Brian Stanley (Laois-Offaly, Sinn Fein)
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I welcome everyone to this morning's meeting. We have received apologies from Deputy Colm Burke.

Members and witnesses attending from within the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19. Members of the committee attending remotely must continue to do so from within the precincts of the Parliament due to the constitutional requirement that, in order to participate in public meetings, members must be physically present within the confines of the place where parliament has chosen to sit. The Comptroller and Auditor General, Mr. Seamus McCarthy, is a permanent witness to the committee. He is accompanied by Mr. John Crehan, director of audit at the Office of the Comptroller and Auditor General.

This morning we will engage with officials from the HSE to resume our examination of the following matters: Financial Statements 2021 - HSE. The committee has expressed particular interest in the following matters: disability services including the provision of disability services from outside agencies; emergency care waiting lists; GP services and in particular out-of-hours GP services; and funding for the disability service agencies. Both the HSE and the Department of Health have been informed that a further area of interest for the committee is the handling of claims relating to nursing home care which have been reported in the media this week. I understand that the Joint Committee on Health also intends to examine this matter. It is the role of this committee to examine accounts and expenditure and this will be the focus of our consideration. It is my understanding that the Joint Committee on Health will examine policy issues as that is its remit.

Both the HSE and the Department of Health have also been informed that the capital allocation for the HSE budget 2023 regarding the national children's hospital is likely to be discussed as well.

We are joined by the following officials from the Health Service Executive: Mr. Stephen Mulvaney, chief executive officer; Mr. Damien McCallion, chief operations officer, Dr. Colm Henry, chief clinical officer; Ms Yvonne O'Neill, national director, community operations; and Ms Ann Marie Hoey, national director of human resources. Ms Mairead Dolan, chief financial officer is joining us remotely.

We are also joined by the following officials from the Department of Health: Ms Deirdre Comiskey, principal officer, disability services unit, and Mr. John O'Grady, principal officer, finance unit.

I remind attendees to ensure their mobile phones are on silent mode or switched off.

Before we start, I wish to explain some limitations to parliamentary privilege and the practice of the Houses as regards reference they may make to other persons in their evidence. As witnesses are within the precincts of Leinster House, they are protected by absolute privilege in respect of presentations they make to the committee. This means that they have an absolute defence against any defamation action for anything they say at the meeting. However, they are expected not to abuse this privilege and it is my duty as Cathaoirleach to ensure that this privilege is not abused. Therefore, if 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.

The evidence of witnesses physically present or who give evidence from within the parliamentary precincts is protected pursuant to both constitution and statute by absolute privilege. However one of today's witnesses is giving her evidence remotely from a place outside the parliamentary precincts and as such may not benefit from the same level of immunity from legal proceedings as those witnesses physically present do. Such witness has already been advised of this and may think it appropriate to take legal advice on the matter.

Members are reminded of the provisions of Standing Order 218 that the committee shall refrain from inquiring into the merits of a policy or policies of the Government, or a Minister of the Government, or the merits of the objectives of such policies.

Members are also reminded of the long-standing parliamentary practice that they should not comment on, criticise, or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I call the Comptroller and Auditor General to make his opening statement.

Mr. Seamus McCarthy:

In opening the meeting of the committee on 29 September 2022, I introduced the HSE’s financial statements for 2021, and outlined a number of issues I had highlighted in my audit report. The latter concerned losses incurred by the HSE in respect of procurement of PPE items; ongoing non-compliant procurement; and the impact of the May 2021 cyberattack on the HSE’s operations. In the interests of saving the committee’s time, I do not propose to revisit those matters.

Given public debate in the past few days about the repayment of long-term care charges unlawfully applied, I draw the committee’s attention to note 9 of the HSE’s financial statements. A note with similar detail has been included in every set of the HSE’s financial statements since 2006. The note indicates that up to the end of 2021 a total of €486 million has been paid in respect of more than 20,300 claims for repayment of long-stay charges improperly imposed on residents of public nursing homes in the period 1976 to 2005. At the outset of the repayment scheme the HSE projected that the costs that would be incurred under the statutory repayments scheme might amount to €1 billion and it disclosed this potential liability. By 2021, most of the claims deemed to be valid under the scheme had been paid.

A number of claims received by the HSE were deemed ineligible under the repayment scheme, in a number of cases because they related to persons who were, or had been, residents of private nursing homes. Beginning in 2007, the HSE disclosed the number of such claims on hand at the year end. The disclosure did not include an estimate of any potential liability attaching to such cases and explained the legal reasons for not including an estimate. The disclosure continued to be made up to and including end 2013.

Those claim cases were subsequently managed by the Department of Health and any settlements made were charged to subhead D of the Vote for health. The accounting policies for appropriation accounts now require a note on the aggregate value and number of cases settled each year but do not require this to be disaggregated by type of case. The accounting policies also require a contingent liability note in the appropriation account, but specifically excludes disclosures that could prejudice the Exchequer’s position in court cases or other negotiations.

Brian Stanley (Laois-Offaly, Sinn Fein)
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We will now move to the HSE. There is five minutes for the opening statement and I ask Mr. Mulvany to keep to time.

Before he starts, when he was drafting his statement the nursing home issue was not live. If he wants to make a brief reference to that in his opening statement, he should feel free to do so.

Mr. Stephen Mulvany:

I thank the committee for the invitation to attend today’s meeting to examine emergency care, waiting lists, disability services, including the provision of disability services by outside agencies, and MIDOC GP out-of-hours service in the context of the financial statements 2021.

At previous meetings in 2022 I have provided an overview of the annual financial statements of 2021 and, therefore, I will confine my remarks to the current financial position for 2022. The HSE has received a revised letter of determination for 2022 from the Minister for Health in December, which provides additional funding for 2022 for revenue and capital expenditure of €22,457.8 million and €1,159.9 million, respectively. This additional funding is welcomed noting that a significant element of the increased funding relates to Covid-19 expenditure incurred in 2022. The HSE is currently working to complete a first draft of the annual financial statements, AFS, for 2022 which will be presented to the Minister and to the Comptroller and Auditor General by 28 February 2023, in line with normal requirements.

The 2022 financial position cannot be viewed as finalised until the completion of the AFS and its audit by the Comptroller and Auditor General, however, it is expected that this additional funding will allow the HSE to achieve to a substantial break-even position for last year.

The committee asked the HSE to provide briefing information on a number of specific focus areas and these were submitted in advance of today’s meeting. These areas included emergency care. All across Europe health systems came under sustained pressure with even the most developed systems struggling to cope with demand on their services in the post-Christmas period due to the high rate of multiple viruses and their impact on the population. These high activity levels have occurred in the context of an earlier than usual influenza and respiratory syncytial virus, RSV, season alongside record hospitalisations of influenza and RSV cases. There was also a surge in Covid-19 hospitalised patients in December 2022. While this surge of respiratory infections was predicted and planned for, the observed levels have been in line with the more pessimistic of the projected models. The briefing note submitted outlines progress of funded initiatives through the current winter plan, previous national service plan 2022 and the additional escalation actions put in place. It also outlines our emergency response measures agreed by our national crisis management team, which I chair as CEO.

On hospital waiting lists, significant progress was made in reducing the time people were waiting for services. The number of outpatients waiting longer than 18 months decreased by 38.5%, that is, by 59,000 patients; the number of patients waiting longer than 12 months for an inpatient or day-case procedure decreased by 22.6%, or 3,800 patients; and the number of patients waiting longer than 12 months for a GI-scope decreased by 86.5%, or 3,500 patients. To be clear, this was below our target, which was severely impacted by Covid-19 in 2022, but we saw significant progress in the latter part of 2022. The HSE has also set challenging targets in 2023 to further reduce the time people are waiting for outpatient appointments so that 90% of people are waiting no longer than 15 months, 90% of inpatient or day case are waiting no longer than nine months and 95% of patients for a GI-scope are waiting no longer than nine months. Given the impact of Covid-19 and the ongoing recruitment challenges, not all waiting list funding was spent in 2022. We are currently finalising the hospital group and community healthcare organisation, CHO, waiting list plans for 2023. Where practical and appropriate, initiatives that were in place at the end of 2022 are being continued, to ensure that the momentum created in the latter part of 2022 is maintained and built upon in the first half of 2023.

On disability services, the briefing that was submitted outlines the governance arrangements for disability services, regional distinctions and the criteria being used in respect of the level of services provided as well as disability services for children and related respite care.

On GP out-of-hours services, the committee specifically asked for a briefing note on the expenditure and function of MIDOC out-of-hours GP services, which has also been circulated in advance. This outlines GP out-of-hours services to the public in the MIDOC area have continued to be provided, with increased support from the local community health care area, despite the challenges the service faced.

I have confined my opening statement to the key points relating to the 2022 accounts and the specific focus areas requested by the committee in the context of the 2021 financial statements. We will be happy to take any questions the committee has regarding these matters. This concludes my opening statement.

The Chairman mentioned repayments. The Health Act 2006 set out who was eligible for what repayments. It dealt with the fact that residents in nursing homes had been inappropriately - unlawfully - charged under two or three specific sets of regulations going back over a number of years. It provided a scheme of repayment, which has been properly set out in our accounts over the years, as the Comptroller and Auditor General indicated, which saw more than €450 million paid directly to those clients. To be eligible you had to be either a medical card holder in a public community nursing unit or a medical card holder in a publicly-funded contracted bed in a private nursing home. As far as we are concerned, the accounts have properly reflected that. It is a separate matter regarding patients who were in private nursing homes who were not charged under those subsequently determined to be unlawful charging regulations. They had contracts with their private nursing homes and, where they qualified for a means-tested scheme, they received a subvention from the State towards the cost of those. If they did not qualify under that, they could qualify for tax relief. Whether that was sufficient is a different matter.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Could some people have had medical cards?

Mr. Stephen Mulvany:

Some could have had medical cards. Predominantly they would not have had medical cards but some certainly could have had them.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Okay. I thank Mr. Mulvany. Deputy Devlin is first.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I welcome the witnesses. It is good to engage with them again. I will stay with the private nursing homes. I understand the HSE is tasked with the management of the health repayments scheme. It was referred to in the Comptroller and Auditor General's reports at various times. The most recent accounts were signed off by the then CEO, as Accounting Officer, Mr. Paul Reid on 26 November 2021. I understand 35,417 applications were made to the repayments scheme and 20,302 claimants received a payment. As of 31 December 2021, €453 million had been paid to claimants and €32.5 million paid in administrative costs or a total of €486 million in overall cost to the Exchequer from 2006 to 2020 was paid. That was referred to in the Comptroller and Auditor General's opening statement this morning. The HSE webpage on the repayment scheme notes that a few complex cases are still being progressed. The Comptroller and Auditor General previously commented on this repayment scheme as part of the 2009 report on the accounts of public services, which came before this committee in 2011. The report examined the incidence of appeals and legal actions arising from that scheme. That report stated:

Proceedings have been instituted in 306 cases, involving patients who spent time in private nursing home facilities. None of the cases have yet proceeded to hearings.

That is according to the 2009 report so that may have changed. It would be helpful to the committee this morning if it had an indication of how many cases brought by residents in private nursing homes or their families were settled and how many are still active. Can Mr. Mulvany advise how many of the 306 cases that have been settled are included in the category of a few complex cases, which is stated on the website still?

Mr. Stephen Mulvany:

The repayment scheme is obviously separate to any cases where people may have applied under the repayment scheme and not been deemed eligible because the eligibility criteria were decided by the Oireachtas. The policy was set out and the Oireachtas voted on the Act, which set out the eligibility. The latest figure I recall seeing, and it may not be the most up-to-date because the HSE is not currently managing these cases -----

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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The Department is, yes.

Mr. Stephen Mulvany:

----- is a figure of 329. That is a slight increase on the number the Deputy mentioned. Again, some of those individuals would have applied under the scheme and would have been refused under the scheme because they did not meet the criteria set by the Oireachtas, and others were making a different case. Beyond that I do not have more up-to-date information.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Is the Department able to shed any light on that? I think it is 2013 since the Department has been handling the cases.

Mr. John O'Grady:

I am not sure if it was that year. The Department pays those out of a subhead in the Department's Vote as opposed to the HSE.

I do not have any more detailed information here but would be happy to bring the Deputy's query back in a written format and respond to it in that way. I will talk to colleagues in the Department.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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That is under note 9, as the Comptroller and Auditor General outlined in his statement. Will Mr O’Grady state from 2013 onwards how many cases have been settled?

Mr. John O'Grady:

I do not have that information here.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Did Mr. O’Grady not think that was topical and look at it in advance of this session?

Mr. John O'Grady:

I am sorry. I do not have that information.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Will Mr. O’Grady find it and furnish it by the end of the meeting? It is a long session, as the Chair said, and we are breaking at 11 a.m., so maybe that information could be found.

I referenced €32.5 million in administrative costs for the scheme between 2006 and 2020. This figure includes almost €4 million in legal and professional fees. Will the CEO confirm if this figure includes legal fees accrued from defending the cases? Does he have a breakdown between legal and professional fees?

Mr. Stephen Mulvany:

I do not have the detail. The CFO may have some of the detail. The figure the Deputy mentioned for legal cases and whatever is related to the overall operation of the repayment scheme. If there are legal costs in that relating to individuals in private nursing homes, they relate to their application under the scheme and the processing of that application. That would be a refusal under the scheme because they are not eligible under what the Oireachtas has set out. I do not believe it would include costs. Separate to that, where they subsequently took a case having been refused under the scheme because they did not meet the criteria, it should not and, I believe, would not cover those costs.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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The €32.5 million is only for the administration of what they were entitled to as per the legislation. For anybody who took a case who was outside those parameters, there is additional cost associated with that. Is that right?

Mr. Stephen Mulvany:

My understanding is not everyone who took those 329 cases applied first under the scheme, but a lot are likely to have done so. They would have been processed under the scheme and refused. Any cost up to that point should be reported in the €485 million in our accounts. Any cost beyond that point would not be reflected under the scheme costs. If the HSE incurred at the initial stage pre-2013 any cost from processing those cases, that would be in our accounts, but we have not been processing those cases or leading on that for some years, as the Deputy mentioned.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Can the CFO shed any light on that?

Ms Mair?ad Dolan:

Any legal fees charged to the long-stay repayment scheme will be directly related to the running of the scheme and not, that I am aware of, to any legal cases. We have not been managing those legal cases.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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The Department does not have the number of cases, but does it have the figure for the cost of defence or litigation in relation to the scheme or to those who fall outside the scheme? Does it have a cost, at all, of any legal fees?

Mr. John O'Grady:

I do not have a discrete cost for that issue. The overall legal cases settled by the Department and some other related costs for tribunals of inquiry and the CervicalCheck issue are disclosed in the appropriation account. There is overall expenditure in subhead D of the Department of Health’s Vote of €9.3 million in 2021 compared with €4.7 million the previous year. There is an overall settlement of 60 cases in 2021 and 13 in 2020. I do not have a breakdown of how many relate to nursing home issues but we will get that and revert to the committee.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I appreciate the witnesses have some figures. However, it is a pity, given the public comment and comment within the Houses of the Oireachtas on this issue and the fact it was given in the briefing in advance of today that it would be raised that they do not have the breakdown. Mr O’Grady said 13 in 2020. Is that right?

Mr. John O'Grady:

There were 13 legal cases disclosed in our appropriation account, possibly including, though I do not have a breakdown, cases relating to historical nursing home charges. There were 60 in 2021 but we will get a breakdown of the nature of those cases in aggregate when we revert.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I understand the Attorney General is preparing a memo for Cabinet on the legal strategy employed by the State, Department of Health and HSE to defend these claims, which is due to be published next week. It has been reported there are two substantive memos detailing legal strategy in this area, one from 2011 and another from 2017. I am conscious of the CEO's time spent in the role, but is he aware of any other substantive memos on this that the committee should be aware of?

Mr. Stephen Mulvany:

Not at this point, unfortunately.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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In terms of the 2021 liability, €1.7 million was calculated for the health repayment scheme. The estimated provision for the repayment scheme was €1.7 million spent in 2021, while only €486 million of the estimated scheme cost of €1 billion has been spent to date. In December 2021, the figure was €486 million, which works out at an average of nearly €22,600 per claimant. How was the 2021 contingent liability of €1.7 million for the health scheme calculated by, I presume, the HSE?

Mr. Stephen Mulvany:

I will start the answer and then ask the CFO to comment. The €1 billion figure the Deputy mentioned was the original estimate from 2005 or 2006 of the cost of the repayment scheme. Then the scheme was organised based on the Oireachtas passing the legislation. We appointed a scheme administrator. The vast bulk of the claims and cases were processed in the next four or five years and there has been a trickle ever since. The actual cost has come out in the most recent accounts at €485 million, of which €453 million was paid out to claimants. The figures the Deputy quoted are correct. In excess of 35,000 people applied and 20,000 were approved. There are very small numbers not fully finalised, if any. There is a €32 million total cost of administration broken down between the HSE's administrative legal costs, the original scheme administrator and the costs of advertising and other ancillaries. I ask the CFO to comment on any contingent liability figure.

Ms Mair?ad Dolan:

The cost of the scheme recorded in the long-stay repayment accounts to the end of 2021 was €486 million, as referred to. We referred in note 9 to the AFS for 2021. There is a figure of €1.7 million set aside for claims that might be settled for 2021 and paid in 2022. That is based on claims that are being worked out and will likely have been paid in 2022.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Okay. I return to the applications to the scheme. There were 35,417 applicants and 20,302 claimants received payment. The witnesses have alluded to people outside the parameters of the legislation etc. Were any refused for reasons other than legislative? Was there a bulk reason for refusal based on certain criteria? Are the witnesses aware of any other criteria applied for refusals of these applicants?

Mr. Stephen Mulvany:

I am not. The legislation was quite clear and the eligibility criteria were quite clear in terms of medical card holder in a public community nursing unit or a publicly funded, contracted bed in a private nursing home. There were certain criteria whereby residents needed to be alive or have deceased at a certain stage and the money gone to the estates. It was a formally organised scheme externally run largely by the scheme administrator, which is a consortium of a firm of accountants and a firm of lawyers. There were no reasons for claims submitted and processed to be refused other than what is in the scheme as per the legislation.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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The CFO commented on the €1.7 million. The website states a few complex cases are still being processed. I understand those complex cases are being dealt with by the Department of Health since 2013.

The HSE has no more hand, act or part in this scheme at all. It is all the Department of Health now. Is that correct?

Mr. Stephen Mulvany:

No, there is no end date on the scheme. The scheme is still being administered by the HSE and we take responsibility for it. We no longer need, nor have we needed for some years, the external consortium of the accounting firm and the lawyers because the volumes are not significant. It is a HSE responsibility. The claims being processed are the claims under the scheme, which are separate to any cases for people who did not qualify under the scheme but felt aggrieved that they should have received some recompense.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Does the HSE have an average payout per the scheme for claimants? Every case is obviously different as per stay etc., but is this working out as an average per claimant?

Mr. Stephen Mulvany:

It will be the figure the Deputy has quoted, which is €452-€453 million, which are the actual payments rather than the actual administration costs, divided over the 20,301 claimants, and that will give us the average figure. I do not have a calculator with me but it is in or around the figure mentioned by the Deputy, which was €22,000.

Ms Mair?ad Dolan:

That figure is €22,300.

Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Okay.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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I thank our guests for being here. We have been discussing the long-stay repayment scheme in the context of two distinct groups, if I am correct in respect of what is being said by Mr. Mulvany. We have the medical card holders in public nursing homes who, largely, were all eligible under the scheme and medical card holders in private nursing homes, which the HSE and the Department have contended are outside of the scheme. Is that correct?

Mr. Stephen Mulvany:

That is not correct in that the HSE is not contending that they were outside of the scheme. The Dáil and the Oireachtas approved the 2006 Health (Repayment Scheme) Act. That Act set out the scheme. That Act, the Dáil and all of the parties in the Dáil agreed through that process that the eligible criteria was that a person had to be a medical card holder in a public community nursing unit, CNU, or in a publicly funded contracted bed in a private nursing home.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Mr. Mulvany’s point is made. Is it not correct to say that there is a third group, because there were also medical card holders in what are known as section 38 and 39 disability services homes, in community hospitals, essentially? Is that not correct?

I refer Mr. Mulvany to the financial statements of the HSE from quite a number of years ago, for 2009, 2010 and 2011, which I will read from:

In addition, the HSE with the Department of Health and Children has lodged an appeal to the High Court in respect of determinations by the Appeals Officer granting eligibility to clients of certain disability services. Consequently, it is considered inappropriate to attempt to estimate any potential future liability arising from these actions...

Essentially, what we know from the HSE’s annual statement is that there were residents in these community services and disability services who applied for the scheme, were deemed ineligible, and then appealed it to the appeals officer within the HSE. The appeals officer, as I understand it, took three test cases related to services at St. Michael’s House, Cheeverstown House and the Daughters of Charity. He determined, on the basis of those three cases, that those residents were eligible under the scheme. The HSE and the Department of Health actually initiated an appeal against their own appeals officer to the Courts Service. Is Mr. Mulvany aware of any of this?

Mr. Stephen Mulvany:

I am not aware of the details here, no.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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I have read the 2011 accounts. That was the case in 2009 and 2010, and in 2011 the HSE lodged an appeal to the High Court. By 2012, note 31 in the HSE’s financial accounts stated:

Following discontinuation of appeals to the High Court brought by the HSE and the Department of Health in respect of determinations by the Appeals Officer granting eligibility to clients of certain disability services, €8m has been provided in the 2013 HSE budget to fund repayments for outstanding claims...

Essentially, it was accepted these people qualified under the scheme. Does Mr. Mulvany accept that?

Mr. Stephen Mulvany:

Absolutely. I do not have the detail, but as I said, the scheme was set out in legislation. The HSE operated the scheme. If the issues the Deputy has mentioned clearly arose and were resolved between those two years, and there were some additional people who the scheme administrator did not feel at the start were deemed to be eligible, that would have involved substantial amounts of money-----

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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I am surprised Mr. Mulvany does not know this because this is even included in the Comptroller and Auditor General’s report of September 2011, which noted that a hearing in this area was awaited.

As I mentioned, the 2012 financial statements provided for €8 million in the 2013 HSE budget to refund repayments to these outstanding claims. A total of €8 million was allocated again in 2014 and €4 million was allocated in 2015. Will Mr. Mulvany inform the committee if these were the actual amounts of money that were actually paid?

Mr. Stephen Mulvany:

Again, just to be clear to the Deputy, I absolutely accept everything that is in the HSE accounts. Those issues occurred and were dealt with. I cannot tell the Deputy whether any specific amount of those contingencies in one year were paid in the next year. If the Deputy wishes to give us a specific query, we can check that. I have no doubt the bulk of these payments would have been made, as is the normal practice. There is no issue of lack of clarity in the accounting in any way around the administration of the repayment scheme.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Is Mr. Mulvany aware of the reason the appeal was dropped? The State was going to appeal its own appeals officer in respect of these particular cases. As I understand it, there were potentially up to 10,000 people across all homes, but more than 300 had lodged appeals. These were going to be deemed eligible as a result of the appeals officer’s decision. The HSE and the Department of Health decided, with ministerial approval we have to assume, to appeal that decision, and then decided to withdraw its appeal. Does Mr. Mulvany know why that appeal was withdrawn?

Mr. Stephen Mulvany:

I do not, but in the first place, the reasoning involved in considering or making an appeal to the High Court is generally only to clarify a legal point and to ensure we are properly implementing the wishes of the Oireachtas as set out in the legislation. That is the only typical reason we would do that. If it subsequently transpired, through legal advice, that that clarification could be got in another way, that may well be why that appeal was withdrawn. It is entirely done to ensure-----

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Let me help Mr. Mulvany for a minute------

Mr. Stephen Mulvany:

Let me finish, please, Deputy. It is entirely done to ensure we can attend at the Committee of Public Accounts and say we have done the job the Dáil has asked us to do.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Let me just clarify. There were 515 similar appeals to the three tests the appeals officer initiated at St. Michael’s House, Cheeverstown House and the Daughters of Charity. These were residents within those institutions for whom appeals had been made on their behalf. An appeals officer had determined they were eligible. A decision was made to appeal that. That appeal was withdrawn. Mr. Mulvany states he does not know why. We now have a memorandum which was circulated to senior Government members in 2011 which actually sheds light on this. This says the State was likely to have difficulty successfully proceeding with these appeals. It was estimated that an additional funding of €20 million would be required to implement the appeals officer’s decision, which would account for the provisions in the HSE’s subsequent accounts. In addition, there are other institutions similar to St. Michael’s House, Cheeverstown House and the Daughters of Charity with residents who would have similar potential claims.

Will Mr. Mulvany inform the committee whether contact was made with those people who applied for the scheme but did not appeal that decision? Was provision ever made to provide payment to them?

Mr. Stephen Mulvany:

I cannot tell the Deputy that now, as I sit here. What I can tell him is, as I said, that the scheme was based on the legislation in the Dáil. The Dáil would have specifically referred to public nursing homes or publicly contracted beds in private nursing homes. The emphasis, therefore, would clearly have been on older persons, typically, who resided in those facilities. What was clearly raised along the way was, I am sure, an entirely valid question as to whether people in a similar situation, albeit in disability services, should be entitled. I do not have any more detail than that.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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The memo I refer to which lays out the legal rationale states:

The particular difficulty with challenging such a finding by the appeals office is that it raises a wider issue, that the legal basis under which payments were collected from residents and community homes, if it were found by the High Court that they were not recoverable health charges, there appears to be no other legal basis for the levelling of such charges.

This is not a grey area. In terms of the legal advice and the information provided to Ministers, this was a slam dunk that the State was liable to pay for them. Nevertheless, according to this memorandum, many people, beyond the 500-odd I mentioned, decided not to appeal, probably on the basis of advice from the HSE that the payments did not come within the definition of the recoverable health charges. If these cases had materialised, it would have created a potential liability of some €360 million, but that liability has never been included in the HSE's accounts.

Who received long-term payments in respect of section 38 and section 39 residential care? Provision was made for about €20 million, which, according to the average the witnesses cited in response to previous questions, would apply to those approximately 500 people who made appeals? We know, however, that almost 10,000 people in addition had applied and qualified but did not appeal on the basis of advice from the HSE. Has any measure been taken to ensure those people will be recompensated?

Mr. Stephen Mulvany:

The scheme is the scheme. It is-----

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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These people are eligible for the scheme. That has been determined by the HSE's appeals officer, a decision it did not appeal, on the basis of legal advice indicating it did not stand a chance in hell. There are, potentially, 10,000 people additional to the people we have been talking about all week, and these are people who are in disability services in section 38 and section 39 organisations. Is provision going to be made to ensure they will be compensated as per their legal entitlement?

Mr. Stephen Mulvany:

If I could finish, unfortunately, I do not have the detail nor the documentation the Deputy has in front of him. I am very happy to look at it in due course-----

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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For clarity, the documentation I have in front of me is the HSE's own financial statements on an annual basis and its notes relating to 2011, 2012 and so on.

Mr. Stephen Mulvany:

If I could answer, those financial statements and that scheme have gone through both the auditing process and the Committee of Public Accounts process since 2007 to date. I am saying that in respect of the specific issue the Deputy is raising, I need to understand it better and be briefed. I will be happy to answer questions at a future point.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I thank Mr. Mulvany-----

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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May I finish with one further point?

Mr. Stephen Mulvany:

To be clear, the scheme was operated in accordance with the legislation, and it is not quite closed but is largely closed-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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We will ask Mr. O'Grady from the Department whether he has any information on this. I ask the Deputy to be brief as we have gone over time.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Here is the situation as we know it. Up to 10,000 people in those homes were eligible, a number of them appealed and the appeal was upheld but, because of delays as a result of a court challenge that did not materialise, it was a number of years before those who had appealed were paid. A number of people who had applied in the first instance did not appeal based on the advice of the HSE that they did not stand a chance, whereas the HSE's own legal advice was that they would win those cases and should have fallen under the remit of the scheme.

Brian Stanley (Laois-Offaly, Sinn Fein)
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That point is taken.

Mr. Stephen Mulvany:

That figure of up to 10,000 is a figure I do not know. It is not a fact that has been confirmed here today but is an assertion the Deputy is making. I do not have the detail.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Can Mr. O'Grady, who is representing the Department, shed any light on this?

Mr. John O'Grady:

Unfortunately, I cannot. I will make contact with colleagues in the Department to see whether, during this meeting, we can shed further light on it. I do not have the information here.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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In respect of where my figure of 10,000 has come from, according to this memorandum we have received, €20 million would be required to satisfy the appeals of the 512 who had made appeals. That was subsequently included in the HSE's financial statements. The memorandum also stated, however, that in the worst-case scenario, the HSE estimated a potential liability of some €360 million. That is where the potential number of people has been extrapolated from. It may not be 10,000, therefore, but it certainly runs into the thousands of individuals who were denied payments they were entitled to.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I ask Mr. Mulvany and Mr. O'Grady to see whether their officials can get any information before the end of the meeting and to revert if they are able to do so.

Mr. Stephen Mulvany:

They will not be able to get anything more before the end of the meeting.

Brian Stanley (Laois-Offaly, Sinn Fein)
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If that is the case, can we have a reply within two weeks?

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Why would Mr. Mulvany not be able to get further information today?

Mr. Stephen Mulvany:

Because it has to be found and, in fairness, we have to have some time to consider it. We will absolutely comply with the two-week requirement.

Verona Murphy (Wexford, Independent)
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To follow on from Deputy Carthy, was Mr. Mulvany the chief financial officer at that time, in 2011 and 2012?

Mr. Stephen Mulvany:

No. I think that was in 2013 and 2014.

Verona Murphy (Wexford, Independent)
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As another follow-on, we gave a week to the Department to gather documentation and information in preparation for a Dáil debate some day next week, to be decided today by the Business Committee. Was any member of the team accompanying Mr. Mulvany involved in gathering that information or documentation?

Mr. Stephen Mulvany:

Colleagues can answer that for themselves. I am not sure.

Verona Murphy (Wexford, Independent)
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Has anyone been involved in providing this historical documentation? The witnesses are shaking their heads. That is grand. I am not going to discuss this further with them because I firmly believe we will get the information and discuss it in the Dáil next week.

I want to concentrate on disability services, and I could probably take up the entire meeting on my own based on how poor the performance is, to be honest. Ms Comiskey might tell me about the children's disability network teams, CDNTs, and why the system is such a failure.

Ms Deirdre Comiskey:

In respect of the CDNTs, the Department acknowledges there are challenges in the children's disability services. Going back to why the CDNTs were set up-----

Verona Murphy (Wexford, Independent)
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We know why. I have little time and I will try to be cordial. If I get the answers, I will be cordial, and if I do not, I will be like I always am. I am asking this on behalf of the children and their families who are not getting services.

I will outline one instance. I am dealing with an eight-year-old, who is physically bigger than his mother and his siblings, who constantly beats his mother to the point where she is afraid her life and those of her children are in jeopardy. The terminology used by Tusla is that four lives are being lived as one. Nobody else gets to do anything because all the focus is on the child. That family cannot get respite. All the stakeholder agencies are involved. This is just one case I am referencing. Why is the system in such disarray? We set up the CDNTs for all the right reasons. What we have not been able to do is staff the model. Is it a resourcing issue? That is a binary question. Is it money?

Ms Deirdre Comiskey:

It is not funding. Funding has been provided for in excess of 600 posts since 2019. The problem, and I am sure my HSE colleagues can speak to this in detail, relates to the challenges around recruitment and retention, which have caused significant issues with the CDNTs.

Verona Murphy (Wexford, Independent)
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What is the clinical governance structure for the CDNTs versus that of primary care? What is the difference?

Ms Deirdre Comiskey:

In respect of the governance structure for the CDNTs, I am going to have to hand the Deputy to my HSE colleagues, if that is okay, because they are on the operational side.

Mr. Stephen Mulvany:

Clearly, the HSE takes responsibility because we deliver children's disability services. The children's disability networks work very well in some places but in some cases, as the Deputy said, families and children are not getting the service they need or that we would like to provide. That is accepted-----

Verona Murphy (Wexford, Independent)
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Where is it working well?

Mr. Stephen Mulvany:

My colleagues will give examples of where CDNTs have been there for some years and are effective.

Verona Murphy (Wexford, Independent)
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Mr. Mulvany stated they are working well. Will he give an example of that?

Mr. Stephen Mulvany:

I will let my colleagues give that detail, if I can. I have met some of the CDNTs and that is the information I have got. As background, and this is part of the questions the committee asked, about 20% of children's disability services are provided directly by the HSE. The other 80% are provided-----

Verona Murphy (Wexford, Independent)
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The question related to clinical governance.

Mr. Stephen Mulvany:

Agreed. The rest are provided by voluntary agencies. Part of the answer to the Deputy's question as to why we are in such difficulty is that we are seeking to get a lot of partner agencies to make a substantial change in a relatively short period, as well as having resourcing issues-----

Verona Murphy (Wexford, Independent)
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I ask Mr. Mulvany to answer the question. I asked what the clinical structure of a CDNT is versus that of primary care. Are they the same?

Mr. Damien McCallion:

There are 91 teams throughout the country and most of them have significant staff deficits. There are challenges there around it.

Verona Murphy (Wexford, Independent)
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Does that mean they are not working that well?

Mr. Damien McCallion:

No. What I am saying is that clearly if the teams are under-resourced in terms of where they should be relative to the numbers of people that we want in them, we are a long way from the level that we want to be at. As I think was detailed in the report we provided to the committee, one of the areas in terms of progressing disabilities is trying to set out a roadmap over the next few years for how we can try and address some of those recruitment difficulties.

Verona Murphy (Wexford, Independent)
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In the next few years.

Mr. Damien McCallion:

The reason I say that is that we will not resolve the recruitment issue straight away. There are very significant challenges in terms of the numbers of people coming out of our colleges for some of the therapy professions versus the numbers we need. We are looking at all measures to try to incentivise people to work in those services, and also in relation to international recruitment.

On the Deputy's specific question on clinical governance, perhaps Ms O'Neill can explain how that works in a community setting. There is a head of disability service and a structure under that.

Ms Yvonne O'Neill:

The CDNTs are governed under the children's disability network manager. As my colleagues have said, depending on the location, it is jointly provided by the section 38 and section 39 organisations and the HSE. The teams may be made up differently in terms of where the person is employed, but the governance structure is standard. It is led by the CDNTs. Around two thirds of the posts in the teams are filled. That varies across the country. I am very aware that-----

Verona Murphy (Wexford, Independent)
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Sorry, I am confused. Do the CDNTs have a clinical governance structure?

Ms Yvonne O'Neill:

Yes, they do.

Verona Murphy (Wexford, Independent)
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What is the difference between that governance structure and the structure in primary care? It does not appear that we have a problem in primary care. As a matter of fact, primary care seems to be the only part of all of these services that is working. How many staff left the CDNTs before Christmas?

Ms Yvonne O'Neill:

I do not know the numbers.

Verona Murphy (Wexford, Independent)
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I am informed that in one facility in CHO 5, seven staff walked out. Is the HSE aware of that? If I am hearing from staff that we have to engage and there is a crisis, is that worrying for the HSE?

Ms Yvonne O'Neill:

It is very concerning for all of us.

Verona Murphy (Wexford, Independent)
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It is very concerning. Imagine how it feels for the mother of an eight-year-old child who cannot get into her car for fear of the child choking her. She cannot bring him to respite services herself and she cannot let anybody else do so either because he cannot be restrained by normal family members, as it were.

Ms Yvonne O'Neill:

I know the Deputy engages closely on specific cases with our colleagues in CHO 5, which is in her area. We would have the same level of concern-----

Verona Murphy (Wexford, Independent)
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The close engagement is that I have to constantly harass the staff to get the services that do not exist because the staff do not exist to provide them.

Ms Yvonne O'Neill:

That clinical governance does take on the responsibility for clinical prioritisation and in the acknowledged gap that there is on the available resources to do it.

Verona Murphy (Wexford, Independent)
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Why are do staff want-----

Ms Yvonne O'Neill:

Respite care has been a considerable challenge.

Verona Murphy (Wexford, Independent)
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Why are staff moving from CDNTs back to primary care?

Ms Yvonne O'Neill:

There is also a gap in health and social care professionals across the whole of the HSE, including mental health services, primary care and disability services. The promotional posts that have been developed as a result of the enhancement of community care in primary care services has meant that our own people, because of their own experience and career progression-----

Verona Murphy (Wexford, Independent)
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I have two minutes and I have not got an answer.

Ms Yvonne O'Neill:

The only thing-----

Verona Murphy (Wexford, Independent)
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Is there a head of discipline for the----

Ms Yvonne O'Neill:

Can I just say one thing? There are 29,000-----

Verona Murphy (Wexford, Independent)
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Excuse me, Ms O'Neill-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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Deputy, please.

Verona Murphy (Wexford, Independent)
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Chair, I have been asking questions for nearly ten minutes without getting an answer.

Ms Yvonne O'Neill:

There are 29,000 children who are provided a service.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Allow the witness to finish, Deputy. Then I will let you in.

Verona Murphy (Wexford, Independent)
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Is there a head of-----

Ms Yvonne O'Neill:

I only wanted to finish by letting the Deputies know that there are 29,000 children in receipt of services from a very dedicated-----

Verona Murphy (Wexford, Independent)
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There are about 20,000 children who do not get the services because we do not have-----

Ms Yvonne O'Neill:

-----group of professionals.

Verona Murphy (Wexford, Independent)
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How many do not have the services? Give me that figure.

Ms Yvonne O'Neill:

The documents that we have provided show the types of areas, like respite and residential-----

Verona Murphy (Wexford, Independent)
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It rolled off Ms O'Neill's tongue that there are 29,000 children in services. How many are not in services because they cannot access them? How many?

Ms Yvonne O'Neill:

Some of those 29,000 may not be getting the full range of services they need. It is much harder to provide the number in need.

Verona Murphy (Wexford, Independent)
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Is there a head of discipline?

Ms Yvonne O'Neill:

Yes, there is a clinical governance structure in the teams.

Verona Murphy (Wexford, Independent)
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Is there a head of discipline in the CDNTs?

Ms Yvonne O'Neill:

Yes.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Okay, that has been clarified.

Verona Murphy (Wexford, Independent)
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No, it has not been clarified.

Mr. Damien McCallion:

There are heads of discipline in each of the CHOs that provide the clinical governance, as Ms O'Neill has said, for each of the disciplines.

Verona Murphy (Wexford, Independent)
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Is that for primary care or the CDNTs?

Mr. Damien McCallion:

In some cases, the clinical governance is provided across a range of services. The Deputy's point on primary care is a fair one, in that what we are seeing is that, through the investment in primary care, over 2,000 posts have gone into our enhanced community care and primary care programme in recent years. There is no question that is impacting on our other services such as disability services.

Verona Murphy (Wexford, Independent)
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If there is no question that it is impacting those services, what is the HSE doing about it?

Mr. Damien McCallion:

Part of the roadmap that we have set out looks at international recruitment to try to grow the numbers. We cannot grow the numbers that are coming through our colleges overnight. We have addressed this issue with the Joint Oireachtas Committee on Health in terms of the challenges we face. The Department has been working with the Department of Further and Higher Education, Research, Innovation and Science to try to ensure we train more people in therapy professions such as speech and language therapy, occupational therapy and physiotherapy.

Verona Murphy (Wexford, Independent)
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That is a long-term response. I am asking what we are doing for the children and the families today. There are good staff in the HSE who are doing fantastic work but are "demoralised, fatigued, saddened, undervalued and voting with their feet", as I have read. The good staff that are left are going to leave. Does that concern Mr. McCallion?

Mr. Damien McCallion:

Of course.

Verona Murphy (Wexford, Independent)
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Does it concern everybody here?

Mr. Damien McCallion:

One of the reasons we have put that roadmap together is to try to give staff and families some sense of the direction-----

Verona Murphy (Wexford, Independent)
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Mr. McCallion-----

Mr. Damien McCallion:

May I just finish?

Verona Murphy (Wexford, Independent)
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Let me just read a sentence. Flowery language is used in this 20-page document. It is wonderful, but it means absolutely nothing.

Mr. Damien McCallion:

Could I respond?

Verona Murphy (Wexford, Independent)
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It states: "The HSE works in partnership with organisations." Is the payscale the same? Are the section 39 organisation staff on the same payscale as the HSE staff?

Mr. Damien McCallion:

No. That is the straight answer to that. Just to be clear-----

Verona Murphy (Wexford, Independent)
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So the HSE thinks it is going to recruit-----

Mr. Damien McCallion:

May I answer the question?

Verona Murphy (Wexford, Independent)
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Does Mr. McCallion agree it will be difficult to recruit and retain staff under those circumstances?

Mr. Damien McCallion:

If I could comment, I actually agree with the Deputy. We agree that the fact that section 39 organisations are not able to pay their staff at the same level or a similar level as section 38 organisations or the HSE is a challenge.

Verona Murphy (Wexford, Independent)
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Given that 80% of the services are provided in that sector, how does the HSE propose that the sector will be able to stand up to that?

Mr. Damien McCallion:

What we are saying is that it is a very significant issue. I and others have called the issue out, including at meetings of Oireachtas committees. There is a Workplace Relations Commission, WRC, hearing coming up shortly and the HSE will be represented at that. These people are not our employees. However, because of the service impact, we see this as a very important issue that needs to be resolved. It is referred to as the pay parity issue for the section 39 organisations.

Verona Murphy (Wexford, Independent)
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Hold on a second now.

Mr. Damien McCallion:

We want to be part of any solution that can be found for that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I will allow the Deputy to come back in, but we are way over time.

Verona Murphy (Wexford, Independent)
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I will come back in because, as I said, I could do the meeting on my own.

Brian Stanley (Laois-Offaly, Sinn Fein)
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The WRC hearing concerns section 39 organisations.

Mr. Damien McCallion:

Exactly, Chairman.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Okay. I call Deputy Dillon.

Mr. Stephen Mulvany:

There is no target level for patients on trolleys because there is no acceptable level of people awaiting admission to hospital. Our daily Trolley Watch figure indicates that if there are more than 236 people waiting for admission on a trolley in the morning, the system is in the red. The system goes into green at a level that is much lower than that, but even that is not an acceptable level of emergency department, ED, trolley waits, as we have said. What are we doing about it? I suppose the positive news is that once we recovered from the first week of this year, which was the worst week we have had on record in terms of trolley waits, the system stabilised and gradually improved week on week in the three weeks after that. Again, we are not saying this is a good position. We are simply saying it is a better position than it was, to the extent that in each of those three weeks up to week 4, which was last week, the waits at 8 a.m. - as I said, even one person waiting is not acceptable - were lower than all of the years outside the two pandemic years when the issue did not really arise for different reasons, going back to 2017.

The task for us is to see to what extent the impacts of the additional measures we have put in place have enabled that, which of those can be maintained or which will need to be stood down and then reintroduced once we can make them sustainable. We are focused on reducing the trolley wait as much as possible.

Mr. Stephen Mulvany:

We have about 11,500 inpatient beds for a population of approximately 5.1 million. We are clear that the number of inpatient beds is not where it needs to be and is not particularly high when we look at EU comparators. We are looking at increasing that number of beds. Over the last three years, 970 additional inpatient beds have been added to the system. There are a further 209 this year and there are 49 we still have to determine. They are all part of the 1,228 beds-----

Mr. Stephen Mulvany:

No. I do not believe that is sufficient. We are redoing the capacity analysis carried out by the Department. Not only did that look at beds, it looked at other things as well. More beds is part of the solution and the Government, in fairness, has invested in beds and has indicated a continued desire to do so. Process improvement is also part of what our focus is on. It is not enough.

Mr. Stephen Mulvany:

I would have to check but I know we have lost beds in the system. The number of beds-----

Mr. Stephen Mulvany:

In fairness, medical care changes. If you go back over 40 years, the number of beds has changed. It decreased across a number of years for a variety of reasons. In the past three years, more additional beds have been put in place than at any time over the past 40 years. We have checked that. It is not enough, but, if you think about it, we did not have day cases 40 years ago. Now, the average length of stay for most procedures has been reduced. Do we need more beds? Yes. Are more beds being put in place? Yes. Are further needed? Yes, but it is not just about hospital beds; it is also about capacity in the community and processes.

Mr. Stephen Mulvany:

It is similar. Every bed, as the Deputy is indicating, needs to be staffed-----

Mr. Stephen Mulvany:

Looking at the hospital side, and, again, we cannot just focus on the hospital side-----

Mr. Stephen Mulvany:

Emergency care, as we know, is just a symptom of the problem across the whole system, in both community and hospital care. We cannot solve it in emergency departments. We have to solve it across the entire system, including emergency departments. With regard to our workforce planning around acute hospitals, last year we commissioned, paid for and completed the ESRI study into acute hospital staffing requirements out to 2035. We have a good picture of how much we need to grow the numbers by and what the attrition levels are and, therefore, how much we need to expand the recruitment, training and retention of staff. We have processes in place for each of those.

Mr. Stephen Mulvany:

Publication may be at that point, but the planning starts a lot earlier. Over time, we would like to move away from annual winter plans. Even this year, a lot of what was delivered as extra capacity was in service plans for this year or last year in terms of extra beds or extra staff. There is a multi-annual approach. The winter plan should really only be for additional point capacity that you can turn on quickly. Our aim is to produce those plans much earlier. They are published in October but they are worked on much earlier. We would aim to produce this year's plan in the next month or two because we know we need to be starting new recruitments then. That is what we have done in the past, anyway. We are also working on a three-year plan so we have a longer term view.

Mr. Stephen Mulvany:

It is the HSE executive management team, which I chair. We have a chief operations officer who leads the operational delivery and system, supported by the chief clinical officer and colleagues.

Mr. Stephen Mulvany:

The key focus from 2022, and the Minister and Government have been very clear on this, is on access. That is both in terms of access to emergency departments and admission for acute care on the unscheduled care side and access on the scheduled care side by reducing waiting lists. They are the two specific focuses. The Government has indicated a willingness to continue to invest in that, as it has over the last three years.

Mr. Stephen Mulvany:

Yes. Learning from incidents is a standard part of healthcare across the world and is a standard part of our business. It is not just-----

Mr. Stephen Mulvany:

It is not that we would expect it. In fairness, people are entitled to take claims where they feel they have not received the care they should have or where people have adverse outcomes. People have adverse outcomes across healthcare systems around the world. Ireland is no different in that context.

Mr. Stephen Mulvany:

So far, looking from December to the end of January there is not an increase in the trend compared with previous years. There are still cases being reported and those cases will need to be assessed. If required, they will be investigated.

Mr. Stephen Mulvany:

On the extreme end of the scale, from 1 December to the end of January there were 12 cases. That would be the extreme end of incidents.

Mr. Stephen Mulvany:

I do not have that figure.

Dr. Colm Henry:

We only have the serious incidents-----

Mr. Stephen Mulvany:

After that there is moderate, minor and negligible.

Mr. Stephen Mulvany:

We can of course.

Mr. Stephen Mulvany:

Reacting to those and seeking to prevent incidents where we can is part of the ongoing aim of all our teams and staff, not just in emergency departments. It is a key part of what they seek to do, which is reduce any potential for harm for both patients and staff.

Mr. Damien McCallion:

One of the things we are trying to encourage is more reporting of incidents and issues when they happen so learning can be applied. We have a whole process but that will increase the amount of reporting so learning can be taken from anything that happens within the system. That is really important. As a metric, the number has not changed, but we would like to see more reporting across all services in terms of things people can learn from. That may not mean there is an incident from the patient's perspective in all cases. That is an important point to note about the numbers.

Dr. Colm Henry:

There are two forms of harm. One is the harm associated with overcrowding. Studies carried out in England and Australia show that certain levels of overcrowding over certain increments of hours are associated with increased harm. That was studied in the context of retrospective cases. Then there are the cases the Deputy alluded to, that is, individual cases where harm is suspected in the course of giving treatment and providing care. Such cases cross a certain threshold and we set that threshold low. We instigate what is called a serious incident management team under the policy of 2018. That does not necessarily mean harm was done in the course of care. However, there are certain trigger incidents, such as a sudden deterioration in somebody in an emergency department while waiting to be seen, or maternity incidents, which automatically trigger an event and an investigation. During the course of that investigation of course the family would be informed or fully briefed at the end as to the outcome.

Paul McAuliffe (Dublin North West, Fianna Fail)
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Like Deputy Verona Murphy, I await the documents that are being prepared for the Dáil next week. It is a serious matter and I would certainly want to have the full range of documents in front of me before I comment on it. However, there is one area in the reporting that I think is appropriate for this forum. That is the suggestion, and I want to be careful in how I phrase this - I will try to rely on what was in the article - that somehow there was an arrangement made with the Comptroller and Auditor General in regard to how these matters would be reported and that this would then be used as a way of hiding the overall legal activity. It is appropriate that we comment on that matter at this forum and try to find out if there was some sort of special arrangement in respect of this liability, as opposed to the liability that might be due for any other account that would come before us.

The article states: "Ultimately it proved possible to agree a form of wording which complied with government accounting requirements without jeopardising the confidentiality of the State's strategy in defending this litigation." I ask the Comptroller and Auditor General and the officials from the Department to comment on that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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The Comptroller and Auditor General clarified that matter earlier, but I will ask him to come back in again.

Paul McAuliffe (Dublin North West, Fianna Fail)
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It is important to know. I do not know the source of either the quote or the documents. Perhaps they are exaggerating what was possible in the conversations with the Office of the Comptroller and Auditor General. Was there a special arrangement for this particular one or was this something which was normal practice across other Departments and other notes?

Mr. Seamus McCarthy:

I might just comment to begin with. I do not believe there was anything special involved. We were concerned about this. We made significant inquiries into the contingent liability that was associated with the matter. We had lengthy engagement with the Department in successive years. We were satisfied with the level of disclosure in the HSE financial statements at the time. I would always be in favour of more disclosure and more detail being given about these matters but obviously there is a limit. I am quite satisfied that the notes explaining the liabilities in respect of it were what was required by the accounting standards at the time.

To bring further light to the matter, my predecessor reported to the committee in 2010 in a chapter relating to the annual report of 2009 - it was published in 2010 - because of the novelty of the matter. It is a fair representation of the issues that arise in relation to the scheme. There is always an element of pushback in relation to the completion of the audit, particularly where there are novel issues and where there may be sensitivities. We find an appropriate place to settle. I am not familiar with the document that was quoted. I do not know who said those things. I do not know what experience they had had with us. I am quite happy with what we did in respect of this matter.

Paul McAuliffe (Dublin North West, Fianna Fail)
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Would one of the departmental officials like to comment?

Mr. John O'Grady:

I have been in the department for two years, so, obviously, I would not have been privy to any of those discussions. I am not involved in the preparation of the appropriation account either. I know that the Government asked the Attorney General to look at the issue. I am aware that other colleagues - I am not involved with that work - are working to support that, and there will be a report provided to the Minister and the Government in due course.

Paul McAuliffe (Dublin North West, Fianna Fail)
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Mr. O'Grady is in a difficult position because the documents have not been published. This is very important for the integrity of this committee and of the process. I go back to the article, which states that this:

... would not be publicly reported by its spending watchdog. To achieve this, agreement had been reached with the Comptroller & Auditor General (C&AG). Any mention of the matter in C&AG reports to the Oireachtas could have alerted the wider public to the matter and results in a flood of new cases.

Regardless of what documentation is made available next week, we know there was no attempt or willingness on behalf of the Comptroller and Auditor General to hide something in collusion with or in co-operation with the Department. I would welcome the Comptroller and Auditor General's comments on that.

Mr. Seamus McCarthy:

I would say that the opposite was the case. We were pushing for disclosure, not accepting-----

Paul McAuliffe (Dublin North West, Fianna Fail)
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My colleagues, Deputy Fleming and the former Chairman of this committee, Deputy McGuinness, made similar comments about the State Claims Agency and contingent liability - revealing more information and detail from that. I raise that matter here in this forum. Like Deputy Verona Murphy, I await the full report next week.

On disability services, I am with Deputy Verona Murphy in that I do not know where to start. It is such a wide area. I want to just focus on one aspect. I wish to talk about people who require assessment of needs, particularly for the purposes of special education or provision of supports in mainstream education. I continually receive reports that people who cannot afford private assessments are left waiting for long periods for assessments. Last year, there was an attempt to move to a kind of accelerated assessment of needs. That was overturned and they had to come back. What efforts are being made to try to improve the waiting times for assessment of needs?

Mr. Stephen Mulvany:

I will ask my colleague Ms O'Neill to give that detail.

Ms Yvonne O'Neill:

The Deputy has articulated that the assessment process in itself was an underlying cause of the delay which was not acceptable for any of us in the provision of disability services. Back in 2021, we changed to a level of assessment of need which allowed us to see more children more quickly. That assessment process was then challenged. It allowed us between 2020 and 2021 to reduce the waiting list down from 6,500 to less than 2,500. Unfortunately, because of the High Court decision and the move back to the assessment in its fullest extent, that waiting list has gone up again substantially.

Paul McAuliffe (Dublin North West, Fianna Fail)
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What is it at now?

Ms Yvonne O'Neill:

It is back to 6,349. We have been involved in a revised waiting list programme. As other Deputies identified, we have gaps in our service in terms of personnel, notwithstanding the 1,600 additional posts made to disability in the last number of years. We are looking to the private system to see how we can improve the waiting list and waiting times. We are currently in a procurement process because we have to do that under fairly strict procurement-----

Paul McAuliffe (Dublin North West, Fianna Fail)
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I would certainly any attempt to try to reduce it. A school on the north side of Dublin where parents do not have the means to seek a private assessment is likely to have fewer SNAs than a school on the south side of Dublin with the same number of children with the same conditions where parents might be able to pay for it. That is completely unacceptable and it is happening purely because of an assessment process by the HSE.

Ms Yvonne O'Neill:

My departmental colleagues might like to comment because actually that is a policy issue in respect of the requirement in the education sector to have this level of assessment in order to secure an SNA. One of the reasons we were trying to change to a different assessment process was also to accelerate that. In terms of the HSE's provision of services to young people in school, irrespective of diagnosis, we are trying to intervene and provide the right level of service-----

Paul McAuliffe (Dublin North West, Fianna Fail)
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I am of that opinion as well. It is also about accessing treatment and therapies. The support for school provision is one element. We are making reforms on that. There needs to be much more joined-up thinking on special education between the Department of Education and the HSE. The reports about treatment and therapies are even more dire. People are often being told that the allocation for their child for this year has been used up by the assessment process and there are no hours left for them to access treatment and therapies. People are often handed a technical diagnosis on a piece of paper. They really do not have the ability to understand what that actually means for their child. They are not presented with any treatment plan. There is no roadmap and no connection. Parents are told their child has been diagnosed, linked in with the school and told they will get supports in the school. There is absolutely no connectivity for the parents. Parents are handed a diagnosis by a clinical person, and there are no wraparound supports.

Ms Yvonne O'Neill:

I challenge that by saying actually the very core of the current children's disability services is about driving the family support plan, which is exactly what the Deputy has just described, which is translating not only a diagnosis but also the extent of their needs into a plan which is delivered with the partner agencies in schools, by the HSE and with the families.

Paul McAuliffe (Dublin North West, Fianna Fail)
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The difficulty is that we do not have the enough people in posts.

Ms Yvonne O'Neill:

I agree that one of the things that hampers that happening as effectively as it should is the available resources. In the roadmap my colleague referred to earlier, there is also a move to being able to quantify the proportion of time that is spent with intervention rather than assessment, which is very important. Looking at our overall numbers, we are at two thirds of the number of posts filled, just to be positive, and the level of service that is being provided by those staff is phenomenal. We want to have a very clear roadmap for disability services and what people can experience in that service, as a family or a young person, but also for the staff to continue to make working in disability services attractive. We all have a responsibility in that regard.

Paul McAuliffe (Dublin North West, Fianna Fail)
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Do we have a target date for when we will have those posts filled so we can deliver the services Ms O'Neill has talked about?

Ms Yvonne O'Neill:

Mr. McCallion referenced the difficulty in the market. We have secured additional posts, we have the funding for them, and we are running active campaigns, but we are not-----

Paul McAuliffe (Dublin North West, Fianna Fail)
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As Deputy Verona Murphy said, if the HSE does not have a target, it cannot achieve it.

Verona Murphy (Wexford, Independent)
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This problem has grown since last year.

Ms Yvonne O'Neill:

We know the target, we have increased the numbers between last year and this year, and we have additional funding, but-----

Paul McAuliffe (Dublin North West, Fianna Fail)
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The question is when we will have those posts filled.

Ms Yvonne O'Neill:

The Deputy has to understand that we could recruit two posts and somebody could retire or move to another post. We have that level of churn.

Paul McAuliffe (Dublin North West, Fianna Fail)
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Is Ms O'Neill saying the HSE has no target to fill posts?

Ms Yvonne O'Neill:

We have a target to fill all of the posts.

Paul McAuliffe (Dublin North West, Fianna Fail)
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When will we achieve that?

Ms Yvonne O'Neill:

I cannot tell the Deputy when it will be achieved because every time we gain a post, we might lose a post, which is not something we can predict, except to say we have a very focused recruitment plan to fill every post.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I thank Ms O'Neill. The issue raised by the two Deputies is the crunch issue, and other Deputies have raised it before. If the HSE cannot come back on this today, I ask it to come back with a schedule of projected recruitment, for want of a better term. I know it takes three or four years to train people, and everybody here would accept that. One of my party colleagues received the population statistics for all of those posts throughout the country, and Ms O'Neill is correct that roughly a third of them are not filled and in some areas it could be up to a half. That is the crux of the matter. The least we expect is that there is a plan. Taking on board what Ms O'Neill said about retirements and people exiting from the services, we need to see a schedule of training and recruitment of people coming through the colleges, but also a note on what the HSE is doing. We could go around on this forever and get nowhere. It is as clear as mud. I ask that we would have that within the next two weeks.

Catherine Murphy (Kildare North, Social Democrats)
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As I have a short amount of time, I would like contained replies because there are a number of things I would like to ask. When the HSE gets a claim, how does it handle it? Does it handle it itself or does it go to the State Claims Agency? How does it deal with it?

Mr. Stephen Mulvany:

The books of claims are handled for us by the State Claims Agency. There is a process to go from us to them but, fundamentally, that is it.

Catherine Murphy (Kildare North, Social Democrats)
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Does it advise the HSE or does the HSE instruct it? What way does that work?

Mr. Stephen Mulvany:

The State Claims Agency operates under its own legislation and it is given that authority by the Oireachtas and the State, not by the HSE. It manages the cases. We engage with it and it with us, and it is a good positive relationship, but it is effectively managing this.

Catherine Murphy (Kildare North, Social Democrats)
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There will be a file in regard to, for example, this particular issue in regard to nursing homes and disabilities.

Mr. Stephen Mulvany:

No, there are files for every claim that was made under the repayments scheme but the repayments scheme is separate to the types of cases and claims that the State Claims Agency manages. It manages clinical indemnity and other schemes. That is a different thing from somebody who might feel they were entitled to something. The State Claims Agency does not manage those types of cases.

Catherine Murphy (Kildare North, Social Democrats)
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I understand there is a difference in regard to what is lawful. I want to go to the Ombudsman's report, in particular the executive summary. We are here trying to decode language because people hear something and it is then qualified, and we nearly have to describe that. The Ombudsman's report, which was published about 2012, stated that, after a long delay, the HSE responded. In summary, it said it acted in accordance with its statutory obligations but then qualified it by saying “within the resources available”. Therefore, the reading of it is that it acted, but only within the resources available. This is what the Ombudsman said, not me, and the witnesses can read the report. Another response was that it would not be able to pay compensation because the impact of that would affect other patients. Did the HSE act strictly within its statutory obligations or was that qualified? What engagement did it have with the Department and what instructions did it get from the Department in regard to that?

Mr. Stephen Mulvany:

The Deputy has not clarified what topic she is talking about.

Catherine Murphy (Kildare North, Social Democrats)
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I thought Mr. Mulvany would appreciate that because I opened up by talking about the nursing home issue that has been in the news in recent days.

Mr. Stephen Mulvany:

First, it is a legal requirement for the HSE to operate within the resources available to it, so it is not one versus the other, if that makes sense.

Catherine Murphy (Kildare North, Social Democrats)
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It is qualified. If it does not have the resources, it cannot operate strictly according to its statutory obligations.

Mr. Stephen Mulvany:

We have a statutory obligation to operate within the resources available and we will have other statutory obligations, and they have to be balanced.

Catherine Murphy (Kildare North, Social Democrats)
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Would the HSE have engaged with the Department if it could not meet its statutory obligations?

Mr. Stephen Mulvany:

Again, just to understand this, if we are talking about claims from people under the repayments scheme for the unlawful charges levied, as I have said, they were based on the scheme, the scheme was based on the Act, and we operated that scheme within the confines of the Act.

Catherine Murphy (Kildare North, Social Democrats)
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Within the context of the limits of the resources available.

Mr. Stephen Mulvany:

I would have to check.

Catherine Murphy (Kildare North, Social Democrats)
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I am just reading the Ombudsman's report on this. The HSE would have a lot of engagement with the Ombudsman in regard to this because it is said it was after a long delay that the HSE responded. There should be a file in the HSE on this.

Mr. Stephen Mulvany:

Is the Deputy talking about residents of private nursing homes who applied under the scheme or felt they had an entitlement?

Catherine Murphy (Kildare North, Social Democrats)
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I am talking about the report that the Ombudsman did in regard to people who were under the age of 65 and it concluded there was age discrimination. It was in 2012 and it was a report that was done specifically on this. The HSE might give us a note in regard to how it was handled, specifically in regard to the very limited resources available, how the HSE handled cases it was not able to compensate because it would have impacted on other services, and what dialogue it might have had with the Department in that regard. I will leave that issue but I ask the HSE to give us a note on it.

Mr. Stephen Mulvany:

We will certainly look at that report from ten years ago, but the primary determinant of who we paid or did not pay was the scheme, and the scheme was set out by the Oireachtas.

Catherine Murphy (Kildare North, Social Democrats)
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Within the limits of the resources available; I highlight that again. I will move on. Every one of us wants to talk about disability services. I met with community healthcare organisation, CHO, 7, as we all do with our relevant CHO. CHO 7 is one of the largest in the country and it has very good people in disability services who are utterly frustrated. They are telling me that all of their time is going on assessments of need to deal with that issue but they are not getting to do what they are supposed to do. The people who are doing therapies are the same people who are doing the assessments of need. Has the HSE identified the kind of resources that would be required to get to this without interfering with the services that are supposed to be provided? That is not meeting anyone's needs.

Mr. Stephen Mulvany:

I have met with the team in CHO 7, including the voluntary partners there, one or two of the staff on the teams themselves and the parents. They are operating in very difficult circumstances. As Ms O'Neill said, we had sought to streamline the assessment of need process to make it more suitable for what people needed, but that fell in the High Court. There is an element of fact that a constrained resource is being asked to assess need when, obviously, our preference would be more to actually meet need.

Catherine Murphy (Kildare North, Social Democrats)
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What is happening is that there may well be one list going down for assessments of need, but the list for the actual delivery of services is going up.

Mr. Stephen Mulvany:

That is absolutely the risk. Again, the assessment of need is set out in the legislation this House passed, so it is a policy and a legislative matter. We sought a workaround to streamline it but that was held not to be legal, so we now have to do the assessment of need and, yes, it is consuming resources. As my colleague has indicated, we are seeking to keep that away from our staff resource by getting private contractors to do an element of that. We are focused, like the Deputy and those teams, on meeting need as opposed to just assessing it.

Catherine Murphy (Kildare North, Social Democrats)
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There are two other things I want to deal with. I will just mention one of them because I will not get to my second question if I get into a dialogue. On GP services, people contact me every day because they cannot get on a GP list. If they get a lung infection, a chest infection or something like that, they have to go to the accident and emergency department. We now hear that routinely. We do not want hospital accident and emergency departments clogged with people who should have been dealt with by a GP. There is a real issue here. There is a perception this is an issue only in rural areas. There are nearly 250,000 people living in Kildare. The area is growing but the services are not growing with it. I am highlighting this as a real and growing issue that is putting pressure on accident and emergency departments. We need to know the plan to deal with that issue.

Mr. Stephen Mulvany:

We agree. We are growing the number of GPs. We accept there are not enough GPs and other alternatives to give people options other than attending emergency departments. In the interests of time, I will leave it there.

Catherine Murphy (Kildare North, Social Democrats)
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Mr. Mulvany might tell us again what the-----

Mr. Stephen Mulvany:

Elements of it are contained in the briefing we have already provided. If the Deputy wants anything additional, she should give us a shout.

Mr. Damien McCallion:

There will be an increase for each of the next five years. We can give the Deputy the numbers in that regard.

Catherine Murphy (Kildare North, Social Democrats)
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I will go back and look at that specifically. On the national children's hospital, how much of the 2023 capital allocation has been drawn down at this stage?

Mr. Stephen Mulvany:

The provision for this year is €325 million. We expect that to be sufficient.

Catherine Murphy (Kildare North, Social Democrats)
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Additional funding will not be required.

Mr. Stephen Mulvany:

The allocation for the children's hospital in the capital plan this year is €325 million. I expect that to be sufficient for this year.

Catherine Murphy (Kildare North, Social Democrats)
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We were looking at the amount that had been allocated, that is, €1.3 billion for the build and additional funds for the fit-out and children's health aspect. The National Paediatric Hospital Development Board has to go through a number of additional claims totalling somewhere in the region of €500 million or more. There is a very sizeable number of additional claims. Does Mr. Mulvany expect the budget of €1.3 billion to be exceeded?

Mr. Stephen Mulvany:

On the budget for this year, as I have said, the allocation will not be exceeded this year. On the overall question of what the children's hospital will cost in total, as the Deputy will know, there is a lot of uncertainty with regard to those claims. A way must be found to deal with that which minimises the exposure for the State. Other than that, it is a matter between the development board and other colleagues.

Catherine Murphy (Kildare North, Social Democrats)
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I completely understand that we need to minimise the exposure for the State. I know each of the claims is being gone through and that many of them are being disputed. However, when there is €500 million worth of claims, some will succeed. I am not talking about the HSE undermining the role of the National Paediatric Hospital Development Board in dealing with those claims. Mr. Mulvany tells us that the allocation will be sufficient for this year. Does he foresee it being sufficient next year because we ultimately have to get this hospital finished and opened? Does the HSE project that there will be a shortfall next year?

Mr. Stephen Mulvany:

My colleagues from the Department may wish to comment on this but, as CEO of the HSE, I am very clear the hospital will be finished and opened. The financial matters will be dealt with appropriately. We do not want to undermine the position of the development board in dealing with the contractor, but that will not be allowed to delay or impact on the opening of the hospital. Anything else-----

Catherine Murphy (Kildare North, Social Democrats)
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Mr. Mulvany is giving me a lot of waffle. Some of those claims will succeed. Does he anticipate that more money will be required to complete the build and fit-out before this hospital opens?

Mr. Stephen Mulvany:

It is reasonably well known so I do not think I am adding any new information to the public debate when I say that the currently-----

Catherine Murphy (Kildare North, Social Democrats)
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Mr. Mulvany expects that to happen.

Mr. Stephen Mulvany:

-----approved budget will need to be looked at to make sure what Government has committed to doing will happen and that the hospital will open.

Catherine Murphy (Kildare North, Social Democrats)
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It will not be enough.

Mr. Stephen Mulvany:

I believe more funding will be required. The question of whether that comes through those claims or through the overall governance process is ultimately a matter for the development board and the Department.

Brian Stanley (Laois-Offaly, Sinn Fein)
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We have the principal officer from the finance section in the Department here. Perhaps he could give the Deputy a reply on that question as well.

Mr. John O'Grady:

The Department has previously acknowledged that the national children's hospital will take longer and, as a consequence of this extension of time, the project will ultimately cost more than was originally allocated. Some €1.433 billion was approved by Government in 2018. That budget has not been depleted to date. Some €1.275 billion of it has been drawn down. We cannot give any update on the quantum of uplift that budget may require. We will engage with Government in due course when that figure is clearer. As the Deputy herself referenced, there is a claims settlement process under way. We need to protect the State's interest here and cannot put any information about that process in the public domain.

Catherine Murphy (Kildare North, Social Democrats)
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May I make one comment about the Department? What we have seen from the witnesses today is happening all of the time. This committee needs to have a discussion about what we expect from witnesses with regard to detail. What I have just heard may be a reply but it is not an answer. There is a difference between the two. We need to have a discussion about this.

Mr. Stephen Mulvany:

In fairness to ourselves and the Department, with respect, that is not a reasonable position. I have been very clear. Nothing we can control is going to be allowed to delay the completion and opening of the children's hospital. The issue of how much it will ultimately cost the State is an important and related matter. If we engage in too much discussion about it in a public forum, it will simply cost the State more. The hospital will be opened as quickly and safely as possible. I do not believe the financial issue is an impediment to that. The Government is, quite rightly, dealing with that separately. That is where the protection of the State's interest comes in. It is inappropriate to discuss it in this forum.

Brian Stanley (Laois-Offaly, Sinn Fein)
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It is safe to conclude from the replies that more cash will be required. If the witnesses have further information on that, they might provide it to the committee. We will break for ten minutes. We will restart at 11.15 a.m. sharp.

Imelda Munster (Louth, Sinn Fein)
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The HSE recently announced that it will carry out a review of open cases in CAMHS but it will particularly focus on the cases that have not been monitored in the past six months or more. In March last year, I asked the HSE to carry out a full audit of CAMHS. That audit never happened. Do the witnesses regret that now? Do they have a timeline for the audit to be completed? If so, what is the timeline?

Ms Yvonne O'Neill:

Last March, we were already involved in a number of audits. I cannot comment on the request the Deputy made for an audit. We were already in our improvement programme looking at the functioning of teams.

As regards the current situation, 20,000 open cases means that our estimate is the cases that may not have been reviewed in more than six months is probably 3,000 to 4,000 cases nationally. We will prioritise that. We want to be able to complete the review in a three-month timeline, approximately.

Imelda Munster (Louth, Sinn Fein)
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The HSE has set that out as three months.

Ms Yvonne O'Neill:

Yes.

Imelda Munster (Louth, Sinn Fein)
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There are 3,000 to 4,000 cases. Is it nearer to 4,000 cases?

Ms Yvonne O'Neill:

No. We put it in the range of 3,000 to 4,000 cases because there will be a lot of variation across the country. It is from 3,000 to a maximum of 4,000 cases. There are two elements to the audit. When we review based on the recommendations from the report, we will also review their prescribing associated with particular drug regimens at the same time as the six-month criterion. In that period, it would probably draw 3,000 to 4,000 cases for review.

Imelda Munster (Louth, Sinn Fein)
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Okay. Is Ms O’Neill confident that if the HSE had carried out a full review of cases that were closed up to the past 12, 24 or 36 months, as members of the committee requested but the HSE did not commit to undertaking, it would not have identified any additional cases with issues?

Ms Yvonne O'Neill:

One of the things from which we were getting assurance in the context of the report and the review that was done by the commission was the number of cases they brought to our attention relative to the total number of cases. That was giving us some assurance that the more widespread practice is that cases are reviewed across the teams.

That review process will always give us learning but the reassurance is that the overall case numbers were small - not that any number is never not serious - on foot of the Mental Health Commission's interim report.

Imelda Munster (Louth, Sinn Fein)
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The HSE does not know that for sure, however. It took the MHC to publish that report for this review to happen, and what a damning report it was. How long has the HSE been without a national clinical director for mental health?

Ms Yvonne O'Neill:

There is a national clinical lead for mental health who has been in post for a long number of years now. There was agreement, prior to the commission's report, that we would look for a clinical lead specific to child and youth mental health. That is part of the improvement programme we have been involved in pre the commission's report.

Imelda Munster (Louth, Sinn Fein)
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The HSE has never had one in relation to-----

Ms Yvonne O'Neill:

No. We never had a clinical lead specific to youth mental health. However, at regional level we have clinicians who are clinical directors in CAMHS services so we have that specialism. Apropos of the point around the review, clinical review is a routine part of how teams work. It is not that we need a national call for a review to assure. In clinical practice, and my colleague, Dr. Henry, might want to speak to this, it is a routine part of how the teams function.

Imelda Munster (Louth, Sinn Fein)
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Why does the HSE suddenly believe it needs one?

Ms Yvonne O'Neill:

I have not said that we needed one. We are responding to-----

Imelda Munster (Louth, Sinn Fein)
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No, but the HSE is looking for one. Is it recruiting?

Ms Yvonne O'Neill:

Sorry, I was speaking about the review. We have said for some time that we would like a clinical lead specific to child and youth mental health because of the types of issues that crosscut around transition from child to adult services, preventative-----

Imelda Munster (Louth, Sinn Fein)
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Was the delay in appointment a recruitment issue?

Ms Yvonne O'Neill:

We secured the funding this year. We have already advertised the post.

Imelda Munster (Louth, Sinn Fein)
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When was the funding requested?

Ms Yvonne O'Neill:

It was part of the 2022 funding request.

Imelda Munster (Louth, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Does the HSE accept the utter dysfunctionality within the CAMHS service? It is, at best, utter dysfunctionality and, at worst, putting children's lives at risk. We could all cite cases. I could cite a harrowing case that only happened last week where it took a father almost a fortnight to secure his child a place in a psychiatric unit. It meant that father had to sit in a hospital for three days and three nights with his daughter begging and pleading, and that he had to go public on Michael Reade's show on LMFM, which covered it on consecutive days. That is happening today, and it will happen tomorrow and the day after.

I have listened to the debate from the start. It displays a lack of credibility from the HSE officials as the people tasked with providing our public health service, when they cannot acknowledge there are problems. It is a case of, "We don't have an answer for this Deputy. We don't have those figures for that. We don't have this for that. We don't have that", and they divert and so on. Can the officials not acknowledge, because it would lend them some credibility at this stage, that the CAMHS service, as it currently stands, is not meeting its service requirements and is at best dysfunctional.

Ms Yvonne O'Neill:

It was fully acknowledged that it is not meeting its requirements.

Mr. Stephen Mulvany:

As CEO, I will comment on that. Describing the entire child and adolescent mental health service as "utterly dysfunctional" is inappropriate.

Imelda Munster (Louth, Sinn Fein)
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We know there are good staff providing services but, for the majority of cases that we come across as public representatives, to say the service is dysfunctional is giving the HSE some ends of credit. It is a disgrace. That is what it is.

Mr. Stephen Mulvany:

I have no doubt the Deputy has come across, as we have, some very difficult cases where the service has let down families. For those families, that service would absolutely, in their view, be dysfunctional. That is accepted.

Imelda Munster (Louth, Sinn Fein)
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It comes back to the fact that we asked the HSE to carry out a full audit last year that it stated it did not need. On foot of the MHC report, all of a sudden we are getting it now. If the HSE were to admit its failings and, in some cases, dismal failings, as I said, it might have a little more credibility. I will just move on because-----

Mr. Stephen Mulvany:

No, Deputy. Sorry, Chair. You have to allow me to answer that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Just briefly.

Mr. Stephen Mulvany:

We accept our failings. We apologise for them and we say that very publicly.

Imelda Munster (Louth, Sinn Fein)
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Apologies are no use to children that the HSE has failed and are no longer with us-----

Mr. Stephen Mulvany:

In years long gone by-----

Imelda Munster (Louth, Sinn Fein)
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-----because of failures.

Mr. Stephen Mulvany:

-----we were often castigated for not apologising. Apology is important. Acknowledging where we have failed is important. The MHC report is very clear. Many children and families are getting an excellent service and the staff, despite the shortages in staff, are also being innovative in how they provide that service. Yes, we have failed some families individually.

A review is ongoing of the CAMHS operational guidance, which is a national review. A review is nearly completed, if not completed, on prescribing practice and there is one other externally researched review. All these things are under way to determine what more we can learn from the service.

Mr. Damien McCallion:

I will add that actions have been taken to improve the service, such as those national appointments, trying to increase the resources in the CAMHS teams and trying to look at how those teams interact with the other services in transitioning to adult, disability and primary care. We are taking a range of actions to improve it. It is not just about-----

Imelda Munster (Louth, Sinn Fein)
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We are not seeing them in the here and now and-----

Mr. Damien McCallion:

They are being felt as we get more resources into teams, as we said.

Imelda Munster (Louth, Sinn Fein)
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How long has this been going on?

Mr. Damien McCallion:

We are accepting-----

Imelda Munster (Louth, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Parents have buried their children because the HSE has failed them.

Mr. Damien McCallion:

If I can, Deputy-----

Imelda Munster (Louth, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

That is the reality. I will move on because, to be honest, the HSE officials are all sitting there saying we can see the effects of its plans, but everything is in the future. It is, "We are working on it. We are currently working on"-----

Mr. Damien McCallion:

There are 20,000 children-----

Imelda Munster (Louth, Sinn Fein)
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-----but nothing ever transpires in delivery for people.

Mr. Damien McCallion:

I need to just briefly say-----

Imelda Munster (Louth, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I want to touch back-----

Mr. Damien McCallion:

There are 20,000-----

Imelda Munster (Louth, Sinn Fein)
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Sorry, no. I have listened. If Mr. McCallion is telling me that it is in the here and now that the HSE has learned lessons-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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The Deputy's time is nearly up.

Imelda Munster (Louth, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

The issue of nursing home charges has been going on since 2019 when I first raised it with the HSE. Eventually, after much toing and froing, the executive stated it had sent a communication to nursing homes advising them that people in receipt of medical cards were entitled to the items they would ordinarily be entitled to if they were living in the community. Charges had been applied by nursing homes to people with medical cards for items such as wound management, ointments and painkillers, while there was a lack of physiotherapy, occupational therapy and speech and language therapy, which were not being applied. The HSE cc'd the committee and eventually told us that it sent a communication to nursing homes, but such charging is still happening.

I received a response to a freedom of information, FOI, request from, I think, the national director for the primary care reimbursement service. It stated, and this is in the officials' documents, that it would appear to be fairly clear that the primary place where an intervention could be put in to ensure that nursing home clients are not charged for items that would be covered under the medical card scheme would be via inserting a clause in the document between the HSE, the residential care facility, RCF, and nursing homes that actually states the requirement not to charge. Will the officials confirm whether the HSE has acted on that?

Mr. Stephen Mulvany:

We may not have the detail with us today.

Ms Yvonne O'Neill:

I am sorry. I do not know the answer to that.

Imelda Munster (Louth, Sinn Fein)
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It was flagged continuously by this committee that there was an issue with people being ripped off, not unlike the big scandal we are dealing with at present. We have had constant correspondence over and back. It was suggested by the assistant national director of the reimbursement scheme that that clause be put in and the officials cannot tell me about it. There was no follow-up. It was a-----

Mr. Stephen Mulvany:

We cannot tell the Deputy today but we will reply-----

Imelda Munster (Louth, Sinn Fein)
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Can you actually-----

Brian Stanley (Laois-Offaly, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Can we have an answer by next week?

Mr. Stephen Mulvany:

We will have it in the normal timeline for requests from the committee. It was not flagged for today, in fairness. We will reply in the appropriate timeframe.

Neasa Hourigan (Dublin Central, Green Party)
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I want to get to two areas so I will cut myself off five minutes in and move to a different area.

I will ask about the children's hospital. I took note of what was said in previous contributions. Will the witnesses confirm when the substantial completion will be finished? I do not need a precise date but a month.

Mr. Stephen Mulvany:

I was thinking of what month. It will be next year. It is January-----

Neasa Hourigan (Dublin Central, Green Party)
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Is it June 2024 or around then? The departmental officials might know.

Mr. John O'Grady:

If we can find out, we will verify it.

Neasa Hourigan (Dublin Central, Green Party)
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I am looking for the date for substantial completion and not when all the commissioning will have taken place. That is the first thing. I am trying to get a timeline in place for substantial completion. I have a tendency to refer to everything as commissioning but I would like to understand the commissioning period in respect of physical equipping, including the equipping of theatres.

Mr. Stephen Mulvany:

Six months is the normal timeline.

Neasa Hourigan (Dublin Central, Green Party)
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I know. For argument's sake, let us say that the date for substantial completion is June 2024. Would all equipping be completed six months after that?

Mr. Stephen Mulvany:

Six months after substantial completion. Then there is the question of when the national children's hospital should be opened. Should it be opened-----

Neasa Hourigan (Dublin Central, Green Party)
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No, that is not my question. Last week, the health committee heard about the digital strategy for the national children's hospital - I have received this information a number of times through parliamentary questions - and how the hospital would be incredible and high-tech. However, I noticed in the capital funding figures that we are meant to be discussing at this meeting, that it is not necessarily clear what spending has been assigned to that. It is my understanding that that kind of spending will not go to the National Paediatric Hospital Development Board, NPHDB. Rather, that particular part of commissioning, which is more digital, will go to Children's Health Ireland, CHI. Is that correct?

Mr. Stephen Mulvany:

I believe that is correct.

Neasa Hourigan (Dublin Central, Green Party)
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CHI drew down €135,000 in 2021 and €489,000 in 2020 for digital or ICT purposes, but I presume that funding related to the satellite hospitals. To Mr. Mulvany's knowledge, has it drawn down any funding for digital planning or commissioning within the national children's hospital?

Mr. Stephen Mulvany:

My view is that it will have done so. I do not have the figure, but we can get it for the Deputy. As she alluded, the figures she mentioned were quite small, so they would not be anything like the-----

Neasa Hourigan (Dublin Central, Green Party)
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A sum of €4.3 million was flying around, but none of that has been drawn down so far.

Mr. Stephen Mulvany:

I will check that for the Deputy. I do not have those data.

Neasa Hourigan (Dublin Central, Green Party)
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I am watching the clock ticking down. I am asking these questions because we on the health committee heard last week that, despite Deputies like me asking parliamentary questions about when we were going to get digital health records, given that they are such an important part of Sláintecare's roll-out, there would only be digital records in the national children's hospital, this hospital or that hospital. That is meaningless unless digital health records are applied nationally. The idea is that a person can take his or her digital health record anywhere. What emerged from last week's meeting was that, in the business case, we had linked the national children's hospital to the roll-out of digital health records. Until they are up and running in the national children's hospital, the Department of Public Expenditure, National Development Plan Delivery and Reform will not accept the business case.

I want to understand the roll-out of ICT and digital records at the children's hospital. The HSE's position last week was that digital records would be up and running and it could immediately see whether they worked. In real life, though, commissioning does not work like that. Something must be in place for six, 12 or 18 months before we can know whether something has worked. As such, if we have a date of mid-2024 for the children's hospital to be substantially completed and a further six months for commissioning, which would take us into 2025 at the earliest, we would only then see the ICT systems up and working and start looking at a business case and procurement for digital health records across the health service as a whole. I know it is in some hospitals and has been rolled out in respect of maternity services, but by my reckoning, and if all the winds are in our favour, we will only be at the business case and procurement stage at the end of 2025 or start of 2026. That puts us about a decade and a half behind the rest of the EU.

This is not a question for the HSE, which is running the children's hospital. This is more a question for the Department of Health. Has it had any interaction with the Department of Public Expenditure, National Development Plan Delivery and Reform on linking the roll-out of digital health records to the children's hospital? Even in 2018 when the latter Department first refused to move ahead, we knew that the children's hospital project would go way over time.

Mr. Stephen Mulvany:

Mr. O'Grady might wish to comment, but from our perspective, the Deputy is right about the procurement business case timeline. To some extent, the timeline she set out would probably be aggressive.

Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source

I believe so, but I am trying to be helpful.

Mr. Stephen Mulvany:

In fairness to colleagues in other Departments, the concern was the level of risk in a national electronic health record, EHR, project. By breaking it up, we reduce the risk of the project somewhat. That does not help the rest of the country to access EHRs, though. The Deputy can take it that we have ongoing engagements with the Departments of Health and Public Expenditure, National Development Plan Delivery and Reform regarding how to shrink the timelines and reduce as much as possible the dependency, if any, on the time the children's hospital has to have its system in place before we can move on to the other stages.

Neasa Hourigan (Dublin Central, Green Party)
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I have gone over my five minutes on this issue. We have not dreamed up this technology. It is operating in other countries. We could examine their findings. I understand that we have a health system that has more complexity in the form of sections 38 and 39 organisations, but if we will only be at the stage of examining the business case in 2025 because the Department of Public Expenditure and Reform continued to link it to the children's hospital, we should decouple it from the children's hospital.

Mr. Stephen Mulvany:

In fairness, colleagues from that Department are not present to reply. To be clear, and as the Deputy knows, the technology is never the problem. Rather, the change in management, clinical and operational processes is the problem.

Neasa Hourigan (Dublin Central, Green Party)
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I would have expected the Department of Health to tell the Department of Public Expenditure and Reform that its 2018 refusal was ridiculous and that the Department of Health would not accept it. As I understand the matter, the Department of Health has not even started to update the business case. It has accepted the link.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Could we get clarification on that issue from Mr. O'Grady?

Mr. John O'Grady:

I am not familiar with the detailed engagement between the Departments. There are colleagues on the capital side who deal with the ICT programme.

Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source

Could I get a briefing note on the matter-----

Mr. John O'Grady:

Absolutely.

Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source

-----in the context of the children's hospital's timeline? We will leave it at the briefing note, as I wish to discuss another matter.

I thank the witnesses for the briefing notes on disability services. I was glad to see a recognition of the UN Convention on the Rights of Persons with Disabilities, UNCRPD, but as noted here, there is a discussion around regionality under the Transforming Lives policy. We have spoken at length about east Cork and north Cork and I do not necessarily wish to revisit the same questions, but I want to understand what the HSE's operating procedures are locally within CHOs for auditing matters such as regionality. Where capital funding is not meeting the recognition of the UNCRPD, what happens? For example, the HSE has closed down the Owenacurra Centre and there are 42 placements in north Cork and none in east Cork. This repudiates regionality in terms of the provision of long-stay beds. When that happens and someone flags it, what transpires next?

Mr. Damien McCallion:

Is the Deputy referring to the capital and the estate as regards mental health?

Neasa Hourigan (Dublin Central, Green Party)
Link to this: Individually | In context | Oireachtas source

This is all about capital funding.

Mr. Damien McCallion:

And mental health investment. Some of our mental health facilities are not at the level we want them to be. The Deputy has cited an example, but there are many around the country. We identified many of them ourselves and the MHC highlighted some of them to us. There is a capital investment plan for mental health. We are trying to grow that. We have set up a group and brought in resources to look at getting a national plan. There is guidance on what facilities should exist in each area under A Vision for Change in terms of what mental health services each population should have.

Neasa Hourigan (Dublin Central, Green Party)
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When that guidance is not adhered to by senior management, what does the HSE do?

Mr. Damien McCallion:

We are happy to look into individual issues, but each area's chief officer will, with the heads of mental health services and the executive clinical directors for mental health, have a plan for capital development that is driven by service need. They will make judgments, given that what is needed in north County Dublin may be different than the model used in County Donegal. However, the population-based numbers are still consistent in driving that.

Neasa Hourigan (Dublin Central, Green Party)
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Where population numbers do not align with the service decisions being made in terms of capital funds, what happens?

Mr. Damien McCallion:

In general, the chief officers and heads of mental health services will map and align those decisions with national policy. If the Deputy is flagging variations, we would be happy to look into them. Each area has to consider the nuances of its geography in where and how it provides services.

Neasa Hourigan (Dublin Central, Green Party)
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It is difficult for someone like me to follow that. In all of the conversations we have had about Owenacurra over the past year, I still do not know where the people who were moved out of the centre have landed. Even that level of basic detail is not available to people who are trying to scrutinise such decisions.

Mr. Damien McCallion:

I was not sure whether the Deputy was asking a broader question or one specific to Owenacurra. We have that detail. It would probably not be appropriate to give it to the committee now, but we would be happy to provide a briefing. I believe a briefing has been given locally by the chief officer and the executive clinical director of mental health-----

Neasa Hourigan (Dublin Central, Green Party)
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It has, but the information we require has not been.

Mr. Damien McCallion:

-----in general terms without identifying individual patients. It identified groups of patients and where it was appropriate for them to go.

Neasa Hourigan (Dublin Central, Green Party)
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To be clear, I do not wish to discuss individual patients. Rather, I wish to scrutinise issues like moving people to temporary accommodation in Garnish House, which is outside east Cork, instead of allowing them to stay in their own region.

I have many more questions and would like a second round, if possible.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I will allow the Deputy in a second time.

The first issue I wish to raise relates to out-of-hours GP services. Last year, we dealt with the issue of SouthDoc services being closed in a couple of locations without much warning to the public. The provision and cost of those services were raised. On 23 December, people in Laois-Offaly and Longford-Westmeath in the midlands, which is the area I am in, noticed that a company limited by guarantee would be pulling the plug on its services within a week. I heard about this on Christmas Eve. A few facts have been discovered since.

I acknowledge the efforts of local HSE management to try to put an interim solution in place. It was dealing with a very difficult situation.

There are 17 providers and six different models throughout the State. The cost for 2021, insofar as I can extrapolate it from the documents the witnesses supplied for today, is €55 million. There is a service support cost of €26 million. In 2022, an extra €10 million was provided for out-of-hours GP services under the winter plan. Therefore, according to Mr. Mulvany's figures, it would be safe enough to assume that the cost of the service is between €90 million and €100 million per year. The situation is that there was reliance on a private company. It engaged with the HSE for a number of months before closure. As I understand it, the engagements might not have been what they needed to be, and then the plug was pulled. The problem is that we are left with a collapse in essential services at the same time that emergency departments and hospitals are overloaded. A member of my family needed to see a doctor but finished up in an accident and emergency unit and in hospital for six days. They would not have needed to be in hospital for six days had their condition been caught in time over the Christmas period. This is the kind of difficulty being caused. Some GPs in the region may not have been paid for the services they provided at different times through the model we have.

I ask Mr. Mulvany to keep his answers short. I do not want to be rude to him but I want to try to get to the bottom of this. There are six different models. The system basically grew in an ad hocway. I raised this with the Taoiseach, who is a GP, and he acknowledged it. The cost is in the region of €90 million to €100 million per year.

Mr. Stephen Mulvany:

The figures are probably accurate but, as the Chairman said, the system grew up in the way it did over more than 20 years, including in the days of the health boards. To be clear, and as the Chairman probably knows, the responsibility in the first instance for providing the out-of-hours GP service is a contractual responsibility of individual general practitioners. The HSE provides a huge amount of support to the service because, as the Chairman said, it is essential. His comments on colleagues in CHO 8 are appreciated because they have put in considerable work.

To be clear, on the five cells in the area, four of which were covered by the company the Chairman referred to, the HSE provides and fully staffs the call-taking service in Ardee. It provides and staffs fully the triage nurse service based in the Scott Building in Tullamore. We provide another 50 staff, including ancillary support staff and drivers. The GPs provide, or did provide, the input to that service. At short notice, after the company limited by guarantee, not the HSE, got into difficulty with the company it had engaged to provide operations-management services and then decided it was itself going to wind up operations at short notice-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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Can Mr. Mulvany see how convoluted it is?

Mr. Stephen Mulvany:

I absolutely agree with the Chairman, but the HSE is delivering approximately 80% of the service. In fairness, the chief officer in the area should be commended - the Chairman has commended that individual - for making sure there was no loss in continuity of service.

Brian Stanley (Laois-Offaly, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I acknowledge that but we are dealing with a convoluted system.

Mr. Stephen Mulvany:

Agreed.

Brian Stanley (Laois-Offaly, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Mr. Mulvany has outlined already that there are two companies.

Mr. Stephen Mulvany:

And there is a review. In fairness, the Department is-----

Brian Stanley (Laois-Offaly, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Then there are the GPs, each of whom is a sole trader.

Mr. Stephen Mulvany:

They are.

Brian Stanley (Laois-Offaly, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

Could Mr. Mulvany clarify, with a "Yes" or a "No", that the figure I am quoting for the service, that is, €90 million to €100 million per year, is correct? It is €7.8 million for the midlands services. Direct payments are involved. Could I have a "Yes" or a "No"?

Mr. Damien McCallion:

I will have to confirm that for the Chairman. It is in that range in terms of the out-of-hours parts of it.

Brian Stanley (Laois-Offaly, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

That is what I extrapolated.

Mr. Damien McCallion:

An important point to make on why the system has grown organically is that the services went in partly to support GPs. It goes back to a question Deputy Catherine Murphy asked earlier. Owing to the challenges in retaining GPs, the old rotas, under which a GP was on call for 24 hours a day for seven days, were not sustainable.

Brian Stanley (Laois-Offaly, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I know that.

Mr. Damien McCallion:

As Mr. Mulvany said, the review that has been kicked off will help with that. However, the services are functioning. I know they differ in different parts of the country. We got increased capacity from GPs over Christmas. Unfortunately, the incident the Chairman cited-----

Brian Stanley (Laois-Offaly, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

There are six different models.

Mr. Damien McCallion:

There are different solutions in terms of the commercial element but the principles are still the same. There is a call centre that takes the call. It is triaged and the GP is assigned then. The principles of the model are the same but there are different commercial and other models behind it.

Brian Stanley (Laois-Offaly, Sinn Fein)
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And the HSE is providing substantial support with costs, along with buildings.

Mr. Damien McCallion:

To support the services.

Brian Stanley (Laois-Offaly, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

In the case of County Laois, there is a new building.

On the basis of any glance at this system, and having tried to look at it as a layperson, I cannot see how you could run it, manage it or hand it to anybody and expect him or her to keep on top of it, because it has so many potential flaws and weaknesses. There are so many opportunities. There are so many links to the chain that if anybody pulls the plug along the way, the system collapses. That is evident to me because I have looked at this in depth over the past five weeks. I was trying to get to the bottom of it over the Christmas period.

Mr. Stephen Mulvany:

The services in question did not collapse.

Brian Stanley (Laois-Offaly, Sinn Fein)
Link to this: Individually | In context | Oireachtas source

I thank Mr. Mulvany for that. I acknowledge that an interim solution was put in place. That is a temporary measure, however; there is no permanent solution. After the meeting, I can show the witnesses the last piece of information I received. It is not tied up yet. It was not as of a few days ago, despite the best efforts of HSE management. The simple fact is that the GPs and whoever the private providers are have the HSE over a barrel. Is that not the simple truth of it?

Mr. Stephen Mulvany:

I do not think we would characterise it like that. In fairness to our GP colleagues, they put a lot of effort in. Hundreds of thousands of contacts happen every-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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I acknowledge that individual GPs are doing fantastic work. However, what I am saying to Mr. Mulvany is that when depending on agencies and private companies to do the administration and all that type of thing, they can pull the plug if they do not get the cash, or sufficient cash. Is that not correct?

Mr. Stephen Mulvany:

I do not think so. Typically, we deal with a group of GPs, either as part of a company or a co-operative. In some cases, as in this case, that group of GPs will have subcontracted part of the work to another company. Usually, there are only two parties, namely, the HSE and the GP group, and in some cases there are three, at most.

Brian Stanley (Laois-Offaly, Sinn Fein)
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And that company has now ceased trading. That is the problem.

Mr. Stephen Mulvany:

That is correct.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I acknowledge that individual GPs are doing it. Different GPs in different parts of the State report problems with payment. I am not going to get into specific cases.

There was a review of out-of-hours GP services in 2010 and a further review in 2016. I have the recommendations from the 2010 review to hand. I do not have those from 2016 because I understand the 2016 report was never published. However, we do have the recommendations from the 2010 report. That report sets out a number of actions concerning GPs' income related to non-GMS patients, service level agreements in relation to the provision of nurses, telephone triage, drivers, drugs to be used, etc. Why has this not been acted upon? It is now 2023; 13 years have passed. This is partly why the public is frustrated. The HSE and Department felt it was important to have a review in 2010 because the system was growing on an ad hocbasis. We all accept that. It is not about beating people up over it; it is a matter of fixing it. A review was carried out in 2010. I want a straight answer. There is substantial funding going into the system and the Committee of Public Accounts is looking at the figures. Money is going in but we have difficulties with the service. It is still operating on an ad hocbasis. My reading of it is that it is going to get worse before it gets better, because of demographics, ageing GPs and other reasons. Many GPs now coming out of college may not want to work all night or to be tied to GMS contracts. Why has this not been acted upon? I want a straight answer.

Mr. Stephen Mulvany:

Again, I do not have the specifics on the ten-year-old report but, if you look at what has happened over-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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Are you aware of the report.

Mr. Stephen Mulvany:

Yes, I am. Could I just answer the Chairman's question? He just referred to transport, drivers, nursing and triage. Effectively over the past ten years or so, the HSE, in order to provide co-ordination support, has taken on more and more parts of the services. That is effectively the implementation of the recommendations the Chairman is talking about.

On the matter of going forward, we also recognise that GPs are under pressure. That is why the Department is conducting a review to see what comes next. It will be finished in the first half of this year. As has been said, the HSE is significantly supporting each of the services to give as much assistance to GP colleagues as possible, remembering that, under current policy, the ultimate contractual responsibility to provide an out-of-hours service rests with the individual GPs.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Could the HSE and the Department representatives revert to us, maybe by next week, and tell us why the recommendations from the 2010 review were not implemented?

Mr. Stephen Mulvany:

The Chairman is saying they were not implemented. I do not have evidence stating that is the case. I have just told the Chairman that-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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My introduction-----

Mr. Stephen Mulvany:

-----in his area we are providing directly all the services he mentioned. I would say that when the review was done, we were not.

Brian Stanley (Laois-Offaly, Sinn Fein)
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My information is that, in the main, this has not been implemented.

Mr. Stephen Mulvany:

Let us check the position rather than assuming that it has not been.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Then Mr. Mulvany should come back to me with a progress report on it. Can he tell me why the 2016 report was put on a shelf, into a box or into a drawer at the back of a filing cabinet? It has not seen the light of day.

Mr. Damien McCallion:

We can come back to the Chairman on that. In terms of those recommendations, many of the things the Chairman have mentioned have actioned. What is really important here is the reason-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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The 2016 report.

Mr. Damien McCallion:

I do not know the 2016 one. I will have to come back to the Chairman on that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I want to know - it is a straight question - why was that report not published-----

Mr. Damien McCallion:

I will have to revert to the Chairman on that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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-----and who made the decision not to publish it.

Mr. Damien McCallion:

I do not have that information here. We will have to come back to the Chairman on that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Could I ask Mr. O'Grady to come back to me next week with an answer in respect of this matter?

Mr. John O'Grady:

Yes.

Mr. Damien McCallion:

One of the reasons the HSE is investing more in that is to try to protect GP time in light of the shortage of GPs. I refer to the drivers, triage and all of those aspects. I fully accept the Chairman's point in terms of the different models of operation, but the core principles are the same. The State has invested to try to protect GP time in order that we minimise the impact.

The Chairman's second question links back to Deputy Catherine Murphy's earlier question. We need to increase the number of GPs for the reasons the Chairman set out in terms of trying to ensure that there will be an adequate number of GPs to cover daytime and out-of-hours services. There is an increase - up to 350 GPs - planned across the next five years. We know we need to increase the number of GPs. That will be done through working with the Department and the Irish College of General Practitioners, ICGP. We will revert on the 2010 and 2016 recommendations, but I want to say that the Chairman listed out many things.

Brian Stanley (Laois-Offaly, Sinn Fein)
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GPs are under huge pressure. You would be reluctant to go near them in winter unless you really need to because you already know that they have a substantial workload. I acknowledge that. Of course, the number needs to be increased because the ratio of GPs per head of population is only a little over half of what we need.

Mr. Damien McCallion:

We will revert on that. Through the winter, the GP out-of-hours service did a lot of additional sessions in the evenings, put extra GPs on and that supported this. We reckon over half of GPs, approximately 1,500, participated in running extra evening and Saturday sessions to try to avert the pressures on emergency departments. They really did stand up for us.

Brian Stanley (Laois-Offaly, Sinn Fein)
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The general point I am making is that the HSE has recommendations-----

Mr. Damien McCallion:

We will revert on that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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-----on a report in 2010. As for the 2016 report, I do not know and nobody else has seen it.

Mr. Damien McCallion:

We will revert on that.

Brian Stanley (Laois-Offaly, Sinn Fein)
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The report did not see the light of day. It was never published. I ask Mr. Mulvany to come back and tell me. I ask the Secretary General of the Department of Health why that report was not published, what progress is being made and can we move to a single model of providing care.

Can Mr. Mulvany come back with an answer to a further question on this matter. I have nothing against the model of GPs being stand-alone private entities if that is what people want. Has the HSE considered employing a cohort of salaried GPs at any point? If not, why is that the case? I ask the same question of the Department. I would appreciate it if they could include that in the answer as well for next week.

Mr. Stephen Mulvany:

Obviously, our aim is to continue to support GPs because, as we said, they are in trouble.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Is there any aim to employ salaried GPs?

Mr. Stephen Mulvany:

We do employ them in some instances. Local pharmacists employ GPs The policy - this is a policy matter - is set out in legislation. GPs are independent contractors. That is the model-----

Brian Stanley (Laois-Offaly, Sinn Fein)
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Absolutely.

Mr. Stephen Mulvany:

-----that many countries we would aspire to reaching the same standard as, such as Scotland, still adopt. There is no evidence to say that changing this would be a good thing.

Brian Stanley (Laois-Offaly, Sinn Fein)
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The countries in question also have salaried GPs. Can I ask Mr. Mulvany a straight question? Would he bow to the opinion that if the HSE had salaried GPs, it would give it more leverage? If there was a cohort of them, it would improve the HSE's leverage.

Mr. Stephen Mulvany:

I do not believe so.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Mr. Mulvany does not think so. I will disagree with him on that one.

I will now bring members back in for a second round of questions. I call Deputy Carthy.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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I want to go back to the issue I raised earlier. I will be clear in terms of the questions I am seeking to have answered. Section 38 and 39 residential homes are voluntary community disability services. In many cases, we are talking about some of the most vulnerable people in our society in the context of those homes. The HSE advised patients in those settings that they would not be eligible for the nursing home refund scheme. A number applied anyway. The first question I want clarification on over the next number of days relates to how many people in that category applied. They were denied initially. Most applicants did not appeal on the basis of advice that was provided to them by the HSE to the effect that they stood no chance of success. As I understand it, appeals were made on behalf of 515 residents. I would appreciate it if we could get clarification on that. They people in question were residing in St. Michael's House, Cheeverstown House and with the Daughters of Charity. On looking at a sample of the cases in question, the appeals officer deemed that the people involved were eligible. The Government, along with the HSE and the Department, bizarrely decided to initiate legal challenges in order to appeal the decision of its own appeals officer. The appeal was withdrawn appeal when the Department was informed by its legal adviser that it was 100% guaranteed that a court would deem that there was no legal basis for the residents involved to have been charged. As we understand it from the financial statements, the HSE then proceeded to make payments. Were all 515 appellants awarded payments? What was the total sum involved?

We know from the 2011 memorandum that the estimated cost of paying those 515 was €20 million. That figure stacks up if we look at the financial provisions that were made in the HSE accounts. From the same memorandum, we know that there were thousands of residents in those section 38 and 39 voluntary disability services who either did not apply or who applied but subsequently did not appeal. The memorandum suggests that if they were to be compensated, the cost could be up to €360 million. If we look at the 515 appeals that cost €20 million, the amount per case works out at between €38,000 and €39,000. If we were to extrapolate that in respect of the €360 million to which I refer, we can see that, potentially, more than 9,000 people were affected. I want clarity in respect of the actual number of people who would have been affected. We know, again from the 2011 memorandum, that Ministers approved a strategy of purposely refusing to provide information to the people who were eligible for payment.

Can Mr. Mulvany ascertain the total number of people affected? In other words, how many people were entitled to payment but were denied? Can he indicate whether any effort was made by the HSE in the intervening period to contact those people, their guardians or their descendants to inform them about what had happened? If not, what will now be done?

I want to ask a question in relation-----

Mr. Stephen Mulvany:

May I respond?

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Go on then.

Mr. Stephen Mulvany:

The questions are clear, and we will work on answers to them. I have to say, for the record, there are certain characterisations that the Deputy used - certain assertions of things as facts - which we would not accept.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Which one would Mr. Mulvany not accept?

Mr. Stephen Mulvany:

I would have to go through the whole transcript, but the use of words like "bizarre" and assuming that people acted in a certain way for certain reasons. We could not accept those necessarily as facts until we establish the facts.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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I literally only just said it approximately a minute and a half ago. What did I say that Mr. Mulvany disputes?

Mr. Stephen Mulvany:

We will take away the Deputy's questions - they will be in the transcript - and seek to answer them faithfully. I have made the point, Chair, for the record.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Mr. Mulvany made the point that he is disputing some of what I said. I am asking him what he disputes. Does he dispute the use of the word "bizarre"?

Mr. Stephen Mulvany:

I do not wish to be argumentative with the Deputy. I dispute the use of the word "bizarre".

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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Okay.

Mr. Stephen Mulvany:

It assumes motive, in some respects, where we have not established the facts. Let us establish the facts.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Just a second. The Deputy has asked which parts. What I would ask is that the Deputy give the witnesses an opportunity to come back with their reply regarding the numbers and that they come back and tell us what they dispute. Mr. Mulvany is disputing the assertions that were made. He can come back and clarify the position and provide answers to the questions asked.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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I will say this. If the word that caused concern is "bizarre", just to reflect on how I used it, I said it was bizarre. I accept that it is a subjective position. However, I consider it bizarre that a Department would take appeal its own appeals officer's decision in court. That is a bizarre scenario. In that instance, the chief executive is entitled absolutely to have a different view on it. It does not impact on the specific questions I posed.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I thank the Deputy.

Mr. Stephen Mulvany:

Of course, the Deputy is entitled to his opinion.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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I will need to come back in again on a different issue, if I can, Chair.

Brian Stanley (Laois-Offaly, Sinn Fein)
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Okay. Mr. Mulvany will come back with a detailed reply on that.

Mr. Stephen Mulvany:

We will, Chair.

Verona Murphy (Wexford, Independent)
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I will go back to Ms O'Neill. Of the 6,349 assessments of need, how many were carried out? That is the number they said that were waiting. Is that today's figure?

Ms Yvonne O'Neill:

Yes. It is the close-of-December-2022 figure.

Verona Murphy (Wexford, Independent)
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What percentage of those would Ms O'Neill expect to be deemed requiring services?

Ms Yvonne O'Neill:

I expect all of them to require an intervention and a service, absolutely.

Verona Murphy (Wexford, Independent)
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Given the revelations that we have been discussing for the past week, or, in my case, not been discussing as I am waiting for information, it would not be entirely fictional for people to come to the conclusion that there was a deliberate strategy to hold up the assessments of need.

If we were to do 6,349 assessments, that would add pressure because most likely all of their parents would be eligible for carer's allowance and they would probably all go into autism units. There would also be pressure put on the CDNTs and CAMHS. It would not be beyond the realm of possibility that people would start to think that. I am looking at the sustainability of section 38 and 39 services being provided. Is it sustainable that 80% of the care will be provided by section 38 and 39 organisations? Is Mr. Mulvany concerned about that?

Mr. Stephen Mulvany:

No, I am not concerned that 80% is provided directly by organisations outside the HSE. I am concerned about issues such as pay parity between section 38 and section 39 organisations.

I can see how an individual parent might wonder whether the HSE is deliberately trying to delay assessments but I reassure the Deputy that is absolutely not the case.

Verona Murphy (Wexford, Independent)
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I really do hope that is the case.

Mr. Stephen Mulvany:

That is why we came up with the streamlined methodology, which unfortunately did not meet the legal requirement. As all the parents know, our focus is on the assessment of need, which is a legislative requirement, so we will not comment on that. The next step is a statement of service. It is in the statement of service where one finds out the limitations on the service that we can provide.

Verona Murphy (Wexford, Independent)
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How often are statements of service provided? Most of those children will probably wait for four years until they are six or seven for the assessment of need. What happens when they get to 13 or 14 and it needs to be done again?

Mr. Stephen Mulvany:

The statement arrives in whatever the timeline is. The issue is when the services listed in the statement-----

Verona Murphy (Wexford, Independent)
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I understand that, but the question for Ms O'Neill is whether there are many who require a second assessment?

Ms Yvonne O'Neill:

Under legislation there is a period of time in which the statement of need has to be reviewed.

Verona Murphy (Wexford, Independent)
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Or there is an assessment of need again. How many are in that situation?

Ms Yvonne O'Neill:

I do not know the number. It is on the statement of need.

Verona Murphy (Wexford, Independent)
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Ms O'Neill does not have the figures but they are substantial, are they not?

Ms Yvonne O'Neill:

Yes, they may be but most of those individuals also will be in receipt of services and be very involved with teams and other types of services.

Verona Murphy (Wexford, Independent)
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Time is of the essence. What I am really pointing out-----

Ms Yvonne O'Neill:

They are very much a core part of the system.

Verona Murphy (Wexford, Independent)
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What I am really pointing out is that a child is often five or six when he or she gets a first assessment of need. Parents do not understand that they will need another assessment and how it operates within a timeline or that one starts again. They are not receiving the service that is required. They are receiving it for a five-year old when they are 13. They are now back to waiting for the statement because it all starts again.

Ms Yvonne O'Neill:

One of the points I was clarifying-----

Verona Murphy (Wexford, Independent)
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Is that not a fact?

Ms Yvonne O'Neill:

There is a legislative requirement on the assessment and statement.

Verona Murphy (Wexford, Independent)
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There is a legislative requirement to do the assessment of need and it just does not get done.

Ms Yvonne O'Neill:

However, that is not the basis on which services continue to be provided to people as they progress through our services from child to adult.

Verona Murphy (Wexford, Independent)
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How many parents have taken the HSE to court? How many have taken legal action to get the assessment of need carried out?

Ms Yvonne O'Neill:

They do not have to take legal action.

Verona Murphy (Wexford, Independent)
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I know they do not need to but, unfortunately, they do.

Ms Yvonne O'Neill:

There are a number of cases.

Verona Murphy (Wexford, Independent)
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How many?

Ms Yvonne O'Neill:

I think that information was provided in the detailed report that was given.

Verona Murphy (Wexford, Independent)
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How much has it cost?

Ms Yvonne O'Neill:

I do not have the information right in front of me. The majority of the cases are settled. Generally, if they are not settled-----

Verona Murphy (Wexford, Independent)
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The strategy seems to be one of settlement.

Ms Yvonne O'Neill:

No, if they are not settled it is because there would be some follow-up or detail in regard to the underlying reason for termination.

Verona Murphy (Wexford, Independent)
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Is it not damning that any parent-----

Ms Yvonne O'Neill:

The most important work that is happening is to avoid anybody having to go to court.

Verona Murphy (Wexford, Independent)
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Yes, but it is damning that we have to resort to that. I just have one other question.

Brian Stanley (Laois-Offaly, Sinn Fein)
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I will let the Deputy back in. There will be a third round.

Verona Murphy (Wexford, Independent)
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I have one question. This is very important.

Brian Stanley (Laois-Offaly, Sinn Fein)
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The Deputy must be very brief.

Verona Murphy (Wexford, Independent)
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There is a significant issue arising with colonoscopy waiting lists. Do we have a figure on how long we are waiting for results? The private sector seems to have come under serious pressure due to this as well. I am informed the waiting list in the private sector is 32 weeks. The waiting list for a colonoscopy in the public sector is 52 weeks, with the results taking weeks and months after that. I would like a briefing note on what the issue is, if that could follow on.

Mr. Stephen Mulvany:

What we call gastrointestinal, GI, scopes, is the waiting list which has reduced the most. It is down 89% for those waiting up to 12 months. We have a separate list of people who need urgent colonoscopies. We will come back to the committee with a briefing on that. That is a much shorter timeframe. We have a screening piece as well. We will come back with a note.

Verona Murphy (Wexford, Independent)
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I will come back in if there is another round.

Mr. Stephen Mulvany:

There is no registry, as such, for autism, but the prevalence and incidence of it is reasonably well researched so there is a good handle on the numbers and therefore on the numbers of staff. The issue is trying to have a tiered model which can deal with those at the low complexity end so that the children's disability network teams, when we can get them up to their full complement – they are not there yet – and the other teams are better able to deal with them. As far as I am aware, there is not a specific registry of people with autism.

Mr. Stephen Mulvany:

The bigger challenge is not in having the data, as such, on the prevalence of autism, to decide on the size of the teams, it is the recruitment of the team members and the integration of those teams across primary care, CAMHS, and disability services. That is a much bigger issue than whether we should have a registry. I think there is sufficient information.

Ms Yvonne O'Neill:

I will come in. There is a piece of work that was established last year in terms of improving services for autism. That has information on delivery, end service user and other information, one of the priorities for it-----

Ms Yvonne O'Neill:

We have a paper-based system. One of the important things about that piece of work is looking at how health services are provided and there is less focus on the diagnosis. That is coming from the work with our own service users and the family members involved.

Mr. Stephen Mulvany:

I do not disagree on the need for electronic health records across the system but the implication in the Deputy's question is that it would help us know who has autism. That is not really the issue. It is about managing overall services, whether it is autism or anything else.

Mr. Damien McCallion:

I might add that is similar to CAMHS.

Mr. Stephen Mulvany:

I think we know where the prevalence is. Additional systems data would help to operate the system but it is not the key issue.

Mr. Stephen Mulvany:

I would be surprised if they could not say how many had gone through the assessment process or that they had diagnosed themselves.

Mr. Damien McCallion:

There is no question that having a manual system is not good in terms of getting easy access to information. Any area should be able to pull those numbers together. We can revert to the Deputy on it, but I suspect the issue is the capacity and resources to trawl through all the files to try to collate the information. Deputy Dillon made a point about IT. In terms of CAMHS - the area of children's disability is similar - we need to develop systems and support those services. We are looking to do that. We have asked IT services to prioritise some interim solutions. A wider solution is being developed for community services. Deputy Hourigan referred earlier to electronic health records. We want to build a system for the community as well to manage that.

Mr. Stephen Mulvany:

I do not have that here now. However, we could tell the Deputy exactly how much we give each of the section 39 organisations. It is a relatively small number of bigger ones-----

Mr. Stephen Mulvany:

We do not collate that.

Mr. Stephen Mulvany:

I do not have specific figures. The local CHOs will receive individual business cases from section 39 organisations. We know absolutely what we give them. For the larger section 39 organisations that are providing services that we are relying on in terms of disability services, we have a fairly good handle on the level of financial issues they are facing. Remember, in the first instance, the issue is for them to manage their own resources within their limits. We do not collate centrally. At many times, everyone asks for the business case-----

Ms Yvonne O'Neill:

One thing I would add to what the CEO said is that there is a good process under the service arrangement review with the additional funding needed for the growth and cost, which gets collated into the estimate submission in relation to the provision of disability services. If the Deputy is referencing the individualised business cases, say, for where an individual's complexity has changed, they come up through the CHO and are prioritised. We review them as part of the engagements between the national and local through the disability teams.

Catherine Murphy (Kildare North, Social Democrats)
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I have a couple of questions. The Department of Health and the Comptroller and Auditor General did a special report on the procurement of ventilators by the HSE. That has been with the Department since December. Why has the report from the Department not been laid before the House at this stage?

Mr. John O'Grady:

I do not know the answer to that. I believe the Minister indicated we will be doing so shortly. However, I do not have any more information on that.

Catherine Murphy (Kildare North, Social Democrats)
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Can Department officials come back to us with a definite on that?

Are we depending on the section 39 organisations that are in a specific area to deliver the health services? They may not deliver absolutely the required services.

Mr. Stephen Mulvany:

Is the Deputy talking about disability services?

Catherine Murphy (Kildare North, Social Democrats)
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