Jerry Buttimer (Cork South Central, Fine Gael)
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I welcome the Minister for Health. We have received apologies from Deputies Peter Fitzpatrick and Seamus Healy.

This meeting has been convened for the purpose of considering a Supplementary Estimate for the Department of Health in accordance with Standing Order No. 94A(3). I remind officials that, according to the rules, they cannot speak during the meeting. That said, I welcome Mr. Greg Dempsey and Ms Mary Jackson. 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 Houses or an official, either by name or in such a way as to make him or her identifiable.

Dáil Éireann referred the Supplementary Estimate for Vote 38 to the select committee on 3 December. Pursuant to Standing Orders 82A(3)(c) and (6)(a) and 159(3), we must report back to the Dáil no later than 9 December.

The first part of the meeting will be a short discussion on financial scrutiny, particularly how we can improve the Estimates process and the financial scrutiny of the Vote for the Department of Health. In this regard, members were only given the relevant information shortly in advance of the meeting. They will be aware that the OECD recently presented a report on a review of budgetary oversight by parliaments. In the Irish context, the report placed the Oireachtas at the bottom of the international rankings for parliamentary oversight of budgets. This is exemplified by the fact that the committee only received the Supplementary Estimate material yesterday, 7 December, which gave members very limited time to consider the issues involved or carry out a proper analysis of same. I ask that in the future the Department and the committee work together more closely to ensure information will be provided for members in a more timely fashion. In the context of parliamentary oversight, there must be a better way to do business. I hope the Minister will agree that the provision of financial information for a select committee of the Oireachtas should be given priority by his Department. I also hope he will join me in finding ways to improve both the quality and timeliness of financial information provided for the committee, including on the Estimates, in order to enhance performance based scrutiny. Is that agreed?

Leo Varadkar (Dublin West, Fine Gael)
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I totally agree. The Supplementary Estimate was only agreed to by the Cabinet on Wednesday last and I only had the excruciating, up-to-date detail myself on Friday. It is not satisfactory all round that we all have to make these decisions within such a short timeframe. After five years in government we probably should have done more about it, but perhaps the position will improve in the next five years.

Jerry Buttimer (Cork South Central, Fine Gael)
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Is everyone happy to move on?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Yes.

Jerry Buttimer (Cork South Central, Fine Gael)
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I call on the Minister to make his opening remarks.

Leo Varadkar (Dublin West, Fine Gael)
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I thank the select committee for giving me the opportunity to present the Supplementary Estimate for Vote 38. The total additional funding being sought for 2015 is €665 million. However, this figure is offset by the receipt of an additional €65 million in respect of the UK-Ireland bilateral health care reimbursement agreement, leaving a net requirement of €600 million, as indicated on budget day.

The Department of Health is one of many Departments seeking a Supplementary Estimate this year. While the amount sought is significant, it is worth noting that it represents less than 5% of overall health expenditure. In percentage terms, the Department of Health does not have the largest Supplementary Estimate this year, but the Supplementary Estimate does recognise the particular challenges to be balanced in the health sector and the priority the Government attaches to addressing unmet needs.

Rising employment levels and an improving economy have made extra spending on the health service and in other priority areas of public expenditure possible, while still comfortably achieving our deficit and debt reduction targets. We need to keep the recovery going and the economy strong in order that in the years to come we can hire more nurses, therapists and medical specialists and provide more services and new infrastructure. We must not repeat the mistakes of the past.

There are significant drivers of demand and costs within health services which are a source of pressure on health budgets. We face a growing and ageing population, with a considerable burden of chronic illness. New expensive technologies are developed and approved every year. There will always be more that we would like to do in the health service than we can afford, but thankfully, because of our very strong economic recovery, we can afford to do more now than we could during the economic crisis.

It is welcome that this year's economic performance has provided us with scope to significantly increase budgets and provide for additional acute hospital capacity, long-stay and home support for older people, new drugs and appliances, additional discretionary medical cards and access to universal GP services for the very young and the very old for the first time. In each of these service areas the funding sought will allow additional people in need of health and social care to benefit. There is also provision in the Supplementary Estimate for unavoidable costs in 2015 outside these service areas. It is preferable, where there is room to do so, that these be addressed without the need for reductions in service areas. It is also welcome that, in general, where responses and service improvements have been approved and implemented in 2015, the funding is in place for their continuation into 2016. This will provide an enhanced basis on which to address the health needs of the population next year.

I will now set out the items making up the Supplementary Estimate. During the course of 2015 I took the initiative to discuss with Government colleagues the need to anticipate and deal with emerging problems in a number of critical areas of the health service. In particular, specific target initiatives were approved to reduce delayed discharges in acute hospitals, waiting lists and emergency department overcrowding. We all know that the health service is constrained in its capacity to respond to growing demands, particularly for acute hospital services. While we cannot introduce all the capacity required overnight, we worked with hospitals and community services to address responses that could be introduced relatively quickly.

The problems in emergency departments are the manifestation of wider operational and capacity weaknesses. The emergency department task force was convened last December and came up with a set of recommendations to reduce emergency department overcrowding. I acted to support their implementation and secured an additional €74 million to do so. This funding came on top of measures already taken in budget 2015, when the Government provided €25 million to support services that provided alternatives to and relieve pressure on acute hospitals. This funding has allowed us to reduce the waiting time for the fair deal nursing home support scheme from 15 weeks to four. This cost approximately €44 million and an additional €35 million will be provided next year to keep the waiting time at two to four weeks. It has also allowed us to open another 150 community beds, including at Mount Carmel Community Hospital, formerly a private hospital, and at Moorehall Lodge in Drogheda under a public private partnership arrangement. These and other measures have, in turn, reduced the number of delayed discharges in hospitals from 850 to 558 as of 1 December. This means that almost 300 acute beds have been freed up and are available every day to treat acutely ill patients.

We have also used the funding to keep patients out of hospital altogether or allow them to return home earlier through community intervention teams. These are nurse-led teams of health professionals who provide a rapid and integrated response in the community or home for patients with an acute episode of an illness who require enhanced services for a defined, short period of time. The community intervention teams provide a range of services, including administration of intravenous antibiotics at home, wound care and dressings and enhanced nurse monitoring following fractures, falls or surgery. Last month an infusion service commenced in north Dublin. This community based service provided by the community intervention team is linked with Dublin's northside hospitals.

There are currently ten community intervention teams in operation across the country and it is expected that a new team will commence operations in Waterford shortly, under CareLock. To date this year, more than 16,500 patients have received a community intervention team service. On average, this equates to a saving of between five and ten hospital bed days per patient and represents a significant saving on hospital resources. It is better for patients and avoids unnecessary emergency department visits and hospitals stays. We need to do a lot more of this in the years to come.

At the start of the year I put in place maximum permissible waiting times for inpatient and day case treatment and outpatient appointments of 18 months by 30 June 2015 and 15 months by year end. Additional funding of €51 million has been provided to ensure that these maximum waiting times are achieved. The funding provided is intended to fully utilise capacity across public and voluntary hospitals as well as outsourcing activity where the capacity is not available to meet patient needs within the maximum allowable waiting time.

The latest NTPF figures, published yesterday, continue to show improvements in waiting times with significant reduction in those waiting longest now clearly evident. For November, reductions were achieved in the total inpatient day case waiting list, and in the numbers of patients waiting longer than 15 months and waiting longer than 18 months. Similarly, there are reductions in the total number of people waiting for outpatient appointments, which has now fallen below 386,000 for the first time this year. As Deputies will be aware those figures include anybody who is waiting any amount of time, even if only a few weeks. Through facilitating additional clinics outside conventional working hours or by outsourcing where capacity is limited, the end of November sees a reduction of more than 11,000 in the overall outpatient waiting lists and of more than 10,000 in the number of people waiting more than 15 months for appointments. It is encouraging to see that the number of people waiting more than 18 months has also decreased by 4,000. The reductions being achieved are very welcome and I want to ensure these very positive trends are sustained and continue. Further additional funding of €18 million was provided in July for a winter initiative, which includes the provision of approximately 300 additional hospital beds across the country in November and December.

The situation in emergency departments is extremely challenging and I recognise the difficulties experienced by patients and the frustration of staff. However, we are seeing some improvement as the measures taken and under way make a difference. These measures are fully in line with the recommendations of the emergency department task force and are now generating results. The special delivery unit figures show an 8% drop in the number of patients on trolleys in November 2015 compared to November 2014. While INMO figures for the month of November show a 3% rise, it is significant that the INMO's own figures show an 8% drop in the second half of November. Today, for example, the special delivery unit recorded a peak of 325 people of trolleys, 135 for more than nine hours. That is a 20% drop on this day last year, when the number was 404. Today's figures for the Irish Nurses Midwives Organisation, taking both trolley watch and ward watch together, put the number at 411, down 15% on this time last year when the number was 461. It is nothing to celebrate but it shows we are moving in the right direction for the first time in a long time.

Further beds are due to open this month. We are headed in the right direction and must persist with the considerable efforts under way right across our health service. The November numbers, or today's numbers, whichever are used, are a big change from August when overcrowding was 40% worse than August 2014 and it is clear that things are not as bad as was the situation early in the new year when there were 500 to 600 people on trolleys. These were all real actions taken on my directions, with resources I secured, with the assistance of the Minister of State, Deputy Kathleen Lynch. These actions are starting to show some results. These are actions and solutions, not commentary, criticism and analysis which is all we get from the Opposition. The HSE director general and his team are working closely with the worst affected hospitals and there will be a continuing focus on achieving further improvements throughout the winter and into next year. There are expenditure overruns in acute hospitals, social care services and the PCRS and the factors are different in each case.

Acute hospitals are projected to be €149 million in deficit by the end of the year. The deficit is predominantly caused by non-pay cost pressures, with non-pay costs projected to grow by 5.5% in 2015 compared to 2014. All hospitals internationally are seeking to manage such costs which are associated with the increased age and complexity of patients being treated. I notice that many chest hospitals this year are €2 billion over budget. Additional payroll costs have been incurred including through the recruitment of some 2,300 additional acute hospital staff, of which significant numbers are front-line doctors and nurses. The impact of risk-related reports and difficulties in recruiting and retaining medical and nursing staff has put strong upward pressure on pay costs in some hospitals. Having a stable, well trained workforce in place is essential for the performance of hospitals in terms of access, quality and cost. With the removal of the recruitment moratorium this year progress was made by a number of hospitals in this area but others have more work to do. There has been underachievement in certain cost reduction initiatives. That being said, it is projected that €25 million in savings will be made on agency expenditure compared to 2014 levels, which is a significant saving. However, this is less than the target for the year and there will be a continuing focus on this area in 2016, particularly for those hospitals that did not make as much progress as expected. We see considerable variation from one hospital group to the next in terms of how they managed their budgets this year.

The primary care reimbursement service, PCRS, has a projected deficit of some €151 million. This comprises a deficit of €136 million on schemes administered centrally and a deficit of €15 million on locally administered schemes, including for the provision of aids and appliances, such as crutches and wheelchairs. The PCRS overspend is driven predominantly by increased expenditure on the long-term illness, LTI, and the GMS schemes, including high-tech medicines. The increased burden of chronic illness, including diabetes, is seeing the costs of the LTI scheme grow significantly.

The introduction and increased prescribing of new and innovative but highly expensive medicines is increasing the cost of the high-tech medicines scheme. Earlier this year, agreement was reached with the Irish Medical Organisation on a package of measures, including terms for the delivery of GP care without fees for all children under six years and the provision of GP care without fees to seniors aged 70 years and over. These represent the first phase in the delivery of universal health care. We intend to move on to children aged six to 12 years in the next phase. The introduction of universal GP services for the very young and the old has been highly successful. As of 1 December some 2,242 GPs or 93% of all GMS contract holders have signed under-six contracts. More than 214,000 children have been signed up for the new service.

The new enhanced service involves age-based preventive checks focused on health and well-being and the prevention of disease. These assessments are being carried out once when a child is aged two and again at age five. This is important in identifying issues such as childhood obesity early on. The contract also covers an agreed cycle of care for children under six years diagnosed with asthma, under which GPs are carrying out an annual review of each child. As of 1 December, 18,700 children have been registered for the new service under the Asthma Cycle of Care by their GPs. With regard to the universal GP service for seniors aged 70 or over, more than 49,000 people have already signed up for the service.

The HSE, Department and the IMO have commenced talks on a new comprehensive GP contract. A priority of these discussions will be further enhancement of chronic disease management for patients. As a first step in this process, agreement was reached on the introduction of a diabetes cycle of care for adult patients with type 2 diabetes who hold a medical card or GP visit card. The cycle of care aims to augment the service available to diabetic patients prior to the introduction of a comprehensive structured chronic disease programme. The cycle of care commenced on 1 December and to date more than 59,000 patients have been registered for the new service by their GPs.

On the increased costs of operating the PCRS, at the end of October there were 95,887 people covered by a discretionary medical card - the most recent figures are more than 100,000 - an increase of 23,000 since October 2014. This reflects the significant changes made to the rules and guidelines for discretionary medical cards more than a year ago.

Social care services give rise to a net requirement of €53 million additional funding. The main issue within social care relates to disability services with a deficit of €48 million. Significant staffing and once-off minor capital pressures have arisen in response to the enhanced regulatory focus by HIQA on disability residential services. This enhanced focus, with external inspection and publication of reports, is a very good thing and is in line with the legislation adopted by this House. The problems being identified by HIQA in disability services and in care for older people cannot be new, they must have been going on for decades. The difference is we are now doing something about it.

It is important that these improvements are planned and undertaken in a cost-effective manner and in line with the community-based model of care. This will be the focus of the use of significant additional ongoing funds provided to these services in 2016. The Supplementary Estimate also provides for pay cost pressures in respect of overnight residential staff in the disability sector.

Pension costs including pension lump sums require an additional €52 million. The scale and number of retirements in any financial period is difficult to predict with certainty and, in line with some other Departments with large numbers of staff, additional funding is required in 2015 to meet the pension entitlements of those retiring. In the main, these are front-line and clinical staff.

Payments are made by the HSE to the State Claims Agency for clinical indemnity, public liability and other awards and settlements. An additional requirement of €93 million is estimated for 2015. It is difficult to predict the exact expenditure in any one year as this is dependent on the number and severity of claims, particularly the number of high cost catastrophic birth injury claims. Another critical variable in projecting the cost is the uncertainty regarding whether these high value claims will be awarded lump sum payments by the courts, or whether they will be awarded a deferred periodic payment award pending the introduction of periodic payment orders on a statutory basis. I expect legislation to be enacted early next year to provide a statutory basis for periodic payment orders, whereby a court may decide that catastrophically injured people can receive the cost of future care in the form of annual payments instead of a lump sum award. If this legislation is enacted and works we may have an underspend in State claims next year, but we are not projecting for that.

The Government approved the independent symphysiotomy payment scheme and the scheme commenced in November 2014. It provides awards to women who have undergone surgical symphysiotomy or pubiotomy. It was estimated that approximately 350 women would be eligible to apply. In the event, 578 applications have been accepted by the scheme. There are approximately 140 applications still to be assessed. The scheme will conclude as soon as possible in 2016.

In 2012 the Medical Defence Union made a settlement with the State in respect of outstanding past liabilities relating to indemnity cover for medical consultants. Work is under way to delegate responsibility for managing these claims to the State Claims Agency. Pending completion of this work, payment of these claims must be made by my Department. It is estimated that €16 million of the Supplementary Estimate requirement will be sufficient to address these areas.

As Deputies may be aware, €131 million of once-off cash receipts from health insurers were built into the 2015 budgetary arithmetic. The HSE and VHI have now agreed terms which commit the HSE and VHI to work towards finalising a claims and payment arrangement and allows for an initial payment of more than €100 million before the end of 2015. This represents a substantial portion of outstanding private patient charges. I welcome the progress made in this area by the HSE, with the support of my Department and the VHI. Discussions are continuing between the HSE and other health insurers and I hope that these can also conclude positively and with agreement.

While I acknowledge that the extra funding being requested through this Supplementary Estimate is substantial, I am convinced that it facilitates much needed improvements in our health services. This additional funding, combined with the 2016 budget provision, will see us continue to use the fruits of economic growth to restore funding to our health service. In doing so we are maintaining and adapting existing levels of services and introducing enhancements in some priority areas. The above items, together with cash projections to year end, involve a gross requirement of €665 million. The total Supplementary Estimate request reduces to an Exchequer requirement of €600 million following the receipt of an additional payment under the UK-Ireland Reimbursement Agreement. In conclusion, I seek the committee's approval of the Supplementary Estimate, Vote 38.

Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the Minister. We are in the invidious position of short timescales for advancement of information and looking at the principle of Supplementary Estimates in the no-change policy areas. We accept there have to be Supplementary Estimates. However, year in and year out we have notifications of a Supplementary Estimate, knowing well in advance that there has to be a requirement for a Supplementary Estimate simply because there was inadequate planning, forecasting and demographic proofing. That all flows from the inability of the Department of Health and Children and the HSE to actually assess what it needs for the year ahead, and put a figure on it. The Department and the HSE is incapable of doing it and this has not changed in recent times, in fact it has become progressively worse. The figure of €665 million, some of which I know has been because of changes in policies, is still a significant Supplementary Estimate considering that some of the policy decisions announced in 2014 that would have had an effect could have been factored into the 2015 figures also.

We have not progressed in accountability either. The Department of Health, the Minister, senior officials and the HSE at senior management level are incapable of actually managing a budget. It is a harsh thing to have to say but that is the simple fact of it. It has been chaotic at times. I understand the need for Ministers to flex muscles at times or to try to get a headline in the newspapers. We have seen the previous Minister for Health trying to face down the cuts that were forced by the Department of Public Expenditure and Reform. However, behind all that and when one strips it away there is a chaotic system - which is an oxymoron I suppose. It is an issue which must be addressed because, fundamentally, if we are serious about delivering health care and services for people under the obligation of the State to provide public health services, there needs to be a foundation and a base upon which the year ahead can be planned.

The question must be asked whether the Minister holds back on always having a Supplementary Estimate because he knows full well the HSE is incapable of managing its budget itself. If that is the case it is a damning indictment of the HSE. Does the HSE always know there will be pressure on at the end of the year and that a Supplementary Estimate will come in anyway so there is no real inclination or obligation to make an effort to maintain the services within budget? It is probably a little bit of all of the above. When one does not have certainty, security or a defined plan to implement health services then one gets panicked situations at the end of the year. It happens time in and time out in the provision of health care. With the Supplementary Estimate some procedures can be ramped up while other services are cut in order to try staying within budget. It all seems to be chaotic.

The Minister talks about the potential privatisation of hospital trusts in the years ahead, or at least farming out the management of hospital trusts or groups to private companies. Is the Minister concerned about the consistent, major overspend in our acute hospitals as currently constituted? Is there an incentive for acute hospitals to overspend on a continuous basis knowing that when the trolleys are out as far as the car park, the ambulances are backed up and patients are unable to discharge, the political pressure comes on and all of a sudden extra money is allocated at the end of the year under a Supplementary Estimate? Old habits seem to not have gone away on the Minister's watch. Perhaps he could elaborate on that.

The Minister made announcements on increases such as the €74 million for emergency department overcrowding and late discharges and €25 million for the fair deal scheme. That was indicated to him as far back as July 2014 when, on taking up his position, the Minister was briefed that delayed discharges were going to have a major impact on health care in terms of freeing up additional beds, moving patients from emergency departments into the hospital proper and moving people out of hospitals into step-down facilities in the community, nursing homes and home care packages.

It seemed there was a very long and lethargic effort to address that obvious challenge facing the health services in general. I acknowledge matters are moving along much better in the accessing of nursing home care. Clearly, much work needs to be done on the community care area, home package supports and so on.

With regard to the National Treatment Purchase Fund, I note the Minister stated that, "Funding of €51 million was provided to ensure that these massive waiting times would be achieved .... across the public voluntary hospitals ... [and] outsourcing activity where the capacity is not available." He abolished the National Treatment Purchase Fund and set up a special delivery unit but who procures the extra capacity? Is it the National Treatment Purchase Fund and, if it is, why do we not say that? Why are we pretending that the National Treatment Purchase Fund has been castrated and is now effectively unable to do what it was meant to do? We should try to bring it to the fore again to deal with the capacity issues. We all accept there are difficulties with capacity in the public health system. That is the reason we have seen major increases until recently in the number of outpatient, inpatient, day-case and other elective procedures. If there is a capacity issue in the public hospital system, admitting it would help and the National Treatment Purchase Fund should be reintroduced to provide and procure private capacity to deal with the backlogs. I cannot understand why we seem to be pretending that we do not outsource when we are outsourcing, which effectively means purchasing from the private sector.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome the Minister and his officials. I disagree with Deputy Kelleher in lumping the HSE in with the Minister, the Department of Health and the Government on the issue of the assessment of need and the capacity to operate within budgets. As I well recall it, the HSE sought substantially more than was afforded to it for funding for the service plan for 2015. Its assessment was more in line with the reality of this year and the additional provision being provided under the Supplementary Estimate before us. It was the Minister and the Government who failed to provide the required funding. On the reference to HSE's incapacity to operate within budget, again I believe Deputy Kelleher is wrong about that. I believe it has the capacity but with under-resourcing, underprovision and a fault line in regard to accurate forecasting of the potential presentation of footfall, it would have found itself in a very difficult, if not an impossible, situation over the course of this year and that manifested itself on a number of occasions. The bottom line in regard to all of that is underprovision and insufficient resourcing with the result that it had neither the human resources nor the physical wherewithal to cope within reasonable timeframes.

I would make a number of points in response to the Minister's opening remarks. The €600 million he is seeking now is €65 million less than has been adjudged required to bring us up to the end of this month. Can he clarify for the record if the €65 million additional payment in respect of the so-called UK-Ireland bilateral health care reimbursement agreement has been received? It is important to note that he referenced in his remarks the difficulty there has been historically in having private health insurers provide payment for specific service provision and that he is now seeing a €100 million initial payment. Is that an upfront payment? There was not necessarily a correlation but a joint difficulty of taking the money from the health insurer entities and in regard to the British arrangement. Is this money promised or has it been received?

When the Minister talks about addressing the areas of unmet need, he is again confirming the situation, to which that I have alluded, with respect to the HSE. This is unmet need and it is unmet most certainly because of under-resourcing and undercapacity.

I wish to make a number of other brief points. On the emphasis on reduced delayed discharges, reduced waiting lists and reducing emergency department overcrowding, these are the areas of critical concentration in dealing with the issues in the hear and now which I believe will continue to be the areas of critical concentration. It is important that everything is done to address these matters as quickly as possible. The Minister stated that he cannot introduce all the capacity required over night but that he has responses in train that could be introduced relatively quickly. Will he elaborate on the specific set of measures he hopes will be in put place now and towards the end of this month to get us through this last period of 2015? Has there been an uptake in terms of nurse recruitment? Apart from the winter months initiative in regard to the additional 300 beds, are other bed capacities being created that would add to that much needed resource to deal with the numbers presenting, which is expected to continue to rise.

There are a number of points to be welcomed and it would be wrong of me not to do so. We have seen a significant reduction in the delayed discharges from 850 to 558 as of the beginning of this month. The delivery of that improvement will compliment the additional bed capacity but there is no reason to be complacent. Delayed discharges are indicative of underprovision with respect to future care needs, either in terms of home care packages or residential long-term care provision. It is important we recognise that this needs to be part of any package of measures to address this particular vexed difficulty.

The Minister stated that at the start of the year, he put in place maximum permissible times for inpatient and day-case treatment and outpatient appointments but, in fact, what he actually did is not what he said he did. He actually extended the maximum permissible waiting times in each of these areas up to 18 months. That is something that needs to be revisited. Eighteen months in that respect is unacceptable. We heard voices on his side previously, either in this committee or in the Dáil Chamber, which were hugely critical of much shorter waiting times across inpatient and outpatient need, including day-case treatment, and yet we have permissible waiting times now of up to 18 months and 15 months by the year end. What is current position on that?

The number of people waiting for outpatient appointments has fallen below 386,000. We should reflect on that number for a moment - there is no reason for celebration in this matter.

We have a huge job of work to do and I emphasise "we" because it is critically important that these matters are addressed comprehensively across the board.

I will conclude with a brief comment on the nine hour wait on trolleys and the Minister's recent indication of a penalty on hospitals that exceed nine hours. That is the wrong way to go about the matter. It is not about penalising those who fail to realise a timeframe regarding trolley use for patients. Those hospitals may well be the hospitals that need even more support.

Jerry Buttimer (Cork South Central, Fine Gael)
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I propose to move on to the subheads of the Estimates and we will go through individual subheads on the Vote. I remind members that we are only considering the Supplementary Estimates and while members may discuss issues relevant to the individual subheads they may not recommend an increase or decrease as there would be no Votes taken by the committee. I propose to go to subhead D.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Will the Minister clarify why there is an increase in the miscellaneous legal fees? The Minister said there was an overall increase of 310%. Could the Minister say if the HSE's own legal service could be better utilised to try to reduce the fees paid to other legal firms?

Jerry Buttimer (Cork South Central, Fine Gael)
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Have members any further comments on subhead D?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I would like a clarification please on subhead D and the rest. Are these the actual sums or are noughts not shown?

Jerry Buttimer (Cork South Central, Fine Gael)
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No, the figures are for millions.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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That is not indicated. It is important to point out for the record that the graph detail provided to members does not indicate that those figures are millions of euro.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is our fault here and it will be rectified for the next year, if we are still here. Deputy Ó Caoláin will probably still be here.

Leo Varadkar (Dublin West, Fine Gael)
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Does the Chairman want me to reply to everything that has been said today?

Jerry Buttimer (Cork South Central, Fine Gael)
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Just to subhead D.

Leo Varadkar (Dublin West, Fine Gael)
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On the matter of legal fees?

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

Leo Varadkar (Dublin West, Fine Gael)
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The increase in the figure for miscellaneous legal fees relates to the symphysiotomy scheme; legal fees for the HSE side, the legal fees which were paid for the women and the cost of settlements.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Is that the HSE's own legal teams or outside legal services?

Leo Varadkar (Dublin West, Fine Gael)
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On occasion the HSE uses external legal advice which is done on the basis that it is cheaper to get external legal advice from an expert on a particular issue than to have that expert on staff. Because we have an independent referral Bar, any barrister the HSE uses to appear in court must be external. The best way to save on legal fees is to look again at the HSE's legal strategy, but that is another day's work.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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We have seen where there is an acceptance and an apology much earlier it is better than waiting ten years and dragging good people through the courts.

Leo Varadkar (Dublin West, Fine Gael)
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Yes. I do not have access to individual patient information or legal files so I do not know much about many of those cases. However, I do know from one or two cases that the media can report the cases as being ten or 13 or 14 years on the go. Actually the claim itself is not made for years until a child is ten or 11 years of age, which is not reported.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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This is not a criticism in any way of the Minister, but if a child is born with a disability and needs help it is in the early ages that the people, the parents and family need the money. They do not need to be dragged through the courts fighting day in and day out. These parents have appeared before this committee and members have heard terrible cases. Parents need that money early on to put services in place for their children.

Leo Varadkar (Dublin West, Fine Gael)
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I have a particular view on that. Bear in mind why these cases occur, why they end up in the High Court, why they do not end up in court and why settlements are made out of court - it is because the parents or the patient are alleging medical negligence as the reason they have cerebral palsy, for example. It is a scientific fact that in those cases cerebral palsy is not caused by negligence, it is because of something that happened in the womb. That is essentially what this boils down to. The no-fault way would be a better way to do this by saying: "A child with cerebral palsy needs support. Whether it was a natural occurrence or medical negligence is not the point, let us just look after all these children." This requires a total change of policy and a significant increase in costs because one would then be treating equally those who could prove medical negligence and those who cannot. It would mean that in cases of cerebral palsy occurring for natural reasons - which is usually the cause - those children should get whatever supports they need anyway. While that would be a totally different approach and a very costly one, I think it would be the right one.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Could the Minister indicate if he has figures on the symphysiotomy redress scheme regarding the total paid out, or committed to be paid, up to this point in time?

Leo Varadkar (Dublin West, Fine Gael)
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So far €23 million has been paid out, until the end of November 2015. There are 140 cases remaining to be assessed and paid.

Jerry Buttimer (Cork South Central, Fine Gael)
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I will now move on to subhead H. Deputy Kelleher and I attended a meeting last week with three members of staff who had retired six months ago from an organisation under the HSE and who had not yet received their lump sums. I welcome the Minister's figure of an additional €52 million for lump sums. I understand it may not be in his direct remit but these people have given huge service and since they retired have not yet received their lump sums despite ongoing involvement of members of the Houses and the HSE. Could the Minister clarify if there is guidance or direction given to the HSE regarding this? We thought it had been resolved but it seems not to have been. I apologise to Deputy Kelleher as I had interrupted him.

Billy Kelleher (Cork North Central, Fianna Fail)
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I will elaborate on the point raised by the Chairman. It is a section 38 so it is really just the facilitator of paying the lump sum. One wonders if it is an effort by the HSE to roll the lump sum into 2016. It would not surprise me at all that these old tricks happen from time to time. I do not know whether that is the case or not but I would be very concerned if individuals who have given a lifetime of service in the provision of health care and who retire are left waiting for their lump sum. Is that six months on?

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

Billy Kelleher (Cork North Central, Fianna Fail)
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I do not know any Secretary General in a Department who waits six months for their lump sum. I have checked it out and unless I am misreading it that has not happened in the Department of Health in recent times and certainly not in most other Departments. It is extraordinary that, with a provision of €52 million, the Department cannot pay out lump sums which are due to people. I urge the Minister to look at that situation and if his Department is short of money he might keep it from those on the higher pay scales and first give the lump sum to those on the lower pay scales.

I will now turn to the matter of pensions. I understand there is difficulty in assessing how many people are going to retire.

I know it is probably a bigger issue, but will the Minister consider including in all employment contracts a longer period of notice than the statutory notice period for people who wish to retire early? I am not proposing a change in contract law but asking whether it is possible to facilitate additional notice or even a requirement that people indicate they are considering retirement. From time to time, the health service experiences large, rapid outflows of staff, frequently as a result of the conditions and pressures they face. The lack of resources and so on sometimes causes staff to throw in the towel. The departure, over a short period, of staff with a wealth of experience has impacted on the ability of the health service to deliver and resulted in a serious loss of corporate memory, medical knowledge and experience.

Leo Varadkar (Dublin West, Fine Gael)
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I am not familiar with the details of any of the individual pension cases the Deputy raises and, in any case, I do not have a role in adjudicating on such matters. If the individuals in question were employed by section 38 organisations, they would not be Health Service Executive or departmental employees but employees of another body. To the extent that there is any policy direction to the HSE, it is that individuals who are legally entitled to payments should be paid.

Jerry Buttimer (Cork South Central, Fine Gael)
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The problem is that they have a legal entitlement to payment. The committee met representatives of the Health Service Executive and the individuals in question. As Deputy Kelleher stated, the three individuals involved have given more than 100 combined years of service. I know them personally and they are dedicated individuals. They did not have high salaries but worked in nursing and administration. They have given long service and it is appalling that they continue to wait for lump sums. We have been informed that the money has been provided, yet they have still not received their payments. I know that is not the Minister's fault. This is, however, a forum for members to raise the issue because the individuals in question should not have to wait.

Leo Varadkar (Dublin West, Fine Gael)
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The Chairman raises a fair point. As far as I am aware, €52 million is exactly what the HSE asked for in terms of supplementary expenditure for pensions. If the individuals in question are legally entitled to lump sums, these sums should be paid. I would certainly not like the HSE to roll the payments into next year because every year is tight in health. I would prefer if the executive cleared all of its bills this year, rather than leaving some of them over to next year.

On retirements, I understand all employment contracts require three months notice. While it may be possible to change the period of notice to one year, this would require a change in contract. Requiring someone to give one year's notice before retirement would also have other consequences. Many retirements were linked to the Haddington Road agreement. Under the accelerated retirement process, people left the public service early and received a better pension.

Billy Kelleher (Cork North Central, Fianna Fail)
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I am referring to senior levels of the health service, rather than all levels across the service. Perhaps a longer period of notice could be required of those who advance into senior management and clinical roles in the health service. When a large number of senior staff walk out the door in one fell swoop it causes immediate problems.

Leo Varadkar (Dublin West, Fine Gael)
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This is a particular issue with consultants and single-handed general practitioners who can be extremely difficult to replace if they retire at short notice. The replacement periods are often the genesis of service gaps.

The head of primary care, Mr. John Hennessy, has started a specific project with the new community health care organisations, CHOs, to identify general practitioners who are likely to retire in the coming years in order that succession planning can commence. This is particularly important in rural areas and areas where there is a single-handed practice. Some hospital groups where it is known that consultants will retire have started to make what are known as proleptic appointments. This was already done to some extent. It means that if it is known someone will retire in three, four or five years, the post may be given to a registrar, for example, who is heading off to America. This proleptic appointment means the job is available should the registrar wish to return. We could do much better on succession planning than has been done to date. If it was politician succession planning, it would certainly be done much better.

Jerry Buttimer (Cork South Central, Fine Gael)
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We move to subhead I1.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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On subheads I1, I2, I3 and I4-----

Jerry Buttimer (Cork South Central, Fine Gael)
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We will take each of them separately.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I would like to ask a comparative question.

Jerry Buttimer (Cork South Central, Fine Gael)
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That is fine.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Noting the increased provision of 3%, particularly the much stronger base from which subheads I3 and I4 operate, consequently securing a significantly larger supplementary provision for the end of 2015 than subheads I1 and I2, HSE Dublin Mid-Leinster and HSE Dublin North East, did the HSE carry out an exercise to confirm need in each of the four regions in questions, rather than simply providing for a blanket percentage increase? There could be circumstances within subheads I1, I2, I3 and I4 where greater need can be identified.

Do these named HSE regions coincide with the new designated hospital areas? I assume they cover more than simply the hospital groups, in other words, all the various service needs, including community health services and mental health services. I presume this is the wider picture for each of these areas. To take subhead I.2, Dublin North East, elective orthopaedics are no longer provided in the entire new RCSI region. The former elective orthopaedic hospital at Our Lady of Lourdes Hospital in Navan is now in a very different entity. This has a significant impact in terms of the range of services that are available to people across the RCSI group of hospitals. In any event, to return to the basic premise of the question, which relates to the critical 3% figure, would it not have been a better exercise to establish need rather than to increase expenditure by a percentage figure? Is there a logical, assessed basis of need that has determined the various figures provided?

Jerry Buttimer (Cork South Central, Fine Gael)
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We will discuss the subheads together.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I am not sure if BreastCheck comes within subhead J1 or subhead I1.

Jerry Buttimer (Cork South Central, Fine Gael)
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It comes under subhead K1.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Is BreastCheck a primary care service?

Leo Varadkar (Dublin West, Fine Gael)
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It comes under health and well-being. My apologies, I cannot say which subhead it comes under. I must give the Deputy an Alice in Wonderland answer. Once upon a time, when I was a senior house officer in St. James's Hospital, I used to get a pay cheque from what was known as the Western Area Heath Board, an entity that no longer existed at that time. Similarly, the regions referred to here no longer exist. We have moved away from regions to hospital groups, as Deputy Ó Caoláin noted, and community health care organisations, CHOs. A range of national services are also in place, including the national cancer control programme and the health and well-being programme, under which BreastCheck would fall. As such, accounting continues be based on regions that no longer exist.

Beneath it, the health boards still exist on a financial basis. While we have national services such as the National Ambulance Service, for payroll purposes the ancient health boards still exist. A major financial reform is required in the health system to align how the accounts work with how the service is configured. This is a big job that must be done over the coming years and it requires a big IT investment.

There is no logical basis for funding across regions. It will happen for the hospitals with activity-based funding. Generally, people in health are funded on a historical basis. They receive the allocation they received the previous year, plus or minus an certain amount. This is not the way to do it. Hospitals will move to activity-based funding whereby they will be paid for the work they do and the procedures they carry out. Similarly, for the community health organisations there will be an assessment of population need. Beyond this are the national programmes. The HSE Dublin north east region includes the Mater hospital, which could be providing cardiology and cardiothoracic services to the entire country. It also includes Beaumont Hospital, which could provide neurosurgery for the entire country, other than Cork.

It will never be straightforward. Although the old legacy regions no longer exist, they are still used for accountancy purposes, and it has not changed much. Even after the HSE was established ten or 11 years ago, the health boards were never abolished. It is Byzantine, and will take more than the months remaining to me as Minister to sort it out. It is very hard to justify spending tens of millions of euro on new financial systems and be told one is wasting money on IT systems and accountants when one should be spending it on front-line services. However, if we do not start spending some money on those areas, we will never really be able to implement the "money follows the patient" model.

Jerry Buttimer (Cork South Central, Fine Gael)
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It is a good point.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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BreastCheck was to be extended to include women from 65 to 69 years of age. Is there provision for it in the Supplementary Estimates?

We have done cochlear implants in Beaumont Hospital very well in the past two or three years.

Leo Varadkar (Dublin West, Fine Gael)
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While the accounting is done top-down from these health regions that no longer exist, the management of the budget is bottom-up. People receive the money and they budget and spent from the bottom up. It is all put together again at the top and reallocated to the different areas. The roll-out of BreastCheck to women aged 65 to 69 was in the service plan and is in the Estimates, and it has started already.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Good. It is a very good, top-class service.

Leo Varadkar (Dublin West, Fine Gael)
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It is. The first cohort of women in the group will have received their invitations and many will have had their mammograms.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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There is a Senator saying it is not happening.

Leo Varadkar (Dublin West, Fine Gael)
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It is happening; however, it is being rolled out over four years. Women aged 65 or 66 will have received invitations during the past few weeks. Women who are now 69 will be 70 or older by the time it gets to them. We can only roll it out at a certain speed, given that we must supply the kit and hire the radiographers and radiologists. It is happening on schedule.

Jerry Buttimer (Cork South Central, Fine Gael)
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Has the HSE signed off on the service plan for 2016?

Leo Varadkar (Dublin West, Fine Gael)
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I have the service plan, but it has not yet been signed off by the Government. It needs to go around the Departments. I intend to bring it to the Cabinet next week.

Jerry Buttimer (Cork South Central, Fine Gael)
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We had hoped to have our usual meeting on it before the recess, but will not be able to. Are there any questions on subheads I1, I2, I3 or I4? Subhead I5 is grants in respect of other health bodies, including voluntary joint hospital boards.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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There is no specific reference to disability services across the different subheads. Is it possible that within subhead I5 there is additional money for disability services?

Leo Varadkar (Dublin West, Fine Gael)
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Disability services come under social care and today I am asking people to vote through €48 million for it in the Supplementary Estimates. It is mainly to provide for the additional staff and capital improvement works that had to be provided to meet the HIQA requirements.

Jerry Buttimer (Cork South Central, Fine Gael)
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There seems to be a recurring issue with organisations around HIQA registration and certification, complying with work and the capital programme. Anecdotally, some organisations have been told not to worry about HIQA regulations or compliance with the HSE and that something will be worked out. It is costing organisations money for registration, which is ongoing, in terms of becoming compliant, and there are staffing issues. The Minister's report mentioned that HIQA is a good thing, which we all support, but it is having a profound impact on the ability of organisations to balance budgets and provide services within budget. It is proving contentious in some cases.

Leo Varadkar (Dublin West, Fine Gael)
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I agree. Although some argue the HIQA standards are too high, I disagree. The HIQA standards are about right. However, it takes time to meet them, whether to carry out the capital works required or to hire or train additional staff. Some of the buildings HIQA is criticising have been in use as health care facilities for 200 years, and we cannot replace them all overnight. On disability, we have extended the date to 2018 and for the older people's buildings it has been extended to 2021. While they do not necessarily have to comply immediately, every body or group has to agree a funded plan.

Billy Kelleher (Cork North Central, Fianna Fail)
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The HIQA inspections of long-term residential care have been extended to 2021. Some disability service providers have been told by the HSE that they cannot incur costs they would be obligated to incur in order to comply with HIQA. They are running a service that is deficient in terms of HIQA standards, yet the HSE is telling them to ignore the HIQA recommendations if they would incur additional costs. This puts them in a very invidious position. In some cases, staffing may be an issue. We are led to believe that staffing eventually follows through, although not always. Services that are not compliant with HIQA standards could be forced by the HSE to continue to provide the service and advised to ignore the HIQA recommendations. It is unfair for any State agency to put a service provider in a position in which it is required to have additional staffing complements that are not being provided on time. HIQA is doing on-the-spot inspections and finding services in breach of the guidelines, while the HSE is telling the service providers to ignore them. It must be examined.

If the regulator, HIQA, says something, one of two things should happen. Either the service is provided or the services goes. If it were anything else, this is what would happen. In this case, we would require that the funding be made available to allow compliance. For the HSE to tell some of these organisations and service providers to ignore HIQA recommendations is a very serious breach of basic public confidence and trust in service provision.

Leo Varadkar (Dublin West, Fine Gael)
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Obviously, I have contact with some of these service providers, particularly at constituency level. It is more on the administrative side than me but I have overview of it all. I have yet to come across anyone who was bluntly and boldly told in writing to ignore HIQA. What they are supposed to do is agree a plan of action, not just with HIQA but with the funder, which is the HSE. It would not be right or reasonable for charities or even sections of the HSE to just go off and spend the money. There have been instances where bodies have gone off and simply spent a great deal of money before just presenting the bill. They say "We had to do this because we have to comply with HIQA" but when one goes through the bill, it is clear that they could have complied at a 20% or 50% lower cost in the view of the funder. The message should never be "Ignore the HIQA requirements", but equally the message should not be "Go off and spend whatever money you like on the basis that you have to comply with HIQA standards". A body has to agree something.

Billy Kelleher (Cork North Central, Fianna Fail)
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I accept that a body cannot go spending money in advance of getting approval but the HSE ignoring requests for funding that is required for an organisation to comply with HIQA regulations is, in effect, telling that body to ignore HIQA standards.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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What I am hearing about it is that private owners, including nursing home owners, have more exacting considerations from HIQA. They feel they have to do it whereas public facilities seem to get away with it. As such, it costs them more. For example, private nursing homes say to me they are afraid that if they do not have the right nursing staff, they will be closed down. If HIQA goes into a public hospital for older people, that does not happen. It will not close the public facility but the private facility is made to spend money and to comply with more exacting guidelines. I do not know if the Minister has heard that.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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HIQA recommendations are not options. Ultimately, the failure in terms of compliance is going to push everybody into a situation where powers for HIQA or some other entity will have to be realised in order to effect implementation either through oversight or using the bata mór - the big stick - in terms of these improvements, amendments and changes to any physical entity in respect of providing services. They need to be undertaken. HIQA is not doing its job lightly. It is doing a professional evaluation. That evaluation and the recommendations which follow must be respected.

Leo Varadkar (Dublin West, Fine Gael)
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On nursing homes and facilities for older people, public ones are better staffed, generally speaking, and have a higher proportion of nurses. It is worth bearing that in mind. In contrast and from a building-standards perspective, private sector nursing homes are generally much newer and in better nick than the public ones, some of which are in old workhouses which date back to the 19th century. The private sector has had to bring its buildings up to standard more quickly than public institutions. The private sector thinks that is unfair and I can understand where it is coming from. While the private sector has had to meet the highest building standards quicker than the public sector, in the real world we would not have anywhere for the older people to go if we started closing all those old nursing homes and district hospitals around the country. That was just not a viable option. Perhaps there is an element of unfairness but the legislation acknowledges that HIQA must have regard to the HSE's resources. That is written into the legislation.

HIQA has significant powers to remove licences and takes public and private facilities to the District Court to remove licences on occasion. I consider that the heavy-handed, bata-mór approach is probably not the right one. I would prefer to see HIQA take a more compliance-based approach to work with providers whether they are voluntary bodies, charities or the HSE to help them to comply. Obviously, if there is a major patient safety issue, it must be dealt with straight away. However, there are other areas where we would do better to adopt the approach the Health and Safety Agency adopts with employers, which is not to shut down a factory or business, unless there is a major safety issue, but rather to help them to comply. That would be a better approach than to say "Here are the rules. You must implement them. We are gone now".

Jerry Buttimer (Cork South Central, Fine Gael)
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On J5 in respect of the State Claims Agency, I refer to the Minister's proposal earlier in the year on medical indemnity and the costs incurred by health professionals in particular. Has there been any progression in that regard?

Leo Varadkar (Dublin West, Fine Gael)
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A report arrived just yesterday from the State Claims Agency on that. We have not looked at it yet, but we will.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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It is just on the Supplementary Estimate.

Jerry Buttimer (Cork South Central, Fine Gael)
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We have done a committee report on it. It is an issue on which health professionals have become more vocal in the last couple of months. I apologise to Deputy Ó Caoláin.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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It was just for clarification. In the Supplementary Estimate to cover the State Claims Agency to the end of this year, there is an almost doubling of the provision as originally anticipated. There is a 97% increase, which is a phenomenal sum. Can the Minister provide the committee with an explanation as to why there is such a significant increase to get us across the line to 31 December?

Leo Varadkar (Dublin West, Fine Gael)
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Very simply, we thought that periodic payment orders would be introduced. Had they come in, the awards of €7 million, €10 million and €13 million would have been divided by 20. We had thought the periodic payments legislation would have been enacted by now but it has not been. It will be, however, in the next few months.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Good.

Jerry Buttimer (Cork South Central, Fine Gael)
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We all agree that the way things are carrying on is unacceptable. People are settling on the steps of the court at the 11th minute of the 11th hour. We welcome any change that would bring about certainty for people.

Leo Varadkar (Dublin West, Fine Gael)
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The main certainty it would bring about, which would be good for everyone, would be the implementation of annual payments which can then be reviewed as needs change. There are two sets of oddities. Even though an award may be very high, the person may run out of money or sometimes a person may get a huge award and, very sadly, pass away shortly afterwards leaving a huge amount of money which is not for their benefit but becomes an inheritance. That is not the best use of the money either.

Jerry Buttimer (Cork South Central, Fine Gael)
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K1 is the next subhead.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I want to ask about that. I congratulate the Minister on the new service he has introduced for diabetics. I also congratulate him on the long-term illness service which is a very good one. People are very grateful for it. A local issue involves dementia and the pilot Genio projects on the latter in different areas. The pilot has worked very well in Stillorgan and Blackrock. I ask the Minister to consider it down the line. It is great that people with dementia can be facilitated to live at home and to be helped there. I am delighted that Professor Ian Robertson received €160 million to carry out research at Trinity College. It was announced a few weeks ago.

Leo Varadkar (Dublin West, Fine Gael)
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Was it €160 million?

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Yes. It came via Chuck Feeney's Atlantic Philanthropies. It is great. The more research and health we have for people with dementia, the better.

We know the figures will increase because we have an aging population. I would like to ask the Minister a final question. The Minister for Children and Youth Affairs, Deputy Reilly, announced in the budget-----

Jerry Buttimer (Cork South Central, Fine Gael)
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We are not on child care now.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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That is why I am asking this question. Will the money that is to be made available for children to get speech therapy through schools come through the Department of Health, the Department of Children and Youth Affairs or the Department of Education and Skills? It was announced in the budget. If the Minister does not know the answer, I suppose he can write to me.

Jerry Buttimer (Cork South Central, Fine Gael)
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I would like to ask a question about the increase in high-tech drugs. Has the renegotiation of the drugs deal with representatives of the pharmaceutical sector commenced? Has it concluded or where does it stand? The Minister referred earlier to drug costs and the use of high-tech drugs. He might comment on that.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I would like to put one more question to the Minister in his capacity as a Minister and as a doctor. I hear criticism of the decision to give a doctor-only card to children under the age of six. I ask the Minister to spell out the reasons for that decision to those who are questioning it. Why are we thinking of extending the card to those between the ages of six and 12? I understand that one's lifestyle starts at that age. I appreciate that health issues like obesity and the propensity to have diabetes down the line can be helped at that stage. Perhaps the Minister, as both a doctor and a Minister, can elaborate on that matter.

Leo Varadkar (Dublin West, Fine Gael)
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I would like to make a correction for the purposes of clarity. I think I mentioned the Mater and Beaumont hospitals earlier under subhead I2. I should have mentioned them under subhead I5.

The Genio project and all of that is relatively new. It is the responsibility of the Minister of State, Deputy Kathleen Lynch. Of course I am aware of it. I think it holds a great deal of potential for the future. As it is relatively new, we need to see how it goes and how it is assessed in the future.

Some €8 million is being provided for therapy intervention teams in areas such as speech and language through the HSE. It comes through our Vote. It was announced in the budget. There might be a case in the medium term to move speech and language services to the Vote of the Department of Education and Skills or that of the Department of Children and Youth Affairs. For now, such services are provided through the HSE under the Vote of the Department of Health.

The talks with the Irish Pharmaceutical Healthcare Association on a new drugs deal have not yet started. Those talks will begin in the new year. They will be led by the Department of Health in conjunction with the Department of Public Expenditure and Reform and the National Procurement Service.

Deputy Mitchell O'Connor also asked about the decision to extend the scheme of GP care without fees. In the end, after a great deal of consideration and legal advice, we decided to extend it in the first instance to children under the age of six and people over the age of 70 because people in those groups are most likely to need to see a doctor. We thought it was particularly important to make this provision in respect of children under the age of six, because children are most likely to need to see a doctor at that age. Illnesses and issues like obesity can be picked up at a very early stage. At the time of making this decision, those whose children were most unlikely to have medical cards or doctor visit cards were working parents. I know that a small number of people in this category were very wealthy but many of them really had to think long and hard about the €50 required to see a doctor. If this is done on its own, it will all be for nothing. It was only ever a first step. This involved starting with the oldest and the youngest. We want the next steps to include all children because it is my strong view - I know this is not shared by everyone or by every party - that children should not be means tested on the basis of their parents' incomes. We do not do it for education. We do not charge people for primary or secondary education because their parents earn more than €50,000 or whatever. We do not do it for the early childhood education year. We do not means-test child benefit. The only thing we means-test in Ireland, when it comes to children, is health care. Ireland is the only country in western Europe that does this. It is a total anomaly. I do not think we should do it. Ireland is an oddity in Europe in so far as it does this. Health is an oddity in Ireland in so far as this is done in the health area. I think it is really unfair because working parents who get up early in the morning to go out to work lose out yet again as a result of the means testing of their kids. I do not think that is fair. This is just the first step in the process of redressing all of that. Notwithstanding the health care benefits of this approach, there is a social justice element to it too.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Provision of €10 million is made in the budget for 2016 for the roll-out of access to free GP care to those between the ages of six and 12. As the cost of the same service over a year is €39 million, does that reflect the Minister's anticipation that the engagement with the Irish Medical Organisation is unlikely to come to a conclusion before the last quarter of the coming year? The Minister decided earlier this year to extend access to medical cards to certain children on a medically-diagnosed basis. This will benefit children with cancer, for example. Is he considering an extension of that to include other areas of medical need? A few moments ago, he expressed his preference to look at children's needs on a medical basis rather than on the basis of their parents' income streams.

Billy Kelleher (Cork North Central, Fianna Fail)
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I have to raise an issue relating to the Primary Care Reimbursement Service that I was going to raise at the end. The provisions and anticipated costs for the roll-out of free GP care in the coming year are outlined in the documentation we have been given. This is really an issue of access to health care, which has been narrowly defined by the Minister as access to GPs. Of course, there is means testing on a continual basis for medical cards. Unless I am reading it wrong, children are getting GP visit cards, in effect. That is why people have contrary views about how universal health care might be advanced. Many people are saying that someone who receives domiciliary care allowance, for example, should get a medical card. It would be straightforward. If someone meets the terms of the means test for the domiciliary care allowance, why not give him or her a medical card? In such circumstances, at least medical cards would be targeted at those who are most in need of them. While it is fine to give GP cards to kids under the age of six, the reality is that means testing for medical cards is continuing. I have yet to find a medical card that is not means tested. That is the grave difficulty.

I am getting going on this. While there have been improvements in facilitating medical cards on a discretionary basis, in many cases it is still like pulling teeth to a certain extent. I know there has been a major increase of approximately 95,000 in the number of discretionary medical cards in the system. That dramatic increase has resulted from a change in policy. The policy that was reversed was denied for 18 months before this policy change took place. I think we need to look at this entire area. The Minister speaks about universal health care and everything that flows from it but I think the policy of rolling out free GP services to the whole nation at a time when people in any age cohort who are already in receipt of domiciliary care allowance are being asked to undergo a means test when applying for a medical card should be looked at very quickly. It makes sense to look at it. I am no expert in this area but I suggest that when the social welfare and health codes intermesh in places like this, one means test should be sufficient for the awarding of the medical card. My view is that such an approach would cut out a great deal of red tape. I think it is something the Minister should look at as a means of advancing universal health care, as opposed to universal access to a GP which is fundamentally not the same thing.

Leo Varadkar (Dublin West, Fine Gael)
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I reiterate that if the extension of these cards to those under the age of six and over the age of 70 is the only thing we do, it will not be worth doing. It was never intended to be anything other than a first step. One of the first steps towards universal health care in Ireland was taken in the late 1940s and 1950s, when efforts were made to introduce the mother and child scheme. It is a pity is stopped there. The same arguments were made at the time against the mother and child scheme, which was originally proposed by Dr. Noël Browne and, in fairness, was actually brought in by Fianna Fáil. Dr. Browne did not manage to bring it in. It was brought in by the subsequent Fianna Fáil Government and it all stopped there. It is a pity we did not do something like that every three or four years.

Had that been done, we would have universal health care by now. What needs to be done as part of the roll-out of universal health care is not just the roll-out to six to 12 year olds and then twelve to 18 year olds; it is a new medicines reimbursement scheme. The current scheme is Byzantine and unfair. There is the long-term illness scheme, under which some people pay nothing, no matter how wealthy they are; a medical card scheme under which people, some of whom are extremely poor, pay up to €25; and then there is the drugs payment scheme for everyone else, which is based on a monthly payment. It is not a good system. In a few weeks' time, Members will see proposals in my party's manifesto as to how we might resolve all of that, or at least come up with a fairer scheme. That would be the medicines element of it. The Deputy is right to say that the €10 million is there because it is anticipated that we could bring in the next step - GP care without fees for children aged six to ten - starting in Q4. However, we have always made it very clear that we would not impose this on the GPs ahead of an agreement on a new contract, so it will not be a standalone contract in the way the under-sixes contract was. It would form part of the new contract that we hope to agree with the IMO, which I imagine will include things other than the roll-out to six to 12 year olds. It will include supports for rural practice and urban deprived areas, chronic disease management and other measures. I hope we can agree that by the end of March.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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No charging for blood tests.

Leo Varadkar (Dublin West, Fine Gael)
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We have a common view on that. All of those things. That is one of the things being discussed now. I would like to have that agreed as soon as possible and then be able to commit to its implementation in the programme for Government, but my concern is that we will not be able to agree the contract until after the new Government is formed, and then we have to go looking for the money for it. That is not ideal, but that is where we are.

On children with a diagnosis of cancer, that decision was made by the director general on the advice of the clinical advisory group, which now advises on the guidelines for the discretionary medical cards. That whole area is fraught. Nobody has the right answers when it comes to the guidelines for discretionary medical cards, which is why we need to keep changing them and updating them. The whole issue of using the domiciliary care allowance, DCA, as a proxy for medical card eligibility was considered by the clinical advisory group. On the face of it, I thought it was a good idea. Maybe it is still a good idea. I would not rule out doing it, but the view I came to was that it was not a good proxy for eligibility for a medical card because many people who receive DCA have a disability, but that does not necessarily mean they have high medical needs or considerable medical costs. One will come across people with disabilities who will say they are not looking for a medical card - that they would like to have one, but they would prefer more educational supports or more supports around employment. That is the dilemma. Members will know themselves. They will know people who have a disability but do not have to see their doctors a great deal and are not on any medications.

Billy Kelleher (Cork North Central, Fianna Fail)
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They are not drawing the medical card then.

Leo Varadkar (Dublin West, Fine Gael)
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The GP would still get the fee, even if they never attended.

Billy Kelleher (Cork North Central, Fianna Fail)
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Yes.

Leo Varadkar (Dublin West, Fine Gael)
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I would not rule it out, actually. Until we get rid of means tests or sickness tests altogether, which is what we should be trying to do, there is no right answer to this. We specifically asked the clinical advisory group to examine that and it did not recommend it, but it did recommend that action on cancer.

Jerry Buttimer (Cork South Central, Fine Gael)
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Has the clinical advisory group been stood down or is it still there?

Leo Varadkar (Dublin West, Fine Gael)
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It will never be stood down, because we are never going to get this exactly right. It meets periodically to consider, not individual cases, but instances in which a set of hard cases arises, and then it makes recommendations to the director general.

Jerry Buttimer (Cork South Central, Fine Gael)
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Okay. We will move to subhead K2.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Very briefly - I made reference to it earlier - my concern is that we are not providing expansion and new builds in terms of the public long-term residential care network. There are real concerns at a number of sites around the country that, as the Minister acknowledged in earlier commentary, because of the age profile of many of the buildings in use, which were not purpose-built for their current usage, significant works are required. HIQA reports are valid and are reflective of the fact that these buildings are not of the standard required today and that they need to be significantly enhanced or replaced.

I was due to meet with representatives of St. Patrick's Community Hospital in Carrick-on-Shannon yesterday evening, although the floods, unfortunately, made that unachievable. That is just one example of a community that has a huge dependence on such a facility. It is dependent on it not only for the critical function of providing nursing home and long-term care needs for people within the community - some 85 people in that reduced-capacity building - but also a whole range of ancillary services provided there, extending from Sligo Regional Hospital, which are very important to the dependent catchment area. What can the Minister tell us about a capital plan that will give some hope and comfort to people in that community, for example, which is not in my own constituency, that they are not facing further downgrading and contraction and can look forward to a replacement construction on the site of the existing facility or utilising the wider campus area to provide a much-needed new facility?

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I am going back to the private nursing homes. They tell me they are finding it really difficult to source nurses. Even when they do, and they come through the long registration system for nurses, they seem to be poached nearly immediately into the general hospitals. I have heard the HSE is nearly parked outside.

Leo Varadkar (Dublin West, Fine Gael)
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I apologise for that.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I am sure it is exaggerated a bit, but they are telling me they have serious problems. We had the nursing people in here. Is that improving? For example, St. Joseph's in Shankill is a dementia centre and there was a fundraiser for it at the weekend. Again, really good work is done there, but they are finding it very hard to keep nurses.

Finally, two separate sets of four parents who have adult sons and daughters in the 40s and 50s have come to my constituency office recently. These parents are getting older and they are very worried. They are looking after their children, who have a disability, at the moment, but they are very worried about what will happen in the future. These adults are able to live independently with a little support. They are all on the housing list in Dún Laoghaire and the parents feel that, for example, they could come together and live independently in one home. At the moment, the HSE in Bray is saying it has no money for this, but could we look at a policy in the future whereby accommodation for people with disabilities does not always have to be residential, in a home. Some people can live independently, but they need supports from the HSE and the local authority. Instead of giving four houses, in this case, they would be funding one house.

Leo Varadkar (Dublin West, Fine Gael)
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Approximately €330 million was spent between 2009 and 2014 on replacing and upgrading some of these community nursing units, district hospitals and so on.

The facility I am most familiar with in my constituency is St. Mary's Hospital in the park, which has now been replaced by a fabulous community nursing unit. An additional €200 million is to be spent in the coming years upgrading or replacing some of the existing facilities. There is also a public private partnership bundle as well.

Priority will be given to those which are least HIQA compliant, if that makes any sense. HIQA will have expressed views on all of these facilities. Some are more in need of being replaced than others. The intention is to keep all of them open as much as possible until they are replaced or refurbished, for all sorts of obvious reasons.

I do not have a timeframe on any of them at the moment. Certainly a facility such as St. Patrick's Community Hospital in Carrick-on-Shannon has to be done. Again, I would rather not put a date on it because I do not want to be held to something that I cannot be sure of, but certainly it would have to be fully done, built and occupied by 2021. The question of how it will be done has not yet been determined. My best guess is that it will be done as part of a PPP. In that case a total rebuild is probably required. The existing facility probably cannot be refurbished. In other words, we would have to rebuild next to it in the way the new community nursing unit was developed beside St. Mary's Hospital in the park. Similar designs will probably be built throughout the country. They will probably be done as a bundle of community nursing units similar to the bundles of schools or primary care centres that Deputies will be familiar with. It is difficult to put an exact timeframe on it. We hope it will be done as soon as possible. However, it has to go through planning, design and so on. It is difficult to put a timeframe on these things.

Nursing recruitment is a real struggle. Everyone is recruiting at the moment, not only nursing homes but private and public hospitals as well. Everyone is looking for nurses. The HSE is 750 nurses up on this time last year. Some of this is accounted for by agency conversion but most of it is a result of new extra nurses. The Nursing and Midwifery Board of Ireland is getting better at speeding up the applications. Often there are problems with paperwork and so on. A particularly encouraging development this year is the effort being made to retain the graduating class of this year. I was in Connolly Hospital in Blanchardstown, where 16 of the 18 trainee nurses are staying. The other two are going to Cork.

Jerry Buttimer (Cork South Central, Fine Gael)
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They are very welcome in Cork.

Leo Varadkar (Dublin West, Fine Gael)
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I hope they went to Cork University Hospital and not the Bons Secours Hospital. The issues are similar elsewhere. In the case of another graduating class, three quarters chose to stay and one quarter decided to go.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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Are they going to nursing homes?

Leo Varadkar (Dublin West, Fine Gael)
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I do not have a breakdown of the detail. However, the general backdrop is an international shortage of nurses. The reason Irish nurses are in Canada and the Middle East and the reason Filipino nurses are in Ireland is because there is an international shortage. There is no surplus of nurses in the world. We are all begging from each other. Moreover, for a period during the recession we were not creating posts. We lost many people during that period. It will be difficult to get them back because many of them have settled elsewhere. Anyway, we are doing well with the graduating classes. I believe we need to make a particular effort to keep them in Ireland and give them career and educational opportunities to encourage them to stay.

Certain nurses like particular types work. Older care is a particular type of work. It is very different to theatre or ICU nursing. The NMBI has tried to speed up the whole process around registering nurses from overseas.

Another point we touched on was the need to provide more community houses. The policy is not to put people in institutions or homes anymore and to de-congregate. The idea is to have many more people with disabilities and special needs in houses in normal housing estates with everyone else, perhaps with two or three people in each house. We know this happens and there are many examples in our constituencies.

The demands and the needs are vast. A sizeable number of people are still in institutional settings, for example, in Áras Attracta and other settings. We are keen to get them out into houses in the community. Many people are at home too. There may be adults in their 40s and 50s with parents in their 60s and 70s - Deputy Mitchell O'Connor referred to such cases. These parents are concerned about what will happen. We should be providing more of these houses than at present, frankly. The money simply was not available during the recession years. I know that in Dublin West the Daughters of Charity opened a new house almost every year up until 2008 and then did not open any for six or seven years because of the recession. The result is that we have pent-up demand that needs to be relieved. The Minister of State, Deputy Lynch, is in discussions with the Minister for the Environment, Community and Local Government, Deputy Kelly, because this is partially a housing matter and partially a health matter. They need to agree something. I hope we will have good news on that front sooner rather than later.

Jerry Buttimer (Cork South Central, Fine Gael)
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I thank the Minister, Mr. Greg Dempsey, Ms Mary Jackson and all the officials in the Department of Health for their courtesy to the members of the committee. I wish you all a peaceful and happy Christmas. I thank our clerk, Mr. Ronan Murphy and Mr. Damian Byrne, who produced an excellent paper for members. The committee is appreciative of the resources they have provided. I hope we can progress the-----

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I have one question on the opening commentary in respect of the British transfer of funding of €65 million. Will the Minister indicate whether we have received it?

Leo Varadkar (Dublin West, Fine Gael)
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Yes, we have received it.

Jerry Buttimer (Cork South Central, Fine Gael)
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In conclusion, I hope we will see-----

Leo Varadkar (Dublin West, Fine Gael)
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I am unsure whether it was changed from sterling in the transfer, but we have it.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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That could be something else.

Jerry Buttimer (Cork South Central, Fine Gael)
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We hope that whoever the committee members are in the next Dáil, there will be more timely provision of financial information to assist the committee and that the committee will look at the Estimates in a different guise as part of parliamentary reform. The Estimates process would be better served by more financial scrutiny. I thank the Minister for his co-operation, participation and informed commentary and analysis today.