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.