Michael Harty (Clare, Independent)
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The select committee is now in public session. The purpose of this morning's meeting is the consideration of the Department of Health's Estimate for 2018. The Dáil ordered that the following Estimate for public services, Vote 38 - Health, be referred to the select committee for consideration.

I welcome the Minister of State at the Department of Health with special responsibility for mental health and older people, Deputy Jim Daly, and his officials. The purpose of today's meeting is to consider the Revised Estimates for 2018 - Vote 38. I invite the Minister of State to make his opening statement.

Jim Daly (Cork South West, Fine Gael)
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Fáiltím roimh an deis labhairt leis an gcoiste. I welcome this opportunity to address the select committee on the Revised Estimates for 2018 for the Department's Vote 38. Unlike many other Votes, the health Vote is not configured along programme lines. While the Department is working towards the development of programme budgeting, this will take some time as the financial systems in the HSE will have to be adapted to allow for this in the context of the financial reform programme currently under way.

The level of funding provided in the 2018 Revised Estimates will allow the Department and the Health Service Executive, HSE, to deliver better access, more health for families and more supports for disability, mental health and older and vulnerable people. In addition, the welcome increase in the health capital budget over the period to 2021 will allow completion of key developments such as the new children's hospital and will ensure capital investment supports our strategic initiatives and ehealth improvements.

The improving economy has enabled the health service to achieve much-needed budget increases in each of the last three years. We are very aware that there are areas where further improvements are required and the Department will continue to work with the HSE to optimise service provision within the constraints of available funding.

The gross provision for the health Vote in 2017 was €14.801 billion, comprising €14.347 billion in current expenditure and €454 million in capital expenditure, inclusive of €195 million granted by means of a Supplementary Estimate. The supplementary requirement arose due to new initiatives approved in 2017, central pay decisions, a shortfall in income and additional funding required in the State Claims Agency. Funding was neither sought nor granted for deficits that arose in service areas which were within the management control of the HSE.

In framing the 2018 budget, the Oireachtas allocated €15.332 billion in Exchequer funding for the health sector. This represents an increase of €492 million on the 2017 post-supplementary current expenditure budget and €39 million, or 8.6%, on capital expenditure and recognises the Government's commitment to providing a health service that seeks to improve the health and well-being of the people of Ireland.

The issue of health funding is a major policy challenge internationally. Despite welcome increases over recent years, the need for effective financial management remains crucial as the health service deals with a larger and older population, with more acute health and social care requirements, increased demand for new and existing drugs and the rising costs of health technology. The costs associated with these service pressures will increasingly need to be managed not solely through increased Exchequer allocations but also through improved efficiencies, productivity and value from within the funding base in 2018 and beyond.

I would like to address the recently published Project Ireland 2040 and the Government's capital spending plans for the next ten years. Capital funding for our health service has been agreed at €10.9 billion for the next ten years, which is 165% higher when compared with the past ten years. We now have a solid ambitious plan to build a better health service for the future through the combination of this significant capital investment programme alongside the implementation of the Sláintecare reforms. The €10.9 billion funding over the next ten years provides a real long-term opportunity to improve our health services, provide modern fit-for-purpose health facilities, increase bed capacity and modernise how we deliver services through ehealth, reformed pathways of care and the implementation of Sláintecare.

Capital investments over the coming decade will support existing Government priority projects and commitments and will enable the roll-out of new additional capacity, guided by the Sláintecare report and the recently published health service capacity review.

The strategic investment priorities for the public health sector in Project Ireland 2040 include a number of major investment projects and programmes over its lifetime, including: the new children's hospital at St. James's campus Dublin and the two children's outpatient and urgent care centres at Connolly Hospital, Blanchardstown and at Tallaght hospital, Dublin. The priorities also included the national maternity strategy developments, including the relocation of stand-alone maternity hospitals to acute hospital campus such as the move of the National Maternity Hospital, Holles Street to the St. Vincent's campus; national cancer strategy capital developments, including the national programme for radiation oncology at Cork, Galway and Dublin and the expansion of BreastCheck; building the new national forensic and mental health service hospital at Portrane, Dublin; the primary care centre construction programme at various locations around the country; and the replacement and refurbishment of community nursing units for older people and long-term residential care units and housing in the community for people with disabilities at various locations across the country. In addition, the national development plan provides capital funding to implement the health service capacity review.

With this unprecedented capital investment in the health services we must ensure that we carefully plan and select projects.

To achieve that, we will put in place a robust method of project appraisal, assessment and selection in order to implement health strategies, including developing capacity to meet the population health needs and achieve value for money.

Along with my ministerial colleagues in the Department, I am committed to advancing a programme of both investment and reform for our health and social care services. The recent Health Service Capacity Review provides an evidence base to determine the extent and nature of the capacity that will be required up to 2031. It forecasts that by 2031, we will need an additional 1,000 general practitioners, GPs, and additional capacity requirements in primary care, acute hospitals and services for older persons for that period.

The Government is committed to making tangible and sustainable improvements in our health services and the Sláintecare report, published last March, provides a framework to do that. There is now an unprecedented level of consensus and support for the vision and strategic direction outlined in the report. We must harness that and work with colleagues across the political spectrum and with all stakeholders to move forward on a programme of health reform. The Government has already given its approval to move ahead with the establishment of a Sláintecare programme office in the Department of Health. This office will be tasked with implementing a programme of reform, as agreed by Government, arising from the Sláintecare report. The recruitment of an executive director of the Sláintecare programme is under way.

It is important to note that many recommendations in the Sláintecare are already policy priorities. These include: the roll-out of our ehealth and health and well-being strategies; the development of a new GP contract and proposals for an enhanced community nursing service; further roll-out of integrated care programmes; the undertaking of a capacity review; and development of an integrated workforce planning framework. The majority of additional funding for new health initiatives in budget 2018 has been targeted at areas identified in the Sláintecare report such as the primary care fund, additional home care and transition beds, reduced medicine and prescription charges and targeted funding for waiting list reduction. These actions are important first steps in a long-term reform process.

Work is under way in the Department to develop an implementation plan in response to the Sláintecare report. A steering group, with representation from both the Department and the Health Service Executive, HSE, has been directing this work over the past months. Work is well advanced and the Minister, Deputy Harris, expects to bring proposals to Government shortly. Furthermore, a memorandum will be brought to Government in the coming weeks with the general scheme for a Bill to introduce a governing board for the HSE, which is a key recommendation in Sláintecare.

Reducing waiting times for hospital procedures is a key priority for this Government. The HSE has been allocated €12 million for scheduled care measures, €10 million of which has been ring-fenced for scoliosis and Merlin Park University Hospital orthopaedic capacity and €2 million for other priorities.

Waiting list figures for the end of February published by the National Treatment Purchase Fund, NTPF, show that 72% of inpatient day case patients and 61% of outpatients are waiting nine months or less. There was a reduction of 1,165 patients waiting for an inpatient or day case procedure compared to the end of January 2018 and a reduction of 7,175 when compared to the numbers waiting at the end of July 2017. That is against a background of increasing demands on our acute hospitals which, since 2000, are carrying out four times more procedures for patients aged 65 and over and twice as many in the under 65 age group. An additional €35 million has been allocated to the NTPF for commissioned patient treatment, which brings its total budget for 2018 to €55 million. It is estimated that the NTPF initiatives in 2018 will enable the provision of treatment for up to 20,000 patients on the inpatient-day case waiting list across a range of specialties and procedures.

This winter has been very difficult for our health services. During February, there was a 7.7% increase in attendances and a 5% increase in emergency department admissions compared to February 2017. That growth in demand is well ahead of population growth and reflects international evidence that emergency department demand is driven by more than demographic factors. This increased demand was further exacerbated in March by the impact of Storm Emma and the associated severe weather experienced across the country since the beginning of March.

While demand for services is growing considerably, the inpatient bed capacity to meet the demand is constrained, resulting in an 11.8% increase in the number of patients waiting on trolleys, compared to February 2017. While fully acknowledging the need for productivity improvements and reforms across the health service, the bed capacity review outlines that in order to reach international standards of bed occupancy levels, the acute hospital system needs an immediate injection of additional beds. It is only through continued investment in capacity, in hospital staff and in reform of our health services, in line with Sláintecare, that we will deliver better services for patients.

The Government provided an additional €40 million for measures to alleviate the pressure on emergency departments during winter 2017-2018. Timely discharge of patients is vital to ensuring that a ready supply of beds is available to those patients requiring to be admitted through emergency departments. Delayed discharges are a major contributory factor to emergency department overcrowding and adversely affect patient flow throughout the hospital. It is essential that, in so far as is possible, egress meets demand, and that hospital and community health care organisations, CHOs, processes support timely and safe discharge. Accordingly, over 60% of the 2018 funding for unscheduled care access measures is being targeted towards providing additional social care supports. These additional supports have been targeted at the hospitals with the greatest number of patients awaiting discharge home and will help improve patient flow in those hospitals, which will in turn help to relieve congestion in their emergency departments. As of today, 189 additional beds have been opened this winter and further beds will open throughout 2018.

In the light of the recommendations of the Health Service Capacity Review and the current pressures on the hospital system, the HSE has been asked to develop a plan to identify the location and mix of beds across the hospital system which can be opened and staffed by 1 November 2018 in order to improve preparedness for winter 2018-2019 and relieve overcrowding in hospital emergency departments. In addition, the HSE and the Department have started the process of reviewing the winter initiative 2017-2018, with a view to providing a report in late April and ensuring the learning from this year will inform the agreement and early implementation of measures for next winter.

Primary care services can provide key opportunities in the implementation of Sláintecare as it proposes the adoption of a new model of integrated care, centred on comprehensive primary and community care services. In 2018, primary care funding of €850 million will continue to build on the significant additional resources that have been invested over the past number of years in the State’s primary care services. For example, we have seen the extension of eligibility for GP cards to the under-sixes and the over-70s and the development of the diabetes cycle-of-care programme.

Quite significant investment has also been made in the development of primary care capacity, particularly in the therapy area, continued investment in the development of community intervention teams and enhanced community diagnostic programmes with the delivery of ultrasound and X-ray in the community. We have also invested significantly in our primary care infrastructure providing modern, well equipped primary care centres - 114 to date - to enable patients access health care in their communities in a more integrated manner. Capital funding of over €29 million will continue to support the roll out of these centres.

The funding allocated in 2018 will continue to deliver these key services and dedicated additional funding of €25 million therein will focus on disease prevention and early intervention, particularly through the further development and expansion of GP services.

In line with the Government’s commitment to promoting care in the community, the Department is developing a new statutory scheme for the financing and regulation of home care services. Pending this, the Department and the HSE are continuing efforts to incrementally improve the existing services. Home support services were a particular area of focus in budget 2018, with an additional €18 million allocated. The additional resources made available brings the total budget for the direct provision of home support services to €408 million. The HSE’s national service plan provides for a target of 17 million home support hours to be provided to 50,500 people.

Of course, there will always be a cohort of people who require long-term residential care, and the nursing homes support scheme, NHSS, commonly known as fair deal, continues to provide financial assistance to those who need long-term nursing home care. The aim of the scheme is to ensure that long-term nursing home care is accessible and affordable for everyone, and that people are cared for in the most appropriate settings.

Mental Health remains a priority care programme for the Government. For this reason, budget 2018 made allowance for an additional €57.5 million for mental health services for 2018, inclusive of €22.5 million of pay-related costs and €35 million to continue to progress new initiatives. The additional funding will help build on the work commenced in 2017 on the enhancement of community teams for children, adults, later life and mental health intellectual disability services. It will also help to continue our move towards a full 24-7 service, with an initial focus on increasing the provision of services on a seven-days-a-week basis. The HSE has been asked to prioritise this work in 2018 as well as develop a service response which is as seamless as possible for every service user.

Budget 2018 announced a reduction in the prescription charge and the drug payment scheme, DPS, monthly threshold. Since 1 January, medical card holders have benefited from a 50 cent reduction in the prescription charge, from €2.50 to €2 per item, and the maximum monthly cost reduced by €5, from €25 to €20. For approved treatments under the DPS the maximum monthly payment reduced by €10, from €144 to €134. This will benefit all families who exceed the threshold in any month.

While wehave secured a significant increase in funding for the health services in recent years, I do not underestimate the challenges involved in the delivery of a safe, efficient health service for the Irish people. Despite welcome increases in recent years, a financial challenge remains as we deal with a larger and older population, with more acute health and social care requirements, increased demand for new and existing drugs and the rising costs of health technology.

The costs of payments under the State Claims Agency are also rising, adding to the overall cost of health above the operational costs funded to meet the health demands of a growing and ageing population. We must maintain our focus on improving the way services are organised and delivered, and on reducing costs, in order to maximise the ability of the health service to respond to growing needs. It is essential that those managing and delivering the service demonstrate good practice by delivering the best possible health care within the limits of the resources that have been made available by Government each year.

Michael Harty (Clare, Independent)
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I will now bring in the party spokespersons on health, starting with Deputy Kelleher and continuing with Deputies O'Reilly and Kelly.

Billy Kelleher (Cork North Central, Fianna Fail)
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I welcome the Minister of State. As we go through the Estimates for the year, it is looking at things in a historical context to a certain extent as well as everything else and trying to learn from what has been done to date as regards funding and policy itself. In that context, the Minister of State referred towards the end of his opening statement to primary care. There is no doubt that a couple of related issues are being discussed at other fora currently, including the GP contract, which is a critical component of the delivery of health care. That was also alluded to in the Sláintecare report where we talked about the transfer of services from the hospital-centric system we have at the moment to the community by way of bolstering primary care, community diagnostics, therapy and so on. The following is an observation as much as it is a criticism. I think often that officialdom lives in a parallel universe when it comes to what is happening on the ground in terms of investment figures showing increases in home care packages and home help hours. When one drills down into it, one still finds huge problems in trying to deliver the very basics in terms of home help hours. Where a person is deemed to need home help hours to get out of bed, there may only be funding to get out of bed five days a week. As such, the person has to stay in bed two days a week.

We have almost dehumanised our health services in some key areas. It is not a reflection not the people at the coalface, but it seems we do not have that ability to understand in officialdom and through the system what individuals go through in their lives. We have to look harshly at how we assess and view cuts to services or the lack of a service in the first place and the impact that has on an individual's life. I have an 84 year old woman whose husband cannot get out of bed himself. They need a hoisting system and all of that is in place, which she appreciates very much. However, she is only funded six mornings a week. On the seventh morning, every Sunday, she has to get neighbours or friends to help her get her husband out of bed. She only wants 20 minutes. That is an issue that has to be addressed if we are to have any meaningful change of heart in the delivery of health care in primary and community settings. It is just an individual case but it can be extrapolated across the whole are of home care packages, home help hours, access to diagnostics, access to therapy and all of that.

When we talk about primary care, which is the Minister of State's particular area, we talk about extending eligibility for free GP care. While I opposed it at the time, I did so on the grounds that I did not think the GP services in place would be able to cope with what would be thrown at it in the context of the roll-out of universal GP care given the demographics of both the population and of GPs. We are at the crossroads in how we look at primary care and its delivery. We talk about it a lot but we have not resourced and funded it accordingly. The Minister of State refers to the availability of €850 million for primary care, but when one looks at what we expect that to do from a policy and demographic perspective, the two will not match and marry very well. We will end up with a gravely abused primary care system which is incapable of delivering in the key areas the Minister of State has identified from a policy perspective or, primarily, from the perspective of Sláintecare. That is chronic disease and illness, more diagnostics, retention of people in home or community care settings or step-down facilities. That requires a great many more GPs.

I refer to the involvement of GPs in home care delivery and primary care teams and where we are with the number of GPs, the numbers who are retiring, the capacity of the primary care system in general and its funding and the tortuously slow negotiations around the GP contract, if it is even possible to say there are negotiations at all. I am beginning to think this is just window dressing. If negotiations are not moving between the primary actors, namely, the Department of Health and the IMO, others must intervene to push this on. It is the central and most critical issue in terms of how we deliver care in community and primary care settings in the foreseeable future. Obviously, we would like to see a rolling contract that is revisited on a regular basis, but we will have to get the basics right or we will end up in circumstances where no GPs are coming into the system while those who are trained and qualified are leaving. Meanwhile, those at the other end of the scale approaching retirement age will step off because they have had enough. We could end up with a very difficult situation in which policy refers to primary care but everybody is sent to hospital. These are observations but they are important from the point of view of the focus on funding.

There was an RTÉ report yesterday by Brian O’Connell who visited Cork and spoke with GPs and families in Munster on the availability of psychiatric services. The fact remains that child and adolescent mental health services in the Munster region are not what the Minister of State and I would like. Certainly, they are not up to standard for those who depend on them. We have situations in which GPs have no choice where a child attends who is at risk of self-harm, has suicidal ideation or has attempted suicide. He or she must be referred to an emergency department. If that is not done, the person is put on a waiting list. That goes back to my original point about how we dehumanise the health system. It causes trauma to the individual, the family and the medical professionals trying to deal with it that they cannot access any particular service.

The Minister of State referred a few times in his opening statement to the number of people we require to expand the health service. We must carry out a full root and branch manpower assessment as to what we need in our health services beyond the horizon. We talk about training health professionals and it is seven to ten years before some are fully qualified. It requires a great deal of long-term planning but we have not carried it out in enough areas. We have not assessed the demographics and the demands the changing profile of the population will place on health service. We have not determined what professionals we need to meet those demands. That means getting involved with the training bodies and agencies to expand and enhance capacity in key areas. We all speak, for example, about the fact that we will be older. When one looks at investment in training in geriatric services, however, we are not crowning ourselves in glory notwithstanding the fact that we know the population will be quite elderly down the road. That is one key area where a failure to drill down and determine what illnesses like diabetes and obesity, which are evident in the population, will mean.

We do not seem to have enough capacity to assess what our manpower requirements will be, not next year or the following year but in five, seven, ten or 15 years' time. That is something that is never referred to in speeches or in policy other than it being said that we know we need additional doctors. We have never carried out a detailed analysis. The last time such an approach was taken was in the context of the Hanly report on consultants. We need a detailed analysis of all grades - including physiotherapists and occupational therapists - right across the spectrum. I urge that such an approach would be taken in the context of the Sláintecare report and the funding of same or that the Department would independently get someone to carry out a detailed assessment of manpower requirements and then put in place the capacity to train them.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I bid the Minister of State and his officials a good morning. When members ask these questions, we tend to throw about 57,000 issues at the Minister, which means we tend to get very vague answers. It is hard not to take such an approach because there are deficiencies in so many areas but if I can I will try to focus on a number of areas. One is scoliosis. That is something we have raised time and again. We are not alone in that, as other Deputies, including Deputies in the Minister of State's own party have raised it. The waiting lists are still unacceptable. I do not think anyone would defend them. It is not that long since the Minister was on television apologising in what I am sure was a very sincere way about it, but the waiting lists are unacceptable, in particular for those who have complex medical conditions. The Minister had promised a detailed action plan for parents, which I suppose is just like a normal action plan but is perhaps a bit longer. Parents have still not seen the action plan. They are contacting me and I am sure they are contacting Deputy Kelleher and others as well to ask if we can ascertain when the detailed action plan will be ready. When the plan is ready it could just be put with all the other detailed action plans. What people really want to know is when the children will be treated and whether there is a plan to increase the operation of the theatre in Crumlin from three days to five. If there is, could the Minister of State advise how many staff have been recruited to deal with that? Given the length of the waiting lists, there is a case to be made for increasing the theatre openings to seven days a week until the crisis is over. Could the Minister of State outline the position in terms of the recruitment of doctors, nurses and everybody else who will be needed to open the theatre for extra days?

That brings me to my next point. Deputy Kelleher raised a similar point. We all know that if additional beds are to be opened additional staff will be needed. Could the Minister of State give an indication of the age profile of staff? Doctors, nurses, allied health professionals, porters, theatre assistants and everybody else are coming into the system - I do not believe we are getting anywhere near the numbers needed - but at the other end people are leaving because in some instances the workplace is intolerable but there are also people whom we know will leave due to retirement, for example. It is my understanding that there is not a plan in place to deal with the retirements. Perhaps the Minister of State could point us to the section in the Estimates concerning recruitment and where the additional moneys for the additional capacity have been put aside. The Minister of State, Deputy Jim Daly, has said it himself and the Minister, Deputy Harris, has definitely said that one could open a bed in the morning but it is just sitting there if one does not have the staff to care for the patient in it. How much of the additional €530 million is allocated for additional staff and potential pay increases and how much is just for standing still and maintaining the current level of services?

During Storm Emma the Minister for Health announced that €5 million would be provided for additional capacity. Could the Minister of State give us a breakdown of where the money was spent and whether money was taken from the budget for other areas and ring-fenced for that purpose?

It is hard to believe that there are negotiations, much less intense negotiations of any sort going on with general practitioners, GPs. Can the Minister of State provide us with information on whether any discussion has taken place with regard to salaried GPs? All of the reports in the media and from the representative organisations suggest there is a crisis in capacity in terms of GPs at the moment. One issue identified in Sláintecare is that we might look at salaried GPs to alleviate the crisis. I understand that it would not be a panacea. Could the Minister of State advise us if that has formed part of the discussions and perhaps give us an update?

The Minister of State referred to 179 beds that had been opened and that a detailed plan would be provided, perhaps on 1 November, for the opening of additional beds. Could he give a breakdown of the staffing for those beds? Is there recruitment in the pipeline? One cannot just fill out a form. It is a long process to recruit a staff member at any grade into the health service, except as it turns out, administrative staff because we saw over the weekend that they are being recruited at a rate of knots, unlike health professionals. That is not to say administrative staff are not needed because of course they are but it strikes me as a bit odd that the recruitment of administrative staff is outstripping the recruitment of front-line health care professionals.

Margaret Murphy O'Mahony (Cork South West, Fianna Fail)
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I welcome my colleague, the Minister of State, Deputy Jim Daly, and his officials here today. I assure him that while he is busy with his ministerial ship, I will mind the ship in west Cork. He can rest assured of that.

On a serious note, I see the budget for people with disabilities is on par with that for 2017. I would have expected more progress with the transport support allowance, for example. I know that is within the remit of the Minister of State, Deputy Finian McGrath, but perhaps the Minister of State, Deputy Jim Daly, has some comments to make on it.

In the Minister of State's own area of mental health, I note there is a 10% increase in funding, which is very welcome and should not be knocked. However, the Minister of State must admit that not enough is being done. Without the likes of organisations such as Pieta House, the country would be in a very difficult place. I would welcome a comment in that regard.

Does the Minister of State think the extra 4% spend could help to tackle the waiting lists which are now at 288 for an autism spectrum disorder, ASD, assessment in Marian House, Cork? Both the Minister of State and I have a lot of constituents who are on the waiting list for two years. Because of the importance of early intervention, two years is not good enough. Will some of the extra funding be channelled in that direction?

Deputy Louise O'Reilly mentioned scoliosis. The Minister of State put a strong emphasis on what would be done to address the issue in his speech. A boy in west Cork was diagnosed at the age of 11. He is now 16 and he has yet to be treated five years later. What is happening is not good enough.

What resources does the Minister of State envisage being put into rural hospitals such as Bantry General Hospital in our constituency? As he is aware Bantry General Hospital has been seeking a rehabilitation and endoscopy unit for some time. The Minister of State might just tell me what resources will be allocated to Bantry General Hospital?

Jim Daly (Cork South West, Fine Gael)
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I thank the Chairman and members for their attention and questioning thus far. I will answer to the best of my ability. I do not have the answers for all of the questions but anything I can answer I will to the best of my ability and anything I fail to answer I will come back to the members directly or to the committee with more detailed information.

Deputy Kelleher spoke about humanising the system and officialdom versus reality. The role of politicians and politics and the role we play all day every day as representatives is to attempt to humanise it. I appreciate where the Deputy is coming from. A lot of the figures, facts, percentages and statistics tend to mask the reality and be a protective mechanism, and appear as such to us as public representatives. Nonetheless, that is how systems are run and analysed and metrics have to be involved but I take on board the point and I accept what the Deputy has said. Our job is to keep humanising it and bring to the fore real examples as the Deputy did, of the 86 year old lady who is in a bed and getting help six days a week but not the seventh day. These are real challenges for the system.

The Deputy asked what can we expect from the €850 million funding for primary care. He made the point that if we are to move towards primary care and go along with Sláintecare, which we all accept is the way forward, it will be important. If we are going to put such emphasis on primary care we will have to fund it accordingly, which will be a real challenge, and the Deputy will appreciate this from his years of observing the health system and other areas where he has served. The challenge will be in trying to reorient a system away from the here and now, and the day to day pressures on the demand-led scheme, and trying to pull funding back and reorient it into a new system. It takes time and it is a huge challenge, and the very best we can really hope for is that a lot of it will be done with new funding, and that as new funding comes on stream, a larger proportion of it will go into primary care and this is how we will slowly and, hopefully, substantially build the funding to run it. We are aware of the Sláintecare report.

The Deputy made a point on requiring more GPs, and in my opening remarks I acknowledged that we will need up to 1,000 new GPs. The GP contract and negotiations were mentioned by a number of members. I understand negotiations with the IMO will recommence in the coming weeks. They have been stalled since the end of last year. They are due to commence with intensity and there is an expectation. It is not for me to put a timeline on it, but I hope that by the end of the year significant progress will be made on this to substantially address the issues that are there. There is the FEMPI issue about which the GPs are very vocal and there are a number of other issues. The Government will make the point that in return for any additional funding new ways of doing business will be required along with it.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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The IMO has already indicated that it is not in that space and it wants to talk about the reversal of FEMPI first and then any additional services. I do not mean this disrespectfully in any way and I am sure that is not how the Minister of State will take it, but every time there is an intervention from a Minister or Minister of State we get further away from any possibility of there being any agreement on this. The Minister of State does not have to take my word for it. It is in the newspapers. The GP service is in crisis. Laying down markers such as this in advance of a negotiation while, at the same time, the Minister of State states he thinks it might be finished by Christmas, is pushing it further back every time. I apologise for the interruption.

Jim Daly (Cork South West, Fine Gael)
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The Chairman will appreciate I will not go into this type of discussion here. I will not negotiate the GP contract across the floor with anybody or go into its details. I have made some points on this. I addressed the National Association of General Practitioners, NAGP, over the weekend and I am merely reiterating some of the points I made to the GPs there. It is not in my gift. I will not be leading those negotiations and neither would it be appropriate or helpful for me at this stage to start entering into such discussions at that level.

Deputy Kelleher also mentioned child and adolescent mental health services, CAMHS, in Munster. I am aware of the challenges, particularly in the Cork area. One of the biggest issues we still have in mental health is recruitment, and we are blue in the face from listening to it on every Topical Issue and parliamentary question, but it is a fact. If one always does what one always did, one always will get what one always got. If we continue just to acknowledge that challenge and to struggle on, we will be in the same place for a long time to come. My attitude as Minister of State with responsibility for mental health is to look at how we do what we do and look at a new way of doing it. The future of mental health, from looking at international best practice and what is done abroad, is to look at online delivery of the service. This is the space we need to go to. It does not make sense for a consultant psychiatrist to leave Cork to travel to Castletownbere to see somebody given the amount of time it takes. These are posing real challenges while we want to have a seven-day week service and availability in every area. If we look at a model where somebody with a mental health issue can go into his or her local primary care centre where there is an interactive screen and he or she can speak to a mental health professional, whether a therapist, psychologist or psychiatrist and avail of the services online, that could be a new way to revolutionise and radically look at how we deliver online mental health services. I have asked the HSE to trial the online delivery of mental health services and to select a primary care centre where we can start to trial this. We need to consider this.

There is an ancillary issue, which is the management of waiting lists. Various people manage their waiting lists in various ways. There is huge disparity in various parts of the country where the numbers and percentages are broadly the same, such as 70% filling of posts and a certain number of people coming through, but there are various ways of managing it. Every list must be prioritised on an immediate basis. If someone presents with a serious mental health issue that person must be seen immediately. I heard the report with Brian O'Connell yesterday to which the Deputy referred. Nobody should be told he or she has to wait seven or 12 weeks. There is supposed to be continuous prioritisation. The consultant psychiatrist in charge of the team is supposed to look and assess. There are various ways to do this to deliver the service. I am aware of the issue and, ultimately, the solution will be to continue with this. We should not, as politicians, continue to accept recruitment is a challenge. It is a challenge, but there are ways around everything and the online space offers enormous potential.

Long-term planning for staffing is something on which a certain amount of work has been done by the HSE. A staffing skill mix has been looked at and a review was launched recently into nursing in particular. I also take the point that we should look at the challenges that will come from a range of illnesses that will present, such as obesity, diabetes and chronic illnesses, and not just look at particular skill sets.

Deputy O'Reilly raised the issue of scoliosis and the detailed action plan. I will have to come back to her on that. As she knows, there was an initiative last year and an additional €10 million was put into it. A new theatre was opened in Crumlin and its capacity is to be increased this year. It went from carrying out 220 procedures in 2016 to 321 procedures in 2017, which is a 46% increase. It will take time to catch up. When one launches an initiative one does not get an immediate result and return. It takes a bit of time. Work is ongoing and I will get the Deputy more details on the action plan.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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Does the figure include patients who were sent abroad or is it an increase in operations carried out in the State?

Jim Daly (Cork South West, Fine Gael)
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As I understand it, it is operations carried out at home.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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To be very clear, because we fall out sometimes and perhaps that is because the questions are not clear, I want details on when the plan will be published and information on how, precisely, the staffing arrangements will be organised for the increase in the number of days the theatre is open. The plan is to increase it from three to five. I would also like information on the timelines by which this will be achieved.

Jim Daly (Cork South West, Fine Gael)
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I will ask the Minister to revert to Deputy O'Reilly directly on that. I will address the rest of her questions as best I can, but a number of them are staffing related. I know this is her background and interest but I cannot go into that level of detail as to how many staff are apportioned to new beds and what percentage will go on staffing. These are operational matters and are done by the HSE. They are not part of my remit in the Department. If the Deputy wants to ask specific questions she can address them to me and I will ask the HSE to come back to her directly on them. I believe the HSE will come before the committee on 6 May for its quarterly update, and its representatives will be better placed to address staffing issues. They really do not come under my remit.

The Deputy sought a detailed breakdown regarding the €5 million in respect of Storm Emma but I do not have it to hand. I can ask somebody to come back to the Deputy on it. Again, it is a HSE matter. The Department will not prescribe where exactly the €5 million will go.

We have already addressed the general practitioner negotiations and the salary of general practitioners. I am not aware of what the Deputy described and would not be involved on that side of it.

On the staffing of new beds, 189 new beds have been opened but I would not be aware of the staffing arrangements for them or any future new beds. Those will be operational matters for the HSE. I am sure the HSE will answer those questions for the Deputy when its representatives appear before the committee on 7 May.

On the question on the additional €530 million, the Deputy was wondering about the proportion for additional staff. Again, I do not know. I suppose the HSE has a standard. I am not sure what it is. In any new development, I assume staffing would be accommodated but I do not know. I presume the HSE will answer that for the Deputy.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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These are the kinds of things the Minister of State should know. If the Minister for Health says he is confident that a certain number of beds are to be opened or that a certain sum of money is to be put aside and the Minister of State then comes in and says he does not know what it will be spent on, it does not inspire a massive amount of confidence. It certainly does not do so in me. It will not inspire a massive amount of confidence among people waiting on these services.

I apologise for the interruptions. I have asked several questions related to health expenditure but they cannot be answered. I fully appreciate that the Minister of State is here to deputise for the Minister but it is not acceptable for him to say he does not believe it is the job of the Department or the Minister to answer. Of course we will ask the HSE — we do so when its representatives appear before us. On the one hand, the Minister of State is telling us a certain number of beds will be opened and that there will be plans for this and that but on the other hand, when he is asked for the detail, he says it is someone else's responsibility. I do not believe that is acceptable.

Jim Daly (Cork South West, Fine Gael)
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All I can do is repeat what I said to the Deputy. I do not manage or micro-manage those operations at that level, even within my own area of responsibility. It has nothing to do with whether the Minister, Deputy Simon Harris, or any Minister of State is here. In my area, I do not micro-manage the system as suggested. The HSE is in place to deliver the services. It is an operational matter. Some of the questions the Deputy has asked are clearly related to operational matters. There are generic headline percentages that would be accommodated for any new development. Of course staffing would be accounted for. I cannot tell the Deputy how many staff will be required for each of the new 189 beds. I cannot give that kind of detail. I hope that is acceptable to the committee.

Deputy Margaret Murphy O'Mahony mentioned mental health and the great work of organisations such as Pieta House. To go back to the answer I gave to Deputy Kelleher about mental health, I believe the issues and challenges are similar across the country. Pieta House does wonderful work but it is funded by my Department, as is any such organisation. One of the issues I referred to a number of times is that the organisations do wonderful work but I am concerned that there is a challenge when somebody with a mental health issue in west Cork or anywhere else wonders whether he should go to Pieta House, Jigsaw, Lisheens House in my constituency, the Samaritans or ChildLine. On one's best day, it would be a challenge. When one has a mental health issue and is feeling down when trying to figure out where to go, it is particularly challenging. One of the objectives I have set is to ask the Department to lead with the HSE to put in place one single telephone number that people with a mental health issue can dial. The number would be universal. One would be assigned to the most appropriate service.

Margaret Murphy O'Mahony (Cork South West, Fianna Fail)
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The person answering the phone-----

Jim Daly (Cork South West, Fine Gael)
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There would be a person answering the telephone who would be appropriately qualified to signpost where people should attend. If one says one is Jim Daly from Clonakilty and has an ongoing feeling of anxiety in the stomach that has not gone away in two weeks-----

Margaret Murphy O'Mahony (Cork South West, Fianna Fail)
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It makes it easier on such people.

Jim Daly (Cork South West, Fine Gael)
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The person answering the telephone would say the most appropriate thing would be to call to Jigsaw in Bandon, for example, rather than figuring it out oneself.

We are also examining the delivery of the solutions online and through texting facilities whereby people could text and receive a response. A lot of our research shows that young people are much more comfortable texting than picking up the telephone and ringing. These are developments we are considering and trying to grapple with. A number of working groups have been set up within the HSE and the Department to drive forward this particular initiative so that there will be one single point of contact for those who wish to reach out to mental health services and which would refer one appropriately to the most suitable service.

Margaret Murphy O'Mahony (Cork South West, Fianna Fail)
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Does the Minister of State envisage that happening?

Jim Daly (Cork South West, Fine Gael)
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Every four or five weeks, I meet the groups to receive an update on the work. There is a lot of work involved. I hate setting a timeline because I may not be able to live up to it. I am confident, however, that by the end of the year I will have very significant progress made on this, irrespective of whether the telephone number will be available then. There are many challenges because existing services must be integrated and brought in under the new arrangement. One is not just going to ignore the Samaritans and all such organisations, which have done superb work. They must be brought in and an effort must be made to streamline the service. We are meeting the challenges head-on. There are some wonderful people working behind the scenes.

On waiting lists and Marian House, there is a challenge for the Department in respect of any of the organisations that are funded separately. How they do their work comprises an ongoing challenge. I will get Minister of State Deputy Finian McGrath to provide the Deputy with more detail on that, particularly on the waiting list at Marian House. I will work with the Minister of State and we will send the Deputy a response on the matter.

Margaret Murphy O'Mahony (Cork South West, Fianna Fail)
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I thank the Minister of State.

Jim Daly (Cork South West, Fine Gael)
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The Deputy asked me about Bantry General Hospital. I met the management there last Monday. I met senior management from the South/South West Hospital Group. There is a proposal, of which the Deputy has been very supportive, to develop the rehabilitation and endoscopy facilities. Both projects have gone to the HSE and have been technically cleared. They have proceeded to the Department and are in the mix for funding with hundreds of other applications for capital developments at various hospitals throughout the country.

As the Deputy will be aware, the operating theatre in Bantry General Hospital is open for only two and a half days per week. I am very anxious to have it open for five days per week. These are the kinds of solutions required in hospitals throughout the country, not just in Bantry General Hospital. The smaller hospitals offer unique services. Bantry hospital is unique because it is the only remote rural hospital in Ireland. As the Deputy knows, it has a mixture of long-stay beds, continuing-care beds and acute beds. It is very unusual. We will continue to work with the HSE. I will continue to try to get the theatre working for more than two and half days per week and to have more surgeons down from Cork, resulting in more outreach. I will try to get the relevant services up and running. That will contribute significantly to addressing the issues in Cork University Hospital. Bantry hospital has enormous potential in this regard.

Michael Harty (Clare, Independent)
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The next to contributors are Deputies Kate O'Connell and Bernard Durkan.

Kate O'Connell (Dublin Bay South, Fine Gael)
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I thank Deputy Bernard Durkan for allowing me to contribute before him. I have to leave shortly. I thank the Minister of State for attending this morning.

The Minister of State spoke about online therapies. This is interesting. The Minister of State might follow up on what occurs in the other jurisdictions where these therapies are practised. How are conditions triaged? In recent years, our attitude to mental health has changed and there is not as much stigma attached to mental illness but I do not imagine that we or the Minister of State could say, hand on heart, that everybody from Bantry to Donegal is happy to talk about his or her mental health. While I do regard the initiative as having value in taking pressure off the services, I wonder about the absence of the general practitioner. General practitioners, who tend to have a whole-of-person approach to health care, note that if people's mental health is segregated to be dealt with by another entity, be it somebody online or a service in another jurisdiction, there is fragmentation. We heard last week or the week before about fragmentation of services. Having the general practitioner in the community as the anchor person for people's health care, be it physical or mental health care, has considerable value. Is the pilot to complement existing services or to serve as an add-on, bearing in mind the increase in the diagnosis of mental health issues and the significant rate of prescription of antidepressants and such medications in Ireland at present? We all know there are problems in the Irish health service. I am not against the initiative but would be interested in knowing the international evidence supporting it. How will it cascade down into the practical setting?

If general practitioners, in the first instance, and then psychiatrists are not seeing the genesis of mental illness and how it progresses in people's lives, will there be a deficit in education when it comes to health care professionals?

It is very hard to engage with some people when it comes to mental health. Are we going down a road where the people most resistant to treatment will be segregated and we only sort out the people who have a willingness to engage? I do not see how this will help that cohort of people who, whatever their personal or family circumstances, do not engage with the services. Will the Minister of State outline that, perhaps after the meeting? I would be very interested to hear where this is coming from.

Bernard Durkan (Kildare North, Fine Gael)
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I welcome the Minister of State and the statement and information he has given to the committee. There are two or three things that came to my attention. I am delighted to see the move towards programme budgeting. One of my fetishes has always been comparison with the health boards, which always had programme budgeting. Since that finished we do not seem to be able to go anywhere with certainty. That has been one of the intrinsic problems in the health service over recent years. It was a woefully bad decision to move away from that. With programme budgeting, they can assess fairly regularly where they are going in the first, second, third or fourth quarter well in advance. It cannot be done any other way because it is too vague.

In the area of home help carers and home care packages, there is a need for some co-ordination with the Department of Employment Affairs and Social Protection. The carer's allowance is the first step to deal with situations in which older people do not require institutional care or a home care package but can benefit from being looked in on by a friendly neighbour or family member. They can have meals prepared at crucial times and can be looked in on in the morning and the late evening and so on. Most families have done this themselves. Modern labour force requirements do not allow that to happen to the same extent it used to. I saw a file last week where a person caring for a person in his or her 90th year was deemed to be ineligible on the basis the person he or she was caring for was insufficiently immobile. The presumption is that when the person tripped and fell and hit his or her head on something, he or she would become eligible. It is then too late for that level of care and requires either hospitalisation or institutional care. It is quite common, as the Chairman knows. I would like some interaction between the two Departments in that area as a matter of some urgency. It will not cost anything and it will dramatically improve the quality of life for those who need care and will relieve the pressure on the Department of Health.

Waiting times are another of my hobby horses. There are waiting times for everything and I cannot understand it. I will never begin to understand why we have them. It is almost as if somebody decides to pick a time in the calendar and tell people they will deal with them then. I do not accept it. I think it is just as easy to tell a person he or she will be dealt with next week. Waiting lists become longer and longer as time goes by. It is an acute system. We need a fairly rapid response. If we are going to be successful we need a rapid response. I am anxious that all areas where waiting times occur, whether as a result of a lack of theatre space, lack of adequately qualified nurses in theatre, consultants or GPs, waiting times have to stop because they go on forever. It will have to be done. The lists will have to be caught up with and overtaken. The question of how to eliminate those waiting times is important.

I agree with Deputy O'Reilly on the GP contract. We are long enough talking about it. We need to see some progress but not in the future. We are talking about waiting times again. Why do we have to wait for that? Why not do it now and have done with it? At least then we would have some certainty in the future. I do not want to talk about the procedure or negotiate here but it is not helpful to have a long waiting period in which we promise this in the future. It has been long enough promised so we should get on with it and do it soon. Let us produce something in the very near future that will indicate we are serious or not serious about it.

Deputy Louise O'Reilly referred to recruitment and I know the Minister of State may not want to comment on it. Somebody approached me recently about the issue and will come back to me with further information. There are some strange things happening in recruitment. Administrators seem to be of greater importance than the front-line staff. That should not be. I know we have to have administrators but the fact is we are in a crisis and we need the people on the front line dealing directly with the patients. We need them as a matter of urgency or else we are back to long waiting lists again and it will go on forever.

I have some questions for a different time. There are a couple of little niggling parts that I am not too sure about, for instance, the issue of medical cards. The number of full medical cards has dropped and there has been an increase in the number of GP visit cards. We are a bit uneasy about it. It is not always to the benefit of the patient. I would like some comment on it.

I try to avoid being parochial at these meetings but when everybody else does it, I think I should do it. My local hospital in Naas is in the picture. The endoscopy unit extension is much wanted and has been for some considerable time. I am anxious to clear the air, get it out of there, have it approved and get on with it. There is also an oncology unit upgrade required as well. It is a very busy hospital in a very important location. To drag out what is required now only reduces the confidence of the staff in the hospital. We need to avoid that.

The shortfall in the health budget has been reducing slowly but surely over recent years. In 2014, it was something like €600 million or €700 million. Gradually it has reduced to €295 million or thereabouts. Could we be coming to the spot where we can identify almost precisely what is required? I referred already to programme budgeting. I presume that as we move into that area, we should be able to get dead-headed budgeting. We should not need to be vague. A shortfall of €600 million or €700 million is way off target in terms of planning in advance. If we are going to plan for the health services in advance, we need to be more precise about the exact cost, where it will come from and where it will go.

Michael Harty (Clare, Independent)
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I thank Deputy Durkan. Before the Minister of State answers those questions, I will put a few questions to him. The Minister of State referred quite often in his opening statement to the Sláintecare report and the need for health reform and the shift from secondary hospital services to primary care services. Is there anything in the Estimates to indicate there is a start in attempting to move from the expensive secondary care services to much more practical and efficient primary care services? Will the Minister of State point out where that is in the Estimates?

There is also reference in the Minister of State's opening statement to the expansion of eligibility for medical cards and free care to those under six and those over 70.

There has been an expansion in delivering medical cards to people in receipt of disability allowance. There is now a proposal to increase eligibility for those who receive carer's allowance. However, there is limited capacity in general practice to deliver these services. General practice is at its maximum, yet eligibility is increasing without any recognition that there is a huge manpower crisis. I do not expect the Minister of State to negotiate the GP contract across the floor of the committee room this morning but there is huge difficulty relating to GP manpower. The Minister of State would have heard it at the weekend. How can we propose to shift from secondary care to primary care if we do not have the GPs to deliver the service? General practice is at maximum capacity and many areas are facing the possibility of not having a GP at all. Many practices have closed their lists. We need to move to a new model of care and the GP negotiations are critical. They have been ongoing for two years. The Minister of State said they are a challenge and hope to deliver a contract by the end of the year but we have been listening to that for two years. Perhaps the Minister of State could address the accelerators to develop that contract.

Every part of our health service is interconnected, so if we fail to invest in primary care, naturally, people will gravitate towards secondary care. Therefore, we have trolley queues, increasing outpatient waiting lists and increased waiting lists for inpatient elective care, so there is a connection. Will the Minister of State outline his view on how those interconnections can be changed so that primary care can relieve the pressure on our hospital service?

Will the Minister of State address bed capacity? He identified a number of capital investments in his opening statement. One of the proposals in Project Ireland 2040 was to build three elective hospitals which would just deal with elective care and would not be overwhelmed by patients coming in through casualty departments and displacing people who are waiting for elective treatment. It is not mentioned in the Minister of State's opening statement but it is in Project Ireland 2040.

Model 2 hospitals are coming under severe pressure regarding recruitment and retention, particularly for nurses and medical specialists, because they are seen as unattractive places to work. There is a huge number of consultant vacancies - up to 400. Many of those are in model 2 and model 3 hospitals. Certainly University Hospital Kerry in Tralee is under severe pressure at the moment because it is losing three of its major specialists and is having difficulty recruiting. Ennis Hospital is having difficulty in recruiting geriatricians, so there is a difficulty in recruiting people in specific areas in our health service. Perhaps the Minister of State might address that.

The Estimates contain an allocation of €1 million to development the Sláintecare office and the implementation office. Will the Minister of State refer to how this is progressing? Regarding the funding of our hospital services, €670 million comes from private health insurance. This figure seems to be dropping because private health insurance companies are encouraging patients who come through emergency departments not to designate themselves as private patients because it will not give them any additional care. This is leading to a reduction in the amount of money coming from insurance companies to fund our public system. The appropriation-in-aid part of the budget is €460.2 million. Will the Minister of State let me know what this funding consists of and where it comes from?

Jim Daly (Cork South West, Fine Gael)
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Will the Chairman repeat the last question?

Michael Harty (Clare, Independent)
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Appropriation-in-aid is €460.2 million. When it is added to the Vote, the total allocation for the health budget for the year comes to €14.871 billion. I want to know the detail of that.

Jim Daly (Cork South West, Fine Gael)
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Deputy O'Connell asked about online therapies. She offered to have a conversation with me afterwards. Shall I do that or does the Chairman want me to go through it on the record?

Michael Harty (Clare, Independent)
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The Minister of State can go through it for the record if he likes.

Jim Daly (Cork South West, Fine Gael)
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I was not 100% clear whether the Deputy was talking about the phone line or the online service. I think she referred to the online service but when she spoke further, it was more about the phone line. She said that it would be assumed that certainly the online delivery of any mental health therapy would done in primary care centres under the guidance of the GP. I think she seemed to be concerned about that. Of course, the GP would be central to a phone line but GPs face a challenge as well. If someone presents to a GP, the GP is supposed to be an expert in every area when obviously they cannot be. They are also expected to be up to date on the whole range of services so GPs would be central to directing people. What I want to do is create that directory and signposting and make tools available to people regardless of whether people ring to find out the nearest available mental health support or go to their GP, who will also have immediate access to this directory and can direct people to the most appropriate means, because we do have an issue with people being referred. Not every teenager who presents with a mental health issue, be it anxiety, stress or bullying, needs to go to CAMHS. In some cases, they do not need to see a consultant psychiatrist. There can be interventions at different levels, therapies, psychologists and so on. It is about appropriateness and appropriate referrals but GPs will always remain central and will be the front door and first point of contact for people.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I have a question about the phone number because it is very interesting. The idea is that a person will ring in and will just be directed to the right service. I could probably say something smart about the waiting list but I am not going to. Will that person be qualified or will he or she be more of a telephonist? If somebody rings up and says he or she anxiety, which I think was the example used by the Minister of State, that person would be directed to the service. If somebody rings up and says he or she anxiety but actually that person might have something else, the person dealing with that could be an administrative person. Is intended that this person would be a triage person or merely a telephonist?

Jim Daly (Cork South West, Fine Gael)
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Obviously, they are taking on a degree of responsibility when they are referring so they would need to have an appropriate qualification and they must be a triage person because they would have to be able to detect if it is much more serious than the person presenting says it is. For example, has the person suicidal ideation? The person at the other end of a phone line would need a level of qualification. The challenge is actually making the directory of services available because a lot of these organisations are opening up and collecting money through voluntary activity. Some of them are funded by the HSE while others are not. We need to streamline that. It is about creating the directory.

To answer Deputy O'Connell's concern, the GP will still be very central and the focus of all of this and will use this directory. However, some people will choose to ring a phone line and not go to their GP, so we are trying to cover all angles. Is it a complement or an add-on to existing services? Again, it is both but it is mainly to complement the existing services. Again, it is about how we do it, what we do and doing it better as opposed to continuing to do what we have always done.

Deputy Durkan asked about the presentation of budgets and programme heads. I was in the Department during the week preparing for this meeting. Some of the officials there mentioned to me that Deputy Durkan has been very consistent in his querying and challenge to have this presentation done. The challenge is acknowledged and recognised. Basically, it is a case of syncing the Department's accountancy practice with the HSE. The HSE is developing a new model of financial accountancy and presentation. Once that is done, the Department can tie into it. I apologise that we are still on the outdated model this year but we live in hope. Certainly Deputy Durkan's consistency in highlighting this has been acknowledged and recognised and has been instrumental in forcing the change to come about.

Deputy Durkan made a very interesting point about home help, carer's allowance and tying up between the two Departments. It is something of which I am aware as a practising politician but I am not sure I was aware of it in my role in a Department as a Minister of State. As the Deputy knows, we are trying to devise a statutory scheme to provide home care and to make sure that people can get it as a right as opposed to the current haphazard arrangement where a lot of it is down to a postal code lottery.

As things stand, a lot depends on waiting lists, queues etc. We want a system similar to the fair deal scheme, where everybody is entitled to the service. People will merely have to go through the formalities of the paperwork and they will get it. To accomplish that, several challenges must be met. Obviously we have to upskill the workforce and make sure it is sufficient to deliver the service. We must also ensure that there is transparency and-----

Bernard Durkan (Kildare North, Fine Gael)
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The Department of Health must liaise with the Department of Employment Affairs and Social Protection. The two are very interconnected.

Jim Daly (Cork South West, Fine Gael)
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As a result of Deputy Durkan's contribution today, I will certainly ensure that there is more liaison with the Department of Employment Affairs and Social Protection as we progress that statutory scheme.

Waiting lists were referred to. Why are there waiting lists? I know the point being made. Why can we not deal with everything today or tomorrow? It is not all about money, but money helps. It is about how we do what we do. We allocated an additional €85 million to deal with waiting lists for this particular winter. Some €40 million was allocated to winter initiatives. A further €11.6 million was allocated directly to waiting lists, and an additional €35 million was allocated to the National Treatment Purchase Fund, NTPF, to source procedures outside of the State. We could talk about why we have waiting lists all day.

I take the point that GP contracts have been waiting to begin for a while . I am assured that they will begin very shortly. In regard to recruitment, I am not sure what specific question was asked-----

Bernard Durkan (Kildare North, Fine Gael)
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The question concerned administrators versus front-line staff.

Jim Daly (Cork South West, Fine Gael)
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I have heard that argument being made. Senator Colm Burke makes much of that.

Bernard Durkan (Kildare North, Fine Gael)
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Unfortunately he cannot be here today but if he was, he certainly would be raising it.

Jim Daly (Cork South West, Fine Gael)
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We have to be careful. A lot of administrators are front-line staff. People assume that administrators are people in back offices, pushing paper around. However, they are involved in processing medical cards and things like that. We must think carefully about whether we want to institute a pause on the hiring of administrators. Deputies should feel free to-----

Bernard Durkan (Kildare North, Fine Gael)
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I am sorry to interrupt again. Yes, that is true. However, if we are beset by waiting lists, as we have been for many years now, there has to be some reason for it. Maybe it is a shortage of administrators. Maybe administrators are what we need. I do not know, but I do know that we have to overhaul our waiting lists. Otherwise we may as well close the shop altogether and go home. The fact of the matter is this; if we cannot identify the snags in the system and resolve them, then we are wasting money, because time is money. The costs of running the health service will be reduced very considerably if we can identify and remove those glitches. It goes back to the old system. We may ask, for example, how long one has to wait for the result of an X-ray, a scan or whatever. One should not have to wait at all. If time is money, then we need to know the results as quickly as possible.

I would emphasise this point. Some time ago, the comparison between private sector and public sector hospitals was brought to my attention. It appears that a consultant could work a full day in the private sector uninterrupted. If they change over to the public sector the following week, they might have a day's work, but they might not. That might be because some part of the system is not ready. There may be insufficient staff in the theatre, theatres may be unavailable or whatever the case may be. All of these are serious contributory factors that make the health service less efficient, and that is what we need to address.

Jim Daly (Cork South West, Fine Gael)
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I take the Deputy's point on board, but I am not sure that there is any policy of focusing on additional administrative staff instead of front-line staff within the HSE. I can only speak for myself however. If we want to be pedantic about it and talk about what administrators do, I am sure they would argue that a lot of their time is spent dealing with the political process, that is, portraying accountability, openness and transparency. Are we to cut back on that as well? However, that is just an aside.

Deputy Durkan also asked about Naas General Hospital and its endoscopy unit. That is part of the capital plan that is being developed at the moment. As I said to my colleague about Bantry General Hospital, all of those projects are currently being progressed through the national capital plan within the Department and the HSE. Deputy Durkan's enthusiasm and support for the project is noted.

The Chairman asked about Sláintecare, its development and where the corresponding proposal is included in the estimates. An additional €25 million has been allocated to primary care, which is part of that. The Minister for Health, Deputy Harris, has committed to bringing several specific proposals on Sláintecare and its development to Cabinet in the next several weeks. We will have to wait for those to come through the Cabinet before I can bring them to this committee. Those proposals will answer the Deputy's questions about the specifics of Sláintecare and progress thereon.

On the technical side-----

Michael Harty (Clare, Independent)
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That report was due at the end of December, and then due before Easter. When is the next deadline?

Jim Daly (Cork South West, Fine Gael)
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I do not know if the Cabinet is meeting in the next two weeks. I understand that the Minister will bring specific proposals on developing Sláintecare to Cabinet in the next three to four weeks. An executive director will be appointed within the same period. That recruitment process is substantially under way at the moment, and should be completed within the next three to four weeks. The appointment of an executive director is the starting point for driving forward the proposals that are cleared by the Government.

The expansion of medical cards and GP practice were raised. As the Chairman will be well aware, there is a proposal in the programme for Government to increase the number of training places for GPs to 259. I appreciate that it takes so many years to train a GP. The number of training places this year has increased to 190, up from 120 trained last year. There were 400 applications last year for those 190 training places. That is a significant increase. The future in the medium term looks reasonably promising, notwithstanding the challenge involved in bridging the time before those people become GPs.

On the topic of recruitment, I note-----

Michael Harty (Clare, Independent)
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I wish to respond before the Minister of State leaves that topic. Increasing the number of training places for GPs does not actually address the manpower issue. We are training GPs in order that they will emigrate because no young aspiring GP will sign the existing GP contract. Nobody who is recently qualified is signing a new GP contract.

Jim Daly (Cork South West, Fine Gael)
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We must be careful not to talk the GP career down to new aspiring candidates. My own son was with me at the event last weekend, and he told me he would love to be a GP. We have to ensure that we protect the future. These efforts will be made in tandem. We must increase the number of training places. We cannot simply state that all new GPs will all emigrate and throw our hat at the issue. However, we also have to reform the contract. We must make it fit for purpose and make it an attractive career. Those goals must be pursued together and I think the Chairman and I both recognise that. It is not a case of doing one or the other.

I was recently in New Zealand, representing the country on St. Patrick's Day. I was amazed to hear New Zealanders tell me of their high regard for the Irish medical workforce. They see it as incredibly talented and well trained, which we can be very proud of. They had one difficulty, however; they cannot retain these workers. They all want to go back home. This is the issue they are experiencing on the other side of the world. Irish professionals come for a short while, but they do not commit. They are not willing to stay. That includes different disciplines, including nurses, GPs, physiotherapists and everything in between. That is the other side to this. The New Zealanders said to me that the Irish workforce is very mobile, even in the far-off countries to which they go. They do not necessarily settle there but they like to go for a while. That has always been part of the Irish psyche and make-up.

Bed capacity and ambulatory care have been referred to. The move towards ambulatory care is a part of the national development plan. It informs the decisions on where to locate elective procedures and where those hospitals will be built. They will always be connected and related to the acute hospital but those decisions are being taken.

Recruitment for model 2 hospitals has been raised. The questions mentioned are challenges for Kerry General Hospital and Bantry General Hospital. This is a particular challenge for remote hospitals, model 2 hospitals and some model 3 hospitals. The South/South West hospital group is currently undertaking a review of all its consultants and their particular skill sets to see where the demand is more acute and attempt to find solutions.

I discussed it with the hospital group on Monday of this week. It assured me that the review would be completed within the next two to three months and that it would devise proposals to deal with the consultant challenges that have been mentioned. I expect a number of recommendations from the South/South West hospital group, which I suspect will be replicated nationally.

I do not have information on insurance companies to hand but I can get someone to revert to the Chairman on the issue.

As to the €460.2 million figure of appropriations-in-aid, the recovery of cost of health services provided under EU regulations is €280 million and the receipts from certain excise duties on tobacco is €167.605 million. They are the main components. There are a number of others, including recoupment from social insurance for certain ophthalmic and dental treatments, miscellaneous receipts, the Dormant Account Fund, which is €2.7 million, and receipts from pension-related deductions in public service remuneration, which is €3.9 million, but the bulk of the figure relates to the recovery of cost of health services provided under EU regulations.

Michael Harty (Clare, Independent)
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I thank the Minister of State. Do Deputies Murphy O'Mahony and O'Reilly have further questions for him?

Margaret Murphy O'Mahony (Cork South West, Fianna Fail)
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No.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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When I asked specific questions about scoliosis, the Minister of State undertook to revert to me. Will he do that as soon as possible? People have been waiting a long time and they want to get a few answers.

Jim Daly (Cork South West, Fine Gael)
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I will.

Michael Harty (Clare, Independent)
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I thank the Minister of State for attending to review the Revised Estimates.