Oireachtas Joint and Select Committees
Tuesday, 6 December 2022
Select Committee on Health
Estimates for Public Service 2022
Vote 38 - Health (Supplementary) (Resumed)
Seán Crowe (Dublin South West, Sinn Fein)
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At the committee meeting on Wednesday last, 30 November, we considered the 2022 Supplementary Estimate for Vote 38 - the Department of Health.
The aim of today's meeting is to conclude that consideration. I welcome the Minister for Health, Deputy Stephen Donnelly, the Minister of State, Deputy Mary Butler, and their officials from the Department of Health. I would also like to thank the Minister for submitting substantial material on Friday evening last.
Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if any of their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against persons outside the Houses or an official either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask members partaking via MS Teams to confirm, prior to making their contributions, that they are on the grounds of the Leinster House campus.
To commence consideration of the Supplementary Estimate, I invite the Minister to make his opening remarks.
Stephen Donnelly (Wicklow, Fianna Fail)
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I very much welcome the opportunity to continue the discussions on the Supplementary Estimate for Vote 38. I and my officials have taken on board the discussion at our engagement last week. We also noted the specific queries made by committee members. In this regard, my officials have supplied an updated brief to the committee, which I understand was received last Friday. The brief included a more detailed exposition of the drivers of the requirement for a Supplementary Estimate, as well as further briefings on specific issues raised by the committee. These were in regard to the National Ambulance Service and capital expenditure, and additional briefing was provided yesterday on the State Claims Agency and the pandemic recognition payment. Additional issues were raised that were not directly pertinent to the Supplementary Estimate but it is very important that they be addressed. Briefings on these are being prepared by my officials and will be provided to the committee in due course. There are several of these, including future cost projections for the State Claims Agency associated with clinical negligence cases, an update on the national maternity hospital new build, a note on new arrangements for GPs in regard to CervicalCheck screening, a note on e-health expenditure and a note on broader HSE expenditure on information and communications technology, specifically including costs and budgets associated with the roll-out of two specific HSE projects: the integrated financial management system, which we discussed at some length last week, and the national integrated pay records and pay programme.
I now seek the committee's approval for the Supplementary Estimate of €1.392 billion for Vote 38.
Seán Crowe (Dublin South West, Sinn Fein)
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I open the meeting to members. I call Deputy Durkan. I ask the Deputy to confirm he is within the confines of Leinster House.
Bernard Durkan (Kildare North, Fine Gael)
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Yes, I am in my office in Leinster House. I have a couple of questions on the national children's hospital. I have heard, as I am sure others have, speculation on the likely cost, and we went through that the last day. Some suggest it is in the wrong place. Since the hospital is built, I am not certain whether a discussion on that basis is intent on doing anything material, and I do not think it is relevant at all. Can the Minister outline the extent to which the project is nearing completion, or is half completed or otherwise, and whether it is in keeping with the specification, whatever the specification has been? Will it be in keeping with the best available global standards at this time? Will it be possible to assume that the best quality of service is readily available to children and their parents from whenever it is available?
We received some information on the State Claims Agency. I am concerned that it is running away from us in a worrying fashion and we need to do something about it. I have not had an opportunity to read the new papers that came through. What is needed is to be able to identify the areas most State claims originate from. It is at approximately €530 million so it is time to do something serious about that, to identify what mistakes are being made and what was identified over the past four or five years in this context, and where we can go to ensure the State's interests are safeguarded, as well as patients’ interests, because that is where the State Claims Agency comes in when something goes wrong.
Stephen Donnelly (Wicklow, Fianna Fail)
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Good progress is being made on the national children's hospital. I spoke to the contractors on-site in the past few weeks and they believe they will finish their build at the end of quarter 1 of 2024. Some of the commissioning happens in parallel with the build and final commissioning happens when the build has been handed over. The HSE believes it can have children in the hospital as patients in the second half of 2024. The contractors’ timeline came with the caveat we would all expect, which is that we are in uncertain times, given we have been living with Covid, war in Europe and so forth, but that is their intention.
It is an extraordinarily impressive build and it really is going to mark a new departure for healthcare provision for children. The hospital will have more than 6,000 rooms and, within that, it will include 39 clinical specialties, all in the one location. There will be 380 inpatient beds and the rooms are single-room occupancy with large windows and beds for parents. It is state-of-the-art and very impressive in terms of care for children and supporting their families as well. There will be 93 day beds, 60 critical care beds, 110 outpatient examination rooms, 22 operating theatres and procedure rooms and a 300-seat lecture theatre, given this will be a teaching hospital. The corridor that the operating theatres are on is a sight to behold; it runs the full length of the hospital and each of the operating theatres is state-of-the-art. The difference they will make is huge.
Work on the main site is progressing well and the building phase is nearing 80% complete. The focus through this year has been the internal fit-out. The most advanced areas now have finished floors, walls, ceilings and joinery, such as nursing stations installed, and equipment and rooms in clinical areas are now discernible. Other areas such as the emergency department, imaging, critical care and therapy areas are progressing at pace. The external scaffolding is now coming down with the completion of glazing, and the external façade and the very large glass biome over the central staircase is nearing completion. The first rooms have been completed, with the other 4,600 rooms to follow in a sequenced manner in the coming months. That is where progress is with the hospital.
We had a useful conversation on the State Claims Agency last week. As the Deputy rightly said, the numbers have been increasing. There are two schemes which I get information on: one is the clinical indemnity scheme and the other is the general indemnity scheme, that is, CIS and GIS. Clinical indemnity, as the Deputy would expect, is a lot larger.
Between 2010 and last year, that grew from about €78 million to about €358 million. I was looking through the additional briefing the committee received and it is very useful. For example, it identifies the main clinical areas in recent years, of which obstetrics accounts for nearly half of the claims. The note also points out that the volume of claims remains broadly constant and that the awards are going up significantly to account for inflation and rates of return. Those are some of the drivers.
As we discussed last week, there is a concerted effort required, first and foremost, to address patient safety issues. All of this is simply a financial manifestation of patient safety issues and we have to make sure those issues are identified and eliminated. The HSE does ongoing work on that. We need to keep the focus on it and look at implementing other mechanisms as well, as opposed to taking only the judicial or State claims route.
Bernard Durkan (Kildare North, Fine Gael)
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Is it possible to identify specific areas where changes might be made that would improve patient safety and reduce State claims?
Stephen Donnelly (Wicklow, Fianna Fail)
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Yes. First and foremost, we have to be able to systematically identify the causes of patient safety issues and eliminate them. There is considerable work being done on that. There is, for example, a new obstetrics incident team looking at exactly these kinds of issues. We need to do that across the board. In fairness to our public service doctors, they spend a lot of time reviewing their work, identifying errors made and updating training, guidance and protocols to eliminate patient safety issues.
Bernard Durkan (Kildare North, Fine Gael)
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To what extent can measures be taken now to reduce potential accidents or errors at birth that subsequently end up with the State Claims Agency or before the courts? Has that been done? Have the particularly sensitive areas and most common likely incidents been identified? Has the HSE been able to put in place rule-of-thumb measures that would apply in all maternity hospitals to try to ensure the patient or patients are given the best possible chance in the circumstances?
Stephen Donnelly (Wicklow, Fianna Fail)
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Yes, there is much work ongoing. The HSE is using multidisciplinary patient safety tools to look at this to identify and minimise risk. This approach is embedded in the clinical strategies, for example, in the national maternity strategy. It is worth noting that analysis conducted by my Department shows there is a time lag of about nine years between an adverse incident occurring, for example, where there is medical negligence, and an award being made in the case of catastrophic birth injuries, which I think the Deputy referenced. This indicates that any effect from the patient safety initiatives would take several years to come through in terms of reduced claims. We need to keep pushing on that and make sure our clinicians, who are pushing for more improvements and safer practices all the time, have the resources they need. The national maternity strategy is fully funded and it looks at this issue very methodically.
Nonetheless, I am keen that we take further action. I am considering measures to examine what more can be done. As I said, there is one major increase in costs and it is a technical driver. It is essentially the real rate of return, the investment return plaintiffs are assumed to obtain should they invest the lump-sum settlement award. Simply put, the higher the real rate of return applied to the lump sum, the lower the reward and vice versa. It is a technical issue.
I am in exactly the same space as the Deputy in that this is ultimately about patient safety. We need to ensure our clinicians have the tools and resources to systematically identify, reduce and, wherever possible, eliminate risks for patients.
Bernard Durkan (Kildare North, Fine Gael)
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Is it possible to reduce the time lag between the time of the incident when the liability arises and the eventual addressing of the compensation or claim in whatever area that needs to be done. I am thinking about issues that have been common in the past, such as loss of oxygen at birth with obvious consequences. A number of similar areas have serious consequences for the patient, either the mother or the baby. I would be anxious, insofar as is possible, to eliminate the chief dangers and try to deal with them on an ongoing basis, so at least we would make progress on two headings, namely safety and claims.
Stephen Donnelly (Wicklow, Fianna Fail)
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I do not have much to add to that, other than to say I fully agree. That is exactly what we need to be doing. We need to look at this from a clinical and operational perspective to keep patients safe. Where patient safety incidents occur, we need mechanisms that get a resolution for the patient and his or her family as quickly as possible.
David Cullinane (Waterford, Sinn Fein)
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I will cover four issues as quickly as I can. First, with regard to the updated briefing document the Minister gave me, I wish to return to the issue of the access to care fund. The earlier presentation and budget 2021 featured a subhead of €697 million - €497 million for Covid measures and €200 million for the access to care fund. In the briefing document, the access to care fund from that subhead now amounts to €7 million. The document states that this is not the full spend of the access to care fund, in terms of the €200 million, that this is more likely to be approximately €130 million and it will now come from core acute expenditure. Is it correct that whereas €200 million was allocated on budget day as part of the €697 million figure under the subhead I mentioned, only €7 million for access to care will now come from that subhead and the balance, to give a total figure of €130 million, will come from core acute expenditure? Is that a correct reading?
Stephen Donnelly (Wicklow, Fianna Fail)
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Does the Deputy want to go through these one by one?
David Cullinane (Waterford, Sinn Fein)
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I am just asking if that is a correct reading.
Stephen Donnelly (Wicklow, Fianna Fail)
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The Deputy said he had four questions. Does he want to go through them one at a time?
David Cullinane (Waterford, Sinn Fein)
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Yes.
Stephen Donnelly (Wicklow, Fianna Fail)
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I will ask the officials to respond on the accounting. What I can give the Deputy from a policy perspective, if he likes, is the planned spend and the projected actual spend. I think that is probably what he is most interested in.
David Cullinane (Waterford, Sinn Fein)
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It says here it is €130 million. Is that correct?
Stephen Donnelly (Wicklow, Fianna Fail)
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The projected end-of-year spend is €252 million against €350 million.
David Cullinane (Waterford, Sinn Fein)
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I will read out what we have been given. It frustrates me that when we ask for an updated note I have to read it out. It states that the Department understands that the €7 million reported by the HSE against access to care with the HSE Covid expenditure, as detailed, is not the full spend against the €200 million allocation made under this subhead to the HSE. The total expenditure by the HSE on waiting list initiatives, it continues, is projected to be approximately €113 million, with the balance of expenditure charged against core acute expenditure. I know there is perhaps other money spent from elsewhere, but in terms of the actual access to care fund and the €200 million, it states here in black and white that the expenditure incurred will be €130 million. The Minister is giving me a different figure again. Perhaps the Minister’s official will shed more light on the issue because it gets more confusing as time goes on.
Mr. John O'Grady:
I thank the Deputy for his question. The €252 million figure the Minister referenced is a combination of spend against the €200 million fund, which is allocated to the HSE-----
David Cullinane (Waterford, Sinn Fein)
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I am asking about the access to care fund-----
David Cullinane (Waterford, Sinn Fein)
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-----so we are very clear about what I am asking.
David Cullinane (Waterford, Sinn Fein)
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Yes.
David Cullinane (Waterford, Sinn Fein)
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That is fine. It is what I asked for at the start. The figure is €127 million, not €230 million, as the Minister stated. The document goes on to say that the balance of the spend currently embedded will be currently embedded within the core acute deficit. What is the core acute deficit?
Mr. John O'Grady:
The HSE has reported, in the latest data that we have, approximately €7 million specifically against the Covid budget.
David Cullinane (Waterford, Sinn Fein)
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I know that.
David Cullinane (Waterford, Sinn Fein)
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What is the core deficit?
David Cullinane (Waterford, Sinn Fein)
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So we are now running a deficit to pay for the access to care fund as opposed to the money being spent in the way it was meant to be spent. Is that right?
Mr. John O'Grady:
It is a technical accounting thing. We are working with the HSE to get the expenditure lined up against the correct subheads. Based on the latest data we have, there is a slight mismatch. We will balance that out by the end of the year. It is in the detail of individual subheads. It balances out in overall terms.
David Cullinane (Waterford, Sinn Fein)
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I imagine that it has to balance out somewhere. However, my point is there is a lot of reprofiling of money here for this one particular fund alone. It suggests, as the Minister has acknowledged, that this centralised financial management system is more important than ever. It is really difficult to track. I will not even have time to go into PPE, which is even worse. It is mind-boggling to try to understand those paragraphs and to make sense of how all that works. Last week, the Minister told us that the total estimated cost was €118 million. The Revised Estimate was also €118 million, but now the projected estimate is €151 million. That information was not there last week. That is a new figure. It continues to show different figures and where the money comes from. From an accounting and presentation perspective, it seems like an absolute disaster and impossible for us to understand it.
David Cullinane (Waterford, Sinn Fein)
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The €497 million.
Mr. John O'Grady:
The Deputy should let me answer the question. The estimate was approximately €1.57 billion. That was our estimate when budget discussions were going on in September and October 2021. At that point, obviously, there was a level of volatility regarding where the Covid pandemic might go in 2022. It was agreed between the Departments of Health and Public Expenditure and Reform that we would effectively take a wait-and-see approach. There was an initial allocation of €500 million for public health. Of that, €497 million went to the HSE and €3 million was held in the Department. We did not break that down further in terms of individual budgets for PPE, for testing and tracing, and for vaccines on the reasonable assumption, I think, there was likely to be a shortfall so it did not make sense to break that shortfall into further individual shortfalls.
David Cullinane (Waterford, Sinn Fein)
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I get all that; that is what we said last week. I am saying that different figures have been presented today.
David Cullinane (Waterford, Sinn Fein)
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It is welcome because it provides more clarity. I welcome and accept that.
The third issue I want to raise-----
Stephen Donnelly (Wicklow, Fianna Fail)
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May I make a quick clarification?
David Cullinane (Waterford, Sinn Fein)
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It needs to be very quick because I only have four minutes left and I have two issues I need to get to.
Stephen Donnelly (Wicklow, Fianna Fail)
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The figure provided last week was €118 million, which is the figure here today. The Deputy, very understandably, asked for the breakdown for additional information, which is the €151 million. All the officials have done is to provide the extra information the Deputy sought.
David Cullinane (Waterford, Sinn Fein)
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That is exactly my point. We should have had that information last week. We asked for that last week. In fact, Deputy Shortall spent a long time trying to establish what the estimated figure for PPE was. She was told it was €118 million; as it turns out it was €151 million. I agree with the Minister, but it is now that we are getting the information which vindicates us sitting here again.
I want to get back to my questions. My third question relates to the pandemic bonus payment, a matter on which we also spent a lot of time. Nursing Homes Ireland received correspondence from KOSI Corporation stating that if they got their claims in by 11 November, people would be paid by 30 November. It stated that this delayed timeline is extremely disappointing and is yet another example of the failure of the Department of Health and the agency to properly plan for an efficient roll-out of the payment. I cannot disagree with that. How in God's name are we still here? We put a process in place where people would be paid through a self-assessment system and it still does not seem to be working.
Stephen Donnelly (Wicklow, Fianna Fail)
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It would be useful if Nursing Homes Ireland recognised the enormous sums of public money which we, the Oireachtas, have all agreed they should get for PPE, for testing and tracing and for the various schemes the Minister of State, Deputy Butler, has run with them, including most recently another €10 million. When Nursing Homes Ireland states it is disappointed with Government, all of us in the Oireachtas should remember how much money has been given to take care of people in our country during the pandemic. That is why we did it.
Regarding the pandemic recognition payment, these are private for-profit organisations. There was nothing to stop any of these organisations paying the money themselves to their employees over the last while. As the Deputy will be aware, in the briefing note the officials laid out what the many months this year were spent doing. Part of it, as we said last week, was engaging with the representative bodies to ensure we had an agreed approach. As the Deputy will be aware, the HSE was concerned that it could be double-paying people in nursing homes because they might also work in a HSE facility. The HSE was trying to ensure the public money was spent in the right way. I intervened, as the Deputy will be aware, to suggest using this other approach and many nursing home staff have been paid.
David Cullinane (Waterford, Sinn Fein)
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I accept that. Perhaps by next week, the Minister might provide us with a note on when people might expect to be paid.
Stephen Donnelly (Wicklow, Fianna Fail)
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Sure.
David Cullinane (Waterford, Sinn Fein)
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We should not pass the buck on any organisation. The responsibility for ensuring prompt payments were made, in my view, rests with the Department.
I wish to ask about issues relating to the State Claims Agency. The Minister mentioned that a note on future claims would be sent to us in due course. He also mentioned CervicalCheck and patient safety. Earlier today, the Minister and I had a telephone conversation on the Patient Safety (Notifiable Patient Safety Incidents) Bill and amendments coming up tomorrow, which, I have to say, I am extremely disappointed with. I have a concern about those amendments. I do not believe they do what they should do. I have a real concern about what that means for women who will be tested for cervical cancer. In my view open disclosure, duty of candour, is what it is and should be what it is. If there is a discordant CervicalCheck slide in any lab, the woman should be informed irrespective of whether she asks. Duty of candour does not mean that a woman must ask. When an error is identified, it must be given. We will debate that more extensively tomorrow. What will be in the briefing note on future claims through the State Claims Agency the Minister is going to send us. What information is being compiled? I am not clear about that.
Stephen Donnelly (Wicklow, Fianna Fail)
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I will also respond to the Deputy's original point, if I may, because we are going to have to agree to disagree on this. It sounds like the Deputy is advocating that audits, which would be the quality control exercises, would not be done on an anonymised basis. That is the only-----
David Cullinane (Waterford, Sinn Fein)
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I am asking-----
Stephen Donnelly (Wicklow, Fianna Fail)
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May I just answer?
David Cullinane (Waterford, Sinn Fein)
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The Minister is misunderstanding what I said.
Seán Crowe (Dublin South West, Sinn Fein)
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Please Deputy, let the Minister respond.
David Cullinane (Waterford, Sinn Fein)
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Yes, but he cannot misinterpret what I said.
Stephen Donnelly (Wicklow, Fianna Fail)
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I really do not mean to. We need - I know we all will - to come at this in terms of what is in the best interest of women and men, everyone using the screening service. It is a debate for another day. Because the Deputy referenced it, I want to say that on the patient-requested look-back, the amendment we are bringing in, regardless of whether there is a discordance, mandatory open disclosure will apply. Tomorrow we will have a debate when we will hear his views, my views and the views of others as to whether the large-scale audits should be anonymised, which would be the only way any patient, man or woman, could be-----
Stephen Donnelly (Wicklow, Fianna Fail)
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The committee asked for a note outlining a future projection. The Department has now contacted the State Claims Agency and asked for that. The advice I have is that it will take a bit of time because it is, in actuarial and mathematical terms, quite complex to work through all the moving parts on rates of return, inflation and so forth. I understand that the committee has requested an estimate for the projected increase in the annual payments under those two schemes. If the committee wants any more, it should just let us know and we will ask for that.
David Cullinane (Waterford, Sinn Fein)
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For me, CervicalCheck involves a simple test.
Whatever happens in the context of the Bill, one question will have to be answered. It is not about whether any woman requested information. In real time, when Vicky Phelan and all the other women had discordant slides, one of whom found that out by accident when she read her own records, that was part of an audit and that audit had not been anonymised. CervicalCheck and the women's clinicians were notified but the women were not. It strikes me that we are moving away from a different type of audit that was carried out then to an anonymised one. Our guests can talk about the logic of this. That is fine, but it is a departure and a new way of doing it. In those circumstances, if a discordant slide is made available, a woman will not be notified, and I have a problem with that. We will debate this tomorrow, but it is a fundamental point-----
Seán Crowe (Dublin South West, Sinn Fein)
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We are dealing with Supplementary Estimates at the moment, so the Deputy is drifting a bit.
David Cullinane (Waterford, Sinn Fein)
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We were talking about the State Claims Agency as well and this comes under that.
Seán Crowe (Dublin South West, Sinn Fein)
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We might park that and move on to Deputy Shortall.
Róisín Shortall (Dublin North West, Social Democrats)
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On the point about the Bill to be debated tomorrow, did the Minister give a commitment to providing a briefing?
David Cullinane (Waterford, Sinn Fein)
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I had contacted the Minister directly in regard to the State Claims Agency.
Róisín Shortall (Dublin North West, Social Democrats)
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It would be helpful to have a note on the 42 pages of amendments. I made the point earlier in the Dáil that this is not a good way to do business.
Stephen Donnelly (Wicklow, Fianna Fail)
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Specifically on the issue we were debating about the amendment, which is where a lot of focus will be, a note is being prepared.
Róisín Shortall (Dublin North West, Social Democrats)
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Turning to the Covid recognition payment, there is now a bit more information than we had on the previous occasion. It was stated that this applies to 800 groups and non-public organisations, 532 of which have made submissions. Have the payments been made to those 532 or has the Department just received the submissions?
Róisín Shortall (Dublin North West, Social Democrats)
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Is that 300 in total?
Róisín Shortall (Dublin North West, Social Democrats)
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What is the total figure that applies to?
Róisín Shortall (Dublin North West, Social Democrats)
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The figure is from a total of 800, however.
Róisín Shortall (Dublin North West, Social Democrats)
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I appreciate that, but the Department did not ask them until November.
Róisín Shortall (Dublin North West, Social Democrats)
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I agree with some of the points the Minister made. Nursing homes got a ton of money during Covid; there is no doubt about that. There was a lot of talk in the early days of Covid by the then Taoiseach, Deputy Varadkar, to the effect that we would have to take a new approach to the care of older people, that congregated settings were not the best model, that we needed to develop a new model of care and so on, but that all seems to have gone by the wayside. In any event, this is not about the owners of nursing homes; it is about the people who work in nursing homes and other groups and organisations in the general health and social care area. Many of those people are very poorly paid. These are the people everyone was thanking and so on. The Government announced last January that it was introducing a recognition payment scheme. It is very bad form that that issue has not been addressed for non-HSE or non-section 38 organisation staff. A large number of people in private sector organisations have not yet received their payment and our guests are telling us 300 of the organisations will have been paid by Christmas. That is very disappointing. A much greater effort should have been made to reach those people. I get queries all the time from these people on low pay, obviously with a very definite focus on Christmas and the increase in the cost of living. Is there any way of expediting the payments? It is unfair to treat people like this.
Moving on to the question of State claims, I raised this, in the context of the final Scally report, during Leaders' Questions with the Taoiseach about two weeks ago. I asked at the time in regard to an issue related to the Meenan review and the Taoiseach stated he would revert to me with details on that. He did not do so and I followed up, and the response I got from him just the other day suggested he had asked the Minister to provide the detail on that. The expert group under Mr. Justice Meenan was set up in the middle of 2018 and reported around this time two years ago, but there still has not been an implementation of those recommendations. We can ask all the questions we like and we can talk about policy regarding State claims, but why have we not introduced these reforms the expert group recommended and what is the reason for the delay? There are 17 recommendations, ten of which relate to the Department of Health. What timescale is the Department working to with a view to implementing all of them?
Stephen Donnelly (Wicklow, Fianna Fail)
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I agree with the Deputy in that I would like to see quicker progress on this, for all the reasons we have discussed, the main one relating to patient safety. An updated incident management framework was launched in 2020 and is being built on. Officials are working with the national women and infants health programme. A new serious patient safety team is in place but, as the Taoiseach committed to and asked of me, I will put together a note.
I would like to see a consideration of non-judicial approaches for patients. A total of 98% of SCA claims are settled outside the courts, but it is nonetheless a very legalistic process. I would be interested, therefore, in the no-fault compensation scheme-----
Róisín Shortall (Dublin North West, Social Democrats)
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With all due respect, that is why an expert group was set up under Mr. Justice Meenan. Its recommendations are two years old. Does the Minister have a timescale for implementing them?
Stephen Donnelly (Wicklow, Fianna Fail)
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I am putting one together. The intended progress was, unfortunately, blown off course by Covid but we are putting together a timetable.
Róisín Shortall (Dublin North West, Social Democrats)
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When does the Minister expect to have that timescale?
Stephen Donnelly (Wicklow, Fianna Fail)
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We will have something early in the new year.
Róisín Shortall (Dublin North West, Social Democrats)
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Okay. Costs are mounting, as we know from these Estimates-----
Stephen Donnelly (Wicklow, Fianna Fail)
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I appreciate that.
Róisín Shortall (Dublin North West, Social Democrats)
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In addition to the cost for the taxpayer, this is not a proper way of dealing with adverse incidents. There are better ways of doing that and the difficulty is that this is something of a bonanza for the legal profession. Furthermore, it is not treating families properly and people are being left, for years on end, waiting for proper recognition of the adverse incident.
Stephen Donnelly (Wicklow, Fianna Fail)
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I would not disagree with any of that.
Róisín Shortall (Dublin North West, Social Democrats)
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Under the HSE’s core operations, savings, as they are called, of €500 million in pay costs have been made. This is in the context of very many health services simply not functioning properly and some of them not functioning at all, because of the lack of staff or of any workforce plan of any significance, along with all the other issues relating to housing, culture within the HSE and everything else. That €500 million, in what the Department refers to as savings, representing an underspend in recruitment, relates to 8,500 staff. How are we in a situation, coming up to the end of the year, where all services are crying out for additional staff or even the basic allocation of staff, and the Department cannot fill the posts? How is it that there are 8,500 vacancies?
Stephen Donnelly (Wicklow, Fianna Fail)
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There are two points I will make in response. First, we are cognisant of the vacancies, particularly in specific areas. The Minister of State, Deputy Butler, spends a lot of time on, for example, child and adolescent mental health services, CAMHS. It has been a significant challenge to hire into CAMHS and into the progressing disability services for children and young people programme. Some areas are doing well, such as enhanced community care, that is, the new primary care teams, but there are issues. Some of them relate to the global shortage of healthcare professionals, while others relate to the consultant contract, for example, not being fit for purpose. Moreover, some of them relate to a non-consultant hospital doctor, NCHD, work-life balance that is simply not sustainable-----
Róisín Shortall (Dublin North West, Social Democrats)
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The Minister is again describing the problem.
Stephen Donnelly (Wicklow, Fianna Fail)
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The Deputy asked me why we are where we are-----
Róisín Shortall (Dublin North West, Social Democrats)
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The Minister is aware of the problems.
Stephen Donnelly (Wicklow, Fianna Fail)
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I am trying to answer the question.
Róisín Shortall (Dublin North West, Social Democrats)
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The problems have existed for many years and there seems to be a lack of action on them.
Stephen Donnelly (Wicklow, Fianna Fail)
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I do not mean to talk across the Deputy. Can I speak to it? That is a fair challenge. The NCHD working group is up and running, is doing good work and changes have already been made. We will have a new consultant contract in place soon and it will be an attractive contract.
Róisín Shortall (Dublin North West, Social Democrats)
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Sorry, apart from doctors.
Stephen Donnelly (Wicklow, Fianna Fail)
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Safe staffing is moving very well. The expert review of nursing and midwifery is being implemented at pace. The Deputy will be aware that we are advertising now for a chief health and social care professional officer. There is a lot of work going on.
Róisín Shortall (Dublin North West, Social Democrats)
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The Estimates show 8,500 posts were not filled and the savings so I wonder how serious people were about recruiting.
Stephen Donnelly (Wicklow, Fianna Fail)
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That is a fair question. The second point I would make is, yes, we would all prefer if there were no vacancies. The HSE and the Government ultimately overestimated how many people could be hired into the service this year. Clearly that is the case. Since Covid started 16,000 more healthcare professionals work in the HSE and that has never happened before.
Róisín Shortall (Dublin North West, Social Democrats)
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That is cold comfort to people who are on waiting lists for various community services or hospital services for years, and especially children. The waiting lists are just scandalous.
For the last six months I have raised the issue of workforce planning and I have seen no evidence of any serious workforce planning going on either in the Department or in the HSE. We were promised reports on what was going on by Mr. Paul Reid but they never materialised. We raised workforce planning and had a special meeting about it. The Minister's Secretary General and Mr. Paul Reid spoke about recruitment and not workforce planning, which is a major problem. There is no long-term or even medium-term planning going on for the workforce.
My last question is on the Covid spend and has two aspects. Last week, the Minister said that the figure for PPE was €118 million and now we are told it is €151 million. Where did the €33 million come from?
Stephen Donnelly (Wicklow, Fianna Fail)
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The figure of €151 million was the initial estimate by the Department of what would be needed during the year. As part of the Estimates process, when one adds up all the various pieces such as PPE, testing and tracing, vaccines and so forth a lower provisional figure was agreed of €500 million with the understanding that if there was a significant wave, which we had with Omicron, that spending would go up. The €151 million was the Department's initial estimate as to what would be required. The estimate now for the total year is €118 million.
Róisín Shortall (Dublin North West, Social Democrats)
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My last question is on the allocations made for Covid. With only three weeks remaining in this year I appeal to the Minister to personally intervene in the issue of the proposed closure of the only existing long Covid clinic that has dealt with 1,500 patients, which is a vast number, in the Mater hospital. In 2021, a business case for the clinic was submitted to the HSE but there was no response. In July 2022, a further business case was submitted but yet again there was no response. The Mater clinic has the expertise and produced numerous research papers over the last two years. I make a very strong appeal for the Minister to intervene because, on a national basis, the Mater clinic has the expertise, particularly in terms of the neuro impacts of long Covid which are the most dominant ones. I also ask him to intervene as a representative of the northside of Dublin because I do not want to see people on the northside of Dublin being deprived of a long Covid clinic on which they are very dependent.
I have looked at what the Minister has done with other proposals. The clinics are not functioning. There is one neurologist shared between six clinics. There is a waiting list of eight months to see somebody in one of the other clinics and the clinics are grossly understaffed. There is no recognition of the neuro impacts of the long Covid, which are the most debilitating and most long lasting. There has been no response from the Minister's office to Jack Lambert. I ask him to give a commitment that this week he will get a briefing on the business case and review the decision that was made not to continue with the clinic.
Stephen Donnelly (Wicklow, Fianna Fail)
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I am aware of the issue and of the HSE's position. I have spoken to the HSE at a senior level about the matter. It is the HSE's view rather than the departmental view. This is not a political call but a clinical judgment. I am more than happy to take up the issue again and talk to the HSE about it in the coming days.
Róisín Shortall (Dublin North West, Social Democrats)
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It does not look like a clinical decision. The research on which the HSE has based its plan for the six clinics is very old research from the end of 2020, which is before there was an understanding or an appreciation of the neurological impacts. It is old research and the most up to date research in this country was done in the Mater. The decision to close seems to have been done on the basis of having one clinic for each of the hospital groups rather than where the greatest expertise exists. Will the Minister give us an undertaking that he will look at the matter again this week?
Stephen Donnelly (Wicklow, Fianna Fail)
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I am more than happy to ask for an update. We will receive clinical advice on this clinic and the others. Certainly, my only objective is to make sure that anyone who is dealing with long Covid, and we are learning more about long Covid all the time, can access the appropriate care and supports. I am more than happy to ask for an update on the HSE's thinking on this and the proposed model of care.
Róisín Shortall (Dublin North West, Social Democrats)
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I thank the Minister.
Seán Crowe (Dublin South West, Sinn Fein)
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I agree with what the last speaker said about long Covid. I ask the Minister to tell us at some stage about how much it costs to run a long Covid clinic. I know there are factors but it does not make sense to close a clinic that seems to operate well and has the expertise but open a clinic that does not necessarily have the same expertise. The decision to close is mind boggling. It would be helpful if the Minister came back to us about the matter.
Neasa Hourigan (Dublin Central, Green Party)
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Chair, I add my support for what has been said as the clinic is in my constituency. I am glad to hear the Minister talk about clinical advice because we are talking a lot about the business case. Recently the committee had a session on long Covid and the HSE said that it looked at the business case but not so much the clinical advice. I suspect that eventually we will follow the UK's lead and include children in our discussion on long Covid and I believe that the location at the Mater hospital would be particular useful in that regard. Anything the Minister could do to progress the issue would be much appreciated.
My next question might be more appropriate for the Minister's colleague as I would like to understand more about the accounting in terms of the €497 million. Throughout the information that we have been given there was a decision not to assign the €497 million to particular subheads but to hold it for whatever eventuality might take place. There is a discussion later on as to how that relates to the vaccination roll-out. Can Mr. O'Grady please explain how the money will be tied away towards the end of the year in terms of the subheads?
Neasa Hourigan (Dublin Central, Green Party)
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Yes, I got that.
Mr. John O'Grady:
-----and part of an overall estimate of €1.57 billion. That ultimately was not funded. We were given an initial allocation, by agreement with our colleagues in the Department of Public Expenditure and Reform, €500 million, which was allocated as €497 million to the HSE and €3 million within the Department. It is a single subhead. We do not get into individual reporting from a Vote perspective of a PPE line, a vaccination line or a testing and tracing line within that.
Neasa Hourigan (Dublin Central, Green Party)
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Please be super clear about why the decision was made. Was it because the Department did not know how Covid was going to progress?
Neasa Hourigan (Dublin Central, Green Party)
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Can Mr. O'Grady give me a timeline on that?
Mr. John O'Grady:
Our estimate was submitted in September or early October 2021. As I said, there was significant volatility but in fairness to our ability to predict, the lines were not vastly different to where they have landed. It just was not funded so we were left with a potential shortfall in the hope that Covid would diminish. That was a reasonable expectation. In the back of the brief, there is some visibility of case numbers during the year. You can see how you would form that assessment in September or October.
Neasa Hourigan (Dublin Central, Green Party)
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I accept the principle; I am just asking about the accounting of it. I am not looking to do the Comptroller and Auditor General's job for him, but I am trying to understand when that will be rectified and what the oversight for those subheads is.
Neasa Hourigan (Dublin Central, Green Party)
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Does the Department envisage that eventually that subhead J2 will not really exist and those costs will be allocated to different subheads?
Neasa Hourigan (Dublin Central, Green Party)
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That is not being done retrospectively. If the Committee of Public Accounts were to look at these numbers, it would still see €497 million under subhead J2.
Neasa Hourigan (Dublin Central, Green Party)
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There is a breakdown of that single subhead and that is available.
Neasa Hourigan (Dublin Central, Green Party)
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There were changes in how some of the accounting worked last year. Things like subheads K1 and K2 are standard from previous years. Subhead K1 still relates to the primary care reimbursement service, PCRS, and K2 is still long-term residential care.
Neasa Hourigan (Dublin Central, Green Party)
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Okay, so what are K1 and K2?
Neasa Hourigan (Dublin Central, Green Party)
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I thank Mr. Colman for that. I want to move on to another area before I run out of time but before I do, I wanted to follow up on something from last year in the context of ICT. Throughout the year, we have been discussing the cyberattack and the impact on ICT. There is not any significant overspend in terms of updating technology or computer systems. Is that fair to say?
Stephen Donnelly (Wicklow, Fianna Fail)
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That is correct.
Neasa Hourigan (Dublin Central, Green Party)
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Not that I am looking for overspends but I am surprised-----
Neasa Hourigan (Dublin Central, Green Party)
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While Mr. Colman is doing that, he might get subheads K2, K3 and K5 as well, because it does not show what they are. That would be great. One of the things I am surprised about is that there is not an overspend on ICT or computer systems because. We have been hearing throughout the year that we are constantly looking for evidence-based data and disaggregated data. There are consistent queries around not having access to those data in terms of policymaking. We are told that our systems do not really allow us to centralise that information and make it available for policymaking. The number I am seeing here is €130 million. Is the idea that we are running to catch up and would have been further along in upgrading our systems except for the cyberattack? Is that correct or not?
Stephen Donnelly (Wicklow, Fianna Fail)
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It just reflects that a large amount of money was allocated and that a large amount of money has been spent. The number went up quite a lot for this year. It will go up again substantially for next year, partly in response to the cyberattack to increase security and patient information protections, and partly because we need a fundamentally different infrastructure to bring all the patient information together to create the electronic patient records. There is a separate piece around operational information, to which the Deputy referred, such as how many patients are being seen in any given hospital on any given day, how many patients are going through theatres or how many are being seen in outpatient services. A great deal of work has been done on that and the HSE now has sight of a lot of that operational detail. There is a lot more that needs to be done but the big win will be electronic patient records. In pretty much every hospital I go to, the clinicians say one of the most frustrating things about their jobs is the inability to access-----
Neasa Hourigan (Dublin Central, Green Party)
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How far are we from the completion of that project?
Stephen Donnelly (Wicklow, Fianna Fail)
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We are a bit away.
Neasa Hourigan (Dublin Central, Green Party)
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Yes, we are. Before my time runs out, I want to move to capital delivery. As always, there have been some questions from Deputies on specific projects. One of the things I wanted to question is the general decision-making relating capital plans. The briefing provided states that when developing the annual capital plan, the number of projects competing for inclusion in the plan each year invariably exceeds the funding available and it is therefore necessary to carry out a robust prioritisation exercise to ensure the best value is achieved from the available capital budget. That seems fair enough. Obviously, we have more plans than we have money to spend on those plans, which is also fair enough. I am trying to understand who is doing that prioritisation and who is at the decision-making table when that happens. The briefing also states that the final decision to proceed with construction on any proposal, and therefore to estimate the cost or timelines, cannot be made until a project has the final business case, the tender process has been completed and the costings reviewed to ensure the proposal delivers value for money and remains affordable.
To follow up on my question regarding who is making those decisions and prioritising various capital spending, is it the case in regards to the decision-making around capital spending that final business cases are in place, the tender process has been completed and the costings have been reviewed? That is not necessarily what we are seeing on the ground. I would cite, for example, the situation in Carrigaline, where a project was moved ahead with but planning permission was not even in place. Significant sums of money are being spent. I am not going to bring up the national maternity hospital, but that is a case in point where significant public money is being spent on projects where the full costings are not known, planning permission or tender processes are not necessarily in place and the business case, as with the national maternity hospital, is not held by the Department.
Stephen Donnelly (Wicklow, Fianna Fail)
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On the overall direction of travel in terms of the amount of money spent on capital in healthcare, be it primary care centres, new hospitals or whatever it may be, the total amount and the major projects the Government is backing are set out in the national development plan. We have an allocation within health. I would obviously like it to be larger, just as I am sure all my colleagues in the Government would like their capital envelopes to be larger. That agrees the total amount and then it agrees the priority projects like the children's hospital, the elective hospitals or whatever it may be. Major policy decisions on substantial capital projects are made by the Government within the national development plan. Locally, there is a process within the HSE where it does a strategic assessment review and assesses a project internally. It goes up through various parts of the HSE, including the services line and the estates line. Ultimately, these things are decided by the HSE board and then they are funded within the envelope of funding for that year. As an example, the capital plan, which I will sign off on shortly, has two appendices. Appendix 1 is the list of projects that are currently active. Appendix 2 is the list of projects that are in the appraisal phase the Deputy is referencing. What moves from appendix 2 to appendix 1, that is, which of those go from being actively considered to we getting authorised, depends on the project. A small project like adding ten beds or even 20, 30 or 40 beds to a hospital would ultimately be agreed by the HSE board, with oversight from the Department and the Minister.
Essentially, the major capital projects are Government decisions. However, even Government decisions such as those on the national maternity hospital and elective hospitals still have to go through the full public spending code.
Neasa Hourigan (Dublin Central, Green Party)
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They are not going through it, however. In terms of a final business case, a tender process and estimates of cost, we have seen several projects come through this committee that do not hit that bar. Is there a level of oversight there? When the Department gets a recommendation from the HSE, is there an audit of whether something as simple as planning permission is in place?
Stephen Donnelly (Wicklow, Fianna Fail)
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There is a lot of oversight of the process. I understand why we have the public spending code. The one with which we are dealing came about after the issue with the national children's hospital. While I know why it is there and I know we need to ensure value for money for the State, there is a balance in terms of how long it can take to build new beds, operating theatres and MRI scanners. In my view, it takes too long to go from a Government decision to putting a new MRI machine in this hospital or 100 extra beds in that hospital or to building a new hospital. The balance has become skewed in terms of business cases and strategic reviews.
Neasa Hourigan (Dublin Central, Green Party)
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Does that apply to planning permissions?
Stephen Donnelly (Wicklow, Fianna Fail)
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No. Obviously, that is a statutory requirement and it is needed. It would be in the interests of patients to have a quicker process but, obviously, we must ensure value for money.
Colm Burke (Cork North Central, Fine Gael)
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I will go back to nursing homes, which I raised the last day. I apologise for raising the issue again but from what I am hearing around the country, I am a bit concerned about nursing homes in difficulty. I referred to the underspend last week. Has the figure for 2023 been underestimated? Getting people out of hospital is crucial because the cost savings are huge. Where are we with the review of that given that we seem to have had an underspend of over €40 million in 2022, yet nursing homes are finding it difficult. I heard of one case where the owner of a nursing home is putting in €40,000 per week to keep it afloat. He cannot get any increase in what he is being allowed per patient and cannot hold staff because they are telling him that what he is paying them is not sufficient. In addition, they do not have the same pension rights as they would have if they were employed by the HSE, which would also provide them with far more effective cover in other areas. There has to be a margin there.
The nursing homes have been paying back capital costs. They also have to pay insurance and commercial rates and meet the cost of administering nursing homes whereas any of the public nursing homes have a central administration hub. We are talking about €1,650 or €1,700 per bed per week in a public nursing home, whereas private nursing homes are getting on average between €1,100 and €1,150. Does the amount offered to private nursing homes need to be reviewed for 2023? Seventeen nursing homes have closed and I know of ten that are at risk of closure. I am concerned about that.
Mary Butler (Waterford, Fianna Fail)
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I thank the Deputy for his question and for his continued interest in the nursing home sector. We have had many conversations about this. We acknowledge across the Department that there are variations in the cost of care across public centres and private nursing homes. We have provided an enormous amount of financial support since Covid started.
Colm Burke (Cork North Central, Fine Gael)
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I accept that but the problem is that we have clear evidence that nursing homes are in serious financial difficulty. I know of one nursing home in which there is interest from outside Ireland and the holding company is in difficulty. If those nursing homes come back on the market, we may not have a purchaser for them because people do not see a return on their investment. We need to-----
Mary Butler (Waterford, Fianna Fail)
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The Deputy may have noticed during the summer that Bartra Healthcare sold four nursing homes in Dublin and European investors rushed in and paid €180 million for-----
Colm Burke (Cork North Central, Fine Gael)
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Not all of them are in the fair deal scheme. That is the issue. This is what I am saying to the Minister of State.
Mary Butler (Waterford, Fianna Fail)
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If the Deputy gives me a chance to answer, I will try to address some of the issues he raised. He started off by talking about the surplus of €45 million. My understanding is that we continue to provide the temporary assistance payment to any nursing home that has a Covid outbreak. This will run up to the last day of the month and into the new year. Part of the temporary assistance scheme will be funded from that.
I have secured an extra €41 million for the National Treatment Purchase Fund, NTPF, next year for the private, public and voluntary sectors so there will be an uplift next year. One of the areas that does not get any recognition from the private nursing homes is €70 million in free personal protective equipment, PPE, and oxygen has been provided since April 2020. This year, the cost of PPE provided to private and voluntary nursing homes is €23 million. I will add the caveat that the voluntary sector accounts for 3.7% of that. The Deputy will also be aware that I put in place a scheme, backdated to 1 July, called the temporary inflation payment, which will cover 75% of energy costs. Each nursing home is entitled to claim up to €31,500 up to the end of this year. We will certainly keep that under review.
Regarding the nursing homes that closed, the records provided to me show that 18 nursing homes have closed this year, with a reduction of 514 registered beds. This includes two nursing homes with a total of 43 beds that were not active. Four nursing homes have opened with a total of 448 registered beds. However, I accept that even though we do not have a net loss of more than 30 or 40 beds, it is very problematic if three or four small nursing homes close in an area as that could be a challenge in respect of capacity.
We are considering a couple of issues. I believe private nursing home providers should negotiate their fee with the NTPF on a yearly basis as opposed to every 18 months or two years. Neither I nor the Minister can intervene in respect of the rate set by the NTPF.
Quite a number of small family-run and voluntary nursing homes could face challenges with regard to HIQA compliance, for example, as regards fire safety audits, many of which have been carried in the past two years, and ligature issues. We are looking at this issue to see if we can provide any support.
Colm Burke (Cork North Central, Fine Gael)
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It is not just about nursing homes closing. I spoke to one nursing home manager during the week. The home has 14 beds which it cannot get up and running because it cannot attract staff with what it can afford to pay staff. It is fine saying there is only a reduction of 514 registered beds but how many beds in private nursing homes are not being used because nursing homes cannot get staff as they cannot give them the rate of pay the HSE can give? It is difficult for a nursing home to balance opening a bed with what will cost to do so and what it will get under the fair deal scheme. It must decide whether it is more beneficial to leave the bed unoccupied than lose further money. This particular nursing home had 14 beds that were not being used.
Mary Butler (Waterford, Fianna Fail)
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There are 31,500 registered beds with HIQA across the country while there are 22,500 beds that are registered under fair deal. We are running a bit ahead of profile this year. The figure I was given today was that there are 22,613 people under fair deal.
People leave the nursing home sector for myriad reasons.
A HIQA report was published last week. I compliment the authority on the phenomenal work it did over the two years of Covid. It was not able to publish its report for the first year of Covid, but it published a two-year report last week. The report showed that during 2020 and 2021, 30 nursing homes closed in total. Five of them were closed by HIQA. The report sets out all the details of the closures and the clear guidance used. Ten of the nursing homes closed were HSE homes that were repurposed to care for older people for short stays. Of the other 15 nursing homes that closed, a myriad of reasons was given for the closures. Some of the nursing homes closed because they were not compliant with HIQA regulations on 1 January 2022. Other closures were caused by financial issues. Homes also closed for family reasons. For example, it might have been the case that parents ran a nursing home and the younger generation did not want to take it on. Another reason cited for closures was Covid burnout. There is a myriad of reasons nursing homes close. At the same time, one of the issues I have to be conscious of is that 80% of nursing home care is provided by private and voluntary providers. We have really stepped up the amount of money being provided in the past few years. Indeed, the nursing home sector was provided with €145 million in temporary assistance payments, and €70 million has been provided in the past two years for PPE and oxygen, along with €10 million for inflationary costs. The sector also received €1 billion in fees as part of the fair deal scheme. I have a budget that I have to work within, and I am very conscious of that.
Colm Burke (Cork North Central, Fine Gael)
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I am aware of that. I want to raise another issue. A brand new outpatient unit and two new theatres have been built the South Infirmary Victoria University Hospital. It is waiting for one piece of equipment for one of the theatres, which will be available on 15 December. The theatres cannot be opened because funding for the employment of a consultant ophthalmology surgeon has not been signed off. As a result, the whole section, which was to move from Cork University Hospital, CUH, in Cork to the South Infirmary Victoria University Hospital is not going to happen. I am concerned that when funding is provided for a capital project, at the same time it should be ensured that funding is available for the supports that are going in there. I am concerned that this facility has been built and it looks like it might take anything up to six months for it to open. A proposal was made by the South/Southwest Hospital Group to the HSE at central level. There are also brand new premises in Ballincollig, where ophthalmology services were supposed to move from CUH and one section was to go to Ballincollig and another to the South Infirmary Victoria University Hospital. As public representatives, we were all shown the facility in Ballincollig more than 14 months ago. It is still lying idle. According to the proposal from the South/Southwest Hospital Group, a total of 35 staff is required. It is great that money is being spent on capital projects, and it is welcome but the two relevant sections of the HSE do not appear to be working together. All this money has been spent and the facilities built are lying idle. What can be done about that? It is a cost to the Exchequer that is yielding no benefit.
Stephen Donnelly (Wicklow, Fianna Fail)
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I was made aware of this issue yesterday. I followed it up with the Department. The Department has been in touch with the HSE and the funding is being released for the consultant ophthalmology surgeon post. The service that is going to be provided is essential. People are waiting too long, particularly in the Munster area. We are all aware of people travelling to the North for treatment. That should not be happening. We are determined that this will not happen in the future. As the Deputy has said quite rightly, there is investment in state-of-the-art facilities in Cork in the sites that he referenced. It is going to be an excellent service. That funding is being released.
Colm Burke (Cork North Central, Fine Gael)
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I welcome the Minister's comments on the release of the funding. In its proposal, the South/Southwest Hospital Group stated that it needs a total of 35 staff. That is the full complement of staff required to operate the facilities based at Ballincollig and the South Infirmary Victoria University Hospital. Is there only going to be sign-off on funding for the consultant ophthalmology surgeon post or will be there a sign-off on the release of funding for the 35 positions the hospital group feels are required?
Stephen Donnelly (Wicklow, Fianna Fail)
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I will provide the Deputy with an update on that.
Colm Burke (Cork North Central, Fine Gael)
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I appreciate that.
David Cullinane (Waterford, Sinn Fein)
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I have three more questions. We will support the Supplementary Estimate because we have to, rather than because we want to. Page 11 of the Minister's briefing note makes reference to acute capacity beds and the number of beds that will be put in place this year. We had some discussion on this last week. In fact, a number of weeks ago when some of the Minister's colleagues from the Department and the HSE were in, we had a more in-depth discussion on it. We know that of the 1,200 beds that were funded as late as October 2020 for budget 2021, when approximately 70 additional beds came onstream as part of the service plan for 2021, approximately 170 will not be delivered until 2023. How does that square with what we saw in Drogheda this week, where multiple ambulances were parked up and could not leave because there were no beds for the patients? I also ask that question in the context of the plans in place to close the emergency department, as it is, in Navan Hospital. The Minister corrected a letter that was sent from hospital management to staff, which caused further consternation. What we saw in Drogheda, which was very graphic and quite disturbing, we have seen several times there, with ambulances parked up with patients in them who are not able to get a bed. How does that square with beds that were funded as early 2020 still not being delivered? Some of them will not be delivered until 2023.
Stephen Donnelly (Wicklow, Fianna Fail)
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Both the Deputy and I will agree that there have not been and there are not enough beds in the public health service. Since the start of Covid we have added nearly 1,000 beds. It is the biggest increase in beds in public hospitals since the formation of the HSE and long before that, according to my understanding. The Sláintecare report sets out a target for us, which I think we are all signed up to. Under the reform scenario that is happening we need an extra 2,400 beds over the period of the report. With the 1,000 beds that have been added, we are now significantly ahead of the Sláintecare target. The current pipeline of new beds will pull us further ahead.
David Cullinane (Waterford, Sinn Fein)
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We got that information a couple of weeks ago. I accept that a lot of additional beds have been provided. However, my question concerns the fact that notwithstanding that 1,000 beds have been delivered and 1,200 were funded, some will not be delivered until next year. In the case of Drogheda, there has been a clear bed problem. When is that going to be addressed? If I were to respond in kind, as the Minister did, to patients who were in those ambulances, should I tell them that they should not complain because he provided 1,000 beds elsewhere, when all they are worried and concerned about is the fact that they are in the back of an ambulance and unable to get a bed? That ambulance crew cannot do their job and go somewhere else because they are parked up. Where does Drogheda fit into those plans? I do not see it mentioned in the briefing note. Portiuncula Hospital, Beaumont Hospital, South Tipperary General Hospital and the Mater Hospital are mentioned. Where does Our Lady of Lourdes Hospital Drogheda sit?
Stephen Donnelly (Wicklow, Fianna Fail)
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There has been investment in Drogheda in terms of the provision of additional budget, staff and beds, and more is required. As the Deputy will be aware, I intervened to stop the closure of the emergency department in Navan Hospital. One of my concerns - and it remains a concern - was that were the closure to go ahead, and it has not been agreed that it will go ahead, any consideration of any reconfiguration must happen after capacity has been put in place. I agree that what was circulated in the letter from Navan Hospital was incorrect information. It caused a lot of concern and worry, and was incorrect information.
David Cullinane (Waterford, Sinn Fein)
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But that came from a hospital manager.
Stephen Donnelly (Wicklow, Fianna Fail)
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Yes, it did. I accept that. The information was incorrect. One of my concerns has been that any consideration of any reconfiguration must happen after capacity has been put in place. The Deputy will be aware that we asked for a review, and we are considering that at the moment. As part of that review, it is recommended that additional beds be put into Drogheda.
I met with the Drogheda team. I was in the hospital again recently to talk to its representatives about exactly this point, and I asked what was needed in the region to ensure patient safety issues were dealt with and that, critically, we do not have what we had at the weekend which is just not acceptable. The team told me the most important thing was access to step-down beds in Navan. That is one of the issues we are discussing with the HSE, the hospitals and the hospital groups. We are in absolute agreement that what happened in Drogheda simply cannot happen. One of the long-term solutions to that is a lot more beds. There are 2,400 beds-----
David Cullinane (Waterford, Sinn Fein)
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I agree. I have been saying for some time that, if we want to solve the problems in our emergency departments and acute hospitals, we need to look at the community, step-down, convalescent and rehabilitation beds.
I move to a second issue and two related issues. I am seeking information. Page 11 of the document refers to agency savings. No matter how many times I ask this question, I do not always get the answer. Maybe there will be an answer today and, if not, I would like it to be given. My question relates to information I sought weeks ago and which the secretariat has confirmed we still have not received. We were promised it and had quite a lengthy discussion on it. What was the total agency spend for the end of 2021 and what is it anticipated to be at the end of 2022?
Stephen Donnelly (Wicklow, Fianna Fail)
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We will have to get a note on that.
David Cullinane (Waterford, Sinn Fein)
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Okay. It says here the savings were made but my understanding is that, for 2021, the spend was in the region of about €500 million. Can we get that briefing note this time? It is reasonable for us to know how much money we are outsourcing. Can I ask for a bit more information as well? I have asked this in parliamentary questions and we never get the answer. We get thrown from Billy to Jack and we might get one part but we never get the full answer. I do not think it is outrageous for me to ask how much of total spend we outsource to the private sector. I am asking about the total agency spend. What is the total spend on outsourcing, whether for care, diagnostics or whatever, outside of our acute hospitals? Then there is the National Treatment Purchase Fund, NPTF. Will someone in the Department provide me with that information, the total spend across all of that? I want to know how much in total of any money allocated under any of the subheadings is spent on outsourcing and agency. Can that be sent to me?
Stephen Donnelly (Wicklow, Fianna Fail)
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It is a large number so I want to check that we can get the Deputy what he wants. There are private hospitals, agency, clinical, security, contracting, catering, cleaning and all that, GPs, pharmacists, nursing homes, and right across-----
David Cullinane (Waterford, Sinn Fein)
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Everything, and it can be broken down. It would be great if the Minister could provide me with that. It would be what I would have asked for several times through parliamentary questions and I was not able to get it.
Stephen Donnelly (Wicklow, Fianna Fail)
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I will follow it up.
David Cullinane (Waterford, Sinn Fein)
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My third question is one on which I asked the clerk for clarity. We had a very lengthy discussion about waiting lists with the Department and the HSE some weeks ago. They were here to discuss waiting lists. I agreed that reducing the length of time people are waiting is the most important thing. I know that has reduced and I acknowledged that. That is great. However, I asked a simple question, which was how many people are on waiting lists across all elements of healthcare, namely, acute, which is broken up into inpatient, outpatient and others; community, which can be dietetics, ophthalmology, occupational therapy, speech and language therapy, mental health, child and adolescent mental health services, CAMHS, and home help; diagnostics, which is a whole different area; chronic disease management programmes, CDMPs; and so on. I still have not got that. We had a very lengthy discussion. We were told by the officials that they did not have that information available, yet they were coming in to discuss waiting lists. They were not able to tell me how many people are on all the waiting lists. That is one figure which could be broken down if needs be. Does that figure exist and can it finally be given to us? If we do not understand the scale of the problem, how are we going to fix it? What I am asking for is clear: the total number of people on all HSE waiting lists. What is the total figure? How does it break down? How long are people waiting?
Stephen Donnelly (Wicklow, Fianna Fail)
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First, I thank the Deputy for acknowledging the very significant reduction in the long waiters. I appreciate his saying that. It may or may not be a comfort to the Deputy but I have asked the same question myself many times and the Department is also asking the same question. It goes back to the question we were having with Deputy Hourigan, that until we have electronic patient records and unique patient identifiers, we will not know.
David Cullinane (Waterford, Sinn Fein)
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We might not know whether there are people who are on waiting lists who should not be, but there are still waiting lists, so let us just list them all. There may be issues within that whereby people might be on it twice or there might be duplication, but there is a validation process which we know is working and is underway. The Minister's response is not really an answer. I want to know what waiting lists are held centrally. I want them with a breakdown and a total figure. It is not unreasonable to ask that. Not getting that information is not good enough.
Stephen Donnelly (Wicklow, Fianna Fail)
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I would go further. It is perfectly reasonable for the Deputy to ask. I am asking the same question. It is something we are working on. We do not need to go over it again but, this year, we have been focusing on areas with the waiting list action plan. Next year, this is exactly where we need to go. A lot of money was invested in diagnostics and in community care, but the big focus was on the hospital waiting lists: scopes, inpatient and outpatient. There has been a lot of progress. The Minister of State, Deputy Butler, has been pushing on various areas and the Minister of State, Deputy Rabbitte, has been pushing on other areas, including community therapies. What I can tell the Deputy is I am posing the same question. The Department will now seek to answer that in a useful way. Unfortunately, it is more difficult than any of us would like. I will give one example.
David Cullinane (Waterford, Sinn Fein)
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I will give the Minister one example, if I can.
Seán Crowe (Dublin South West, Sinn Fein)
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Deputy, please. No more. I need to move on. Deputy Durkan is looking to come in, so will the Minister finish, please?
Stephen Donnelly (Wicklow, Fianna Fail)
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Yes. I can commit that this is something we are looking at next year. We need to broaden the strategic approach to reducing waiting lists to encompass diagnostics, community care and other elements of hospital care as well.
David Cullinane (Waterford, Sinn Fein)
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In the absence of that, can we get what the Minister has?
Stephen Donnelly (Wicklow, Fianna Fail)
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Yes.
Mary Butler (Waterford, Fianna Fail)
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May I make one comment on that same question in relation to young children who present in autism, mental health or whatever? Sometimes children are referred to three different teams - primary care, CAMHS and the National Educational Psychological Service, NEPS, because the person making the referral might not be able to determine which is appropriate. If we could verify some of the waiting lists, it would be very helpful because we know some people are on multiple waiting lists and it is important to acknowledge that.
David Cullinane (Waterford, Sinn Fein)
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I agree. I thank the Minister of State.
Seán Crowe (Dublin South West, Sinn Fein)
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Before I let Deputy Durkan in, I ask that he give me a couple of minutes. I know the pandemic payment is small in relation to the overall budget. It is tiny in relation to it. I just do not understand the delay in making the payment. The Minister said in a reply earlier that he expect about 300 groups to get the payment. What kind of percentage is that? Is it about half the people getting paid? When do we agree to pay out this goodwill payment? We are all hearing from different groups. The fire brigade staff were on to me about it. If they are not front line, I do not know what is, particularly in the Dublin area where Dublin Fire Brigade fulfils the role of an ambulance service and so on. Can we get a broad outline of how many people the Minister thinks will be paid by Christmas? If he does not have it now, I will get it later. What is the delay? I hear what the Minister is saying about it but it is a long time since we agreed to pay this, yet the system does not seem to be operating. The goodwill is going out of it. Many people were expecting to be paid by Christmas.
Stephen Donnelly (Wicklow, Fianna Fail)
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First, 133,000 have been paid. That is important. Very understandably, we all focus on the people who have not been paid because they are the people who contact us. They are our priority, but 133,000 men and women have received €1,000 tax free. It is a small way of saying, "Thank you for everything you did during Covid." There are a number remaining and we need to pay them quickly. I fully agree. To date, about 86,000 have been paid who are HSE staff and about 40,000 or 41,000 who are in section 38 organisations.
More then 6,000 people have now been paid in nursing homes and section 39 organisations. This number will rise quickly now. Regarding Dublin Fire Brigade, the latest figures, as of 17 November, and presumably this figure has increased by now, 765 staff there have now been paid. Turning to the Defence Forces, we are expecting a number of approximately 1,300 and this money was transferred some time ago to the Department of Defence for it to issue this payment.
The next question quite rightly asked was what about the other people involved. We have issued hundreds of self-assessment packs. These are now being returned. I will ask the officials to give the committee members an update in this regard. The process is, however, working. The HSE has received 523 returns from employers out of the 861 packs issued. There has, therefore, been a good return. There are more people whom we want, of course, paid before Christmas. As quickly as these packs are being returned, payments are being made. The one word of caution for us all, though, in respect of public money is that the advice is that about nine in every ten of the returns being made do have errors in them. It takes a bit of time for the HSE to work through these. Would anyone like to add anything to this?
Ms Louise McGirr:
I am thankful for the question. I understand the frustration in this regard. To go back to the initial Government decision, it required additional criteria to be put in place. This is where much of the frustration stems from. While people thought the Government had made the decision, as do the Minister and the other members of the Government, the issue was that the criteria concerned are quite specific around who was affected. This took several months to clarify in terms of who was included and what were the eligibility criteria. I say this because the payment is not for everybody. This is where some of the delays have happened. I refer to trying to isolate those who are eligible.
As the Minister referred to, it was necessary to work with many of the representative bodies and managers to ensure everybody understood who was part of the scheme. The process was then devolved to hospitals to apply these criteria. It was not, then, a case of just making the payment and that was it done. This process involved people having to be eligible and certified for this payment. This is what has really caused a great deal of the delay experienced in respect of some of the HSE staff, certainly. They have all been paid now, as have staff in the section 38 organisations. Huge swathes of people, therefore, have been paid. It is the significant majority of people.
Regarding the private organisations and the section 39 entities, I understand that the situation here looks very frustrating. Some of those people were really on the front line in nursing homes and other areas and certainly deserve this payment. The best reassurance I can give is that this process is now moving really quickly. It took time to set up because we had to go to tender and through the proper processes. This has taken a couple of months, just by its nature. The 90% statistic the Minister referred to mainly shows duplication, where people are being put in for multiple organisations. This is why it is important we do stop this happening. The company dealing with this issue has set up a helpline and it is getting thousands of calls. It is doing everything it can. The process, therefore, is happening very quickly now that it has been set up. I appreciate, however, the frustration that exists. It remains a major priority to get this done as fast as possible.
Seán Crowe (Dublin South West, Sinn Fein)
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I have one more question. Screening has been mentioned. There has been a major challenge in this regard, particularly concerning cancer screening. The figures are frightening in this context. Is there anything in these Supplementary Estimates concerning screening? I refer in particular as to whether consideration has been given to rare diseases. We have discussed this issue before, especially concerning natal heel prick testing, expanding this service, being proactive in respect of how it is undertaken and getting in earlier in the context of affecting the quality of life of the child and so on. Is there anything of this nature in these Supplementary Estimates? Again, it is very difficult to separate this information from the figures here. Are there any plans in this regard? The Minister can answer and then I will then bring in Deputy Durkan straight away.
Stephen Donnelly (Wicklow, Fianna Fail)
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I thank the Chair for the question. Yes, is the short answer. Many additional activities are happening this year and more will happen next year. I can ask the Department to supply the Chair and the committee with a note on the national screening services. An awful lot of activity has been going on in terms of expanding these services. New questions are being posed, for example, around the age criteria for breast screening in the context of BreastCheck. I heard representatives of Spinal Muscular Atrophy, SMA, Ireland on RTÉ this morning talking about the heel prick test for SMA. There is a national screening advisory committee. It is looking at expanding the heel prick test and I have already authorised one. The conditions are also being examined. As the advice comes into me, the committee can be sure we will authorise and expand this undertaking. One of my own constituents, Les Martin, has been a brilliant and fierce advocate for expansion in this area.
Seán Crowe (Dublin South West, Sinn Fein)
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We are not talking about large amounts of money for expansion in this regard.
Stephen Donnelly (Wicklow, Fianna Fail)
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Not for this. The only thing directing us in terms of the heel prick test is clinical advice. It is not a question of money at all. It is about clinical advice for what is best. The national screening service is funding large-scale advertising campaigns to encourage people to attend for screening. This endeavour has been funded.
Similarly, rare diseases were mentioned. One of the things this Government has been keen to do is to provide additional funding for drugs, a good number of which are so-called orphan drugs for rare diseases. Last year, development funding of €50 million was provided for new drugs. In the budget we are considering today, it is €30 million. There are larger, full-year impacts in this regard, so there will be more money than this in the following years. Of the total number of new drugs approved over the past two years, between these two budgets, quite a number have been orphan drugs and intended for these rare diseases. We can get the committee a more detailed note, if that might be useful, but the short answer is that a lot of activity is going on in this regard.
Bernard Durkan (Kildare North, Fine Gael)
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Were the Minister might able to supply this information, it would be helpful to know the length of time taken to approve the orphan and rare disease drugs. Moving on, the area of community healthcare organisation, CHO, 7 has been in difficulty for some time. It is my area and that of the Chair's, and also includes west Wicklow. I refer to CAMHS, as well as adult mental health services. Are any particular initiatives ongoing in this context? Some improvements were made, but there were also some areas where we fell down. The facility in Cherry Orchard was closed as a result of a lack of the necessary staff. What is the story with that now? Is this matter in hand? Are we making a long-term decision that it is going to be finally resolved that we will have places for children, adolescents and adults in the event of that becoming necessary?
Mary Butler (Waterford, Fianna Fail)
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I thank the Deputy for his questions. As he knows, for next year the budget for mental health will be €1.2 billion. Regarding psychiatry of later life, for example, which refers to the care of older people with enduring mental health issues, there is no waiting list in this area at all. Regarding general adult mental health services, the turnaround time is 12 weeks. We do not have to keep waiting lists. People with acute mental health situations will be seen straight away. We have 56 approved centres and departments of psychiatry. The good news coming for next year is that there will be more of a focus on capital expenditure in respect of mental health. We have approximately 16 facilities now that will need capital expenditure and we are putting in place a plan, like we did with the community nursing units throughout the country, to ensure these will be compliant with the findings of the Mental Health Commission.
Regarding the Cherry Orchard facility, it is fantastic. I visited it. There is a school on site and phenomenal work is done there to support children and young adolescents under 18 needing inpatient mental health supports. Many of the young people referred to the facility have eating disorders. They need this specialised care. The situation we had was that due to safe staffing levels, we did not have enough staff to be compliant with the safe staffing model in August. The posts were funded. If memory serves me correctly, we had funding for 60 posts but we only had about 30 nurses in place. We could not have it operating from a safe staffing perspective. We are, however, actively staying on top of it.
Our aim is to reopen every one of those beds. What we did in the short term was we developed more community supports but we also had the support, if we needed it, of a service level agreement with one or two of the private places, if it was required. I keep in touch with that particular CHO about the situation. We have actively tried to recruit the newly qualified psychiatric nurses in the last few months. We have a lot of developments coming onstream across all the CHOs. The purpose of the Sharing the Vision policy is to provide community supports first and foremost, and early intervention is key.
One of the areas where we are challenged is our waiting list for child and adolescent mental health services. We have seen an increase of more than 20% being referred last year and about 2% of children will need these vital supports. We are looking at a waiting list initiative and I am delighted that the Minister is in a position to provide the funding.
Bernard Durkan (Kildare North, Fine Gael)
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I thank the Minister of State. I ask the Minister to send me a written update on the capital plans, extension upgrades, etc., for Naas General Hospital and the Lakeview unit.
Seán Crowe (Dublin South West, Sinn Fein)
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Will the Minister supply a written reply to the Deputy?
Stephen Donnelly (Wicklow, Fianna Fail)
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I thank Deputy Durkan for his request. There are a lot of eyes on Naas hospital and there is genuine concern in the community. There has been significant investment in Naas in terms of additional capacity to date. There is new investment coming into the hospital in terms of beds, rehab beds, diagnostics, additional staff, additional specialists and additional services. It is my view, and I believe it is the Government's view, that that investment will continue in Naas hospital, there will be ongoing investment, the budgets for the hospital will grow, the workforce will grow and the number of beds will grow and, most importantly, for the people who are served by that hospital, the services will expand and grow. We will continue to invest in the hospital.
Bernard Durkan (Kildare North, Fine Gael)
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When? The endoscopy and oncology areas were due to be upgraded and have been listed for quite a long time.
Stephen Donnelly (Wicklow, Fianna Fail)
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I will get the committee a note on exactly what has happened over the last few years and on what is currently in progress. On another date, we are happy to discuss future possible investments in the hospital.
Bernard Durkan (Kildare North, Fine Gael)
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I thank the Minister.
Seán Crowe (Dublin South West, Sinn Fein)
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I thank the Minister, the Minister of State and their officials for attending and for their work.