Jerry Buttimer (Cork South Central, Fine Gael)
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I wish to remind members, witnesses and those in the public gallery to please ensure that their mobile phones are switched off or are on aeroplane mode so that the recordings of proceedings are not disrupted. Such phones can also interfere with the broadcasting of the programme.

This is our quarterly meeting on health issues. I wish to welcome the Minister for Health, Deputy James Reilly; the Minister of State, Deputy Alex White; Mr. Tony O'Brien, director general of the HSE; Dr. Fergal Lynch, acting deputy Secretary General, Department of Health; Mr. Fergal Goodman, acting assistant secretary, Department of Health; Dr. John Devlin, deputy Chief Medical Officer; Ms Joan Regan, principal officer; and Mr. Séamus Hempenstall and Mr. Paul Howard from the Department of Health. I also wish to welcome the following from the Health Service Executive: Ms Laverne McGuinness, Mr. Pat Healy, Mr. John Hennessey, Dr. Áine Carroll, Mr. Ian Carter, Mr. Stephen Mulvany and Mr. Ray Mitchell.

I have received apologies from the Minister of State, Deputy Kathleen Lynch, who has a family bereavement. Her father-in-law passed away and is being buried this morning. I am sure all members of the committee and others will join with me in offering our condolences to the Minister of State and to Deputy Ciarán Lynch, who is the son of the deceased person. I have also received apologies from Deputy McLellan, who has had to leave to attend another meeting, and from Deputy Robert Troy. Deputy Dowds has also had to absent himself from the meeting.

I apologise to the witnesses for the delay in starting. We had a private discussion on the issue of universal health insurance. It is fair to say that some members of the committee are concerned about being asked to discuss a policy which is perhaps not a matter of unanimity for the committee. We will revert to the Minister on that at a later date.

Before we commence, I must inform witnesses about the question of privilege. Witnesses are protected by absolute privilege in respect of the evidence they are to give to the committee. However, if they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings be given, and they are asked to respect the parliamentary practice to the effect that, where possible, they should not comment on, criticise or make charges against any person or persons by name or in such a way as to make him or her identifiable. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I wish to remind members that the replies to the questions they submitted are in their information packs. I ask them to refer to the question number when they comment on a question. Question No. 21 is a revised answer to Deputy Robert Troy.

At the conclusion of this meeting, we will be presenting to the Minister our committee's report on its pre-legislative scrutiny of the public health (standardised packaging of tobacco) Bill. Members who wish to attend the photo call are more than welcome to join us on the plinth.

I now call on an tAire to make his opening remarks.

James Reilly (Dublin North, Fine Gael)
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I thank the Chairman and other members of the joint committee for their invitation to attend this meeting. I am accompanied by the Minister of State, Deputy White. As the Chairman has pointed out, the Minister of State, Deputy Kathleen Lynch, could not attend because of a personal bereavement. Our sympathies are with her and also with Deputy Ciarán Lynch.

I will give my opening statement and then we can deal with any questions the committee may have. I will address the issue of the rare diseases centre, as members have requested. They have also asked for an update on the current position regarding section 38 and 39 agencies. Mr. O’Brien will address this issue is his opening statement.

As the committee is aware, I launched the White Paper on Universal Health Insurance yesterday. The White Paper underpins the Government’s resolve to deliver on the programme for Government's commitment to end the current unaffordable and unfair two-tier system and establish a single-tier health service under which access to services is based on medical need and not on ability to pay.

The Government is keen to engage with the public and stakeholders on this major policy reform of the health service. This gets to the heart of what we want from a reformed health service - accountability and transparency.

Yesterday’s launch of the White Paper is the beginning of a national conversation about UHI and the future of our health services. The Government is keen that this committee will be instrumental in enabling that national conversation to take place. I noted certain concerns in this regard in the Chairman's opening remarks. I want to make it quite clear that the Government would like to invite the committee to partake in this debate. The Government is equally clear, however, that this committee makes its own decisions and if it chooses not to partake in that conversation, that is entirely a matter for the committee. Personally, I think that would be a sad outcome because, under the Chairman's stewardship, this committee has proven to be extremely helpful and informative. The committee has also been calming in its tone previously concerning sensitive national issues, particularly with regard to the Protection of Life during Pregnancy Bill.

At the launch yesterday, we started a formal public consultation process. I would encourage everyone to engage in that consultation, and the easiest way to do so is through our website. The process is open for the next eight weeks to the end of May.

We will also be consulting separately on the future health basket, including the services to be covered under UHI. As important as it is to decide what will be in the basket, it is the value framework that underpins those decisions. Under UHI, everyone will be insured and will have equal access to a standard package of services, based on need and not on ability to pay. If that goal is to be achieved, we need to involve the people in the process. This committee will be invited to conduct hearings on the values which should underpin decisions on the future health basket. I must re-emphasise, however, that it is a matter for the committee itself as to how, or whether, it will be involved in this.

In relation to the basket of services, I will be establishing an expert commission in the coming weeks. The expert commission will advise on the basket of services and will take account of the values framework. This committee may consider those costed options and the Government will then make a decision on what goes into the basket. It is important to note that the commission will be consulting with the public; it will not work in isolation. This deals with the values of transparency and accountability.

The core value of UHI is equity: no preferential access based on ability to pay, and a system of financial support to pay for or subsidise the cost of standard UHI policy premiums for those who cannot afford them. People will still be able to pay privately for services not included in the standard UHI package, or purchase supplemental health insurance cover for these. However, insurers will not be allowed to sell insurance that provides faster access to services covered in the UHI standard package of care.

I will not go into all the details of the White Paper but I do want to talk about costs. Obviously, costs are a concern for this Government, stakeholders, families and communities. As Minister for Health, I want a health service that meets people’s needs but does so efficiently. Over the last few years, we have delivered significant savings to the Exchequer in our health services and we have managed to maintain - and, indeed, improve - services. For that I wish to thank the people who work in our health service, particularly those working on the front line.

UHI is part of the overall plan to ensure we can continue to deliver efficiencies over the medium to long-term. We have generational challenges to face, such as chronic diseases, obesity, tobacco and alcohol misuse – as well as continuing to provide acute and primary care today and tomorrow for our citizens. That is why UHI is so important, not just as an end in itself but as part of a series of interlinked reforms that will deliver a health service fit for the 21st century.

That is why, along with delivering on UHI, we are delivering on the money-follows-the-patient model, which is a more cost-effective way of paying for vital health services. It is why we launched Healthy Ireland, our strategy for improving the health and well-being of people in Ireland. It is why I am so deeply committed to making Ireland tobacco-free by 2025, as set out in Tobacco Free Ireland. I want to thank the committee for its great support in this regard.

At a practical level, along with these strategic plans, the White Paper sets out a cost control framework that will ensure affordability and keep costs to a minimum. The cost control measures included range from price-monitoring of insurers and setting maximum prices for health care providers to more aggressive measures such as capping insurer overheads and profit margins.

We have a job of work to do in estimating the costs before we implement the reforms inherent in UHI. This is only right and sensible. We must take into account not just the basket of services but the demand for and utilisation of health care, service delivery models, payment systems and regulatory and administrative costs. My Department will progress work in this area during 2014 for completion in January 2015. Only then will we proceed on foot of the approval of Government to draft legislation to give effect to the reforms set out in the White Paper. The goal is to introduce UHI by 2019.

If UHI is our final destination, the term "structural reform" describes the road we must follow to that destination. We have already made good progress with new HSE governance and management structures, establishing hospital groups on an administrative basis and establishing the Child and Family Agency. The Health Service Executive (Financial Matters) Bill, which I published in December 2013, provides for the HSE to be funded through the Vote of the Office of the Minister for Health and Children from January 2015. The Bill is on Second Stage in the Dáil and I expect enactment to take place before the summer recess. We will also be establishing new and revised structures for primary, social and mental health care. This will follow on from the recent integrated service area review carried out by the HSE. The next stage is the establishment on an administrative basis of the entities that will bring in the purchaser-provider split. We already have the Healthcare Pricing Office, which is attached to the HSE, while a new shared services division is up and running also. We will be working further on the health care commissioning agency, a patient safety agency and a national entity to promote health and well-being as well as the evolution of hospital groups into trusts. We will also be putting the revised primary and social care delivery system on a statutory footing.

To reassure the committee, I note that the Healthcare Pricing Office will be independent. While it is currently operating on an administrative basis, legislation will be brought forward to underpin its absolute independence. It must be seen as independent if it is to be able to do its work. My Department is preparing legislation to set up the new structures on a statutory basis and I have put in place a high-level steering group led by the Secretary General to oversee the process. The third and final phase of structural reform will see a move to a combination of universal health insurance funding for acute hospital and certain primary care services, with general taxation funding for other services including social care services such as disability and long-term care. At that point, the Healthcare Commissioning Agency will divest some of its purchasing functions to health insurers under UHI.

I have mentioned the importance of health and well-being and, in particular, tobacco control. We are ten years on from the implementation of the workplace smoking ban, which research has found has resulted in over 3,700 fewer smoking-related deaths. This is indisputable evidence that tobacco control measures are saving lives and improving our overall health as a nation. The measures which have been put in place have worked. There has been a decline of 7.5% in the number of Irish adults smoking since the last large-scale study in 2007. Our work will continue. We are aiming for a smoking prevalence rate of less than 5% by 2025. We propose to introduce a tobacco licensing Bill to provide for a licensing system and other measures in relation to the sale of tobacco products. I was very pleased that we received approval from Government last November to proceed with a public health (standardised packaging of tobacco) Bill. I thank the committee again for its valuable contribution in that area and in advance for the assistance it will provide to me and my officials in introducing the legislation. We will not be complacent, however. We cannot afford to be in any sense. We are saving money but, more importantly, we are saving lives. We know we face the mother of all battles with the tobacco industry, which has enormous resources at its disposal. We will not be intimidated by any external entity when it comes to public health issues and, in particular, the well-being of our children.

The committee has asked that I address the issue of a national office for rare diseases. Rare diseases place a significant burden on patients and their families. The important work of developing the national plan for rare diseases continues, and the plan is close to being finalised. The policy framework relates to the prevention, detection and treatment of rare diseases based on the principles of high-quality care and equity. It will be patient-centred. The plan we implement will deal with the prevention, diagnosis and care of people with rare diseases, enhancing access to orphan drugs and technologies, responding to the needs of patients with rare diseases and their carers and research into the area of rare diseases. My Department's steering group is also considering for its report the development of a national office for rare diseases, the purpose of which would be to facilitate and support the HSE in the coordination of centres of expertise for rare diseases nationally and internationally. Such an office could act as a national point of reference on services, diagnostics, care pathways and information relating to rare diseases.

The report by my Department on recommendations for dealing with rare diseases, including the establishment of a national office, is being finalised. Departmental officials have met with the Health Service Executive to discuss the implementation of the report. In the meantime, the HSE is developing a business case on the establishment of such an office. The HSE has established a national clinical programme for rare diseases. A national clinical lead has been appointed and a programme manager is in place. The programme aims to improve and standardise patient care for individuals affected by rare diseases in Ireland by increasing detection and prevention, facilitating early and timely diagnosis, intervention and coordination of care and increasing awareness, information and support. The programme has already started to map out current services and develop care pathways for patients with rare diseases.

Many of the reforms we have introduced to date represent the building blocks for universal health insurance, which is our ultimate goal. The underlying principle will always remain that of better outcomes for patients. That is our business.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the Minister. I welcome the director general of the Health Service Executive, Mr. Tony O'Brien.

Mr. Tony O'Brien:

I appreciate the invitation to attend the committee. The other members of my team have already been introduced by the Chairman. I note that the committee requested information and will have received a written response from the HSE and the Department of Health and Children. I will therefore confine my opening statement to updates for the committee.

Members will be aware of last week's television programme on the National Ambulance Service, or NAS, and I would like to clarify a number of points in that regard. The programme placed considerable focus on officer response vehicles, or ORVs. These vehicles and the officers who operate them - all of whom are paramedics or advanced paramedics - are available to respond to emergency calls as and when required. During the period January to March 2014, ORVs carried out 629 emergency call-outs, of which 252 occurred outside the normal working hours of the relevant officers. The NAS has recently commissioned a national capacity review which will utilise a modelling provider with extensive international experience of modelling ambulance operations. The review will analyse current ambulance vehicle numbers, call cycles and response time performances. Additionally, the review will examine current and projected resourcing levels for emergency ambulance cover, intermediate care and ORVs. Overall, the review will determine the level of resource required across the country.

Despite statements in the programme referring to cutbacks in the NAS, it is important to understand that despite cutbacks in other areas of the health services, the budget available for the National Ambulance Service increased by 4.3% between 2012 and 2013. There is a further increase of 2.6% in the 2014 allocation to the service. I note that €9.3 million was spent on NAS vehicle equipment and vehicle replacement in 2013, while a further €7.5 million is set aside for 2014. This has resulted in the purchase of replacement vehicles as part of the fleet modernisation programme, including 27 emergency ambulances, 25 intermediate care ambulances and 27 rapid response vehicles. It is planned to purchase a further 35 emergency ambulances this year. A total of €26.2 million is being invested in the development of a single national control centre which will operate at two sites, one in Tallaght and the other in Ballyshannon. It is also planned to spend €4.6 million on a national defibrillator and mechanical CPR purchase programme in 2014. Since 2008, the number of staff in the NAS has increased by 16%.

This is despite a significant reduction in staff in the wider health services.

At the end of 2014, it is anticipated that the complement of advanced paramedics will be 300, an increase of 400% since 2008. The NAS has also trained approximately 300 paramedics since 2008, as well as recruiting and training approximately 70 emergency medical technicians, EMTs, during 2013 and proceeding to recruit a further 20 paramedics during 2014. In addition, the Emergency Aeromedical Service has completed 556 missions since its inception in June 2012 to February 2014. In 2013, the Irish Coast Guard also performed over 300 helicopter missions in support of the NAS and will continue to do so in 2014. The HSE and the NAS are fully committed to and will continue to invest in services to ensure the best outcome for their patients in addition to the investments towards improvement which are already under way across the service.

On the eight overall recommendations specific to the HSE in the recent report on maternity services at Midland Regional Hospital Portlaoise, I will update the committee on the following key actions that have been undertaken to date. The staff at the hospital have apologised unreservedly to any families who experienced care below the expected standard. On behalf of the HSE, I reiterate that apology. A new management team was appointed on 28 February on an interim basis to run the hospital’s maternity service. Dialogue has already commenced with the Coombe Women and Infants University Hospital to provide support to the Portlaoise maternity unit in a collaborative working arrangement. The HSE is implementing its policy on open disclosure, while a full diagnostics review is under way at the hospital. The HSE has issued a directive to all health care providers requiring them to notify the director of quality and patient safety and HIQA, the Health Information and Quality Authority, of all key risk events.

Other cases that have become known to the HSE since the airing of the television programme where families were not treated in a sufficiently compassionate manner by the hospital’s maternity service are being dealt with by the new management team and the regional director for performance and integration.

The 2014 service plan highlighted that the health service faced a severe financial challenge in 2014. As of the end of January, the HSE is not flagging any new concerns or risks beyond those which were clearly set out in the national service plan. On 31 January, the HSE showed expenditure of €999.5 million against a budget of €975 million, representing a variance of €24.5 million. A material proportion of this variance, €20.2 million, is in the acute hospital sector, with €5.9 million, or 29%, of the acute deficit relating to hospital income generation and €10.1 million, or 50%, relating to agency staffing levels. Up to €4.2 million, or 41%, of the acute variance relating to agency staffing is in the medical category, which relates to the growth in NCHD agency costs. However, it should be noted that there remains a significant issue nationally relating to the recruitment of NCHDs, which is driving agency expenditure in certain hospitals.

As well as the wider performance management of the acute system in 2014, a more targeted approach with individual poorer performing hospitals is now being undertaken. The acute system is facing a challenging year, with legacy deficit issues to be addressed and with hospitals expected to meet the full value of cost containment plans unachieved in 2013 of €56.5 million. This is in addition to the full value of savings measures that are to be delivered in 2014.

There is an emerging issue with private health insurance income, and the HSE has identified an increase in claims being pended for payment by insurers. This issue has been highlighted to insurers and the HSE is actively engaging with them to reduce the lead time from submission to payment of claims. This will improve the overall cash position.

Overall in January, the data with regard to activity against the service plan shows that the health service has seen an increase in new emergency department attendances of 3%, or 2,261 people, and a 3% increase in emergency admissions in January of 2014; a 34% reduction was achieved in the number of emergency department patients waiting on trolleys for ward-bed accommodation between January 2011 and 2014; and day care attendances were 2% lower, at 1,100, than in January 2013.

The health service saw an overall improvement in adult waiting lists in January 2014. At the end of the month, 96% of those on waiting lists, or 41,251 adults, were waiting less than eight months for a planned procedure, as compared with 94% in the same period in 2013. There were 1,764 adults waiting over eight months at the end of the month compared to 3,073 in the same period in 2013.

During the 12 months of 2013, the ambulance service responded to more than 281,000 emergency calls in the AS1 and AS2 categories, a significant increase of 14,000 over 2012. The number of people covered by medical cards as of January 2014 was 1,840,760, or 40.1% of the population. Included in these numbers are 50,505 medical cards granted on discretionary grounds. The total number of general practitioner visit cards as of January 2014 was 125,930, including 27,204 cards granted on discretionary grounds. There are 46,513 clients in receipt of a home help service and 11,969 clients in receipt of home care packages. There are 22,959 clients supported by the nursing home support scheme, NHSS, with 4.1% of the population, or 21,880 people aged over 65 years, supported in either NHSS or saver beds.

The process which has been ongoing with the section 38 agencies to reach compliance with the Government’s pay policy is nearing completion. Since the beginning of the year the regional directors for performance and integration, with support from regional human resources, have been working with each agency through a further process of verification and clarification where a deviance from pay policy was previously recorded to ensure full implementation of the provisions of the pay policy and assist the agencies in reaching compliance. In line with the pay policy, and as part of the ongoing process of reaching compliance, organisations seeking to make a business case for the continuation of an unapproved allowance were invited to submit their business cases for consideration by the HSE. Business cases were also required for the continued payment of allowances which are not encompassed by or in line with the Department’s consolidated salary scales but may have been sanctioned in the past. A total of 202 business cases have now been received. An internal review panel, comprising nominated members of the HSE leadership team, has reviewed each business case in detail and is in the process of making a decision on each case. A report will be published shortly. Up to 143 business cases were received in respect of senior managers - those at a salary level of grade VIII and above - for consideration by the panel. In addition, 59 business cases in respect of salary levels below grade VIII have been reviewed at operational level by the regional directors for performance and integration. The process is nearing completion, following which we will be in a position to provide a full report on the outcome of the compliance process. It is important to note that as a result of the co-operation received in reaching compliance with the pay policy, no agency received a reduction in cash funding.

Turning to section 39 agencies, since the introduction of the national standard governance framework with the non-statutory sector, the HSE has been continuously reviewing and strengthening these arrangements in accordance with the requirements of sound governance and accountability and to ensure they are aligned with the ever-changing exigencies of our health and personal social services. One such enhancement was the introduction in 2013 of a requirement for all agencies covered by a service arrangement, under either section 38 or section 39, to complete a template setting out details of the remunerative arrangements for senior managers - grade VIII and above. The HSE is close to completing a template for verification and validation of service managers’ remuneration in the larger section 39 agencies - namely, those which receive in excess of €5 million in funding annually from the HSE. A report will be finalised by week commencing 14 April, which will be available to the committee.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. Tony O'Brien for his very comprehensive report, and I thank him and his staff for the work they do in the delivery of health services.

Without naming specific agencies, will he give the committee a sense of a business case for a section 38 or a section 39 agency?

What is allowed for in the business case?

Billy Kelleher (Cork North Central, Fianna Fail)
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I thank the witnesses for their presentations. I may have to leave at some stage before the witnesses might get to my questions but I will be observing their responses from my office. The Minister outlined his pathway to universal health insurance yesterday. We welcome the publication of the White Paper which will hopefully stimulate some form of discourse and broader debate about how we fund our health services. The Minister has decided to go down the route of universal health insurance. This will not necessarily meet with universal support. However, it will stimulate some form of debate.
We are all prone to platitudes and self-appreciation from time to time but I do not believe that what was announced yesterday was earth-shattering. There is nothing very new in it. It was a case of defining what the Minister already said on previous occasions. That is not a criticism, rather it is an observation. The work that must be done on universal health insurance relates to the basket of services and types of cover. The more cover is included, the more expensive universal health insurance will be. It should cost the same to the State but cost to individuals is an issue that will be discussed. The more we include in that basket of services, the more expensive it is going to be for some individuals. That is a key issue that must be discussed.
The Minister said that he is putting building blocks in place. When putting building blocks in place, any handy builder or project engineer would also have a rough idea as to the actual cost of the various materials going into that project. Assessing how much a project will cost is basic due diligence. The difficulty we have is that there seems to be no view as to what it will cost. It depends on many assumptions. If we want to have a proper debate, we need to get down to some harsh realities with regard to how much this will cost and we cannot make assumptions about what will happen in 2019. We must assess what it will cost based on what we have now as opposed to hoping that down the road, taxation-based policy will be friendlier to universal health insurance or that certain events will address it. If we want to have a genuine up-front debate for everybody, not just politicians in this room, but the public, the least we should do is decide a basic suite of services and what that would cost, which could be done quite quickly. This does not necessarily mean that this will be the actual suite of services that we decide on but there is a matrix there and the Government can work it out. The problem is that if it works it out, it will find that it will be a bit more expensive than it thought it would be. We could try to look at that but it is probably for another day.
For fear the Minister would take us up wrong - I am not saying he did so intentionally - the committee will play its part. The fact that members are from different political parties who may have differing views on universal health insurance does not mean we will obstruct the passage of it. We fundamentally do not agree with the policy. If legislation flows from that policy we will co-operate as legislators like everybody else. We are not going to be outside the door with placards opposing it but we will use whatever means we have to explore other avenues regarding how we fund health services in the years ahead.
In respect of broader issues surrounding medical cards and primary care mention has been made of primary care and free GP care for the those under the age of six and moving to universality over the next number of years. There is a major problem which I said I would bring to the Minister's attention because he does not seem to accept that there is a problem. A number of meetings are ongoing around the country. GPs are attending in large gatherings and highlighting the huge concerns they have. It is not just in the context of the under-sixes contract, although there is no doubt that this was the catalyst in terms of bringing them together. Even prior to the publication of the contract for free GP caver for those under six years of age, many people were saying that there is a major crisis with GP services in this country. There have been recent cases where GPs have passed away, the HSE has advertised and nobody took up that GMS practice. If this is happening, the Government has a problem. We are now having difficulties in maintaining GPs in the country, which is a key issue.
When the Minister refers to the roll-out of primary care as a critical plank in reducing admittance to acute hospital sections, at the very least, there should be some quid pro quoincrease in budget over the next number of years. There seems to be no concept of how the Government is going to fund primary care other than it being lauded every day and the strategy since 2001 being rolled out on a continual basis as being a central plank in the delivery of health care in the least complex and least expensive setting. We all agree on that but there is no commitment to making sure that it is working in a way that is sustainable not only for the individuals providing the service but collectively for customers, patients, clients, GPs and other allied professionals.
How much time do I have left?

Jerry Buttimer (Cork South Central, Fine Gael)
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I will give the Deputy between eight and ten minutes.

Billy Kelleher (Cork North Central, Fianna Fail)
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There is a reduction in the number of medical cards. We can assume this is because of two things - a drop in unemployment and a number of people emigrating. We are not quite sure but we hope that it is primarily due to a take-up in employment figures. What is disturbing is that we are now down to 50,501 discretionary medical cards. Over the past number of years, the Minister has consistently said that there has been no real change in policy. I must beg to differ. I raised this issue last week in the Dáil and I want to say it again, not only in front of the Minister but in front of the HSE officials who are supplying the Minister with the answers to these parliamentary questions, which are answered up-front by and large. There has been a change in policy. The Minister even tried to pretend that the word "discretion" had been removed from the lexicon of the HSE in terms of assessing medical cards. This word had been used for years in accounting in respect of the HSE budget. It has been used in the service plan for the previous number of years but all of a sudden, there was an effort to remove the word "discretion".

In response to a parliamentary question I tabled, I was told that there was no such thing as a discretionary medical card but that is not the case. At one stage, there were over 90,000 of them in the country and we are now down to 50,501. Week in, week out, organisations who consistently represent and advocate for individuals, families and cohorts of people with very profound disabilities and illnesses consistently say that their members are having their discretionary medical cards withdrawn. Regardless of whether one describes it as an entity or otherwise, it is still a fact that many families are encountering huge difficulties. Even in recent weeks, organisations representing people with Down's syndrome have said publicly that there has been a blatant attempt to reduce the number of discretionary medical cards issued to their members. That is something with which we must deal.

Mr. O'Brien referred to the National Ambulance Service, the NAS. We could talk indefinitely about this issue, which needs to be addressed. There is now a pretence from the Minister, officialdom and the NAS that no problem exists. People representing those working in the NAS appeared before us a couple of weeks ago. There was almost a pretence on the part of union representatives at the top that no problem exists. The "Prime Time" programme has exposed what we all knew was happening. Week in, week out, we are having major difficulties and are continually hearing about the lack of response times and the fact that we are now pretending we have a NAS that is in some way meeting the guidelines that have been laid down by HIQA.

We should examine the situation regarding ORVs. It is amazing that Mr. O'Brien can come in here and say that in the first 90 days they were called out 629 times. Let us be very clear. The fact that these very expensive vehicles are driving around the country and are unavailable to deal with emergencies should be examined. However this is just one item of the malaise at the top echelons of the NAS. The NAS is under-resourced and to pretend it is not is an insult to the professionals who are trying to provide a good service and, more importantly, the many people who depend on that service, some to their detriment in terms of injury and loss of life.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome, the Minister for Health, Deputy Reilly, Mr.O'Brien, their colleagues and the Minister of State, Deputy White. The response I received to my first question on the ambulance service, which I heard again in the Dáil this week, does not equate with the reality I know. The NAS is not safe, responsive or fit for purpose. Those are the facts and it is a very widespread view and experience. I do not base my view solely on the recent "Prime Time" programme. It is underscored by a series of information flows recently. I refer to the experiences of and representations made to individual Members of the Oireachtas. I have never referred to it before. I was angry, to put it mildly, about the Minister's retort to me in the Dáil this week. Despite the experience of individual Members he resorted to name-calling and rejectionism without facing the facts.
In January I had a heart attack a quarter of a mile from the local ambulance station, yet the ambulance came from Virginia, County Cavan, more than 40 miles away, to the doctor's surgery where I was waiting to be taken to Cavan General Hospital. There is another ambulance station 15 miles away. The GP and nursing staff in the clinic were incredulous at the delay and it was a continued issue of concern to them. That was not my first such experience. I have been fortunate twice. As a consequence I had further stents inserted the following morning.
I do not question the ambulance personnel, who are the most professional people in carrying out their function. They also make the points I am making today. It is not just me reporting this. They have recently come before this committee and outlined the situation they contend with. It is a very serious matter. They have made detailed submissions to us via their union and membership representations. We have other media investigations and reports, including the series by Kitty Holland in The Irish Times. All this evidence must be recognised as a serious attempt to bring to light real and significant failings within this service. The responses in the Dáil this week do not acknowledge the reality and the deep fears of so many people. I could add further personal experience from my family of a less favourable consequence regarding an ambulance call-out before Christmas, but I will not.
We are not just discussing statistics. We are talking about a situation in which lives have been lost. People believe that had the ambulance arrived within the expected time there would have been a chance that they might have been able to save their loved one. Nobody is foolish enough to say they would have been saved in every situation, but they might have been saved. That is a very serious matter for people to live with and contend with for weeks, months, years and perhaps a lifetime afterwards. I am deeply worried.
Do the Minister and the HSE agree that a figure of only one in every three people with life-threatening conditions being responded to by the ambulance service within the set target time in 2013 is acceptable? Surely those figures must prompt emergency action. Will the Minister undertake a comprehensive capacity review of the ambulance service with a view to enhanced provision across the State? Will he require the HSE to cease the current process whereby it is trying to take over the Dublin Fire Brigade ambulance service provision, which operates more effectively and with greatly superior adherence to call-out times than the NAS throughout the rest of this jurisdiction? Here in the city of Dublin this is a very serious matter. The people of this city have no faith, only fear, about the prospect of the Dublin Fire Brigade ambulance services being subsumed in the HSE and the NAS. There is no confidence in it and it is not a runner when the NAS provision is clearly failing. Will the Minister and Mr. O'Brien establish a national ambulance authority? We need a national ambulance authority outside the remit of the HSE.
My second question is on the shortage or nurses. A study by The Lancetjournal, which included this State, reported that for every patient added to a nurse's workload the chance of dying within a month of surgery increases by a shocking 7%. While that is incredible, it is not disputed. The survey included 420,000 patients. It was not pulled out of the clouds. In January the Irish Emergency Medicine Trainees Association, IEMTA, stated that overcrowding in our hospital emergency departments was unequivocally dangerous for patients. Do the Minister and the HSE accept that with a growing and aging population we cannot sustain safe services with over 5,200 fewer nurses within our service since 2010? Those are the figures. We have 13.5% fewer nursing staff across the services since 2010. Do they accept that there must be a significant recruitment drive to ensure safe staffing in our hospitals? We are training nurses for export. We need them within our own services to ensure the safest possible provision of care.
My last question is on the Minister's reply on the national plan for rare diseases. He stated that his Department's steering group is also considering for its report the development of a national office for rare diseases.

The committee is certain that the establishment of such an office is essential. Will he qualify "also considering" and give us the certainty regarding that intent?

Jillian van Turnhout (Independent)
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I welcome everyone. With regard to the questions I tabled, I would like to follow up on question No. 9 about the HSE's national oversight group and day service or rehabilitative training places for young adults with a disability. The reality is every year between 650 and 700 young adults with an intellectual disability or autism leave school. They are viewed every year as new people in the system as if officials do not know they are coming into it. There is an annual issue over where the funding comes from to provide places for them. Similarly, 700 young people leave rehabilitative training every year and where they go and where the funding comes from is also an annual issue. As budgets have been cut back, the services providers affected have said no additional funding is available for school leavers and, therefore, they are falling into this limbo because they are considered to be new clients. No funding was made available in 2012 while €4 million was made available in 2013 and I am advised by service providers that this was not nearly enough.

I was disappointed with the reply I received. It mentions the membership of the national oversight group. Will the Minister outline the membership? Reference is made to a service user representative. I contacted several disability groups and they did not know that such a representative is on the group. They do not even know who is on the group. Will the Minister publish a list of the members of the oversight group? I am also disappointed that there is no mention of the New Directions policy, which is his policy for the provision of day services and supports to adults with a disability. This recommends a move away from centre-based segregated day services. Given post-school supports are day services, it is strange that the New Directions policy is not mentioned.

The second issue I wish to raise relates to question No. 10 about the pre-hospital emergency care council and allowing pronouncement of death by advanced paramedics. This came up in the committee's end-of-life care hearings. I welcome that the Minister is examining the issue through the Forum on the End-of-Life in Ireland but I remind him of the urgency of this issue. During the hearings, Professor Patrick Plunkett, a member of the council from St. James's Hospital, outlined to us that in cases where the patient has suffered a cardiac arrest, there is a natural reluctance on the part of the pre-hospital emergency care providers ambulance personnel to pronounce death in the home, which leads to ongoing resuscitation efforts and pronouncement of death in the accident and emergency department. This leaves the department's team to deal with the process of informing relatives and their grief, the logistical difficulties of identification and referral to the coroner. Dr. Geoff King also told the committee about how they cannot pronounce death and they must remain at the scene for ten minutes or an hour or until the next day, which is wasting time. I wonder if this contributes to our ambulance service issues because staff are waiting for a pronouncement of death at the scene. We were given vivid descriptions about staff who seemed to be resuscitating somebody they knew was dead. We need movement on this. I welcome the steps being taken but this issue was raised by several groups during our hearings.

The final issue I would like to raise relates to question No. 11 about the Children's Rights Alliance report card which gave the Government a worrying E grade on mental health services. The response I received states, "While noting the contents of the recent report card by the Children's Rights Alliance on mental health services, real and significant improvements have taken place". The Government went from a D grade to an E grade on mental health services. There was no urgency in this reply. I could have received this reply a year or two years ago. Will the Minster provide an update? At the previous quarterly meeting, I asked about a protocol between the Child and Family Agency and the child and adolescent mental health service and I was told that would be produced within days. Is it in operation? I have not heard any details since. I am advised by social workers that they are finding it hugely difficult to access child and adolescent mental health services.

In November 2012, the HSE issued an access protocol for 16 and 17 year olds to mental health services, which stated: "From 1 January 2013, CAMHS will accept referral of all new cases up to their 17th birthday and from 1 January 2014, where feasible, up to their 18th birthday". However, last year there was an increase in cases with 16% of cases involving 16 year olds. A protocol was put in place but the position is getting worse. More young people are entering adult services when they should be entering child services. Five children under the age of 16 were put into adult psychiatric wards between January and September last year when everybody agrees this should not happen. Service providers say places are available but they are not being accessed. Does legislation need to be introduced for this to happen?

We are all supportive of the Minister's initiatives on tobacco. What is the position on the smoking in cars with children Bill initiated by Senators Crown, Daly and myself? Will it be taken in the Seanad next week to complete its journey there?

James Reilly (Dublin North, Fine Gael)
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I thank the members for their questions. Deputy Kelleher made a number of comments. The publication of the White Paper is a key and important step along the road to UHI. It allows for a public conversation to take place and I hope that everybody will engage in that because it is our health service and we all need to be involved in the shaping of its future and the implementation of what I believe to be a more equitable, fair and affordable system than the one that has evolved over decades in a rather chaotic fashion. I refer to building blocks, money following the patients, the directorate, the hospital groups, new GP contracts and access to free primary care, which the Minister of State, Deputy White, will address in a more detailed way but I acknowledge that people are focused now on cost. I reiterate that it is impossible to say what the cost will be in 2019 when we have not even determined what will be in the basket of services. It is important that we have a public conversation around that because it underscores the very values of our society. I believe in a republic that all people should be cherished equally and that everybody should have access to medical care based on their medical need, not what they can afford to pay and I believe most right minded people support that.

People are fixated on the issue of cost. I cannot predict what will happen in 2019 with certainty but I can say what it would have looked like in 2013. I refer in particular to a newspaper article today which states families face huge bills for universal health cover. An individual - he is not here to defend himself and, therefore, I will not mention his name - states that there will be no subsidy for the 40% of people who are currently covered by a medical card - but they will be fully subsidised by the Government - and the top 30%. Clearly the gentleman did not hear me and some of those who wrote the article and who attended the press conference yesterday did not hear me. I made it clear there, here and elsewhere that there will be a considerable subsidy for families in that group and they will be the big winners in this because not alone will they have affordable health insurance, they will have access to free GP care at the point of delivery and a range of services that will be developed through our primary care initiatives locally.

Last year the average premium was €920. If the proposed UHI efficiencies were in place last year that average premium would have been lower in any event. However, the State would have paid for all those people on medical cards and it would have subsidised considerably those on lower incomes - the very group this paper suggests will not get any subsidy at all. So it would be a fraction of €920 and it will not cost families thousands of euro or anything like it.

That debate will continue. I have clearly said we need to have this conversation. We need to continue to make the progress we have made. I again thank the front-line service and all involved for making this progress in the context of a 20% reduction in budget, 10% reduction in staff and 8% growth in population. Deputy Ó Caoláin made the point that with an ageing population things will just get worse. He is right that with an ageing population things will just get worse if we leave it as it is, which is why we must change it from a hospital-centred service to a primary care-centred service where 90% to 95% of patients' needs can be met. The focus must move from episodic illness cover to prevention and secondary prevention - the care of chronic illness such as diabetes, asthma and other conditions.

I look forward to that debate and having a wide discussion. With the commission having reported hopefully by January of next year we will be in a position to bring it to Government to make a decision on what should be in the basket and at that point in time the average costs will be considerably clearer. However, we need to continue to drive down costs. We have done that in the public sector; it has yet to be done at all to my satisfaction in the private health insurance market, but it will be done. Pat McLoughlin's group is working on that with the insurers.

The VHI, as the biggest payer out for insurance with 80% of the market, is considering how it can address this issue through clinical audit of what we are paying and benchmarking what we are paying for the procedures we pay for. It is also looking at how many of them are being done that should be done and how many of them are being done that should not be done. Members have heard me speak previously about an individual who took €1 million from one insurance company here a few years ago.

All those issues need to be addressed. In addition reform of the Department of Health is taking place. All these things form part of the roadway to get to universal health insurance and give better outcomes for all our people and all those who need our health service.

Deputies Kelleher and Ó Caoláin raised the issue of the ambulance service. Yesterday I did not call Deputy Ó Caoláin names but did I accuse him or shroud waving, as he has done in the past. Again today he is talking about only a third of people with very serious illness getting the ambulance on time. I will let Mr. O'Brien respond to that because it is factually not correct. I am very sorry to hear that the Deputy was ill earlier this year. I am glad to see he is in good stead and that he had the medical care available to him in his doctor's surgery. I want to come to that key point.

There has been too much focus on how quickly the ambulance gets there, although that is important. I do not deny that nor do I deny that we need to do much more to improve our ambulance service. That is critical, as everyone here would accept - I certainly accept it. However, what is really important is that the patient gets the care as quickly as possible, which is why the responders, the first responders, the paramedics, the advance paramedics, the response cars and motorbikes are so important in this respect.

I can accept that Deputy Ó Caoláin has had experiences personally and among his in his family which I am very sorry to hear about. As a Minister, overseeing a service, I must bring that service up to speed - and we are doing that. Mr. O'Brien has outlined the number of new vehicles on the road and that we now have new vehicles for inter-hospital transfer thus freeing up our emergency ambulances to do the emergency work. The volume of calls has increased and an amount of money has been invested in recent years and will continue to be invested.

We have targets for response times. While I do not want to be over-political about it, when Deputy Kelleher raises the issue of response times, I remind him that his party had 14 years in government and did not even have a target. I do not even know if HIQA had reported at that point of time-----

Billy Kelleher (Cork North Central, Fianna Fail)
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I remind the Minister that he has had four years in government.

James Reilly (Dublin North, Fine Gael)
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No, it is three years and a couple of weeks.

Billy Kelleher (Cork North Central, Fianna Fail)
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However, this is his fourth year.

Jerry Buttimer (Cork South Central, Fine Gael)
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Members should address their comments through the Chair.

James Reilly (Dublin North, Fine Gael)
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That is classic Fianna Fáil-----

Billy Kelleher (Cork North Central, Fianna Fail)
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This is a health committee not a history committee.

James Reilly (Dublin North, Fine Gael)
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That is correct.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will chair the meeting, thank you. I respectfully ask all members and witnesses to make any comments through the Chair.

Billy Kelleher (Cork North Central, Fianna Fail)
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How many years is it, Chairman?

Jerry Buttimer (Cork South Central, Fine Gael)
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It is just over three, not four.

James Reilly (Dublin North, Fine Gael)
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Through the Chair-----

Billy Kelleher (Cork North Central, Fianna Fail)
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It is the Government's fourth year.

James Reilly (Dublin North, Fine Gael)
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Could I make an observation, through the Chair?

Jerry Buttimer (Cork South Central, Fine Gael)
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Thank you, Minister, would you address------

James Reilly (Dublin North, Fine Gael)
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That is a classic Fianna Fáil tactic to digress from the topic on to something else.

The reality is that we have an ambulance service with extremely well-trained people and some very good equipment. We have invested in training, personnel and equipment and we will continue to do that. Should I go back to President Bill Clinton's comment? Is Deputy Kelleher's problem that it is taking me so long to clean up the mess his party left? We are working on this. The people in the service are working it. Mr. O'Brien and his staff, including Ms Laverne McGuinness, and Mr. Martin Dunne who is the head of the service are all working on this to improve it. It is not by any means where we would like it to be but we are making progress. I will let Mr. O'Brien and Ms McGuinness go into this in greater detail.

The same is true with our emergency departments. Of course there is still some overcrowding and I am not happy about it. However, I have to be realistic in what I ask of the staff who work in our service in terms of making the progress we have made. We have made huge progress at a time when we have reduced money and reduced staff. When we had loads of money and quadrupled out spend between 1997 and 2009, we ended up with the greatest mess ever in 2011 before the Government came into power.

I am asking people to be patient. I know it is difficult particularly when one's own loved one is sick, unwell or in danger and it can be very hard to have patience with the system. I think most people will acknowledge that in the main - not always, sadly - patients in our hospitals get excellent treatment, as good as anywhere in the world. When I was in America around St. Patrick's Day in order to promote the country and tourism and also to explore getting partners for our new hospital groups, I went to some of the top clinics in America and every one of them had Irish doctors and nurses, and they were right at the top. So we have the best people; we train them to the best standard and they rise to the top of the very best institutions in the world. I know some people will ask why we cannot keep more of them at home. That is why we have a review group looking at the workload and career prospects of non-consultant doctors to try to keep them here. I heard Deputy Ó Caoláin's comment about our nurses; we want to keep them here also.

However, all this takes time. In all these reforms as we peel back the layers we find more and more legacy issues to be dealt with. We will go through it until we get to the core and fix it. We will do so, particularly with universal health insurance in mind with the full involvement of the people who will have their say in how we shape our new health service.

In response to Senator van Turnhout, I will certainly ensure that the names of the oversight committee are made publicly available; that is a no-brainer. I will ask Mr. Pat Healy to comment on the New Directions policy not being mentioned. The Senator also spoke about pre-hospital emergency care and paramedics pronouncing death. It makes sense to me and I will ensure it is looked into. That is a very stressful time for everybody involved, particularly the families and it is not acceptable to have red-tape delay and may further impact on ambulance service performance.

I will ask Mr. Mulvany to address the question on the Children's Rights Alliance report card.

Alex White (Dublin South, Labour)
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Deputy Kelleher made some observations and asked some questions about primary care. I am aware of the issues that have been raised at various meetings organised by general practitioners around the country. I am fully aware of the concerns people have raised and I am in regular contact with general practitioners as a Deputy as well as a Minister of State. I have visited general practitioners in their practices and have met them in my office, and am fully aware of the issues they have raised.

A considerable amount of the concern GPs have is not related to the provision for those under the age of six. That is perhaps in some ways a proxy or the occasion for these issues being raised rather than the reason they are being raised. I can see the concerns people have, particularly after the period we have come out of. There are people in general practice who have made commitments in some cases who are struggling in many situations in common with many other people across society who have come out of a huge economic collapse. This has also affected GPs who are also citizens and who have seen their material circumstances decline, significantly so in some cases. That is the case across the board. It is certainly the case across the public service. There is no public service worker who has not had their pay reduced. Similarly, GPs have had to face that as well. Of course, they are providing an essential public service for citizens.

Despite the concerns raised by GPs, which I take seriously and understand, they are continuing to provide a highly efficient and professional service in general practice in rural and urban areas across the country because I have seen it for myself. One could not criticise the level of service. I know colleagues have been contacted by GPs, as have I, but I do not get a sense from the people that they are getting less of a service. I am not infallible and there may be cases of this but that is not the sense I have. GPs often say somewhat rhetorically, although I do not disagree with them, that it is the most successful part of the health service. Perhaps other people in this room might have different views about that but they do make that point. I think they are right. It is a very successful and vital service carried out in a professional, efficient and effective manner for which I thank them. They deserve huge credit from this committee and society for the work they do and the efficiency and professionalism with which they deliver it.

In response to Deputy Kelleher, I must point out that the number of GPs in the system has increased. One of the first things this Government did was change the law to liberalise entry into general practice, which has been a success. There are concerns and issues which are legitimate and must be addressed. The issue of resourcing must be addressed across the board in terms of public services. We all understand that we want excellent public services and that they cost money, which brings us to the debate touched upon by the Minister in respect of how we fund our health services in the future, including primary care. We must all face up to this.

One clear question relates to who will be funding health services in the future. The answer is the people of Ireland. It is just a question of how they will be doing it. Regardless of whether it will be through taxation or an insurance-based system, the people of Ireland will be paying for it. Is it the case that it is more effective and equitable to do it through an insurance-based system? It is not just this Government that has said that. The resource allocation report commissioned by the former Minister for Health, Mary Harney, made the point that insurance-based systems have advantages because there is greater visibility in terms of what people pay and what they get from it. Other people say taxation is the way to do it. Can any Government persuade its electorate to pay the level of taxes that would be required to have a fully tax-based health system in the future? I do not know the answer to that question but I doubt it. We must have the debate. At the outset, Deputy Kelleher conceded that at least the universal health insurance white paper helps get this debate properly grounded in terms of-----

Billy Kelleher (Cork North Central, Fianna Fail)
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Just to clarify, that was not a concession. It was an observation as opposed to a concession.

Alex White (Dublin South, Labour)
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It was not a concession. The Deputy should give it a fair chance. How else will we address the two-tier system? If Deputy Kelleher says it should not be through insurance, what is the alternative for addressing the two-tier system we undoubtedly have? Let us have that debate.

I mentioned the wider context and the reduction in pay in the public service. The clear stated position of the Government is that it does not intend to further reduce wages in the public service. We can have the confidence to say that this applies equally to the FEMPI cuts, which is the issue that has most concerned doctors. It is my confident belief that the Government will not be going back to that well again and that people can have some level of certainty in terms of where they are going in the future. That is an issue of Government policy and I am simply reflecting what has been said by others in that regard.

Deputy Kelleher pulled me up again on the use of the word "discretion" in respect of medical cards. I do not want to get into semantics but the Deputy has drawn me into it. The Deputy's own question asked the Minister for Health to provide details of the number of medical cards and GP cards and the number of each card issued on a discretionary basis. The card is the card no matter how the person acquires it. If citizen A has a medical card granted in the normal way and citizen B has a medical card granted on through the discretionary process, the cards are exactly the same. That is the point I was trying to make. I was trying to say that there is no separate entity called a discretionary medical card. If two people are holding the card, the cards are exactly the same in terms of entitlement. Deputy Kelleher knows exactly what I meant by that but he persists in coming back and pulling us up on it. That is the position. There are two different routes - one is the basic means test and the other is through discretion. That is what we mean in terms of there being no separate entity.

Deputy Kelleher said that there was a belief on the part of Down's syndrome advocacy groups that there was a blatant attempt to reduce medical cards issued to their members. We have previously dealt with this issue, which I know is of concern to people and has been constantly raised in the committee. I want to state categorically that there is no targeting of people with particular illnesses or conditions. It would be perverse for the HSE to decide that it will go after this or that patient group and take away their medical cards. Even if I am wrong on that and there was an extraordinary policy of targeting particular patient groups, it could not be done anyway because the system does not retain information in respect of medical condition or illness. I want to again state that it would be impossible to do this. It would be perverse if anybody was to think that one would go after particular groups but the system is simply not geared to do that in any event.

Jerry Buttimer (Cork South Central, Fine Gael)
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Perhaps the system should retain information because many of us in this room have heard from people with serious illnesses, be they transplant patients or people with chronic illness or cancer, and families of children with Down's syndrome who have had medical cards removed or up for review and have been questioned. I would make the point that the system should have that capacity. To be fair, when one does engage with staff in the Primary Care Reimbursement Service, PCRS, they are very fair-minded and genuine people but perhaps the system should be changed. I have made the point here and to the Minister and Minister for State that we need to look at the issue of transplant patients or people with Down's syndrome so that they do not have go through the rigmarole all the time. I know the Minister of State can quote the Act but the reality is, and I would be wrong to say otherwise, that there are people with Down's syndrome and transplant patients who have had their medical cards taken away.

Alex White (Dublin South, Labour)
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There are people whose medical cards have been removed across the board, including those who do not have illnesses or conditions.

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

Alex White (Dublin South, Labour)
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It always sounds a bit harsh to make the point this way but I will state the reality. We do not have an illness-based scheme.

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

Alex White (Dublin South, Labour)
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We do not have a medical condition-based scheme. We have a means-based scheme. If the Oireachtas was to decide to change that, so be it but the fact is that the HSE must administer the scheme the Oireachtas puts in place, which is a means-based scheme. There is no way that the HSE has the power to act in a way that is outside the law. As the committee is aware, the medical condition enters into the equation because there is flexibility. Where somebody is above the means test limit and there is medical condition or illness that has an effect on their means and financial situation, that can be taken into account in respect of the award of a card on a discretionary basis.

Mr. Tony O'Brien:

If I may, I will ask Mr. Healy to deal with the issue of school leavers that was raised by Senator van Turnhout.

Mr. Pat Healy:

Just to reassure members, everything we have done in respect of school leavers and those exiting rehabilitation training, RT, is based on New Directions. It is taken as read in the system that everyone must have due regard to New Directions. Since I entered office last year, the committee and others have identified this issue as a top priority for us in 2014. Indeed, it has been identified specifically in the operational plan. The oversight group, which has met four times, is driving that work. The intention is for a more co-ordinated process in 2014. In my response, I tried to outline the specific targets that we set for people to meet by February, March, April and June. We have met the February, March and April targets. We have identified more than 1,400 people who require the service, approximately 900 of whom are school leavers while the remainder are seeking RT exits. We are going through the process of working with service providers and families to settle on the types of service to be offered. This will be done by June. I do not doubt that we will not get it exactly right, but there will be a significant improvement on last year. With the oversight group, we intend to undertake a review of performance in September or October, learn from that and ensure that everything is right by 2015.

Mr. Tony O'Brien:

I will ask Mr. Mulvany to respond to the questions on mental health and child and adolescent mental health services, CAMHS.

Mr. Stephen Mulvany:

The Children's Rights Alliance is a separate and independent body and we respect its role. However, we have not been engaged on its scoring mechanism. According to its papers on what led to a reduction from a D to an E grade, one reason was the fact that the €20 million in additional investment was not €35 million. We acknowledge that an approximate €45 million extra has been invested in overall mental health services in the 2013-14 period. This is significant.

The issue of children being admitted to adult psychiatric units was another key factor in the grade. That five children under the age of 16 years were admitted to adult units is not acceptable.

A scoring should consider progress over time. In 2008, there were 16 appropriate beds for the admission of children, yet there were 247 admissions of children to adult units. In effect, 75% of all children admitted in 2008 were admitted to adult units. In 2013, the number of beds had increased to 44 and there were 90 admissions of children to adult units. That was 90 more than we would have liked, but it was still a reduction to 32% of total admissions. While this is not just an issue of beds, the number has since increased again. It was 51 when we wrote our paper, but it is now 56. By the end of this year, it will be 66. Next year, it will increase to 74. The remaining increases to 80 and 104 will occur when the new forensic unit at St. Ita's Hospital, the new Central Mental Hospital, opens and the children's hospital opens. There will be significant progress in terms of the investment in beds.

Geography and exceptional cases remain issues. Sometimes, it can be appropriate for children older than 16 years of age to be admitted to adult units. However, a significant amount of progress is also being made in this respect.

As to other indicators, waiting times for CAMHS present an issue. We hit the target of 70% being seen within three months after referral, but it is a priority-based service. More than 50% of all referrals to CAMHS are seen within one month or less. Urgent cases are seen in a matter of days or, if necessary, hours. We have put more staff into mental health services, but we have also accepted more referrals and seen more people. In 2013, the waiting list increased by a little under 500 people, but that increase was much less than the amount of extra work that the service has done. CAMHS is not yet at the stage where it is sufficient to meet an increasing and latent demand, but we have put in place 230 additional posts through the 2012 and 2013 investments-----

Jerry Buttimer (Cork South Central, Fine Gael)
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If I might interrupt Mr. Mulvany for a second, we have just received a note from the broadcasting unit. If mobile telephones or iPads are on, members should switch them off, as they seem to be interfering with the broadcasting equipment. I ask members to co-operate.

Regina Doherty (Meath East, Fine Gael)
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If their Internet is turned off, they do not interfere.

Jerry Buttimer (Cork South Central, Fine Gael)
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Do not shoot the messenger. I am only relaying a message, as requested.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Could the volume in this room be turned up, please? Sometimes, it is difficult to hear different speakers.

Mr. Stephen Mulvany:

Through a total investment of €90 million in 2012 and 2013, 230 posts - accounting for €3 in every €10 - have been created in CAMHS. Of those, approximately 80% have been filled. This process will continue, improving our chances of improving the waiting list.

We would not want to give the impression that these matters are not being dealt with urgently. At the last meeting, it was mentioned that an overall protocol was being put in place across all HSE divisions with the Child and Family Agency. This protocol was not specific to mental health services. Previous protocols are in place governing how CAMHS and the Child and Family Agency interact. In this year’s operational plan, one of our focuses is on integrating our work with the agency to build on what has already been put in place. Where existing mechanisms are not working, they are subject to review.

Jillian van Turnhout (Independent)
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May I ask another question?

Jerry Buttimer (Cork South Central, Fine Gael)
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No. I will bring in-----

Jillian van Turnhout (Independent)
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Is the new protocol in place?

Jerry Buttimer (Cork South Central, Fine Gael)
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Nine members are waiting, to be fair.

Jillian van Turnhout (Independent)
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I just want to know whether the protocol is in place.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will allow the Senator back in at the end. Other members wish to speak and Mr. O’Brien must still answer some questions.

James Reilly (Dublin North, Fine Gael)
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In deference to Deputy Ó Caoláin, I did not cover the issue of rare diseases. I will call on Dr. Devlin to address it.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will invite him to contribute after Mr. O’Brien.

Mr. Tony O'Brien:

I will add to the Minister of State, Deputy White’s comments on medical cards. I will also seek to address the concerns raised about the ambulance service. The degree of passion and concern expressed around health services that we often hear in questions is appropriate. I recognise that there is nothing more personal or, indeed, political than health care, particularly if something is seen not to be working as effectively as it might.

Regarding medical cards, the reason we do not hold data relating to a person’s medical condition where that condition has been factored into the calculations to determine whether someone would suffer under financial hardship and, therefore, qualify on discretionary grounds is that the medical condition itself is not a relevant decision making criterion. Under the Data Protection Act, we would not be entitled to hold those data. Only at such time as the law changes or situations evolve to where a medical condition becomes a qualifying criterion would we be entitled to classify claimants in that regard and hold those data.

That said, the discretion arises from the 1970 Act. It is important to stress that we have a mathematical formula for basic entitlement. In order to exercise discretion in a way that will withstand tests as to sound public administration, it must also be standardised. This has been done on the basis of a higher financial threshold calculated by reference to particular circumstances in particular cases. Since the discretion was, in effect, vested in the chief executives of the health boards at the time and, therefore, is now vested in me, I am conscious of the importance of the exercise of that discretion. We are constantly examining whether that discretion can be exercised in a different or better way. For now, though, we are using exactly the same approach that has been used for a number of years. To that extent, I can say definitively that there has been no change in policy or practice.

However, what appears to be clear is that, previously, there were regional variations. One of the effects of having a level playing field is that, as regards persons who may previously have been granted medical cards on discretionary grounds when they did not fulfil those narrow criteria, one will find on review that----

Jerry Buttimer (Cork South Central, Fine Gael)
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I am sorry, but there is a vote in the Seanad.

Mr. Tony O'Brien:

Persons whose individual circumstances may not have materially changed may none the less find, when a standardised set of rules are applied, that they no are no longer entitled to a medical card. I can categorically stated that there is no targeting of any particular group. Medical cards are reviewed on a batched or random basis, except where on the basis of information which is now available to us through linkages with the Department of Social Protection, there are specific reasons to believe that an individual's circumstances have radically changed. There is no targeting based on medical condition or otherwise. As stated by the Minister of State, Deputy White, even if we were bizarre enough to want to do that, we do not have the capacity to do it. I can categorically assure members of the committee that is not happening.

In regard to the National Ambulance Service, NAS, the Health Information and Quality Authority, HIQA, introduced guidance targets in January 2011. At that time, the service was not organised in such a way as to be able to meet those targets and since that time continuous investment and reorganisation has been producing a steady improvement of performance against target times. I resent the suggestion that there is any pretence about the performance of the National Ambulance Service. This data is published monthly in the HSE's performance reports. The fact that we are engaged, at a time of extraction of significant investment in health care from almost every other sector, in very substantial increases in investment in the ambulance service, resources, training and personnel, is a signal that we do not believe that without that investment or reorganisation the ambulance service can meet the demands that are placed upon it. There is no suggestion anywhere, either at this level in the HSE or in the leadership of the NAS, that the service is currently organised to do everything that is required of it. There is no definitely no sense of pretence.

Some of the changes that we have introduced include, the introduction of immediate care vehicles which now carry 74% of those on into hospital transfer. In the past, emergency ambulances were used for this purpose. The incremental centralisation of the control system to enable the resources to be used dynamically where ever they may be is important. The intention is that as this rolls forward the national control centre, which is being developed with input and guidance from then National Association of Chief Officers of Ambulance Services in the UK - we have been done this path before - will bring about a significant improvement in deployment.

On the Dublin Fire Brigade ambulance service, with no pun intended, there is an awful lot more heat than there is light in the discussion on this issue thus far. The Dublin Fire Brigade, which we fund for this purpose, operates 11 emergency ambulances in Dublin. The NAS operates 28 emergency ambulances in Dublin and, in total, 50 in the former eastern health board area. The Dublin Fire Brigade ambulance is an important contributor but it is by no means capable of description as Dublin's ambulance service. The NAS out-classes it in terms of scope and scale in almost every respect. I wish also to ensure that members are aware that the NAS response time in the most recent monthly data for Clinical Status 1 ECHO calls, for which the target is 70% the response rate was 75.27%. The Dublin Fire Brigade, DFB, supplies the NAS with activity statistics in respect of on-call, volume and response times on a monthly basis, one month in arrears. The most recent data, in terms of the same standard of Clinical Status 1 ECHO calls, in respect of which the target is also 70%, shows that the response was 58.4%. There has been much inaccurate information in this regard. The Dublin Fire Brigade is an important contributor but it is no means the exemplar that some people suggest it is.

I am also concerned by the notion being put about that there is some kind of agenda for a HSE take-over. I remind the committee that I was appointed as final head of the HSE. I am winding up the HSE for the Minister. There is no land grab going on. What we want to do is ensure that one of the legacies is an appropriately structured National Ambulance Service. It will not be a HSE ambulance service but a National Ambulance Service. I agree with Deputy Ó Caoláin on the need for a national ambulance authority. I am sure that following this exercise we will have a National Ambulance Service appropriately governed as hospital groups and so on. There is no selfish organisational corporate agenda. We are happy that the city manager for Dublin City Council has initiated the review. We are working with him in that regard. It does not make sense to have a control centre in the centre of Dublin, with the NAS resources being managed by controllers on one side of the room and the Dublin Fire Brigade resources being managed by the controllers on the other side of the room, with little interaction between them. That is not a good use of resources. I am sure that if we could find a way through this review to manage those resources in a more co-ordinated manner the people of Dublin would have a combined ambulance service, which would be much better. Let us retain a sense of proportion.

That having been said, I in no way diminish the impact of ambulance service delays, such as that outlined earlier or by other citizens. The purpose of the ambulance reforms under way is to ensure a better service.

Dr. John Devlin:

On Deputy Ó Caoláin's question, I am aware that the Rare Disease Patient Organisations appeared before the committee a couple of weeks ago. I take this opportunity to mark their contribution not only in terms of the steering group but also in terms of the public consultation process. There have been two national consultation days and some online consultation. Their input into that has been very valuable in terms of assisting us in completing our report.

The establishment of a national office was highlighted during that consultation process. There are currently approximately 8,000 rare diseases. There is lack of strong clinical focus in this regard on behalf of patients and families. There is also difficulty in accessing information and all that entails. We know that the model of a rare disease office works well in other countries. In response to the Deputy's question, this issue is a strong feature of the report. In terms of where we are at, the final meeting of the national steering group will take place next week. Subject to that, and all things going well, we will make a recommendation to the Minister. This will be done by way of publication of our report, which will then be presented to the Minister, alongside the consultation document. Publication of the report is imminent. The issue is being addressed seriously within that report.

Eamonn Maloney (Dublin South West, Labour)
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I will be brief. We learned this week of concerns in regard to consultants' contracts between the HSE and St. Vincent's Hospital. We know that some but not all consultants on salaries of approximately €100,000, with contracts that limit them to working within the public hospital system, are on leaving the public hospital at St. Vincent's entering the private hospital next door to do what are termed "nixers", which is double-jobbing. I object to this, as I believe would all tax compliant taxpayers because it is they who are paying the salaries of these consultants.

I presume Mr. O'Brien is tax complaint.

Mr. Tony O'Brien:

Yes.

James Reilly (Dublin North, Fine Gael)
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There is no room for nixers in Mr. O'Brien's case.

Eamonn Maloney (Dublin South West, Labour)
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I commend Mr. O'Brien on his firmness in addressing this issue. I am sure that like me other members will support his intention to deal with this issue in the context of funding to the hospital. Can Mr. O'Brien assure me, as a compliant taxpayer, that if it is established that people have been double-jobbing all taxpayers' money paid through the HSE will be recouped?

They were paid the money but were spending time in a private hospital.

Ciara Conway (Waterford, Labour)
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I thank the Minister and the officials for making the time to come before us today. There are a number of questions taking in issues from Mr. O'Brien's opening statement to the committee, particularly the events in Portlaoise and what is happening there. In the opening remarks it was indicated that there is now a policy of open disclosure regarding the sad and tragic events that took place in Portlaoise. Is it envisaged that this will become a national policy? I know it was piloted in some hospitals in recent months and years. What is the vision for such a policy? The research indicates that in dealing with people in a humane fashion and with issues like litigation, there is a positive impact if a policy of open disclosure is followed when there are unforeseen mishaps.

The witnesses may be aware that the Irish Nurses and Midwives Organisation, INMO, recently had a survey on the clinical and midwifery work force, with data taken in February this year across 19 public maternity units. It has indicated the appropriate and safe level of care for women and expectant mothers is one midwife for every 29.5 women. I am alarmed to see what the figures have indicated, with Portlaoise the worse case at a ratio of 1:55. It is followed by Mullingar, the Rotunda and my own local hospital in Waterford, which has a ratio of approximately 1:36. The national average has one midwife for every 40 patients. What is happening in this regard? How are the standards and recommendations of the HIQA report arising from the death in Galway of Ms Savita Halappanavar being implemented across the 19 public maternity wards in the country? All expectant mothers and their families want reassurance on this and the results of the survey carried out by the INMO are quite stark and frightening for people. I would like some update in that regard.

Will the witnesses give an update on how the hospital groupings are proceeding and how service reorganisation is happening? With the publication of the Higgins report, certain undertakings were given with regard to participation in the process. One undertaking concerned the provision of 24-hour cardiology services in Waterford Regional Hospital, so I would like to know how that is proceeding.

Catherine Byrne (Dublin South Central, Fine Gael)
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I thank everybody for their contributions this morning, and some were very interesting. I will stick to three questions and perhaps I might be able to get some more information. I was disappointed with the response to Question No. 25 as it did not constitute a reply. I asked if the Minister had considered the cost for the introduction of a nicotine replacement programme for pregnant women. The response did not even touch on the cost. I have raised the matter a number of times and I am fully aware of other measures that seek to prevent people smoking. There are 21% of pregnant women still smoking and there are no statistics indicating how many of the 10,000 smokers receiving support have succeeded in giving up smoking.

Professor Luke Clancy appeared before the committee a few weeks ago and I asked him a question about pregnant women who smoke. I queried if, with his expertise in respiratory illnesses, he believed nicotine patches for pregnant women would be better than a woman continuing to smoke. He told me they would be 100% better than anybody putting a cigarette in a mouth. He indicated that women who smoke would be better off using patches. I acknowledge that the Minister's response indicated that the patches are given free in England through a general medical scheme. I will submit the question again about the cost of these patches.

There was another question regarding primary care health centres. My area takes in Inchicore, Ballyfermot, Drimnagh, Crumlin and the Liberties and there has been a very significant response to the primary care centres. People are overwhelmed by the condition of the facilities and quality of the service which is provided. My concern is with the centre on Curlew Road. A response was sought from the HSE in January regarding the planning application and that is still awaited. When will the response be received? The development cannot go ahead unless Dublin City Council gets the required information. People living in the Crumlin and Drimnagh area welcome this primary care centre but the response from the HSE is required sooner rather than later. We are now four months in and the issue must be pushed on.

My final question concerns the proposed new national children's hospital. Yesterday I read an article in a newspaper indicating the planning application must be pushed to 2015 but is there any truth in that? There is much local frustration about this as we all thought the planning application would be made in September. Has there been purchasing of facilities outside the complex to help move along the development? Will the witnesses confirm if a site on Davitt Road has been purchased by the HSE to facilitate ambulances and the information technology section of St. James's Hospital? What about the site on Brookfield Hill, as I cannot find anything about it? Locals believe those sites have been purchased in conjunction with the development of the proposed national children's hospital.

James Reilly (Dublin North, Fine Gael)
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Deputy Maloney asked about the arrangements and contracts of consultants with regard to the private hospital at St. Vincent's. Mr. O'Brien will deal with that in detail. I started an inquiry into these issues arising from the Tallaght issue, with the HIQA report exposing a separate stream of income for certain individuals. That process is continuing and I fully support Mr. O'Brien and the HSE in ensuring that people observe the rules as laid out in the contracts they have.

Deputy Conway addressed comments mainly to Mr. O'Brien but as a Minister I must respond to the issue of open disclosure, which will be our policy to be rolled out across the country. The Deputy is 100% correct in that it improves patient safety and reduces the amount of litigation. The patient safety agency will be formed and the chief executive job is to be advertised shortly. The agency will play a significant role in helping patients who have complaints, from those which some may see as less important to the most important. Any complaint from a patient must be pursued to his or her satisfaction, and a patient safety agency will help them do that. As we have seen with Portlaoise, people have one blockage after another put in their way and end up totally frustrated before going to the law, which creates tremendous expense and stress for families and, ultimately, the taxpayer, as we will have to pay the costs in the end. I am deeply disturbed that with one recent year, from €60 million paid out in medical legal claims, €20 million went to the legal profession. I have no fight with the legal profession but I want the people who suffer harm to get the money rather than those in the legal profession.

Mr. O'Brien can give an update on hospital groups, as well as on Portlaoise and the INMO figures on midwifery.

Deputy Catherine Byrne asked about a number of issues, some of which I will have to refer to the HSE. I can comment on the Davitt Road site. A site was purchased on Davitt Road. The purpose of purchasing it is to reduce any planning risk on the St. James's site, which is minimal but exists. I cannot say what precisely is planned to go on it at this juncture; I do not know if that has been decided yet. The delay in planning is true. I am told it will be delayed for a couple of months but, due to parallel processes, we will still have the commissioning of this hospital in 2018. The Deputy also asked about nicotine patches for pregnant women. I will ask the Department to carry out a costing exercise. Dr. Devlin is here and while it is not precisely his remit, but it would be loosely in that area. He will talk to Dr. Fenton Howell, who is head of our tobacco unit. I agree with the Deputy that it is terribly important to protect the unborn child from the hazards of tobacco. Mr. John Hennessy will reply to the question about the primary care centres.

Mr. John Hennessy:

The Dublin South Central area was prioritised in the stimulus package for primary care centres, and the Crumlin site is targeted there. The planning application has been lodged and I will check on the further information required by the local authority that is delaying things. However, as the Minister said, I do not expect it to interfere with the long-term plan for that Crumlin site. The Bride Street development is on track and will open in 2014. I will revert to Deputy Byrne with details on the Curlew Road site.

Mr. Tony O'Brien:

I will ask Mr. Carter to respond on the broad range of maternity issues.

Mr. Ian Carter:

In terms of the exercise taking place at present with regard to staffing levels, the benchmark staffing levels that are being quoted are slightly more complex than 1:35. This is an exercise the HSE is conducting. The staffing ratios accepted internationally are 1:38 for complex services and 1:45 for district general services, so it is slightly more complicated than the 1:35 given in the information.

Specifically with regard to Portlaoise, a significant recruitment exercise was commenced to supplement current staffing levels there. We mentioned this at the last meeting. That commences next week. There are 27 applicants to be considered to add to the current vacancy factor of ten posts in that institution. I hope those people will be able to be taken on board by the end of April, which would have that facility working at full complement.

With regard to the recommendations after the HIQA report, while they are many and varied the key recommendation for the future was the introduction of the early warning system and the escalation system, which is the systematic way of managing patients should their condition deteriorate. That commenced implementation last year across all hospitals and all maternity units. We are now at the stage of validating that, but it is introduced into the 19 specific maternity units in the country. In parallel with that is the issuing of clinical guidelines relating to the medical care of mothers. Those have been issued.

I will also refer to the question on hospital groups. There are seven hospital groups. The current position is that those groups are established and we are at present looking at moving them forward, appointing chairs and activating the groups. If one links it to the chief executive officer appointment, we now have five of those appointments in place so the groups are advancing.

Jerry Buttimer (Cork South Central, Fine Gael)
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With regard to the question Deputy Conway asked, we received correspondence from the Irish Nurses and Midwives Organisation in February which expressed its concern about the staffing situation in our hospitals. It made the point that there is a deficiency in the staffing number and it is concerned about staffing levels and the safety of maternity services. That was stated in a letter to the committee last February.

Ciara Conway (Waterford, Labour)
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Mr. Carter mentioned international guidelines and gave a much more inflated number than the INMO. He said that in uncritical or uncomplicated cases the ratio was 1:46. I think that is the number he gave. Where are these numbers coming from, because they are hugely at variance with the INMO figures? The INMO corresponded to the committee and the outcomes of its survey of the 19 public maternity units are of huge concern.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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This is related to the question I asked earlier about the report in The Lancet, the nurse staffing levels at our hospital sites and the reduction of 5,200 in nursing staff since 2010. The Lancet report is very worrying. It covered nine countries, including this State. It demonstrates very clearly, and it has not been disputed in any subsequent publication, that there is a 7% increase in the likelihood of the patient being lost within one month of a procedure and that after a particular point a nurse can no longer function to the optimum level. Has there been any consideration of that report and its findings? Does it not ring alarm bells? We must create employment opportunities for nursing staff within our hospitals.

Mr. Ian Carter:

The benchmark I am referring to is Birthrate Plus, which is the UK tool and is now being used in Ireland. It is a study that has happened over the last four years in the UK which rightly distinguishes that there are two types of maternity services. There are those that are tertiary and complex, where high-risk mothers will go, and there will be a lower level of dependency, which would be the classic district general. Accordingly, there are different benchmarks in terms of dependency levels. The more complex the service, the lower the ratio and vice versa. Those numbers I quoted are from the exercise that is happening at present. We are now re-examining our services to see if those numbers would still be accurate with the complexity of the mother. It is a UK number.

Mr. Tony O'Brien:

With regard to staffing numbers overall, it is worth noting the decision announced by the Government this week, which I welcome, on the recommendation of the Minister for Public Expenditure and Reform, to defer the exit date under the grace period that would otherwise have arisen next August. That would have been quite challenging for the health service. The last grace period exit over two years ago had a very significant impact on health services, so that is welcome.

In general, we must have at least as much focus on floors, if I can use that term, as we have on staff ceilings. As part of what the Minister, Deputy Howlin, has referred to as the reform dividend as we move to the next stage of health service reform, we are very keen to ensure that this forms part of that dialogue. If we took all of the available international comparators and applied them universally to every service in the country and add up all the floors, we could end up with a building that is taller than the ceiling. We must have a different approach. As Mr. Carter mentioned, we are now going through the Birthrate Plus exercise with regard to maternity services, which is an objective measure and will be adjusted for different levels of complexity, bearing in mind that not all 19 maternity hospitals are the same in terms of the complexity of what they deal with. However, it is a very important issue in the health service and there is no single magic number, be it 100,000 or 95,000, that one can always say will be right for the health service. We must do it from the other way up and we are engaging-----

Ciara Conway (Waterford, Labour)
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How long will that exercise be?

Mr. Tony O'Brien:

We are expecting an answer on Birthrate Plus at the end of April.

With regard to the open disclosure policy that has been published, it is a national policy. We must recognise that moving from an environment of limited or no disclosure to open disclosure is a challenging journey for individuals to make.

At a central level we have to provide appropriate supports to enable staff to do so. Our quality and patient safety division is working on same. Certainly, we are also looking at how we support in a different way institutions - like Portlaoise for example - when they find themselves or get into a situation they find difficult to handle and, in an appropriate way, how we support them to do so in a different way. That is part of the CMO's recommendations.

With regard to the issues arising at St. Vincent's University Hospital and St. Vincent's Private Hospital, the approach that I have taken to this issue throughout the sections 38 and 39 audit is that it is somewhat less about the individuals and more about the governance environment.

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

Mr. Tony O'Brien:

I have no doubt that the consultants in question are fulfilling, in terms of hours, excellence and so on, the full extent of their commitments in the public hospital. I have no reason whatsoever to suspect that they are not doing so. What I am concerned about is that contracts exist which have certain ranges of entitlements and, in this particular hospital - either by special arrangements or by interpretation - they have arrived at the position in which they are allowing consultants to do so when other institutions would not work in external private institutions. That is, primarily, an issue between us and the governance of the hospital and it is through that medium that we are seeking to address the matter. I have said to the hospital very clearly that if this situation continues for whatever reason, on whatever basis and with whatever justification, it will have a material impact on our ability to direct additional resources in the way of that hospital. That is not to suggest that existing services will be curtailed. That is not what I am talking about. I mean that the further development of the hospital is in jeopardy unless we come to a better arrangement.

Jerry Buttimer (Cork South Central, Fine Gael)
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With regard to sections 38 and 39 and governance in St. Vincent's, Mr. O'Brien is right that it is not about the individual personality or the person but the governance.

I asked him earlier about the business plan. If an organisation submits a business plan to the HSE what is the criteria for its acceptance? If Mr. O'Brien is referring to compliance with Government policy or pay policy, are we allowing a situation where some of the organisations can have a salary paid in excess of the recommended salary?

Mr. Tony O'Brien:

No. Each institution is entitled to put forward its best arguments objectively. If their arguments have merit or they can objectively, by reference to external data, suggest there was some error in the past-----

Jerry Buttimer (Cork South Central, Fine Gael)
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What does Mr. O'Brien mean by merit? I ask him to give an example of merit in terms of an organisation making a business case. For me, it means receiving X when Y is the standard amount.

Mr. Tony O'Brien:

Let us take a hypothetical example.

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

Mr. Tony O'Brien:

A hospital might feel that because of the size and complexity of its operations it would never have been able to attract a clinical director or chief executive at the salary set for the hospital by reference to hospitals of similar size - a classic job sizing-type of argument. If it can successfully demonstrate that situation then the review panel might be minded to agree. On the other hand, if its arguments are found not to have substance then the review panel will not be minded to agree. I must say that the review panel has approached its work with considerable rigour. It has not come across as soft and woolly in its outcomes but that will all be apparent to the Chairman when we publish the report.

Jerry Buttimer (Cork South Central, Fine Gael)
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Will the report of the review panel and its workings be published on 14 April?

Mr. Tony O'Brien:

We are going through a process now of ensuring that the individual institutions are aware of the outcomes, of the consideration of their applications, so that they can ensure that the individuals, who are the subject of the business cases, are fully informed before the information goes into the public domain.

Jerry Buttimer (Cork South Central, Fine Gael)
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Does the HSE intend to publish its report at a press conference or at a separate meeting of the HSE?

Mr. Tony O'Brien:

My current thinking is that it will be made available to the Oireachtas committees that have a particular interest in this matter.

Jerry Buttimer (Cork South Central, Fine Gael)
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Does that include this committee?

Mr. Tony O'Brien:

Yes.

Jerry Buttimer (Cork South Central, Fine Gael)
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Will it be published on 14 April?

Mr. Tony O'Brien:

Yes, on 14 April or thereabouts.

Jerry Buttimer (Cork South Central, Fine Gael)
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It is important to have the publication released at our meeting rather than somewhere else but I understand that it is a matter for the HSE. However, I shall make the point that as the committee-----

Ciara Conway (Waterford, Labour)
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The committee sent correspondence to the HSE on this matter for a number of months.

Jerry Buttimer (Cork South Central, Fine Gael)
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Yes. We have also received correspondence from Mr. Tony O'Brien which he sent to us in January. I hope that this committee will be the forum chosen to present the report.

Mr. Tony O'Brien:

It would be of great assistance to me if the committees with an interest in this matter could reach some agreement between themselves but I recognise that may be challenging.

Jerry Buttimer (Cork South Central, Fine Gael)
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We are the committee responsible for health and, therefore, we would be the appropriate committee for it. That is my opinion as Chairman. We will formally write to the HSE this morning on that basis.

Ciara Conway (Waterford, Labour)
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As Vice Chairman of the committee, I second the Chairman's suggestion.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the Vice Chairman.

Mr. Tony O'Brien:

Clearly, his advice, as Chairman of an Oireachtas committee, will be taken very seriously.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. O'Brien. Senators Colm Burke and Crown had to attend a vote in the Seanad but have now returned. I call Senator Burke.

Colm Burke (Fine Gael)
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I thank everyone for their contributions here this morning.

I wish to refer to a reply to Question No. 7 on vacancies in consultant posts. Today is the first time that we have seen the real figures but they are only in respect of HSE hospitals and do not deal with the voluntary hospital issue. We can see that there are 250 wholetime equivalent posts consultant vacancies at present which is 12% of the total consultant workforce. Let us take the voluntary hospitals which have another 500 consultant posts and apply 12% to them which means there are possibly 300 consultant posts vacant at present. What strategy will be put in place to deal with the issue? There has been talk about making sure we have a comprehensive health service but in order to do so we need people to provide the service. One of the key components to providing the service are consultants. When one adds the number of posts vacant, including senior house officers and registrars, the total is 462. Three years ago I highlighted the fact this was going to happen. Based on the percentage rise per annum that has occurred over the past three years then we may end up with between 15% and 20% of posts not filled. What strategy is being examined to deal the issue? When will we see the strategy change implemented?

With regard to Question No. 8, I wish to raise the issue of absenteeism. I understood previously that we were going set a target to reduce absenteeism down to 3%. The reply that I have received seems to indicate that we must accept and live with the current level of absenteeism. Absenteeism rates are not reducing but vary between 1.3% for medical staff, 4.64% for management and administration staff and 5.36% for general support staff. We compared replies received from other State agencies but we did not compare absenteeism rates with the voluntary hospital sector. From the figures that I have received from the voluntary hospital sector it is obvious that absenteeism and sick levels are around 3%. Why has there been no real change in percentages? Let us look at the graph in the reply that I received to question 8. It shows a sudden rise in absenteeism and sick leave levels in August, September and October. Why did the level increase for those three months? The same applied to the month of January. Has the issue been examined?

The total absenteeism rate for 2013 is 4.73% which means 4,730 people, on average, are absent from work in the HSE every day. Absenteeism is a major issue but there does not seem to have been any progress made to resolve the matter in the past three years. Why the variation, particularly in cases where there was 1.3% in one area and 4.64% in another area?

Jerry Buttimer (Cork South Central, Fine Gael)
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Finally, I call Senator John Crown.

John Crown (Independent)
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Go raibh maith agat. I am speaking slightly out of turn because I misunderstood the procedure for dealing with the questions this morning. However, I shall make a few very general points.

I welcome the Minister's unveiling of the White Paper on universal health insurance. I look forward to studying it, collaborating with him and working on it in the years to come. It is something that I have advocated for 20-odd years. I have spoken about health insurance over the years and I have always editorialised about the three problems with the health service in Ireland and that is being unequal, inefficient and of poor quality. I have heard a great deal of stress being put on addressing the equality issue which is correct. However, it is the quality issue, in particular the poor and mediocre quality of the service delivered to public patients over the years, which is the key pathology that must be addressed. That must be the first priority.

In addressing this, and perhaps pre-empting some of the criticisms the Minister will encounter, I think it is fair to state that built into this kind of plan, where at present a big chunk of tax money goes into paying for a health system which will now be paid for in a different way, is that the tax take goes down by exactly that amount. It also means that those within the public service who are making their living out of that part of the tax will seek alternative employment, in many cases, in the new health system or in some other service entirely. This is because it is in the logic of an insurance-based system, even the kind of social democracy-based insurance system I would espouse, based on a principle of social solidarity.

As a little throw-away remark about the high qualify of our medical graduates internationally, I would say, with great respect to the Minister because this is not his fault, we have high quality medical graduates despite, and not because of, our medical schools where one has six medical schools for 4.5 million people, which is twice the European average, and where one has a total - an aggregate - of I believe 60 consultant level people employed by those medical schools, or ten per school, in contrast to Harvard Medical School which has 1,500. One has to ask how the schools regularly get recognised by the international authorities with such dismally poor levels of clinical staffing.

I am going to say something, which I am sure will be the provocative thing to state today. One of the reasons we have such high quality is unfortunately that the shortage of consultant staff means that our junior doctors get to practice on patients.

Jerry Buttimer (Cork South Central, Fine Gael)
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Representatives of our medical schools are not here to defend themselves.

John Crown (Independent)
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I am not attacking our medical schools.

Jerry Buttimer (Cork South Central, Fine Gael)
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I know but I am making that point.

John Crown (Independent)
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Am I, as a public representative who was elected by a university group, one of whose constituent colleges I am making an editorial comment about, to be prevented from bringing to the committee any expertise and experience I have over 20 years because of some highly theoretical argument that some legal department or PR department in a medical school some place might have an objection to it? To hell with them.

Jerry Buttimer (Cork South Central, Fine Gael)
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I am not preventing the Senator at all.

John Crown (Independent)
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On the specific questions I raised today, I do not believe the specific question about the gagging clause in the GP contract has been as yet addressed in the written answer I have been given nor has the onerous increase in the bureaucratic demands which will be made on GPs in the new under six GP contract.

Similarly, I would like to get a quick opinion as to why we do not have electronic record-keeping and telemetry in our ambulance service. It was piloted in the north east but, for some reason, that pilot was discontinued. The company which did it has taken that expertise, developed the software and is now doing it under contract on a routine basis in the United Arab Emirates. Would it not bring specific advantages to us here?

On the issue of hospital boards, the reply to my query about the ambiguous nature of our hospital boards is that at present, if I understand it correctly, these are separate independent entities which exist under a separate part of corporate governance with whom the HSE has service contracts. I would say to the Minister and Mr. O'Brien with respect that I think there is a world of difference between the kind of service contract the HSE may well have with some place like the Beacon Clinic to give a certain specific service, such as dialysis or some other service, or perhaps to contract something under the National Treatment Purchase Fund under service contracts to other private entities, to the situation that applies where a big public hospital, which effectively has monopoly status in the area where it does its business, is entirely funded by the health service. I do not believe we can basically exculpate them from having any answerability or responsibility to the HSE, the Department of Health and to the health service because they exist under some separate corporate structure with whom we have in theory a cancellable commercial relationship. We all know that is not the case. The Minister or Mr. O'Brien can no more tell St. Vincent's hospital or the Mater hospital tomorrow that they will no longer do business with them than it could completely "undefund" St. James's Hospital or Blanchardstown hospital.

This goes to the core of what happened. The chairman of the board of St. Vincent's hospital stated that it would consider appointing public interest directors to the board. In the name of God, if the current board is not acting in the public interest, in whose name is it acting? I think we all know in whose name it is acting, and it is not in the public good.

This unbelievable fiasco that is now occurring with the B contracts will be a loss for public patients when private patients are clogging up their waiting lists, a loss for private patients who will have decreased access to private hospitals and a loss for public hospitals which may well find it as an increased burden on them. It is great for people like me because I am on the old contract and will have fewer people competing with me, so do not think this is self-interesting talking. The only group which will benefit from this developing fiasco, which was brought down on the heads of the patients and doctors of St. Vincent's hospital by the actions of the board of the hospital, are the insurance companies which will make fewer payments.

James Reilly (Dublin North, Fine Gael)
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Senator Colm Burke raised a number of issues around consultants, NCHDs, training and levels of staffing. Mr. O'Brien would have all the details on that. Senator Crown raised issues around the medical schools. I would have one comment to make on that. While one likes to have as many staff as possible, it is the same argument in regard to teaching. I think the Finns have shown quite conclusively that it is not the student-teacher ratio that is as important as the quality of the teaching. I think our medical schools have proved, that as have their peers in the educational system generally.

Senator Crown also raised the issue of electronic telemetry and Mr. O'Brien will deal with that. He also raised the issue around GPs and all the new documentation mentioned in the new contract. The Minister of State, Deputy White, will be anxious to speak on that.

Senator Crown referred to the issue of the funding of hospitals. I put it to the Senator that what he described in his analogy was the nuclear option and, of course, in the modern world the nuclear options are not used but what are used are all the other conventional arms available and there is a myriad of them. One can have material change within hospitals, which can be quite effective, without actually hurting patients. However, I will let Mr. O'Brien deal with that in a more comprehensive fashion.

Alex White (Dublin South, Labour)
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As the Minister and I have both said repeatedly, there is, and could be, no question of a gagging order being imposed on general practitioners. There is no intention to interfere with the professional independence and integrity of general practitioners. As to whether the particular clause in the draft contract can be interpreted as a gagging clause, that is open to argument.

Jerry Buttimer (Cork South Central, Fine Gael)
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It clearly is but by one side.

Alex White (Dublin South, Labour)
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Exactly. Could I just conclude because I am trying to get to the table where we can get this thing resolved? We are having great difficulty in doing that. I will not extract one-----

Jerry Buttimer (Cork South Central, Fine Gael)
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I am sorry to interrupt the Minister of State but, in terms of having great difficulty getting to the table, he has made a number of requests.

Alex White (Dublin South, Labour)
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I have.

Jerry Buttimer (Cork South Central, Fine Gael)
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Has he received replies?

Alex White (Dublin South, Labour)
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I have. I will mention that when I come to the conclusion of my remarks. In the course of the engagement that we have to have on the draft contract, this particular clause, which has been described as a gagging clause, is one that we will clearly have to address. I think we may well be persuaded that it should be reworded. Conceivably, we may well be persuaded that it should be removed. However, we cannot have a discussion with ourselves on this, and I now come to the Chairman's point.

We cannot negotiate with ourselves. We cannot say all of these things are on the table but, as I said yesterday, there is nobody sitting at the table. On three occasions, I have invited the representative bodies of the general practitioners to meet me in regard to the draft contract. I did so on 31 January, when I met them in person, by letter on 27 February, if my memory serves me correctly, and again last week on 26 March. I want to have the real and meaningful engagement the IMO, for example, has said correctly is necessary on this, the so-called gagging clause and a number of other issues it has raised with me. In fairness to the IMO, it has made a submission in regard to the draft contract which would be the basis for our addressing the issues about which it has concerns. However, it would be much better if we discussed it across the table. I again invite the representative bodies to meet me.

I repeat that if there is any question in anybody's mind that it is my intention, or that of the HSE, the Minister, or the Government to gag general practitioners or to, in some way, prevent people from advocating, for example, on behalf of their patients or from exercising their independent professional judgment, they are wrong in that impression. That is not our intention and we can deal with in negotiation when we get to the table and address it as with all the other issues in the draft contract. I keep describing it as a draft contract.

I can understand the media to some extent. The desire for the rhetoric of back and forth is always understandable, and I do not criticise that; we are in the political world and words come and go. The fact is, however, that when we put out a draft contract in January, that was our proposal in terms of the direction we see the thing travelling. It was not the last word and was never intended to be the last word. Sometimes when I meet general practitioners, I have to explain to them that this is our initial offering for debate, discussion, engagement and negotiation. I repeat that we must resolve this together, in terms of having a contract in place that is in the best interests of patients, citizens, the HSE, the health system and doctors themselves.

On the bureaucracy question, I understand the point that was made in that respect. I have been in GP surgeries and people have pointed out to me the amount of paperwork, e-mails and general administrative work that doctors are being asked to address. Data on population health is a hugely important element of what we need to do in the future in primary care. We need good data. The unique patient identifier legislation is going through the Oireachtas at the moment and in order to manage the health of the population in primary care, we need good data. In that context, we seek the co-operation - and make no apologies for it - of general practitioners and other professionals. This is also about the configuration of resources in primary care. The doctor does not have to be the person who does all the administrative work. Doctors argue that they need resources, and of course there is an issue with resources, but we do not want doctors sitting at a computer all day long. We want the doctor doing the work that the doctor is trained to do. It is an issue of how resources are configured within general practice. I can see that myself when I visit people and I can understand the issue. However, there will be an element of administrative return in general practice no matter what model we adopt. Anyone who looks at international best practice in primary care will see that data collection and return is an enormous part of that. Once we get the proper IT systems in place, it will get easier as we go along. The hard part is at the start but once the systems are in place, it will be possible for it to work in a smooth way in the future. Consultation, engagement and negotiation is what we need to do with regard to the draft contract.

Mr. Tony O'Brien:

I will ask Mr. Carter to speak on the issues around consultant staffing.

Mr. Ian Carter:

If we start with NCHD staffing, there are currently 4,900 NCHDs employed across the 48 hospitals. The majority - I believe around 80% - are on recognised training schemes. Generally, there is no recruitment issue or difficulty in that context and, in fact, there is quite a degree of competition to get onto those schemes. Therefore, the main recruitment issue lies with the hospitals without training recognition which are employing service grades. In terms of the issues raised by the Senator, a survey of NCHDs identified three main concerns. The first was working hours, with certain NCHDs working very significant hours. The second was a perceived lack of training and support, either from the medical school or from the consultants, and the third was a concern about career opportunities.

In terms of moving forward this year, an accelerated effort was made last year and in the first three months of this year to reduce the number of working hours for NCHDs. Last year the target was 68 hours and our target by the end of this year is to be compliant with the working time directive, at 48 hours. The main piece in the last three months was removing the requirement to work shifts of over 24 hours, and that has happened. The other piece in terms of actions this year is to move away from automatic reliance on NCHD deployment and to start, in certain instances, to replace the NCHD workforce with a direct consultant workforce, particularly in areas such as anaesthesia. The aim would be to also increase the number of training posts, thereby increasing the attraction. We are setting a trajectory that our workforce will have some degree of stabilisation by year end, to be achieved by working-hour reductions, consultant replacement and certain tasks being undertaken by the nursing fraternity. However, it is still an area of tension and difficulty. There are active international recruitment campaigns going on to try to attract our extremely good medical staff. This is about us making sure we can retain staff while also recognising that many other Western countries are conducting very vigorous recruitment campaigns.

On the question of the recruitment of consultants, at hospital group level we have been examining the posts for which we have had difficulties recruiting staff with a view to restructuring them to make them more sensible and attractive. That is happening in some of the smaller hospitals in particular, where, without a link to one of the national tertiary centres, the post is unattractive. That is true of at least 25 posts as we speak. It is felt that this will yield an attractiveness which will enable us to fill those posts.

Mr. Tony O'Brien:

I will ask Ms McGuinness to deal with the questions on absenteeism.

Ms Laverne McGuinness:

In terms of absenteeism, we compared ourselves both nationally and internationally because the health service provides a 24-hour service and we wanted to determine whether a target rate of 3.5% is actually achievable in a 24-hour health-related service. There is a continued focus throughout the health system on active management of absenteeism. We are continuously reviewing our sick pay policy. We immediately conduct back-to-work interviews once the employee presents back. We also involve occupational health. Absenteeism is also part of our disciplinary code, so if attendance is unsatisfactory, that can lead, ultimately, to the termination of a contract. A number of people have been taken off our sick pay scheme and we do not continue to pay them as a result. There is not an automatic entitlement to sick pay. This issue is continuously focused on by each manager at all levels throughout the system. The question is whether the target of 3.5% is actually achievable in a 24-hour health-related service.

Colm Burke (Fine Gael)
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What is the situation in the voluntary hospitals, by comparison?

Ms Laverne McGuinness:

I can give the committee information on the voluntary hospitals, which are included in our numbers. I have a detailed breakdown for the voluntary hospitals which I can forward to the clerk. We have also introduced a new sick pay policy. I can give the committee the individual details on the hospitals.

Mr. Tony O'Brien:

Senator Crown raised the issue of differential contracting between conventional private suppliers and the section 38 hospitals. The contract documentation is very different and the relationship is different. St. Vincent's University Hospital is regarded as a public sector employer, as per section 38. In common with other instances that have emerged through the section 38 audit, we have uncovered a number of hornets' nests around the place. These have been aired here and at another committee. The current issue with St. Vincent's University Hospital is one of trust and transparency. At a point in time we were advised in writing that only a handful of public consultants - that is, those without rights to practice off-site - were working in St. Vincent's private facility and that this only occurred in rare and exceptional instances of critical patient care need. Obviously, one would have to accept that such instances could arise. However, what has emerged in correspondence within the last month is a very different story, with dozens of consultants routinely practising in the private hospital and a series of legal arguments advanced in support of that. Our position is very clear. Whatever pretext or grounds have been developed, consultants have been appointed through an approvals process on the basis that they would be public consultants. It now appears that the St. Vincent's Group is seeking, effectively, to operate its private hospital substantially on the back of that provision, where the primary employment is a public employment funded by the tax payer. We will not do anything to jeopardise ongoing patient care, but this does fundamentally impact on our future relationship with that hospital if this situation pertains. We certainly could not see our way to sanctioning further investments in that hospital.

As Senator Crown correctly identifies, one cannot just be pulling the plug from hospitals that are contributing very significantly to the totality of our health care environment, but we need to return to a position where we are no longer operating on the basis of trust because trust, once given and not reciprocated, tends to disappear very fast. We need absolute transparency. There is a new interim chief executive officer of the public hospital. We will shortly be seeking to meet him and the chairman of the group to establish a fresh basis for our future relationship.

John Crown (Independent)
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The information Mr. O'Brien has given is very helpful and I thank him very much for it. I seek clarification. Does he regard the primary problem not as the actions of the doctors but perhaps - I am trying to think of the most discreet and diplomatic way of putting this - the board being a little bit economical with some of the facts?

Mr. Tom O'Reilly:

The doctors are operating under the purported approval of the hospital board to operate in the way they do. I said when the Senator was out of the room that I am certain they are fulfilling their hourly commitment in the public hospital, and probably doing more. This is typical of our consultant colleagues. This is primarily an issue of governance between us and the hospital.

Jerry Buttimer (Cork South Central, Fine Gael)
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It is important that governance be tightened, controlled and managed across the board and that everyone have the appropriate status.

I thank everyone for attending. I remind members of the committee that we are meeting at 12.30 p.m. on the plinth. If the Minister, Deputy Reilly, and the Minister of State, Deputy White, wish to join us there for the presentation of the report, they may do so. I thank all the representatives of the HSE. They may convey to their staff our thanks and appreciation.