Oireachtas Joint and Select Committees
Thursday, 11 May 2023
Public Accounts Committee
Appropriation Accounts 2021
Financial Statements 2021: HSE
Special Report No. 114 of the Comptroller and Auditor General: Emergency Procurement of Ventilators by the HSE
Vote 38 - Health
9:30 am
Brian Stanley (Laois-Offaly, Sinn Fein)
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I welcome everyone to the meeting. We have received apologies from Deputies Imelda Munster, Catherine Murphy, and James O'Connor. If attending the meeting from within the committee room, members and witnesses 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 do so from within the precincts of Leinster House. This is 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 Ms Sinead Foy, audit manager at the Office of the Comptroller and Auditor General.
This morning we will engage with officials from the HSE and the Department of Health to examination of the following: financial statements 2021, resumed, as we have dealt with some of this at previous meetings; the Comptroller and Auditor General's special report No. 114, emergency procurement of ventilators by the HSE; Appropriation Accounts 2021; and Vote 38 - health, and subhead (e) the National Treatment Purchase Fund.
We are joined by the following officials from the HSE: Mr. Bernard Gloster, chief executive officer; Mr. Stephen Mulvany, chief financial officer; Ms Anne Marie Hoey, national director, human resources; Ms Mary Day, national director, acute operations; and Ms Martina Queally, chief officer, CHO 6, and by the following officials from the Department of Health: Mr. Derek Tierney, assistant secretary general; Ms Louise McGirr, assistant secretary general; Ms Tracey Conroy, assistant secretary general; and Mr. Kevin Coleman, principal officer. We are also joined by Mr. Sean Flood, chief executive officer, National Treatment Purchase Fund, and by Mr. Eoin Dormer, principal officer, and Mr. Evan Coady, principal officer, Department of Public Expenditure, National Development Plan Delivery and Reform. They are all very welcome. I remind all those in attendance to ensure their mobile phones are switched off or on silent mode.
Before we start, I wish to explain some limitations to parliamentary privilege and the practice of the Houses as regards reference witnesses may make to other persons in their evidence. The evidence of witnesses physically present or who give evidence from within the parliamentary precincts is protected, pursuant to both the Constitution and statute, by absolute privilege. As witnesses are within the precincts of Leinster House, they are protected by absolute privilege in respect of the 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, witnesses 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 that direction.
Members are reminded of the provisions within 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 House or an official either by name or in such a way as to make him or her identifiable.
I call on the Comptroller and Auditor General, Mr. Seamus McCarthy, to make his opening statement.
Mr. Seamus McCarthy:
Go raibh maith agat a Chathaoirligh. As I already introduced the HSE financial statement and the Appropriation Accounts, I will confine my remarks to the findings of the special report. The report before the committee examines from a value-for-money perspective the emergency procurement of ventilators by the Health Service Executive during the early months of the Covid-19 pandemic in 2020.
At this stage, the objective is to identify lessons which may enable our health management systems to achieve better value for money in the context of the next pandemic. The EU's public procurement framework provides for the normal tendering and competition rules to be set aside in situations of genuine urgency such as the Covid-19 emergency. However, good procurement practices can assist in achieving value for money even in emergency situations. These include speedy recognition of the key risks to achieve value for money and the capacity to identify strategies to mitigate those risks. For example, it is important to involve users and specialists in product specification and quantity required; to use established suppliers, forms of contract and contract terms, where possible; and to adhere to established procurement authorisations to ensure that managers with the appropriate knowledge and experience are involved in decision-making.
At the beginning of March 2020, the HSE identified that additional ventilators were urgently needed to deal with the expected surge in demand for critical care. HSE procurement commenced ordering and purchasing ventilators before a target number of devices required was determined. By late March 2020, clinical staff had estimated that an additional 326 ventilators would be needed. This was based on the maximum extent to which critical care capacity could be increased in response to an influx of Covid-19 patients, referred to as surge capacity planning. In the event, the HSE was able to procure 581 additional ventilators from its established suppliers at a cost of €20.5 million. These ventilators met the EU regulatory standards required for such devices.
Over a four-week period spanning March and April 2020, the HSE placed orders for a total of almost 3,500 ventilators at an agreed cost of €129 million. This was almost twice the number of devices which the HSE had been sanctioned to purchase and was over ten times the number of additional ventilators that could be clinically used. Unit prices for the devices were escalating rapidly as many health authorities were scrambling for supplies. Because the HSE had concerns about the capacity of its established suppliers to meet its planned purchasing, it ordered ventilators directly from three manufacturers in China who were identified with the assistance of IDA Ireland. The HSE also placed substantial orders with seven intermediary companies which had little or no experience in the supply of the devices and with which the HSE had not previously done business. The examination found no due diligence checks had been completed on four of the new suppliers while the extent of checks varied for the other six. The checks which were undertaken flagged significant financial and quality risks with using these suppliers but the HSE perceived that its need for ventilators outweighed the risks and made advance payments totalling €81 million to the new suppliers.
Subsequently the HSE cancelled many of the orders which had been placed and received refunds of €50.5 million. No benefit or value has been received by the HSE for expenditure totalling €30.5 million. At the time of reporting, the HSE was continuing to pursue refunds of €22.3 million and regarded €8.1 million as unrecoverable. The latter included payments for devices which were received but were deemed unsuitable for use due to quality issues and risks to patient safety.
It is important that established oversight and accountability arrangements continue to operate to the extent possible where a significant level of unplanned expenditure occurs in a short period. Although the HSE provided weekly reports to the Department of Health of expenditure incurred on its response to the Covid-19 pandemic, the reports did not include information on the advance payments which had been made. This was seriously misleading and negated the effectiveness of the Department's oversight of the level of expenditure being incurred.
Members will recall that the HSE undertook emergency procurement of substantial quantities of personal protective equipment, PPE, around the same time. I drew attention in the audit certificates for the 2020 and 2021 HSE annual financial statements to write-offs of stocks of PPE and hand gel totalling almost €483 million due to unsuitability of purchased items, obsolescence or price fluctuations.
In conclusion, I acknowledge that procurement in an emergency situation is challenging and is unlikely to result in optimum value-for-money outcomes. However, it is important to learn the lessons of experience and to improve processes where we can, so that better outcomes can be achieved in the use of public resources in similar future circumstances. Gabhaim buíochas leis an gCathaoirleach.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I thank the Comptroller and Auditor General. Mr. Gloster is very welcome. It is his first visit to this committee as head of the HSE. I wish him well in the job.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I know it will be a big ship to steer. Mr. Gloster is the third HSE CEO we have had appearing before the committee in the past year, with the exit of Paul Reid, who appeared before the committee on a number of occasions. The gap was filled by Mr. Gloster's colleague, Mr. Mulvany, at the most recent meeting we had with the HSE. Mr. Gloster's statement is quite long in the context of his speaking time of five minutes. Given that we have read it, he might summarise some of it.
Before he starts, I wish to ask about an immediate issue with regard to home care. I do not want to go into this issue in any great depth because I believe the HSE is in negotiations on it at the moment. There are approximately 40,000 recipients of private home care from private providers funded through the HSE. That is hanging in the balance at the moment. Almost 7,000 clients have been granted home care hours but have not been received that care because of the lack of providers. There is a challenge there. I understand the challenges in respect of the workforce, and so forth. The current arrangement, which was set in 2018, has expired. There is the issue of the living wage for the workers. Another issue is that the providers say they are not receiving enough money. This issue has been raised with me on a number of occasions in the past week, as I am sure it has with other colleagues also. In that regard, is Mr. Gloster confident that this can be brought to a conclusion in the next week or fortnight?
Brian Stanley (Laois-Offaly, Sinn Fein)
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I will be very happy for Mr. Gloster to deal with the question in that way.
Mr. Bernard Gloster:
I thank the Chair and the members of the committee for the invitation to meet with the committee today in the resumption of the examination of the financial statements of the HSE accounts. I welcome the opportunity to join with colleagues from the Department of Health and the Department of Public Expenditure, National Development Plan Delivery and Reform to discuss the matters set out in the committee's invitation. The Chair has already introduced members to my witness colleagues. I am supported by my business manager, Ms Niamh Doody.
On the Comptroller and Auditor General's report on the emergency procurement of ventilators, the committee will be aware of the unprecedented context within which these matters occurred. The onset of the pandemic in early 2020 was a period of enormous uncertainty. Health systems across the world were challenged beyond capability, particularly in the phase of what was not known and what would be needed to respond. There was no vaccine to what was a deadly and novel disease at the time.
The first case in the EU was on 24 January 2020 and the first case in Ireland was on 29 February 2020, followed by the first death in Ireland associated with the disease on 11 March 2020. The WHO assessment was that Europe was the epicentre of the pandemic in March 2020. Scenes from Italy were the reference point of what was to come. There was a serious excess in demand in the global healthcare products market with what were then characterised as eBay-style bidding wars. Normal purchasing and sourcing practices did not apply. Payment in advance was effectively mandatory, even then with no guarantee it would secure delivery.
Assessing requirements for volume of products, including ventilators, was an impossible task with no realistic predictability models in the early months. The staff involved at the time had to deliberately over-order to try to secure necessary volume of supply, knowing that cancelling later and managing the financial risk would be factors that might arise. The HSE stopped ordering ventilators on 20 April 2020, which was a very short window from the commencement.
There was no compromise on quality or actions that put lives at risk, with ventilators tested after delivery and before any were put into service. The entire process in those weeks was about balancing risks. A greater level of financial and procurement risk outside of the norm was and had to be preferred over the very real risk to the public. The more significant risk was associated with newly sourced or identified providers as part of the overall pandemic response.
An overview of the detail in appendix 1 is provided by the procurement service of the HSE.
Overall in this period, the HSE spent €20.5 million with established suppliers and €81 million with previously unknown suppliers, of which €8.1 million was the value of ventilators received, €50.5 million was refunded from suppliers to date for non-delivery and €22.3 million is being pursued through legal process.
The committee has previously received detailed briefing papers on this matter and an updated version is contained in appendix 2 of my statement, having been prepared by the relevant technical staff of the HSE. I appreciate these matters are detailed and complex, however I am satisfied that the HSE has acted appropriately in the public interest on the following three key milestones given the prevailing circumstances at the time: the initial response to purchasing in the pandemic, the previous briefings to the Oireachtas and other accountability mechanisms and the co-operation with the Comptroller and Auditor General's special report.
Waiting lists are another matter on the agenda for today. The HSE is currently working through a targeted waiting list action plan. The plan, approved by the Minister, includes both core activity in the service plan and dedicated additional funding for both the HSE and the National Treatment Purchase Fund, NTPF. I have previously advised committees that the issue and focus of waiting list management is not significantly the volume of people waiting but the length of time waiting. Looking at the end of March 2023, we can examine the position through two waiting time views. I have set out the approach to that, and from the figures already published to date. As of the end of March 2023, 490,993 people are waiting longer than the Sláintecare maximum wait times, which is a 5% decrease in comparison to the end of February. For the most recently available 12 months of hospital activity data there were 3.4 million outpatients and 1.7 million inpatient and day case attendances. In addition to this planned scheduled care, our hospital system also treated 1.6 million patients during this same period in emergency unscheduled care, which represents a 10% increase on pre-pandemic 2019 levels. This reflects the ongoing pressure on hospitals from viral surges and increased emergency department attendances.
In our service plan hospital and scheduled care waiting list targets, targets continue to be challenged. We are seeing people well ahead of target and more people are being seen and treated. We are, however, experiencing pressure as more new people are being added to the lists than was anticipated and so affecting overall volume. I am advised this experience is not unique to Ireland in 2023. Dedicated additional resources across our hospital and community services have been provided and will continue throughout 2023.
On the issue of the home care service, matters are subject to very complex tendering processes and other expert reports, including a workforce advisory group. At the end of March the hours targeted to be provided by the HSE were 5.84 million and the actual activity was 5.2 million. The number of people targeted to be provided with the service at the end of March was 55,000 and the actual number was 56,980.
The current matters that have been aired in the media this week are the subject of ongoing negotiation with the providers and engagement with the HSE and the Department. There are significant commercial sensitivity matters within that. Currently, 6,400 people are approved for funding for the provision of home care and they are waiting for the home care. This was the concern expressed by the Cathaoirleach. It is to our regret. There were only seven people to the end of March actually awaiting the approval of funding. It is about the provision of the home care itself. I have discussed the matter with my Department colleagues practically every day over the past couple of days, and late last evening with the Minister. While I do not want in any way to influence the discussions that are ongoing, or the potential outcome of any processes that remain, I do hope the matter will come to a resolution at a very early stage.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I thank Mr. Gloster for that. I do not expect Mr. Gloster to have a detailed briefing on it today, and I am aware it is a sensitive matter, and I do not require Mr. Gloster to go into the figures about how much home care costs per hour, but I understand up to now it was €26.50 per hour, which has been the arrangement with the private providers. I do have a question for Mr. Gloster. In previous years, there has been the directly employed HSE home helps and home care workers. Then there have been the voluntary agencies or charities, and then are the private providers. Just for clarification, in this instance are we talking about the private providers?
Brian Stanley (Laois-Offaly, Sinn Fein)
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Off the top of his head, I believe Mr. Gloster has the breakdown, what percentage of the hours are provided by the HSE, by the voluntary sector and by the private providers?
Mr. Bernard Gloster:
It is my understanding that our dependency on the for-profit, and on the charity, voluntary and not-for-profit sector combined is probably in the area of 60%, but it is variable across the country. My colleague Ms Martina Queally is here from Wicklow where she is the chief officer in that area. Ms Queally's area, for example, is entirely dependent on a provider model whereas in another part of the country it would be very substantially HSE.
Brian Stanley (Laois-Offaly, Sinn Fein)
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So would it be 30% or 40% private and about 20% voluntary. Would it be around those figures?
Brian Stanley (Laois-Offaly, Sinn Fein)
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I have one last question in relation to it. I have tried to get this information previously by way of parliamentary questions, but with difficulty. Will Mr. Gloster tell me what is the cost per hour for directly employed HSE home care? Figures on this are bounced about in the media sometimes. What is the cost per hour? I am aware that Mr. Gloster will not have this figure off the top of his head now but perhaps one of his support staff could access that during the meeting. We would appreciate it. What are the costs per hour for a directly employed HSE home care support worker?
We hope those negotiations can be concluded and that it can be got back on track. It is very important, as I am sure Mr. Gloster will understand, in getting people out of hospital, keeping people out of hospital, and keeping people in their own homes. I am sure that people are complaining about this in every county. A great service is being provided and we acknowledge that, but for the people who are waiting and who do not have the service yet, or who are waiting in the process with their application, we need to get them sorted.
Mr. Bernard Gloster:
The Chairman will find no disagreement on that from the HSE, nor I suspect from my Department colleagues. We rate it as the most critical part of our actual capability to deliver a response to people as an alternative to other events in their lives. There is no dispute about it. We are concerned about the fact that we have not concluded, but there are very significant factors in doing it, and we are trying to do the right thing.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Is Mr. Gloster hopeful that this can be concluded within the next week to fortnight? I am aware that it is hard to put a timeline on it.
Mr. Bernard Gloster:
I would certainly hope it would be at a very early stage. I spoke with the Minister about it as recently as late last evening and he is very focused on it and committed to it, as is the Minister of State, Deputy Butler. There are, however, sensitivities. It was reported in the media in a radio interview this week that the HSE had made a specific offer and then withdrawn it, and that is not the case.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I know that sometimes I do not believe everything that I read.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Perhaps Mr. Gloster will also come back to us with that figure.
Mr. Bernard Gloster:
I certainly will. The challenge with the HSE cost figure is that one just goes with the cost of employing the home help worker, the cost of travelling and the cost of administration, and if one can do that it can ramp up to very significant figures. There was a very detailed analysis done but we will certainly do our best to get it before the end of the meeting, if possible.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I thank Mr. Gloster.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I welcome Mr. Gloster. I wish him well in his new role. It is not only the committee but also the country that would wish him well. It is a big task and we all want to see the reforms necessary. As the Cathaoirleach has said, there are many challenges, not just in the community care but right across the board, as Mr. Gloster will be very well aware.
I also welcome the officials from the Department of Health, from the National Treatment Purchase Fund, NTPF, and from the Department of Public Expenditure, National Development Plan Delivery and Reform.
It is good to engage in this particular aspect. As the Comptroller and Auditor General has outlined, we have already touched on the issue of personal protective equipment, PPE, and the procurement around that. In hindsight it is easy to examine. If we all cast our minds back, it would be fair to say that we were all wishing there were enough ventilators in the country for what we were anticipating would be an extremely difficult couple of months, as it was for many, especially for health staff and those who contracted Covid-19.
That said, there are a number of issues that have been highlighted, which we must examine. The first issue is the review internally by the HSE, post-pandemic.
What internal reviews have been carried out by the HSE and the Department of Health into the chaotic time we experienced at the outset of the pandemic, with a view to ensuring we are better prepared in the event of another pandemic or some other global crisis? The witnesses might comment on any such internal reviews and the co-operation between the HSE, the Department of Health and the Department of Public Expenditure, National Development Plan Delivery and Reform.
Mr. Bernard Gloster:
The appendices to our statement are very detailed, which reflects the examination of the detail at the time to ensure it was properly considered. That is the first point. The second point is that the level of advance purchasing during the pandemic of ventilators and other equipment was never previously seen at anywhere near that level of scale. There were controls in place in the pre-pandemic phase and they have now been reintroduced and reinstated. The risk of advance purchasing into the future is at a much lesser scale. The Comptroller and Auditor General, on page 38 or 39 of his report, has made a recommendation across all public sector spending in respect of advance purchasing. Colleagues from the Department of Public Expenditure, National Development Plan Delivery and Reform will give effect to that recommendation. We will be bound by, and fully accept, the spirit of that. Despite the nature of the emergency, there is always learning from these types of things.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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What is the Department of Health's perspective from its oversight and reviews of the pandemic, particularly in respect of the purchasing of necessary and vital equipment?
Ms Louise McGirr:
From our perspective, we are satisfied on the most important point, which is that the practice of advance payments was very quickly stood down. The issue applied only for a very short time. It is fair to say it was very condensed. We fully support and accept the HSE's assurances that all of that has ceased. Normal procurement procedures have kicked in following the crisis.
Regarding future preparedness, the Deputy will be aware from previous discussions on this issue that there is significant annual investment in our Health Research Board, HRB, part of which is around pandemic preparedness. There is significant work going on at EU level on procurement generally across member states and how that is best done. We are looking at how all countries were in the same position and everybody was competing and bidding for things. There is a significant look across multiple layers around how Ireland is prepared. That is also happening at EU level in terms of procurement and other issues. There is a lot going on in this regard. We can provide more detail on that to the Deputy.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Will the witnesses from the Department of Public Expenditure, National Development Plan Delivery and Reform comment?
Mr. Eoin Dormer:
We accepted the recommendation in the Comptroller and Auditor General's report that more guidance was needed around some of the general issues to do with advance payments. Two sets of guidance were published on our website in March this year. One is to do with clearer definitions around advance payments. The other is more detailed guidance on the exceptional circumstances in which an advance payment may be justified, including what considerations should be taken into account, how to have provisions in contracts that protect the risk of loss and criteria around the circumstances in which consideration might be given to doing an advance payment. That guidance is available on the website for bodies to use.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I refer to the period of decision-making on the purchase of ventilators. Mr. Gloster indicated that this started in early March 2020 and concluded at the end of April. Was early March not a bit late to start assessing the need for ventilators, given what we knew, including the issues that had arisen in January in Italy and elsewhere around the globe? I accept that Mr. Gloster was not in post at the time but it is important to hear his perspective. It seems to me that March was a little late for us to be coming to the table looking for ventilators.
Mr. Bernard Gloster:
That is not an unreasonable observation to make, looking back. It should be noted, however, that the first Covid case was confirmed in Ireland in February. Going back to 12 or 13 March, when the country went into the first phase of lockdown, many people would say this was the first time the entire country moved into a very different understanding of what was likely. I would not seek to defend that and the Deputy makes a fair observation. However, we must take into account what was unfolding at the time. Ventilators were not really being talked about in January, at which point we were only hearing about the emergence of a virus in China. February presented a slightly different scenario and then the country ramped up. The Deputy will remember all the news bulletins about aeroplanes leaving Dublin Airport to go to China for PPE and so on. It was all done in that phase. Having said that, the Deputy's observation is fair.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Of the 3,500 ventilators that were ordered, reference was made to €20.5 million being spent on purchases from existing suppliers and €81 million on purchases from new suppliers. Mr. Gloster mentioned China in his opening remarks. Were all the ventilators from new providers sourced from China or were some sourced from elsewhere? There are legal proceedings ongoing in this regard, as referred to in the appendices to the opening statement. Of the ventilators that were ordered, what percentage were delivered and what percentage of those delivered were usable?
Mr. Bernard Gloster:
A total of 581 were delivered from traditional source providers. From newly sourced providers, predominantly in the Chinese market, 467 were delivered. The rest is the recovered money or the money being pursued in recovery. Mr. Mulvany might comment on the number from new suppliers that were usable versus unusable
Mr. Stephen Mulvany:
We donated 365 ventilators to India, where they are in use in five medical centres. We checked on them twice in the course of 2020 and 2021 and, so far, we have not been advised of any issues. Of the remainder, a large number did not meet the testing, either the first test we carried out or the on-site test before being put into use. They are in storage at the moment, only because we are pursuing the €22 million in those four legal cases. When we started, the sum involved was €50.5 million, of which €30 million has been secured and €22 million is being pursued. We are not saying we will get it all but we will continue to pursue it as long as it makes sense to do so, which it does.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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The donation of 365 ventilators to India is very welcome and was the right thing to do because the authorities there had a far worse situation on their hands than we did. To clarify, is Mr. Mulvany saying that approximately 600 machines were unusable?
Mr. Stephen Mulvany:
No, I am saying that 467 arrived into the country from new suppliers. We got 581 from our traditional suppliers, which were all usable and are either in use or in storage pending use. Of the 467 ventilators received from other suppliers, 365, or more than 80%, were donated to India, where they are in use. The other 100-plus, most of which failed our tests, are in storage.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Those are the machines that are the subject of the legal proceedings.
Mr. Bernard Gloster:
They are being held for the purpose of the legal pursuit to recover the moneys. The product has to be kept in case there is a demand for its return. Going back to the Deputy's earlier point about readiness for anything else that might come, 581 ventilators were delivered from traditional suppliers. We have a reasonable supply of approved ventilators in stock and ready to be used.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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What is the life span of a ventilator? I ask Mr. Gloster to excuse my ignorance on the topic. How long can the ventilators in storage be held onto for use in the future?
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Are they well stored? I hope the committee does not have to deal with a situation at a future date whereby we discover they are in some sort of shed out in west Dublin or something like that.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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That is fine.
The advance payment issue was referenced by the Comptroller and Auditor General in his opening remarks. A weekly expenditure report was provided by the HSE to the Department of Health but the advance payments were not included in it. I have a question regarding the Department's perspective on this.
It is a complete blindsiding of the Department when the figures that were being provided on a weekly basis were not accurate. Is that fair to say? At what point did that process become more inclusive of all figures?
Ms Louise McGirr:
The Department accepts and acknowledges the extraordinary circumstance here. It is important that there is huge learning from it, but this happened over a combined period of time. We did introduce very quickly the flash reports, as they were referred to, for overall code expenditure. Our oversight mechanisms began to meet weekly on expenditure and we still have continued reporting and oversight in this area. Of course, we accept it was not ideal. I am sure the HSE similarly does not think it was ideal in those few weeks, but it was a finite period and measures were taken very quickly to put in the frequent oversight. The reporting improved significantly. We learned quickly and moved to ensure there were better oversight mechanisms for all.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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From the HSE's perspective, what was the rationale for excluding the advance payments from the flash reports, as I think the Department refers to them?
Mr. Stephen Mulvany:
The flash reporting was a weekly reporting mechanism that the HSE stood up. The first report was on 20 March. The second report was on 27 March. Those reports were very clear across all the Covid expenditure. They were indicative that they could not cover all of the costs. The piece on ventilators was also clear. It was based on ventilators received. There is also a clear note in the report on 27 March, which states: "As at 27 March the full €73.5 million which had been approved by the Department on 21 March had been committed." Yes, in hindsight, I would prefer that we had put in the payment, an actual cash out, but we account on an accruals basis and it would have been more informative.
Was the Department blindsided? I do not believe the Department felt it was. Other communications were going on about the race to get these additional ventilators. If we look at the Comptroller and Auditor General's report, on the first of the orders, which was problematic, we were still pursuing the money back. It was on 23 March. The last one that is problematic, where we have not yet got the money, went out on 3 April, so it is an even narrower window. The report started on 20 March and by 27 March we had confirmed in writing that the full €73 million had been committed.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I have less than a minute left. Could I just turn to the NTPF please? Mr. Flood is very welcome. Given the volume of waiting lists, he might furnish a note on the targets, if he does not have it to hand. In terms of the number of people applying for NTPF funding and availing of it, he might just furnish the committee with the last four years of the uptake of the NTPF service and also the existing waiting lists to show how the targets for 2022 are being met. He might please speak to those targets in his response now for 2022 and into this year.
Mr. Se?n Flood:
To clarify, I am the interim CEO of the NTPF. I say that just for the record. In terms of commissioning activity, we arrange the treatment on three active waiting lists. That is inpatient day case, gastrointestinal, GI, scopes, and the outpatient waiting lists. In the past two years we have offered full packages of care. That is where patients can go for an outpatient consultation and if a procedure is required, they will also get that as well as part of the package of care.
The other thing that we do is we fund diagnostics as well. In terms of the active waiting lists, last year we arranged treatment for 153,000 patients. In addition, diagnostics were arranged for a further 67,000. That is a total of 220,000.
In 2021, we arranged treatment for 100,000 patients on the active waiting list, and a further 44,500 diagnostics. That is a total of 145,000.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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What I am trying to get at is whether these are on target, in terms of the NTPF's set targets. Has the fund exceeded them, met them, or are the numbers less than the targets?
Mr. Se?n Flood:
Over the past few years we have to take Covid into account as that obviously had an impact. For example, when Covid hit in 2020 the private hospitals were effectively taken over by the State for three months. That meant we could not offer treatment for that period, so all the best laid plans went out the window.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I mean specifically for last year.
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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I am out of time. Did the NTPF meet its targets or not?
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Was the NTPF far off?
Cormac Devlin (Dún Laoghaire, Fianna Fail)
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Mr. Flood might send a note please on those figures. I thank him.
John Brady (Wicklow, Sinn Fein)
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I welcome everyone to discuss what is a very important topic. Much of what we have discussed and will discuss, in hindsight will point out a lot of failures but it is important to portray the backdrop to what was happening. As Mr. Mulvany alluded to himself, everyone was looking at the images. There were horrific scenes in Italy where military trucks were carrying coffins and that was playing out across all our screens. There was very much a sense of panic, not knowing what was happening and what was coming at us.
We do know that on 11 March, the WHO, elevated Covid to a pandemic level. Was it only at that stage that the HSE carried out analysis on ventilators? Prior to that, it was widely reported that ventilators would be critical to address the needs. Was it only after the 11 March when the WHO declared it as a pandemic that the analysis was initiated by the HSE?
Mr. Stephen Mulvany:
According to references in the Comptroller and Auditor General's report, the first additional ventilators were ordered on 6 February. Work would have been ongoing before 11 March and in the middle of March the WHO declared Europe as the centre of the pandemic. Work had been done before that.
John Brady (Wicklow, Sinn Fein)
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Was it only in late March, as part of the surge capacity planning, that it was identified that 326 additional ventilators would be required?
Mr. Stephen Mulvany:
As the report states, that is the figure that was identified at that point in time, and it was never increased. The report is also clear that it was 15 March when the minutes of Professor Nolan's modelling group were available that we actually modelled the likely ICU need. That was the point at which the level of likely need of ventilators was pretty definitive, and that correlates fairly closely with both the last orders and when we started cancelling orders.
John Brady (Wicklow, Sinn Fein)
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At that stage, arrangements had been made with 18 private hospitals to utilise them as part of the HSE's response. Is that correct?
John Brady (Wicklow, Sinn Fein)
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How many ventilators were available within those 18 private hospitals?
Paul McAuliffe (Dublin North West, Fianna Fail)
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It was 48.
John Brady (Wicklow, Sinn Fein)
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Were they taken into consideration in the HSE's analysis?
John Brady (Wicklow, Sinn Fein)
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The HSE identified through the established supplier of ventilators that it was able to procure 581 ventilators.
John Brady (Wicklow, Sinn Fein)
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On 21 March, the Department sanctioned the purchase of 1,900 ventilators. Is that correct?
John Brady (Wicklow, Sinn Fein)
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Was a business case prepared by the HSE for the procurement of 1,900?
Mr. Stephen Mulvany:
There was a sanction request issued with some analysis to the Department on 20 March. There would have been some discussions before that. The report also states that on 15 March there was a memo for the Government relating to 500 ventilators. Therefore, there was analysis and commentary.
John Brady (Wicklow, Sinn Fein)
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There was analysis and a discussion, but a business case-----
John Brady (Wicklow, Sinn Fein)
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So there was no business case prepared for that.
Mr. Stephen Mulvany:
There was an obvious business case and necessity. It is not that we did not set out our best estimate of what was required and what we might have to do to get it. The issue was the uncertainty in the market and in respect of the need, which was not finally clarified until 15 April.
Mr. Bernard Gloster:
There are three important steps to reflect the process. The first was that there was a consideration of what was available in the country or what the health service already had access to. As Mr. Mulvany said, if we were going to take the 2,000 beds in the private sector, they would come with the 48 that were there. The second was an attempt to maximise our number through the approved providers that had already been put in a framework of some type of tendering process. Obviously, we would have had reliability and quality assurance regarding what was available from them. Throughout that very tight period in March, the scale of the public anxiety right across the world fundamentally changed.
John Brady (Wicklow, Sinn Fein)
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There absolutely was public anxiety at scale-----
John Brady (Wicklow, Sinn Fein)
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-----but that is no way to plan for emergency situations.
John Brady (Wicklow, Sinn Fein)
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Absolutely not. Sanction was given for 1,900 ventilators. Ultimately, orders for 3,500 ventilators were made. Who sanctioned that?
Mr. Stephen Mulvany:
The sanction was to get up to 1,900 ventilators at €73.5 million. It was obviously left to the HSE to figure out how to do that. As the report states and as mentioned in the CEO's opening statement, the only way at that time to get ventilators was to over order and pay in advance, because we were being gazumped continually.
John Brady (Wicklow, Sinn Fein)
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So we put in orders for 3,500, expecting to get-----
John Brady (Wicklow, Sinn Fein)
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At the time of the HSE's surge capacity planning, looking at ICU, staff and all the other resources needed to operate an ICU, how many ventilators would the HSE have been able to operate or man?
Mr. Stephen Mulvany:
As the Deputy will see in the report, 328 was the number that it got before the extended surge. That number never went up. That was reported at the end of March. The chair of the same group looking at this – in fairness to the Comptroller and Auditor General, it is in the report – was clear in his email of 30 March that they had not settled on a final number and were still in a position where they needed to get every available ventilator.
John Brady (Wicklow, Sinn Fein)
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In the region of 328 is what-----
John Brady (Wicklow, Sinn Fein)
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What plans were being made to bring the figure up to 1,900? The hope was to get that number of ventilators. What actions had been taken to get additional oxygen and to put in place the additional beds and teams, including ICU teams?
Mr. Stephen Mulvany:
The Deputy will recall that, on 20 March, we wrote to the Department. On 21 March, it sanctioned the 1,900. The actual definitive numbers, including both the 328 and finally the modelling by Professor Nolan, respectively, became available towards the end of March and then 15 April. It is really all about the timing, what was known when, and the uncertainty, as the Deputy referred to in his opening comments. At the time, we were pursuing the maximum number of ventilators knowing that we would have to figure out then how we would actually staff them. At the time – you would need an anaesthetologist here to talk about this – all sorts of medical and ethical discussions were going on about who would be ventilated and what the standard of ventilation care would be. There was no certainty at that point because we had no vaccine. We are sitting here behind a wall of vaccines and we all understand Covid variants, but back then there was no sense of whether there would be a vaccine and, if there was to be one, when.
John Brady (Wicklow, Sinn Fein)
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Of the ventilators that did arrive, a sample test was done on 100. Is that correct? How many of them were deemed unsuitable or not up to the necessary standards?
Mr. Stephen Mulvany:
Of the 581 we got from our traditional suppliers, they would all have gone through the normal certification process under an engineer certified by the actual company in the actual model. We did not have that level of certification for the new suppliers so we got an expert company to carry out tests. Forty percent of what we tested failed, which was a much higher failure rate than expected. We further tested some of them on site and, again, the results of that were not positive. Therefore, they were all quarantined. As we said in the opening statement, we took financial risks to avoid and manage patient safety risks. We did not take risks with patient safety. We only sought WHO-approved specifications and then we carried out two series of tests, and then we quarantined.
John Brady (Wicklow, Sinn Fein)
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The normal procurement procedures led to a 40% or 41% failure rate in ventilators.
John Brady (Wicklow, Sinn Fein)
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Regarding the ventilators with which there were issues and that did not arrive, the Department or HSE is now trying to recover €22.3 million. There was €8.1 million deemed unrecoverable. What does unrecoverable mean, and where are we at in terms of the €22.3 million we are trying to get back?
Mr. Stephen Mulvany:
That €22.3 million is with, let us say, four entities, to put it simply. When we started pursuing refunds with those four entities, the figure was approximately €51 million. It is now down to the €22 million. We will continue pursuing that through the Chinese legal system. That is the process we are going through. The €8 million included an €800,000 settlement that was written off, and the bulk of it is for the 365 ventilators. Again, they were from new suppliers. The cost to us was €6.6 million. They were of no value to us but were donated successfully to five medical centres in India, where they have been in service since they were donated.
John Brady (Wicklow, Sinn Fein)
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With regard to the overall approach, we know proper planning and procurement were not in place. There was an effort to procure 3,500 ventilators without the approval of the Department. Does Mr. Mulvany agree there was a breakdown in command and control at senior level within the HSE around the whole process of dealing with the response and the procurement of ventilators, PPE and the hand sanitiser required?
Mr. Stephen Mulvany:
I totally disagree with that. There are people better qualified than me to say there is no real evidence that any amount of planning in any country, certainly not in Europe, would have managed to fully deal with what was faced at the time. The evidence is that Ireland Inc., in terms of excess mortality and the financial report, performed reasonably well. The excess mortality is something you would not wish for; however, while we had 12.5 deaths per 100,000, the EU figure was close to 300 and the UK figure was ten times 12.5. By any measure, it is by no means clear or certain that planning at any level could have dealt with the issue. This is something to be looked at in the future. I certainly do not agree that there was a breakdown in the HSE. The HSE manages risk every day. We chose to put patient risk ahead of financial and procurement risk. We took more financial and procurement risk to manage patient risk. We could just as easily be sitting here having an inquiry about why we did not have enough ventilators.
Verona Murphy (Wexford, Independent)
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Good morning, everybody. I welcome Mr. Gloster and wish him good luck in the role he has recently taken up.
To be fair, the procurement exercise commenced before both Mr. Watt and Mr. Gloster took up their positions. Mr. Watt is the Accounting Officer and Secretary General and Mr. Gloster is the CEO of the HSE, so it all took place with actors who are not before the committee.
However, the committee does recognise that it was in a time, as the witness says, of impending crisis of unknown dimensions and proportions. We all accept that. That does not mean that we will not examine in it detail. The scale of the funding concern in the context of the overall budget may not seem a lot to the witness or to anybody that is operating within the €26.5 billion budget that the HSE has. However for the ailing agencies that depend on funding under section 39, €30 million would be like winning the lotto ten times over.
I heard what Mr. Mulvany said to my colleague in relation to planning and every other country. There was omission when the reports were provided to the Department of Public Expenditure, National Development Plan Delivery and Reform. Page 12 of the Comptroller and Auditor General's report states that the "report only included expenditure for ventilators that had been delivered and did not include the payments in advance and refunds received from cancelled orders". Who compiled those reports?
Verona Murphy (Wexford, Independent)
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Does Mr. Mulvany see any problem with that?
Verona Murphy (Wexford, Independent)
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Mr. Mulvany has just said that it was clear. Allow me to say this again; the Comptroller and Auditor General says that this was seriously misleading. So clearly, it was not clear. It was clearly misleading
Mr. Stephen Mulvany:
The Comptroller and Auditor General has compiled his report and I respect that. However, the Deputy is asking me the question. I am giving my view on it as chief financial officer, which I also was at the time. Those weekly reports were part of something that we developed. First, they were not intended to mislead anybody. Second, they started with the first report on the weekend of 20 March and by the second report-----
Verona Murphy (Wexford, Independent)
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: I have no interest in the dates.
Verona Murphy (Wexford, Independent)
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The witness has answered it.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Let him finish briefly.
Verona Murphy (Wexford, Independent)
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I did not ask anything about a date. I asked Mr. Mulvany about the omission of the detail.
Verona Murphy (Wexford, Independent)
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What about the €24.5 million for instance? We see on page 27 that there is €24.5 million agreed under verbal contract.
Mr. Stephen Mulvany:
The Deputy's question first of all was about the report. In hindsight, as I agreed earlier, I would prefer if it was a cash figure as well, but it is pretty clear when someone says the full €73.5 million has been committed. I do not know and I certainly never heard from colleagues in the Department of Health or in the Department of Public Expenditure, National Development Plan Delivery and Reform that they felt misled.
Verona Murphy (Wexford, Independent)
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Would Mr. Mulvany agree or disagree with what the Comptroller and Auditor General had to say? It was not misleading, is that what the witness is saying?
Verona Murphy (Wexford, Independent)
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This means you would agree, so it was misleading. I want to move on to the Department of Public Expenditure, National Development Delivery Plan and Reform on the same question. How did the Department deal with the fact that it did not receive the full information in order to make an informed decision?
Mr. Eoin Dormer:
I will go back to the sanction that we conveyed to the Department of Health. One of the conditions of the sanction was that there would be weekly reporting up to the limit of the spend. That was the case. There were more frequent weekly meetings, at which lots of queries were exchanged back and forth across the various Covid spending lines. The purpose of those engagements was to get to the bottom of, or to track where the Covid spend was being incurred.
Verona Murphy (Wexford, Independent)
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To be fair then, did the Department feel that it had been misled?
Mr. Eoin Dormer:
Similarly to the HSE, we fully accept the Comptroller and Auditor General's finding on that issue.
Verona Murphy (Wexford, Independent)
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The fact that the Department was being misled is what I am really trying to get to. Did the Department seek to hold anyone accountable on that basis, given that it accepts the report?
Verona Murphy (Wexford, Independent)
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In that case, the answer to my question about holding someone accountable is "No". The Department has not sought to ascertain in any shape or form who was accountable for submitting a report to the Department that completely misled it.
Verona Murphy (Wexford, Independent)
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Clearly not. I suppose we can all make up our own minds then as to accountability. Referring to page 27 of the report, Mr. Mulvany, €24.5 million was advanced to three suppliers on the basis of a verbal contract. Emergency or no emergency, how was such a massive amount transferred and authorised by the HSE without a written contract?
Mr. Stephen Mulvany:
It all comes back to the same point around uncertainty and managing risk. We can look back now and disagree with the judgments that were made and the Deputy is quite entitled to do so. However, they were the decisions that had to be made at the time. We were clear and our CEO was clear, that we would not get every decision right. There was a real fear that we would not have sufficient ventilators to be able to provide care to people. I would prefer to be here arguing over why we are down to the last €22 million we have not yet been able to secure, than having a discussion about why people died because we did not have enough ventilators. That was the very real risk we faced.
Verona Murphy (Wexford, Independent)
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The reality is that the ventilators that were procured were worthless to us. People did not die because ventilators were not procured. They died because ventilators that were of no consequence were procured. No, I am wrong. Sorry, to be fair, they are consequentially of use in India. We were lucky to be able to do something for somebody, after wasting €80 million. I agree with the witness on that point. However, the ventilators that were purchased have no bearing on the statement the witness is making because we could not use them. The question I asked was about the €24.5 million.
Mr. Stephen Mulvany:
Facts are important. For the record, of the €80 million we are down to €30 million. Those ventilators in India account for €7 million of that. We have yet to get value for the other €22 million. I am not saying that we will get value for all of it but we are pursuing it in the legal system.
Verona Murphy (Wexford, Independent)
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How much is it costing us per annum to store the 100 that we have left over?
Verona Murphy (Wexford, Independent)
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How much is that over three years?
Verona Murphy (Wexford, Independent)
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Does the HSE expect to recover that?
Verona Murphy (Wexford, Independent)
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I have heard the witness say that. There is no need to run down the clock on me.
Verona Murphy (Wexford, Independent)
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I do not agree with any of it, Mr. Mulvany, regardless of emergency. I operated a business throughout the emergency, and I did not make any mistakes like this. That is probably because I was working for myself and looking after my own money. I was not looking after part of the public purse, which is what the HSE was doing. I already said at the outset that it was important to consider the context.
Verona Murphy (Wexford, Independent)
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Neither were you..
Verona Murphy (Wexford, Independent)
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As financial officer, the witness's role was procurement. Those looking after the patients were under extreme pressure because of the ventilators that were ordered.
Verona Murphy (Wexford, Independent)
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In that case, did we even need ventilators that were ordered?
Verona Murphy (Wexford, Independent)
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The real issue is that unless a mistake is recognised as a mistake, it does not change. The question I wanted to get to is, do we still have verbal contracts in operation? Are we still paying out moneys on the basis of verbal contracts?
Verona Murphy (Wexford, Independent)
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Did we have verbal contracts before Covid?
Brian Stanley (Laois-Offaly, Sinn Fein)
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Thank you, Deputy. Do you have one more brief question?
Verona Murphy (Wexford, Independent)
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No, I will come in for the second round.
Colm Burke (Cork North Central, Fine Gael)
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I apologise for not being present for the presentation. I was in the Dáil, dealing with questions to the Minister.
I would like to deal with the issue of the pending legal proceedings in respect of the refund of the figure of €22 million or €23 million. Where are those proceedings held? Are they in Ireland or are they outside of Ireland's jurisdiction?
Colm Burke (Cork North Central, Fine Gael)
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They are involved in the Chinese legal system.
Colm Burke (Cork North Central, Fine Gael)
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Is it the case that we have someone employed in China who is dealing with this?
Colm Burke (Cork North Central, Fine Gael)
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In relation to the legal process, what stage is it at? Are we, for example, six months, 12 months or two years away from hearing about it? What is the process there? It is obviously a totally different legal system from ours.
Mr. Bernard Gloster:
There are various stages to the process. The figure related to the recovery pursuit went from €50 million down to €22 million. There were therefore obviously mechanisms already and various types of arbitration that led to that. The sum of €22 million is at various stages of being pursued. They will have to be pursued at different scales depending on the options available in the Chinese system. That is really as far as I can comment. It is not possible to pick out a timeline, for example, by saying that it is in the final stage and that it will be concluded in six months.
Colm Burke (Cork North Central, Fine Gael)
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I have another question about the legal proceedings. Is it the case that there are people here in the legal system in Ireland who have a connection with China? I presume that it is.
Colm Burke (Cork North Central, Fine Gael)
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Another issue relating to the legal proceedings is that it is fine to get a court order or whatever the process in China is, but there is also the matter of collecting. Has that been analysed in regard to whether or not it is feasible? If there were an order at further recovery would that be deliverable on at the end of the day?
Mr. Stephen Mulvany:
That is all part of the process. As Mr. Gloster said, we have been successful in a number of arbitrations. We are now pursuing people for money, but we do not want to say too much. We will pursue the money for as long as it makes sense to do so. Without saying what the future legal costs may be, to date, in securing back the €30 million we have spent approximately €500,000 on legal fees. It is therefore a matter of risk and rewards.
Colm Burke (Cork North Central, Fine Gael)
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I fully accept that.
Colm Burke (Cork North Central, Fine Gael)
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It is the case, then, that for €500,000 in expenditure, we got back €30 million of what we were trying to recover.
Colm Burke (Cork North Central, Fine Gael)
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That is okay. I want to move on to the issue of the operation of the National Treatment Purchase Fund, NTPF. There is a major problem with delays in getting access to treatment. If someone has an 18-month or two-year delay in getting access to treatment, they may very well then require a higher degree of treatment, at a far higher cost. Has the NTPF been analysed regarding how we can expedite the process from the time it is decided that a person needs treatment to the time they go on the fund? I refer to the decisions that have now been made in relation to treatment abroad and the entitlement. These are different from the National Treatment Purchase Fund. Do we now need to review the process?
Brian Stanley (Laois-Offaly, Sinn Fein)
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The chief officer from the National Treatment Purchase Fund, Mr. Seán Flood, and Ms Tracey Conroy, are before the committee. The Deputy may feel it is more appropriate to ask the question of them.
Mr. Bernard Gloster:
Before that, I will make a comment to be helpful to the Deputy. The current waiting lists for all types of care are managed essentially by using two types of processes by the consultant doctors. One of these is clinical prioritisation, which means that they will be constantly reviewing the scale of prioritisation of the person's need. The other is chronological scheduling, which looks at the length of time the person is on the list. Very often, there is balancing between those two.
The HSE has two streams of resourcing and funding for tackling the waiting list. The first is what is built into the annual service plan. That sets out the number of people who are to be removed from waiting lists. It tries to anticipate the number of people who will come onto the list. The second is the waiting list action plan, which is the targeted, dedicated fund for the year. It is monitored and measured every month by the Department. In the waiting list action plan, the HSE has a portion of funding to operate initiatives to take people off the list. The National Treatment Purchase Fund has its own dedicated pathway for certain procedures. I would nearly let the National Treatment Purchase Fund decide whether it is time to revisit any particular access schemes. At the moment, the sole focus is to maximise every single pathway that is available in order to reduce the length of time a person spends on the waiting list.
Colm Burke (Cork North Central, Fine Gael)
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Can I go back to the issue of the process? I have come across a process whereby a person is referred to be assessed under the National Treatment Purchase Fund. The person who assessed them then sets out a report on the care they require. This may include surgery, for example. The person is referred back to the HSE for that surgery. The problem, then, is that the consultants to whom they are referred back will say they did not review this patient and did not take the decision that the patient needs surgery. They say that if something goes wrong, that consultant will be the person who is going to be sued. Therefore, they are not prepared to do the surgery. If we are to refer people out under the National Treatment Purchase Fund, why do we not do the whole process, from assessment right through to getting the treatment?
Colm Burke (Cork North Central, Fine Gael)
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Well, it is an issue, because I have come across it.
Mr. Bernard Gloster:
Okay. Well, I have not heard about this on any scale or heard it as a thematic issue. However, I would say that there are two stages of the waiting list process for everybody. The first is from general practitioner referral to consultation with a consultant as an outpatient. That will result in either a discharge, a review or a referral onto another procedure. If it requires another procedure, the patient then goes onto the inpatient day case waiting list to be treated via that. The National Treatment Purchase Fund operates across both, so it is not the case that the fund-----
Colm Burke (Cork North Central, Fine Gael)
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I know, but there is a concern about this process that the person they are then referred to will say that they are not prepared to do a surgery until they do their assessment.
Colm Burke (Cork North Central, Fine Gael)
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Therefore, while the HSE might be taking them off the waiting list, it is technically putting them back onto another waiting list.
Colm Burke (Cork North Central, Fine Gael)
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I am asking if there is a need to review this, first because of the decision regarding treatment abroad and people's entitlements. The second reason relates to the process I am talking about, which is not actually expediting the reduction of the list in real terms.
Mr. Bernard Gloster:
I can say to the Deputy that there is no evidence, scientific or otherwise, available to the HSE that would suggest that one doctor seeing a patient on an outpatient list and referring the patient to the list of another doctor for a procedure presents any type of clinical risk or problem-----
Colm Burke (Cork North Central, Fine Gael)
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It does.
Colm Burke (Cork North Central, Fine Gael)
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It does. I can assure Mr. Gloster that it does.
Colm Burke (Cork North Central, Fine Gael)
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People who are on the front line will say that they are not prepared-----
Colm Burke (Cork North Central, Fine Gael)
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I am hearing otherwise.
Mr. Bernard Gloster:
The risk to a patient being left to be seen by nobody is far greater than the risk of being seen by one specialist and then potentially being referred on to another, depending on the nature of the assessment of that specialist. The risk there is far less. The risk of sitting there waiting for one doctor to do the whole lot is an awful lot greater.
Colm Burke (Cork North Central, Fine Gael)
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Maybe Mr. Flood would like to comment.
Mr. Se?n Flood:
In terms of our own process at the National Treatment Purchase Fund, we collate all the waiting list data from all the hospitals. We use that data then and we target specific procedures. The Deputy will see in the waiting list action plan, which Mr. Gloster referred to and which is published online, that we have funding this year of €150 million. We send a list of patients for particular procedures to a public hospital. The public hospital obviously has clinical oversight of the patient. They will review those patients to see if they are clinically suitable to go out for treatment into a private hospital. What happens then, if that is the case, is that the HSE hospital will contact that patient and tell them that they have an offer by the NTPF for treatment. If they accept that offer, they will then go for an assessment to that private hospital.
Colm Burke (Cork North Central, Fine Gael)
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One of the problems we are all coming across is the length of time people are on the waiting list. By the time they require treatment, in fact, the degree of treatment they require has greatly increased.
Can we look at the system with a view to taking people off the waiting list at an earlier stage and getting them referred out? There seems to be a policy that we will not even dare talk about the National Treatment Purchase Fund until such time as the patient has been on the list for certain period. I know that some hospitals will not even consider referring patients out unless they are on the list for at least 18 months. That adds to the patients' problems, because they need a greater degree of care, are going back and forth to the GP on a regular basis, and are constantly on to the HSE asking when they will be dealt with. I am wondering if there is a need to review this process of getting people in under the NTPF, knowing full well that they are not going to be reached on the public waiting list for at least three to four years.
Mr. Se?n Flood:
The NTPF deals with surgical procedures. We obviously target long-waiters. We do not wait for patients to get to 18 months plus. At this point in time, where there is available capacity in the system and for the specific procedures that we do, we go down to patients waiting over-----
Colm Burke (Cork North Central, Fine Gael)
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I got a letter back from a hospital telling me that a patient had only been on the list since 2021, more or less clearly indicating to me that it was not prepared to put the patient on the list under the NTPF.
Mr. Se?n Flood:
I cannot speak to that instance, but I can speak in general. For targeted procedures, we are targeting patients waiting three months plus. In doing so, we work closely with the HSE. It contacts those patients, who are within the acute hospital system, for inpatient-day case, IPDC, or gastrointestinal, GI, procedures. For outpatients-----
Colm Burke (Cork North Central, Fine Gael)
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Is that once they are on the list for three months?
Colm Burke (Cork North Central, Fine Gael)
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Okay. Can the list of certain procedures be expanded so that we do not have patients, who are waiting for other procedures, waiting for two to three years and still cannot get on the NTPF list?
Colm Burke (Cork North Central, Fine Gael)
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Could that list be expanded?
Mr. Se?n Flood:
It has been expanding. For example, when we had our first full year of commissioning in 2018, we arranged treatment for 30,000 patients. Last year, we arranged treatment for 150,000, which represents a fivefold increase. We are looking to grow those procedures where appropriate. There are around 100 procedures on the list at this point in time.
Mr. Bernard Gloster:
I am very happy to look at any instances referenced by the Deputy. I think the point about giving certainty about the option of NTPF being available to people or, to put it conversely, not being delayed by a hospital because a patient is not long enough on the list, is a fair one. We will certainly take that away.
Alan Dillon (Mayo, Fine Gael)
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I welcome our guests and wish Mr. Gloster the best of luck in his new role. I look forward to working with him, as I have done as a member of the Joint Oireachtas Committee on Children, Equality, Disability, Integration and Youth. Staying on the topic of the NTPF, today, I read about 70 patients in a Cork nursing home who are facing an uncertain future, after being informed that the nursing home is opting out of the fair deal scheme. This development was associated with the extreme financial pressures due to State supports. The NTPF was blamed for the decision to withdraw from the fair deal scheme, owing to the gap between funding provided and the actual cost of care. Perhaps the witnesses can provide us with an understanding of the HSE's response to the growing number of nursing homes opting out of the fair deal scheme due to financial pressures. Is that something the HSE is concerned about?
Mr. Bernard Gloster:
Certainly, regardless of the view of financial pressures, we are concerned at the loss of any capacity in the system. At the moment, the demand for care is there, and it is going to continue. The demographics of the population indicate that. While people are living longer and there are certainly improvements in the quality of life, our focus is on trying to build as much support to avoid people going into care as far as possible. However, the reality is that care is needed. Ireland is very heavily dependent on private nursing home volume as part of the mix, so when there is loss of capacity in the system it can have a serious impact on patient flow and access to care for people near to their own homes, families or counties.
Alan Dillon (Mayo, Fine Gael)
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Does the HSE recognise the disparity in weekly funding rates between the NTPF rates and the rates of what the HSE pays its own nursing homes?
Mr. Bernard Gloster:
To be fair, I am not going to stray into NTPF negotiations; that is its task. Our task is to pay out, under the nursing home support scheme, to nursing homes based on the rate that is set by the NTPF. On the operation of our own public units, it is well reported, documented and rehearsed over many years that there is a difference in the cost of a bed in a public nursing home as opposed to a private nursing home. I would say three things in relation to that. The first is that we operate, most likely in many cases, at a higher staffing level. The second is that our staff are all public servants and their salary scales are set by Government, along with their terms and conditions. The third, which I accept that some private operators will dispute, is that in my not insignificant experience, I would say that our level of dependency and the level of care needs of people in public nursing homes is, on balance, higher than that in many - but not all - private nursing homes.
Alan Dillon (Mayo, Fine Gael)
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How is the HSE going to deal with the potential influx of residents from private nursing homes into public ones due to the withdrawal of some of these homes from the fair deal scheme? Up to 20 have closed to date. Is that not a real concern? Is there capacity within the public system at the minute?
Alan Dillon (Mayo, Fine Gael)
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What current measures are being taken? Have any positive measures been taken? We listen to private nursing homes and they continue to see the disparities. It is not just in Cork, but in every region across the country.
Mr. Bernard Gloster:
There are two or three things that affect the capacity of the State in responding. Deputy Colm Burke, to be fair, has raised the issue with me previously at the Joint Oireachtas Committee on Health. The modern day regulatory standards for the provision of continuing care for people rightly require very significant capital infrastructure improvements and replacements. In some cases, that has caused a loss of beds. It has caused a much better improvement in the quality of care, but it has caused a loss of beds. We have a continuous programme of building new capacity-----
Alan Dillon (Mayo, Fine Gael)
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I do not mean any disrespect to Mr. Gloster, who I know has been in this role for only a few months. Mr. Mulvany knows the situation because the concerns around private nursing homes, the operation of them and the financial burden associated with that has been raised at meetings of the Committee of Public Accounts and the Joint Oireachtas Committee on Health. Again, we are here today discussing what measures the HSE is taking in this area.
Mr. Bernard Gloster:
The HSE is taking measures all the time to develop its own capacity where and when it can. We have also used private nursing home beds outside of the NTPF nursing home support scheme for short-stay care. We use a lot of private nursing homes for transition care, where we pay the nursing home directly to care for people for periods of between two, three, four, and in some cases, six and eight weeks while their care is transitioning. On the core issue that the Deputy is raising, of the difference in the price per bed or the cost per bed between public and private, that is not for us to comment on. We do not set the rate for private nursing homes.
Alan Dillon (Mayo, Fine Gael)
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Are there plans to review the disparity in the NTPF rates process to address the claims of lower rates for certain providers?
Alan Dillon (Mayo, Fine Gael)
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Can we get clarification on that, Mr. Flood?
Alan Dillon (Mayo, Fine Gael)
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Can the representatives of the Department outline what its supervisory role is with the NTPF, and the extent to which the Department engages with it in relation to these key issues?
Alan Dillon (Mayo, Fine Gael)
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Nursing homes.
Ms Louise McGirr:
In relation to the nursing homes, we are obviously very aware that nursing homes are closing in 2023. However, overall, there continues to be growth in this area on a net basis.
New beds are opening, as well as new residential places. It is difficult for families affected by this if it is not in the locality or the region. It is a priority for the Department that in the event of local closures, they are managed and well planned with access to new residential care. It is also important to note a number of actions taken to support nursing homes, most recently in the last budget which had the temporary inflation fund of €100 million towards the end of the last year. This was dispersed among the voluntaries and the nursing homes to assist them.
Alan Dillon (Mayo, Fine Gael)
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That still does not address the core issue around the disparities in regard to the lower rates being offered to private nursing homes compared with public. Again, we are so reliant on the private sector that we see time and again that they are actually engaging with public representatives in addressing the issue. We are not listening to the challenges they are facing. I would like to get an understanding of the net bed capacity Ms McGirr spoke about.
Alan Dillon (Mayo, Fine Gael)
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Another issue I wish to raise relates to those Ukrainians who have had access to medical cards. There is a lack of available GPs to support the general medical card scheme. How is the HSE addressing the shortage in regard to access to GP services throughout the country in this respect?
Alan Dillon (Mayo, Fine Gael)
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By how much has that increased?
Alan Dillon (Mayo, Fine Gael)
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Is that to cover the existing shortage in the system?
Alan Dillon (Mayo, Fine Gael)
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There is a shortage of GPs. However, we are now talking about those 70,000 Ukrainians and international protection applicants who now have medical cards and are looking for access to GP services. How are we addressing that situation?
Mr. Bernard Gloster:
That relates to the second course of action to increase GP capacity. A number of doctors from South Africa are coming in groups of 25. We already have 25 with a further 25 coming in the autumn. They are qualified doctors. There is an agreement with the Irish Medical Council that by working here under supervision and in partnership with GPs they will after two years meet the registration requirement to become GPs.
Alan Dillon (Mayo, Fine Gael)
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Has there been any increased financial support for GPs or medical centres in regard to addressing the issue? For example, County Mayo has more than 4,000 additional Ukrainians and international protection applicants but we still have not had an increase in the GP count. All of these people have medical cards but nobody is talking about the issue of fair distribution of these guests onto the general medical card scheme. It needs to be addressed.
Mr. Bernard Gloster:
I am not sure whether specific financial supports are targeted at the Ukraine piece in regard to GP care. There are certainly additional financial supports targeted at a number of support mechanisms throughout the local authorities and so on. Overall, however, the issues of eligibility and capitation support to GPs are being negotiated currently with the Irish Medical Organisation, IMO. These negotiations are quite sensitive but are at a very advanced stage. That is in part dealing with the eligibility factor of the number of people who have entitlement to GP visit cards.
Alan Dillon (Mayo, Fine Gael)
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The issue here is out-of-hours services at Westdoc. People are being sent to emergency departments. That is causing huge delays in waiting times. That needs to be addressed.
Brian Stanley (Laois-Offaly, Sinn Fein)
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There is a review going on in regard to that. We raised that previously. In regard to the number of GPs, as was already said, the shortage of GPs and the difficulties in accessing general practitioner services is loading on problems further up the line in emergency department units, and in people not being treated in time. Mr. Gloster stated that 300 extra students are entering training this year. How many would normally be trained? What is the increase? Were there 300 last year? Is this an additional 300? Were there 1,000 last year? I am trying to get a sense of it. Colleagues in the party I represent have raised the issues of workforce planning and pipelines a number of times.
Brian Stanley (Laois-Offaly, Sinn Fein)
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How many would normally be in training? Mr. Tierney wants to give me a figure.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Will it not go further?
Brian Stanley (Laois-Offaly, Sinn Fein)
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Is anyone slowing that down? Is the IMO slowing it down?
Brian Stanley (Laois-Offaly, Sinn Fein)
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That is welcome. However, there are rural areas, not just urban areas, where there are gaps. Trying to fill these gaps will present a huge challenge. As we know, a percentage of GPs are over 55 years of age and will be retiring. Along with the health implications, this has huge financial implications because if an issue is not dealt with at primary care, it is being loaded onto the hospital system, which means a bigger cost down the line with poorer outcomes. An increase of 8% or 9% is not significant. I would have hoped that we were upping to at least double figures of maybe 20%, 25% or 30% or trying to get to that increase in the numbers in training. The issue with Westdoc, and Midoc is another one that replicates the issue and we discussed SouthDoc here in the past, is that we need more GPs to cover those out-of-hours services. We need more people for day surgeries in general practitioner centres throughout the country.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Mr. Gloster, the 8% is pedestrian given the scale of the crisis we are facing in general practice.
Mr. Bernard Gloster:
In fairness, I would not go so far as to say it is pedestrian. It is a targeted initiative to increase the numbers going into training in the general practice programme. The general practice programme in Ireland is one of the most developed and most skilled programmes and while the doctors are in that training, they are already qualified doctors and making a contribution to seeing patients. The added bonus to that is now the two-year scheme for doctors trained outside the EU to come in. That will bring 50 doctors into practice this year alone, separate to the GP. The 9% is just 9% in our training programme. As the assistant secretary said, that will grow well north of 300 by 2026. There will still be pressure. No matter how many GPs we have on the register in Ireland, the nature of general practice and the work pattern of general practice is fundamentally altered from what it was.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I am aware of that.
Mr. Bernard Gloster:
That is going to affect such issues as out-of-hours availability. Finally, last year and this year, another support to general practitioners, apart from the direct payments to them, has been a substantial increase in their direct access to diagnostics. Therefore, they do not have to send people to hospital. There has also been a substantial increase of allied health professionals with more than 2,000 now working directly in primary care accessible to GPs such as physiotherapy, occupational therapy, speech and language therapy and community nursing, with specialist services available to GPs only for chronic disease management. Substantial efforts have been made to increase support. To be fair to Deputy Dillon, there are parts of Ireland where it is seriously challenged.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Yes, and the midlands as well. We have outlined the situation in the west. The increase in population has added further pressure. We have highlighted this in regard to management, governance and planning. It really is an area on which we need to go hell for leather to try to increase it.
Brian Stanley (Laois-Offaly, Sinn Fein)
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The committee will now resume in public session. Deputy Ó Cathasaigh is next.
Marc Ó Cathasaigh (Waterford, Green Party)
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I thank the many officials for attending and for their opening statements. While I know other Deputies have done so already, it is worth thinking back to the context for this. We were faced with an unprecedented global pandemic and the political landscape was such that we were in an interregnum. We had held a general election but a new government had not been formed. That is probably pertinent in that some of what could be described as the looseness of procurement processes might not have been thus had there been a permanent government in situ. I am not sure if that is true but what we have seen reminds me of the quote from Mike Tyson, "Everyone has a plan until they get punched in the mouth". All across the globe we saw that whatever emergency plans and emergency systems were put in place were stress tested beyond anyone's expectations.
I would not say that this means that there is no point in crying over spilt milk. I will come back later to the spilt milk element because a significant amount of public money has been wasted through this procurement process but the most important aspect is the lessons to be learnt. The emergency response procurement system has been stress tested in a way that none of us could have anticipated and lessons must be learned from this.
One thing that leapt out from the page for me was the issue of a centralised assets register. Do we now have a centralised assets register? What steps have been taken to put one in place? How was the assets registers maintained at the time? Was it by hospital group or by healthcare area? Are the registers on compatible systems? We hear again and again that we have incompatible systems that will not talk to one another. If that was, or still is, the case then it is something that needs to be resolved.
Mr. Stephen Mulvany:
The Deputy is correct. We do not have a single financial system and therefore we do not have a single financial assets register. Registers are kept by the individual areas on the systems of the former health boards and by the individual voluntary bodies. The HSE's integrated financial management system, IFMS, project will deliver 100% of the HSE onto a single instance of a national financial procurement system during 2025. The first go-live date for that, for about 40% of the country in the east, is 3 July this year. However, as the report calls out, we did have a centralised database held by our national clinical engineering division as part of estates which turned out to be accurate to within 2%. There was a difference of about 15 ventilators in the count between that central unit and what came back from hospitals. The totals were somewhere in the order of 713 versus 730.
Marc Ó Cathasaigh (Waterford, Green Party)
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It took some time to figure out that the information was available in some format, somewhere. Is that right? It was not immediately at the HSE's fingertips when the executive went to procure.
Mr. Stephen Mulvany:
It was not immediately at our fingertips because there was not a centralised register. However, the central clinical engineering database was immediately at our fingertips because that was and is maintained. It is just not an asset register in the sense of being a financial system asset register. It was a reliable list, centrally maintained by a clinical engineering team, of ventilators and as I said, it proved to be 98% accurate.
Marc Ó Cathasaigh (Waterford, Green Party)
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If we are still in a situation where our lists of assets are being maintained on a hospital by hospital basis, does that mean we have duplication of assets and the possible under-utilisation of those assets? If we had oversight by the HSE or the Department of Health of where exactly our assets are, we could sweat those assets or at least make sure that they are properly deployed and utilised at all times. We have stresses and strains all across our health system so if we have assets in hospitals that could be maximised by being used elsewhere, or by being shared, we should know about it. I know that not all of these assets can be physically shared in that way but why are we not driving at this as a matter of urgency?
Marc Ó Cathasaigh (Waterford, Green Party)
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We have had the HSE for a long time.
Mr. Bernard Gloster:
Yes, for 18 years and within that, there have been at least five iterations of structure within it. There is, with the support of the Department, investment now in a national system specifically for estates because we do recognise that there are issues. A question came up earlier about learning and we do recognise the learning in the very point the Deputy is making. That will give us a very significant handle on the totality of estate and assets that can be better used to reduce duplication and be shared. That will run parallel to the IFMS.
Marc Ó Cathasaigh (Waterford, Green Party)
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I want to go back to the spilt milk component. We are talking about a sum of €30 million where no benefit or value has been received from its expenditure. At the time of reporting, €22.3 million was still being pursued. Is there any update on that since the time of reporting? What proportion of that can the taxpayer realistically expect to see a return on?
Mr. Bernard Gloster:
We dealt with an aspect of that in response to an earlier question. The sum of €22.3 million is already down from just north of €50 million. The recovery of approximately €30 million has already taken place through different types of arbitration. Predominantly, the €22 million has been pursued through the various mechanisms that are available in the country of origin of the companies, which is the Chinese legal system. I am sure the Deputy will appreciate that it would not be helpful for us to indicate that we are pursuing anything less than the total amount but there would be a concern as to how much of all of that we would actually recover.
Marc Ó Cathasaigh (Waterford, Green Party)
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It is entirely reasonable for Mr. Gloster to say that the HSE does not want to write off any of that in the context of legal proceedings but there must be some expectation, without referencing any individual, because I am sure that is over a number of individual pots. That said, I can grudgingly accept that Mr. Gloster is not in a position to state how much we can expect to recover.
In terms of the €8.1 million that is not recoverable, I want to dig down into a case listed in the appendix involving 102 ventilators from China which are in quarantine due to quality-related issues and which were the subject of dispute resolution attempts. We are talking about 102 ventilators that were paid for but which could not be used because they were not up to standard. I ask the witnesses to give us a sense of where they came through. We had established suppliers which were tried and tested routes. We felt the need to go beyond established suppliers in this scramble for resources so we had three companies that were mediated through IDA Ireland and a further seven intermediary companies. Due diligence was carried out on six of those companies but not on the other four. In the case of those 102 ventilators, what route did they arrive through? Did they arrive through established providers?
Marc Ó Cathasaigh (Waterford, Green Party)
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Did they come through one of the companies that due diligence was done on or one of the companies that it was not done on?
Marc Ó Cathasaigh (Waterford, Green Party)
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Is Mr. Mulvany saying that the 102 ventilators came from multiple sources?
Mr. Stephen Mulvany:
The 102 ventilators are part of 467 ventilators that came from those unestablished or new suppliers, and 365 of them went to India. The 102, a subset of the 467, were tested and, as we said, a lot of them failed. They came from a number of sources. Those problematic orders with the newly established suppliers were a mixture in that in some cases due diligence was done or, as the report states, there was no due diligence or there was a high-level risk assessment, if anything, so-----
Marc Ó Cathasaigh (Waterford, Green Party)
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Is Mr. Mulvany telling me that, across multiple orders, a certain proportion or percentage of the ventilators within each batch was found not to be up to scratch? As I read 102 ventilators, I thought that must have been one consignment, we got it from one place and it was the wrong place to source it from, but he is telling me now that a certain percentage of multiple batches were found not to be compliant.
Mr. Stephen Mulvany:
I would have to check the details. It is probably here somewhere in the data. The 102 represent four or five models that came from, I think, two suppliers, possibly three. When I say suppliers, that does not mean the original manufacturer; it means in many cases an intermediary we got them from.
Marc Ó Cathasaigh (Waterford, Green Party)
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Because time against is me, I want to put a quick question to the Department of Health. It was known that only an additional 326 ventilators could be deployed because ventilators do not operate on their own; they need to operate within a hospital system, with a bed and all the supporting staff around them. Yet 1,900 ventilators were sanctioned. That is quite apart from the fact that the Department then tried to procure 3,500 ventilators, which is ten times what we needed. Why did it sanction the purchase of five times the number we needed?
Mr. Stephen Mulvany:
As to why we asked for that sanction, the HSE wrote to the Department on 20 March-----
Marc Ó Cathasaigh (Waterford, Green Party)
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It was the Department that asked for a sanction of 3,500, which was double the 1,900.
Marc Ó Cathasaigh (Waterford, Green Party)
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The Department placed orders-----
Mr. Stephen Mulvany:
We asked for it on 20 March. We started ordering on 6 February, if the Deputy remembers. As the report states, clarity on the actual number, in terms of modelling of the ICU demand, was available to us when the minutes of Professor Nolan's modelling group became available on 15 April, so it is all-----
Marc Ó Cathasaigh (Waterford, Green Party)
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It is 1,900 versus 326. I would accept that kind of argument if it were 326 versus 500.
Mr. Stephen Mulvany:
With the greatest of respect, the Deputy would have to have been there at the time and involved in the discussions. There was not clarity at the time as to how many would need to be ventilated, what ventilation would mean or what standard of ventilation would be appropriate, given the potential numbers, which we did not know. Again, there was no vaccination. There was a whole conversation, medically and ethically, about what ventilation would mean-----
Marc Ó Cathasaigh (Waterford, Green Party)
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But we had a finite number of staff.
Mr. Stephen Mulvany:
We had a finite number of staff in the traditional notion of how we did ventilation, but we were faced with scenes from Italy where anaesthetists were telling us how they made decisions as to who they could and could not ventilate because they did not have enough ventilators. There are different ways to ventilate people. Ultimately, it became clear that our surge capacity was approximately 328 and an extended surge capacity was a number somewhere in the 500s, but that was not clear until after we had made these orders. As soon as it became clear, we were cancelling orders. As I said, we took the risk on the procurement and financial side to avoid a potential risk on the patient side.
Marc Ó Cathasaigh (Waterford, Green Party)
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May I put a further short question?
Brian Stanley (Laois-Offaly, Sinn Fein)
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Yes, briefly.
Marc Ó Cathasaigh (Waterford, Green Party)
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As I said, as regards learning, whether we use the words "misleading" or "difference in understanding" as to how they were reporting, have the HSE and the Department adequately resolved the expectations of the Department of Public Expenditure, National Development Plan Delivery and Reform as to how this type of reporting will be done in the future? Have the HSE and the Department resolved that between themselves?
Mr. Eoin Dormer:
As I said to the Deputy earlier, we looked earlier this year at the way the health budget oversight group operates and we have tried to tighten up on the frequency and quality of information we get. It is not just through that mechanism that we engage with colleagues; it is also with colleagues in the Department of Health and the HSE outside of those forums. Ultimately, we are reliant on the information we get to have those discussions.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I will go back to the home care supports in the context of the current situation and the question about the cost of the ones directly employed by the HSE. We know there is a figure reported in respect of the private ones and what has been asked for, and I do not want to get into that too much. There are figures put out there, but what about the HSE ones?
Brian Stanley (Laois-Offaly, Sinn Fein)
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What is the breakdown of that between voluntary-----
Mr. Bernard Gloster:
I do not have that. Some 62% is outsourced because they also work in consortiums to try to cover the full footprint of a county, but I will certainly get that breakdown for the Cathaoirleach. The HSE provision, then, is just under 38% direct. The best estimated cost of providing a HSE hour is €28.32. That includes a number of headline costs such as supervision, management and so on. The actual rate we pay our staff is on a scale of €15.60 up to just over €20 per hour. We have, I think, somewhere in the region of 5,300 people. There would be about just over 3,000 whole-time equivalents in that directly employed as healthcare assistants or home helps or home care providers by the HSE. There have been various quoted rates as to what we pay per hour to the private sector and, just given the scale of where we are at today, I would rather not hang to one.
Brian Stanley (Laois-Offaly, Sinn Fein)
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That is okay. I certainly do not want to impinge on that. The €28 per hour, all in, would compare very favourably, judging from previous replies and partial replies I have received to parliamentary questions and here in this forum to the effect that the ones directly employed by the HSE are cost-effective and directly under the control of the manager of the home help organiser. I acknowledge as well that they provide a great service. The feedback is very good. Obviously, we understand the importance of the home help or home care worker, as they are now called. Certainly, I am a big advocate for keeping people in their own homes as long as possible. It is cost-effective. In terms of quality of life, it is better. It is where they want to be and so on, and it takes pressure off because we have a shortage of nursing home beds. We know that from the previous discussion. In that regard, there are a lot of restrictions, some of which I suppose are necessary, as to what the home care worker can do. My mother was one.
Brian Stanley (Laois-Offaly, Sinn Fein)
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She was one of the first of them when it came into being, first,l doing it for nothing, and then there was a very small sum for it. I think a cheque used to come once a month, but it was a very small cheque for looking after two people. What can the home care workers do? It is very restrictive.
Brian Stanley (Laois-Offaly, Sinn Fein)
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It is overly restrictive. Compared with other countries, we seem to tie ourselves up in knots here as to what we allow people to do, and it has consequences. I know there have to be rules, particularly around handling vulnerable elderly people's finances, their shopping and so on, but it just seems that it is holding back that system. The system, I believe, could do an awful lot more, save us an awful lot of money and even provide a better service. Would Mr. Gloster like to comment on that?
Mr. Bernard Gloster:
Absolutely. I underscore my comments with the Cathaoirleach's. The majority of home care staff, be they employed directly by the HSE or by not-for-profit or for-profit organisations, are really good, well-trained, decent, kind people. We can never lose sight of the value of that, apart from the core task. I can go back to my previous life as a chief officer in the HSE, and the restrictions on tasks came from the time of the financial crash, when the amount available to provide services was capped and we had years when there were no developments. To meet the best possible demand, an assessment of need was introduced for the person receiving the service, and they received a service in respect of their personal care. That took out elements of social interaction, which I think the Cathaoirleach has mentioned, that would have an added value in quality of life. We understand that, but when there is the demand we have and the availability of the hours we have - and we have 6,000 people waiting - we try to condense the tasks to the essential personal care and clinical tasks to get to as many people as possible.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Did Mr. Gloster say the HSE has 6,000 home care workers directly employed-----
Brian Stanley (Laois-Offaly, Sinn Fein)
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Is that the reason, the shortage of staff, both private and directly employed, that the HSE had to limit that?
Brian Stanley (Laois-Offaly, Sinn Fein)
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Is that done by the public health nurse?
Mr. Bernard Gloster:
It is usually a public health nursing assessment but sometimes it can be informed by other clinical views. To get the best use of it to the greatest number of people possible, it is restricted to the very significant personal care tasks a person has a dependency on. The Cathaoirleach would not find anybody working in the Irish health service disputing with him that if we could do more over time and move on to elements of social care, we would.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I want to go through with Mr. Gloster the finances, planning and all of that. From the figures he has given, it is very cost effective and competitive to have home care workers. From talking to regional managers, I know there is a challenge with recruitment. They tell us there is a problem with recruitment. There was a round of recruitment that passed me by and that I never heard about. In some areas they are having a second go at it to try to increase the numbers on panels and to employ people. Many people would do that job. It is tailor-made for people who are in part-time employment in smaller towns and villages, but one of the key points is to keep them in their local area. Some of the private providers were sending them ten miles to one person and five miles to another person and they all had to be done within the same hour, which is not feasible. We are trying to organise it in clusters so that insofar as possible people would be dealing with an area close to where they live, but also that the times are as close as possible to each other. I know it is hard to always get it right, but staff retention is an issue, although not so much with the HSE carers. I know people who have left because of that. They just could not keep up with the regime. I just want to highlight that for Mr. Gloster.
Mr. Bernard Gloster:
Home help organisers generally and home support managers across the country make every possible effort to get the best use out of what is available from a person. Most of the staff we employ directly are part time because it suits them and the hours suit them. We take the hours we can get from them.
Brian Stanley (Laois-Offaly, Sinn Fein)
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We have an ageing population. We all know the demographics. Could we look at having a national campaign to try to increase the numbers? I am told by some people in the HSE that it is the intention to try to increase the percentage of HSE carers directly employed. There are obvious reasons in terms of management and all of that and financially as well. The HSE would be doing okay with it. I ask the question of Mr. Gloster, as CEO of the HSE, and his management team. Mr. Tierney or Ms McGirr could also come in on it. Is it the intention to try to increase that percentage?
Mr. Bernard Gloster:
It is. That is reflected in the fact that the contracts the private providers have today include a clause that at any time when we have the capability, we can move to direct public provision ourselves. It is in the contemplation of potentially having a statutory home care scheme that the HSE, the Department and the State would build capacity right across what are currently the nine community healthcare organisation, CHO, areas.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Are there plans in place to increase that number? I see Ms Hoey from HR is looking at me. Are there plans in place to do that?
Brian Stanley (Laois-Offaly, Sinn Fein)
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Will that be actively pursued? One point I would make to Mr. Gloster is that we are not aware of everything. My attention has not been drawn to any campaign to try to employ people as home help or home care workers. I am not saying that has not happened. There have been recruitment campaigns, but I think the HSE needs to up the profile of it. Home care needs to be held up to workers as a career option.
Mr. Bernard Gloster:
That is why we now use healthcare assistants. We use a certain level of Quality and Qualifications Ireland, QQI, training for them. It is recognised as a significant professional contribution. All of that lifts the standard and attractiveness of it, but there is a history in some parts of the country of providing it directly and not in others. Where we can add most is where there is already a history of providing it because we can promote it with word of mouth. The Chair's point is a very fair one.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Does Ms Hoey want to comment briefly on that?
Ms Anne Marie Hoey:
I concur with what the CEO says. Over recent years we have seen some increase in the number of directly employed home help workers, but there are different models in place. In some areas it is predominantly provided by home care providers but in other areas it is predominantly directly employed HSE workers.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Does the HSE have a target of 50:50 or does it want to tilt the balance the other way in terms of 60:40 in favour of the HSE?
Brian Stanley (Laois-Offaly, Sinn Fein)
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It will be as hard as the question I am asking.
Brian Stanley (Laois-Offaly, Sinn Fein)
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As the head of HR, does Ms Hoey have a target to work towards?
Ms Anne Marie Hoey:
I do not have that to hand at the moment but we will certainly look at that. It will be an incremental shift away from the model that exists in some areas at the moment for outsourcing towards directly employed staff and putting in place the supports that are required then for directly provided home support.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I thank Ms Hoey. I want to go back to ventilators for a moment. There were 55 ventilators in the private hospitals, but they did not seem to figure. Mr. Mulvany might want to answer this question because, in terms of continuity, he was there at the time. Why did they not seem to figure in the calculations?
Brian Stanley (Laois-Offaly, Sinn Fein)
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I am asking about the 55 ventilators.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Okay, but the number I got was 55.
Brian Stanley (Laois-Offaly, Sinn Fein)
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But that was not counted in the assessment of what the HSE had that could be used.
Brian Stanley (Laois-Offaly, Sinn Fein)
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It was relevant at the time in that the fact we had 48, 50 or whatever extra ventilators in the State would have been a factor in terms of the calculation of what we needed. We needed 326 extra ventilators. That is what the established capacity was.
Brian Stanley (Laois-Offaly, Sinn Fein)
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What I am saying is that those could have been requisitioned in a national emergency. Surely if we were able to take over the hospitals, the public system could have used their ventilators. Does Mr. Tierney want to add anything?
Mr. Derek Tierney:
I think it is a fair point. The Comptroller and Auditor General, Mr. McCarthy, has covered it in the summary of his report that it was recognised within the arrangements under discussion with the private hospitals that there were 55 – 48 and seven - ventilators available. The report also points out that they would not be available until at least April to June, over a three-month period. In fairness to colleagues in the HSE, they were looking at what was currently in stock, what the projected surge demand might be, and trying to forecast how to fill that impending gap.
Brian Stanley (Laois-Offaly, Sinn Fein)
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They were not included in the figures.
Mr. Seamus McCarthy:
It was under a temporary arrangement. The surge planning was looking forward over a longer period and therefore, if you like, the HSE was trying to gear up with its own equipment. It was not necessarily counting on having those available in the long term. I think that was the point, which was reasonable. We are certainly only talking about 48 in the ICUs and there were seven in ambulances.
Brian Stanley (Laois-Offaly, Sinn Fein)
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My point is that it is significant that they were there in terms of filling in for an emergency situation.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I want to ask briefly about personal protective equipment, PPE, generally. There is €485 million of unsuitable or obsolete equipment in storage. It includes hand sanitisers, gowns and protective suits that, along with the ventilators, we will not get a benefit from. It is a high figure. I know the context. I always acknowledge the work that was done during the pandemic. On a global scale we fared better than most, considering we were at the epicentre of it in Europe. This State did well. Of course mistakes were made but overall we did well. There is €500 million of a hangover. Masks are an issue that bothered me at the time.
We were being told not to wear masks. I know we had to take the Chief Medical Officer’s advice on it, but looking at those interviews with people on television, I was not convinced, as a non-medical lay person, that we should not be wearing masks. It would appear the reason was they were needed in the hospitals, which I accept, but other countries told people to make masks. I am not sure that was dealt with - I do not want to use the word “honestly” - but I thought it was a bit disingenuous at the time that we were told in March and April not to wear masks and by June, if I recall, we were told to wear masks.
With regard to mask supply, I was shocked that the only place on God’s earth that we could get masks was to send Aer Lingus off to China. At this point, I do not want to go back over that and I know we were in an awful emergency, and ten out of ten for the huge efforts made by staff in terms of trying to meet that emergency. However, in the here and now, this is what is important. If we needed millions of masks tomorrow morning, where would we get them from? I am just giving that as an example and it could apply equally to gowns and protective clothing.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Some of it is obsolete.
Mr. Stephen Mulvany:
Some of it is obsolete now but it was not when we bought it. The vast bulk of that impairment charge, as the Comptroller and Auditor General will confirm, was price impairment. In other words, we bought it at a price and we would have preferred had we not had to buy it at that price, but we were not in arbitrage. We were not saying we would not buy it at the time and that we would wait until the price went down. We bought it at a price and, simply in technical accounting terms, when it was still in stock at the end of the year, we had to write down the price. That is what the vast bulk of that €484 million is. We could wish we had bought it cheaper but we did not.
On the Chair's comments on the masks, that is for a different committee or different day.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I know that.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I am asking if, in May 2023, we needed millions of masks tomorrow morning, let us say there was a Covid mark 2-----
Brian Stanley (Laois-Offaly, Sinn Fein)
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Here in this State?
Mr. Stephen Mulvany:
Our strategy now is on-island, so there is more production and we have bought more from local producers. There is near-shore, in other words, EU manufacturers have stepped up, and then, we have put the far shore, that is, the Asia market and the Chinese, at the very end of a list where we would hope we would not have to go for the obvious reasons of time and distance and so on. There are efforts to be able to produce and buy closer to home.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Many small manufacturers stepped up to the plate at the time in providing stuff, including gowns and protective clothing generally. I do not expect ventilators to be produced at every crossroads, but within the EU, are ventilators being produced?
Brian Stanley (Laois-Offaly, Sinn Fein)
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So we now have good supply lines of masks and equipment, including gowns and those basics.
Brian Stanley (Laois-Offaly, Sinn Fein)
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It was terrible to watch. I know one facility very close to me where many people died over a weekend and the protective clothing was not available. It was in the worst part of the emergency. We cannot do anything about that but, going forward, it is that we do not get ourselves into that situation again where we are depending on somebody to go to China and use a contact they have there, who may be an unreliable one. That is all.
Mr. Bernard Gloster:
The important point is to accept the observation the Chair is making about our resilience now and, as the chief financial officer said, the capacity for indigenous supply is much better than it was. That is not to say we would not arrive at a point where we might have a challenge on a particular issue in the future but it is certainly much better than it was, and there are huge learnings on that.
Brian Stanley (Laois-Offaly, Sinn Fein)
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It is not a case of trying to be nativist and I am not trying to do that.
Brian Stanley (Laois-Offaly, Sinn Fein)
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It is about the practicalities and efficiency.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I call Deputy Brady.
John Brady (Wicklow, Sinn Fein)
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I want to look at the issue of the emergency departments, EDs. What is the average waiting time for someone who presents in an emergency department?
Ms Mary Day:
The PET is the patient experience time. There is variation nationally. What we are aiming for is that patients wait in an emergency department and are seen and treated and either discharged home or transferred to the ward within a six-hour timeline. There are national targets in that regard and about 56% to 60% of patients meet that timeline. We then have a further timeline of nine hours, which is a higher percentage, going up to 75%. Then, unfortunately, we have patients who breach the 24 hours, but that is all dependent, as the Deputy can imagine-----
John Brady (Wicklow, Sinn Fein)
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Sorry to cut in but I am conscious of time. There is a figure that the average waiting time is about 12 hours.
John Brady (Wicklow, Sinn Fein)
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It is considerably higher than the six hours.
John Brady (Wicklow, Sinn Fein)
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On the number of people who leave emergency departments without getting into triage or going further, are those figures recorded?
John Brady (Wicklow, Sinn Fein)
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Do we have figures for January or February or for the first quarter of this year?
Mr. Bernard Gloster:
To reflect the context of those people who are coming in, during the first quarter of this year we had 350,000 ED attendances, which is up from 345,000 the previous year and it is higher than the five-year average, which is 307,000 for that period. Therefore, the numbers are going up exponentially and that will affect and drive waiting times, and I have no doubt it may reflect some of the experience where people leave before their treatment is concluded.
John Brady (Wicklow, Sinn Fein)
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I ask the HSE to come back to us with those figures. I think the witnesses would agree that one person leaving an emergency department because they are not being seen to is one too many.
John Brady (Wicklow, Sinn Fein)
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Another area I want to touch on is the dental treatment service scheme, DTSS, and the complete collapse, it has to be said, of that service over the past five years. Has the HSE concerns about the collapse within that service and the implications for medical card holders?
Mr. Bernard Gloster:
There is no doubt the oral health strategy the Department of Health has produced, in conjunction with input from the HSE and from the profession, is the direction of travel, but it is challenging within that and there is no doubt there are challenges within the DTSS.
John Brady (Wicklow, Sinn Fein)
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I am not sure if Mr. Gloster has the figures to hand. I know that in 2017 there were 1,660 dentists participating in that scheme. Do the witnesses have the current figure?
John Brady (Wicklow, Sinn Fein)
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To be helpful, the latest parliamentary question reply I received has a figure of 1,052 in March of this year, so it is more than a 30% decline nationally in dentists participating. If we drill down into those figures, obviously, there are areas that are proportionately much higher in terms of the impact. If we look at my own constituency, which is covered by LHO 7, there is a 70% reduction in dentists participating in the scheme, down from 40 in 2018 to 16 now. I think Mr. Gloster would agree that is alarming, to say the least.
John Brady (Wicklow, Sinn Fein)
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I have some questions for the Department representatives. This is not a crisis that has developed overnight. There is a timeline over the past five years where there has been a downward spiral of dentists participating in the scheme.
What actions are being taken by the Department to address this major crisis, which is impacting so many people in terms of access to dental services?
Ms Louise McGirr:
I thank the Deputy for the question. There is a new dental strategy and significant investment in dental in the 2023 budget. I am looking through my brief to get those figures around the level of investment, so I will commit to getting those to the Deputy afterwards. We accept that services are not where they need to be. Increasing those services is a key priority for the Minister and for the HSE. There are a range of things happening. It is also dealt with through some of the waiting list funding for dental care, as well as delivery of the dental care strategy. If it is okay I will try to get the details during this meeting and come back with figures.
John Brady (Wicklow, Sinn Fein)
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Is there an ongoing process of engagement with representative organisations for dentists to try to address their major concerns around the scheme? Those concerns date back to the early 1990s, when this scheme was put in place.
Mr. Bernard Gloster:
There is engagement to try to ensure not just probity but also consistency. There is a national lead for oral health in the HSE. It is not left to local negotiation to try to achieve consistency in terms of both standard probity and the supports available to people.
John Brady (Wicklow, Sinn Fein)
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When can medical card holders, who rely on this scheme, expect to see a service in place so they do not have to travel from one end of the constituency to the other or into neighbouring counties to find a dentist who is participating in the scheme? When will people start seeing a tangible benefit in terms of accessing a dentist participating in this scheme?
Mr. Bernard Gloster:
With regard to what the Department has said about the overall strategy and increased investment in it, there will be incremental improvement. I could not nail it today and say when exactly there will be substantial improvements in the number of dentists participating in the DTSS.
John Brady (Wicklow, Sinn Fein)
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When it comes to the haemorrhaging of dentists participating in that scheme, is Mr. Gloster happy that we will not see a further bottoming out?
John Brady (Wicklow, Sinn Fein)
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That is not very reassuring.
John Brady (Wicklow, Sinn Fein)
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They have no faith in the scheme.
Mr. Bernard Gloster:
As I say, every effort is made to improve on that. Our wish is that maximum access exists for people to access dental care, like there is in HSE dental services from the time children go to school and so on. I do not dispute the Deputy's concern.
Brian Stanley (Laois-Offaly, Sinn Fein)
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What happens in the case of people who cannot access the DTSS and it is not available? What happens there? Where does somebody go who is on a medical card and needs emergency treatment?
Brian Stanley (Laois-Offaly, Sinn Fein)
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In most areas. Is that accessed through the local health centre?
Brian Stanley (Laois-Offaly, Sinn Fein)
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The Deputy referenced a 70% reduction. In the county where I live there has been a 100% collapse. There has been no dentist for a considerable period of time. I raise it at every meeting, as Mr. Mulvany will confirm. There is absolutely no dentist who will take on a patient under the medical card scheme. There is one dentist who still has a handful of people on medical cards. That is the last one, and he is definitely not taking on any new ones. There is nowhere to go. Has the Department considered employing dentists directly in a situation like that? Can another couple of dentists be employed to fill that gap?
Brian Stanley (Laois-Offaly, Sinn Fein)
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I know that. I am talking about adults in the medical card scheme accessing the DTSS.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Can Mr. Gloster come back to the committee on that?
Verona Murphy (Wexford, Independent)
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On that I will give Mr. Gloster the benefit of the doubt. He has a lot to get through, but he will be here next year. There is no dentist in County Wexford taking part in the DTSS. There was an 80-year-old man this time last year who pulled four of his own teeth because we do not have an adult emergency service in County Wexford. Ms Queally might also consider that when she is discussing the DTSS. It has been raised in the Dáil a number of times. There are umpteen promises. We are told there has been €20 million in extra funding, which brings the funding to €60 million. That leaves a deficit of €20 million compared to what they were getting ten years ago. It is not rocket science. I tell the witnesses not to come back next year and make the same statement, please.
I have a question for Mr. Mulvany on the subject of reporting. If we are going to make progress the committee needs to understand, from the perspective of the public purse, how a report was generated which left out so much financial information that it misled the Department. How do we have an IT system in the HSE? That is a straightforward question. I do not want dates or waffle. I want an answer, because I have five minutes.
Verona Murphy (Wexford, Independent)
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I did not ask you that now. I asked how do we have a report-----
Brian Stanley (Laois-Offaly, Sinn Fein)
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Sorry, Deputy----
Verona Murphy (Wexford, Independent)
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Chair, I asked a straight question.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Mr. Mulvany will reply to the question.
Verona Murphy (Wexford, Independent)
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What do you mean you established it quickly? Do you not have it all the time?
Mr. Stephen Mulvany:
Like most public sector organisations, we report monthly in financial terms. Because of Covid and because of the extra moneys involved, the HSE decided to add an additional set of weekly reports, referred to as flash reports. Indeed the Department was happy for us to do it.
Verona Murphy (Wexford, Independent)
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But it left out the information-----
Verona Murphy (Wexford, Independent)
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I do not have to remember anything. I will read this again. This is for you, Mr. Gloster. While Mr. Mulvany is the financial officer, the buck will stop with Mr. Gloster and with Mr. Watt when he decides to appear. According to the Comptroller and Auditor General's special report:
The report only included expenditure for ventilators that had been delivered and did not include the payments in advance and refunds received from cancelled orders.
Why? What is wrong with the system?
Verona Murphy (Wexford, Independent)
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I have read what the report said.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Deputy, I want to-----
Verona Murphy (Wexford, Independent)
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He is avoiding answering the question.
Brian Stanley (Laois-Offaly, Sinn Fein)
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No, no. Sorry, just stop for a second. No, sorry. I am allowing the Deputy to ask the question, to pursue it and to drill down into it. However, the witness must be shown respect and he must be allowed the opportunity to answer.
Verona Murphy (Wexford, Independent)
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But sure he is not answering the question.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I want to give him the opportunity.
Verona Murphy (Wexford, Independent)
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At the outset I said I did not want any waffle. I wanted an answer.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Allow the witness to answer the question, please. I think it will be beneficial to the Deputy, the committee and everyone.
Verona Murphy (Wexford, Independent)
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If we get the answer.
Mr. Stephen Mulvany:
First, the flash report sets out the basis of reporting generally. Second, it tells - specifically about ventilators - the basis for the expenditure reported; that is, ventilators actually received. Third, in note 12 it clearly said on 27 March that the full €73 million was committed. Finally, as I said earlier, in hindsight would I prefer if we had also put a cash payment amount in there? Yes. That would not be normal in accounting terms. Do I believe anyone was actually misled? No. Was there any intention to mislead? Absolutely not.
Verona Murphy (Wexford, Independent)
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Right. Can Mr. Mulvany tell me this then? I love the way you accept everything. In 2017 and 2018, this committee made recommendations relating to guidelines. The Committee for Public Accounts requested that the then Department of Public Expenditure and Reform amend guidelines concerning advanced payments. Yet, it would appear there was no express guidance issued.
Verona Murphy (Wexford, Independent)
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I was asking this of the officials from the Department of Public Expenditure, National Development Plan Delivery and Reform. No guidelines were issued, which is clearly how this has arisen. Have we guidelines now?
Verona Murphy (Wexford, Independent)
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After the event, but we do have them now.
Verona Murphy (Wexford, Independent)
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Will they be provided to the committee?
Verona Murphy (Wexford, Independent)
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That is grand. Going back to Mr. Mulvany, can reports still be generated with information deficits that would mislead, intentionally or not?
Mr. Stephen Mulvany:
I do not believe that anyone was misled. However, you can always have problems with reporting and its interpretation. We are always trying to improve the quality of the reports. We have done a lot to improve the quality of the reports. The IFMS goes live in the east of the country on 3 July. It will be everywhere in the HSE, on 100% of our services, by 2025. That will be another step up in terms of improvement, but we do not wait for that. We report as clearly and comprehensively as we can. We do not just send reports. We also account and turn up for meetings. We discuss the information and hear what further information people want. We then do our best to provide that.
Verona Murphy (Wexford, Independent)
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Then it just seems highly coincidental that this happened, I suppose.
Verona Murphy (Wexford, Independent)
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In the report, it was stated that they included only the ventilators which had been delivered, not the ones which were paid for in advance, or for which refunds were received. It is just very strange, and I am sure people will make up their own minds. Anybody looking in will find that strange, I am sure. Mr. Mulvany does not, clearly, but then, that is probably part of why we are where we are. These things just keep happening.
Verona Murphy (Wexford, Independent)
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Advices issued by the Committee of Public Accounts are ignored for 2017 and 2018, and then this arises. We lose €30 million, of which we have to follow €22 million of through the legal system, and then we get guidelines. It is absolutely atrocious, Chair. Could I ask Mr. Gloster who in the committee here is responsible for section 39 funding?
Verona Murphy (Wexford, Independent)
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Is there anybody here with whom the buck stops with regard to it?
Verona Murphy (Wexford, Independent)
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There is nobody here today.
Verona Murphy (Wexford, Independent)
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Ms Queally.
Verona Murphy (Wexford, Independent)
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That is grand. The question I have then for Ms Queally is, were funds sanctioned last October to a section 39 called Windmill Therapeutic in Wexford? The funds were never received. Is there a reason for that, and is Ms Queally aware of that now?
Verona Murphy (Wexford, Independent)
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If it closed its doors and left a couple of hundred service users without a service, would Ms Queally be aware of it?
Verona Murphy (Wexford, Independent)
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What does Ms Queally mean by a service arrangement?
Verona Murphy (Wexford, Independent)
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I reported to the Minister for Health in October. The Minister visited the facility with staff from the HSE, or had a visit with them in November, and sanctioned the funding. We are at the middle of May. The funding has not been received, and it is about to close its doors.
Verona Murphy (Wexford, Independent)
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I have three more, Mr. Gloster.
Verona Murphy (Wexford, Independent)
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Yes, and the parliamentary question, the answer and the letter from the Minister is here.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Okay, that would be appreciated, if Mr. Gloster could help the Deputy with that. I call Deputy Colm Burke.
Colm Burke (Cork North Central, Fine Gael)
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I would like to follow up on what Deputy Dillon raised earlier on about the cost of nursing home care. He raised the one issue in relation to Cork, where 73 beds have now been withdrawn from the fair deal scheme. We now have a problem. We have 73 people who do not have beds from now on if they cannot pay for it themselves.
I would like to raise the issue with regard to Laois. The average cost of a nursing home bed in the HSE system is €2,585 per bed per week. That is €600 higher than the cost of a bed in Dublin, and it is €1,500 higher than the cost of a bed in the private sector. My understanding is that there is one facility in Laois where beds costs €4,500 per bed per week. Can I have a report as to why that is arising? I know Mr. Gloster cannot give it to me here but I ask that it be given to me. If one looks at this, if what I am being told is true, then for €45,000, ten patients are being looked after per week-----
Colm Burke (Cork North Central, Fine Gael)
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-----in a public facility, whereas a private facility will look after 45 patients for the same cost.
Colm Burke (Cork North Central, Fine Gael)
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Can I ask Mr. Gloster for a report on that? There was a 10.3% increase in the cost of public nursing homes between January 2022 and January 2023. What I am concerned about is that for the private sector, which is only getting €1,000 per bed per week, the increase was only 3%. Yet, here we have €2,585 per bed per week in Laois.
Mr. Bernard Gloster:
There are two things which will affect the percentage and cost increase in a public bed. First, in the older public community nursing units, the number of residents being cared for has reduced because of things like regulatory compliance issues, which I mentioned earlier, and available rooms and space-----
Colm Burke (Cork North Central, Fine Gael)
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In fairness now, over €2,500 per bed, per week. It says something, and that is the average cost in Laois. One of the reasons for that average cost is that if one has a facility which was costing €4,500 per bed, per week, then when one averages it out over the three units, one is having problems.
The second thing that I want to ask-----
Colm Burke (Cork North Central, Fine Gael)
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I know that, but what I am saying to Mr. Gloster that is if one is costing 150% more in a public system, then one is depriving other people of care, because one could look after a lot more people with the lower cost that is provided in the private sector. How can this be allowed to continue? Even if you vary it, the average cost of a nursing home in Dublin in the HSE is €1,917 per bed per week, and in Laois it is costing over €2,500.
Colm Burke (Cork North Central, Fine Gael)
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Then do we need to revisit on the basis of getting for value-----
Brian Stanley (Laois-Offaly, Sinn Fein)
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Could I intervene for a second? There are a number of issues. Deputy Burke can continue with the question, but there is one which I am intimately aware of, and have been dealing with HSE management on. However, there are factors, and I will outline them when Deputy Burke is finished.
Colm Burke (Cork North Central, Fine Gael)
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There may be factors, Chair, but this is about the cost to the taxpayer.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Absolutely. It is a legitimate question.
Colm Burke (Cork North Central, Fine Gael)
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This is the Committee of Public Accounts. We need to have accountability.
The second issue which I want to raise, and I have raised this before, is about the delay in getting people out of public hospitals, where nursing homes are prepared to take patients, but they feel that the fair deal scheme will not be adequate because a person needs a higher degree of care than the normal nursing home patient. I ask Mr. Gloster that this issue be revisited over the next three or four months, because of the fact that at any one time, we have over 500 people in public hospital beds who can be discharged but where that is not possible because we cannot get a facility. I have had a number of cases in Cork, where there were facilities prepared to take them, but they were not prepared to take them at the fair deal price. Can that issue be reviewed?
Colm Burke (Cork North Central, Fine Gael)
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I am aware of that. That is not the issue. The issue is where it is clearly identified that the patient needs a higher degree of care than a normal nursing home. There are contracted beds that the HSE has in nursing homes.
Colm Burke (Cork North Central, Fine Gael)
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In one case, for instance, where there were ten contracted beds, that facility was prepared to take an extra two patients under the contracted beds system, and the HSE would not agree. It wanted to send them off to outside of County Cork, which does not make sense to me.
Colm Burke (Cork North Central, Fine Gael)
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If, however, they went into a public nursing home, it would be costing a lot more anyway. If one is getting €1,000 under the fair deal scheme, and the nursing home says that it would require an extra €350 or €400 per week to look after this patient because they need more staff assigned to them, and a higher degree of care, why can we not? We would get an awful lot of people out of hospital far faster if we were prepared to have that flexibility with regard to trying to get people out of hospitals. If one is in a hospital bed, it is costing the State between €7,500 and €8,000 per bed per week. If they are in a step-down facility, at most it would be costing, in the private sector, €1,500 per bed, per week, so the logic is quite clear.
Verona Murphy (Wexford, Independent)
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Chair, might I have one minute-----
Brian Stanley (Laois-Offaly, Sinn Fein)
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I will let Deputy Murphy in during the next round.
Abbeyleix is the one Deputy Burke is talking about, the old nursing unit there. That was pencilled in to be closed this time 12 years ago, but that was revisited and kept open, and rightly so, after a local campaign.
It is recognised by the HSE that it was the right thing to do. It is a brilliant site and a brilliant location. The issue is that there is underutilisation at the site. I do not want to go into every detail but one issue the HSE might get on top of is that there is still underutilisation there. The hospital used to have a capacity of 50-plus beds. The HIQA rules mean that if the day care centre is not there, there can only be 28 beds. The day care centre has been reopened and we want it kept on site. The HSE was eventually convinced to do that. It was the right thing to do, which it has acknowledged. It is there as part of a health hub, with all the services on site. It is good news that the day care centre is reopened and is busy. That leaves room for 22 beds.
There are a couple of issues in this regard. The first is that only ten of the beds are operational at the moment. Public representatives from across the political divide, including myself, have been trying to get the facility up to full capacity. If the HSE's estates section does one thing, I ask that somebody there gets a handle on this situation, for God's sake, and gets the 22 beds open. Up to recent weeks, only seven beds were open. That is one of the reasons there is a higher cost involved in operating this facility. I realise it is not possible to flick a switch and get everything up and running, but the issues must be addressed. I have been to the hospital and met the new young manager, who is excellent. She has worked in this sector before and has really taken Abbeyleix on as a mission. I expect it to be very successful under her.
There are various works to be done. One side of the building will offer step-down services for people leaving the acute hospitals. That part is not ready. There is plumbing work and different things to be done. It is a lovely building and it is ready to go but it needs to be fitted out. The other side of the building, in which the ten beds are now open, is under the control of Abbeyleix hospital management and provides respite services. There is one elderly patient resident there. There used to be a lot more resident patients in the past but there is only one now. On that side, people from the HSE estates section discovered the shower heads were not working, which held things up for months. Then they discovered ramps were needed at the door. After that, there were doors that had to be changed. Each of these issues took time to address. Why can an engineer or clerk of works not go in to assess what is needed and then procure it? I know there is a problem with getting builders and tradesmen at the moment but it seems to take forever and a day to get things done. That side of the facility still has issues that need to be dealt with but it is almost fully operational. The side that will be used as a step-down facility to take people out of acute care is not ready. People at senior level in the HSE estates section need to get their finger out and get it sorted. The delays are part of the reason costs are high.
The good news part of the Abbeyleix story concerns the people who have come to the nursing unit. I do not mean to say anything bad about private nursing homes, which are generally good. Some people have been sent to Abbeyleix from private facilities for specific reasons, including that their condition was not getting better and they needed more intensive treatment and more services on site. I recently had a letter from a woman who said she could not thank the staff of Abbeyleix enough for the care her mother has received there. Her mother has not only recovered but she is now back living in her own house after spending a few weeks in Abbeyleix. She got the services she needed on site. A multitude of services are provided there that are not provided in private nursing homes. I am not trying to defend anybody here but we have to compare like with like. As Chair of the Committee of Public Accounts and as a Deputy representing County Laois, I am asking the HSE estates section, for God's sake, to get the bloody place open. The staff want to get it up and running.
I have a final point to make regarding Abbeyleix. The facility is to operate under a dual management system. This is an operational management matter for the HSE to handle. It is not my baby. However, it does not make sense to have a 22-bed unit with two separate management structures and with corridors crisscrossing each other. There needs to be a single manager. Will Mr. Gloster come back to me on these issues to do with Abbeyleix?.
Brian Stanley (Laois-Offaly, Sinn Fein)
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There should be a single management structure.
Brian Stanley (Laois-Offaly, Sinn Fein)
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The current situation is a recipe for chaos. There must be one manager and one management structure. Abbeyleix is a small unit with 22 beds and a day care centre attached. It needs a single management structure. In addition, the step-down service for taking patients from acute care must be opened. Will Mr. Gloster give me a commitment on those points?
Brian Stanley (Laois-Offaly, Sinn Fein)
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Part of the problem is that only seven out of 22 beds were being used.
Colm Burke (Cork North Central, Fine Gael)
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A bed there costs €600 more than a bed in Dublin.
Brian Stanley (Laois-Offaly, Sinn Fein)
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That is the problem and it is why we need the 22 beds to be open. The good news story is that there are people who have really benefited from being in Abbeyleix. I gave one example. It is only in recent weeks that I got word from that woman about her mother.
Brian Stanley (Laois-Offaly, Sinn Fein)
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That is the good news story about Abbeyleix. Ten out of ten to the staff and the new manager.
Deputy Verona Murphy wants to come back in with a brief question, for which she has three minutes.
Verona Murphy (Wexford, Independent)
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In CHO 5, which includes my constituency of Wexford, there are 1,300 service users whose core funding or capitation is between €2,000 and €6,000 per annum. The equivalent 2,391 service users who are school leavers, and who are entering the same facilities and doing the same things for the same length of time, are getting €18,000 per capita. There is a deficit there of somewhere between €12,000 to €14,000 per capita. I am told that over the next five years, the requirement will be to bring the first group up to €18,000 in order for section 39 organisations to remain available. That works out at just over €9 million. Mr. Mulvany can see where the frustration arises with the loss of €30 million. The entirety of CHO 5 needs €9 million. The €30 million we have been discussing today would cover that three times.
There are 4,000 people involved who are in dire need of these day services. I am aware of two section 39 organisations that have had to halt their respite service. They have no staff. There is a list of things I will discuss with Mr. Mulvany if he sets up a meeting on this matter. The reality is that there is no plan. This is a shit show. There is no other way to describe it. It is not getting better; it is getting worse. I attended a meeting on Monday night at which there were 60 people, all over the age of 60, who are caring for very intellectually disabled adults who not only do not have respite, but are heading for residential care. We got six beds in total in the month of May in CHO 5, which are all now occupied, at a cost of €37,000 per person per month. The 4,000 service users I referred to may well end up in residential care at some point. I want to see a plan for their care. I am pointing to the problem of €30 million going astray when €10 million would make a difference. That is what I do as a public representative. It is about getting value for money and ensuring services are fully staffed in order to provide a service to the most vulnerable in our society.
Mr. Bernard Gloster:
The Deputy has raised three issues. There is the issue of section 39 organisations being promised money they have not received. My colleague, Ms Niamh Doody, will talk to the Deputy on the margins of the meeting and I certainly will look at the issue.
Second is the issue of the adequacy of disability services, whether respite, residential or home support. I will look at that for CHO 5 and come back to the Deputy.
Third, there is the discussion around the overall sustainability of the section 39 sector, which is well rehearsed across the country.
Verona Murphy (Wexford, Independent)
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It is no longer sustainable.
Verona Murphy (Wexford, Independent)
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To be fair, I agree with Mr. Gloster that this is a policy and legislative matter, on which I am working. However, I would expect him to advise the Government it is not sustainable. When a policy or legislation is introduced, whether by my group in the Dail or whomever else, it needs to be accepted and it needs to be part of a plan.
Verona Murphy (Wexford, Independent)
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I thank Mr. Gloster.
Brian Stanley (Laois-Offaly, Sinn Fein)
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I have a quick question regarding the number of people leaving hospital emergency departments.
We assume that most of them were in need of medical care, although people will leave for different reasons, particularly at weekends, when they go in and out, and staff are being hassled, threatened and everything else. People may have to leave for other reasons. Is it correct that, last year, the figure was approximately 75,000?
Brian Stanley (Laois-Offaly, Sinn Fein)
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Yes, before treatment.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Does the HSE have a figure for any part of this year, namely, for the first quarter or for January and February?
Brian Stanley (Laois-Offaly, Sinn Fein)
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A figure of 14,500 is being reported. I ask the HSE to clarify the position.
Brian Stanley (Laois-Offaly, Sinn Fein)
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On hospital capacity, what is the ratio of beds to population at present?
Brian Stanley (Laois-Offaly, Sinn Fein)
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How does that compare on an EU level?
Mr. Bernard Gloster:
We are on the lower end internationally in the context of beds per 100,000 of population. The increase in beds restored in recent years is obviously much higher than it was over the past decade. Approximately 200 beds will come into profile in this calendar year alone. I am in what are fairly active discussions with the Department and Minister about the possibility of expediting 1,500 beds under more rapid-build and-----
Brian Stanley (Laois-Offaly, Sinn Fein)
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There are 200 extra beds coming in this year.
Brian Stanley (Laois-Offaly, Sinn Fein)
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There are active plans for 1,500 beds.
Mr. Bernard Gloster:
Some 1,000 have gone in and there are approximately 200 more to come. They are not funded so they are not profiled - I will be clear about that - but we have made an approach to the Department and the Minister about the possibility of 1,500 rapid-build acute hospital beds distributed across the country.
Brian Stanley (Laois-Offaly, Sinn Fein)
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Is that at an early stage?
Brian Stanley (Laois-Offaly, Sinn Fein)
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That concludes the questions from committee members. I thank the witnesses from the Department of Public Expenditure, National Development Plan Delivery and Reform, the National Treatment Purchase Fund, the Department of Health and the HSE. Many areas were covered in the work preparing for this meeting. I also thank the Comptroller and Auditor General and his office staff for attending and assisting in the preparation for today's meeting.
Is it agreed that the clerk will seek any follow-up information and carry out any agreed actions arising from the meeting? Agreed. Is it also agreed that we note and publish the opening statements and briefings supplied for today's meeting? Agreed.