Jerry Buttimer (Cork South Central, Fine Gael)
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I remind members of the joint committee, witnesses and those in the Visitors Gallery to ensure that their mobile telephones are switched off, or are on aeroplane mode rather than on silent, because they do interfere with the broadcasting of our proceedings. We are being broadcast live today on UPC. It is also unfair to staff whose hearing is disturbed by mobile telephones going off.

This is our quarterly meeting with the Minister for Health, Deputy James Reilly, the Minister of State, Deputy Kathleen Lynch, and the Minister of State, Deputy Alex White, as well as the director general designate of the HSE, Mr. Tony O'Brien, and their officials. They are all welcome.

It has been a busy term for this committee, so I wish to thank all the members for their patience, assistance and co-operation. Before we commence today's business, as Chairman of the committee and on behalf of the members and clerk of the committee, I wish to thank and pay tribute to Ms Mary Lindsay who is leaving us.

Mary has been magnificent as a member of staff of the Committee on Health and Children. Her work has been outstanding and she has often been here at unsociable hours in the morning and late at night over the past two and half years. She is leaving us to transfer to the finance unit and I wish her every success in her career and thank her for her friendship, diligence, patience and courtesy to me and other members of the committee, particularly during our six days of hearings on the Protection of Life During Pregnancy Bill 2013. We will miss her.

Kathleen Lynch (Cork North Central, Labour)
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I have worked with Mary since long before I entered Government. She has given longer service than most of us and has been incredible in terms of organising committees.

Jerry Buttimer (Cork South Central, Fine Gael)
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Before we proceed further, I remind witnesses they are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make comments or charges against a person by name or in such a way as to make him or her identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that members should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

We have received apologies from Deputies Kelleher and Healy and Senator Henry. I welcome the Minister for Health, the Ministers of State at the Department of Health and the officials from the Department and the HSE. I will not name them all I invite the Minister to make his opening remarks.

James Reilly (Dublin North, Fine Gael)
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I thank Mary for her kindness and great service over the years and wish her well in her new position. I thank the Chairman and members of the committee for their invitation to meet them. I am accompanied by the Ministers of State at the Department of Health, Deputy Kathleen Lynch and Deputy Alex White, and we look forward to providing the committee with as much information as possible.

To save committee members the effort of continuing to refer to Mr. Tony O'Brien as DG designate, I am pleased to announce that he is now the director general. The health service is embarking on an important step on the road to reform. I know Mr. O'Brien will be all that he promises in terms of being the leader of a new way of doing business and ensuring better outcomes for our patients and citizens.

A number of notable developments have taken place in the health service since I last addressed the committee on 23 May. It has been my great pleasure to announce the Government's intention to relocate the National Maternity Hospital from Holles Street to the St. Vincent's University Hospital campus at Elm Park. An indicative sum of €150 million has been approved in the HSE's capital plan to allow this to proceed. This project heralds a new and exciting chapter in maternity care for women and infants in Ireland. The proposed relocation addresses a key recommendation in the 2008 KPMG independent review of maternity and gynaecology services in the greater Dublin area, namely, that Dublin maternity hospitals should be located alongside adult acute services. Co-location of maternity hospitals with adult acute services is the optimal solution for the provision of hospital based maternity services because it can provide access to the full range of medical and surgical specialties and clinical support services in sufficient volume and complexity to provide added value. This is particularly important for high-risk mothers and babies. This commitment by the Government underpins a determination to provide strong maternity services for Ireland. It will also strengthen the successful relationship with University College Dublin as part of the Dublin east hospital group.

When I addressed the Committee in May I reported that the INMO had recorded 20,352 fewer trolleys in 2012 compared to 2011, which is a reduction of 23.6%. As of 12 July 2013 the INMO reported a further 10.6% reduction in trolleys compared to the same period in 2012. This is equivalent to 4,244 fewer emergency patients waiting for an inpatient bed. At the same time, however, the severe pressures experienced in emergency departments had a knock-on effect on waiting times for elective care. As shown by the June figures for inpatient and day case waiting times, which are now on the National Treatment Purchase Fund website, this resulted in a rise in waiting times since the very significant achievements at the end of 2012. The special delivery unit, together with the NTPF and the HSE, is engaged in a national intervention strategy to address the recent rise and to work towards the 2013 maximum wait times.

I have recently received Government approval to begin the process of introducing standardised or plain packaging of tobacco products in Ireland. Smoking places an enormous burden of illness and mortality on our health services, with over 5,200 people dying every year from tobacco related diseases. One in two of all smokers will die from a tobacco related illness. Standardised packaging of tobacco products will remove all forms of branding, trademarks, logos, colours and graphics. Plain packaging is one of a number of measures that are required to denormalise smoking in our society. Education and awareness, cessation services and extending the smoking ban to other areas are just some of the other measures which I am currently progressing.

A landmark political agreement was reached by Ministers at the Health Council in Luxembourg last month. This agreement brings the EU a step closer to revamping rules on how tobacco products are produced, packaged and presented in member states and improving health protection for EU citizens. I had the honour of chairing that Health Council, which reached agreement just six months after the original proposal was published by the Commission. It will enable the incoming Lithuanian Presidency to open up final negotiations on the tobacco products directive with the European Parliament. Reaching a Council agreement on the revision of the tobacco products directive was the main priority of the Irish Presidency in the field of public health. This is only right and proper given that 700,000 Europeans die every year from tobacco related illnesses. This has caused a reaction in the tobacco industry globally but our determination and conviction will not change. I thank members for their support for this initiative.

The Health (Pricing and Supply of Medical Goods) Act 2013 commenced on 24 June. The Act provides the Irish Medicines Board and the HSE with a robust statutory framework for the introduction of generic substitution and reference pricing on a phased basis. It will provide much greater access to generic medicines in Ireland and reduce medicine costs for patients and for the State. Generic substitution will be introduced incrementally, with the Irish Medicines Board prioritising those medicines which will achieve the greatest savings. The legislation will promote price competition and greater use of generics and deliver lower medicine prices for the taxpayer and the patients.

Another key step in the health reform programme was achieved when the President signed the Health Service Executive (Governance) Act 2013 on 3 July. This Act is designed to prepare the health system for the changes ahead while also making the HSE more directly accountable to the Minister for Health, who in turn is accountable to the people through the Oireachtas. The Act provides, inter alia, for the abolition of the board structure of the HSE and for a directorate headed by a director general to be the new governing body for the HSE. As is currently the case with the CEO, the Act provides that the director general will be the Accounting Officer for the HSE. This is a temporary arrangement as it is the intention to return the Vote to the Department of Health from 1 January 2014. At that point the director general will no longer be the Accounting Officer. This will require further legislation to disestablish the HSE Vote and fund the HSE through the Vote of the Office of the Minister for Health.

During the consideration by the Dáil of the Health (Amendment) Bill 2013, I announced new rates for all private in-patients in public hospitals, which will take effect on 1 January 2014. The Bill has subsequently been passed by both Houses of the Oireachtas. As a result of discussions with private health insurers, I decided to phase in the charges for private patients over a number of years. The rates included in the legislation are set at the level to raise an additional €30 million in hospital revenue in 2014. This phasing is intended to enable the insurance market to adjust to the new charges without destabilising impacts and it will also allow for assurances to be provided to the insurers that the additional revenues raised in 2014 will amount to €30 million in the calendar year.

As a result of this legislation, the hospital charges for a private day-case patient will be reduced from a total of €828 to €407 in a category 1 hospital. The daily charge for a private patient accommodated overnight in a multi-occupancy room in a category 1 hospital will be €813. Currently, the equivalent charge applied to a patient in a semi-private bed is €1,008. In support of this phased approach, the private health insurers have confirmed their commitment to participating in the initiative, to be chaired by Mr. Pat McLoughlin, that will address costs in the private health insurance industry to support the ongoing sustainability of the market. I am sure the members have all read the newspapers today and acknowledge the VHI's success in reinsuring in the market. While that is very welcome, it is no substitute for cost control, and that initiative will continue unabated. Costs are far too high in our private health care system.

Reform of our health service is essential. Modern medicine is helping people to live longer, healthier lives but we are still trying to deliver 21st century medicine in health systems that owe more to the 19th century than to the new millennium. Future health is specifically designed to dismantle the failed centralised command and control system of management, and return power to patients and professionals. To help re-direct this power the Government has decided to re-organise all of Ireland’s adult public hospitals into six groups which will, over time, become self-governing trusts. The objective is to create networks of hospitals which are big enough to offer patients a full range of high quality services safely, yet small enough to be flexible and adaptive.

The response from health-care professionals to date has been very encouraging. People working in the system know better than anyone that change is required, and importantly, they want to be involved in that change. We must continue to develop a system that allows more empowerment of the people who work on the front line and, most importantly, of the patients. The informed patient is the safest patient.

The Department is currently working with key stakeholders to develop a number of quality and patient-safety outcome indicators, with the intention of publishing the results. The HSE has also developed an Irish hospital mortality index which will also be published. Once the HSE is abolished, a new healthcare commissioning agency, HCA, will be established. It will be called the new healthcare agency. The contracts it commissions will be used to achieve improvements in patient outcomes. Outcome measures will be developed for both primary and community care. I am sure the Chairman and his committee are tired of hearing me say we need better outcome measurements. Outcomes for patients is what our health services should be all about. As long as we continue to focus on patient outcomes, all we do will be right.

I welcome the passage through both Houses of the Oireachtas of the Protection of Life During Pregnancy Bill. No Bill has been so fully debated, nor so long awaited. It is 21 years since the X case. Oral hearings took place before the heads of the Bill were published which informed those heads of Bill. Oral hearings took place after the heads of Bill were published which informed the Bill itself. Second Stage debate, to which virtually all Deputies contributed, resulted in more amendments. An extended Report Stage debate took place in the Dáil and after that the Seanad debated various Stages over several days.

This Bill is about protecting lives, those of the mother and her unborn child. It is to clarify for women what they are legally entitled to by way of medical services and how to access those services. It is to clarify for the medical and nursing professions what is legally permissible and what services they are legally obliged to provide. I have a deep respect for life. I have spent my entire professional life, spanning three decades, helping protect and save life. This Bill will do both. I thank the Members of both Houses for their contributions, and this committee in particular. I thank members of the Opposition for their support. All have deep conviction in their beliefs. I thank my ministerial colleagues, Deputies White and Kathleen Lynch. I thank the Chairman of this committee for his tremendous support and the manner in which he chaired the committees and kept the conversation at a civil level so that people could speak, listen and hear. This has been a very difficult journey for many people, but the right thing is rarely the easy thing to do. We have collectively done the right thing.

The Ministers of State, Deputies White and Kathleen Lynch, and I will continue to strive to give the Irish people the kind of patient-centred health service they need and deserve. Recognising the scale of the challenge involved, we will oversee the development of a health service that provides timely access to patients, high-quality, safe care, and provides an example of best practice in health care provision internationally. Both my ministerial colleagues and I will be very happy to answer members' questions on these and other issues during the meeting.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the Minister. I reiterate my thanks to the committee, particularly to Deputies Ó Caoláin, Kelleher and Healy and Senator van Turnhout for their co-operation during the Protection of Life During Pregnancy Bill. I thank the Minister, Ministers of State and Department officials for the manner in which they held the hearings and assisted the committee in their presence at the meetings. I particularly pay tribute to Ms Geraldine Luddy for her work in the Department. She worked very hard behind the scenes, along with others.

I welcome Mr. Tony O'Brien and congratulate him on his appointment as director general of the Health Service Executive, soon to be the healthcare commissioning agency, HCA. During this year our committee has been concerned about medical cards, cost containment by the HSE and the plight of non-consultant hospital doctors, NCHDs, regarding recruitment and working conditions.

Mr. Tony O'Brien:

I thank the Chairman and members for the invitation to attend this meeting. I am joined by my colleagues Ms Laverne McGuinness, chief operating officer and deputy Director General, Mr. Tom Byrne, chief financial officer, Mr. Barry O'Brien, national director, human resources, Mr. Ian Carter, national director, acute hospital services and Dr. Áine Carroll, national director, clinical strategy and programmes. They will assist me in dealing with any questions that arise as we go through. Before the meeting, the committee requested replies on a number of specific issues and will have received a written response to these issues from the HSE and the Department of Health with a detailed report on medical cards and information on NCHDs.

Overall activity remains high across the majority of HSE services within community and acute hospitals. Emergency admissions were up by an additional 7,969, or 4.9% in the first five months of this year over the previous year, and remain 6% over expected levels of activity.

A total of 414,220 elective inpatient and day admissions were carried out in our acute hospitals for the first five months of the year, which is broadly commensurate with the volume recorded for same period in 2012.

GP out-of-hours contacts remain high at almost 420,000 contacts up to the end of May, which again is commensurate with activity in the same period of last year. This service plays a very important role in pre-hospital emergency care.

At the end of May more than 2 million people were covered by either a medical card or GP-visit card, which is a significant milestone in terms of numbers. In May some 22,706 long-term public and private residential places are supported under the nursing home support scheme in the first five months of the year, broadly in line with the figure - different by three - for the same period in 2012.

In setting out the financial situation it is important that it is considered within the following context. As outlined earlier, there were significant pressures on our services. This has had an impact to date on our costs as well as on our ability to fully sustain the very important improvements made last year in areas such as access times to scheduled care. There has been a total reduction to the HSE budgets and costs of €3.3 billion, 22%, since 2008. There has been a reduction in staffing levels of more than 11,320 whole-time equivalents since the peak employment levels in September 2007.

In Vote terms to the end of June there is a cumulative €10 million surplus on net current HSE Vote 39 expenditure. However, it is important to note that the areas which give rise to the surplus are in most cases expected to reverse by year-end and therefore are unlikely to be available to offset other deficits on an ongoing basis. On income and expenditure, the HSE is reporting a year-to-date deficit of €49.34 million to the end of May 2013.

The HSE is not flagging any new concerns or risks beyond those clearly set out within the national service plan for this year as approved by the Minister on 9 January 2013 and within the regional and hospital group service plans which were published in February. Four key risks remain which I will now outline. It should be noted that it is not within the HSE’s sole capacity, within the parameters of service plan, to address all shortfalls that may arise in respect of the following items.

Within PCRS the scale of savings required in the year is €353 million. There has been strong financial performance against this target. The service plan anticipated that regulations under the FEMPI legislation would provide for projected savings on professional fees of approximately €8 million to €9 million per month from May onwards. While the implementation of this legislation was delayed, it is now in place and savings under this heading will be delivered from August.

Achieving the €150 million budget reduction assigned to the HSE within the 2013 service plan is fully reliant on the outcome of the recently published Haddington Road public service agreement. While we are in the process of assessing in detail the potential savings arising from the implementation of the agreement, this validation process is complex. However, we are confident that €420 million will be delivered during the life of the agreement.

Private health insurance income legislation has already been mentioned. That legislation is now in place. We expect to see the full benefit of that in 2014. On private health insurance income - €104 million accelerated income in 2012 - the accelerated income received will need to be sustained this year in order to avoid any adverse effect on the HSE Vote. Of this, €20 million can be achieved through HSE internal processes. Engagement is ongoing with the insurers through the consultative forum on health insurance, seeking to progress this matter.

In terms of direct services, without corrective action within the remainder of our community services and in particular hospital services, there would be a deficit of €104 million, inclusive of €25 million in local schemes based on cumulative data for May 2013. For this reason hospital and community services have been formally requested to identify additional cost containment measures to safely bridge any projected direct services deficit.

Assuming that approval will be given to utilise once-off surpluses, including potential pension and time-related savings, the expectation is that direct services will substantially deliver within the allocated resources.

As members will be aware, in advance of this meeting we submitted a detailed report on medical cards. However, I wish to refer briefly to the issue of discretionary and emergency medical cards which has been the subject of recent publicity and is covered in our submission. The HSE has guidelines in place on the provision of discretionary and emergency medical cards. Medical cards can be provided on discretionary grounds in certain circumstances where an applicant’s income is in excess of the income guidelines. As at 1 June 2013, the number of discretionary medical cards is 59,012 and discretionary GP visit cards is 19,186. The guidelines for the consideration of discretion have not changed in the centralisation of medical card processing.

Since the number of medical cards is higher than ever, it is incorrect to conclude that because discretion has been involved in fewer cases medical cards are harder to get. In the case of emergency medical cards, these are provided to patients who are terminally ill, or are seriously ill, and in urgent need of medical care they cannot afford. Emergency medical cards are issued within 24 hours of receipt of the required patient details and letter of confirmation of condition from a doctor or consultant.

As with discretionary medical cards, the guidelines for the consideration of emergency medical cards have not changed in the centralisation of medical card processing. We have given reassurance to cancer sufferers over the past days that there has been no change to the eligibility criteria for receiving a medical card.

Investment in mental health services is important. There are 123 general adult community mental health teams nationally. In its 2012 service plan, the HSE prioritised €35 million and 414 WTEs for reinvestment in mental health to progress the objectives in the programme for Government. One of these objectives was to enhance general adult, and child and adolescent community mental health teams. In its 2013 service plan, the HSE will build on this investment with a further €35 million to strengthen general adult, and child and adolescent community mental health teams. Of the 414 posts allocated in 2012, 363 posts are in place with a further 23 offered and being processed through Garda clearance, etc. These posts include multidisciplinary team members across all the health professions.

Of the 477 posts approved in 2013, 133 posts have been accepted by candidates. A further 16 offers have been made from existing panels. The HSE is establishing new panels and other arrangements to fill the remaining posts with the intention of filling as many of them as we have candidates for within the current year.

This concludes my opening statement and together with my colleagues we will endeavour to answer any questions members may have.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I join the Cathaoirleach in welcoming the Minister, Ministers of State and Mr. O'Brien along with their colleagues from the Department and the HSE. I join the Chairman in congratulating Mr. Tony O'Brien and I wish him success in his now confirmed role as director general of the HSE. I also wish to be associated with the expressions of thanks and good wishes to Ms Mary Lindsay.

I wish to raise with Mr. O'Brien the HSE report on medical cards and the recent focus on discretionary medical cards for people with what are termed terminal illnesses. There is a particular focus on children with what I prefer to term life-limiting conditions. I ask Mr. O'Brien to define "terminally ill". I believe there is clever use of language to avoid facing up to the fact that the statistics confirm, as Ms McGuinness outlined at a recent meeting, a significant reduction in the exercise of the discretionary granting of medical cards in these circumstances. I have met parents of children with what I would call life-limiting conditions, including cancer with all that entails, who have not received medical cards. They have either been withdrawn or they are continuing through a process of appeal having had them refused in the first instance. It is a terrible situation for those families, many of whom are only marginally outside the qualification threshold. It is unacceptable.

There is a need to define "terminally ill" and, if possible, to differentiate it from "life-limiting". The truth needs to be faced in this regard.

It would be remiss of us if we did not also ask the director general designate of the HSE and the Minister to address briefly before the meeting concludes what can only be described as the compounding exposure of the fact that the wrong scope was identified as the problem in the colonoscopies carried out on children at Crumlin hospital. It is important that this issue be addressed and that an explanation be given. In many people's minds, there is no better example of what appears to be gross carelessness. For the 18 families contacted yesterday, no list of excuses could possibly mitigate the consequences of labelling the wrong scope as being at fault. It is harrowing, yet their children were not the ones at risk. Seven new families needed to be contacted yesterday evening. Rather, six have been contacted and one is still being sought. We need to know what steps have been taken to avoid the compounding of the problem that presented in the first case by the identification of the wrong scope and the consequences of same.

Before going into each question and reply, the replies that I have received to my questions have been most unsatisfactory. In fact, two have been derisory. I have no other way of describing them. It is grossly unfair to members of this committee who have put so much work into preparing their questions, researching the issues and contributing to health debates and legislation that we are given such cursory replies, some of which ignore the core of what we are trying to establish.

I wish to deal with question No. 12 on the national dementia strategy. The reply sets out the scale of the problem of dementia, which is considerable and is set to grow in the coming years. We all know this. The reply reminds us that the programme for Government is committed to developing a national Alzheimer's disease and other dementia strategy by this year. However, the reply also states the intention that a draft strategy would be completed by the end of this year. We are clearly not going to have the strategy in situif we are only going to have a draft strategy by the end of this year. There is no word of when we can expect publication of the strategy and, crucially, no mention whatsoever of an implementation plan. I ask that this issue be addressed by the Minister and the director general designate.

There are fine words in the reply, for example, "practical focus" and "action oriented". If we consider what is actually happening - some of us have personal experience and are coping with situations of dementia presenting in our families - I am deeply concerned that the actions being taken in tandem with these fine words run contrary to the strategy's stated intent. I wish to draw the Minister's attention to the home adaptation grant scheme, which is a current issue. It was drastically cut by 38% by the Government this year. Only yesterday, Dublin City Council announced that the scheme was closed for 2013 because it had run out of funding. There is no money available.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Deputy has one minute remaining.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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The one minute bell. I would happily take the Fianna Fáil slot as well, as its members are not present.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is this a sign of things to come?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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There are other alarming situations-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Allow the Deputy, please.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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The time is running on me. Other councils did not even include provision for home adaptation in the current year. South Dublin County Council is a case in point, just to draw the Minister's attention to it.

For carers, the story is the same. The reply reads, "The objective is to ensure that carers feel valued and supported in their caring role and are empowered to have a life of their own outside of caring". This sounds reassuring, but let us recognise that the backdrop is the reduction in the carer's respite grant from €1,700 to €1,375 only in the year gone by. There is no living up to the fine language employed.

Jerry Buttimer (Cork South Central, Fine Gael)
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Thank you, Deputy.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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With respect, the Chairman will give me just a moment's grace to add these last points.

My question No. 13 was on neurorehabilitation. When will the rehabilitation medicine programme be presented? Will it be simultaneously published? My question on why the implementation plan is not being developed by the Department is not addressed in the reply. I am anxious to know why the Department of Health stopped being the lead agency for the development of the implementation plan for neurorehabilitation.

My last comment is on question No. 14 on a meningitis B vaccine. We all well understand the role of the National Immunisation Advisory Committee. However, to provide a reply on the possible introduction of the meningitis B vaccine that has been cleared on a European stage without referring to it at all is unacceptable.

Jillian van Turnhout (Independent)
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I also wish to extend my thanks to Ms Mary Lindsay and to congratulate Mr. Tony O'Brien. I welcome the significant publication of the Assisted Decision-Making (Capacity) Bill 2013 and look forward to our consideration of it.

The Minister is right to acknowledge his personal initiatives on the tobacco front as well as the Department's. I have two concerns in this regard. The first has been raised in the Seanad, where my group tabled a Private Members' motion on lobbying by industry. The Minister for Public Expenditure and Reform, Deputy Howlin, took the motion. The motion also considered our role as parliamentarians and whether we should sign a pledge or code about meeting certain industries, for example, alcohol and tobacco. Everyone was comfortable discussing lobbyists, but not our role as parliamentarians. I welcome the Minister, Deputy Reilly's opinions. The World Health Organization, WHO, convention on lobbying by the tobacco industry is clear, but we do not advise parliamentarians of it.

Senator Crown will undoubtedly join us. I co-sponsored a Bill with him on my second area of concern, that being, the Protection of Children's Health from Tobacco Smoke Bill 2012, which covers issues such as smoking in cars. The Seanad debated it in May 2012. We worked seriously with the Department. We are constantly told that the Bill is very close to beginning Committee Stage. Will the Minister outline a timeline? Will it be taken in September or October?

I wish to ask about two of my submitted questions. The first is on-----

Jerry Buttimer (Cork South Central, Fine Gael)
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The Senator might mention the question numbers.

Jillian van Turnhout (Independent)
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Question No. 3 relates to Health Ireland: A Framework for Improved Health and Wellbeing 2013-2025. I attended the launch, where there was great fanfare about it being a superb initiative. However, I was disappointed. It is all about joined-up government and working together to have a healthier Ireland. Despite this, the Department of Education and Skills has reduced the number of physical education hours on the new junior cycle. I am sure that Deputy Fitzpatrick will have something to say on childhood obesity. The reply to my question referred a great deal to social, personal and health education, SPHE, but not to physical education. I am concerned by the reduction in hours. This committee held many hearings on childhood obesity. The recommendation to get children into the habit of exercising more was made repeatedly.

Question No. 5 is relevant to recent events. I am very pleased that the Protection of Life During Pregnancy Bill has been passed, but 28,500 women are diagnosed each year with perinatal or postnatal depression or post-traumatic stress disorder relating to their pregnancies. The waiting list is nine plus months. It is a critical time for these services.

To echo what Deputy Ó Caoláin has said, the answer gave me a lot of information but did not address my question on accessing services for these women. They need supports and services at the critical time of bonding with their child or approaching the birth. We have had a lot of discussion on mental health and pregnancy but these services must be made available. I have worked with a small organisation called NURTURE that tries to provide these services. Dr. Anthony McCarthy and I launched the organisation over a year go. NURTURE often provides free counselling to women using the other part of its business to subsidise the cost. I am concerned about the area of supports and services for women.

I did not table a question on mental health expenditure. However, I have read many newspaper reports on the matter and want a clear statement. Earlier this year we were told that the €35 million that was not spent last year will be added to this year's funding. I was seated here in the committee rooms when we were told that there is €70 million to be spent. What is the anticipated spend for year end of the €70 million?

Colm Burke (Fine Gael)
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I thank Mr. Tony O'Brien and the Minister for their presentations. I also thank the Minister and Ministers of State for enduring four days of misinformation in the Seanad.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will not go into that again.

Colm Burke (Fine Gael)
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I am slowly recovering from those four days of hearings. I thank the HSE for furnishing replies to the questions that I tabled.

I wish to return to the junior doctor issue. My question No. 9 referred to the agency costs for 2012 and the first five months of 2013. My calculations indicate, including the first five months of 2013, that we will pay well in excess of what we paid last year in agency costs for junior doctors.

I have received details on the number of unfilled vacancies from the HSE. One of the things that was not included in the response was the number of positions filled using agency contracts for the next six months but a number of hospitals were listed. I know of a number of hospitals where the positions are filled using agency contracts as opposed to a direct contract between a junior doctor and the HSE. I also noted that the supplied response contained, or information published on vacancies not filled, that Limerick was not mentioned. However, Limerick Hospital advertised over 20 positions in all of the medical newspapers. Have the positions been filled by agency doctors? The number of junior doctor positions filled using agency contracts is well in excess of 150 but I am open to correction. That fact was not included in the details supplied on vacancies not filled. There seems to be misinformation. The HSE outlined that 31 positions were not filled but the figure did not include the number of positions filled using agency contracts as opposed to contracts between the HSE and the junior doctor. The matter must be clarified.

I wish to raise a related issue, the reform of junior doctor recruitment. Over the past two years I have had a big issue with the way junior doctors are employed. I accept the report that stated that 80% of junior doctors are employed under a training programme but that does not clarify the type of contract used. Over 2,000 junior doctors are on a six-month only contract. We need to move away from that system of employment. There is no reason for not giving a two year contract to junior doctors who wish to work in an accident and emergency department. A clause could be included which stipulates that they must work between two or three hospitals. I ask for a commitment to be given to reform the contract system over the next six months. If contracts are extended then we will resolve the problem of junior doctors quickly passing through the system and leaving Ireland far earlier than was the case five years ago.

I thank the HSE for its comprehensive response to my question on the fair deal scheme and for the statistic that over 34,000 has benefited from the scheme since its inception in 2009. How are moneys recovered under the scheme? I posed the question because a number of people have contacted me recently about the scheme. Their parents who owned their house will have signed up to the scheme that has a 5% recovery sum for a maximum of three years and they now reside in a nursing home. What happens if the house is the only place of residence for the current inhabitant but he or she is now unemployed and his or her parent or parents reside in a nursing home? The chance of recovering the money will be more difficult in such circumstances. Should the amount to be recovered under the scheme be revised downwards?

Jerry Buttimer (Cork South Central, Fine Gael)
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The final questioner in this segment is Deputy Mitchell O'Connor.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I thank the Minister for his presentation. I have a number of questions. The replacement programme of defibrillators was mentioned. I have a problem with the current scheme and some of my constituents have raised the matter with me. When an emergency arises nobody knows where to access a defibrillator. Even if it is in a town, GAA club or wherever its location is not public knowledge. I ask the Minister to consider providing a system that will inform people where they can access a defibrillator.

Mr. O'Brien answered my question on discretionary medical cards. Constituents have contacted me about Huntington's disease and cancer and I reiterate Deputy Ó Caoláin's request to differentiate between "terminally ill" and "life-limiting" illnesses.

A delegation visited Dáil Éireann comprising doctors promoting the strategic vision framework. They agree that we need a scheme to facilitate the 14,000 people who have gone blind. It stated that we also need to provide a testing programme and strategic framework to cater for the 100,000 that may go blind. Many of the groups who work in the area operate independently but collectively they seek a framework and testing programme. I ask the Minister to consider the matter.

There does not seem to be an easily accessible pathway for people who suffer chronic pain for various reasons to access pain relief. Every group works independently and I shall give an example. Stroke sufferers may go to the National Rehabilitation Hospital but if the pain is caused by something else then the sufferer must go somewhere else. Chronic pain sufferers want a pathway to access pain relief administered by suitably trained doctors in a co-ordinated fashion.

I reiterate what my colleague, Senator Colm Burke, said about junior doctors. I wish to raise two issues, the low morale among young doctors and junior doctors and the hours that they must work. As I have said here before, no other profession must undergo a six-month and 12-month job interview. Those doctors are in a very difficult situation. It was mentioned that some of them get three year stints in different hospitals. None of the junior doctors that I know have such a lengthy contract and must do rounds of interviews every six and 12 months.

With regard to childhood obesity, I urge the delegation to consider the First 1000 Days campaign that covers the period from the first day of pregnancy, the nursing period and small infant period. It is the food and nutrition that both parties receive over that period that sets the pattern for healthy eating.

I must mention the bilateral cochlear implants and symphysiotomy. My colleague, Deputy Regina Doherty, will mention symphysiotomy later but I wish to inquire about natural symphysiotomy. As I have mentioned before to the Minister, I am aware of two women who went into hospital but left it in wheelchairs. They did not undergo the symphysiotomy procedure but were left unable to walk and want the matter addressed. The Chairman is stopping me but those are all of my questions.

Jerry Buttimer (Cork South Central, Fine Gael)
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Four other Members have indicated. I am conscious of the time remaining and wish to give members and Ministers of State who are present an opportunity to speak.

James Reilly (Dublin North, Fine Gael)
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Deputy Ó Caoláin raised a number of issues around the dementia strategy and the carer's strategy and I will defer to the Minister of State, Deputy Kathleen Lynch, in regard to them. He mentioned rehabilitation and we are very fortunate to have Dr. Áine Carroll here from the National Rehabilitation Hospital, so she might address that.

The Deputy also mentioned the meningitis B vaccine. All these vaccines must be properly assessed and the Irish Medicines Board is a very competent authority and is recognised in Europe as such. It will do its own assessment and will act accordingly. We all know vaccines can occasionally have a down-side, so we need to be careful. When we offer vaccines, it is important to remember we are proactively encouraging people to protect themselves or their children. We must ensure that protection is real and that the risks are very low. We know there is a small but vocal group in this country which is anti-vaccine. While many of the great health gains we have had in this country, in terms of longevity, have been due to better social conditions, such as housing, clean water and a proper sewerage system, at least 50% is down to vaccination and it is critically important to remember that. However, we will take our time and will take care, but it will be done.

Senator Jillian van Turnhout spoke about a pledge or a code on meeting various interest groups, in particular the tobacco groups. She is right in that there is a WHO convention on this, to which we have signed up. I am very happy to confirm that I will never meet them, although, as a politician, I am acutely aware of the danger of the words "never" and "always". I hold very strong views about this industry which is mounting a campaign. There is a battle ahead. Later today I will meet interest groups, including the Irish Heart Foundation, the Irish Cancer Society, Barnardos, the ISPCC and Cystic Fibrosis Ireland, which I imagine feel very strongly about this issue too and which understand the dreadful damage smoking does. It is the only product I know which is legally and freely available that will kill one if one uses it according to the manufacturers' instructions. It is a fight from which we cannot run away and which we cannot afford to lose. It is a battle that will continue until it is won, and it will be won. I am very pleased to say the Government has passed a document entitled, Tobacco Free Ireland. By 2025, we hope to have a tobacco-free country and by that we mean less than 5% prevalence of smoking in this country.

The Senator asked about the timeline in regard to smoking in cars. Much work has been done on this. The heads of the Bill are with the Attorney General. We do not have an indication as to when they will be ready. A huge amount of legislation is going through the Dáil but this is a priority for me, as is plain packaging. I am sure the Senator read in The Irish Times that the tobacco industry in America is becoming heavily involved with some very powerful individuals who seek to influence our determination to protect our children from this dreadful killer product.

The Senator mentioned Health Ireland: A Framework for Improved Health and Wellbeing 2013-2025 and the reduction in the number of hours spend on physical education. I am in full agreement with her. Exercise is critically important. Forming a habit of exercise early in life stays with one throughout one's life. We want people to have a qualify of life. There is not much point living to 99 years of age if one spends the last 20 years in a wheelchair on an oxygen cylinder. We know from excellent work done in Trinity College Dublin that the last ten days of one's life are the most expensive ten days on the State. If one dies in one's 40s or 50s, it is three times more expensive on the State than if one dies in one's 70s, 80s or 90s. There has been a huge improvement in longevity in this country, which is most welcome. The Senator also mentioned issues around mental health and I will defer to the Minister of State, Deputy Kathleen Lynch, on that.

I refer to Senator Colm Burke's comments on non-consultant hospital doctors. I consider this to be one of the most serious problems we have. It is immoral. These are the brightest and the best. They study extraordinarily hard in school to achieve 580 points - a margin of error of 3%. They study for five years in college and then they come out to a wilderness with no mentoring, no advice on what career path to take within medicine and no idea of the areas which hold best potential in terms of a future career. They have no clear career path. This is our problem and our fault but it is also the fault of the medical profession and the leaders in the medical profession who have allowed this to evolve and who continue to preside over it.

I have already had a meeting with some NCHDs and further meetings are planned. I want to create a safe place for non-consultant hospital doctors, many of whom do not like that term, which is fair enough, where they can devise and think through a new way and a new career path for themselves without being intimidated by the people who are at the top or by anybody in the HSE or the Department of Health, and I mean no disrespect to them. When they formulate those thoughts, let them come to us with them and then let us look at them with the likes of Mr. Barry O'Brien, Mr. Tony O'Brien and others to see how workable they are.

We are presiding over a perversity where our brightest and best are trained by us to go away while we scour the Third World and rob it and deprive it of its doctors. It is immoral and wrong and it must be addressed.

Jerry Buttimer (Cork South Central, Fine Gael)
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Can we change that in the short term rather than the long term?

James Reilly (Dublin North, Fine Gael)
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Absolutely. I want a report on my desk by the end of September-beginning of October and I have commissioned an excellent individual, who is the head of a university which does not have a medical school, to do this. I want to introduce fairness and transparency and, above all, I want our doctors to stay here to look after us.

Jerry Buttimer (Cork South Central, Fine Gael)
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This committee has dealt with this extensively. The Minister will have our support if that can be done.

James Reilly (Dublin North, Fine Gael)
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I thank the Chairman for that. Make no mistake, it is a battle. There are vested interests who are very happy with the status quo, on which I will make a broader statement. I do not accept the status quo in our health service and in our health training because it has not delivered for patients and it is not delivering for our doctors or nurses. We need to give them a fair and reasonable life so that they are better positioned to give us the excellence in care which they have been trained to give and which they want to give but which they are frustrated in giving.

There was a question about the fair deal scheme and I will defer to the Minister of State, Deputy Kathleen Lynch, on that.

All I will say is that a huge number of people have been accommodated on that scheme. We are currently reviewing the nursing homes support scheme and are very much focused on trying to provide more care at home and in the community. We are acutely aware of the fact that when one has a large fund of money, amounting to almost €1 billion, everyone tends to head in that direction. In some parts of the country people are ending up in long-term care way before they need to be, while in other parts of the country people cannot get such care even though they desperately need it. We have a single assessment tool about which I have advised the committee previously and that will help us to take a more uniform approach to assessing the needs of older people and determining how they can be best met.

Deputy Mitchell O'Connor raised the issue of non-consultant hospital doctors and the EU working time directive and I repeat what I have said previously on this matter. I believe it is wrong and unsafe to ask young doctors to make life or death decisions when they have been on their feet for 36 hours. It is wrong and there is no defending it. We will address it and will do so in a very short, sharp exercise. I hope that those who have become rather comfortable with the situation will realise how wrong the current practice is and become very uncomfortable very quickly. I am pledging to this committee that I intend to make them very uncomfortable.

The issues of defibrillation, childhood obesity, symphysiotomy and stroke were also raised. Dr. Áine Carroll is here and can talk to the committee about rehabilitation, stroke and how it is managed. I would point out that there has been a phenomenal improvement in the care of stroke victims in this country in the last 18 months. I wish to thank those involved in the clinical programme for this because the improvement has been astonishing. We have gone from the bottom of the ladder in Europe in terms of thrombolysis - the use of an agent to dissolve the clot that causes many strokes - to the very top in only 18 months. Dr. Carroll will confirm the improved statistics on the number of lives being saved and the numbers of people avoiding long-term as a consequence of stroke.

I am very concerned about the issue of childhood obesity. This is the first Government to put in place a principal officer across the Departments of Health, Education and Skills and Children and Youth Affairs to deal with this issue. Regarding the issue of symphysiotomy, this was a wrong that was done to women. It is yet another one of the legacy issues that have been left to us by a series of previous governments but is one we intend to address. The Government instructed me on Tuesday last to speak to the women concerned in order to plot a pathway forward so that we can bring some closure to this issue for them. I also met the women who were victims of Dr. Neary, who had inappropriate medical procedures carried out on them and who were excluded from the redress scheme solely on the basis of age, which was utterly arbitrary and wrong. I am very pleased to announce that we had a very good meeting and have put in place a scheme to try to bring closure for them. I know we cannot undo the harm that was done to them but we can, at least, start the healing. I will now hand over to the Minister of State, Deputy Kathleen Lynch.

Kathleen Lynch (Cork North Central, Labour)
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Thank you. I will try to be as brief as possible because I am aware that members of the committee want to ask questions. On the question of perinatal depression and pregnancy-related depression, we have only three perinatal psychiatrists in the country. In the context of the debate we have had in recent months, the president of the College of Psychiatrists of Ireland has put forward a very balanced view on the issue. It is not an argument that people were prepared to accept from politicians but could accept from someone who has been working in the area all of his life and for that, the women of the country were very grateful, regardless of which side of the argument they were on.

We are developing clinical programmes, which have suffered some delays unfortunately. Mr. Stephen Mulvany will be taking up his post very shortly. I had a meeting with him yesterday and we are both determined that those clinical programmes will be driven out. Those programmes will ensure that no matter where patients are located - Donegal or Dingle - when they make contact with the mental health services, they will get the same level of response and service. The number of women needing perinatal psychiatry services is very small but for the individual concerned, it is a serious difficulty. Having said that, it is not necessary to have a perinatal consultant in every single area. The development of multi-disciplinary teams and the way the clinical programmes are being devised to ensure specialty expertise within each team will address that issue.

We are progressing with the filling of posts and I am constantly badgering Mr. Tony O'Brien on that issue. The €70 million fund is ring-fenced and will be spent on nothing else other than those posts. I have been reassured on that point in writing. Last year 389 posts were filled from the €35 million and to date this year, 133 posts have been filled. A difficulty has arisen in terms of finding psychologists but we hope it will be resolved shortly. We are hoping that new graduates will help us in that regard. We are also having difficulties with regard to community mental health nurses. We will have to conduct a new advertising campaign and are hoping that the coming on stream of new psychology graduates this year will help us out. Another issue that is causing delays is that those who have accepted posts must go through a vetting procedure, which is as it should be. We are making satisfactory progress. It is not reasonable to expect that posts advertised in June will be filled by September.

Another issue has arisen with regard to the specialist recruitment panels. There is no point in having someone accepting a position in the service where he or she does not want to be. We must ensure that we are hiring the appropriate people for the appropriate positions and we have the people in place that we want and those people want to be there. Otherwise, they will move as soon as a position becomes vacant elsewhere. The process is a little more complex than we had originally envisaged.

Deputy Ó Caoláin asked about the dementia strategy. Comprehensive work has been done on a dementia strategy but its implementation will take place in the context of the Healthy Ireland strategy which involves a whole-of-government approach. We recently met representatives of the Alzheimer Society of Ireland and other NGOs and they are now on board in developing the strategy. We intend that it will be a very comprehensive strategy. We do not intend it to be entirely health focused. Early diagnosis is hugely important and the Minister spoke earlier about an assessment tool. The assessment tool that has been developed by the Department is very comprehensive but an assessment tool is already in use in an area which straddles both sides of the Border that has proven to be hugely successful. It is less comprehensive than the one developed by the Department but is, nonetheless, very successful. I have been talking to people who have been using it and they are very happy with it, so we are examining that too. This assessment tool is focused on early detection and early diagnosis with the aim of ensuring that one can put services in place so that people can continue to live in the community.

It is not entirely a medical based intervention. We believe that is very important.

We hope to be able to allow people to live a full life for longer than we had previously expected in terms of the progression of dementia. Due to the consequences downstream and the amount of people we are eventually going to have to deal with, the dementia strategy is more complicated than strategies such as the positive ageing strategy. We will have the draft at the end of this year, but the strategy itself needs a bit more work, and I am not prepared to rush it.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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How long will that be?

Kathleen Lynch (Cork North Central, Labour)
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Once the work has been done - the meetings have taken place and people are happy to be on board - we will take another look at where it has progressed at the start of next year. If we think all of the work is done on it, then we will have no difficulty in publishing it but it is important that we get it right. It is not something that can be changed in future, nevertheless it is essential that we get it right. The NGOs such as Age Action Ireland will have a very important role to play in this, because we do not want people diagnosed with dementia ending up in the acute hospitals or in long-stay care. People with dementia definitely do not want it.

We are reviewing the fair deal scheme. It is working very satisfactorily for nursing homes. I know that there will be problems with waiting lists from time to time, but it is still the fairest of all the schemes introduced. It is the only scheme in Ireland that has a "money follows the patient" concept and we should look at this in other areas. We are looking at how to extend it into the community in the same way as we deal with people in long-stay care. We are not talking about the fund at it now exists being used for community care. The fund needs to be used as it is now being used. There already exists an extensive budget for community care anyway, and it is about how people access that. It is about how the fund is delivered. I get very worried when I hear people talking about extending the fair deal scheme into the community, and I know they assume that the fund will be extended as well.

It would be remiss of me not tell the committee that A Vision for Change is moving on apace. As we speak, the staff and other stakeholders in the mental health services in Galway and Roscommon are being informed that the unit in Ballinasloe will close and will be phased out between now and the end of the year. Admissions will not be accepted any longer in Ballinasloe and we are putting in place a community outreach team in that area. Admissions will be to Roscommon and Galway. The new 50 bed unit to be built in Galway will have an incredible impact in that area. It is a good news story for A Vision for Change and the building in Ballinasloe will continue to be used as the headquarters for the community outreach team and for old age psychiatry. We will also develop three beds for people with challenging behaviour who are being treated in that area. It would be remiss of me not to inform the committee of this when I know that the other public representatives in that area are being told as we speak.

Alex White (Dublin South, Labour)
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Deputy Ó Caoláin asked several questions about medical cards, and I will ask Mr. O'Brien or Ms McGuinness to deal with the definitional issue that he raised. The system that we have in place for the allocation of medical cards is based on an assessment of means. It sounds very harsh sometimes to say somebody who has unexpectedly become ill that he or she is outside the limit and is not entitled to a medical card. That is why we have a discretionary system in place. For example, somebody becomes ill and has to stop working, and perhaps the person's partner has to stop working, so the family's means change or is at risk of changing, depending on how the illness progresses. People face situations like that which are catastrophic and stressful, which is why we have this discretionary system in place where people can apply for a discretionary medical card. We have panels of medical assessors to look at this carefully.

I could divide this issue into two aspects. The first aspect is the policy. We could have a debate on whether the policy is right or wrong, and we could have legitimate discussion about that. Our whole system is based on providing medical cards on the basis of undue hardship. That is our current system and we have many ideas about how we might change it. The second aspect is the operation of the policy. Is it operating in the way that it should be operating? That is a related but separate discussion. People sometimes say to me that what I am telling them is not true. It has been suggested to me that cards have been taken from people in pharmacies. I want to know about the specifics of this. Sometimes colleagues are reluctant to provide details of individual situations, which I can understand. However, if we are saying something that members know from experience as public representatives is not the case, will they please tell us? We can establish if a problem exists when we have more detail about it. I do not believe the anecdote that people are having their cards taken from them in pharmacies, but are people saying it to me in order to emphasise a problem?

Jerry Buttimer (Cork South Central, Fine Gael)
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I know cases of people going to pharmacies and their cards have been rendered invalid.

Alex White (Dublin South, Labour)
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Perhaps it is out of date. I am not trying to make excuses but there could be a myriad of different reasons why something happens. The information of the HSE is that when people are contacted, if they engage, there is a very sensitive approach taken where people are given time if they respond with their details of income and so on. That should be the position but if somebody has an experience where that is not the position I would like to know about it and we can solve it.

Senator van Turnhout made an interesting point about lobbying, which is perhaps worthy of discussion on another occasion.

I endorse everything that the Minister, Deputy Reilly, has said in respect of tobacco and I commend him on the leadership he has taken on the issue. The Minister of State, Deputy Lynch, and I support him in this matter.

There are other areas of public health policy, for example, the area of alcohol, where lobbying can be a factor. There is a good deal of controversy in the United Kingdom at the moment in this regard. Legislation on lobbying is being considered by the Minister for Public Expenditure and Reform, Deputy Howlin. I sometimes wonder who will lobby for public health? The Ministers do so. Who will lobby for the health of the nation and of young people and children? We do and, as I look around the room, I see that people in the room do as well. We welcome and value the support of the members of the committee on the public health agenda.

It is important that people are entitled to lobby, whether it is the drinks industry or sporting bodies or anyone else. We live in a free country and people are entitled to make their views known. Sometimes lobbying for public health is a little harder because it is about the future and threats in the future and it is about people who are ill who perhaps do not have advocates. It is about people who will become ill in the future who we do not know about yet. Who will advocate for them if we do not?

Mr. Tony O'Brien:

I will invite Ms McGuinness to give further information on medical cards, Dr. Carroll to comment in respect of neuro-rehabilitation and Messrs O'Brien and Carter to comment in respect of non-consultant hospital doctors. I will begin, however, by dealing with the issue raised by Deputy Ó Caoláin with regard to events in the hospital in Crumlin this week, over which I share his concerns. When I learned yesterday evening about what I would describe as the catastrophic failure of the incident management process, I immediately asked our national director of quality and patient safety to commence a review of the incident management process and a root cause analysis to establish how the management of the event led to incorrect communication to 18 parents. No amount of spin by public relations consultants for the hospital can mask the seriousness of the matter.

It is important the health system as a whole acknowledges that where things go wrong we need to be judged by how we manage them, recognising that from time to time things will go wrong. It is clear that this has not been managed in the way we would like. However, the aim of the root cause analysis is to establish why and how it went wrong and how we can ensure there is no recurrence in such circumstances.

A question was asked about defibrillators. The answers provided were not about community defibrillators but the re-equipping programme in the ambulance service. The defibrillators in question will be exclusively in national ambulance service vehicles rather than-----

Mr. Tony O'Brien:

Deputy Mitchell O'Connor asked a question about defibrillators following one of our answers.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Yes, I heard that part.

Mr. Tony O'Brien:

The answer was in respect of a re-equipping programme in the national ambulance service. All of the defibrillators that the answer related to will be on board national ambulance service vehicles as opposed to in community settings. It is a different subject area.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I am asking about defibrillators in the community not in the ambulance service.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will bring you back in, Deputy.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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He did that before the last time I asked a question.

Mr. Tony O'Brien:

Ms McGuinness will respond to the question on the medical card issue.

Ms Laverne McGuinness:

The first thing to note about the medical card issue is that we now have the highest number of medical cards that we have ever had. There has been a 75% increase in medical cards since 2005. Now, we have 2 million people covered by our medical cards and general practitioner visit cards, which amounts to 44% of the population.

As the Minister of State, Deputy White, stated, to get a medical card the assessment is, in the first instance, a financial assessment. If a person or a family qualifies under the income guidelines they will be granted a medical card. If they do not comply with the income guidelines and if they have got a medical condition whereby additional expenses would be incurred or where there are other social factors - it does not necessarily have to be medical factors that are taken into account - they can apply for a medical card on a discretionary basis.

The assessment is carried out by a team of doctors headed up by one of our public health doctors, Dr. Johanna Joyce. The team is empathetic and applicants are listened to compassionately. If additional information is required the team will engage directly with the applicant. It is not a case of being marginally over the threshold, as one might think. All factors are taken into account, especially the outgoings in respect of the particular medical condition. If that is the case then the applicant would be granted a medical card.

Deputy Ó Caoláin referred to cases involving the terminally ill. There are special circumstances whereby if someone is terminally ill and we learn of it, then within a short period of 24 hours of confirmation of that by the medical doctor we can grant what is known as an emergency medical card. The emergency medical card can be automatically granted. I am using the word "automatic" because it means there is no financial assessment if it is confirmed that a person is terminally ill. These cards are usually issued for a period of up to six months. That is different to a life-limiting case. Life-limiting relates to a longer period. Applicants with life-limiting conditions can apply under the discretionary process and if there are significant medical costs and if the family in question are over the financial guidelines, then they would be so granted a card. There is no automatic entitlement because there is no list to state an applicant will automatically qualify for a discretionary medical card or emergency medical card. There are exceptional circumstances in respect of emergency medical cards as well, for example, if a person is homeless, but we still have to confirm the financial position in such cases. The difference applies to those who we know are in an end-of-life state and in such cases a card is issued for six months and no regard is taken of their financial assessment. That is really the distinction.

Dr. Áine Carroll:

Deputy Ó Caoláin asked a question about the rehabilitation medicine programme model of care. The model of care has been signed off by the working group and signed off by clinical advisory group as well. The next stage in that process is that the draft will be circulated for consultation. I hope that consultation process will be completed in the next few months and that the model of care will be signed off by the senior management team and published before the end of the year.

Reference was made to the implementation of the national strategy. My understanding is that the executive lead appointed through disability has met recently with the new lead for the rehabilitation medicine programme. The working group is being set up to examine the implementation of the strategy. That is a good step forward in terms of implementation of the national strategy.

Deputy Mitchell O'Connor asked a question on chronic pain pathways and she is quite right. Chronic pain is a common condition, specifically chronic pain following a stroke. The stroke programme has looked at the most common type of post-stroke pain, which is hemiplegic shoulder pain. A care pathway has been developed through the stroke programme. We know there are examples of excellent practice and it is a matter of nationalising best practice. Other types of post-stroke pain require more specialised interventions and the stroke programme and the rehabilitation medicine programme will be looking at ensuring appropriate access to the specialist services for individuals with post-stroke pain.

Mr. Barry O'Brien:

The Minister has clearly set out his commitment to a total re-examination of how we manage our doctors in training. It is interesting that it is a decade since the publication of the Hanly report by the national task force on medical staffing. In that time we have seen 966 additional non-consultant hospital doctors and 890 additional consultants, yet we still have fundamental challenges in how we manage such a major resource. There is no doubt that we need a new way of thinking and engagement with this critical group of people. I welcome the Minister's statement that there will be an exercise carried out in a timely fashion to challenge everyone involved in the planning and delivery of our services with this key group of staff.

Senator Burke asked a specific question on the information supplied by my Department. We are committed to giving the committee the most up-to-date information. The information was a snapshot of where we were on 21 July, which we had committed to give when I appeared before the committee last on 11 June. The Mid-Western Regional Hospital is specifically mentioned in some of the data provided. It is giving an inconsistency and we reckon we have what is approximately a 3% or 4% issue with it, but overall we maintain that we are re-balancing and we continue to increase the numbers of training posts. We are now at 81% whereas in 2007 we were at 40%.

There are fundamental decisions to be taken as to how we plan and continue to deliver this service.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. O'Brien? Are there any other comments?

Colm Burke (Fine Gael)
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Chairman-----

Jerry Buttimer (Cork South Central, Fine Gael)
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No. I have five other members who wish to contribute.

Colm Burke (Fine Gael)
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I asked a question about the number of contracts filled by agencies as opposed to contracts with the HSE.

Jerry Buttimer (Cork South Central, Fine Gael)
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Perhaps Mr. O’Brien would answer the question.

Mr. Barry O'Brien:

It is correct to say that approximately 28 to 30 of our hospitals out of the overall 50 used some agency. In some instances it could be quite small but in other cases there is a greater dependency. All of the training posts are filled. The remaining percentage are posts in-service. We continue to work with the training bodies to increase the number of training posts and opportunities for doctors. It is an issue that we continue to use agencies and we are working diligently to reduce their use. On the type of contracts we are offering, I have no doubt the group the Minister will challenge with delivering the timely report will look at the way the training modules and contractual modules need to be reviewed and a parallel approach needs to be taken to avoid the position outlined by Deputy Mitchell O’Connor where one has to go around every six months presenting oneself. The challenge is in changing the thinking about how one structures the training programme and to match the contracts of employment to meet that.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I will be very brief. I asked a question about a defibrillator.

Jerry Buttimer (Cork South Central, Fine Gael)
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Mr. Tony O’Brien answered it.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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He answered one question. I asked about community defibrillators and how the public can know where they are. I did not expect the answer I got. The question was about how people know where to get community defibrillators. It is simple.

Mr. Tony O'Brien:

The question referenced the national defibrillator replacement programme which is part of our answer to question No. 2 tabled by Deputy Naughten. That defibrillator replacement programme relates to the ambulance service.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I am well able to read. This is the second time Mr. Tony O’Brien has given me a smart answer.

Jerry Buttimer (Cork South Central, Fine Gael)
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Members were asked to submit questions in advance of the meeting. To be fair to Mr. O’Brien, he is replying to question No. 2.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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He could note what I have said. He does not have to ignore it.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will ask him to do that. Mr. O’Brien might communicate with Deputy Mitchell O’Connor after the meeting.

Robert Dowds (Dublin Mid West, Labour)
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I thank the Chair. I congratulate Mr. Tony O'Brien on his appointment. On question No. 23 which I submitted, which relates to follow-on services for severely disabled people, would the Minister of State, Deputy Lynch, consider having an examination of the appropriateness of the facilities that are available to disabled people after they leave second level education at approximately the age of 18? It is not just a question of money, in the sense that in many cases services are provided by what were formerly voluntary organisations. Would it be possible to streamline organisations so as to save money in terms of administration costs and to perhaps provide a service that is as good or better?

If I am out of order the Minister could indicate that in his response, but since the time for submitting questions closed I got a very angry letter from a group of GPs in my constituency who say that the further round of cuts in payments to GPs under the FEMPI legislation is leading to a situation where they will provide less service and therefore more people will end up in accident and emergency departments. Is there any basis for that allegation?

Jerry Buttimer (Cork South Central, Fine Gael)
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I assure the Deputy that we all got such letters from GPs in our constituencies.

Robert Dowds (Dublin Mid West, Labour)
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I would be interested in the Minister’s comment. If he is not able to comment now perhaps-----

James Reilly (Dublin North, Fine Gael)
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Could Deputy Dowds reiterate exactly what they said?

Robert Dowds (Dublin Mid West, Labour)
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Okay, I will read the letter. It states, “I want to express our dismay"-----

James Reilly (Dublin North, Fine Gael)
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Not the whole of it, the Deputy could outline it.

Robert Dowds (Dublin Mid West, Labour)
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Basically, they are saying that the further round of cuts in payments to GPs under the FEMPI Act is leading to a situation where they will provide less service and therefore more people will be directed towards accident and emergency departments. I am not saying that is necessarily the case but that is the allegation. Other Deputies received similar letters. Some of the content of the letter seems unreasonable to me but I would be interested to know if that is the case. I am sure that will show up in the statistics in the months to come.

Peter Fitzpatrick (Louth, Fine Gael)
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I welcome all the Ministers to today’s meeting. It is great to see so many of us in the one room. I congratulate Mr. Tony O’Brien on his appointment. I got an invitation to a very important meeting last Thursday in St. John of God, Drumcar. A total of 52 public representatives were invited and 14 turned up. We were told that since 2008 funding has been cut by in excess of €7 million. In 2012 there was a deficit of €550,000 and the shortfall was met through funding. It is estimated that there will be a deficit of €1.2 million in 2013. At present the day care centre is closed for three weeks recess and it will re-open on 12 August. From that time those attending day care will no longer receive meals and are being told to bring their own food with them. Most of those attending are more than 40 years of age. What is happening at the moment is a disgrace. I pleaded with the management of St. John of God in Drumcar. I pleaded with the CEO and with everybody else. What is happening at the moment is totally and utterly unfair. Most of the parents are in their 70s and 80s and they are not capable of giving food to their children. Even though the people concerned are in their 40s and 50s they are still children to their parents.

In 2013 the service received an allocation of €25.7 million from the HSE, which is a drop in funding of 1.4% from the 2012 allocation. In 2012 those receiving day care used to get pocket money of €6.50 a week. The recipients spent the money in the local shops and paid their own way. I have seen that happen numerous times in Dundalk that such people have come into a restaurant and paid for their own food. It is a disgrace that the payment of €6.50 has been stopped.

The staff of St. John of God in Drumcar do an outstanding job. I plead with the Minister to reverse the decision. It is in our hands to do something at the moment. A total of 500 people are employed in the St. John of God service in Drumcar and it is planned to close the staff canteen. On tomorrow, Friday, the staff will meet with Dermot Monaghan, the Louth-Meath integrated area manager for the HSE, and they will also meet the families tomorrow night. All I ask of the Minister is that he would please intervene because we are dealing with vulnerable people. As far as I am aware it would not cost much to feed them. We talk about giving money to various countries but I urge the Minister to help the people concerned. I will meet them tomorrow evening and I told them the Minister is a compassionate man. I urge that he would help in this situation.

Sandra McLellan (Cork East, Sinn Fein)
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I thank the Minister and his team for their presence. I thank Ms Mary Lindsay and congratulate Mr. Tony O’Brien on is appointment. I wish to comment on medical cards. I understand that the number of discretionary medical cards has been increased but that must be expected due to the state of the economy. I disagree that it is no more difficult now to be awarded a discretionary card than it was previously due to the fact that a number of people who had been awarded discretionary cards under review had them removed, even though their circumstances did not change. In fact, in many cases, they were worse off.

Sometimes, when one is aware that people cannot afford to take their medication and one makes a call to the call centre, those who answer the calls are lovely. They give as much information as possible that is before them on the screen but if one needs to speak to someone with more authority or who has the ability to overturn a decision, in many cases, nobody calls one back. That is unacceptable. It is not only on the rare occasion that one does not get a response to a call, it happens quite often and it is most frustrating.

With regard to the questions I asked, Nos. 24 and 26, I thank the Minister for his response. There are some positive developments in the area of community mental health teams but the question answered was not the one I asked. The Minister is correct in stating that there are no legal requirements for a perinatal psychiatrist to see a woman who has presented as suicidal in order for her to have a termination but that is not to say there is no medical need for further perinatal psychiatric treatment. The Minister of State, Deputy Lynch, mentioned the developing clinical programmes but can the Minister tell the committee whether he believes the existing three perinatal psychiatrists are adequate to cope with the demand for their services and treatment? Also, will the Minister outline the current provision of prenatal psychiatric services and whether there are any plans to expand those?

With regard to question No. 25, I thank the Minister for his comprehensive and well thought-out reply, which was primarily about the provision of services, the number of teams and staffing levels but that is not the question I asked. The question I asked was to do with the issue of regulations, rules and codes of practice, and the way procedures are followed. The data show that between 2011 to 2012, levels of compliance in approved centres nationally decreased for seven of the nine articles of the 2001 Mental Health Act relevant to codes of practice, and increased for the other two articles. The report also outlines a number of other areas in which such regulation has failed. What action is the Minister taking on foot of that?

With regard to the mental capacity legislation, it was to be brought before the Cabinet before the end of June. Has that happened and, if not, will the Minister give us a timeframe for that?

John Crown (Independent)
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I welcome an tAire. I preface my question by stating it is regrettable that Deputy Naughten, who had scientific and technical expertise, was removed from this committee.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are not dealing with that. For the Senator's information, the composition of the membership of the committee does not fall within the remit of the committee. That is a matter for Dáil Éireann.

John Crown (Independent)
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I merely state that for the record. I welcome Mr. O'Brien to the ranks of those who have been appointed to an organisation, like Seanad Éireann, whose extinction is planned by its owners.

With respect to the question I raised about the National Centre for Pharmacoeconomics-----

James Reilly (Dublin North, Fine Gael)
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The Senator should acknowledge that the Seanad is owned by the people.

Jerry Buttimer (Cork South Central, Fine Gael)
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One speaker please.

John Crown (Independent)
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Indeed.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will not have a referendum campaign here. This is the health committee.

John Crown (Independent)
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The National Centre for Pharmacoeconomics, NCPE, as the Minister is aware, issued a recommendation on certain cancer drugs as being cost non-effective. The Minister wisely and humanely, following other consultations, overrode that decision and made one drug in particular available. I raise the question that Aviva private health insurance is using the data from the National Centre for Pharmacoeconomics to justify its decision not to pay for the drug, which means that patients who have paid for their health insurance are being rejected for this drug and are then falling back as an extra expense burden on the public hospital system. That is iniquitous. Parenthetically, Aviva pays for homoeopathy - I would like to know if it has ever done a health cost effective analysis for homoeopathy - which speaks to the sincerity of this organisation. I urge people who have Aviva insurance to consider joining another company, and if they are thinking of taking up insurance-----

Jerry Buttimer (Cork South Central, Fine Gael)
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The Senator should not do that. It is unfair in terms of our hearings and that the people he mentioned are not here to defend themselves.

John Crown (Independent)
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I will make them very welcome. I have said it to their faces.

Jerry Buttimer (Cork South Central, Fine Gael)
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I appreciate that but that is-----

John Crown (Independent)
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In reply to my question the Minister stated that these NCPE assessments were in the public domain and, as a result, Aviva had the same right to consult them as anybody else. I was in touch with somebody from Aviva yesterday who told me that it is paying the NCPE for access to the reports. That is a service, which is a legitimate activity for the NCPE to do if it can raise revenues, but there is something seriously wrong with a system where a taxpayer-funded organisation is doing analyses which private for-profit insurance companies are then using to justify not paying for something and putting that burden back on an incredibly overburdened public health service.

I thank the Minister for his reply. I acknowledge his attention to our ban on smoking in cars where children are present. We are working together on that and I am very grateful to the Minister and his Government for allowing the Bill pass through Second Stage; it is hoped the Bill will complete Committee Stage in the near future. I remind the Minister that we had meetings with some of his senior officials towards the beginning of January in which we were told we would have the Bill by the end of January. Six months have passed, although I know other important legislative issues have arisen.

The Minister keeps referring to the heads of the Bill but there is a Bill; the Bill is written. What we are talking about are amendments to the Bill. Perhaps I am legislatively naive on that. I do not know if an entirely different Bill is being proposed or if heads of a Bill are coming forward. There is a very good reason politically to have this Bill passed by the Houses. The Minister is a campaigning anti-tobacco Minister and legislator but at this point in time the only Bill that has been passed is one which makes it easier to sell cigarettes by ending the ban on below-price selling.

On the health technology assessment for defibrillators, Frank Pantridge, an Irishman, invented the portable defibrillator. He was a cardiologist in Belfast. It was used widely since 1967. I remain a little troubled by the fact that we need a health technology assessment done on it.

With respect to the medical cards, I am not asking the Minister a question but I do not often get a chance to bring issues to his attention, and this is important. Public patients receiving repetitive cancer treatment who do not have medical cards are being charged repetitively for coming into hospital for different treatments. That is grounds for thinking that the discretionary medical card should be extended to patients who have cancer who are on active treatment. Some of it makes bad health economics. We have stopped paying for a drug called G-CSF, on which I had the privilege of being involved in some of the developmental research about 25 years ago. That drug reduces the rate of expensive readmission to hospital of cancer chemotherapy patients by reducing their risk of potentially life-threatening infections. This decision will cost money. More patients will be admitted to the hospital with complications of infections from chemotherapy than would have happened if they were given what is now a relative cheap injection.

All the rhetoric about the non-consultant hospital doctors, NCHDs, could be ended with the stroke of a pen if the Minister made the decision that, in future, all non-consultant hospital doctor titles - intern, senior house officer, SHO, registrar - would be scrapped and they would be called trainee 1, trainee 2, trainee 3 or trainee 15 by the year they graduated from medical school. It would remind people that NCHDs are there to train. They are not there to provide a service for anyone.

Regina Doherty (Meath East, Fine Gael)
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On the issue of symphysiotomy, I thank the three Ministers. That has been a commitment not only of the three Ministers but of the Department, and I believe we are getting very close to finding a solution for the entire body of women who have remained trenchant in their search for some resolution.

I have two questions. First, I ask the Minister for an update on the pending redundancy plans within the Health Service Executive. We appear to have gone quiet on them. I refer in particular to anecdotal evidence I have of someone who has been refused a redundancy package even though they have not yet applied for one and they are not front-line staff.

My second question is to the Minister of State, Deputy Lynch. I appreciate that the fair deal fund is for a particular purpose but we are talking about putting something like home care packages on a statutory footing to ensure that people who want to stay in their homes can be afforded that ability even if they have to pay for it in some way themselves. What is the Department's view of that?

Eamonn Maloney (Dublin South West, Labour)
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I have three questions. First, regarding the national rare disease action plan, I was informed at the start of the year that the Department was working on an end of year timetable to try to finalise it. The Minister might update the committee on that. Second, regarding the mobility transport grant, a review group was set up. How does that stand in terms of a timeframe? Third, can we take it that the mobility allowance will continue until such time as the issue of the grant is resolved?

James Reilly (Dublin North, Fine Gael)
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If I may, I will come back to some of the issues referred to by Mr. O'Brien, which are helpful. It is important to point out that non-consultant hospital doctors in their 20s and 30s often have families, so it is ludicrous to be offering them six-month contracts. That has to change and it will change. I am determined to correct this situation because it is undermining our ability to provide a health service. If we do not value those who work in our health service it will not help patient care.

Deputy Dowds raised the issue of general practice and I know there is unhappiness in that community about the cuts they have had to take. Similar levels of cuts have been imposed right across the public service. I wish to put on the record my appreciation of the great job that those in general practice do. I am committed - as is the Minister of State, Deputy Alex White - to support general practice to start working in a different way, so that it can provide even greater care. We will do that through a number of mechanisms. Clearly, however, the role of general practice nurses has to be explored much further because their capacity to deliver care in the community has not been properly taken advantage of. I believe that such a re-examination would lead to much greater job satisfaction for nurses and GPs also.

Deputy Fitzpatrick expressed concern about Drumcar, but I will let the Minister of State, Deputy Kathleen Lynch, deal with that. In a more general sense, we now have somebody in place to review many of the non-governmental organisations involved in the delivery of care. I believe there is a far better way of providing more care services at less cost. I will let the Minister of State, Deputy Lynch, deal with that matter in a more comprehensive fashion.

Deputy McLellan raised the issue of discretionary medical cards and I will let Ms Laverne McGuinness deal with that. I am happy to say that the Government has published the assisted decision-making capacity legislation to establish the Mental Health Commission. I will allow the Minister of State, Deputy Lynch, to deal with that more comprehensively.

Senator Crown has raised some important issues. As he highlighted, there are companies that provide that drug, so let the customer decide where he or she wishes to go. That is what competition is about.

As regards Senator Crown's comments on tobacco, I acknowledge that legislation takes time. Sometimes it is not as simple as it appears. Having said that, however, we have a large amount of legislation which we are trying to get through the Oireachtas. Some legislation has to come through the Department of Finance because of the troika. In addition, my productive and prodigious colleague, the Minister for Justice and Equality, Deputy Shatter, has a large amount of legislation as he tries to reform the legal system. I also have a huge amount of legislation to deal with. We spent much of yesterday in the Department discussing the need for more capacity to progress legislation.

We are striving to introduce legislation on plain packaging for tobacco products, and hope to have the heads of the Bill in September. I will return to this committee to discuss it in due course. I thank members of the committee for their support in this regard. There is a serious battle ahead because there are powerful forces at play. It is astonishing to me how anybody could put in writing their concerns about intellectual property rights over the rights of children and other citizens to enjoy good health. If that is how things were to be prioritised, it is not a society I would like to be living in.

I will ask Mr. Tony O'Brien and perhaps Ms Laverne McGuinness or Mr. Ian Carter to address the issue of cancer patients being charged. I understand there is a limit in that regard, but I will let Mr. O'Brien address that matter.

I thank Deputy Regina Doherty for her support for the women who have endured symphysiotomy.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Minister might also wish to thank Deputy Ó Caoláin who was part of the all-party committee on that issue.

James Reilly (Dublin North, Fine Gael)
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Yes, I wish to mention Deputy Ó Caoláin as well. In fairness, there was a cross-party committee working on that matter. Sinn Féin, Fianna Fáil, Fine Gael and Labour were all represented on it. I acknowledge that Deputy Ó Caoláin was particularly associated with that committee.

I cannot understand the comment on redundancy, however. How one can be refused before one has applied leaves me somewhat foxed, but I will allow Mr. O'Brien to address the redundancy issue. The redundancy programme we are now putting in place is one where we will decide where we need staff and where we can afford to let staff leave. It is not an automatic entitlement, nor should it be. It is a question of rationalising the workforce within our health services in a way that reflects the needs of the service. That is only right and proper.

There is no disagreement between myself and the Minister of State, Deputy Kathleen Lynch, on the Fair Deal and stay at home issues. As we look at providing greater community services in future, we need to address the issue of whether long-term care requires a contribution from the individual who is being provided with the care service. I will allow the Minister of State, Deputy Kathleen Lynch, to address that matter in a more comprehensive fashion. She can also address the mobility allowance issue, which was raised by Deputy Maloney. We have had constructive meetings with the people concerned. I believe that not alone will we sort out this particular problem, but we will also address a much greater problem - and a greater issue for them - which is about people with disabilities being able to access transport more generally.

Kathleen Lynch (Cork North Central, Labour)
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In response to Deputy Maloney's question on the mobility allowance, we set out knowing the difficulty this would cause. There are people who would never be able to leave their homes but for this particular allowance and we have been conscious of that from the outset. The communications concerning it got a bit mixed up and people became worried when there was no need to worry. We hope to have the expert group's report in October. As the Minister said, it is not our intention to deprive people, who are solely reliant on this allowance for their transport needs, of any assistance we can give. I hope that message gets out there because we are very conscious of their needs.

We have changed the title of the assisted decision-making capacity legislation. We still have to keep in certain elements of it for legal reasons until it is enacted. It was published two weeks ago on the Department of Justice and Equality's website. That may be why Deputy McLellan did not spot it. I am working in two Departments, so that may be where the difficulty arose.

It is debatable as to whether we have enough perinatal services in the country. When the clinical programmes are developed, the existing expertise in that area can be used to link people who may have a difficulty with mental health during pregnancy with access to such services. Due to our low population base, I think everyone accepts that we do not need to have perinatal services in every corner. Access is an issue, however, whether for the treating clinician or the woman herself. That matter must be examined.

Deputy Fitzpatrick mentioned funding for Drumcar. The difference between this Government and its predecessors is that funding is limited. Over the years, we used to see continuous supplementary Estimates because budgets overran. Fortunately or unfortunately, that is now a thing of the past.

In respect of vulnerable groups, particularly adults with disabilities, we are looking at a different way of implementing what they consider to be their care needs. We carried out a detailed value for money analysis of how the service was provided and how much it cost and we have now put together an implementation group. Some of those appointed to the group take a particular interest in the needs of people with disabilities and have been revolutionary in their thinking. There is no point in denying that things will change but we have to start consulting people with disabilities to find out what they prefer rather than looking into our hearts and assuming we know what is good for them.

The funding we provide is substantial. On average we spend €1.2 billion annually on services for people with disabilities in the health area alone. This is separate to what is spent in education, social protection and justice. It is a substantial budget and changes will come about.

Peter Fitzpatrick (Louth, Fine Gael)
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All they were given was three weeks' notice. The families never got an opportunity to be consulted.

Kathleen Lynch (Cork North Central, Labour)
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I cannot and do not intend to micromanage services. We are the policy makers and we must ensure that the policy framework is in place to ensure people have access to a safe service. We also fight for the budgets required to allow that to happen. It would be ridiculous to micromanage a service. I would spend my life running around the hundreds of services provided in this country. That is an issue for another day.

We have a specific budget for home care packages. I made this point earlier in respect of extending the fair deal scheme. We are not suggesting that we will distribute the pot of money set aside for long stay care throughout the community. It is a question of how we access the budget and the process we put in place to ensure it is as fair and transparent as the fair deal scheme. The review has been delayed slightly because of the various issues that arose during the year but we are still continuing with it.

Mr. Tony O'Brien:

In regard to the issues raised by Deputy Fitzpatrick, all service providers are required to take their share of the reduction in the overall health budget. He referred to a relatively modest reduction of 1.4% for a particular service provider. It is unfortunate that at certain times of the year, including in particular the run-up to budget negotiations, some service providers insist on putting their clients on the front line of negotiations. The issue is being discussed by the service provider and the area manager for Louth-Meath. We asked the provider to desist from issuing communications of this nature to those who depend on its services and we are seeking to engage with it. Service providers should understand that when they chose to do these things in response to relatively modest adjustments in their budgets, they are unlikely to encourage us to look favourably upon them when it comes to a choice of how to allocate scarce resources. Those which tend not to use their service dependent clients in this way are much more likely to do well than those which consistently put them on the front line. While we will engage with them, that approach does not engender sympathy from the Health Service Executive.

Alex White (Dublin South, Labour)
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I ask Ms McGuinness to deal with Deputy McLellan's question about medical cards.

Ms Laverne McGuinness:

Deputy McLellan had a query about contacting the PCRS. A specific e-mail address has been set up for Oireachtas Members, oireachtas.pcrs@hse.ie, and all calls and e-mails are logged. I am disappointed that the Deputy has not received a response but she can engage directly with our head of customer services, Mr. Kieran Healy, who will look after her. I would also be happy to pursue the issue.

The eligibility criteria for discretionary medical cards have not changed. If the individual's circumstances have not changed it is difficult to see how the card would not be renewed unless he or she qualifies for a GP discretionary card, the threshold for which has increased to €19,000. The guidelines are quite generous over and above the finance threshold for normal medical cards in terms of taking account of medical conditions and circumstances. This is why there are additional numbers of medical cards.

Sandra McLellan (Cork East, Sinn Fein)
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I ask Ms McGuinness to explain why somebody who previously received a medical card on discretionary grounds had it rescinded on review even though the card was not even out of date. We are dealing with a considerable number of such cases.

Jerry Buttimer (Cork South Central, Fine Gael)
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I have pointed out previously that the letters sent to people can be intimidating. Just this morning I received a telephone call from a distressed constitution in respect of the content of a letter. I take Ms McGuinness' point about the sensitivity of the matter but sometimes the letters are couched in bureaucratic language. It might be helpful if the HSE tweaked the language it uses when writing to people.

Alex White (Dublin South, Labour)
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I ask the Chairman to send me a copy of that letter with the names redacted.

Jerry Buttimer (Cork South Central, Fine Gael)
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I can provide a copy next week.

Ms Laverne McGuinness:

I would be happy to pursue individual cases. Now that we have put in place a new arrangement involving medical doctors, there is even more empathy and compassion in assessing discretionary medical cards. Sometimes an applicant's income is €2,000 or €3,000 higher than the income threshold on a monthly basis, which is quite significant, and his or her medical outgoings may not be as high.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the staff of the PCRS for the work they do and pay particular tribute to Mr. Paddy Burke and his team, whom we visited when the unit was first established. There has been significant change since then and the staff are very professional and courteous.

Colm Burke (Fine Gael)
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In fairness to everyone in the HSE, I have come across an individual who held a medical card for three years despite having a weekly income of €300 more than the qualifying criteria for medical cards and not suffering any illness. This individual could not understand why the card was not renewed. Let us get the correct information out.

James Reilly (Dublin North, Fine Gael)
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When I tasked the PCRS with dealing with the delays in issuing medical cards, in which regard Mr. Paddy Burke and his team have done a great job, I pointed out that probity issues would arise and that we would find ourselves explaining the sort of issues to which Senator Colm Burke referred to the Committee of Public Accounts.

Eamonn Maloney (Dublin South West, Labour)
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I asked about the national rare disease action plan.

Robert Dowds (Dublin Mid West, Labour)
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I ask for a response to my comments on disability and the appropriateness of services and facilities for those aged over 18 years. Does the Minister think it worthwhile to examine the entire area with a view to streamlining it?

James Reilly (Dublin North, Fine Gael)
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I do not have the information Deputy Maloney requested but I will communicate with him in writing.

Kathleen Lynch (Cork North Central, Labour)
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I apologise to Deputy Dowds. His question was not on my list. The number of school leavers increased to 832 this year. They are split between day care services and training places, as anyone familiar with the area will know. To date we have managed to place 673 people and we require placements for 159. Additional funding of €4 million was provided this year for the four different areas based on the populations that have to be accommodated. We are also engaging with Genio, which did a very good job for us last year.

I did not answer Deputy Dowds's question in the first round because I wanted to send a message to service providers. They have done an extraordinary job for people who need a service in this area last year and this year with no additional money. It is unlikely they will be able to recruit, but we are working on it. Both the HSE and the service providers have worked extraordinarily hard in a very short time to ensure we are looking for 159 places. They are always the most difficult. Spaces are used up and it is usually those who have greater challenges, but we are still working on it.

Mr. Tony O'Brien:

I will ask Dr. Carroll to respond on the rare diseases issue.

Dr. Áine Carroll:

Deputy Maloney may be aware that we have established a rare diseases clinical programme and very recently appointed a clinical lead. Now that we have a clinical lead, we will be able to proceed with the appointment of a working group and clinical advisory group.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the members, the Minister, Deputy Reilly, and Ministers of State Deputy White and Kathleen Lynch, Ms Bairbre Nic Aonghusa, Dr. Fergal Lynch, Mr. Michael Murchan, Mr. Larry O'Reilly, Mr. Paul Howard and Mr. Ray Mitchell who have been instrumental in being the conduit for us. I thank Mr. Byrne, Dr. Carroll, Mr. Barry O'Brien and Mr. Carter and wish them well in their new posts. I thank Ms McGuinness and Mr. Tony O'Brien for their deliberations and assistance. Members will be glad to hear the next quarterly meeting will be on 17 October 2013.

James Reilly (Dublin North, Fine Gael)
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I thank the Chairman and his committee for all its support. It has done great work and shown how a committee can add to our deliberations on planning for our health services and policy. I thank everybody, even those who often have a view contrary to my own, for their contributions. I wish them all a very good summer. I wish the same to all the people in my Department, who have worked so hard, and the HSE. There has been a real improvement in our health service, with an 18% cut in budget and a 10% loss of staff. I applaud them.

Jerry Buttimer (Cork South Central, Fine Gael)
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I echo the Minister's remarks. It is important we acknowledge the great work done by the HSE staff at all levels. I thank them for their sincere and committed service to the patients and people they come into contact with every day. I thank members of the committee for their work since January. We have had a very long, tedious amount of work and I compliment them all for the way they have parked partisanship and worked as a committee. As the Minister said, and I am very biased in saying this, our committee has been an very good advocate for the committee system in Leinster House. I thank the committee and promise there will be no meeting until 12 September.