakistan as well as another recruitment initiative in South Africa. We will be able to assign those people as they come on stream to areas which, on an annual basis, have a difficulty in filling all their posts.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will now move on to the next group of members who have indicated, beginning with Senator Colm Burke.

Colm Burke (Fine Gael)
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I thank the Minister and his officials for their presentations. The shortage of junior doctors is an issue I have been dealing with for the past two years. In the question I submitted for this morning's meeting, I referred to the fact that more than 4,000 junior doctors are on six-month contracts only. In 2011, we had a major crisis in regard to junior doctors. Two years later, however, we are still dealing with the same type of structure in terms of the contracts we offer while, at the same time, we are prepared to offer two-year contracts to individuals from Pakistan. That does not make sense when we are spending some €75 million per year in producing 600 medical graduates. A survey I undertook last year shows that two thirds of these graduates will leave the county after completing their intern year. Again, that does not make sense.

This is not a criticism of anybody here but I am concerned about the structures that are in place. The delegates referred to the Revenue Commissioners and the issue of termination of contracts. If we can go to Pakistan and South Africa to recruit personnel, surely we can tease out these issues with the training bodies and Revenue in order to offer contracts that are structured so that people are not in a state of uncertainty from one half of the year to the next. Graduates can go to the United Kingdom and obtain a two or three-year contract, but we are not prepared to review the process. No progress has been made in this regard in the past two years and it is time now to sort it out. Am I correct in saying there are 2,000 individuals on six-month contracts only? Will action be taken to extend these to 12 months, even if it requires the operation of rotas between hospitals? I accept that the new regional programme being rolled out offers a way forward in this regard but, in the interim, we must at least begin to put the structures in place for dealing with the situation whereby individuals in whose training a great deal has been invested are leaving the country in large numbers.

Reference was made to difficulties that have arisen in regard to the quality of applicants for positions in smaller hospitals in terms of training or experience. That is a major problem. We have a situation in smaller hospitals where medical consultants are on one in two or one in three rotas and under extreme pressure because of the quality of the junior doctors available to them. This matter must be given urgent priority so that we are not coming back in 12 months time facing the same issues.

In regard to the fair deal scheme, the Irish Nursing Homes Organisation has been in contact with me on several occasions to point out that there is no forum in which all of the people involved in elderly care can sit down together. This is an issue I have raised on the Adjournment debate in the Seanad. As it stands, the Department is meeting people individually, but the Irish Nursing Homes Organisation is seeking a more coherent approach.

It is seeking the establishment of a forum involving people from within its ranks, those who provide home care packages, the HSE, the Department, HIQA, community nurses and home helps which could tease out all of the issues in order that we might put in place a better, more structured programme in dealing with the provision of elderly care. From one week to the next, the organisation is not sure about its requirements in providing nursing home care and in the context of the changes expected of it by the Department, the HSE or HIQA. It is seeking the establishment of such a forum and I request that one be put in place.

Denis Naughten (Roscommon-South Leitrim, Independent)
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The old Western Health Board religiously implemented the law with regard to discretionary medical cards. It is now far more difficult to obtain such a card than was previously the case. Part of the problem is that there is a standardised system in place. For example, people who are diagnosed with cancer are treated in the same way, regardless of whether they live in Dublin or Roscommon. A person who lives in Roscommon will have additional transport costs and he or she will usually be obliged to bring someone with him or her when travelling for treatment. That individual will be obliged to take a day off work. These considerations are not taken into account in the overall assessment.

My first question relates to disability services. I welcome the commitment that people will be communicated with before the end of the school year. I acknowledge this significant step forward. However, has an assessment been carried out of the financial requirements in providing for those 700 school leavers and the progression cases? What is the amount involved? The difficulty with the additional sum of €4 million is that it is being distributed on the basis of demography. This means that approximately €280,000 will be distributed to counties Roscommon and Galway. We need double that amount to deal with school leavers and progression cases. There are a number of complex cases involved and the relevant families are going to be obliged to fight for basic services once again. Allocations based on demographics do not take account of the fact that the area in which I live is extremely rural and we do not have public transport services. Much of the funding not spent on direct services for clients is, therefore, spent in the provision of transport. This would not be the case in Dublin or some of the regional centres.

On ambulance services, we are aware of the tragic case in east Cork. The ambulance service in the west has consistently failed to reach target times. The service in my area has the poorest response times in the western region. The national figures in the performance reports were available up to the end of 2012, but they have been erased from the 2013 performance reports. In addition, the HIQA target for response rates is now 85%. However, the target set in the report under discussion is 70%. Instead of improving targets, there has been a 20% reduction in the objective which must be achieved in 2013 in comparison with what has been set down by the HSE. Sadly, this is leading to the loss of life and placing further lives at risk. Why is it not possible to obtain a regional breakdown of response times? I asked the Minister this question in the Dáil on 20 March, but I did not receive a reply. I specifically requested a regional breakdown and it was not supplied. Why is it not possible to provide such a breakdown? Has progress been made in respect of the public service agreement in the provision of staff for the Tuam base, the west Roscommon bases and other ambulance bases throughout the country?

My final point relates to stroke services. People who have a stroke cannot go to the 22 stroke units at 4 a.m. because they cannot be thrombolysed. At Portiuncula Hospital there is only one consultant who specialises in stroke medicine. At other hospitals CAT scan machines are not available on a 24-7 basis. How many of these units provide thrombolysis on a 24-7 basis? What steps are being taken to deliver rehabilitation services for people who suffer a stroke?

John Crown (Independent)
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I am going to depart from my prepared questions in order to ask the Minister to clarify something. Thankfully, I have had an hour and a half to calm down about this matter. It is reported in today's edition of The Irish Times that on 7 May the Taoiseach, together with the Ministers for Finance and Justice and Equality, Deputies Michael Noonan and Alan Shatter, held a meeting with representatives of the Irish Tobacco Manufacturers Association, namely, Mr. Stephen Donaldson from P. J. Carroll, Mr. Andrew Meagher from Players and Mr. John Freda from Japan Tobacco International.

Jerry Buttimer (Cork South Central, Fine Gael)
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To be fair to the Minister, we are only dealing with the questions submitted. He would not really be prepared to respond to the matter to which the Senator refers.

John Crown (Independent)
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I understand the Minister may not have been briefed on this breaking development. However, he will be in a position to indicate whether he is aware that the meeting in question took place and whether he advised his political colleagues not to proceed with it. The meeting in question may be in breach of the 2004 directive regarding transparency in lobbying by the tobacco industry. Apparently, the main item on the agenda for the meeting was smuggling, but the discussion then took in matters such as plans to ban roll-your-own and menthol cigarettes and introduce plain packaging. Apparently, these are issues on which the industry has lobbied.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Minister is not here to take part in our scrutiny of EU matters.

John Crown (Independent)
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We did not discuss what took place at the meeting held on 7 May.

Jerry Buttimer (Cork South Central, Fine Gael)
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To be fair to the Minister, that is not part of our remit.

John Crown (Independent)
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That is fair enough. I will return to my prepared questions.

I am tremendously concerned about developments in the matter of oversight of ethical committees. For reasons I do not have time to discuss today, I have had a long involvement in this area and encountered the extraordinary dysfunction and pathology of the way these committees worked in the past. In some cases they were under wholly inappropriate and illegal extrajudicial levels of scrutiny by imposed committees of religious compliance which were acting in several of our larger hospitals and preventing access to cancer drugs because research protocols specified the need for contraception, interestingly by some people who have been loudest in calling themselves "pro-life" in the past few weeks. Under proposed European directives, there is a need to regulate the ethical research committee sector. There is a colossal amount of misinformation, misapprehension and, possibly, disinformation. I know he is busy, but I would like the Minister's attention on this issue.

I am very troubled by the fact that it is continually stated the approvals process for clinical trials in Ireland is slow. That is not the case. We have a blisteringly rapid and appropriate process. It is one of the few things which works effectively and efficiently in our entire dysfunctional health service. It has given us a colossal competitive advantage compared to the neighbouring jurisdiction, the United Kingdom, to which many companies and research charities just do not bring their trials anymore because the approvals process is so slow. We are about to engage in a process which will impose a solution that is not needed to a problem that is not there. Not only is this one of those irritating little bureaucratic things which happens from time to time, it could cause real problems. The plan, under phase 2 of the current proposals, to allow HIQA to become the agency which regulates access to drugs and which regulates ethics committees is inappropriate. HIQA is an inspectorate and it should not be running anything. It is slowly being turned into the black ops or military wing of the HSE. This must be stopped and HIQA refocus on its function, which is inspection.

Jillian van Turnhout (Independent)
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I welcome our guests. I also welcome the long awaited appointment of Mr. Stephen Mulvany in the area of mental health. I hope we will now see great developments.

I add my voice to those of Deputies Ó Caoláin and Healy on the issue of cochlear implants. I was also part of the all-party group which met the representatives in question. The Minister of State, Deputy Kathleen Lynch, referred to the business plan and the budgetary process. Does this mean that 2014 will be the earliest date for the consideration of funding? I am very conscious of comments on the likelihood of second implants working only before children reach a certain age. There are children who are borderline in this regard. Time does not stand still when the Government makes policy decisions. I am very concerned by the fact that a decision will not be made on this matter for six or seven months. As an all-party grouping, I have no doubt we will follow up on this matter.

In the context of the questions I posed and in addition to Deputy Denis Naughten's query on stroke services, I welcome what is stated about outpatient services in the reply to question No. 23. I am very concerned about this issue which is very close to my heart. One out of every five people in Ireland will suffer a stroke at some point. In that context, the Irish Heart Foundation is holding its awareness week events from 10 to 14 June next.

I wish to raise the matter of the response given to question No. 32. As a Senator I do not get to ask parliamentary questions. I get to ask three questions at the quarterly meetings here. I go through the material and try to make sure that I have a question. When I get a stock reply similar to that which has been given to parliamentary questions on several occasions, I must note my disappointment. That is exactly what we got to question No. 32. We got a cut-and-paste reply. The last person who got such a response was Deputy Seán Kyne on 25 April. The reply states that an implementation plan beyond the overall operational planned commitments would not be beneficial. That contradicts the foreword by the Minster of State, Deputy Lynch, in the National Policy and Strategy for the Provision of Neuro-Rehabilitation Services in Ireland 2011- 2015, which states: "I look forward to receiving, at a very early stage, a comprehensive implementation plan from the HSE." The policy is unequivocal about the need for a three-year implementation plan to address those key actions that can be initiated and implemented within a short timeframe and on a cost-neutral basis while working towards the achievement of a longer-term vision. The reply I got goes on to state that the rehabilitation medicine programme has been working in collaboration with the national disability unit as part of the expert working group planning for the implementation of the report. My understanding is that this is not entirely accurate. I have been advised by the Neurological Alliance of Ireland, which is a member of the existing working group in this area under the rehabilitation medicine programme, that the initial clinical lead, Dr. Áine Carroll, clearly defined the working group's role as being limited to medical rehabilitation and, therefore, it is not concerned with overall implementation. It is of great concern to me that halfway through this implementation period it has been suddenly decided that we no longer need an implementation plan and only a partial implementation plan could be achieved. I am really concerned about this issue. Promises were made and now there is the question of whether we actually need the plan.

On question No. 34 on the children's palliative care programme, I am pleased to hear that the candidates for outreach nurses have been chosen, but when will they be in their posts? I have asked this question at previous quarterly meetings. Where will the palliative care fit in the reform of the health services? There have been many initiatives and developments, including staff training in palliative and end-of-life care, many of which are currently funded by the Irish Hospice Foundation. Can the Minister and the HSE outline the plans they have to fund these projects in order that they will continue? The Irish Hospice Foundation contributed €5.7 million this year.

In the area of palliative care for children, doctors are sometimes loth to say to parents and to write down that their child has a terminal illness. This is a big issue the Irish Hospice Foundation faces in regard to medical cards for children with terminal illnesses. The parents only get a medical card for their child when the child is at the end of life. Can the issue of medical cards for terminally ill children be addressed?

Jerry Buttimer (Cork South Central, Fine Gael)
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There are five other speakers. I will call the Minister to respond to those questions.

James Reilly (Dublin North, Fine Gael)
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I thank Senator Colm Burke for the issue he raised, as it is one of that is serious concern, and certainly of serious concern to me. The idea that people are on six-month contracts is something I have discussed already with the Department. We are looking at giving people a three-year contract when they have done their intern years. In that way we would have them for two more years as SHOs, and that would also give them some certainty. Equally, when people join the SPR scheme, it costs €150,000 to €200,000 to train a medical student - we have had this conversation previously - but it costs €1 million to create a consultant. If we are looking for value for money and trying to retain people, surely the people we need to hold onto are the people coming off the specialist registrar scheme. We should not be letting three out of four of them go because we have not organised our manpower issues in the manner in which we need to organise them. I want to knock something on the head here. One of the reasons for this situation is unaffordability, because of what we pay consultants. The contract for new entrants is €116,000 to €121,000 per annum. The starting pay for a consultant in the UK and the North of Ireland, which I discussed with the Northern Ireland Minister for Health, Social Services and Public Safety, Mr. Poots, who was down here for the eHealth conference last week - he and I travel up and down and talk quite frequently - is £80,000 sterling. Naturally, people like to compare what they can make in America and the wealthiest countries in the world, but let us consider other places. We are often accused, when talking about drug costs, of looking at a basket of countries whose prices are lower than those in the basket of countries we are in. The same applies here. I believe consultants should be paid well because they do an extremely important job, save people's lives and spend a long time training. I do not know of any other area in which the amount of training they undertake is done. They deserve to be rewarded for that and for the commitment they show to their patients. Without them and without the excellent people on the front line - our NCHDs, all our nursing staff and nursing officers - we would not have been able to maintain a safe service, and in fact to have improved it, in the past few years with the challenges we face.

In terms of the hospital groups and the European working time directive, we are committing to addressing that. The hospital groups are hugely important in allowing and enabling us to do that. Equally, some of the proposals made during the talks with the unions will perhaps allow for a lot of work being done by NCHDs to be done by nurses. There is an understanding that there can be a much greater and much more rewarding role for nurses.

Deputy Naughten raised the issue of medical cards, which the Minister of State, Deputy White, will address. I ask that Dr. Áine Carroll, who is here, have an opportunity to address the issue of strokes, raised by Deputy Naughten. Mr. Tony O'Brien can address the question about the national ambulance service.

The issue Senator Crown raised is one that is very close to my heart. I have declared war on the tobacco industry in the Seanad. I know of no other legal industry whose product causes one out of every two people who use it to die, and that is the reality. Some 700,000 Europeans die from tobacco-related illnesses every year, of whom 5,200 are Irish men and women. Was I aware of this meeting? I was. Would I go to it? No, I would not. I was trying to access a line in the directive on my iPhone, but what I remember from the directive is that it does not recommend that people meet with the tobacco industry except in the area of smuggling, and that was the purpose of that meeting.

I was in Geneva at the World Health Assembly for the WHO last week and I took the opportunity to talk about the tobacco control framework of the WHO and to talk to several other Ministers about the tobacco directive in Europe, of which I am strongly supportive. We have led the campaign in ensuring that this directive makes as much progress as possible. It is our highest priority. Clinical trials are also a high priority. It is an issue for Europe that we are losing funding for research, which is going to other jurisdictions because of the difficulty with bureaucracy that many people experience in Europe. I accept Senator Crown, who I know is involved in research, is up to speed in this area. There is much more we can do to improve this. I take the opportunity again, as I always do, to encourage people to become involved in clinical trials, because not only will they get access to cutting-edge medicine, they will also get a level of supervision they would not normally get as a matter of routine.

Senator Crown mentioned black ops in regard to HIQA. I am going to ignore that, but I will talk about black ops in a different way, and this might be news to some people here because the media do not seem to have taken up this story in a big way. There was a break-in at the EU offices in Brussels last year. The intruders abseiled down from the roof to the seventh floor of the building, cut holes in the plate-glass window, disabled the alarms and got into the offices. There were a number of offices and they went straight to the Office of Tobacco Control and removed all the hard discs from the computers. Who could afford to launch such an operation?

John Crown (Independent)
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I do not think was HIQA.

James Reilly (Dublin North, Fine Gael)
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I think Tracey Cooper will be very relieved to hear that. We could look forward to the inspection of some hospitals through that mechanism in the future.

Jerry Buttimer (Cork South Central, Fine Gael)
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Can the Minister return to the relevant matters?

James Reilly (Dublin North, Fine Gael)
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The relevant matter here is that tobacco is a killer.

The tobacco industry is an industry that promotes its product. It must replace 5,200 Irish people and 700,000 Europeans every year with new clients and those clients are children. A total of 78% of smokers surveyed in this country said they started smoking when they were under the age of 18 and several surveys done across the EU have shown more than 70% in all instances had started smoking under the age of 18. The industry is targeting the most vulnerable in society. Far from being a nanny state, we have a duty of care to minors. One could ask what choice one has once one turns 18 if one is already addicted. One's choice is gone.

I take the area of tobacco control extremely seriously and I know I will have Government backing when I go to Cabinet with a memo on plain packaging for cigarette products in this country. We will be the first country in Europe and the first one in the world after Australia to do that. Australia has faced challenge after challenge, by every conceivable mechanism, including the courts and the World Trade Organization, among others. We will support Australia in every way we can to resist the challenges. I assure Senators Crown, van Turnhout and Daly that we will follow the lead of Australia and go further. I will support their Bill. We are progressing legislation to ban smoking in cars where children are present.

On the issues raised by Senator van Turnhout, Dr. Carroll will deal with strokes and neuro-rehabilitation, the Minister of State, Deputy White, will deal with medical cards, while the Minister of State, Deputy Lynch, will deal with cochlear implants.

Alex White (Dublin South, Labour)
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Two issues were raised on medical cards. Deputy Naughten inquired about a differential approach to medical cards. First, I thought he was saying there should not be a differential approach but in fact he was saying the opposite, that the approach taken should have regard to region-specific issues such as access to services in one part of the country that are not available in another area. I am told that such considerations are taken into account and that even though the system has been centralised, the medical needs assessment is carried out on a regional basis in terms of whether a person is entitled to a discretionary medical card.

In response to Senator van Turnhout’s question on terminally ill children and the views of the Irish Hospice Foundation, I would be happy to get clarification on the point made. However, it must be reiterated that in the case of terminally ill persons, no means test applies to the application for a medical card and a card is provided within 24 hours of application. If that is not happening, I want to know about it.

Kathleen Lynch (Cork North Central, Labour)
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I wish to deal with two issues raised by Senator van Turnhout on cochlear implants and whether it takes six to eight months before a decision is made. It is a fact that such time is required. We made that clear yesterday. The process is that one must budget for certain provisions and if it was not budgeted for last year then it must be a matter for discussion in next year’s budget. People did not expect to walk out from yesterday’s meeting with a cheque for €7 million in their pocket.

Jillian van Turnhout (Independent)
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The children in question are a critical group.

Kathleen Lynch (Cork North Central, Labour)
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I accept that all the children in that category are critical. People who are campaigning, who have a good argument, understood very well the explanation of the process in place. Their point is that at least they now know what the process is and that it has begun. It is also important to acknowledge the people who have been operating under considerable constraints. One lady referred to getting a couple of bob here and a couple of bob there for the past 19 years. People need to have certainty about their position. That is important.

The four palliative care nurses have already been chosen but the normal vetting procedure must take place. We are all conscious of the fact that we are dealing with vulnerable people and such clearance is important. In recent months I have spoken to several people involved in the hospice movement – the focus has now moved to palliative care – and as well as the standard hospice care, the emphasis is now moving towards home-based and community-delivered palliative care. In particular when it comes to children with life-limiting conditions, it is important that the emphasis is not on care in an institution, but in the home and in their community. That is a good development.

Mr. Tony O'Brien:

I will ask Dr. Áine Carroll to address stroke units and rehabilitation-related issues and then Ms McGuinness will comment on school leavers and the ambulance service.

Dr. Áine Carroll:

I thank members for their questions on stroke care and the rehabilitation services. In addition to my current role, my day job is a specialist in neurological rehabilitation. I am a brain injury rehabilitation consultant and most of my patients, unfortunately, are young adults with stroke. It is not an exaggeration to say that stroke care in this country has literally been transformed in recent years with the work of my multidisciplinary colleagues in the stroke programme, but also the work of the Irish Heart Foundation stroke council. Stroke provision has dramatically changed and thrombolysis rates have gone from being among the worst in Europe to one of the best. The rate has changed from approximately 2% to in excess of 9% in two years, which is an extraordinary achievement. I applaud the work of my colleagues in doing that. The stroke programme has been doing much work on getting access in a safe manner to thrombolysis but also to specialist rehabilitation and specialist acute care for stroke patients. The programme is on target. Our hope is that the stroke unit in Cork will be open by the end of June. Access to 24-7 thrombolysis is improving and with the development of telemedicine that will be increased again. We are very happy and the citizens of this country have now got access to high quality stroke care.

With regard to neurological rehabilitation, I can comment on the clinical programme as I was the clinical lead of the rehabilitation medicine programme before I took up my current role. It is correct to say that the clinical programme is examining the strategic delivery of neurological rehabilitation but it is very likely that with the developments in the programme that it will meet a lot of the recommendations that came out of the strategy. The deliverables for 2013 from the rehabilitation medicine programme include the model of care, which is entering its final stages. My colleague, Dr. Jacinta Morgan, has recently been appointed clinical lead of the rehabilitation medicine programme and she will lead it for the next couple of years. We are looking to develop four regional inpatient rehabilitation units and outpatient rehabilitation units. Five additional consultant appointments are currently going through the recruitment process. That is a 70% increase in the number of consultants in rehabilitation medicine.

In terms of community rehabilitation, through the clinical programmes there will be a cross-progamme initiative to look at the management of long-term conditions. Part of the work will be to look at the provision of rehabilitation services not just for neurological conditions, but for all long-term conditions. We hope to see a group being brought together in the next few months. A key part of the work of the clinical programmes is looking at the issues of unscheduled care but also long-term conditions.

Colm Burke (Fine Gael)
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Could we not set targets to reduce the numbers on six-month contracts? I got nothing out of the meeting.

Jerry Buttimer (Cork South Central, Fine Gael)
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To whom is Senator Burke addressing his question?

Colm Burke (Fine Gael)
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My question is for Mr. O’Brien and the Minister. The second issue I raised was about a forum on elderly care involving various groups. The question was not answered and I seek a response.

Jillian van Turnhout (Independent)
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I wish to note my concern. A commitment was made to publish an implementation plan and there should be one in this area. I note the matter and I will continue to pursue it.

Denis Naughten (Roscommon-South Leitrim, Independent)
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My question related to 24-7 thrombolysis in the 22 units. I am aware that Ms McGuinness is very keen to contribute.

Kathleen Lynch (Cork North Central, Labour)
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There is no serious objection to setting up a forum on elderly care provided we know exactly what was on the agenda. For instance, policy must be an issue for both Government and the Health Service Executive but if it is about the way people are managed once they are in the system that would be a worthwhile platform in terms of considering the stage at which people need to go to an acute unit and so on. I do not believe that would be a problem but we would have to have clear lines in terms of the issues on which it could decide and the outcomes.

Jerry Buttimer (Cork South Central, Fine Gael)
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I call the Minister.

James Reilly (Dublin North, Fine Gael)
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What particular question does the Chairman want me to address?

Jerry Buttimer (Cork South Central, Fine Gael)
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Senator Burke asked a question about the time limits-----

Colm Burke (Fine Gael)
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Can we set targets for the numbers on six-month contracts?

James Reilly (Dublin North, Fine Gael)
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I, too, am very concerned about that and I believe we should be moving in that direction. I have spoken to the Department about it. We will engage with the HSE, move the situation forward and revert to the Deputy on it.

Jerry Buttimer (Cork South Central, Fine Gael)
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In terms of the EU working directive, a number of parents of non-consultant hospital doctors, NCHDs, came to see me because they were genuinely concerned about the number of hours they worked, their health and the stress they were under. I have spoken to members of the Irish Medical Organisation who were involved in the NCHD sub-committee and they are concerned.

James Reilly (Dublin North, Fine Gael)
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I want to be absolutely clear about this. I have met with Commissioner Andor on a number of occasions. I have given him a commitment that we will be within the working time directive in the next 24 months, that we have a time schedule laid out and timelines that must be met about different areas. That is why the hospital groups aspect is so important because it will allow for reduced hours for non-consultant hospital doctors.

Equally, the Labour Relations Commission arrangements we entered into with consultants before Christmas are very important. Many people thought the any five days out of seven issue was a big thing, and it is, but what is more important is that we now have clinical directors who are appointed rather than elected and who have authority and responsibility. They can dictate who is and is not on duty and the number of NCHDs that should be on. It is now no longer down to the individual consultant insisting that his or her team has to be on duty at all times when that is not clinically indicated.

Jerry Buttimer (Cork South Central, Fine Gael)
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Dr. Mark Murphy and other NCHDs came before the committee some weeks ago. I do not want to put Mr. O'Brien on the spot in terms of the deal done on career path this week with the Labour Relations Commission but one of the major points from that meeting was the need for a clear career path for our own Irish-educated and trained professionals to stay here rather than going abroad to work, which I accept the Minister mentioned earlier.

James Reilly (Dublin North, Fine Gael)
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I have made this point previously. It is bizarre that we are spending large sums of money training our own graduates, some of whom make the best doctors in the world. We know that because when they go abroad they excel. We educate and train them to go abroad to work and we go to Third World countries and recruit their doctors. That does not make any sense. The issue around a clear career path is critical, and we are exploring how to progress that and make it happen. I do not want to leave this office without having resolved that issue.

Jerry Buttimer (Cork South Central, Fine Gael)
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Does Mr. O'Brien want to comment?

Mr. Barry O'Brien:

To answer Senator Burke, we are working with the training bodies for them to consider offering multi-year training agreements. That would bring greater stability to the employment contract. There is a clear distinction to be made between training and employment, and we are working with them on that.

Jerry Buttimer (Cork South Central, Fine Gael)
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I raise a point on which I do not want an answer today but ask that the witnesses might revert to me on it. It concerns extra accommodation charges being imposed on University College Cork medical students. I accept it is not necessarily their job but they might examine it in a different way.

James Reilly (Dublin North, Fine Gael)
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The Chairman advised Senator Crown a few minutes ago on a question that was not on the clár.

Jerry Buttimer (Cork South Central, Fine Gael)
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I did say I did not want an answer on it today. Deputies McLellan, Fitzpatrick, Troy, Flanagan, McConalogue-----

Denis Naughten (Roscommon-South Leitrim, Independent)
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Chairman, I think Ms McGuinness is anxious to answer my question.

Jerry Buttimer (Cork South Central, Fine Gael)
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My apologies.

Ms Laverne McGuinness:

Deputy Naughten is anxious-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I am glad the Deputy is back chairing the committee.

Ms Laverne McGuinness:

I have two responses, the first of which concerns disabilities, particularly the day places. That money has not been allocated yet to each region but it will be available at the end of May in terms of the number of places and the amount of money required. The money is being held centrally to ensure it is equitable and allocated to the most appropriate places. We have a standards guidance document which will assist with that. Last year, we had a 99% success rate with those day places and we hope to have the same outcome this year.

The Deputy asked a number of questions related to the ambulance service. In our new format performance monitoring report we have a number of pages at the front with about 12 high-level key messages but all the other information is in the supplementary report, and the ambulance information is in that supplementary report which is published on the web. Unfortunately, due to a glitch the Deputy did not get the regional breakdowns. I have them here. I will give him my hard copy. I will also e-mail them to the Deputy.

The Deputy asked the reason we are using targets that are different from the Health Information and Quality Authority, HIQA, targets. HIQA was using targets of 85% in terms of its DELTA calls. We set targets this year of 70% and 68% because other jurisdictions have been using these indicators for years. We are still at an early stage of that but we believe that is what we should strive towards. Already, we are achieving 73% on our ECHO calls but that is not throughout each of the regions. As the Deputy is aware, the west is not performing appropriately.

There is a full 57 point action plan in place in terms of the way we improve our response times. There are critical dependencies in that. We have invested heavily in our ambulance service this year, with €12.2 million in revenue going into it. That is to do with adult retrieval, but particularly regarding our intermediate care vehicles, to which Mr. O'Brien referred. That will make more ambulances available to respond to emergencies. Some 25 new vehicles are on order from June onwards and 80 staff will come in to give effect to that. That will significantly improve our response times.

The other element which will significantly improve response times is a €23 million investment since 2010. We will have a brand new control centre and system whereby we will be able to see every ambulance throughout the country and to where they are being dispatched. That will ensure they are going to the most efficient location. We will also be able to see the length of time they may be delayed, and link that in with the hospitals. That means more effective and timely dispatch, thereby ensuring we will have more appropriate responses. We have approval for that system to go in place. Already, we are moving our control centres to one centre over two sites. We hope all that will be operational by the first quarter of next year, with much of it to be in place by the end of this year. Two sites have been moved already. Cork and Kerry moved last week to Townsend Street, and Navan will move in June-July.

Denis Naughten (Roscommon-South Leitrim, Independent)
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In relation to-----

Jerry Buttimer (Cork South Central, Fine Gael)
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No, Deputy.

Ms Laverne McGuinness:

The industrial relations issues are being progressed significantly and well in regard to those issues. I can speak to the Deputy privately on those if that is required.

Sandra McLellan (Cork East, Sinn Fein)
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I thank the witnesses for their presentations. With regard to question 29, the plans to increase the numbers of school dentists in Cork, the reply stated that 48 dentists are currently employed in the school dental service of Cork ICA and that in the past two years, four to five dentists have left the dental service. Have those dentists been replaced and, if not, when will they be replaced?

Prior to those dentists leaving, a problem arose in Youghal where children were not being seen until they were in secondary school. That gap must be addressed. It was identified recently as a problem by this committee. Do the witnesses have plans in place to rectify that?

Regarding medical cards issued on discretionary grounds, my question related to cancer patients. Aside from the costs of medication, cancer patients are constantly cold. The heating must be on 24 hours a day, seven days a week. When people fill in the income and means section of a form, they do not know how much time their partner who is on that income will have to take off in the course of a year to provide assistance to their partner in the home or bring them to hospital appointments. They have to take off a good deal of time for which they are not paid.

There also are travel costs to and from hospital appointments and if there are young children in the equation, they sometimes must be taken out of the home environment, thereby entailing additional child care costs. If someone is very ill in the home, no account is taken of the need to buy in ready-made meals sometimes, because people are too ill to cope with cooking. This is the human cost and no box on any form will take that into account. In itself, this provides undue hardship and I believe people do not take into account this side of it. I will conclude my comments on cancer services by noting that, as a parent who lost a child to cancer stated on radio yesterday, the medical card is the most important thing to the parents of a child with cancer. We owe it to the children of the country to protect them.

Finally, I refer to the ambulance service in Cork. As the witnesses are aware, two tragedies occurred in Midleton within a short time. In common with everyone else, I wish to extend my deep sympathies to the families. However, I wish to point out that just 12 hours before the death of Vakaris Martinaitis on the bank holiday weekend, there had been an incident in Youghal in which a man was assaulted in an unprovoked attack. He was left seriously injured and lying in a pool of blood on the street, but the ambulance did not come for 53 minutes. I have been informed that two rapid response vehicles were on duty at the time but neither attended. I do not know where they were.

Jerry Buttimer (Cork South Central, Fine Gael)
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For the Deputy's own sake, she should be careful of the facts.

Sandra McLellan (Cork East, Sinn Fein)
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I have got all this information anyway. The local gardaí were obliged to call on the fire brigade to provide assistance. It was on call - not on duty - and came to the scene and provided assistance. However, my point is these are not merely isolated incidents. As people in east Cork have no confidence in the ambulance service at present, does the Minister intend to conduct a review of the reconfiguration of that service there? Ms Laverne McGuinness mentioned that €23 million is being invested in a control system, which is most welcome, and money is being invested in more ambulances. However, will any of them be deployed in the east Cork area? I welcome the HSE's commissioning of a formal review into the manner in which the 999 call was received in Midleton and that a liaison officer has been provided for the family, but these are not merely isolated instances. There have been other instances in the east Cork area and that is the reason people there have no confidence in the service at present,

Peter Fitzpatrick (Louth, Fine Gael)
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Yesterday, together with other Members of the Oireachtas, members of the joint committee had a meeting with the Happy New Ear campaign on cochlear implantation. At present, the number of such implantations stands at 90 patients per year and the annual budget in Beaumont Hospital for this service, inclusive of implants, is more than €4 million. Last year, 48 adults and 42 children received implants and more than 700 patients are in the ongoing support programme for rehabilitation. The cost of a single implant is between €18,000 and €20,000 and the Happy New Ear campaign stated yesterday that one could perform a simultaneous implant for approximately the same price. There is no delegated programme for simultaneous implants to be carried out in Ireland. I acknowledge the HSE is working closely with Beaumont Hospital to further plans for both simultaneous and bilateral implantations. At present, approximately 200 children in Ireland may be suitable for a second implant. A small number of them have received bilateral implants due to medical conditions such as meningitis and blindness. The Minister should note that 22 centres in the United Kingdom carry out these implants at a cost of €30,000 per family. While families are trying to gather together this money to travel to the United Kingdom to have this operation performed, they are worried about the after-care service. Yesterday, they wanted to know whether, were they to travel to the United Kingdom to have these operations done, Beaumont Hospital would provide an after-care service for them. All parents want is for their children to be given a chance to have a normal life. I acknowledge the Minister of State, Deputy Kathleen Lynch, met the group yesterday but were the Minister to meet these people in the near future, I would appreciate it. This would give them the opportunity at first hand to express their concerns. The Minister is a family man like me and I know he will make himself available.

Robert Troy (Longford-Westmeath, Fianna Fail)
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I welcome the Minister and the officials who are present. In response to one question I asked on Mullingar hospital in particular-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Sorry Deputy, what question number is that?

Robert Troy (Longford-Westmeath, Fianna Fail)
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I refer to question No. 25. It stated that a realistic budget for 2013 was based on the level of activity in 2012. Was this based on the level of activity in 2012 that saw accident and emergency services and medical discharges increase by 7%? If so, why was the budget then reduced by €1.5 million? In the reply to the question, the HSE was unable to indicate what would be Mullingar hospital's future role in the context of the hospital groupings. This leads me to ask when the answers to these questions were drawn up, because that information was published last week. I note the aforementioned hospital will be in a grouping with Navan hospital and that the removal of 24-hour accident and emergency services from the latter will result in an increase in patient activity in Mullingar hospital. Will this increase be matched with additional funding? As the Minister's mantra is the money will always follow the patient, given that activity in Mullingar hospital has increased, I would like to think that financial support also will increase there. The Minister might answer me in this regard.

As for the mental health budget, the Minister of State, Deputy Kathleen Lynch, will be aware that I raised this issue on four separate occasions last year through Topical Issue debates. While everyone agrees the service must be delivered where it is needed, one should be honest: the €35 million was not spent last year because it was eaten up in the big black hole in the HSE's budget. It is now halfway through 2013 and the 2012 targets still have not been met. When will the 2012 targets be met fully? When will the roll-out of the 2013 targets begin? Will the €35 million that has been ring-fenced for 2013 be spent this year? Given the rates of suicide and deliberate self-harm, it is imperative that this receives priority.

On the transfer of staff from the HSE to the new child and family support agency-----

Jerry Buttimer (Cork South Central, Fine Gael)
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That issue pertains more to children's services.

Robert Troy (Longford-Westmeath, Fianna Fail)
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The staff are being transferred from the HSE to the new agency. When will the transfer be completed? Are there any industrial relations issues and have the HSE and Department of Health reached an agreement with the Department of Children and Youth Affairs regarding the budget deficit that exists?

Jerry Buttimer (Cork South Central, Fine Gael)
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As this discussion is on the questions members have submitted, I cannot allow that question to be asked.

Robert Troy (Longford-Westmeath, Fianna Fail)
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To be fair-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I am being fair.

Robert Troy (Longford-Westmeath, Fianna Fail)
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The Minister did indicate he would be willing to take any questions. He stated that "I and my ministerial colleagues will be happy to answer the committee's questions on these and [any] other issues" during the course of the meeting. I am merely taking the Minister at his word. I acknowledge the people of Roscommon also took him at his word, to their detriment.

Jerry Buttimer (Cork South Central, Fine Gael)
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Sorry, the last remark was unnecessary and we do not carry on in that way in this committee.

Robert Troy (Longford-Westmeath, Fianna Fail)
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I apologise to the Chairman and the Minister.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will not let you take the last question because it is not relevant. To be fair, the quarterly meeting is on the questions submitted by members and as the Deputy is aware, I allow some latitude.

Robert Troy (Longford-Westmeath, Fianna Fail)
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In that case, may I ask a substitute question?

Jerry Buttimer (Cork South Central, Fine Gael)
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No, the Deputy is over his time. Deputies Luke 'Ming' Flanagan and McConalogue are not members of the joint committee but they wish to ask questions.

Luke Flanagan (Roscommon-South Leitrim, Independent)
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Must it relate to a question that had been tabled?

Jerry Buttimer (Cork South Central, Fine Gael)
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To get an answer, it does. The Deputy should be aware he may not be able to get an answer to a specific question right now.

Luke Flanagan (Roscommon-South Leitrim, Independent)
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This question is for the Minister of State, Deputy Kathleen Lynch. In respect of the Happy New Ear campaign group, what exactly will be taken into account in the business plan? For example, will the provision of special needs assistants in classrooms, who potentially would be required for people who did not receive such implants, be taken into account? Similarly, does it take into account how, as one parent told me, the school was obliged to buy additional audio equipment? Does it take into account every financial impact? How does the Minister of State think the Happy New Ear group will react to the fact it now appears as though nothing really will happen until the new year?

Is that the case? The business plan is due for completion in June. How will it take six months between the report being published and something being done about it? As has already been pointed out, time is of the essence. The longer some of these children must wait, the less successful the implants will be. When I first heard about this, it was amazing news that this invention even existed. It is really good news. It would be a shame that some children would be denied the right to get the best use of this invention.

I have another question which I do not know whether the Chairman will allow. I do not see this issue being dealt with at all. I refer to the €3.7 billion bill that the State faces every year due to alcohol abuse. There was a report published by former junior Minister, Deputy Róisín Shortall, which got a massive amount of media coverage.

Jerry Buttimer (Cork South Central, Fine Gael)
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She did not produce a report. This committee produced a report.

Luke Flanagan (Roscommon-South Leitrim, Independent)
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Fair enough. I wonder what is happening about this. Is there something being done about the price of and ease of access to alcohol? Is anything happening? I attended all of the meetings of the Joint Committee on Transport and Communications on the ban on alcohol advertising. Given the scarity of resources and that it costs the State €3.7 billion a year, I wonder what is happening with it. I am a little disappointed with the way the matter is proceeding.

I also am disappointed that, among many of the members of the committee who spoke on the issue of alcohol abuse, it seems unpopular to do anything about this. Members seem to be running a mile from it and we cannot do that.

Jerry Buttimer (Cork South Central, Fine Gael)
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For the purposes of clarification, when this committee was formed, it was the initial topic of deliberation that we took on as a priority. We produced a report, which we gave to the former Minister of State, Deputy Róisín Shortall. The Minister of State, Deputy Alex White, will respond to Deputy Luke 'Ming' Flanagan on that.

Luke Flanagan (Roscommon-South Leitrim, Independent)
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What was done with the report?

Jerry Buttimer (Cork South Central, Fine Gael)
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It is a priority, as are drugs. The committee shares Deputy Luke 'Ming' Flanagan's concerns regarding alcohol and I thank him for raising it this morning. I call Deputy McConalogue, the last man standing.

Charlie McConalogue (Donegal North East, Fianna Fail)
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I seek a response to a previously submitted question, Question No. 25, part one, on Carndonagh Community Hospital in Donegal, from the Minister for Health and the deputy CEO of the HSE. When the question was submitted over three weeks ago, four beds in Carndonagh Community Hospital had been closed, we were told, on a temporary basis by the HSE. Since then, those four beds have not reopened. In fact, two more have been closed, reducing the amount of beds open in the community hospital, from 30 to 24.

The Minister's response today is quite worrying in that it does not indicate these beds will reopen. I note the Minister indicated in his response that the overall bed capacity in the hospital is 36. I would point out to him that, in fact, it should be 46 because the capacity in the community hospital is 30 beds, of which only 24 are currently operating, and the capacity in the state-of-the-art dementia unit in the hospital, Ard Aoibhinn, is 16, of which only 12 have been operating in the past while. My question to the Minister is will beds reopen and will the Minister address the situation which is leading to these beds being closed, that is, the recruitment embargo and the failure to replace staff as they retire or where they are off for long-term reasons? Hospitals such as Carndonagh provide the capacity to operate beds which provide step-down from general hospitals, assessment which prevents having to admit to more acute hospitals and respite to the community, and such beds are being closed. Since I submitted this question, ten beds have also closed in Dungloe Community Hospital in Donegal for the same reason. The recruitment embargo is getting to a stage where it is long past the tipping point. Will these beds reopen and will the Minister and the deputy CEO of the HSE, Mr. O'Brien, ensure that the Government addresses the recruitment embargo which is driving hospitals to the position where they are closing beds?

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Deputy McConalogue and welcome him back to the committee.

Charlie McConalogue (Donegal North East, Fianna Fail)
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I thank the Chairman.

James Reilly (Dublin North, Fine Gael)
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I will leave Deputy McLellan's questions on the dentists and medical cards to the Minister of State, Deputy Alex White.

I am sure Mr. O'Brien and Ms Laverne McGuinness will have points to make on the ambulance service in Cork. It would be worthwhile, at a mimimum, conducting a review of local GPs to see what is their experience of the ambulance service and to quantify whether there is a problem, and that would not be overly difficult to achieve. On the terrible tragedies, like others, I again express my sympathy to the families concerned. There will be an investigation. The committee will note from the membership of that investigation that there is nobody from HSE south involved and we have sought expertise from both the North of Ireland and the United Kingdom.

Deputy Fitzpatrick mentioned the cochlear implants. We had a good discussion on that already. He asked if I would meet the parents. I would be more than happy to do so. Given the schedule I have had over the past number of weeks, with the EU Presidency, WHO, e-Health conference, etc., that has not been possible. I am pleased that my colleague, the Minister of State, Deputy Kathleen Lynch, was able to meet them yesterday. I am pleased to be able to say that the funding has been put aside for next year to allow for the simultaneous bilateral implantations to take place but, as I stated earlier, there is a business plan to be put in place. There will be recruitment issues as well. I compliment the consultant who does this work, Ms Laura Viani. She is a wonderful person. She has been doing it for years and she works only in the public sector.

There are questions about Mullingar hospital and the removal of the emergency department in Navan. We made clear that there will be no change in Navan emergency department until such time as there is capacity in the system to allow that to happen, and that is not any time soon that I see. For me to preclude what will and will not happen, however, would be to defeat the very purpose of the hospital groups, which is, to devolve as much authority and autonomy locally as possible, and allow them control over their own staff recruitment, over their own budgets and over procurement in so far as it is possible, and that they communicate with us centrally to ensure that the deals they are getting are the best deals available and that we are aware of the best deals available to transpose across the system.

Mr. O'Brien can answer more comprehensively on the budget issue.

Mention was made of mental health. The Minister of State, Deputy Kathleen Lynch, will deal with that.

Deputy Luke 'Ming' Flanagan mentioned the issue of alcohol. I have had many discussions with my Cabinet colleagues on this. The Minister of State, Deputy Alex White, and I met only yesterday on progressing this to a memorandum to Government. There is obviously a degree of tension in certain areas between certain Departments, but we in the Department of Health are clear. We acknowledge the significant damage that abuse of alcohol does. I reiterate my commitment to protecting children and in my view, it is inappropriate to have advertising earlier than a certain hour or watershed at night. Sporting events are critically important to the well-being of children in that we are trying to get them to take more physical exercise and be involved in sport and community and major sporting events are part of that continuum, and I do not believe it is appropriate that these sporting events should be sponsored by alcohol companies.

Luke Flanagan (Roscommon-South Leitrim, Independent)
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The Minister is in a minority.

James Reilly (Dublin North, Fine Gael)
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Deputy Luke 'Ming' Flanagan may find that he is wrong. There has been much negotiation. In fairness, we must allow the sporting organisations to replace their current advertisers and sponsors with others. They stated the same about tobacco advertising when it was removed and, sadly, there is still 29% prevalence of tobacco smoking in the country. Happily, I am able to say there has been an 8% reduction in the number of those aged 12 smoking, which is good news because, like I say, the advertising is focused on children. It is the same with alcohol. However, alcohol is very different from tobacco. No consumption of tobacco is at a safe level. Every cigarette harms you and one out of two smokers will die earlier. However, alcohol can be a normal part of life, in terms of sensible drinking as a social lubricant, etc. The issue is its abuse and young people starting to drink alcohol too young and developing bad habits. Minimum pricing is a significant issue for us. I note the Scottish Government has got it through.

We are examining its legislation. We want to promote that also. We have had very good conversations with Minister Poots in the North and we want to move on these issues simultaneously as one so there will be no cross-Border activity being promoted that would be counter-productive from a public health perspective.

I have already covered the issue of the cochlear implants. Deputy Lynch will talk more about it. She will also deal with care for the elderly in Cardonagh but I must make two points about it, however. I acknowledge we have not had an overly political conversation here but the reality-----

Jerry Buttimer (Cork South Central, Fine Gael)
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We will not try to have it now either.

James Reilly (Dublin North, Fine Gael)
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It is a bit rich to be told about a recruitment embargo that Fianna Fáil introduced itself. It is a bit rich to talk about the country's finances when we all know the cause of the problem and that we are struggling. Despite taking €3 billion out of health services and losing over 10,000 staff, we have not only maintained a safe health service but have also improved it, as evidenced by the figures I gave on inpatient treatment times, the number who must endure long waits on trolleys and in our commitment to deal with outpatient appointments, which no previous Government would even consider. The approach of former Minister, Deputy Martin, was to sweep it under the carpet or throw money at it and hope it would go away.

We have had a good meeting. I will not be overly political about this matter but believe we have made considerable strides. I thank all the staff working in the health service, particularly those on the front line and the management who have stepped up to the plate, are embracing reform and changing outcomes for the better for our people. That is what it is all about.

Alex White (Dublin South, Labour)
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I endorse very strongly what the Minister said about the professional staff, including the management, right across the system in circumstances of enormous pressure. Right across the board, there has been an incredible sense of dedication and commitment to what needs to be done. It is worth stating that, at a time of enormous financial pressure and retrenchment, we still have managed to maintain a very strong health care infrastructure, even in circumstances in which we are under such enormous pressure. My point applies to the primary care system right across the board. Some 38% or 40% of people are on medical cards. I am not seeking praise or thanks but simply saying that we have managed to keep the infrastructure in place, even in circumstances of enormous pressure.

Deputy McLellan is right that in circumstances of family illness, particularly where a child is concerned, the last thing anyone wants to have to struggle with is applications, form filling or box ticking. The humanity of the circumstances is clear to us. We do not want to see people struggling when they are under such pressure already.

We have never had a system in which people got medical cards on the basis of having a particular illness. People have outlined their views on the medical card system on the radio. The system does not distribute medical cards to people on the basis of a particular illness. That sounds like a harsh statement but I am simply repeating it. It is not how cards are allocated but we do have a discretionary system for allocating medical cards to people who have various conditions, such as cancer. However, we must put in place a system such that this can occur. I want it to be done sensitively and do not want it to be a box-ticking exercise. I want us to be aware of the kinds of issues that the Deputy raised. One's income may change over a period of months and may be affected by the illness itself or the circumstances of one's partner. I want the system to take that into account as best it can. If the system can be improved, let us try to achieve that. The system is not such that a person can be automatically given a medical card on the basis of an illness. We must have a way of dealing with that.

I thank Deputy Flanagan for his support on the issue of alcohol. I am aware that he gave very strong support to the public health dimension at a different committee meeting, when he was, perhaps, in a minority. I thank him, other members and particularly the members of this committee, who have a public health perspective. Others have different perspectives, and that is fine also. Our perspective, as stated very well by the Minister, is that alcohol presents a public health issue, particularly in respect of children and young adults. I have no doubt that advertising and sponsorship have an impact on the conduct and behaviour of children and young adults, in particular. I am told by others, including colleagues in the Government, that there is no evidence for this, but there is evidence. There is no direct behavioural link such that someone who sees a billboard will go straight for a drink because the process is far more subtle, but the close association of alcohol with major sporting events is totally inappropriate and should and will be addressed. What I have been trying to do in recent months is maximise agreement across all Departments and Ministers. As with many tasks, this has taken longer than I would have hoped for. We have been doing what I describe with a view to bringing to the Government the memorandum that would have the maximum agreement associated with it. What the Minister, Deputy Reilly, said is absolutely correct.

Jerry Buttimer (Cork South Central, Fine Gael)
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Has the Minister of State a timeline for that?

Alex White (Dublin South, Labour)
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There is a good chance that the memorandum will be signed off this very week. It will be ready in the next couple of weeks. It will deal with the issues of pricing, ease of access to alcohol, and advertising and sponsorship.

James Reilly (Dublin North, Fine Gael)
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The Minister of State and I have been working on this aggressively. The Minister of State has led the charge and I am 100% behind him. I have had meetings with senior Cabinet colleagues on the matter in order to seek agreement. As with the Minister of State, I am hopeful that the memorandum will be signed off this week.

Let me make one point that I got distracted from making on the power of advertising. I thank Deputy Flanagan for his support in regard to it. In a survey carried out on 12-year-olds, they were not able to name one brand of tobacco but could name five brands of alcohol. That shows the power of advertising.

Kathleen Lynch (Cork North Central, Labour)
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Can I respond to Deputy Troy's question on mental health? The Deputy has raised this issue several times. On having seen a "Prime Time" programme recently, it struck me that if one says something often enough, it is taken as the truth. It is sometimes not the truth. We spent the €35 million last year and did so by putting in place 339 additional mental health posts. There are 42 on offer as we speak. The others are not filled because it is a question of geography. People do not want to go to certain areas. It is also a question of people living or working abroad. We must stop saying things that are clearly not true.

What I have said is the truth, a fact. The evidence is that in every community people have found the mental health service has improved dramatically. I have a list to hand of very large institutions in which, until recently, over 1,000 people were living. These institutions have now closed. They have closed because the service has moved to a different space and because it has changed dramatically. There was an allocation of €35 million this year, and with that we are doing exactly what we did last year. We want each region to send us its business case on where it believes there is a gap in its service in regard to old age psychiatry, intellectual disability psychiatry, forensics, etc. The national counselling service is also being rolled out. Circumstances are changing. Some nights ago on "Prime Time", people whom one would expect to know better trotted out the old line that we did not spend the €35 million. I do not know who is paying these people their wages. Someone is doing so; they are not working for nothing.
The Happy New Ear campaign was alluded to by Deputies Flanagan and Fitzpatrick. Deputy Flanagan should note the business case will involve a very narrow process. It is a case of determining what personnel we need to deliver the service if it is in Beaumont or if it moves eventually to the new paediatric hospital. That is in the future. We must ask what we need to deliver the service. I understand the point that if one does not address this, it will cost more downstream, but that is not what this is about.

This is a very clear plan on how we can deliver it. When that business case is made, the Minister, Deputy Reilly, and myself will examine it to see where we go from there. I assume it will not be done for nothing, so in order to get the money and deliver this service we will have to include it in the budgetary process and negotiate it, as we did with mental health services. We simply have to argue the point about this additional service.

The people I met yesterday are happy that there is now a process and they know where it is going. I did not make any commitment to them yesterday. I said we would have to go into the budgetary process in the same way as everyone else, but their case will be clearly made. I think they are reasonably happy with that. If it could be done tomorrow or the day after, of course, everyone would be thrilled but that is not how it works. They know what is going to happen and they are happy about that.

I dealt with the issue of community nursing homes in the Seanad recently. These beds are being closed because HIQA says there are not sufficient staff to deliver a safe level of care. We need to be careful about that because HIQA is our safeguard, both for the Government and those in receipt of care. That is the case even if a member of my family was in a nursing unit where they were getting exceptional care.

Charlie McConalogue (Donegal North East, Fianna Fail)
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There is a recruitment embargo.

Kathleen Lynch (Cork North Central, Labour)
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The recruitment embargo was there before we came in.

Charlie McConalogue (Donegal North East, Fianna Fail)
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It was there last week.

Kathleen Lynch (Cork North Central, Labour)
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That was because people took early retirement which they are entitled to do. They may be on maternity benefit, which they are also entitled to, or they may be out sick. They are entitled to do all that because that is the structure we have in this country, which we all buy into.

If Croke Park II is passed, the additional 1,000 nurses will help the issues of staff shortages and health care. I hope it will be passed.

I never make political points but we are in this position and we need to do it. However, if the renegotiated Croke Park II goes through, it will be a triumph for the Government. It will stand us well in the future. I applaud all concerned, including the unions and the Government negotiators.

Jerry Buttimer (Cork South Central, Fine Gael)
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Does Mr. O'Brien wish to comment?

Mr. Tony O'Brien:

There are a couple of issues to respond to.

Jerry Buttimer (Cork South Central, Fine Gael)
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Please do so.

Mr. Tony O'Brien:

Ms McGuinness will comment on dentistry in Youghal in a moment. I have heard some of the stuff from the "Liveline" programme this week, as well. It is important to make clear that even where a person does not qualify for a medical card or a GP-visit card, there is no circumstance in which - as was suggested on that programme yesterday - a person could be left with a monthly bill of €1,000 for drugs because the drugs payment scheme threshold is €144 per family per month. There are aspects of the debate that will sometimes cause fear and alarm through a lack of complete information, notwithstanding the significance of the underlying issues that are raised by people who call in to that programme.

In a similar vein, we are hearing for the first time about an alleged incident in Youghal, which was 12 hours earlier than the incident we know about. Those alleged facts are now on the record here. They have not been fact-checked or we would know about them. Public confidence is a very important issue. Putting that out in a situation where we are not able to respond with any kind of balancing information is clearly a difficulty for us.

Jerry Buttimer (Cork South Central, Fine Gael)
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Mr. O'Brien might liaise with Deputy McLellan on that matter.

Mr Tony O'Brien:

We certainly will.

As regards the budget of Mullingar hospital, consistent with taking out €121 million of expenditure from the health service this year, a number of budget day decisions were made. There were specific items which, when distributed, do result in a reduction in the budget in Mullingar. However, they do not result in as large a reduction as might otherwise have been the case. There are various issues which, when translated through Croke Park II, will deal to a large extent with those. However, this is balanced by the fact that the hospital is to receive funding in the context of the opening of eight new beds, which are the result of an assessment of its bed capacity requirement. It is impossible to take out that type of funding - some €3.5 billion in recent years - without individual locations suffering budget reductions. It is simply not feasible.

Similarly, as regards an overall reduction of nearly 11,000 staff at this stage from the health service, with more to go this year, that will have an impact on situations such as we are seeing in Carndonagh where the level of staff when assessed by HIQA led to the reduction in the number of beds temporarily, while the local health office makes alternative arrangements to bring staffing up to the necessary levels.

While there is a general moratorium on recruitment it is not so inflexible as to prevent us from responding to particular situations, and the local health office is seeking to do that in Donegal at the moment.

Luke Flanagan (Roscommon-South Leitrim, Independent)
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One can accuse me of being picky but language is very important concerning the alcohol and drug debate. I consistently hear - as I did from the Chairman, although I am sure it was not deliberate - that in talking about alcohol the term "and drugs" is thrown in.

Jerry Buttimer (Cork South Central, Fine Gael)
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In our case, the report was on alcohol and drugs.

Luke Flanagan (Roscommon-South Leitrim, Independent)
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Yes but the point about language is important.

Jerry Buttimer (Cork South Central, Fine Gael)
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It was misuse.

Luke Flanagan (Roscommon-South Leitrim, Independent)
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Yes, misuse or abuse. It is of massive benefit to the alcohol industry to refer to alcohol and then refer to drugs as something separate. Alcohol is a drug, no matter how difficult that might be for people to hear. It is a mind-altering substance. How one deals with it and regulates the substance does not make it something else. We need to keep saying that alcohol is a drug. It is a bit like talking about baguettes and bread, because baguettes are bread. I never heard anyone putting them in a separate category, unless of course it is the baguette marketing company.

Robert Troy (Longford-Westmeath, Fianna Fail)
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Why are the most efficient hospitals being penalised? Activity is up in Mullingar but the money is down. When exactly will the eight new beds be open and at what cost? To be helpful to the Minister of State, Deputy Kathleen Lynch, yesterday the people were extremely appreciative of, and complimentary to, her. They said she was warm and engaging.

I hope she is not paying for any positions that remain vacant, because 414 positions have still not been filled. She acknowledged that.

Charlie McConalogue (Donegal North East, Fianna Fail)
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I thank Mr. O'Brien for his response and saying that the HSE is examining staff issues both in Carndonagh and Dungloe hospitals. The core of the issue is the recruitment embargo. We need to address the impact that is having in those hospitals. It is very disappointing to see-----

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy's line is a repetition.

Charlie McConalogue (Donegal North East, Fianna Fail)
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No. Please, Chairman.

Jerry Buttimer (Cork South Central, Fine Gael)
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Please do not, because you are denigrating the committee.

Charlie McConalogue (Donegal North East, Fianna Fail)
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It is disappointing to state a fact and make it political, rather than dealing with what is a genuine issue.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy is politicising it.

Charlie McConalogue (Donegal North East, Fianna Fail)
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I am sorry to see that the Minister took that approach today.

Jerry Buttimer (Cork South Central, Fine Gael)
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We do not have that type of politicisation on this committee, as a rule.

Sandra McLellan (Cork East, Sinn Fein)
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I may have missed the answer to an earlier question. The HSE is investing in new ambulances and I asked if any of them were going into east Cork.

Ms Laverne McGuinness:

They are not actually ambulances, they are intermediate care vehicles. There will be 25 new intermediate care vehicles that will be able to transport two patients at the same time between hospitals. That will free up and release ambulances, so they will be available to improve response times throughout the country.

Sandra McLellan (Cork East, Sinn Fein)
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Are there any plans to put one, or any, into east Cork?

Ms Laverne McGuinness:

The full plan of where they will go and the timing of when they will be available, will be available from June onwards.

Jerry Buttimer (Cork South Central, Fine Gael)
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Does the Minister wish to make some closing remarks?

James Reilly (Dublin North, Fine Gael)
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I want to echo what the Minister of State said about Croke Park II.

If Croke Park II is accepted, it will be a real triumph for all of the people of Ireland, particularly those using our health services. It will give us many more hours of nursing to enable us to provide more care and services. We can look forward to exciting times of real change in our health service, which will improve conditions and outcomes for patients. There will be new opportunities for those working in the health service as we explore new ways of doing things and delivering more care.

I thank everyone who works in the health service for staying with us. It has been difficult for them but they have done a super job. Given that we have some of the best doctors, nurses and managers in the world, we must ask why do we not have the best health service. It is because the service was allowed to evolve in a chaotic fashion. We are putting order on it and everybody who works in the health service has had an input into that. I want them to continue to have that input and I thank them for it. I thank my colleagues on the committee and the officials from the Department and the HSE for attending today. I include those who did not get an opportunity to speak but who were here and ready to inform us should specialist information have been required.

Jerry Buttimer (Cork South Central, Fine Gael)
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I conclude by thanking everybody who is present. I hope the witnesses will not mind if I do not name everybody and single out Mr. Larry Reilly and Mr. Paul Howard of the Department of Health and Mr. Ray Mitchell of the HSE for their assistance in co-ordinating the meetings. In the malaise and negativity in the media, it is forgotten that we have excellent people working in the health service who have delivered changed work practices and work schedules and greater efficiency. It is a tribute to everybody. I pay tribute to all the staff working in the HSE and the Department of Health no matter who they are. Any hospital or health service facility one walks into is fantastic. I note to Mr. Tony O'Brien and his staff that at a time when public servants are being criticised, my experience has been that HSE staff are courteous and efficient. If the answer is "No", they will say so, but one receives a reply. To be fair to the PCRS staff and Mr. Burke, I thank them for the fact that they reply to Members of the Houses. While officials may feel that we may be too aggressive in some cases in our job of holding them to account, they should know that we appreciate the work of the staff at all levels in the HSE and Department of Health.

Colm Burke (Fine Gael)
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We had three days of public hearings on maternity services and one of the issues which was raised related to the need to review maternity services. Can we place that on the agenda for the next quarterly meeting?

Jerry Buttimer (Cork South Central, Fine Gael)
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That is happening in June. The masters of the hospitals will be attending.

Colm Burke (Fine Gael)
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Can we put it on the agenda of the quarterly meeting also?

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes. Our meeting at 5.30 p.m. on Tuesday next will be in private session.