Jerry Buttimer (Cork South Central, Fine Gael)
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I welcome everybody to our quarterly meeting with the Minister for Health, Deputy James Reilly, the Ministers of State at the Department of Health, Deputies Alex White and Kathleen Lynch, and the representatives of the Health Service Executive, HSE, led by Mr. Tony O'Brien.

I remind witnesses and people in the Visitors Gallery to turn their mobile phones off or switch them to flight mode because they interfere with the broadcasting of proceedings. It is also unfair to staff as they cause interference in their headsets.

I have received apologies from Deputies Seamus Healy and Sandra McLellan. Deputy Robert Dowds was obliged to leave to attend another meeting.

I thank Mr. Ray Mitchell and Mr. Larry O'Toole from the HSE and the Department of Health for their co-operation in liaising to organise this meeting. I wish Mr. O'Toole every success in his impending move. I thank him for all his assistance to the committee. I also thank Stephen Doran from the Minister's office for his work. He has left to take up another position.

This quarterly meeting takes place against the backdrop of the budget and the impending HSE service plan. There are 36 questions from Deputies and Senators to the Minister and the HSE. The members of the committee are interested in, committed to and concerned about the delivery of health care. We are all of the view that this is about the delivery of a service to those who need it most. We are interested not in scoring political points but in ensuring that the committee makes a constructive contribution to try to help the delivery of care and the development of policy. That has been the focus of the committee since it came into being two and a half years ago. As the Minister saw with the Protection of Life During Pregnancy Bill, this committee does not embroil itself in political point scoring. The backdrop of the meeting is an interesting and challenging budget for the Department of Health and the HSE and we look forward to the engagement with the Ministers and the officials.

I wish to put on the record my appreciation of and thanks to the staff of the Department and particularly of the HSE who, in the front line and back offices, do a great deal of work that does not get noticed. We appreciate that.

With regard to the primary care reimbursement service, PCRS, the committee visited the new headquarters for the distribution of medical cards.

Arising from today's meeting, it would be important that we again visit and talk to the staff about the issues pertaining to medical cards and how the new centralised process has been working since our last visit. We will arrange a suitable date with Ms McGuinness after the meeting.

I remind the witnesses that they are protected by absolute privilege in respect of their evidence to the joint committee. However, if they are directed by it to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair and parliamentary practice to the effect that they 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. I invite the Minister for Health to make his opening remarks.

James Reilly (Dublin North, Fine Gael)
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I am joined by the Secretary General of my Department, officials from the HSE and my fellow Ministers, Ministers of State, Deputies Alex White and Kathleen Lynch. The committee will be aware there is a time conflict here with the Private Members' business motion in the Dáil. The Minister of State, Deputy Kathleen Lynch, will have to leave at 12.15 p.m. to take that motion. Perhaps when we finish our opening statements, if members have questions on her area of responsibility, the elderly and mental health, they might be taken first.

I thank the Chairman and members of the committee for their invitation to discuss the health service issues. As I said, I am accompanied by my fellow Ministers, Ministers of State, Deputies Kathleen Lynch and Alex White, senior Department officials and officials from the HSE. We will do our utmost to provide the committee with as much information and clarification as possible. I apologise that my opening statement is significantly longer than the norm. However, as requested by the committee, I have addressed a number of substantive issues.

To the forefront of all our thoughts is patient safety and the care of our citizens but we are also very conscious of the budget announced earlier this week, in particular its implications for the health services. I am pleased the Government has provided funding for free GP care to children up to five years of age and under the age of six as the first step towards providing universal GP care in line with the development of universal health insurance as set out in the programme for Government. I am also pleased a further €20 million has been provided to continue the investment in mental health services, primarily in the area of community mental health teams.

The budget provision for the health sector is €360 million less than was provided in 2013, which represents a 3% reduction in funding over past year. As a result, 2014 will be another extremely challenging year for the health services. The Government has had to make some very difficult decisions in regard to the health Estimates as part of the budgetary arithmetic. The prescription charge will increase from 1 December to €2.50 per item with a €25 monthly cap on expenditure per household. In addition, the income thresholds for medical cards for persons over the age of 70 will be reduced to €500 per week for an individual and €900 for a couple. Legislation to give effect to this change will be enacted before the end of the year. It is important to note, however, that all those who will come off the full medical card will migrate to a free GP card and will have the further backstop of the drugs payment scheme which limits their exposure to medical costs, in terms of pharmaceuticals, to €144 per month.

Very ambitious savings targets have been set in regard to medical card probity and for pay savings to be achieved under the Haddington Road agreement. However, these challenging savings targets will be the subject of a verification exercise as to their achievability, a process which will conclude before the finalisation of the Revised Estimates Volume. The verification exercise will be overseen by the Secretary General of my Department, along with the Secretary General of the Department of Public Expenditure and Reform and the Secretary General to the Government.

The implications of the budget for the provision of health services will be set out in the HSE's national service plan which will be formally submitted to me within the next three weeks, in line with the provisions of the Health Act 2004. The 2013 service plan required the HSE to continue to focus its delivery of services on the dual challenge of protecting patient outcomes while, at the same time, reducing costs. Next year will be no different in this regard and measures impacting on the health system as a result of budget 2014 will again be assessed against these key criteria, with the outcomes of this consideration set out in the service plan.

There is no doubt that the level of funding available for the health services in 2014 creates a significant challenge to the HSE. In setting out the operating framework for the delivery of HSE services throughout 2014, the service plan will look to deliver the maximum level of safe quality services possible within the funding available, with prioritisation, where necessary, of certain services to meet the most urgent needs. The plan will also set out targets in respect of each programme area to ensure that performance can be evaluated throughout the year in order to identify any emerging areas of concern and, should any concerns arise, allow for the implementation of necessary remedial measures without delay.

The joint committee asked that particular attention be given to the employment conditions of non-consultant hospital doctors at today's meeting and I am more than happy to do so. I said before that I want to create a health system that protects, nurtures and develops the people who work within it. That is why I am determined to change the role of NCHDs within our health system. It is essential that doctors enjoy reasonable working conditions. I want to reassure hospital doctors that the Government is committed to achieving compliance with the European Working Time Directive in respect of NCHDs by the end of 2014.

This is a complex task and a key challenge is to ensure that we achieve compliance while maintaining essential hospital services. I want also to emphasise that this is not primarily a matter of resource availability. Among the range of measures to be addressed are changes to NCHD rosters and work patterns, greater use of consultant teams, introduction of electronic time and attendance systems, reallocation of tasks between health professionals and reorganisation of services.

At my request, in 2013 the HSE has brought a renewed and urgent focus to compliance with the European Working Time Directive. In particular, a senior national group has been working closely with individual hospitals, with an emphasis on eliminating shifts of more than 24 hours and instances of doctors working more than 68 hours per week.

Achievement of compliance with the European Working Time Directive cannot be a top-down process. In my view, the best approach is that there be a strong joint process involving the HSE and the NCHDs themselves in working through the practical steps necessary. Ireland must have sustainable arrangements to train and develop the medical workforce we need in order to provide safe and effective services to our population. I am, therefore, committed to retaining doctors who are educated and trained in Ireland within our health service.

In July of this year, I set up a working group chaired by Professor Brian MacCraith, president of DCU, to carry out a strategic review of medical training and career structures, with a view to improving retention of graduates in the public health system. This group is currently working to produce an interim report by the end of November 2013 and a final report by the end of June 2014.

I would like to refer to the issue of medical cards awarded on a discretionary basis. This issue has received a significant level of publicity since our last meeting and, as recently as last week, was the subject matter of Private Members' business in the Dáil. I was glad that, with my colleagues in the Department, I had the opportunity to again set the record straight and to reject out of hand the contention that there is a deliberate targeting of holders of discretionary medical cards. There has been no change to the policy on discretionary medical cards in the past year and the scheme continues to operate in such a way that those who suffer financial hardship as a result of a medical condition receive the benefit of a medical card.

The processing of medical cards at a national level rather than at a local level before mid-2011 ensures that all people are assessed in a similar and fair way when applying for a medical card. At my request, the HSE put in place a process where a medical doctor would consider the assessment for discretionary medical cards.

In previous years, there was a decentralised process which meant there could be inequities throughout the system. Now the process is standardised and there is fair and equitable treatment for all. The variation throughout the country meant people in identical circumstances were getting a discretionary medical card in one part of the country but not in another. Sometimes people who were worse off were not getting medical cards on a discretionary basis because of the variation.

Let me clarify the matter further as it is a topic of major interest to people. Since 1970, medical cards have been awarded to people who were unable without undue hardship to arrange GP services for themselves and their family. The cards are awarded typically when their means are below the HSE's incomes thresholds. That remains the case today. However, I am concerned about the content and volume of recent media stories about vulnerable people whose medical cards have been removed.

On Monday, I met the CEO of the HSE, the HSE director of primary care and the assistant national director of primary care reimbursement service to express my concerns directly to them. I requested a detailed examination of every person who held a discretionary medical card in March 2011. Of these 97,121 people on 1 October 2013, 39% still held a discretionary medical card - that is 38,283; 43% had migrated to an ordinary medical card based on an assessment of means - that is 41,779 people; and 18% of people no longer held a medical card - that is 17,059 people. Of those 17,059 people, 14% are deceased, that is 2,361; 38% did not respond to correspondence from the HSE and their medical cards are now suspended - that is 6,265; 12% initially engaged with the review process but did not conclude the assessment, that is documentation to allow the assessment to be completed was not provided - that is 2,109 people; and 37% of people completed the review process and were found to be ineligible for a medical card or a GP visit card, that is 6,324 people. That figure represents 6.5% of all people who held discretionary medical cards in March 2011.

I also asked the HSE to provide a study of cases in which individuals lost their medical card but had originally been awarded one on a discretionary basis. It found that after allowances were made for loans, mortgages, rent, travelling to work expenses and all medical expenses, 49% of these cases were still over 200% above the guideline amounts for eligibility; 92% of cases were still 50% above the guidelines for eligibility. Member are free to question officials on this after my contribution.

Since my appointment as Minister for Health, the Primary Care Reimbursement Service, PCRS, officials have exercised discretion in a positive way on 36,000 occasions. Since January 2013, some 23,000 new medical cards have been issued on a discretionary basis. Let me assure members there has been no change in policy but there has been probity. The members know full well that the Committee of Public Accounts will inquire as to the reason people have medical cards who should not have them. There is a balance to be struck.

An additional 250,000 medical cards are in circulation since the beginning of 2011 - that means 43% of the population have access to free GP care, the highest proportion since records began. It is not just the highest proportion in terms of the percentage of the population but the highest number in real terms. We have seen a 8% growth in population since 2006.

The Department of Health estimates that the measures in yesterday's budget will further increase the proportion of the population with free GP care to 49%, in effect nearly half the population will be covered for GP care, which is the direction of travel that we wish to go.

Jerry Buttimer (Cork South Central, Fine Gael)
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The Minister's allocation of ten minutes is almost up.

James Reilly (Dublin North, Fine Gael)
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I did warn the committee at the outset that my statement would take a little longer.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is it agreed that we allow the Minister more time? Agreed.

James Reilly (Dublin North, Fine Gael)
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That is the direction of travel as we seek to achieve universal health insurance with free access to GP care for everybody in the community so that people go to their doctors early and have their chronic illnesses monitored and more prevention can take place and fewer people will end up in hospitals, which is the most expensive end of the health service. This is a case of investing now for the future so that in five, ten, 15, 20 or 30 years' time, we do not have the same patterns of morbidity and mortality that we have today.

The most recent HSE performance report shows that 1,991,148 people have access to free GP care in July 2013, comprising some 1,868,565 people with a full medical card and another 124,925 people with a GP visit cards. Of these 75,348 people had discretionary medical or GP visit cards. Some 54,984 were discretionary medical cards and 20,364 were discretionary GP visit cards. Discretionary medical cards are awarded to people who are unable without undue hardship to arrange GP services for themselves and their families even though their means exceed the HSE's income thresholds. In these cases social and medical issues are taken into account when considering whether undue hardship exists for the applicant.

When this Government came into power, there was no established uniform procedure for medical personnel to assess applications for medical cards on discretionary grounds. When I became Minister for Health, I instructed the HSE to establish a clinical panel to assist in the processing of applications for discretionary medical cards. This allows medical professionals to have an input into granting a medical card to people who exceed the income guidelines but who face difficult financial circumstances, such as the extra costs arising from an illness. This procedure ensures that the specific situation of a person with a particular diagnosis can be considered on a case by case basis.

Chairman and members, we must have clarity on the 1970 Act. There never has there been an automatic entitlement to a medical card on the basis of a specific illness or a specific condition. If we wish to change the law, then regulations will have to be brought before both Houses of the Oireachtas.

An assessment for a medical card must be determined primarily by the overall financial situation of an applicant and dependants in accordance with the health legislation. There is no legal basis for the HSE to award a medical card based on a person being diagnosed with cancer or another condition. The HSE is continuing to assess and issue discretionary medical cards to people to avoid undue hardship. The HSE has a system in place for the provision of emergency medical cards for patients who are seriously ill and in urgent need of medical care they cannot afford and for patients who are terminally ill. Emergency medical cards are issued by the HSE within 24 hours of receipt of the required patient details and the letter of confirmation of the condition from a doctor or a medical consultant. With the exception of terminally ill patients, the HSE issues all emergency cards on the basis that the patient is eligible for a medical card on the basis of means or undue hardship and that the applicant will follow up with a full application within a number of weeks of receiving the emergency card. As a result emergency medical cards are issued to a named individual with a limited eligibility of six months. The arrangement is slightly different for persons with a terminal illness and in palliative care. Once the terminal illness is verified, patients are given an emergency medical card for six months. Given the nature and urgency of the issue, the HSE has appropriate measures to ensure the person gets the card as quickly as possible. There is no means test and the nature of the illness is not a factor.

I will speak very briefly on the other aspects of the budget.

A review was carried out earlier this year under the Financial Emergency Measures in the Public Interest Act 2009 of the operation, effectiveness and impact of the amounts and rates payable to general practitioners under the relevant regulations. Having carefully considered the submissions that were made during the consultation process, I decided to reduce certain fees and allowances payable to general practitioners. I am satisfied that the proposed reductions are fair and reasonable. Overall, the reduction in GP fees will save approximately €38 million in a full year.

Payments to general practitioners have been reduced by 7.5%. Rather than introducing a cut of 7.5% across the board, a more strategic approach has been taken. The weighting for patients over the age of 70 has been reduced. In 2001, when the then Government decided to give medical cards to everyone over the age of 70, it was agreed that each patient over that age would be given a certain weighting when allowances were calculated. It is estimated that the reduction in the weighting for these patients from 3:1 to 2:1 will save €5 million in a full year. I will explain what that means because many members might not be familiar with it. When doctors sought their nursing support grant or practice support grant in respect of a patient over the age of 70, they were given the equivalent of three times the grant that was payable in respect of an ordinary medical patient under the age of 70. That was the weighting. They now receive the equivalent of two times the grant.

The elimination of special payments related to the number of discretionary medical cards will result in savings of €10 million in a full year. These special fees, which were negotiated in 2001, were spread across the general medical services as opposed to being focussed on the actual discretionary medical card itself. The fee payable to GPs in respect of the seasonal flu vaccination is €28.50, whereas the fee payable to pharmacists is €15. There is no justification for continuing to pay GPs a higher fee for the same work. Reducing the GP fee to €15 will yield €5 million in a full year. A range of other reductions, which have been made in capitation and other fees and allowances, will bring the overall reduction to 7.5%. During the consultation process, the Irish Medical Organisation and others expressed the opinion that any fee cuts could result in patients no longer being able to avail of a same-day GP service and could cause GPs to reduce staff hours. These issues were considered along with the other points raised during the consultation process.

Two regulations were prepared to give effect to my decisions and came into effect on 24 July last. Details of the regulations are available in the document that has been furnished to members. Pharmacists, consultant psychiatrists and consultant ophthalmologists have also been subjected to fee reductions under the financial emergency measures in the public interest legislation. Public sector workers have taken significant further pay reductions under the Haddington Road agreement. It is appropriate that GPs should share the burden on the country’s road to economic recovery. I am satisfied that the fee reductions are fair and reasonable and will not have an adverse effect on patient care. I am aware that an OECD study which was conducted a number of years ago found that Irish GPs are the best paid in the OECD area, where records exist. A further review is ongoing. The early findings do not indicate that things have changed. Under the financial emergency measures in the public interest legislation, the Minister for Health is required to carry out a review of the operation, effectiveness and impact of the amounts and rates fixed under the regulations each year. This will involve a full consultation with stakeholders in 2014. A decision will be taken at that time regarding maintaining, restoring or further reducing fees.

I will attend the EU Employment, Social Policy, Health and Consumer Affairs Council meeting on 10 December next. The agenda is set by Lithuania, which currently holds the EU Presidency and is hosting the meeting. Ministers will discuss progress on a number of legislative files which are important from a public health and an economic point of view. The tobacco products directive remains a priority for the Government. In recent weeks, I have assisted the Lithuanian Presidency by arranging for 16 EU health ministers to issue a statement supporting the directive and by sending a joint letter with the Taoiseach to MEPs urging them to support larger warnings on cigarette packs. I hope agreement on the directive can achieved by the end of the year because this product kills 700,000 Europeans every year. I asked my party's MEPs - Seán Kelly, Jim Higgins and Gay Mitchell - to write a letter to MEPs seeking a counter-motion to the original motion that was tabled within the EPP group. They did so successfully and I thank them for that.

Other key pieces of legislation under negotiation, in addition to the tobacco products directive, include the new clinical trials regulation and two medical devices regulations. These regulations will enhance patient safety. We must ensure the regulatory framework for the pharmaceutical and medical device sectors continues to support innovation and maintains Europe’s competitive advantage. While it is possible that agreement on clinical trials can be reached by the end of this year, it will probably be the latter part of 2014 before negotiations on medical devices are concluded. Both of these areas are extremely important for Ireland and the Irish economy. They were the subject of much discussion at the recent Global Economic Forum.

I will update the committee on some significant developments in the health sector since I last addressed it in July. The Protection of Life During Pregnancy Act 2013 was signed into law by the President on 30 July last and will be commenced as soon as is practicable. Some operational issues need to be addressed before it can be commenced. The Department is liaising with the HSE in this regard. These issues include the establishment of a panel of medical practitioners for the purpose of the formal medical review provisions and the putting in place of administrative facilities to enable the review committee drawn from the review panel to perform its functions. A committee has also been established to develop implementation guidelines for the Act. I would like to take this opportunity to thank the Chairman and the joint committee again for the great help they gave during the course of the formulation of that legislation. I believe the committee's input was reflected in the final Bill. I thank all members of the committee from all sides of the House for that.

The HSE directorate was established in July following the enactment of the Health Service Executive (Governance) Act 2013. The new directorate is accountable to me, as Minister for Health, for the performance of the HSE. The establishment of the directorate is a step in the much wider process of reform which envisages the eventual dissolution of the HSE, as set out in the programme for Government. The HSE governance legislation builds on existing accountability arrangements under the Health Act 2004, such as annual service plans and reports, codes of governance and the provision of information to the Minister for Health. The legislation allows the Minister for Health to issue directions to the HSE on the implementation of ministerial and governmental policies and objectives and to determine priorities to which the HSE must have regard in preparing its service plan. I wish to formally congratulate Tony O’Brien again on his appointment as director general.

I announced last month that Ms Eilish Hardiman has been selected as the chief executive officer of the children’s hospital group following an open recruitment process led by the Public Appointments Service. The children’s hospital group includes representatives of Our Lady’s Children’s Hospital in Crumlin, the Children’s University Hospital in Temple Street and the paediatric service at Tallaght Hospital. Ms Hardiman’s appointment as chief executive of the group followed the appointment in April of Dr. Jim Browne as the chair of the children’s hospital group and the appointment in August of a further nine board members. The board will oversee the operational integration of the three hospitals in advance of the move to the new children’s hospital. As the client for the building project, the board will play a key role in ensuring the new hospital is optimally designed and completed as swiftly as possible while providing value for money. The construction of this new hospital is hugely important. It is just as important to ensure we have a cohesive and united board, chair and management from the day the hospital opens. We failed to do that in the past when a number of hospitals amalgamated. We are all aware of the consequences of that.

Under the Health (Pricing and Supply of Medical Goods) Act 2013, which was enacted recently, the Irish Medicines Board is responsible for setting reference prices. This is the price the HSE will reimburse to pharmacies for all medicines in a particular group, regardless of an individual medicine’s price. The initial list of interchangeable medicines, containing groups of atorvastatin products, was published by the board on its website on 7 August 2013. It is expected that the first reference price will be implemented by the end of the year.

I wish to speak about research that was launched recently regarding the benefits of using plain cigarette packaging. This research, which was jointly commissioned by the Irish Cancer Society and the Irish Heart Foundation, both of which we support fully, shows how effective cigarette branding is and how it is used by the tobacco industry to entice children to start smoking. I have said for a long time that they are targeting our children. This research provides more evidence in support of the truth of that assertion. A coalition of children and health organisations is supporting legislation that will make it illegal for tobacco companies to use colour, text and packet size to market cigarettes. We cannot continue to allow deceptive marketing gimmicks to be used to lure our children into a deadly addiction that will ultimately kill half of those who become addicted. Standardised packaging is the next logical step in combatting this public health epidemic. I ask the members of the Joint Committee on Health and Children to give their full support and endorsement to this campaign and I hope they will do so.

I hope to bring the heads of the Bill to them soon for their consideration.

I would like to touch on the research for a moment. The research depicts children looking at the nice shiny cigarette boxes and saying they are lovely and look like a car. Then they see the new boxes we intend to introduce and they say they are yucky and disgusting and ask why anybody would want to smoke. Therefore, they work.

The Government is currently engaged in what is possibly the biggest health reform of a western health care system since the formation of the United Kingdom's NHS. The future health reform programme is designed to replace the current failed model of health care and to hand power and control back to patients and professionals. Part of this process involves the establishment of hospital groups and the reorganisation of all of Ireland's adult public hospitals into six groups which will, over time, become self-governing trusts. The objective is to create a network of hospitals which are big enough to offer patients a full range of safe high quality services, yet small enough to be flexible and adaptive to the local and regional needs of the people they serve. They will also have an academic partner, which will give them a scale and a size that will be very attractive to buddying up with international partners, not just in pharma or medical devices, but also in the area of IT, innovation, management and reorganisation. Therefore, health can be a driver of jobs also.

Legitimate concerns have been raised, both inside and outside the health services as to whether the system has the capability to implement the scale of the changes proposed. The reform agenda for the next three years is particularly complex and requires the health system to implement a series of reforms which have taken other countries much longer to introduce. The recent establishment of the new directorate structure, a systems reform office in the HSE and the creation of a programme management office in the Department of Health are specifically designed to assist and support the implementation process.

We are determined to succeed, to learn from others and to learn from our mistakes, some of which had tragic consequences. We are committed to continuing this programme of reform. I and my ministerial colleagues will be happy to answer committee members questions on the future health reform programme and on any other issues.

Mr. Tony O'Brien:

I thank the Chairman and members for the opportunity to attend this meeting. I am joined by Laverne McGuinness, Barry O' Brien, Dr. Philip Crowley and Mr. Patrick Burke.

I will cover four issues in my opening remarks. The first of these is the HIQA investigation into the tragic death of Ms Savita Halappanavar at University Hospital Galway on 28 October. The HSE requested that HIQA conduct an investigation into the events surrounding Ms Halappanavar's death and on behalf of the HSE I want to express our appreciation for the considerable work undertaken by HIQA in conducting a thorough investigation and compiling a comprehensive report. Also on behalf of the HSE, I once again wish to express our sympathy and to apologise unreservedly for the shortcomings in the level of care afforded to Ms Halappanavar that contributed to her death.

I have appointed Ian Carter, our national director of acute hospital services, to oversee the implementation of the recommendations. An implementation team had already been established by the HSE in anticipation of the findings of three reports. This team is currently overseeing the implementation of the recommendations from the coroner and from Professor Sir Sabaratnam Arulkumaran’s report. I have now directed that this team’s work be expanded to include the findings of the HIQA report to ensure that lessons from Ms Halappanavar's death are applicable nationally.

On the issue of non-consultant hospital doctors, NCHDs, implementing the European working time directive, EWTD, this is a significant challenge for the health service and has been a vexed issue for some years. I do not for a moment dispute the fact that the level of hours worked by NCHDs needs to be reduced to a sustainable level, but I would make the following important points. The key drivers of NCHD hours are service needs and the amount of hours NCHDs work is determined by the rosters which consultants, clinical directors and service managers identify as needed to meet those service needs. Maintaining services to the public and meeting the requirements of the directive poses a significant challenge to the health service.

Jerry Buttimer (Cork South Central, Fine Gael)
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I must interrupt as a vote has been called in the Dáil. I propose we suspend until after the vote. Is that agreed? Agreed.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are back in public session. I apologies to the witnesses, Senators and those in the Visitors Gallery. When a vote is called in the Dáil, Members must vote and there are no pairs for committees. I ask Mr. O'Brien to resume.

Mr. Tony O'Brien:

Thank you Chairman.

Part of the challenge is the introduction of new work patterns for NCHDs and consultants, transfer of work currently done by NCHDs to other grades and the reconfiguration of acute hospital services. We have accelerated progress in reducing hours in 2013. Data based on hospital site visits indicates that as of September, 76% of NCHDs were compliant with a 24 hour shift and a further 6% worked no more than 26 hours continuously. It underlines continuing progress when compared to the date for the first six months of 2013.

As part of the ongoing engagement with the IMO, the proposals of 27 September reflect a significant level of agreement between the IMO and health service management. They include implementation of a maximum 24 hour shift by 30 November - other than in exceptional circumstances - with full implementation by 14 January 2014, full directive compliance by 31 December 2014, a joint IMO and management verification and implementation at national and local level and referral of a range of other items to the Labour Relations Commission. One issue remaining between the sides was the matter of sanctions, and the HSE has put proposals to the IMO to resolve this issue. The HSE and IMO have now concluded negotiations facilitated by the LRC, and yesterday the IMO's NCHD committee agreed to put resolution proposals to a ballot of members. It is hoped that this will lead to a final resolution of the dispute.

I would like to turn to the issue of medical cards, and I am conscious that much of the information on this has been covered in the Minister's speech. With your permission, Chairman, I will exclude a few sections which may make things a little harder to follow. I welcome your suggestion of a further visit by the committee to PCRS and we look forward to hosting that in due course. In advance of today's meeting, an update report on medical cards was circulated.

I must re-emphasise that the medical card scheme does not provide an automatic entitlement to a medical card for individuals with a specific illness. It is important to clarify that there is only one medical card, as there seems to be an impression that there are two or indeed three types of medical cards. A medical card is either approved on foot of a means assessment, which meets the current financial guidelines, or where the applicant does not meet the income guidelines but there is undue hardship as a result of the medical or social circumstances. The Minister has already described the procedures that are in place.

Earlier this year the first €50 of travel to work costs became disallowed for the purposes of these calculations, as did the costs of servicing loans related to home improvements.

This followed a budget decision in 2012. Changes in the thresholds for medical cards for the over-70s, with substitution by GP visit cards, were implemented by the Oireachtas in April this year. These are the only changes to affect or limit standard eligibility. The assessment guidelines used in respect of medical cards issued in the case of an assessment of undue hardship for otherwise ineligible recipients have not been altered by the HSE since 2009.

In February 2012 the HSE reached agreement with the Irish Medical Organisation in respect of new flexibility around reinstating and prolonging eligibility in certain cases. Under this arrangement GPs in certain circumstances can extend the period of eligibility for a medical card where a vulnerable person has been unable to engage with the HSE to renew his or her application. It also allows a GP to reinstate eligibility if a patient presents for medical care who has had his or her eligibility removed, for example, owing to lack of a response to the review process or because of a change of address. It also allows GPs to add a newborn baby to their GMS list where the baby's parent holds a medical card. I emphasise again that the assessment procedures used to determine eligibility for medical cards and GP visit cards have not changed. Rather, through the centralised processing of applications since 2011, where discretion is exercised, they are applied equitably and consistently, based on standard operating procedures, with medical officers assessing medical evidence of cost and necessary expense. This ensures people with a serious illness and an income within reasonable reach of the qualifying scales can qualify. This becomes progressively more difficult as incomes increase to multiples of the qualifying scale.

It is important to correct the impression that medical cards are issued automatically or irrespective of means to those with serious medical conditions since there is no such automatic entitlement. It is also important to stress that the medical card system is founded on the undue hardship test and that the Health Act 1970 provides for medical cards on the basis of means. The HSE must, of course, operate within the legal parameters as set out in the Act, while also responding to the variety of circumstances and complexities faced by individuals who apply for a medical card.

I assure all citizens eligible for either medical cards or GP visit cards that the health service will not change its eligibility assessment guidelines. My colleagues and I are as committed to ensuring all those legally entitled to medical or GP visit cards are able to avail of them as we are to fulfilling our absolute obligations to ensure those who are not so entitled neither receive nor retain them. To put this in context, between January and September this year, 289,000 families with 428,000 individuals were reviewed. Some 2.3% were not renewed based on an assessment against guidelines; 87% were renewed, while 8.3% did not respond, resulting in the suspension of eligibility. The probity figure of €113 million which featured in this week's Estimates has no impact on the definition of eligibility or our approach to assessment in each case.

Turning to service plan activity, the HSE has seen significant and extended pressures on services in the first seven months of the year. This has required us to respond, including with additional capacity. The number of emergency admissions was up by 6,842. The number of elective admissions was broadly level with that last year. The level of GP out-of-hours contact remained high, at nearly 567,000. At the end of July, 1,991,148 people were covered by either a medical card or a GP visit card, which is 1.36% above the figures for July 2012. In July 2013 a total of 23,166 persons were supported under the nursing home support scheme, compared with 22,950 one year earlier.

In setting out the financial position it is important that it be considered within the following context: there were significant pressures on our services which impacted on our costs, as well as our ability to fully sustain the very important improvements made last year in areas such as access times to scheduled care. The total reduction in HSE budgets or costs is €3.3 billion, or 22%, since 2008, while the reduction in staffing levels is over 11,320 whole-time equivalents since the peak employment levels in September 2007. In Vote terms, at the end of August there was a cumulative net current deficit of €70 million. In income and expenditure terms, there was a cumulative net deficit of €75 million at the end of July. By comparison, for the same period in 2012, the cumulative net deficit was €298 million. The HSE is not flagging new concerns beyond those set out within the national service plan for 2013.

The 2014 public expenditure estimates indicate health sector measures totalling €666 million, net of demographic and other pressures. The HSE has already commenced the preparation of a service plan for 2014. Preparing the plan will be very challenging for the HSE. I thank members for their attention.

Jerry Buttimer (Cork South Central, Fine Gael)
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I acknowledge the presence of Mr. O'Brien and compliment and thank him for negotiating on behalf of the HSE on the non-consultant hospital doctors issue, on which the committee was very much involved in holding meetings. We wish both sides well in the impending result. We do not want to get involved in it, but I thank Mr. O'Brien and Mr. Eric Young of the IMO for the work they did in, I hope, resolving the issue.

Billy Kelleher (Cork North Central, Fianna Fail)
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I thank the Minister for Health and wish Mr. O'Brien the best of luck in his new role.

In respect of the HIQA report on the death of Savita Halappanavar, guidelines were issued in 2007 after the death of Tania McCabe in the context of national guidelines on dealing with sepsis. The investigation into Savita's death highlighted the fact that only five maternity units had implemented the national guidelines issued after Tania's tragic death. In view of that record, who will oversee full implementation of HIQA's recommendations in respect of maternity services? Will HIQA be invited regularly to observe the ongoing implementation of these recommendations, or will this be done by an internal HSE group?

Against the backdrop of the budget and cuts to the value of €666 million in the health service next year, as well as the withdrawal of discretionary medical cards, I have a major difficulty with the statistics the Minister and Mr. O'Brien gave us. I receive a huge number of e-mails from people who contact me regularly. As I do not think I am a special Deputy, I assume they contact other Deputies, too. There are obviously many who fall through the cracks, as the Minister said. At this stage, the cracks have almost become a canyon. There is an avalanche of people who are genuinely very distressed that their discretionary medical card has been withdrawn or who have been refused a discretionary medical card because they do not qualify under the guidelines for a means assessment.

Mr. O'Brien has pointed out that 53,000 discretionary medical cards were issued up to 8 October. How many discretionary medical cards have been issued this year, as opposed to previous years? I would like to see a profile of the discretionary medical cards issued. I suggest the number issued is reducing rapidly. The empirical evidence is the statistics. We must also acknowledge that the population is fluid. People are born; they might have disabilities or other challenges; they get sick and may not qualify under the income guidelines. I find it hard to believe there has been such a rapid reduction in the number of discretionary medical cards issued. I just cannot reconcile this with the evidence that we receive from various organisations such as the Jack & Jill Children's Foundation and the Irish Cancer Society and people with liver disease. They constantly highlight very tragic cases, yet the people concerned lose their medical cards. We have itemised them. This issue was also highlighted in the Irish Examiner last week, with detailed examples of people who were unable to access a discretionary medical card.

If there have been no changes to the guidelines, how is it that a discretionary medical card was withdrawn from a child with intellectual and physical disabilities, who is incontinent and cannot use his limbs and whose circumstances have not changed and will get progressively worse?

How is it that this child's discretionary medical card was withdrawn? After a long, arduous battle the child was eventually awarded a discretionary medical card for a six month period. The reason I highlight this case is that it is one of a myriad cases and every Deputy and Senator is aware of many similar cases. There has to be some change somewhere along the line because that child's circumstances did not change. It is one of hundreds of cases on which information has been provided for us. We have tabled parliamentary questions and contacted the Department and the HSE without making much progress. People's circumstances have not changed, yet their discretionary medical cards are being withdrawn and they are not receiving medical cards through a means assessment. That is a key issue with which we must deal. I, therefore, ask for a profiling of discretionary medical cards issued in the past few years. That might show that there are fewer discretionary medical cards being issued this year than last year. I do not believe the health of the population has changed that dramatically. People are getting sick and developing very serious illnesses, while babies are being born with disabilities. They may be above the income guidelines and are not now securing discretionary medical cards. Whatever one says, there is a different attitude to the use of discretion. In fact, that discretion has been taken from the HSE in the granting of medical cards.

Fianna Fáil has been raising the broader issue of tax relief on medical insurance premiums for some time. This decision will have a significant impact on the number of people who will be able to afford private health insurance. The stated policy of the Government is that a policy of universal health insurance is to be implemented within a certain timeframe. I would have assumed that there would be active encouragement of as many people as possible to take out medical insurance, yet the change in tax relief on medical insurance premiums announced in the budget will do the exact opposite. The Government and the HSE are planning to charge private health insurance companies the full cost of private patients in public beds. This will have a knock-on inflationary impact on health insurance premiums. The gold-plating to which the Minister for Finance referred is not the whole picture; the cost of health insurance for ordinary people will increase if their insurance premiums go above the tax threshold and tax relief will be lost. The figure is €127 million. This decision will impact on a great number of families. What the Minister for Finance said in the Dáil and other Ministers have said subsequently means that this measure could impact on up to 50% of those who hold private health insurance. This will have profound implications for their ability to retain their private health insurance and mean that they will depend on the public health system which is already under stress.

Prescription charges have been increased up to €2.50 per item. When first introduced, the Minister said the charges would have a negative impact on people's health, that people would be unable to access health care because of them. Is there evidence to suggest this is not the case? Prescription charges are now up to €2.50 per item, with a maximum charge of €25 a month. This is a fundamental change.

On the issue of mental health, it is well known that society is under stress, with families and individuals under pressure. Mental health services do not seem to be in place. The ring-fencing of €35 million a year to implement the strategy under A Vision for Change has been scrapped. The Minister of State with responsibility for mental health issues was handed €20 million. I know the Minister of State well and I am her constituency colleague. I know she made a ferocious argument to secure the sum of €35 million but to no avail. The lack of funding will have a profound impact on the ability of the new HSE directorates to implement the strategy under A Vision for Change and there is no point pretending the strategy is being implemented. For example, the number to be employed as mental health professionals has fallen far short. Why have mental health services received only €20 million when a commitment was made that funding of €35 million would be ring-fenced?

I refer to the new troika in the Department of Health, the three Secretaries General who will oversee implementation of the cuts of €666 million next year. I note that a Bill has been published which will move the HSE into the Department in the near future. The Vote for the HSE will be held in the Department, into which the HSE will be subsumed. What are the roles and responsibilities of the other two Secretaries General in overseeing implementation of the budgetary framework as outlined last Tuesday?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome the Minister and Mr. O'Brien from the HSE. I also welcome the Minister of State, Deputy Kathleen Lynch, who is back at work following her recent bout of illness.

The HSE service plan for 2014 is in the process of preparation. Was any study carried out by the Department of Health or the HSE of the likely impact of a significant reduction in the budget provision for the Department and the HSE for 2014? When the Minister and his Ministers of State were preparing to engage with Cabinet colleagues, in particular the Mniister for Public Expenditure and Reform, were the necessary details available to them in advance of that engagement? It has been signalled that €666 million will be reduced from the budget for 2014. I have no doubt that the significant impact of that reduction is being worked out in the preparation of the service plan. Did the Minister and his colleagues have a sense of the effect of that reduction? Was it part of their armoury of efforts to protect the overall health budget in their engagements with Cabinet colleagues?

The budget announced the planned extension of medical cards - they are not medical cards but GP access cards only - for all children aged five years and under. I ask the Minister of State, Deputy Alex White, to record that I welcomed the inclusion of this measure in the measures announced. I have argued for this as a first step. I emphasise that it is the first step because if it is not, it will contribute to ever increasing levels of disquiet. There are those who are saying, "I have a child who is seriously ill, who is over six years of age, yet my little child who is well will have a GP access card, while my older child will not." If people do not understand there is a timeframe for the introduction of universal free access to GP care, it will totally undermine the notion of universality and feed into an ever growing level of disquiet. Is there a timeframe for the extension of this measure beyond the age of five years and up to 12 to cover the primary school cohort? Can we anticipate such an extension in 2014, or even more bolder steps? Is it anticipated that within a reasonably short timeframe there will be universal access to free GP care? This is essential.

From where did the figure of €113 million relating to probity come? It is a strange one. Is it based on a specific arithmetic assessment, or just a figure that sat neatly into the proposed targets for achievement in 2014? I ask the Minister to elaborate on where the figure of €113 million comes from.

On the notion of probity, the Minister has quoted statistics that were not included in what we previously received.

Those data are not included in the transcript of the Minister's address, nor in the report on medical cards as prepared for today's meeting. The Minister indicated in his opening remarks that 17,059 people previously in possession of a medical card no longer have it. I did not manage to note all of the figures - the detail was quite vast and I do not have shorthand skills - but I understood he indicated that more than 30% of those called to review did not respond. A family member of mine, more than 80 years of age and with Alzheimer's disease, received two such requests for review but did not respond because it is beyond the individual's capacity to do so at this point in time. As a result, this person's medical card was withdrawn. Is it not likely that a significant number out of the 30% plus who failed to respond did so through no fault of their own, simply because it was beyond their capacity to understand or respond? It is a very hard mallet indeed to apply a cessation of entitlement in such circumstances. These are issues that come to us out of our own life experiences. As a political representative, moreover, I know the instance I have cited is not unique to my family. I am sure this is an experience to which all Members can attest.

It would be remiss of me not to refer to page 9 of the medical card report that was prepared for this meeting. It states: "It is incorrect to assert, as has been widely reported in the media in recent weeks, that medical cards are harder to get". We are not suggesting that is the case. However, the evidence is absolutely clear that discretionary medical cards are indeed more difficult to obtain. That is a fact of life. It is evident from the cases referred to by Deputy Kelleher and others and from discussions we have had recently in Private Members' time and in many other fora. There can be no denying that it is becoming ever more difficult for people to obtain and retain a medical card on a discretionary basis. It is clear from the correspondence that is before the committee today. One of the items of correspondence is from the chairperson of Children's Liver Disease Ireland outlining that organisation's concern at the growing evidence that medical cards for children with serious liver disease are not being renewed. We also have a letter from a father describing the impact of the withdrawal of a discretionary medical card on his 14 year old son who has multiple disabilities and medical issues. The evidence is in the correspondence that has been circulated to all members; it is not anecdotal. Such is the enormity of what these people are contending with, I am confident that nobody in this room would conclude that the individuals in question are not entitled to a medical card.

One of the questions we raised concerned the crisis relating to junior hospital doctors. I thank Mr. Tony O'Brien for the update on this issue in his report. The negotiations are ostensibly concluded and members will be balloted thereon. I wish for a good outcome to that process. However, the issue of the absence of sanctions for hospitals which fail to comply with measures to implement the European Working Time Directive has loomed large in recent weeks. If it is the case that this remains an issue, and knowing the situation historically whereby hospitals have been penalised by reductions in budget, it is an absolute travesty that the people who will ultimately suffer are the patients presenting in those hospitals. It is entirely unacceptable. Will Mr. O'Brien elaborate on what sanctions he expects to see applying in regard to non-compliance with the European Working Time Directive?

The last question I tabled relates to nursing home care. There is undeniably a shortage of places, with hundreds of older people languishing in acute hospital beds as they wait for nursing home places. Yet nowhere do I see a commitment to allocate additional funding for the provision of public nursing home bed opportunities. I know of cases in various Dublin hospitals where elderly people who no longer need medical care but do require residential nursing home care are being left for months in critical facilities. I can share the detail with the Minister and Mr. O'Brien after the meeting. It is beyond belief and the dreadful term "bed blockers" that is applied to these people is a horrendous insult. The fact is that the system is not providing sufficient nursing home places either in the private sector or - most important in terms of our responsibilities - in the public sector.

The Chairman has indicated that I am over time. I hope he will allow me to make one final point regarding an issue that was the subject of a unanimous appeal from members at our last meeting. It concerns the earlier signalled intent to include a programme for bilateral cochlear implantation in the budget for 2014. We wrote to the Minister regarding this matter on 11 October but I have yet to see any indication, either in budget speeches or in any of the contributions here today, that the undertaking will be implemented. I take this opportunity to urge once again that this provision be included in the HSE's service plan for 2014. Can the Minister and Mr. O'Brien provide confirmation in this regard?

Jerry Buttimer (Cork South Central, Fine Gael)
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I will now take questions from other members in blocks of three, beginning with Senator Colm Burke and Deputies Ciara Conway and Catherine Byrne.

Colm Burke (Fine Gael)
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Thank you, Chairman. One of my questions, No. 4 on the list, raised the issue that out of a budget of more than €13 billion, €3.4 billion is going to organisations and agencies that are not under the direct control of the Health Service Executive. I have received a number of telephone calls in recent months from people inquiring about salary scales in these bodies. I was advised, for example, that one particular organisation is paying its chief executive officer more than €340,000. We should remember that these individuals are being paid from taxpayers' money. The response to the question states: "This matter is currently being addressed jointly between the HSE and the Department of Health with a view to bringing the pay rates of Section 38 agencies into line with the DoH salary scales and a pay policy will issue shortly in this regard". Does this response indicate that a number of these organisations are paying salaries far in excess of the remuneration for an equivalent post in the HSE?

Another question I tabled relates to the junior doctor dispute, an issue I have been pursuing for two years. While I welcome the proposed agreement on this matter and hope it will bring a resolution to the recent dispute, it does not address the issue of long-term planning pertaining to junior doctors. I am concerned that the number of such doctors coming in from abroad is declining while the number of Irish graduates leaving the country is increasing. How will that vacuum be filled for 2014 and 2015? We must have a new approach to the matter. The Minister has set up a review to examine the issue whereby more than 2,000 of the 4,900 junior doctors currently working in our hospitals are on six-month contracts. When are we likely to see decisive action in that regard? Unless there is immediate action, a staff shortage will inevitably arise.

I also tabled a question, No. 3 on the list, regarding the number of vacancies for consultant posts in hospitals. The answer I received this morning is different from the reply given to a parliamentary question put down by Deputy Gerry Adams last December. There is a variation of more than 200 as between the two replies.

Would it be possible to obtain clarification in respect of this matter? I am not satisfied that the figure supplied to me is correct and I would appreciate it if the position were clarified.

Jerry Buttimer (Cork South Central, Fine Gael)
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I am aware that the Minister of State, Deputy Kathleen Lynch, must go to the Dáil and I would appreciate it, therefore, if members adhered to the time limits.

Ciara Conway (Waterford, Labour)
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The issue relating to medical cards has been well ventilated by previous speakers. However, I wish to make a technical point with regard to the review that was carried out during the summer months. In that regard, I refer, in particular, to those who are over 70. The language used in the letters sent out to people as part of the review was completely impenetrable, difficult and cumbersome. In addition, the letters frightened those over 70 years of age who received them. I would like the HSE to adopt a policy of using plain English in its correspondence with people. I was visited at my constituency office by numerous individuals who were quite entitled to retain their medical cards but who were petrified as a result of the tone used in the letters they received. This has happened on previous occasions, not with the Department of Health or the HSE but with other arms of government. If we have not already learned lessons from how the Revenue dealt with its situation, then it is time we did so. I would like our guests to comment on this matter and indicate how we might move forward in respect of it.

What is the timeline with regard to the commencement of the Protection of Life During Pregnancy Act 2013? Where do we stand in the context of the appointment of panels of doctors and dealing with the other procedural issues which must be disposed of before the legislation can be commenced? The staff of our maternity hospitals are in limbo. This is also the case with pregnant women who continue to find themselves in the precarious situations such as those in which Savita Halappanavar and others like her found themselves in the past. What is the timelime for the implementation of the legislation?

What is the position regarding the Higgins report and the restructuring of hospitals and the promotion of hospital groups? When the report was published, we were informed that all the reforms being made in the area of health care are designed to ensure that patients will be seen at facilities as close as possible to their homes. Unfortunately, the latter is not proving to be the case. Prior to the emergence of the Higgins report, women could access maternity services in regional centres in their home towns. I refer, for example, the to the centre in Dungarvan. Maternity and ophthalmology services are not longer offered in county towns and women in County Waterford are obliged to travel to Waterford Regional Hospital to avail of them. This is a complete contradiction of what we were told when the Higgins report was published. Will our guests comment on that matter?

Kathleen Lynch (Cork North Central, Labour)
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I will deal with the questions posed by Deputies Kelleher and Ó Caoláin. We are continually hearing that the posts relating to mental health have not come on stream. I wish to place on record the exact position in this regard. We received an allocation of €20 million this year. I accept that the programme for Government contains a commitment to the effect that €35 million would be provided each year. I am convinced that we are not finished in the context of mental health and I have been provided with assurances in respect of next year. I will not discuss all of the usual matters relating to mental health - the difficulties that arise, where we should be treating people, etc. - because these have been well ventilated.

It is important to state that on 30 September last the recruitment process had been completed in respect of 378 - or 91% - of the 414 posts in this area. There are a number of posts in respect of which there have been difficulties in identifying suitable candidates. This is due to factors which include the availability of qualified candidates and geographic location. The recruitment process has reached various stages in respect of the remainder of the posts. Some €35 million was allocated in respect of mental health in Budget 2013 in respect of the continued development of our mental health services across a range of headings, including the further development of forensic and community mental health teams for adults, for adults, children, older persons and mental health intellectual disability. A total of 477 posts have been approved in the context of implementing these measures and as of 30 September, the recruitment process had been completed in respect of 19 - or 4% - of these posts. Some 236 - or 49% - are in the final stages of recruitment process. A further 149 - or 31% - are at various stages in the recruitment process. This means that some 85% of the 2013 allocation are in the recruitment process, with the balance undergoing HR approval. The HSE's national recruitment service is currently working to ensure that the remaining posts will be filled as soon as possible from the existing panels - or through competition in the absence of such panels - at the earliest opportunity. Options to enable more local recruitment are being considered and will assist in filling specific posts.

I wish to provide an example of where we currently stand in respect of posts. As long as people keep stating that posts are not being filled, this will appear to be the truth. It is not the truth, however. For example, a total of 21 posts were allocated to Galway-Roscommon health services. Some 19 of these have been filled and two remain to be filled. There is a difficulty with regard to specific posts relating to particular areas of interest. I refer, for example, to very specialised disciplines such as forensic psychiatry, services for older people and intellectual disability. However, another difficulty arises. If we continue to recruit from a general panel in respect of mental health services, those who apply will obtain posts but these may not be in either the areas in which they are interested or in the locations in which they wish to live and work. Let us consider the example of someone who is recruited to a position in Dublin but who wishes to work in Cork, which I can understand. When a post becomes vacant in Cork, the person in question would be entitled to fill it. As a result, a vacancy would arise in Dublin.

There is a particular problem with regard to forensic psychiatry. People are recruited from the general panel and are obliged to undergo very intensive training in order to get up to speed in this area. When posts then become available in disciplines in which they are interested, they tend to move on. We are considering putting specific panels in place and advertising the fact that specific posts relate to particular services. There are difficulties but these do not relate to the bulk of the posts we are trying to fill. We have made great progress filling many of those posts but there are problems in respect of niche specialist areas, which is understandable in the circumstances.

I agree with Deputy Ó Caoláin in that there will be a difficulty in the future in the context of beds. A decision has not yet been made as to whether this issue will be dealt with in the context of the public or private sector. However, a substantial amount of work has already been done and we are aware of the number of beds that are going to be needed. A great deal of the work in this regard has already been done in conjunction with Atlantic Philanthropies and in the context of the The Irish Longitudinal Study on Aging, TILDA. I will provide the Deputy with some statistics in this regard. The target in respect of home care packages was 10,870 and in June 2013 output had reached 11,031. The latter was 1.5% ahead of target. The target in respect of home help packages was 50,000 or thereabouts and in June output had reached 45,739. This was 1.8% behind target. Of course, it must be recognised that home care and home help packages relate to different cohorts. The target for day care was to provide 21,460 places and in June output had reached 21,460. So we were exactly on target in this regard. We are also on target in the context of respite, with some 600 beds being provided. On the nursing home support - or fair deal - scheme, the target was to fund 22,761 older people and in July 22,303 had been funded and an additional 863 had been approved for funding. We are, therefore, also on target in this regard.

We have challenges in regard to our ageing population. I agree with what Deputy Ó Caoláin said about the awful term "bed-blockers", because the situation is clearly not the fault of people who need to move to a more appropriate service. I am not convinced that we can meet that challenge entirely with the provision of long-stay care. It will require a combination of elements. That is something we will have to examine, although it may require the provision of rehabilitation which would be carried out in the community rather than in the hospital where, it is of very little value when one goes home. We have a difficulty in this respect. It is not something we are neglecting. We have done substantial work on it. I do not believe the solution to it comes down to the provision of long-stay beds, even though that must be part of it.

James Reilly (Dublin North, Fine Gael)
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I will address the issues raised by Deputy Kelleher first and in answering the questions raised I will have to defer to some of the team present. The Deputy mentioned the very tragic case of Tania McCabe and the lessons that do not seem to have learned by the rest of the system. Earlier today I was at a national clinical excellence council to discuss the bringing in of new standards - not only the national early warning scheme we have already brought in for all our general hospitals, but a maternal early warning scorecard for our maternity hospitals. There are new standards to be developed around sepsis and around the clinical handover - that is, when nurses and doctors exchange information as shifts change - because that is a time of risk in terms of information being lost. The Deputy asked a specific question and HIQA will be monitoring that area. I have asked it expressly to bear in mind my priorities and those of the Department in terms of patient safety when it is reporting on hospitals. Mr. O'Brien might go into that further. Perhaps it would be more sensible for Dr. Philip Crowley to answer that question when he is responding to other matters.

The Deputy mentioned the figure of €666 million in regard to the budget. I did not take a proper note of what he said. Was he referring to the number of medical cards?

Billy Kelleher (Cork North Central, Fianna Fail)
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Deputy Ó Caoláin raised this point as well. The figure of €666 million in savings has been identified and €113 million of that is to be achieved from a probity review of medical cards. I am wondering about the profiling and the assessment of how that figure was arrived at. That is the point I was making. There was a report by PricewaterhouseCoopers in this regard.

James Reilly (Dublin North, Fine Gael)
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Yes. The report produced by PricewaterhouseCoopers suggested that somewhere between €60 million and €200 million could be saved through probity in the GMS, or primary care reimbursement service, as it is now known. That report was published 18 months ago, so obviously there has been a lot of action since then. None the less, a figure of €113 million in savings to be achieved was given to the Department by the Government. I am frankly concerned about what can be achieved here and about what can be achieved in view of the Haddington Road agreement. That is why I asked for the Taoiseach's Department and the Department of Public Expenditure and Reform to be involved in assessing and validating these figures and the impact these savings would have on the service. I want to reiterate - it is important that people understand this - that probity does not only relate to whether the person holding the medical card is eligible to do so, but also to the prescribing practices of doctors and out-of-hours claims made by doctors. One doctor claimed €180,000 and ended up settling for €15,000. There are issues with regard to pharmacy services as well. Therefore, it is not all about the question of eligibility for a medical card, by any means. I reiterate that people who are entitled to a medical card have nothing to fear.

I reject the Deputy's contention that discretion has been taken from the HSE. In fact, more discretion has been given to it, as there are now doctors to make sure that even more compassion is applied in assessing people and that every latitude is given to try to help people to qualify. As I said to the Deputy earlier, 49% of people who had their cards removed or failed to get a card were more than 200% over the threshold when everything was taken into account. I must re-emphasise that the medical card scheme never operated on the basis of medical conditions or illnesses; it operates on the basis of consideration of undue financial hardship. Clearly, medical conditions have an impact on financial hardship, and that is taken into account. Equity and consistency have been brought into the system because in the past people in some parts of the country got discretionary medical cards based on certain criteria while people in other parts of the country could not get them based on the same criteria. There is consistency in the system, but the rules have not changed.

The Deputy mentioned the issue of tax relief on medical insurance premiums. That is a taxation matter. He will probably ask whether I knew about it. I found out at the same time as all my other Cabinet colleagues. Is that unusual? I know of no Minister for Finance who has discussed his taxation measures with the Cabinet before deciding on them himself. This is a challenge for us as well; of that there is no question.

With regard to the increase in the prescription charge, that is not the direction in which I want to go. I still firmly have concerns about it, but given the options with which I am faced in order to raise €660 million, I would prefer, even though I do not like it one bit, to raise the prescription charge rather than to cut services. That is the choice I am left with. We do not like to be political here, but nobody in this room need be deluded as to why €660 million is needed from the health budget to get us out of the bailout and why we are in the bailout.

The Deputy asked me about the role of the three Departments. I think I have covered that already. I sought that because I want absolute clarity around these figures with regard to their achievability. I want absolute clarity about their impact on the service because if they are not achievable in this area of the budget, they have to achieved somewhere else in the budget. That is the reality and I have the agreement of the Taoiseach's Department and the Department of Public Expenditure and Reform on that.

Deputy Ó Caoláin asked if we had the necessary details in advance of the budget. In no other year have so many hours been spent going over this. There is a new chief financial officer and a new financial reform board in the HSE, and we had well over 30 hours of meetings, not including the hours of work those involved had done before they came to me and the hours we then put in with the Department of Public Expenditure and Reform. We have real information and the figures are real. I also want to clarify another matter. The idea of a black hole in health was something that had currency years ago. I can tell the Deputy there is no black hole there now. We now know where all the money is, how it is spent, where is going and how much we need. As I said previously - not here but in other media - we had postulated an increase in demand of 1% during the year, and asked for €190 million but got €90 million, and then the increase in demand ended up being 2%, which involved a cost of €360 million. The Deputy can recognise the challenges faced by the health service in trying to predict the future with absolute certainty.

The Deputy and the Irish people can be absolutely assured - I will ask the Minister of State, Deputy White, to elaborate on this - that the provision for the under fives is not a stand-alone initiative. This is a part of a key step on the road to universal health insurance. Even with full GP care available throughout the land, that will not end the inequity of the two-tier system. The only thing that can do that is universal health insurance and the delivery of that is something to which I and Government are committed. These are key building blocks towards that goal.

The Deputy asked where the figure of €113 million had come from. I have explained that already. As I said, this is the figure that we were given as a consequence of the Department of Public Expenditure and Reform's deliberations on that report.

On the issue of discretionary medical cards being harder to get, while the Minister of State, Deputy White, will want to deal with that, I have some detail on that in myriad of papers before me.

On 1 January 2010, there were 96,000 discretionary medical cards on the system. On 1 January 2011, there were 98,000 such cards. On 1 January 2012, there were 90,000 such cards. By 1 January 2013, the figure had fallen to 78,959. On 1 September, it was 75,000. I must point out that 22,584 of those migrated to full medical cards. As such, the Deputy's contention that a medical card is more difficult to get is not borne out by the facts and the figures.

Communication around these issues is needed, particularly in respect of probity and medical card reviews. We must review them. People move on. Sadly, people pass on. People leave the country, get jobs or so on, thereby changing their circumstances. At the beginning of an illness, the financial hardship can be quite severe. For some people, it can improve. Sadly, it does not for others. The cases where people have lost their medical cards are the ones where we are particularly interested in determining what changed in their circumstances. However, 49% of the people in question are 200% over the limit, taking all allowances into consideration, and 92% of people are more than 50% over the limit. It is a question of equity in the system.

The Deputy asked me about non-consultant hospital doctors, NCHDs, and sanctions. I will let Mr. Tony O'Brien and Mr. Barry O'Brien discuss those matters, but I have been clear - the sanctions are to be applied to those who have failed to deliver. Patients are not the ones failing to deliver, and neither are doctors. It is management. Let us not forget that management includes clinical directors. They are the ones on whom the sanctions will be focused.

Nursing home care was mentioned and the Minister of State, Deputy Kathleen Lynch, discussed that matter. I agree with her 100%. We must stop viewing long-term care as the only solution to these issues and focus more on trying to keep people at home. People are always attracted to resources. Before this meeting, I mentioned that a survey we conducted a couple of years ago had found that a third of people had never been assessed for home care before entering into long-term care. In the case of a further third, the survey was uncertain. There is a sense that many people who end up in long-term care should not have landed there in the first place. Once one enters, however, the chances of leaving are quite small. We have put in place an elderly care clinical programme so that elderly people who are frail when entering hospital have their medical problems addressed urgently and start their rehab from day one. If that takes a number of weeks, they will move to another facility, albeit not necessarily in the country. This will help us to get more people home instead of in long-term care before they need to be.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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They are not months in hospital waiting to go home.

James Reilly (Dublin North, Fine Gael)
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Exactly.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will take one speaker at a time.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Home is not an option. It is a nursing home-----

James Reilly (Dublin North, Fine Gael)
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No, I will dispute that. There are people in hospital whose acute phase of treatment is over and who do not get access in the way that they could and should to rehabilitative care, for example, physiotherapy, occupational therapy and speech and language therapy. We want to ensure that happens. The end result may be that they still need long-term care, but we can avoid it in many cases, which is of benefit to their quality of life and the taxpayer.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Hundreds of beds in the public sector are being used at this moment.

Jerry Buttimer (Cork South Central, Fine Gael)
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Seven other members have indicated, Deputy.

James Reilly (Dublin North, Fine Gael)
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I am well aware of the figures. The last issue the Deputy mentioned was that of bilateral cochlear implants. I have made this one of my priorities, but we face an extraordinary challenge next year, in that we must save €660 million in the health service after having already saved €3 billion, 10% of our staff having left, an 8% increase in the population, a 2% increase in activity and demand last year and a 3% increase in admissions through emergency departments, from where 80% of admissions originate. We have a major challenge. As I stated at the conference this morning regarding the importance of the protocols on early warnings and sepsis management, at no point will I allow patient safety to be compromised. I must bear all of this in mind. This matter will be decided in the service plan.

Senator Burke referred to NCHDs, audits and contracts and vacancies in hospitals, but I will allow Mr. Tony O'Brien and his team to address those points.

Deputy Conway asked about the letters to the over 70 year olds. The HSE has been asked to draw up a communication plan in this regard and present it to the Taoiseach and me next Monday. Whatever else they are, people should not be afraid. I heard Deputy Ó Caoláin refer to a relative who may have Alzheimer's disease. I am sure that that person has relatives, carers and friends. If they know from radio advertisements and HSE representatives speaking on radio that these letters are nothing to be afraid of, only that they must be answered, people can be reassured. People should never be scared by a letter in the post. Historically, however, people have been. I will speak with the HSE about the language that was used in the letters. It should not be incomprehensible. It should be simple, in plain English and as short as possible. In absolutely no-----

Jerry Buttimer (Cork South Central, Fine Gael)
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We raised that point at previous meetings with the HSE. To reinforce the issue, I recommend that there be a point of contact for people in the review process. A cold letter landing on the mat is not enough. This cannot be an inhumane, bureaucratic exercise. It must be about the person. I hope that the Minister, Mr. Burke, Mr. Tony O'Brien and the HSE consider putting in place a dedicated person with whom a medical card holder can speak instead of simply receiving a letter in reply. Deputy Conway was right.

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

Jerry Buttimer (Cork South Central, Fine Gael)
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There is fear.

James Reilly (Dublin North, Fine Gael)
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I accept that. This issue was discussed last night and a suggestion of a tiered approach was made. In many cases, all we are doing is writing to ensure that someone is still alive or in the country. The very act of returning the letter is the end of the matter. It is a "Yes, I am here, thank you very much".

Ciara Conway (Waterford, Labour)
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What is the-----

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

James Reilly (Dublin North, Fine Gael)
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After that, we can investigate issues of changing circumstances. That should require a different type of approach further down the line. I will discuss that with the HSE. I am sure the Minister of State, Deputy White, will as well.

Mention was made of the Protection of Life During Pregnancy Act. It will be ready by the year end in terms of implementability. Dr. Philip Crowley might say a few words on the matter. I was also asked about an update on the Higgins report. Chairs have been appointed to all of the groups except one. This will allow us to appoint boards. We have already put in train the advertising process for the CEOs of the various groups. We want to move this work on, as it is a critical part of addressing the problems of the long hours and out-of-hours work of NCHDs. It is also a critical part of addressing our budget.

Maternity services in Dungarvan were mentioned. No maternity hospital has closed. Clearly, it was a community service. I will look into the matter directly for the Deputy, but it is not the direction we are taking, as we have opened new services in Mitchelstown and other primary care centres. We want people to have as much of their care in the community as possible. Maternity care is an obvious example, in that a consultant can travel to see 36 women instead of 36 women needing to travel to see a consultant.

Ciara Conway (Waterford, Labour)
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I would appreciate that and I thank the Minister.

James Reilly (Dublin North, Fine Gael)
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I have always maintained that the era of the service serving itself rather than the patient is over. I will turn over to Mr. Tony O'Brien. My apologies - I meant the Minister of State, Deputy White.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will actually allow Senator Burke to contribute briefly.

Colm Burke (Fine Gael)
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Of the €3.4 billion paid out to non-HSE-----

James Reilly (Dublin North, Fine Gael)
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I stated that Mr. Tony O'Brien would answer that question for the Senator.

Jerry Buttimer (Cork South Central, Fine Gael)
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I am conscious that seven other members wish to contribute and that there is a vote in the Dáil on a Private Members' motion.

Alex White (Dublin South, Labour)
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I will try to be quick.

James Reilly (Dublin North, Fine Gael)
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I need to speak up, in that I must partake in the debate on that motion.

Jerry Buttimer (Cork South Central, Fine Gael)
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I understand.

James Reilly (Dublin North, Fine Gael)
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I am time-limited.

Alex White (Dublin South, Labour)
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I will try to be brief and not repeat any of the points that the Minister has made. He has covered many of the issues. Deputy Ó Caoláin welcomed free general practitioner, GP, care for children aged five years and under.

I welcome his welcome. There is a bigger point for the committee, which I wish to make without carrying it too far. In no area of public policy does it apply more than in health that we need co-operation and collaboration across the board in terms of the future funding and structure of the health service. I am not naïve. I am a politician just like most people in this room. The cut and thrust of politics will continue and nobody is complaining about that. In this area of health, given the demands on the health service and the ageing population, there are challenges for this country in terms of future funding of the health service. I would welcome the support and co-operation of colleagues across all parties on future funding. Not everything will be solved before 2016, although we hope many things will be solved by then. We must look to the years ahead for the entire population. This is one area of public policy where we could give ourselves a bit of space to try to work together on the best ways to fund, for example, universal access to primary care and, ultimately, as the Minister said, universal health insurance. In that context, I thank Deputy Ó Caoláin. When he looks for assurance as to whether this is a one-off; this is not a one-off. This is not, as has been described by some, a stunt or a gimmick. It was clearly set out in the programme for Government and emphasised again in the Future Health document. This is a key element of the reform of the health service and it will be carried forward.

I was asked to do essentially two things in July; one related to the interim measure and the other was to bring forward proposals in respect of elaborating the full roll-out. That work continues in conjunction with the Minister, Deputy Reilly. I look forward to more engagement on it as time progresses. The second issue relates to discretionary medical cards in general. The two issues are linked. They have been put together. The controversy arose in recent weeks and then we had the budget. They are linked in this way. I do not think that anybody should have to fight for discretion or even to pass a means test in order to have their basic health care satisfied. That is the system we have in this country and we are trying to change it. We cannot do it overnight. We must maintain the integrity of the system the Oireachtas has put in place, which is the 1970 Act, and at the same time we must bring forward the reforms to change the basis on which health care is allocated.

We are in the position where we have to do both simultaneously. It is not open to the Government or the Minister for Health to instruct the primary care reimbursement service, PCRS, or the HSE, much as we would like to do so on a personal level sometimes, to allocate medical cards on the basis of medical need. We simply cannot do that. The legislation does not allow us to do that. There are so many heart-breaking stories in newspapers and on the radio and television about people or their children who have a medical condition that has caused them so much distress. We can all see that some people are in difficult heart-rending circumstances but it is their income that determines whether they get a medical card. That is the tragedy. That is the law we currently have. Let us try to work together to change that. In the meantime, we cannot change the basis upon which a medical card is allocated by stealth. It is not an illness system. Everyone in this room knows the situation. We are all human, and so too are the people in the PCRS and the HSE. They also have empathy. The suggestion that they do not – not by people in this room – is not fair.

Billy Kelleher (Cork North Central, Fianna Fail)
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The Ombudsman said that the system was being changed by stealth.

Alex White (Dublin South, Labour)
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The Ombudsman also said she could divine no change in the basis upon which medical cards were being allocated. There is a temptation to play politics with this issue. I do not say it is confined to Deputy Kelleher or his party but that is the position he is in at the moment and we are upholding the system that is in place. Could we try to see ahead and uphold the dignity and integrity of the system but work together on reforming it? I include Deputy Kelleher in the invitation. He should join in on the process of reform rather than simply constantly playing politics.

Deputy Conway raised the issue of forms. The Minister dealt with it. I attended meetings with the Minister, Mr. Burke and others. They are changing it. There is always room for improvement in the process by which things are done and the language used in letters. It is changing and it has improved. Mr. Burke would say himself that there is always the possibility of improving things more. People in this room are in touch with citizens all the time and they are the best people to advise us and to help us improve the system. We are all ears in that regard.

Jerry Buttimer (Cork South Central, Fine Gael)
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In upholding the system, in all of our offices, including that of the Minister of State, people are slipping through who are in desperate conditions and in need of a medical card but something has gone wrong somewhere. That is the situation whether we like it or not.

Alex White (Dublin South, Labour)
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If someone is slipping through the system-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I am sorry, but I have one other point. I fully agree with what the Minister of State and the Minister said about people who got medical cards who should never have received them. The question is why they got them on day one if they were 200% or 400% over the limit.

Alex White (Dublin South, Labour)
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Mr. Burke will deal with that. The HSE can only assess someone on the basis of the current situation.

Jerry Buttimer (Cork South Central, Fine Gael)
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I accept that.

Alex White (Dublin South, Labour)
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It cannot go back and compare. It can only assess a person on the basis of the current application and means and whether his or her illness has an impact on his or her income.

Jerry Buttimer (Cork South Central, Fine Gael)
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Could I stop the Minister of State? There is a vote in the Dáil. I will suspend the meeting.

Robert Dowds (Dublin Mid West, Labour)
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Could I suggest that the health authorities would speak to the National Adult Literacy Agency, NALA, about simple language.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will come back to that. We have a letter with the recommendations of Deputies Dowds and Conway.

Jerry Buttimer (Cork South Central, Fine Gael)
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Mr. O'Brien was in possession.

Mr. Tony O'Brien:

It seems that every time I am in possession a vote is called. We should not come to me too often.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will not have a vote for three hours and we hope to be well gone from here by then.

Mr. Tony O'Brien:

Very good. I will group the issues because I need to bring in colleagues, if that is acceptable to the Chairman.

To start with the issue of medical cards, on the issue of the clarity of information, I will show colleagues that the actual medical card application form is stamped with a plain English stamp approved by the National Association for Adult Literacy, NALA, and we are committed to working with it regarding all correspondence. The comment made by the Deputy just before we adjourned, therefore, is very much taken on board.

It is important to stress that the Health Service Executive, HSE, is administering the system we have rather than the system we might wish to have. Each person who receives an assessment, which tells them whether they have been successful, and in particular those who receive an assessment stating they have not been successful, whether that is for a standard application or for an application in the discretionary sense, will receive a detailed statement outlining the financial data known to us which has been used as the basis of the assessment. To date, I am told that no one has ever challenged the accuracy of that assessment. As the members receive inquiries, and I know many members receive many inquiries, I would encourage them to ask those inquiring about the outcome of their assessment to show them that piece of information. I say that specifically because while I hear myself and am aware of the particular challenging circumstances with which many parents and families are faced, having regard to the medical conditions of members of their family, it is the financial impact of those challenges that the HSE is obliged to take account of, not the challenge itself. I say again that we are administering the system we have, not necessarily the one we would wish to have.

Regarding some of the detail of how the process is pursued, I will ask my colleague, Paddy Burke, if he wishes to add anything.

Mr. Patrick Burke:

To confirm, as both the Minister and the Secretary General have outlined, the policy is to give access to individuals without undue hardship to general practitioner, GP, services. What is different is the fact that there is a centralised processing operation. The Minister put that in context in terms of the number of reviews we conducted this year but 87% of those renewals were successful. We assess an individual on the basis of their means, and we apply discretion. The Minister has put on the record the fact that discretion was applied positively 36,000 times since 2011. This year alone, discretion was applied positively more than 23,000 times. In a positive way we have applied discretion this year but in reviewing applications we have also taken away eligibility from individuals who have left the jurisdiction or who are over the guidelines. As the Secretary General said, we provide that statement and therefore we do not have any difficulty if that statement setting out the rationale behind it is produced to anyone else.

Another point was made about the role of the GP. Three months before any card is reviewed we write to clients, and there may well be individuals who are challenged in terms of literacy or something like that but they do attend their GP. We have also provided GPs with the functionality to have that safety net.

GPs can extend eligibility for a further three months and so, in effect, each individual who will be reviewed has that window of nearly six months. We write three months in advance of the renewal date and a GP can extend the eligibility. Moreover, they have a vested interest because if they extend the eligibility, the capitation continues to be paid and they stay on their panel. I am simply answering the earlier point. Other than that, I believe most of the points have been covered. We do exercise discretion and, to use an analogy, we use the ethos whereby in the case of a student who has 38%, we try to make it 40%. However, as the Director General pointed out, while people with serious illness who have incomes within reasonable reach of the qualifying scales can qualify, it is very difficult for us when that income amounts to multiples of the scale, and they are the situations of the hard cases we find.

Mr. Tony O'Brien:

On the issue of the recent HIQA investigation, as I outlined in my opening remarks, I have appointed Ian Carter, the national director of acute hospitals, who will have the role of overseeing the obligations of the HSE under that report, which include the local and national recommendations. Clearly, the chief executive of the group, Mr. Bill Maher, who has delegation from the HSE, has particular responsibilities with regard to some of the local recommendations. HIQA has a monitoring role in accordance with the Safer Better Healthcare standards and the provisions set out in the report itself. This differs markedly from the situation that pertained at the time of the highly regrettable death of Tania McCabe and the local investigation that was carried out into that matter, which was before there was a national incident management team and before there were the standards to which I have referred. With the permission of the Chairman, I will ask Dr. Philip Crowley to add to that answer.

Dr. Philip Crowley:

Obviously, there has been a lot of publicity about this case and there have been two reports, as well as one inquest. As for how we have managed it to this point, it is in contrast to how the death of Tania McCabe was managed, as that was dealt with as a local incident and managed locally. The report was available but was not implemented on a national basis. In recent years, the HSE has established a number of processes to ensure this is not the case with reports of this nature. We have a process agreed between myself and the line division under which we will consider jointly any report that is published into safety of care. Moreover, we will establish a committee in advance of the report arriving in order that it is ready to receive the report, and this is what has been done in respect of our own report into the care of Savita Halappanavar. That same group that is being established with expert input and now under the leadership of Ian Carter will be asked to implement our own report and its implications, the coroner's inquest findings and now the HIQA report. It is important to state that the recommendations that pertain to Galway will be implemented in all units and, most importantly, some of the key priorities already have been advanced, some to implementation. In particular, the Irish maternity early warning score has been implemented in all 19 units. Training is being done in all 19 units and patient information leaflets are being developed for patients in order that they understand the process. I believe we are the first State internationally to have a nationally agreed and implemented maternity early warning score, which is quite different from other adult early warning scores. There are sepsis guidelines, and there were sepsis guidelines in Galway at the time, but they were not properly followed. We need to urgently develop national sepsis guidelines and have in place a group that is tasked with developing those. We will ascertain what kind of resources they now need both to develop guidelines and to develop them to a level and standard that will pass the scrutiny of the national clinical effectiveness committee to which the Minister referred earlier and get the ministerial mandate this will entail.

James Reilly (Dublin North, Fine Gael)
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I wish to make a comment on this issue, because I attended that conference this morning and wish to reiterate forcefully here a point I made there. In the past, people have considered patient safety to be a matter for clinicians solely, and members will have heard people stating on radio that administrators would not understand that issue or that it would not be fair. It is a core duty and a core concern of management, and patient safety must be at the core of what each chief executive officer does. To draw an analogy, the airline industry is one of the safest in the world and no one in this room really believes that only pilots are involved in that, do they? When drawing up the national service plan, we are making it clear where patient safety should be in this plan - namely, right at the top. Moreover, we are making it plain to all new chief executive officers who take over the hospital groups, as well as to existing managers, that it is part of their core duty and core concern and that they are as responsible as anyone else.

Mr. Tony O'Brien:

In respect of the questions of Senator Colm Burke and Deputy Ó Caoláin on non-consultant hospital doctors and the issue of sanctions, the only issue that divided us during the talks process was the nature of those sessions. As members will be aware, the employer side, the HSE, was firmly of the view that these sanctions could not involve a formula that provided for additional remuneration to the individuals who were being obliged to work excess hours. At one point during the discussions, an opposite view was held by the Irish Medical Organisation side. I will ask Mr. Barry O'Brien to describe in detail what those sanctions are in a moment.

As for the issue of the €3.4 billion of funding to external agencies, these agencies fall into two categories, namely, section 38 agencies and section 39 agencies. Section 38 agencies are those which essentially are wholly funded by the public sector and their employees are considered to be public sector employees. Examples are places such as St. James's Hospital or Beaumont Hospital. Section 39 agencies are a wide variety of voluntary sector providers, which are mostly partially funded, even though the amount may be substantial. Senator Colm Burke made reference to a chief executive officer receiving a salary of €340,000, and I can confirm this is not a section 38 agency. The recent audit report, which we expect to be discussing with the Committee of Public Accounts next month, related to section 38 agencies. A clear guidance note - that is, a circular and instruction - has been issued to those entities and they are required to confirm their compliance with the terms of that circular to the HSE by the end of this month. Section 39 agencies will be subject to further audit work by HSE internal audit, supplemented by external auditors. I will now ask Mr. Barry O'Brien to speak on the sanctions issue.

Mr. Barry O'Brien:

It is important to confirm that health service management is committed to ensuring full compliance with the timeframes we have agreed between ourselves and the IMO to reduce non-consultant hospital doctor hours, to implement maximum shifts of 24 hours and to achieve full compliance with the European working time directive by December 2014. One key issue of debate throughout the Labour Relations Commission discussions was the issue of sanctions. I wish to put this in the context of a structure to incentivise compliance, rather than to penalise anyone, but it has been agreed that the national director for acute hospitals will withhold an annual sum of €15 million from the budgetary allocation of the public acute hospital system and this will be redistributed on the basis that we achieve full compliance right across our system. Consequently, we have agreed with the IMO that there will be a three-band structure for hospitals. The larger hospitals, which are eight in number, will be in band one and they can be sanctioned up to a maximum of €650,000 for the year. Band two contains 18 hospitals and they can receive a sanction of up to €350,000 for the year, while band three hospitals, of which there are 15, can be sanctioned up to €225,000. That is where the total of €15 million comes from.

It is important to state that the HSE perceives this as being the exception, rather than the norm. We envisage this as only occurring in the situation where local management have not given effect to already agreed decisions taken by management and the IMO as to how compliance will be achieved in that specific location. Consequently, we perceive this as being highly exceptional. Notwithstanding that, it was one of the key requirements of the IMO.

Mr. Tony O'Brien:

A number of questions touched on the issue of the Estimates and the service plan, such as the question in respect of bilateral cochlear implants or what we can do about addressing the issue of delayed discharges for persons whose acute episode of care has been completed but who need to remain in a bed. As Deputy Ó Caoláin noted, at any given time there are many hundreds of such people, roughly equivalent to a medium-sized hospital. All these issues will form part of the service planning process. Our room for manoeuvre in respect of the service planning process is highly constrained and a €666 million challenge has been set out in the Estimates day announcements.

In addition to that, our own assessment of the impact of the demographic challenge on our service and the need to address very significant deficits in the critical range of services that we are currently able to provide, in our view, mean that the challenge we have to address in the service planning process is broadly equivalent to €1 billion, in other words, the swing that is required is broadly equivalent to €1 billion. It is important to stress that in seeking to address all of these key issues we do have that very significant challenge.

A question has been asked about the €113 million probity. There was a probity measure included in the 2013 service plan. It had a €10 million element attached to it. That has carried forward. Therefore, that needs to be added to the €113 million in that context.

As the Minister outlined, the health side in the discussions was very clear that, in relation to that measure and in relation to pay-related savings which is substantially the Haddington Road agreement, we saw the need for an objective verification process to establish where the risk lies in relation to those issues. For our part, in the Health Service Executive, I have already commissioned both our internal HR and finance functions, supported by PA Consulting, to carry out a thorough risk assessment against those two challenges. As I stated previously, a probity figure of €113 million does not in any sense affect the individual rights of persons who would already have been eligible for medical cards. It will not affect the way we approach the assessment. Therefore, if that €113 million cannot reasonably be expected to be produced from a probity measure, then an alternative way of meeting that shortfall will have to be found. That also applies in the pay-related area. We are carrying out a thorough assessment which will be fed into the process that the Minister has already described. I emphasis that the next few weeks, in terms of service planning, are very challenging and absolutely critical.

Jerry Buttimer (Cork South Central, Fine Gael)
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There are seven speakers: five members of the committee and two non-members. I ask members to be concise in their questions because Deputies Ó Caoláin and Kelleher must speak in the Dáil. If I may, with the permission of the committee, I will ask Deputy Fitzpatrick to speak because he will speak in the Dáil presently.

Jillian van Turnhout (Independent)
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There is a vote in the Seanad and we will be gone shortly.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will let Senator van Turnhout go first, followed by Deputy Fitzpatrick.

Jillian van Turnhout (Independent)
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I apologise to Deputy Fitzpatrick.

Jerry Buttimer (Cork South Central, Fine Gael)
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I try to be fair to everybody.

Jillian van Turnhout (Independent)
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As the cochlear bilateral implants have been mentioned, I will not mention them again. It is the best practice for treating children who are profoundly deaf and it has such an impact on their lives. Prescription charges have already been mentioned also.

I have publicly welcomed the free GP care for those under six - I will not go into that today - and the Minister's moves on tobacco. In that regard, the Minister will be aware that we - myself, along with Senators Crown and Daly - have a Bill in the Seanad and I hope there will be progress on it now.

The issue to which I want to limit myself today is question No. 18, which I submitted several weeks ago and which relates to medical cards issued on the grounds of a terminal illness and, therefore, not subject to means testing. I submitted this question because I have been doing work with organisations, such as the Irish Hospice Foundation and Jack & Jill Foundation. No doubt Senator Mary Ann O'Brien, who is here, will be able to add to this and give of her direct experience of what I am talking about.

Jerry Buttimer (Cork South Central, Fine Gael)
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I should welcome Mr. Jonathan Irwin, from the Jack & Jill Foundation, who is in the room as well.

Jillian van Turnhout (Independent)
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I do not make individual representations. I have the privilege, being a Senator, of not being in that territory. However, the Irish Hospice Foundation has told me of those who get the medical card for six months because they have a terminal illness where the difficulty arises at the six-month point. What happens is that those who live beyond six months and seek to renew their card then must go through the full, quite cumbersome means-test procedure. Everybody here will be aware of the procedure. They are no less terminally ill. The answer I got, perhaps a little like the letters that issue about medical cards, was quite opaque. I read it five times last night, trying to understand what was being said. The crux of it is that while those given medical cards on terminal illness grounds, rather than on emergency or discretionary grounds, are being treated swiftly and sympathetically, there should be a system where the card needs to be renewed after six months. Those with a problem are, not the many in this category who have a medical social worker or palliative care team, but those who fall outside of their remit.

I have heard of many individual cases. It is almost as if we are saying that if the person has lived longer than six months, we will penalise him or her for doing so. It is a bizarre situation when one has a terminal illness. I heard of one case of a man who does not want to face up to the fact that he has a terminal illness. They have managed to work around it but now, after the six months, he must go through all of this procedure and the family must work with him to face up to it. There is something wrong with the system. I will leave the illustrations on the Jack & Jill Foundation to my colleague, Senator Mary Ann O'Brien, but they are equally compelling. That is my big issue.

Peter Fitzpatrick (Louth, Fine Gael)
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Almost 2 million of the population, or 43%, are covered either by a medical card or a GP visit card. As Mr. O'Brien stated, there has been a 74% increase since 2005. The question I came with today relates to the hardship issue. On grounds of hardship, the HSE can apply discretion and grant a medical card. Mr. O'Brien stated here that, as of 1 October 2013, 52,733 medical cards were issued where the applicant's means were above national guidelines and 22,115 GP visit cards were granted. These numbers seem high and are good. This is something that I did not hear previously. That was one of the questions I was going to ask today. I also welcome that a medical doctor will assess these discretionary medical cards. How many doctors are employed to assess the discretionary medical cards?

Sandra McLellan (Cork East, Sinn Fein)
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I thank all the witnesses for their presentations. I have just a few questions. How many full-time respite care beds are there currently available for those with mental health issues where carers might be ill or there may be a family emergency? Are they available in all HSE regions?

I want to mention the prescription charges. The €2.50 levy is a big jump for those who are on the margins. I am aware it was something the Minister had committed to try to abolish. My point is that if the Minister keeps increasing the prescription charges, it will cost more to dispense some of the medication than the medication costs.

I cannot leave it without going back to the medical cards. Like everybody else, I am inundated with representations from those whose discretionary medical cards are being withdrawn. I refer to those who would have been over the income threshold guidelines initially but who received them on discretionary grounds of undue hardship. I suppose what I am trying to ask is, how does one determine "undue hardship"? Is there a price on discretion? Is there a formula that brings it about? It was mentioned earlier that some are 50% over the threshold. However, some live with a serious cost due to the severity of their illness. Are all such persons' costs taken on board when granting discretion? How many of the discretionary medical cards issued were for six months only?

I refer to the 1970 Act. The Minister stated he is abiding by the law. If these laws were there when people received the discretionary medical cards initially and they still got them, why can they not get them now?

Jerry Buttimer (Cork South Central, Fine Gael)
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I will take all the speakers together now. I call Deputy Catherine Byrne.

Catherine Byrne (Dublin South Central, Fine Gael)
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I thank the Minister for the detailed report, and thank Mr. O'Brien as well. I particularly thank the Minister for his extensive explanation on the medical card. I welcome the Chairman's request to revisit the centre. We might be able to ask more questions then, rather than delay today.

On the committee appointed under the Protection of Life During Pregnancy Act 2013, I wonder is there any chance we could have a list of those appointed to this group. Of course, I welcome the appointment of Dr. Eilish Hardiman as CEO of the new national children's hospital, and Dr. Jim Browne. I wonder is there any listing for that committee that Dr. Browne will be looking after for the hospital.

My main question relates to question No. 32. I thank the Minister and the Department for replies to it and earlier questions.

I have been here for the past 18 months practically banging the table in crying out for Hollybrook Lodge in Inchicore to be opened. The glass is half full because, although it will be opened, we are not getting what was promised. We were promised 50 new long-term beds in the community and that 9% of the beds would be allocated locally. Having met the CEO of St. James's Hospital and Mr. David Walsh and having been told the unit will be taken over by St. James's Hospital to facilitate the demolition of hospital 7, which I fully appreciate and understand, the position is clear to me. However, there is growing anger in the community as the beds were to be new beds, not a replacement for long-term beds from any other hospital. However, I understand the urgency in getting the brownfield site ready for the new hospital.

People in the community have spoken to me about the services that are to be in the unit. They have asked about respite for people locally. We were promised 9% of the beds. Will this be the case? We have practically been told that we would get the crumbs off the table at the end of the day. This is a very sad position to put any community in considering the support that was given locally. There were no local planning problems associated with allowing the unit to be brought into service.

I welcome the development, but with reluctance, because we need more beds. We should not just be filling in for other hospitals. I appreciate the urgency but would like the Minister to take on board what I said. When he is speaking to the CEO in St. James's Hospital, I hope he will make it very clear that the people of Inchicore want proper services. If the unit is to be in place, we want 9% of the beds and some respite beds. Respite beds are not accounted for at present. This should be examined also.

Regina Doherty (Meath East, Fine Gael)
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Without dispensing with gratitude for the presentation today, which is obviously very welcome, I must ask two questions, one of which concerns the implementation team that has been set up arising from the report of HIQA, the HSE and the coroner on Galway University Hospital. I refer to Mr. Ian Carter's heading of the team. What is the full remit of the team? Who is on the team and how many are there? What is the geographical spread of membership? What is the timescale for implementing the remit of the team? Who is actually monitoring the team?

At the risk of sounding sarcastic, I ask, in light of the outcome and particularly Mr. Crowley's statement of a number of weeks ago that the HSE does not measure quality well, that the Minister reconsider reinstating the ISQSH’s funding, which allows for the measurement of equality exceptionally well on behalf of patients. I ask that the Minister give the body permission to carry out the patient quality survey it wanted to do on maternity services last year but which was refused.

On foot of an answer to a parliamentary question I received last night, let me refer to the terminal illness process. It desperately needs to be examined. The definition I received last night of a terminal illness really grates and needs to be examined. Could we consider the six-month process or the reapplication process since we are talking about people in the very late stages of their lives? We should be considering how to make the process as enjoyable as possible to allow people to have dignity at that stage of their lives.

Lucinda Creighton (Dublin South East, Independent)
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I thank the Ministers and the team from the HSE and the Department for the very comprehensive statements that have been made. I have two areas of questioning. The Minister has been very honest about the targets set for 2014 in terms of saving the additional €360 million. I agree that some of the bases for those savings are less than solid in terms of the sort of analysis that has been given. What is the likelihood of a supplementary budget or budgets being needed in 2014? How much does the Minister expect will be required in supplementary budgets? Conscious that we will no longer be under the intense scrutiny of the troika, there might be some more leeway afforded to the Minister and his colleagues in the Cabinet. I would be interested in hearing from him on that. The way in which the figure of €113 million has been arrived at is somewhat dubious, and I am quite sceptical about the likelihood of realisation through the probity review of medical cards.

Second, I wish to follow up on Deputy Kelleher's question on the reduction in tax relief for medical insurance. It is quite extraordinary that this taxation measure was arrived at without any consultation with the Minister for Health. That it was exclusively a decision of the Department of Finance is pretty much alarming. I realise that the €127 million in potential savings is a convenient figure to arrive at for the Department of Finance. As Minister for Health, Deputy Reilly has a duty of care to patients, others in the health system and the huge swathe of people who benefit from health insurance at present but who rely on the tax relief that will no longer be available. Has there been any in-depth analysis by the Department of Health or others collectively on the likely impact on public health care costs? There will clearly be an impact.

Can the Minister clarify the likely number of people who will be affected? It has been suggested by a number of people with considerable expertise, including Mr. Dermot Goode, that up to 1.8 million people could be affected, or 90% of policies. Is that likely? Does the Minister believe the figures are accurate? How on earth will this fit in with the Minister's plan to roll out universal health care in the years ahead? It seems quite incongruous.

Noel Harrington (Cork South West, Fine Gael)
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I wish to raise a minor issue, but one that affects some medical card holders under review. A few cases have been raised in my office in this regard. Under the assessment, the HSE is asking for a notice of assessment from the Revenue Commissioners on income where a means test has already been done, for example, by the Department of Social Protection. Ordinarily, one would not be asked for another revenue assessment. An extra layer of effort is involved, particularly for over-70s. A couple over 70 might have non-contributory pensions assessed by the Department of Social Protection, yet they are asked for proof of income from the HSE. This is a necessity. With regard to the under-70s, people on very low incomes, such as those in receipt of the farm assist payment, would be asked for a further assessment of income. Until the day comes that the Department of Finance asks every citizen to file a tax return, asking medical card applicants to carry out a further assessment, which might involve their having to go to an accountant, involves extra unnecessary expenditure, time and effort. The accountancy industry may not thank me for saying that. There is a simple lack of communication between the HSE, the Department, the Office of the Revenue Commissioners and the Department of Social Protection. We could open up channels there and make it a lot easier for people to fit into the guidelines that already exist.

James Reilly (Dublin North, Fine Gael)
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With regard to the medical cards and terminal illness, it is clearly a very emotive and difficult issue. If there is to be a change with regard to the giving of the card without means testing, because of the nature of the situation, I presume there would have to be legislation and new regulations. I will allow the Minister of State, Deputy Alex White, to deal with that as it is more in his area.

Deputy Peter Fitzpatrick asked how many doctors are associated with the assessment. Mr. Patrick Burke could answer that.

Mr. Patrick Burke:

Thirteen.

James Reilly (Dublin North, Fine Gael)
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Thirteen, with one lead.

Deputy McLellan’s questions on what is the formula are very salient. We need to publish them so that we have transparency. This will be part of our communications drive to reassure people they have been treated fairly. As I said this morning at the conference, the informed and empowered patient is the safe patient. Similarly, informed clients can be assured their situation has been dealt with fairly.

The Health Service Executive, HSE, will answer the question on the number of full-time mental health beds for respite care. Mr. Philip Crowley will answer Deputy Catherine Byrne’s question on the membership of the review committee for the protection of life during pregnancy legislation.

Hollybrook Lodge will open under the auspices of St. James’s to allow for the demolition of Hospital 7 which is to make way for the new paediatric hospital. I know the Deputy has been concerned that the hospital would be for locals. I have been assured that many of the patients moving there have addresses in Inchicore. However, no nursing home is entirely occupied by people from its locality.

I will have to refer all Deputy Regina Doherty’s questions about Ian Carter’s team to the HSE and Mr. O’Brien. We can examine the issue of funding for ISQSH, the Irish Society for Quality and Safety in Healthcare. However, as members have already heard this is not a good year to be looking for funding in health.

Deputy Creighton talked about the likelihood of a Supplementary Estimate for the Department in 2014 and that the troika’s scrutiny will be gone by then. I am very conscious it is still here so I am not going to talk about Supplementary Estimates, other than to say we have a serious challenge to meet and we will have to have a Supplementary Estimate this year. I hope to keep it below €200 million. She also raised the issue of the reduction in tax relief for medical insurance. That is a decision for the Minister for Finance. Some work has been done already on the analysis of the impact to which she alluded. We do not have the full figures on this. The Department of Finance will work hard with the insurers around the logistics of this and how it is implemented. They would have entered into contracts and priced them without knowledge of this decision. We want to have as many people in health insurance as possible by the time we reach the stage of implementing universal health insurance. We hope we will have much better growth and income in the future with the economy turning around. I hope this will enhance our plans for universal health insurance but it will be a matter for the Minister for Finance, not for me.

Deputy Harrington inquired about means-testing which is already done by the Department of Social Protection. Deputy Richard Bruton highlighted this when we were in opposition. I have discussed this with the Minister for Public Expenditure and Reform and that it should be once-off and not having people running around to five different agencies.

Alex White (Dublin South, Labour)
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On Deputy McLellan’s fair question as to what constitutes undue hardship, it should be possible for Deputies, Senators, the press and citizens to be able to have regard for the guidelines so as to know what is being done. They are on the HSE website. The guidelines go through the issue of financial means and the various different tests. It is complex but it goes through it in a reasonably digestible fashion. It also deals with the discretionary aspect. This is difficult because a discretionary medical card can be awarded on the basis of an illness. It can be awarded on the basis where an illness has an impact on one’s financial situation. It is not whether or to what extent the person is ill. It is whether or to what extent that illness impacts on the person's financial situation. There is a big difference between the two. It sounds harsh but I am trying to clarify the specifics. The relevance of the illness for the purpose of a medical card is whether the illness impacts on one's financial situation. These guidelines are on the website and they bear reading but I am sure they could be clarified further. No process is perfect, which I am sure Mr. Burke would accept. The guidelines are reasonably clear.

Jerry Buttimer (Cork South Central, Fine Gael)
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It is about making them humane as well, as opposed to them just being a code.

Mr. Tony O'Brien:

Deputy Kelleher asked whether the discretion still lay with the HSE or whether it had been removed. It very much lies with the HSE. The 1970 Act vested it in the chief executive officers of the health boards and the office I hold is the successor office, so the discretion passes through my office, as it were, and down through the system we have described.

Senator Colm Burke spoke to me during one the voting breaks about the duration of the emergency issue of a card in the event of terminal illness. Clearly, it is not possible to issue an indefinite card because there are hopes a terminal illness may not be terminal. We have to have a review period but to the extent we have discretion - I am not sure what discretion we have - we will seek to exercise it in terms of looking at that six-month deadline, recognising there will, nonetheless, have to be some deadline. However, we will look at it.

In regard to the issue raised by Deputy McLellan on the number of full-time mental health respite beds, we do not have that information with us but we will come back to her with it.

In regard to the protection of life review committee established on foot of legislation, the HSE has a statutory obligation to do that. We are going through the process of doing it but it is not yet complete. A number of steps have to be taken and we are not yet in a position to say the committee has been established. It is one of those things on which we are working as quickly as possible because it is, in effect, necessary in order for the Minister to be in a position to commence the legislation, although I think we would all agree not technically speaking, but practically speaking.

The implementation team, which will be headed up by Mr. Ian Carter, will report to me and, through me, to the Minister on a very frequent basis. We had correspondence on that just this week. It will also service the monitoring requirements of HIQA, which are derived both from its standard monitoring process and from some specifics in its report. There will be a very close time-based monitoring process. I only delegated responsibility for this to Mr. Ian Carter this week, having had a chance to fully review the recommendations from HIQA, which were only published one week ago. He will set out to me his intended timetable around the phasing of the various actions and how they relate to each other, the sequencing and so on. We will be very public about that. It is just that it is very early days in regard to the HIQA report, in particular.

I mention briefly the tax relief issue for medical insurance. In terms of the risk assessment we will have to do on the potential impact of that on the HSE's Vote in 2014, the HSE depends for some of its appropriations-in-aid on the income it derives from the occupation of designated beds by privately insured patients in public hospitals. There is also a provision for that to increase next year through a process effectively of de-designations, that is, that it would be derived from patients who are privately insured, irrespective of bed. If there were to be a significant impact on the number of insured patients, that would have a knock-on impact on the funding of the health service for next year. While not wishing to comment, in any way, on the specifics of Government policy in regard to that, it adds a further dimension to the risk assessment we need to go through in terms of the €666 million and the €1 billion challenge I mentioned earlier.

Mary Ann O'Brien (Independent)
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I know we are nearly out of time so I will brief. I really feel we are coexisting in two completely different realities. While the Taoiseach, various Ministers and the HSE still claim there is no problem with the allocation of discretionary cards, I speak on behalf of the Jack & Jill Foundation's nurses who are faced with the reality on the ground. We can say with certainty that everything has changed and that the situation is getting worse in respect of the allocation of medical cards. We are inundated with parents who are stressed and all the words used earlier. There is a lack of compassion and understanding and parents are frightened and overwhelmed by the amount of evidence they need to produce when they are asked to rebook their medical cards. The UN Convention on the Rights of the Child has recommendations in respect of sick children and their entitlement to medical cards. Can we look at that and at least stand up for it?

I have a quick question for Mr. O'Brien who I welcome to the HSE. Has he stress-tested the HSE's value for money in respect of outsourced private health services? I was shocked to hear earlier about the salary scale of €340,000 for a CEO because the Jack & Jill Foundation does not merely exist to look after our children and nurse them at home. According to the report of Professor Charles Normand from Trinity College, it is nine times cheaper to let the money follow the patient and nurse him or her at home. We have raised €47 million and are on our way to €50 million and the HSE has given us €4 million since 1998. I am very interested in understanding things.

The HSE has also changed the way one gets a medical card if one is unlucky enough to give birth to a child who needs palliative care and one would like the child to go home. It used to be the case that one was given a medical card there and then in the hospital. It used to be the case that with a few telephone calls, an emergency medical card would be issued. One must now go out to the General Register Office as a very stressed and upset parent and register the birth. One must then wait a number of days. I heard a case only two weeks ago involving a baby born in the Coombe Women & Infants University Hospital who was transferred to Our Lady's Childrens Hospital in Crumlin. It took a week to get that child a medical card and Our Lady's Childrens Hospital and the Jack & Jill Foundation had to pay for the supply of equipment to feed the child to get them home so they could die at home. I do not want to get too personal but we have two realities here. I asked a question in the Seanad the other night and was not happy with the answer because it did not reflect the reality of what is happening.

Jerry Buttimer (Cork South Central, Fine Gael)
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All of us would accept that it should not take a week for the emergency medical card to be issued. Could the Minister or Mr. O'Brien respond?

James Reilly (Dublin North, Fine Gael)
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I will defer to the Minister of State, Deputy White, in respect of the medical card issues. I certainly think there is a need to answer Senator O'Brien's point about how we measure up to the UN standard for child care in terms of how we issue medical cards. That is something we will do because I believe this country is progressive and provides good standards by comparison with other countries. We should be able to measure up to that standard. If not, we have an issue that we should address.

I thank Senator O'Brien, and I know her husband is here as well, for the great work she does in the Jack & Jill Foundation.

Mary Ann O'Brien (Independent)
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I thank the Minister.

James Reilly (Dublin North, Fine Gael)
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It must be the saddest thing of all to have the joy of childbirth followed by the news that one's child is not going to live and the pain that causes parents. We have had a long discussion here about the difficulties around the issue of terminal illness and how we define it. Perhaps this provides us with an opportunity to refine that definition to benefit people as best we can. It seems churlish to mention budgets in the context of this conversation but that is a reality. Nonetheless, in terms of priorities, I cannot think of a greater priority than palliative care for children.

Alex White (Dublin South, Labour)
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I was unaware of the particular circumstances mentioned by Senator O'Brien. If she wants to discuss that particular case with me or through me with the HSE, I would want that to be addressed. I want to understand what happened in those circumstances and to ensure that there would be no repeat of them. I would also be very concerned if there is a lack of compassion and understanding in the system, as referred to by Senator O'Brien. I am not taking from anything that has been said here but I know from colleagues in the House and from people outside that there is a very high measure of understanding and empathy on the part of the staff in the PCRS. I have heard them complimented widely for that. That is not to say that there are not circumstances where the standard we expect is not achieved. That is why we want to know about that. We are not engaging in any criticism of anybody but if there is a lack of understanding or people have experienced insensitivity, I certainly want to know about it. This is separate from the issue of eligibility and concerns the way people are dealt with. I am sure the Minister and the HSE want to ensure that this is not and should not be the way we deal with our citizens.

Mr. Tony O'Brien:

I will address the specifics of the high-level piece. I do not think anyone in the HSE has suggested that there is no problem. It is a question of what our definition of the problem is. We are administering the scheme as it stands. The scheme does not do all that we would wish it to do. I do not think that the fundamental problem relates to the way the scheme is being administered. It is being administered in accordance with the legislation as it exists and the resources provided to it. What we are really having is a discussion about what the scheme should be as opposed to what it is. We can all relate to that discussion.

In respect of the specific issue raised by Senator O'Brien regarding the unfortunate birth of a palliative baby and the way that case was dealt with, we will certainly review our procedures to see if we can come up with a better way of managing that.

The salary of €340,000 is not being paid by the HSE. I can tell the Senator that it is not in agency that is fully funded by the HSE. I do not know which agency it is. I am assuming it is a section 39 agency, of which there are many from very small to very large. I can only assume it is an entity that has very substantial external funding but they will all be subject to an audit review to ensure that public funds are not used to support excessive salaries such as that salary. Obviously, in respect of the services we buy, we look for value for money in respect of the quantum of service we receive for the funding we provide. Nothing I say is intended to take away from the particular situation experienced or described by Senator O'Brien and her colleagues but what we have is a plea for a different type of medical card system - a universal one.

Jerry Buttimer (Cork South Central, Fine Gael)
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I conclude by again thanking the members, members of the HSE, the Minister, the Ministers of State and staff from the Department of Health. It has been a very worthwhile exercise. It is important that we recognise that the health care system is about the patient and those who need access to medical care regardless of who they are or where they are from. We should also acknowledge the tremendous work done by our staff in the Department of Health and the HSE. At a time when one hears criticism, it is important to acknowledge that the staff in the PCRS and the HSE carry out a very important function and serve the people of this country. I again thank the witnesses for being here this morning.

James Reilly (Dublin North, Fine Gael)
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I did not realise the Chairman was winding up so quickly.

Jerry Buttimer (Cork South Central, Fine Gael)
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I am conscious the Minister must to go the Dáil.

James Reilly (Dublin North, Fine Gael)
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Yes, I must go to the Dáil. There has been much talk about the medical card. I hope things have been clarified for people and that they realise that there has been no change in policy. I understand that people have difficulties, which have been outlined very clearly here by some of the members and which will be taken on board. We need to look at the issues around terminal illness and the needs of those whose primary need is not medicine and to devise some other methodology for supporting them in their needs. I want to put on record my gratitude to everybody involved in the Department of Health and the HSE and the men and women who deliver care on the front line and in our communities because they have done an astonishing job of work over the past couple of years.

I am not going to restate all the cuts we have taken but we have improved the service in a real way. I was struck by the fact that nobody at the press conference two days ago mentioned people on trolleys. That problem is not solved but the situation has improved considerably. We will continue to work on our health service and we will end up with one of the best services in the world because we have some of the best doctors, nurses and managers. As the Minister of State, Deputy White, argued, we need to work together, in a co-operative fashion to get what all of us want, namely, a health service in which we can always feel safe and of which we can be proud.

Jerry Buttimer (Cork South Central, Fine Gael)
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I remind members that the next quarterly meeting is on 12 December 2013.