Mr. Paul Reid:

I will make a few general comments before asking some of my colleagues to make some specific points. In terms of what the Minister referenced, I have strongly heard from all across the organisation the requirement to conduct a deep assessment of the validation lists. As the Minister has touched on, we have kicked off that process with support from the NTPF. I am hearing it from consultants, staff, nurses, etc., that a wide assessment is needed and that process will help us.

Without doubt, and to state the obvious, the demographic pressures are all upwards in terms of requiring outpatient appointments and that has been well proven. Deputy Donnelly is right that there are certain demographic issues in terms of geography and different spread and some of the impacts on us.

I should also mention the new models of care.

One of the big strategic intentions behind Sláintecare is the move to an integrated model of care whereby we increase capacity in the community. In my previous role I visited many primary centres and supported the building of them. There is no doubt that they have capacity for the future when we can invest in some of the diagnostics for them and so on. By continuously running with the same model, we will chip away at it but our real move has to be to transition to the new model of integrated care. My role is to work with the team in Sláintecare and with the Department in order to start moving us in that direction and, as the Minister stated, to leverage off the agreement with the GPs, and how that agreement can be deployed locally, and to leverage off the recently concluded nurses' agreement, and how we can move to the implementation of that for the deployment of nursing care into the community in a stronger way.

Reference was made to the budget, which is a very real issue. I touched on it in my opening statement. The national service plan budget for the start of 2018 was €14.5 billion and the outturn was just over €15.2 billion. This year we have €16 billion. We have to assess how to deal with the upper pressures on the HSE, which are very real, with the demographic issues that press on the health service and with the move to the new model. It is a very challenging environment of assessing every cent and euro we have and where we currently put that money. It is my early assessment that if we continue to put it into the current system of congested acute care and outpatient care, we will make slow progress. I really want us to transition to the new model on a collective basis.

While the assessment we have kicked off primarily focuses on and relates to the winter programme and emergency departments, it will tell us a lot about where there are better processes for management of the patient through group hospitals and CHOs. I visited Waterford and Tullamore last week and I will be visiting other hospitals. One can see variance in respect of how outpatient progress is managed. I want to ensure that we have best practice and that we understand what is best practice. I am hearing a major call from across the service to really look at that. I am seeing some excellent practice, including in Waterford and Tullamore, regarding the management of the outpatient experience and the follow through. We will have to focus on all of these matters. I appreciate that it is a challenge. I shall ask my colleague to provide some specifics.