Dan Neville (Limerick, Fine Gael)
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The Dáil has referred to following Revised Estimates to the select committee for consideration: Vote 38 - Office of the Minister for Health; and Vote 39 - Office of the Health Service Executive. I welcome the Minister for Health, Deputy James Reilly, and his officials. The purpose of the meeting is to consider the Revised Estimates and the supplementary performance information on the outputs and impacts on programme expenditure. A draft timetable for the meeting has been circulated. Is it agreed to? Agreed. A departmental briefing note on each Vote was circulated to members. I call on the Minister to make his opening statement.

James Reilly (Dublin North, Fine Gael)
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I am very pleased to have the opportunity to address the select committee on the Revised Estimates for 2014 for my Department - Vote 38 - and the Health Service Executive - Vote 39. Copies of the Revised Estimates and briefing documents on the two Votes by subhead have been provided for Deputies. As they are aware, the annual Estimates are being reconfigured along programme lines to ensure greater transparency in Government expenditure. The Department of Health is working towards the development of programme budgeting and changing the structure of the health Votes to reflect this. This will take some time, however, as the financial systems in the HSE will have to be adapted to allow for it in the context of the financial reform programme under way. In the interim, the appendices to the Revised Estimates for the health Votes have been constructed along programme lines, based on the HSE's national service plan, to provide a high level programme breakdown of health expenditure. In addition, two programme subheads, concerning the PCRS and long-term residential care, are now included in the Revised Estimates Volume. The third programme for which information had been extracted - the children and families directorate - is now funded through the Department of Children and Youth Affairs following the establishment of the Child and Family Agency.
Before dealing with the Estimates in detail, I will make a few general observations about the overall budgetary situation facing the health sector. As members of the committee are fully aware, the Government is committed to tackling Ireland's very serious deficit problem. Current health expenditure in 2014 will account for 27% of gross current expenditure, meaning that fiscal realignment must, of necessity, affect health sector spending. The challenges facing the health system at a time of growing demand mean that the Government must press ahead with major health sector reform. I will continue to deliver the Government's programme of health reform throughout the course of the year and I am pleased that the HSE has set the advancement and implementation of the reforms at the centre of its planning for 2014, including but not limited to phased implementation of a money follows the patient funding system in hospitals; the transition to hospital groups, including appointment of new group CEOs, where required; the establishment of new community areas with associated governance and organisational arrangements; and the establishment of a patient safety agency.
In 2013 we published Healthy Ireland, the strategy for improving the health of Irish people and enhancing their health and well-being. It is an ambitious strategy that aims to embed health and well-being across public policy and services. It sets out a whole-of-government and cross-sectoral approach to address the demands placed on health and social care services from the growing incidence of chronic illnesses, together with the challenges presented by an ageing population. Chronic diseases such as cancer, cardiovascular conditions and chronic respiratory disease and diabetes are the leading causes of mortality and account for over three quarters of all deaths in Ireland. The risk factors associated with the increased prevalence of chronic diseases such as obesity, a lack of exercise, unhealthy eating patterns, the over-consumption of alcohol and the use of tobacco products are generally preventable. Healthy Ireland is critical in enabling the required shift in emphasis towards health prevention, promotion and improvement in the years ahead. The 2013 edition of Health at a Glance,published by the OECD, shows that Ireland continues to make substantial headway in improving health outcomes. Mortality due to cancer fell by 21%, ischaemic heart disease by 59% and cerebrovascular disease by 54% between 1990 and 2012 and in all three cases the rates of improvement in Ireland were above the OECD average. Life expectancy in Ireland has increased by a full four years since 2000 to reach 80.6 today, again above the OECD average.
I will now address the Estimates for health in some detail. The Revised Estimates for 2014 for the health group of Votes provides for gross expenditure of €13.164 billion for health services. Of this amount, some €12.774 billion is for current funding and €390 million for capital funding. A further €544 million, that is, €537 million in current funding and €7 million in capital funding, for child and family services is funded through the newly established Child and Family Agency under the aegis of the Minister for Children and Youth Affairs. Significant cost extraction is required, with €619 million in savings to be achieved in 2014. The primary aim in targeting savings is to cut the cost of services, not the services. This will be achieved largely through efficiencies and reconfiguration under the Croke Park and Haddington Road agreements, new charging arrangements for private patients in public hospitals and curtailing the growing cost of pharmaceuticals. The required savings have been incorporated in the HSE's service plan published on 18 December 2013 and are recognised in the Revised Estimates.
The funding for Vote 38 provides for gross expenditure of €206 million. This comprises €16 million in capital funding and €190 million for current expenditure. This represents a 6% reduction on the provisional outturn for 2013 and a 17% reduction on the 2013 budget.All health agencies funded by my Department were required to achieve further efficiency savings this year, with the Department's administrative budget being reduced in line with the moratorium on recruitment and the provision for legal costs and statutory inquiries also reduced. The provision for the National Treatment Purchase Fund has also been significantly reduced, pending consideration of its future role in the context of the structural reforms set out in Future Health.
In addition to the funding reduction, some €22 million was transferred from the Department's Vote to the HSE in the context of the drugs initiative. The funding will be used to support approximately 220 drugs task force projects, in respect of which the HSE has acted as channel of funding for a number of years. The HSE also provides funding for a significant number of the same drugs projects from its own Vote. The HSE-funded projects are subject to the standard governance and monitoring procedures of the HSE. Separate reporting, accountability and monitoring arrangements had applied to projects funded by the Department through the channel of funding arrangement. Allocations to drugs task forces will continue to be based on drugs task force recommendations and focus on tackling the drugs problem. The transfer of operational responsibility for the funding administration of drugs task force projects to the HSE is a key priority in the HSE primary care operational plan for 2014. Some €7.4 million remains in the Department of Health's Vote for 2014, €6.6 million of which is in respect of expenditure on 100 community drugs projects. The remainder funds the activities of the National Advisory Committee on Drugs and Alcohol, the Family Support Network and the citywide drugs crisis campaign which represents the community sector.
The gross provision for the HSE is €12.958 billion, comprising an Exchequer contribution of €11.553 billion, plus appropriations-in-aid of €1.405 billion. This is made up of €12.584 billion in current expenditure and €374 million for capital expenditure.
As members will be aware from discussions on the national service plan, some €537 million has been transferred from the Vote of the HSE to the Vote of the Minister for Children and Youth Affairs following the establishment of the Child and Family Agency which is now responsible for funding child and family services. In addition to this adjustment, the Revised Estimate for the HSE includes additional health funding of €47 million over and above the budget provision and €22 million for the drugs programme. The HSE is required to achieve savings worth €619 million next year to remain within the 2014 health expenditure ceiling.
As with last year, the significant cost of drugs and medicines has been targeted for savings measures. In recent years a number of changes to the pricing and reimbursement system have been successfully introduced, primarily through pricing and supply agreements with the pharmaceutical industry, and we have made good progress in addressing the cost base. With the passing of the Health (Pricing and Supply of Medical Goods) Act 2013, we now have a robust system of reference pricing and generic substitution and have already reduced the cost of atorvastatins by some 70%. More reductions will follow in 2014 and some €50 million in targeted savings is built into the budget for the PCRS. This saves patients’ and taxpayers' money, allowing us to focus on maintaining front-line services.
The 2014 Estimates provide for the full-year effect of the reductions to professional fees paid to general practitioners and pharmacists under the Financial Emergency Measures in the Public Interest Act 2009. Overall, these reductions will save in the region of €70 million in a full year, half of which was achieved in 2013.

The savings targets in relation to medical card probity and the demanding set of savings targets under the Haddington Road agreement were discussed at length with the joint committee on 14 and 16 January, and therefore I do not propose to go into any further detail on these now. Suffice to say that my Department will work closely with the HSE, and with the assistance and support of the Departments of the Taoiseach and Public Expenditure and Reform, to ensure that savings from these measures are maximised.

In setting the Estimate for the HSE tough decisions had to be taken by the Government, given the need to take corrective action on public spending. The health service must, of necessity, contribute to the expenditure reductions required in 2014, but the Government's objective has always been to ensure that these reductions are achieved in a way that secures the best possible outcomes for those in receipt of services, with a particular focus on protecting services for the most vulnerable. To protect services, we need to reduce costs and improve productivity.

Suitable and appropriate facilities are required in order to provide safe and cost-effective health care. Recent capital investment has brought about a significant improvement in the standard of facilities across all care programmes. Nevertheless, a significant proportion of the health care infrastructure is old and, therefore, generally unsuitable for contemporary health care delivery.

The HSE has submitted its draft capital plan for the multi-annual five-year period 2014-2018. This is under consideration and requires my approval with the consent of the Minister for Public Expenditure and Reform. For the multi-annual five year period 2014-2018, the major priority projects are the children's hospital, for which we were happy to announce the satellite urgent care centres today; the Central Mental Hospital; the relocation of the National Maternity Hospital; the national programme for radiation oncology; and the continued roll-out of primary care infrastructure in line with the national primary care strategy. In addition, the refurbishment programme for the community nursing homes and residential mental health facilities must be progressed.

Considerable progress is being achieved on numerous projects over all health care groups nationally. Facilities which are due to become operational in 2014 or early 2015 include 21 new primary care centres; 38 facilities in the acute sector; nine facilities with 348 beds for older people under the community nursing unit refurbishment programme; and in mental health, 16 facilities will be delivered, eight of which will provide 212 beds - associated with this programme are an additional 18 high-support residential places which will be provided for persons with disabilities who are currently resident in mental health facilities.

The health services received a large investment of taxpayers' money during the good years, but there has not been the degree of improvement that the people have a right to expect. The Government fully intends to correct this, even in these difficult economic times. Our reform agenda, while ambitious, will be delivered.

I thank the committee for its attention and I commend the Estimates for the health group of Votes to the committee. I will be glad to supply any further information or clarification that members may request.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the Minister and apologise for being late. I was speaking on a Topical Issue in the Dáil and I thank Deputy Neville for taking the chair. I call Deputy Kelleher for his opening statement.

Billy Kelleher (Cork North Central, Fianna Fail)
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I apologise to the Minister as well for being late. I was listening to Deputy Buttimer's fine contribution on the cystic fibrosis unit in Cork and the difficulties experienced in trying to come to an arrangement with those who were involved in the fund-raising. I hope there is a speedy resolution. I took a copy of the Minister's reply and I will have time to peruse it later.

We are where we are again in the context of the discussion of Estimates for 2014 for the Department and the HSE. My party is tabling a Private Members' motion in that regard this evening and there was to be a debate in the Dáil tomorrow for six hours as well. Unfortunately, the latter has been withdrawn, and we will raise that in the appropriate forum, the Dáil.

The Minister outlined in some detail the Estimates for the Department and the HSE. The key issue is the legislative proposals that will transfer the Vote from the HSE to the Department of Health. In his reply, the Minister might give an indication of roughly when he expects that to happen.

An issue that sticks out, not because of the figures but because of the issues that have been raised in recent times with regard to the ambulance service, is that of the Pre-Hospital Emergency Care Council. The primary function of the council, which was established in 2000, is to develop appropriate standards in pre-hospital emergency care. It is in this context that the council is pursuing the development of professional and performance standards for ambulance services and ambulance service personnel in addition to the accreditation of institutions providing training for pre-hospital care providers. There are major concerns among broader society about response times, the stress and pressure under which the front-line ambulance service is working, the delays caused by the lack of resources and personnel, and whether centralisation is working effectively and efficiently and providing the service that people expect. At times of crisis, particularly in emergencies such as myocardial infarctions, persons not breathing, or massive trauma such as car accidents, there is concern that we do not have an ambulance service that is fit for purpose in dealing with the pressures and demands that are placed on it from time to time. We recently had cases in which there were up to eight ambulances waiting outside an emergency department because they could not discharge patients. I note that ambulance service funding has been cut by 3%. I am not making an issue out of that. Would the Minister enlighten me as to what exactly they are doing, given that HIQA is also in place to audit the national ambulance service call-out times to see whether they are in compliance with the guidelines of 7 minutes and 59 seconds and 18 minutes and 59 seconds for first response and second response, respectively? I seek clarity on that issue.

The Minister referred to Financial Emergency Measures in the Public Interest, FEMPI, Act 2009 and said the cuts to GPs and pharmacists would save €70 million in a full year. We have had a dispute on this. I have stated on a number of occasions that I believe that GP services are in crisis. They are working under extraordinary financial pressure. One may argue that there is no sympathy for doctors, but I have sympathy for patients who may not be able to access doctors. That is an area that we must look at before a crisis lands on our lap. With the Minister's knowledge as a GP and his former advocacy role - I am not being sarcastic and I am sure he is proud of this - there is a need for us to assess the impact of the FEMPI cuts on GP services, coupled with the fact that in May or June of this year the Minister will roll out free GP services for children aged five and under. I wonder has any audit been done. Has there been any assessment of the impact this may have on front-line GP services?

Rightly, strong emphasis is put on primary care. The backbone of primary care provision in this country is the GP service, both in-hours and out-of-hours. On a continuous basis, we meet GPs who say they simply cannot sustain the level of cuts and cannot provide the services that they would like and feel obliged to provide because of the cutbacks and other issues being foisted on them. I do not expect any government to make announcements that would tie its hands in negotiations or discussions with an organisation or grouping, but at this stage we must take a strategic look at the role of GPs, how they are playing it, and whether or not they are being severely affected, not only for their sake but for the patients.

We now find that the roll-out of free GP care for those aged five and under will be on a voluntary basis. I am not quite sure how that will work. We could end up with a situation in which those who opt in would become paediatric-type GP services while others would go for other age cohorts, and that would not be healthy in view of the fact that most associate the scheme with their family doctor. They go to their family GP as a family. A little thought should be put into this. I genuinely have concerns about the impact that this could have. There is a strong relationship between the family and their GP. It is not something that people take lightly. If their GP for whatever reason cannot fulfil his or her commitment to those aged five and under, then the parent must up sticks and head off to another GP. I wonder whether this has been thought out. Is it possible that there could be large tracts in which there will be provision of GP services for those aged five and under, and those wanting access to a GP will not go to the GP services that provide for those aged five and under because they are crowded with children and will move elsewhere? It could create upheaval given the strong bond between GPs and families throughout this country.

I suggest that be looked at again because of that concern and many other concerns I have in that regard.

Having met with the National Association of General Practitioners and others, and following discussions with the Irish Medical Organisation and meeting general practitioners individually, I am aware there is a problem and the Minister cannot afford to ignore it because as he said, they are the front-line service providers. We are trying to make them more central to the provision of care to ensure people do not end up in the acute hospital setting but the Minister has been dismissive today of those difficulties that GP services are facing.

I ask for clarity from the Minister on an issue that was raised, that is, consultants. I asked here last week or the week before whether there were any difficulties in general in recruiting consultants, and stated that many posts were vacant. The Minister implied there was no difficulty except in one or two highly specialised areas. It may be that somebody is leaking inaccurate reports but it appears there is a report somewhere, either with the Minister or RTE, that suggests there is a major problem in recruiting and retaining consultants in this country. I was accused of being a mouthpiece for the GPs. I am not a mouthpiece for GPs or for consultants but I would like to be a mouthpiece for people who are trying to access health care. The Minister does not like the term "consultant-led clinical care" - he has changed his vocabulary on that issue - but regardless of what we are talking about it is important that this country has the required number of consultants of all specialties and disciplines. If there is a problem in recruiting consultants, and if there is a report on that either in the Minister's office or in RTE, we should see that report and have a discussion on it because it is in all our interests to ensure we have a remunerative package that is internationally comparative, career pathways in place that will be attractive to consultants here, and attractive working conditions also. I ask for clarity on that.

On the issue of emergency departments, and this is an inherent criticism, 410 people were waiting on trolleys to be treated today. I accept there is a seasonal aspect to that trolley count and that there are fluctuations. The Minister takes credit when the trolley count figure is down to 150 or 160, which equally is because of seasonal factors or that patients are not booked in for procedures at certain times of the year when people are on holiday or there may not be the full complement of staff, but there is a major problem in the emergency departments of our hospitals throughout this country. Any perusal of the Irish Nurses and Midwives Organisation, INMO, trolley count, including the ward count where the trolleys are wheeled out of emergency departments into the hospital proper prior to counting in emergency departments, will indicate that a problem is beginning to evolve again in this area. I accept the Minister made some progress in the past but there is no doubt in my mind, and more important in the minds of the people delivering front-line services in our emergency departments 24 hours a day, seven days a week, that patient safety is now an issue. That is an issue that must be revisited. I do not know who is doing the auditing at this stage. The IMNO does its trolley counts and the Department has its own way of counting trolleys but what cannot be disputed is that day in, day out professional clinicians are now saying that patient safety is being compromised.

Jerry Buttimer (Cork South Central, Fine Gael)
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I call Deputy McLellan who is substituting for Deputy Ó Caoláin.

Sandra McLellan (Cork East, Sinn Fein)
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I welcome the Minister and his officials and again convey apologies on behalf of Deputy O Caoláin who cannot be here today. I am substituting for him.

The post-budget period in the month of January has seen intensive engagements in the media and in this committee on the overall health budget and on the HSE 2014 service plan. Recently, we had the Minister and HSE officials here for their quarterly meeting with the committee, which immediately followed a dedicated meeting on the service plan. It must be said that there is an air of unreality about all of this. Basic figures have changed for unaccountable reasons and other figures have been plucked from the air and no one can explain from where they came.

The bottom line is that the provision for our health services in budget 2014 was inadequate. The cuts being imposed across our public health system this year are unsustainable. The original memorandum to the Cabinet from Mr. O'Brien on the HSE service plan stated that it will not be possible in 2014 to fully meet all of the growing demands placed on the health services. We know this was changed to read that it will be very challenging in 2014 to meet all the growing demands. This sanitised version was released by the Minister and published in the service plan 2014.

We have repeatedly argued that the health funding plans of the Fine Gael-Labour coalition have zero credibility. A total of €660 million of spending cuts to health were signalled in the budget. That became €619 million in the service plan. We are told the earlier version of the service plan stated that the actual budgetary challenges facing the health service in 2014 amount to €1 billion. Mr. O'Brien confirmed on radio on 22 December that he was given no source for the proposed budget figure of €113 million probity cuts to medical cards, since changed to €23 million in the current service plan, and that it did not come from the Department of Health or the HSE. We have repeatedly asked where that figure of €113 came from and we still have not got a satisfactory answer. Wherever it came from, the Minister was able to reduce it to €23 million in the service plan, apparently without the blink of an eye.

What we do know is that medical card holders and medical card applicants are facing an ever-more restrictive regime. The standard reply from the Minister that more people than ever have medical cards on income grounds does not address the issues here. We all know from our constituencies that very young children and adults have had medical card renewals or initial applications refused in circumstances where previously they would have been granted.

By the end of 2014, almost €4 billion will have been taken out of our public health services since 2008. The health services have already been cut to the bone, and the knife is still being wielded. The ongoing recruitment embargo and job cuts-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Sorry, Deputy, is there a phone or an iPad near a microphone that is causing interference?

Billy Kelleher (Cork North Central, Fianna Fail)
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Do iPads cause interference?

Jerry Buttimer (Cork South Central, Fine Gael)
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They do, yes.

Billy Kelleher (Cork North Central, Fianna Fail)
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So we cannot use iPads for reading-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I am not sure. Aeroplane mode I am told. Sorry, Deputy McLellan.

Sandra McLellan (Cork East, Sinn Fein)
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The ongoing recruitment embargo and job cuts will have a seriously damaging effect. A further 2,600 whole-time equivalents are to go in 2014, in addition to the 12,500 that have gone since 2007. The entire management of health funding and health services by this Minister and this Government is called into question by their handling of primary care. The service plan refers to the vision for primary care services whereby the health of the population is managed, as far as possible, within a primary care setting but then it cuts €294 million out of primary care in subhead C.1 in these Revised Estimates. That is reflected in a 10% cut in primary care services.

While the provision of GP cards for children aged five and under is welcome, it is in the context of overall primary care cuts. The Government is to take an additional €43 million out of the pockets of medical card holders in increased prescription charges compared to €50 million saved through generic substitution and reference pricing. The Minister and the director general must account for the failure of the HSE to move more quickly in setting reference prices for medicines under the long overdue legislation we passed last year. As recently reported, a range of drugs placed on the interchangeable lists by the Irish Medicines Board have not had reference prices set by the HSE. The entire process has been far too slow and the HSE and the individual patients are not seeing anything like the savings on medicines we should be seeing.

I am very concerned about the cuts to long-term residential care in subhead C.2. The nursing homes support scheme, the so-called fair deal, is being cut again and this has very serious implications for the lives of vulnerable older people and severe knock-on effects for our entire health system. Already, there is a huge waiting list for places under the so-called fair deal scheme and these cuts spell misery for thousands of older people, many of whom are occupying hospital beds because they can no longer be cared for in their homes and cannot get access to nursing home places.

The first State-wide audit of dementia care carried out by Dr. Suzanne Timmons, consultant geriatrician at UCC Mercy Hospital, has just been published. It shows that one quarter of inpatients in our hospitals are affected by dementia.

That is a huge figure.

The audit also shows that our health system is ill-equipped to deal with dementia. The cuts in these Revised Estimates will result in more older people spending more time occupying scarce, acute hospital beds while awaiting nursing home places. This is a totally false economy as well as a source of misery for older people. When my colleague, Deputy Ó Caoláin has raised this issue both the Minister, Deputy Reilly, and the Minister of State, Deputy Lynch, have tried to divert attention from the cuts by pointing to the need to provide greater support for older people to live in their own homes for as long as possible. We all agree that this is the best option and the preferred option for most older people but the Minister must also recognise that there are many older people and others, especially those with dementia, for whom care at home is no longer an option, and they must have long-term residential care. These cuts should not go ahead. We must provide for an increase in nursing home places, provide decent care for older people while also freeing up many hundreds of inpatient beds in our acute hospitals.

I have no doubt that the Minister and delegates from HSE will have to come to the Dáil and to this committee with further Revised Estimates for health during the course of 2014 because the level of provision in these Estimates is totally inadequate and the cuts are unsustainable.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I will be brief. I agree with what the previous speakers said. This is the third year in a row where we have an unsustainable budget and cuts of €619 million plus 2,500 staff, which will create further difficulties, particularly for patients but also for staff and for the provision of necessary services for patients.
I want to raise again the question of whether there is any information from the HSE on agency costs. I have raised this issue at many meetings. I have got assurances from the HSE and from the Minister that we would get these figures but I have not got them yet. The committee secretariat has been trying to get the figure without success. I ask for an assurance from the Minister that these figures will be made available within the next day or two. They are very important figures because we know that the cost of agency non-consultant hospital doctors is huge. I have been told that it can cost anything up to three times the cost of a directly employed non-consultant hospital doctor. We would also like to know the cost of agency nursing. The overall figure of approximately €60 million for non-consultant hospital doctors was given at one meeting. As Senator Burke said, on the basis of the number of staff involved, that appears to be a huge figure. Hopefully, the Minister might have those figures this afternoon and, if he does not, I ask that they be given to us.
When will we have sight of the McGrath report? What steps are being taken to ensure that non-consultant hospital doctors are available to staff hospitals throughout the country? There is a serious problem in this respect.
On the query raised by Deputy Kelleher on the employment and appointment of consultant medical staff, at a recent meeting we were told that there was no real problem here. I would like some clarification on that. There now appears to be a real problem if media reports are anything to go by. At a very recent meeting, we were told that there was no real problem at all.
I ask the Minister to reconsider the position regarding medical cards. The Minister said in his statement: "Suffice it to say that my Department will be working closely with the HSE and with the assistance and support of the Departments of An Taoiseach and Public Expenditure and Reform to ensure that savings from these measures are maximised." This relates to medical probity. What that means is that very ill people who have held cards for years are being refused cards - their cards are being withdrawn. I hear of this happening on a daily basis and other colleagues, both on the Government and Opposition benches, have told me they find the same is happening.
As I came into this meeting earlier, I got notification that a card that had been withdrawn from a young chap, who is wheelchair-bound, with recurrent epileptic seizures, hyrdocephalus, cerebral palsy, spastic diplegia, who has a shunt in situand suffers from perennial rhinitis. An appeal was submitted against a refusal to issue him a medical card and the decision to refuse it to that young person with those various medical conditions was upheld. That is what medical card probity means in practice. I meet people with such cases on a regular basis, as do other colleagues. I ask the Minister to reconsider this issue and to pull back from the current position. It is a very serious situation for families and for individuals with serious medical conditions who are losing their medical cards.
The Minister has targets set for addressing delays in outpatient appointments but there are serious problems regarding the length of time people have to wait for outpatient appointments, particularly for orthopaedic appointments. This is a problem throughout the country. It is a problem in my area, both on the Waterford side and on the Limerick-Cork side. It is a national issue. Delays in orthopaedic appointments are a particular problem and I ask the Minister to clarify the position on this.

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Neville also indicated he wanted to speak.

Dan Neville (Limerick, Fine Gael)
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I raised with HSE at the last meeting the funding of the mental health services. An additional €35 million was allocated in 2012. Nobody was recruited that year and that allocation carried over into the following year. Therefore, that €35 million allocation was not spent. The following year an additional €35 million was allocated, which resulted in an allocation of €70 million for that year and over that period fewer than 500 were recruited. It is fair to say that only 50% of one of those allocations, €17 million, was spent. In the two years the Government allocated €105 million extra funding to the mental health services but the HSE did not use it. Is that a correct interpretation of what happened?

Jerry Buttimer (Cork South Central, Fine Gael)
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I will go through the Estimate. Are there any comments or questions on Vote 38 - Office of the Minister for Health, Administrative subheads 1 to 8, on subhead A.1 - salaries, wages and allowances? Are there any comments or questions on subhead A.2 - travel and subsistence? Are there any comments or questions on subhead A.3 - training and development and incidental expenses? Are there any comments or questions on subhead A.4 - post and telecommunications? Are there any comments or questions on subhead A.5 - office equipment and general and general external IT services? Are there any comments or questions on A.6 - office premises expenses? Are there any comments or questions on subhead A.7 - consultancy services and value for money policy reviews and subhead, A.8 - EU Presidency?

I should have said the Minister has an opportunity to reply if he wishes.

James Reilly (Dublin North, Fine Gael)
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I can do it at the end.

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Kelleher will have to leave to go to the Dáil to speak on an issue as he has to cover for a colleague. The Minister might like to reply.

James Reilly (Dublin North, Fine Gael)
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I am more than happy to oblige. Deputy Kelleher asked me when the transfer of the Vote will take place. The legislation has been published and it will take place on 1 January 2015. He mentioned the response times of ambulances and pre-hospital emergency care.

The national ambulance service provides pre-hospital emergency care and non-emergency patient transport. It has approximately 1,550 staff, more than 480 vehicles and a budget of €138.5 million. Committee members know from our previous meetings that we have reformed the system so that there is one centre over two locations for ambulance calls, getting rid of all the duplication, and we have brought in a range of intermediate ambulances for inter-hospital transfers, freeing up other ambulances from that work. In essence, we have made more ambulances available for acute emergencies and we have introduced the emergency response vehicle with emergency responders. This is to ensure the patient gets access to treatment as quickly as possible. These are highly trained paramedics who do an amazing job in saving lives.

Committee members were concerned about GPs and their patients. In an OECD report, of the countries that responded in 2011 Ireland's GPs were the fourth highest paid. In 2009, they were the highest paid. GPs do a great job and can meet most patients' needs. Just like the rest of the health service, the model of care needs to change. There is much work that GPs are currently doing that practice nurses could be doing. I would like to see two practice nurses per GP. They will have a major role in the future when we have chronic illness care based in the community. They will monitor that and will also be able to screen patients who come to see the GP, many of whom may not need to see the GP, leaving the more difficult clinical conundrums for the GP to deal with. The Minister of State, Deputy Alex White, will meet with the Irish College of General Practitioners, the IMO and the National Association of General Practitioners on Friday and they will start the consultation programme.

With regard to free GP care for those under six years old, any GPs worth their salt know the value of children to the practice and continuity of care. I cannot see them refusing these patients. They have no reason to refuse them because the pay on offer is what is currently available. As I have often said, research reveals that 1,000 GMS patients are worth €250,000 to a GP when we consider the ancillary benefits, including study leave, holiday pay, nursing grants and secretarial grants. At €50 per visit, 1,000 private patients amount to €125,000, as the statistics show private patients only visit 2.5 times a year. We all accept that many GPs do not charge the full price for return visits and do not charge the full price for two children coming at the same time. The income from the private sector is considerably lower, so it is very attractive from the point of view of GPs.

Jerry Buttimer (Cork South Central, Fine Gael)
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As recently as yesterday I met a group of GPs from a disadvantaged area in Cork. They are telling me a different story in that they do not have a sustainable private practice but a strong GMS practice. They said they were contemplating emigrating. They are a young couple.

James Reilly (Dublin North, Fine Gael)
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They may be saying that to the Chairman, but I am telling him the facts. All situations are different, but what is on offer is very attractive. If we extend GP care across the sector, we will be looking for a new GP contract focused more on prevention and chronic illness care than the current contract. Many of the procedures currently carried out in hospitals could be carried out in general practice. No one is suggesting it can be done without resources - they need resources - but I will not negotiate the new GP contract here; nor will the Minister of State, Deputy Alex White. I have yet to hear doctors say they are paid too much, even when I was wearing my old hat.

Jerry Buttimer (Cork South Central, Fine Gael)
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We know how the Minister got on there.

James Reilly (Dublin North, Fine Gael)
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With regard to consultants, it has always been the case that there are some geographical locations where it is difficult to fill consultant posts. Some specialties are difficult to fill and it is the same with nurses. At the moment we have an active campaign to recruit theatre nurses and intensive care nurses. We are told it is all related to salary, but nothing could be further from the truth. The starting pay for a consultant in the UK is £80,000, which is about €100,000. The starting pay on offer here is between €116,000 and €121,000. It does not stand up.

It was never my intention that the starting salary is what is offered to a returning professor of cardiology who has been in Toronto for ten years. No job works that way. If members say we are being unfair to those starting off, in virtually every walk of life people with more experience command a higher level of remuneration than those starting off. There is nothing surprising about that.

Deputy Kelleher mentioned Trolley Watch and said there were 410 people on trolleys. There are 327 people on trolleys, according to the INMO-agreed Trolley Watch. There is also Ward Watch, which counts people on trolleys in the ward and people in beds that they consider not to be appropriately placed. There are some minor disagreements about the numbers but the bottom line is that the Deputy cannot compare that figure - the combination of the two - because we did not have the second figure last year, the year before or in 2011, when we had 569 people on trolleys according to Trolley Watch. God knows how many more would have been on Ward Watch. There has been a real and sustained improvement and for that I thank the staff working on the front line, who have done an amazing job despite the fact that-----

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Kelleher must leave the meeting.

James Reilly (Dublin North, Fine Gael)
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I think that was the last point Deputy Kelleher raised, and we will see him later, no doubt.

I want to put on record our gratitude to the men and women who work in our health service. They are working in a different way under a lot of pressure. We are trying to change the system to allow them to work in a way that allows more people to be seen more quickly and to improve outcomes for patients. That is what we are all here to do.

Deputy Sandra McLellan asked where the figure of €113 million came from. I do not mean to be rude but I told the Deputy's colleague where it came from two weeks ago at this committee. It came from a report done from by PricewaterhouseCoopers on behalf of the primary care reimbursement service, PCRS, and the HSE project team. The report referred to a figure between €65 million and €210 million being available. The sum of €113 million is in the middle of that range. I am the first to acknowledge that the study carried the caveat that a more detailed examination of the PCRS database was required. That has since been carried out and that is why I asked for the validation process to be undertaken, involving the Department of the Taoiseach and the Department of Public Expenditure and Reform. Arising from that, the figure changed to €23 million. That still means many medical cards will need to be reviewed, but normal probity demands that this happen. When the Secretary General at the Department of Health and the director general of the HSE are before the Committee of Public Accounts, they will get the run-through on why probity has not been done if there are medical cards that people should not have retained. The focus is an exercise in accuracy. While cardholders are legally obliged to inform the HSE of a change in circumstances that may affect their eligibility for a medical card, the Comptroller and Auditor General recently highlighted that in 2012, of 1.8 million cards in existence, just 22 were returned voluntarily. Members can see that there is a need for probity. That is not to say we are not concerned.

I would like the details of the point raised by Deputy Seamus Healy.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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I have them here.

James Reilly (Dublin North, Fine Gael)
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I would appreciate that because it is not our intention that people in those circumstances, unless they have an astonishing income, should lose their medical card. Some people have huge incomes, notwithstanding the fact that they have tremendous difficulties to bear in life.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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This individual has had a card for 11 years.

James Reilly (Dublin North, Fine Gael)
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The point is-----

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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He has no income of his own, and there has been no change in family circumstances.

James Reilly (Dublin North, Fine Gael)
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If he has no income of his own it is not comprehensible to me how it could happen, we will have to look at that and I will be very happy to do so.

Jerry Buttimer (Cork South Central, Fine Gael)
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Will Deputy Seamus Healy supply the details later?

James Reilly (Dublin North, Fine Gael)
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This scheme was always based on financial hardship and discretion was shown when people had complicated, multiple medical conditions resulting in financial hardship. The resolution to all this is to introduce free GP care for everybody and address the needs of people who have disabilities or lifelong conditions and meet those needs outside a medical card. It is often to do with appliances and other things. The medical card has become a passport to other services because means testing is not being done.

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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Absolutely. This individual is in a wheelchair and has no access to repairs.

Jerry Buttimer (Cork South Central, Fine Gael)
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Deputy Healy can give the Minister the details after the meeting.

James Reilly (Dublin North, Fine Gael)
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The Deputy has made his point and making it ten times will not change it. Deputy McLellan talked about job cuts. People are leaving the service. In some instances they are not being replaced, in others they are. Last year we employed approximately 700 nurses. The moratorium is being done in a flexible way. We must change the skills mix. I have said it many times. We have consultants doing work that GPs could do, GPs doing work nurses could do, nurses doing work that health care assistants could do, and all of them doing work that allied health care professionals such as physiotherapists and occupational therapists could do. Just because a few nurses leave it does not mean they need to be replaced. It might be more appropriate to replace them with a health care assistant or physiotherapist. We also want to change the way we do general practice. Before the colorectal cancer screening service came in, only consultants did endoscopies; now they are done by advanced nurse practitioners, who are perfectly able to do them. It is about thinking outside the box and doing things differently, because if we continue to do things as we always have, we will end up with the same problem.

Deputy Seamus Healy raised the issue of agency costs. This is the third time and I fully acknowledge that we said we will get back to him. We will do it, but there is a difficulty. Globally the cost of an agency nurse is slightly less than a full-time employed nurse because of superannuation, sick leave, maternity leave and everything else. A non-consultant hospital doctor, NCHD, is more expensive, but not three times or twice as expensive. They are approximately 20% to 40% more expensive because I have to get the correct grade. A first, second or third year senior hospital doctor, SHO, or a first, second or third year or a specialist registrar are all paid different salary scales. We are trying to get that out of the system, which is proving a little difficult.

We have covered the specific medical card issue Deputy Seamus Healy raised. More generally, at the end of 2013 there were 2,018,162 medical cards and GP cards. That is more than ever before. In 2013 we expected it to go to 2.1 million. In 2014 we expect it to go to 2,277,845. We are extending the number of people who can avail of free GP care year on year and we will keep doing that until all our population is covered. That is a commitment from this Government to achieve that by 2016. I am not saying it will be easy. There will be tough negotiations with the Irish Medical Organisation, IMO. In fact, it will be consultation, because under competition law the IMO is prohibited from negotiating. That does not mean we cannot consult them and talk to them about the shape of a new contract that would meet the needs of their patients and support them in the excellent work they do. I have made the point that it is an income-based scheme, not a disease-based scheme.

Later tonight I will make a statement on outpatient waiting times. It will represent real improvement in the figures people have been bandying about over the last number of weeks. Orthopaedics is a problem area. We did not reach our target but we will put a plan in place to ensure we do this year. I promised we would try to ensure nobody waited longer than 12 months for an outpatient's appointment having seen his or her GP. Only in March were we able to validate the full extent of the numbers, 386,000, more than 100,000 of whom waited longer than a year. Despite the 8% growth in population and 10% reduction in staffing levels and a 20% reduction in the budget, members will be very happy to see the improvement that has been made. I do not have the figures here now. They are being finally validated to ensure we are not misleading anyone. In certain areas we did not reach the target and I am very happy to highlight them because I am not in the business of spin or perception but reality, because reality is what our citizens have to endure, so spin does nothing for them.

Deputy Neville mentioned the €35 million. He is right, many of the posts were not filled in 2012, but virtually all of them were filled in 2013. Many of the posts from 2013 were put in place and we are continuing to fill them. Some of them are highly specialised and it is difficult to pull people into the service. Many people who retired were in the mental health sector because, like the gardaí, they can retire at 55 because of the stressful nature of the job. Recruitment of a further 477 posts funded from the 2013 allocation has been slow to date but, as indicated in the 2014 plan, the posts and other developments relating to 2013 allocation of €35 million will continue and is targeted to be completed in the next quarter in 2014. At the end of November 2013 the recruitment process was complete or in the final stages for 395, or 95%, of the 414 posts approved in 2012.

We hope to catch up this year on the slow start. We surpassed what we sought to achieve for 2013 of itself by moving through many of the people. As part of the overall 2014 budget of €765.8 million, an additional €20 million has been ring-fenced this year for 250 to 280 posts in mental health services in line with the programme for Government commitment. The other €15 million will be made available next year. It is not as fast as Deputy Neville would like. He has always been concerned about this area. It is not as fast as I would like, but the recruitment has been problematic in certain areas. Many of the posts are not nursing posts but ancillary posts such as psychologists, counsellors, etc.

Jerry Buttimer (Cork South Central, Fine Gael)
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We will return to Vote 38: grants, subheads B1, B2, B3; other services, subheads C, D, E1, E2, E3, E4, F1, F2, F3, F4, G, H, I. We turn to Vote 39, a Vote of the HSE.

We will deal with the corporate administrative subheads 1 to 8. Do members wish to raise issues on subhead A1, A2, A3, HSE regions, subhead B1, HSE Mid Leinster; subhead B2, HSE Dublin north east; subhead B3, HSE south?

Séamus Healy (Tipperary South, Workers and Unemployed Action Group)
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When will the regional service plans be available?

James Reilly (Dublin North, Fine Gael)
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They will become available in two days, on Thursday, 30 January.

Jerry Buttimer (Cork South Central, Fine Gael)
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Subhead B4, HSE west. On subhead B5, grants to other health bodies including voluntary and joint board hospitals, may I ask the Minister when the HSE hopes to finish its investigation into sections 38 and 39 organisations?

James Reilly (Dublin North, Fine Gael)
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The investigation into section 38 organisations is nearly complete. We wrote to section 39 organisations some weeks ago. It may take some time as there are 2,600 organisations in total but we focused on the 360 odd that are in receipt of €250,000 or more from taxpayers' money.

Jerry Buttimer (Cork South Central, Fine Gael)
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We now come to other services, subheads B6, B7, B8, B9, B10, B11. Under the care programme, we have subheads C1, C2, C3. Under capital services, we have subhead D1, D2, D3, D4, subhead E. Does the Minister wish to make a final comment?

James Reilly (Dublin North, Fine Gael)
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I thank the Chairman and members of the select sub-committee for their time and contributions. We are all aware that we face a very challenging year. We have shown, by dint of the improvements in outpatient and inpatient waiting times and the emergency department trolley counts, that we are improving the service. I accept and acknowledge that it is not quick enough for many of our citizens, but as I have often said, health can be compared to a great tanker at sea and one cannot turn it around on a sixpence - for those who can remember the sixpence.

I thank the representative from the HSE, Mr. Tom Byrne, and Ms Fiona Prendergast from the Department of Health.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the Minister and his officials for their courtesy and their assistance to the committee. I apologise for the delay in starting the proceeding due to the vote in the Dáil.