Oireachtas Joint and Select Committees
Wednesday, 29 May 2024
Joint Oireachtas Committee on Health
Health Service Executive: Chairperson Designate
Seán Crowe (Dublin South West, Sinn Fein)
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Apologies have been received from Deputy Cathal Crowe. First, before we get to the main item on today's agenda, are the minutes of the committee meeting of 22 May 2024, which have been circulated to members for consideration, agreed? Agreed.
Today, the joint committee will first meet with the chair designate of the Health Service Executive, Mr. Ciarán Devane, in relation to his proposed reappointment as chairperson of the HSE. The proposed reappointment of Mr. Devane as chairperson is for a three-year term from 28 June 2024 to 27 June 2027. The committee will focus on the strategic priorities of the role. Later, we will meet with the Alliance of Community Cancer Support Centres and Services to consider the challenges facing community based cancer support services in the context of the national cancer strategy.
I am pleased to welcome Mr. Ciarán Devane, chairperson of the HSE. I will read a short note on privilege. Witnesses are reminded of the long-standing parliamentary practice to the effect that they should not criticise or make charges against any person or entity by name or such a way as to make him or her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction. Members are also reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.
In relation to attendance by members, I would like to remind them of the constitutional requirement that members must be physically present within the confines of the Leinster House complex in order to participate in public meetings. It is not permitted for a member to participate where they are not adhering to this constitutional requirement. Any member who attempts to participate from outside the precinct will be asked to leave the meeting. In this regard, I ask any member partaking via MS teams that prior to making their contribution to the meeting they confirm they are on the Leinster House campus.
To commence our consideration of this matter, I now invite Mr. Devane to make his opening remarks.
Mr. Ciar?n Devane:
I thank the committee for inviting me on the occasion of the proposal by the Minister for Health and the Minister for Children, Equality, Disability, Integration and Youth to reappoint me as chair of the HSE. In June 2019, the Minister for Health re-established the board to oversee the HSE. He is now calling on me, as it happens. This was an important step in improving governance and was one of the key recommendations of Sláintecare. When I came before the committee in my first week as chairperson, I said what excited me was turning the pages of the Sláintecare report, the fact it has cross-party support and the fact that it set a direction of travel which, when implemented, will give us universal healthcare and a service fit for the future. That excitement remains with me and my fellow board members.
I will speak a little bit on governance. For the last five years, we have focused on the delivery of the policy framework - for example, national clinical strategies. There is no point having them if we do not implement them and have them funded. We have focused on Sláintecare itself and the health priorities of the Government. To do this, the board put in place a corporate plan which set out our three-year objectives. I have attached a summary of that to this statement.
Every year we have the national service plan, which needs to match the ministerial priorities and the corporate plan. We also have an audit plan, a scorecard and a risk register. We have a new transformation roadmap outlining the journey, so that we have a control environment which ensures we cover compliance and performance issues and the risks we see, as well as the priorities for change.
To support the board, we have five committees which report into us: audit and risk; people and culture; planning performance; safety and quality; and a new one, technology and transformation. In our five years, we have had 104 board meetings and 235 committee meetings. We use that committee and board structure to push the priorities, find new ways of working, ensure better use of data, support cultural change and enhance productivity. There is a lot still to do but that is a necessary foundation for the transformation that we all say we need.
The pandemic tested that governance as much as it tested the rest of the health system to its limits. I have to acknowledge the tireless work of all staff across the health service and the health system, in the HSE, in sections 38 and 39 partners, in the Department and across Government. Truly, the commitment, endurance and dedication was outstanding and should never be forgotten. When I look back on that period, I think we should all be rightly proud of how Ireland handled the pandemic. We had one of the best mortality outcomes of any country. This should not be a total surprise. Ireland's health system continues to have outcomes that in many cases are among the best in Europe and, indeed, in the world.
The quality of care in the community and hospital care is recognised by the public, with Ireland reporting the highest self-perceived health status in the European Union. Ireland is also among a small group of seven EU countries where life expectancy is above 82.4 years, two years above the average in the EU. There have been significant improvements in mortality for many of the common causes of death, which shows the benefits of those clinical strategies when well implemented over time. The fact that we sustained that through the pandemic is encouraging for the resilience of the health system, even in the face of the ransomware attack which made a really tough job much harder.
Since the pandemic, the focus has been on transformation. Some of this is structural, with Bernard Gloster, as our new chief executive, progressing the health regions and devolving decision-making out of the centre wherever possible. The regions are going to be critical to the implementation of Sláintecare on the ground and putting it into action. The committee knows well that the hospital groups and community healthcare organisations, CHOs, served different populations and did it in different ways and covered different geographies with separately managed services. Now, with the regional executive officers being in place, the new approach will allow us to integrate the services, clarify the care paths and allow the services to truly be based on the evidence about the population they serve.
Much is going well but I want to talk about the strategic priorities of concern to us, as the board. Our urgent care services are delivering more care to more people each year but the demographics mean we have services under pressure almost all year round. We have done away with the winter plan idea and moved to a year round approach. We are always seeing the implementation of the multi-annual, if not multi-funded, urgent emergency care plan. We still have too many patients on trolleys. Significant progress has been made and they are 12% down this year. We recognise the intense effort it has taken to do that.
Looking at the second six months of 2023, the number of patients on trolleys was down 22% compared with the same six months in 2022.
However, we see some hospitals with particular challenges and, as we have seen, this can have tragic consequences. All patients using health and social care services should consistently receive the safest care. Failures are a matter of great regret to us as a board and to all in the HSE. It is a matter of great concern to all of us, whether we are on the board or part of the wider system. When something goes wrong, the board expects that open disclosure as a principle is applied across the HSE and our partners. We also expect that the appropriate lessons are learned and applied to ensure these events become ever less frequent. We expect senior colleagues to use the tools available to mitigate risk and to follow guidance. It is the only way the frequency of those rare events will become lower. This is true in emergency care but it is also true of safeguarding in residential settings, in maternity care and across the entire system. These are awful events. We have to learn and act to make sure they are not repeated.
Elective care is a second area that needs transformation. A programme is currently being put together to increase surgical capacity, address waiting lists and get ahead of and anticipate future demand. These include the development of surgical hubs and elective hospitals, which are designed to separate elective and emergency care.
The board of the HSE is overseeing the implementation of the multi-annual waiting list action plan, which spans acute and community settings beyond urgent and emergency care. It has to build on the progress of 2021 and 2022 as part of the multiannual approach to sustainably reduce waiting lists and waiting times and move towards the maximum targets in Sláintecare.
On enhanced community care, one of the key aims in Sláintecare is the shift left, as we call it, towards provision of care in the community. There has been significant investment in those community services, with their own diagnostics, community health network teams based around local populations, and new community specialist teams, such as teams for older people and chronic disease management. These are all helping significantly with hospital admission and readmission rates. For example, we have seen that admission rates between 2019 and 2023 are down 16%; 30-day readmissions are down 24%; and 91% of patients with chronic disease are now routinely managed in primary care. However, we have to ensure that the infrastructure is invested in to support this increased workload in the community so that staff have the right tools in the right environment.
We have seen significant growth in staffing, with the highest workforce number since the formation of the HSE in 2005. In 2023, there were just under 146,000 whole-time equivalents compared with December 2019, when there were just under 120,000 whole-time equivalents. This is up 22% over four years. Of course, that is great news but there is now a requirement in 2024 to show we are using that investment well and making sure the money the taxpayer and the public have given us increases activity and improves outcomes through using that increased workforce. We also need to stick to the limit of what is allocated. Specifically, the impact of recruitment beyond available funding during 2023 will need careful management over the next number of months, as we need to move to a fully understood, agreed and compliant pay and numbers strategy. This does not mean that there will not be recruitment in 2024. Approximately 2,200 additional staff are provided for in the NSP on the health side. Another just under 700 staff are provided for on the disability side so it is 2,900 in total. However, it is fair to say that 2024 will be a year of consolidation, lower growth in staff numbers, and better control, with some critical posts open to recruitment and others filled by moving staff into more important vacancies from less immediately critical roles.
I particularly welcome the adoption of the public-only consultant contract. Along with the increase in consultant numbers overall, this means significant new senior medical capacity across our services. Our management and clinical leadership will work to make full use of the potential this provides in hospitals and across all settings to make sure patients experience the full benefit of having senior decision-makers rostered on site for greater proportions of the day, including at weekends.
The board completely supports Sharing the Vision, which is a mental health policy that envisions a mental health system designed around the requirements of the individual. Of concern to us were the findings of the look-back review into child and adolescent mental health services, or the Maskey report, and the Mental Health Commission report into CAMHS. We will continue to prioritise the implementation of those recommendations.
Specialist community-based disability services transferred to the Department of Children, Equality, Disability, Integration and Youth in March last year. That Department secured Government approval for the action plan for disability servicesin July 2023, which along with the Roadmap for Service Improvement 2023-2026: Disability Services for Children and Young People, has to be a focus for 2024. Making that real will be an important challenge for all of us.
The funding allocated for 2024 will progress many acute and community projects throughout the country. The capital plan supports the Government's priorities, including the new children’s hospital and the national maternity hospital, as well as programmes for critical care, surgical hubs, urgent emergency care, elective hospitals, disability services, community and primary care, older persons, mental health and so on. That is an important area for us on which we have been engaging very heavily with the Department recently.
Digital health goes back to the key enabler of supporting people to live well in the community. The digital health and social care framework, which came out recently, and the introduction of the new health app, which will go public very soon, are another milestones.
Those areas, which are all consistent and embedded in the corporate plan and come out of the combination of ministerial priorities and the Sláintecare report, are our priorities going forward. A challenge for us is to ensure that the positive trends for people’s health persist while we manage these capacity deficits, with the increased number of people accessing emergency services in particular. There is still a great deal to do on access. We have been given the tools we have wanted for a long time, such as increased numbers and the new consultant contract. We now have to show that we can use those effectively. We can celebrate unquestioned progress but we also have to apologise for those failures when they happen and act decisively to make sure they cannot be repeated. There is a much to be done on that agenda. I look forward, on behalf of the board, to working with the full range of partners and stakeholders to build that better health and community care service.
That concludes my statement. I am of course happy to answer questions.
Seán Crowe (Dublin South West, Sinn Fein)
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The questions will concentrate on the strategic objectives, but Mr. Devane referenced the board being made up of five sub-committees. Will he outline what areas they cover?
Mr. Ciar?n Devane:
Audit and risk is recognisable for many organisations. Compliance is obviously a major function on the audit side, and then trying to anticipate where the corporate risks are. For example, to its credit, that sub-committee anticipated what we would do and how we would respond if we had a cyberattack.
Related to that is safety and quality, which is both about clinical risk, or when things go wrong, but also around asking what we are doing to improve the quality of outcome. Are we monitoring the clinical strategies and making sure they are being implemented and we are seeing the outcomes they are supposed to deliver?
The people and culture sub-committee looks at things such as recruitment. Increasingly, however, as a board and a committee, we are asking how we create an environment and culture where it is more uniformly a pleasure to turn up at work.
We are also asking what can be done to bring about an improvement and what skills and tools can be made available to the workforce. The major issue, the intractable one, is strategic workforce planning, which we are getting into in a big way. With regard to plans – maybe disability would be an example – things like the roadmap are excellent but it is a matter of how we generate a workforce to deliver on them.
The area of performance and planning relates to the NSP, the corporate plan and monitoring against those. It involves the heavy operational work.
The final area is technology and transformation. We set up the related sub-committee because we were worried about the circumstances if we had one committee examining this year, effectively, and how we were performing regarding the national service plan, and we were worrying about risk. I am referring to where we were doing some of the heavy lifting, in addition to the board itself, in respect of what would really shift the dial, such as eHealth and ensuring that as we address the day-to-day problems, the things we really need to do to build the community-based services are not forgotten. Those are all the areas.
Martin Conway (Fine Gael)
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I thank Mr. Devane very much and congratulate him on his reappointment. Clearly, given that he has been reappointed, the Government feels he has done a good job. That is a very strong vote of confidence in him. Why would the Government not reappoint him? Mr. Devane managed a very difficult health emergency and all involved in the HSE and Department of Health have to be commended because it was an extremely difficult time. The proof of the pudding is the result that we had one of the lowest mortality rates in Europe. That can often be forgotten when there are reflections on the very difficult period. It has not all been plain sailing and there certainly have been challenges. I would like Mr. Devane’s thoughts on the incredible over-expenditure and the supplementary budgets that have been required to keep the health service afloat and have resulted in the recruitment embargo and its consequences. How involved have the board and Mr. Devane, as chairperson, been in getting to the bottom of over-expenditure of hundreds of millions of euro and the need for supplementary budgets almost yearly?
Mr. Ciar?n Devane:
Heavily, I think. It is a topic at every single board meeting on both the financial side and the recruitment side. To give some context, we increased the headcount of the HSE last year by roughly 6,000, but, of course, another 10,000 people have to be recruited to replace those who retire and move on to other careers. We were trying to land on 16,000 but landed on roughly 17,000. I would not use the phrase “recruitment embargo”, although I know exactly what the Senator means. Part of what we were doing was saying you cannot recruit if you do not know where the money is coming from. It is a case of ensuring clear lines of sight between the roles that are approved and the roles that are delivered.
One of the things that caught us out – there is a combination – was that fewer left than we had anticipated. We had been expecting 11,000 people to leave, which would have been consistent with previous years, but fewer did. That caught us out partly. What also caught us out was people being recruited to roles that were approved from a clinical point of view but that had no money allocated for them. This is one of the areas where we would all say more grip is needed going forward. The REOs are under no illusion that they are accountable for bringing the numbers in where everybody thinks they should be landing.
On the wider point, there is a debate every single year between us, the Department of Health and the Department of Public Expenditure, National Development Plan Delivery and Reform on where the demand will land. The deficit in any year is made up of three things. The first of these is demand. There are always debates about whether it will be here or there, and it always ends up at the high end. The second is inflation, which is unfunded. That adds to it. The third concerns the mitigations we can put in place to bring the numbers down. The numbers we have been talking about since October and the higher demand, with 10% more people turning up at A and E departments and so on, will drive activity, and that will drive costs.
Martin Conway (Fine Gael)
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Mr. Devane stated that one of the more pleasant elements was going through the pages of Sláintecare. He must be disappointed at the lack of progress in that regard, in spite of the pandemic. We understand that a pandemic causes difficulties, but he must be frustrated regarding the snail’s pace of progress relating to Sláintecare.
Mr. Ciar?n Devane:
We are all trying to drive transformation as hard and fast as we can. There is much to be done, as the Senator will appreciate, and we have to ensure that we line the resources up in this regard. There is no question but that the pandemic slowed things down. I hope the Senator will see that, since then, the progress made on emergency departments and waiting lists has been real. Progress is being made on these despite the increased demand. The numbers are heading in the right direction. Would we like to go faster? Absolutely. Of course, we would. Are there things we want to happen quicker? From a personal perspective, I believe that the sooner we have electronic patient records and identifiers, the sooner we will be able to open up the world to some of the transformations in Sláintecare. I am impatient for us to get to that, so I accept the premise.
Martin Conway (Fine Gael)
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I represent the mid-west, including County Clare, where a particular pressure point, namely UHL, has received significant media attention and attention from this committee and others. Has Mr. Devane’s board met in UHL? Has he walked through UHL and been briefed by its senior management?
Martin Conway (Fine Gael)
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Can I ask a specific question?
Martin Conway (Fine Gael)
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Mr. Devane is probably aware that the Minister, Deputy Donnelly, requested HIQA to carry out a very specific review of emergency care and the provision of emergency supports in UHL. What is the HSE’s view on that? Did it feel the review was necessary?
Martin Conway (Fine Gael)
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Does Mr. Devane not feel the Minister undermined the HSE’s position by bringing in HIQA, a separate agency, to carry out the review, given that in 2013 an expert group from the HSE went to the hospital and made recommendations? On 6 April 2024, just before members of this committee went to UHL, the HSE sent in a support team and there were measures announced. Does Mr. Devane believe the Minister undermined the HSE by bringing in HIQA to do this body of work?
Martin Conway (Fine Gael)
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I will add to that as well-----
Seán Crowe (Dublin South West, Sinn Fein)
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We are moving away from the strategic priorities of the chair designate.
Martin Conway (Fine Gael)
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I just forgot to say that part of the brief given to the REOs was to carry out a review of capacity. Would Mr. Devane not feel that HIQA is undermining this undertaking?
Mr. Ciar?n Devane:
No. I think we are all in this together, as someone might say. We have a job to do with the hospital in Limerick to reform some of the practices, but we will see what the report says. We cannot dodge the question of accountability for that. Stepping back, everybody is focused on that and asking if the shape agreed several years ago is still correct. I think that is a legitimate question. I would not, though, want to be using this aspect to absolve us of saying what we are going to do about Limerick. It has had significant investment, so it is not about this element. The question is what are the other things that need to be done.
Martin Conway (Fine Gael)
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Absolutely. There has been major investment. I appreciate Mr. Devane's time. I wish him the very best of luck. Of all the appointments that come before this committee, this is clearly the most important from the perspective of the health of our people and our country. It is in everyone's interest that Mr. Devane leads a good board and does a good job. I wish him well in that endeavour.
Seán Crowe (Dublin South West, Sinn Fein)
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I thank Senator Conway. I call Deputy Shortall.
Róisín Shortall (Dublin North West, Social Democrats)
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Good morning. Mr. Devane is very welcome. I will start with questions about his term of office. How long is it?
Róisín Shortall (Dublin North West, Social Democrats)
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Is this Mr. Devane's third term?
Róisín Shortall (Dublin North West, Social Democrats)
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Okay. It is five years and then three years. Is that the limit then?
Róisín Shortall (Dublin North West, Social Democrats)
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I thank Mr. Devane. I was just curious about the number of years.
I turn now to the important issue of budgeting in the HSE and the experience last year when the organisation seemed to have been engaged in deficit budgeting. This issue was highlighted by the chair of the audit and risk committee, who subsequently resigned over the fact that some €2 billion of proposed services were not funded in the service plan. To a large extent, he was proven right at the end of the year when there was a need for a substantial supplementary budget. Is it not likely that the same thing will happen this year? We do not have the exact detail concerning the split between the Department's deficit and the HSE's deficit, but we were recently told by the Secretary General that in the first four months of this year there has been a deficit of €500 million. In this context, are we not just repeating what happened previously?
Mr. Ciar?n Devane:
There is always a tension between the numbers as we see them, in a context where demand will be at a certain level, inflation is not funded and there is an efficiency challenge as well that we believe we must ensure we address, the Department's view on the same data and then the Department of Public Expenditure, National Development Plan Delivery and Reform's view on these figures as well. We are in this negotiation, let us call it that, every year. I think I called this out in the foreword of the national service plan. There is a financial risk in the plan. At one point, I think I was saying that if we do everything in the plan, we will not hit the number, while if we hit the number, we will not do everything in the plan. We will, therefore, end up somewhere in that environment. I would not be betting against the number produced by the HSE being the accurate one by the time we get to the end of the year.
Róisín Shortall (Dublin North West, Social Democrats)
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I would not necessarily be in the camp of people who say the HSE is overspending. I would be more of the view that the organisation is underfunded. Indeed, the Irish Fiscal Advisory Council also drew attention to the fact that the funding allocated by the Department of Public Expenditure, National Development Plan Delivery and Reform was not sufficient to take account of the significant demographic increase in the population and the fact that it is ageing. I am not saying, therefore, that the HSE is overspending.
I am, though, curious about why it is that the budget campaigns in the months during the run-up to budget days in recent years have been so unsuccessful in terms of making the case to the Department of Public Expenditure, National Development Plan Delivery and Reform and, thereby, ensuring that adequate funding is provided. This is notwithstanding the need to get value for money and improve productivity. Structural issues exist in relation to the budget campaign that results in the HSE being underfunded for the following year. Am I correct in saying this?
Mr. Ciar?n Devane:
It is not a question I have an easy answer to. The outcome is always that we need to accept our bit of the efficiency challenge. This is absolutely the case. I do not think there is usually an argument over the inflation component. There is then the demographic bit. If the Department of Public Expenditure, National Development Plan Delivery and Reform is the decision-maker in this process and if its choice is to tell us that it wishes to keep us under a bit of pressure and scrutiny and will then come back to the matter in a few months, this may not be a pleasant situation for us to be in but it is the reality.
Róisín Shortall (Dublin North West, Social Democrats)
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I put it to Mr. Devane, though, that there is no problem with scrutiny. The issue is if costs related to demographic pressures were not funded. How was it that neither the HSE nor the Department of Health could make this case clearly to the Department of Public Expenditure, National Development Plan Delivery and Reform?
Róisín Shortall (Dublin North West, Social Democrats)
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No, but over recent years the HSE and the Department of Health have not been successful in making the case to the Department of Public Expenditure, National Development Plan Delivery and Reform for an adequate budget allocation. I would take this as the primary role of the Secretary General in the Department, Mr. Devane, as the HSE chair, and the chief executive of the HSE.
Róisín Shortall (Dublin North West, Social Democrats)
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Okay. The figures involved here are enormous.
Róisín Shortall (Dublin North West, Social Democrats)
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We could expect that these campaigns would be properly run and they have-----
Róisín Shortall (Dublin North West, Social Democrats)
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-----obviously fallen short in recent years. This needs attention. The Department of Public Expenditure, National Development Plan Delivery and Reform was critical of the HSE recently in relation to the growth in the numbers of management and administration staff. It was said there was growth of 8.8% in this category of staff last year. The understanding with the changeover to Sláintecare, with the advent of the RHAs and so on, was that the organisation would be leaner. Why is this not happening?
Mr. Ciar?n Devane:
I think it depends on what you call management and administration. The increase in the number of people who get medical cards means a couple of hundred people are processing medical cards. These people are down as being management and administration, but this is a decision we have made.
Róisín Shortall (Dublin North West, Social Democrats)
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Why has there been such growth in the numbers? I know that administration staff are needed. I am not saying there should not be any, but why was there such a growth in the numbers?
Róisín Shortall (Dublin North West, Social Democrats)
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There would appear to be a disproportionate growth in numbers. I do not expect Mr. Devane to have the figures now, but could he provide a note-----
Róisín Shortall (Dublin North West, Social Democrats)
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-----showing the split between administration and management grades in relation to this level of growth? He also spoke about shifting the dial and investing to save in the future, to make the organisation more efficient and so on. One of these areas is technology and transformation, as it is called. It was disappointing to hear that the main emphasis of the digitalisation process in the coming year is to be an app for patients rather than to make real progress on the electronic health record, which would have been transformational in terms of efficiency and savings.
Why is the HSE concentrating on an app?
Róisín Shortall (Dublin North West, Social Democrats)
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When will the patient identifier be in place?
Róisín Shortall (Dublin North West, Social Democrats)
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That is the point I am making. Why is the allocated funding being used for an app rather than EHR?
Róisín Shortall (Dublin North West, Social Democrats)
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It is all part of digitalisation, which is a 2015 programme.
Róisín Shortall (Dublin North West, Social Democrats)
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So the HSE does not have funding for EHR this year.
Mr. Ciar?n Devane:
We have some and there will be some. The new children's hospital will be the first major step out of that but if we really want - this is where I am agreeing strongly with the Deputy - to transfer, the Deputy is absolutely right that it is patient identifiers, patient records-----
Róisín Shortall (Dublin North West, Social Democrats)
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Why is that not being prioritised for funding? The children's hospital will not be opened this year. We have been talking about having a patient identifier since 2015.
Mr. Ciar?n Devane:
I completely agree. There is caution across the Department of Public Expenditure, NDP Delivery and Reform around large IT projects of a national scale. In other jurisdictions, they have a history of something sometimes going wrong and therefore taking a staged approach. If we are pushing transformation at a speed which will be relatively quick, we have to go there.
Róisín Shortall (Dublin North West, Social Democrats)
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The Department, or at least the Department of Public Expenditure, NDP Delivery and Reform, does not agree with Mr. Devane.
Róisín Shortall (Dublin North West, Social Democrats)
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This is a case that needs to be made strongly to the Government-----
Róisín Shortall (Dublin North West, Social Democrats)
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-----and it would seem it has not been. I thank the Chair.
Seán Crowe (Dublin South West, Sinn Fein)
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Deputy Hourigan is next.
Neasa Hourigan (Dublin Central, Green Party)
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I might stay in the digital space for a moment. I was also surprised by the championing of the app in Mr. Devane's statement.
Is there sufficient funding currently to deal with cyberattacks? Can Mr. Devane give us a little rundown on that and how he is prioritising it within his workload?
Neasa Hourigan (Dublin Central, Green Party)
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By inherent weaknesses, does Mr. Devane mean that various hospitals or settings are using various types of programmes and networks?
Neasa Hourigan (Dublin Central, Green Party)
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I think "inelegant" might be slightly underestimating the threat that it poses. Is the HSE looking at nearly 500 lawsuits relating to the 2021 breach?
Neasa Hourigan (Dublin Central, Green Party)
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Has Mr. Devane done a scoping exercise on the kind of liability the HSE faces on that?
Neasa Hourigan (Dublin Central, Green Party)
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I presume that is the risk committee, is it?
Neasa Hourigan (Dublin Central, Green Party)
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The financial liability.
Neasa Hourigan (Dublin Central, Green Party)
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I suppose it speaks to maybe going back to the Department of Public Expenditure, NDP Delivery and Reform and saying that here is the financial liability of having a network like this.
Mr. Ciar?n Devane:
Yes. The underlying software of even the most modern kit, such as a multi-million euro scanner which you bought yesterday, is unsupported by the manufacturer. The manufacturers of the scanners cannot get away from that because they have to be certified medically. There are some risks which are really hard to avoid and, therefore, one has to put other inelegant processes around that.
The technology and transformation committee is looking at having a target architecture which says that every step we take, no matter what it is, has to be moving us in this direction because if it is not moving us in that direction, it is not reducing that underlying risk that is built in to an IT system which has everything from the most modern thing you got yesterday through to Lotus Notes in it. We need to be-----
Neasa Hourigan (Dublin Central, Green Party)
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If that committee has an overarching framework it is working towards, does it have a sense of the timeline for that?
Neasa Hourigan (Dublin Central, Green Party)
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When is Mr. Devane expecting it to report on that?
Neasa Hourigan (Dublin Central, Green Party)
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Mr. Devane mentioned the various committees. That issue around investment in digital is separate from the liability that the HSE faces for any data breaches. I presume those two committees are working hand in glove.
Neasa Hourigan (Dublin Central, Green Party)
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Okay. There is currently a report in the media in respect of physical data breaches. Is that a concern? I have some questions about capital spend in the management of estates, etc. I probably will not get to them in this slot but may get to them when I speak next. It strikes me that some of the reports are physical records that have been left in various storage facilities. Those are data breaches. I note the most recent data breach of health records resulted in a fine of almost €500,000 by the commissioner. Could Mr. Devane expand on that in terms of what the board is looking at?
Neasa Hourigan (Dublin Central, Green Party)
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We do not need to discuss the specifics of the case. The HSE owns a huge amount of building stock, some of which is in current use. I imagine that some of the stock that is not necessarily in active use is used as storage. That must be coming up at board level.
Neasa Hourigan (Dublin Central, Green Party)
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Has the case that has recently been opened by the commissioner been the matter of discussion?
Neasa Hourigan (Dublin Central, Green Party)
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I presume that will result in some kind of review or audit of storage.
Neasa Hourigan (Dublin Central, Green Party)
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Mr. Devane would want to speak to the board beforehand.
Neasa Hourigan (Dublin Central, Green Party)
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Okay. I will move to some of the issues around workforce planning. At this committee, we have talked a lot about the HSE, with the Department, undertaking a piece of work around that. Last month, ICTU asked for a timeline for the publication of that pay and numbers report. When will we see that report? We have been talking about it here for six months or a year.
Mr. Ciar?n Devane:
Having spoken to the chief executive about it last night, we are still hopeful that it will come. There has been some progress in recent weeks. That is essential for us because it will allow us to identify the direction of travel, the envelope in which we can operate, how we will handle agencies and so on. If we can have that agreed framework between ourselves, the Department and the Department of Public Expenditure, NDP Delivery and Reform, that will be incredibly helpful because then we can performance manage ourselves, our section 38 organisations and so on to those numbers.
It is not there yet and I gather it is closer than it was.
Neasa Hourigan (Dublin Central, Green Party)
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What does "it is not there yet" mean with regard to a timeline?
Neasa Hourigan (Dublin Central, Green Party)
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Are you given to understand it will be by the end of the year or by the end of the month?
Neasa Hourigan (Dublin Central, Green Party)
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Does Mr. Devane know are we gathering evidence within the framework of the current moratorium on hiring?
Neasa Hourigan (Dublin Central, Green Party)
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In terms of the recruitment embargo or however you want to phrase it, is the workforce plan written in reference to or in the context of that?
Mr. Ciar?n Devane:
Yes, it is. It all ties together. How we manage our overall numbers will depend upon the pay and numbers strategy. It ties into agencies and agency conversion into full-time jobs. We will continue to have agency staff, no doubt, but not at the same level. It also ties into what we are allowed to recruit and where, having agreed to clarity on that in terms of the development. We are getting on with doing the development. It is not a moratorium in the total sense. There are, in health, the 2,200 additional jobs. It is around saying we need clarity we can performance-manage to. It does not absolve us from doing performance management today as well and holding the REOs in particular accountable for those numbers.
Neasa Hourigan (Dublin Central, Green Party)
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When we had Bernard Gloster here before, we talked a number of times with him about the use of private management consultants and that commitment to reduce their use by up to €40 million. I was certainly very keen on that reduction because it is very worthwhile for any institution to build up its own in-house knowledge and not to be relying on external private management consultants. However, it strikes me that in the context of a freeze on hiring or less contracting out, that might be difficult. Will Mr. Devane speak to that a little bit in terms of the board's overall approach to reducing that use of private consultants?
Mr. Ciar?n Devane:
I will separate from that agency staff who may be doing particular work. We have to be less reliant on external consulting capability. There will be a place for it but it is much more likely to be where we need two people with specific skills for three months rather than putting ten people on a problem for six months. We have to stop that for a number of reasons. One is it is not efficient. Two is that you have to own the solution yourself. If we need the capability to supplement our own great people, who are genuinely great, to work through and find the right solution by setting up a working group with help which will come back quickly with a decision, it is just a better way of working.
Neasa Hourigan (Dublin Central, Green Party)
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We are investing in our own staff on the flipside of reducing-----
Bernard Durkan (Kildare North, Fine Gael)
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I thank our guests for coming before the committee this morning. Are they happy with the structures over which they preside, their effectiveness and their ability to respond to particular situations, and do they see the need for any changes? I ask this against the backdrop of this committee being very specific during the Sláintecare debate on how the whole country could be represented at board level within the HSE.
Mr. Ciar?n Devane:
The move to the regions and to the health areas is hugely positive for a number of reasons. One is that it is the enabler for genuine population-based healthcare. That has to be good. The second thing is that it forces us to have a more collective culture, let us say, where not everything goes up to Dr. Steevens' Hospital and comes back down again. Taking the, let us call it power, out of that building as much as possible and giving it to the regional health areas has to be a good thing. That will allow benefits but only if the culture is also right. I am never a fan of people taking a kind of structural approach to something which is not a structural problem.
One of the things Bernard will have to do is make sure there is crossway communications so that if you are a clinical lead in one region, you have a peer in another region, or several peers in several other regions, whom you talk to and you do the kind of sharing and learning which many health systems, including our own, do not always do as quickly as they need to.
Do I like the new aggregate structure? Yes, I do. Do I think it fixes everything? No, because that is why-----
Bernard Durkan (Kildare North, Fine Gael)
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It wants fixing.
Bernard Durkan (Kildare North, Fine Gael)
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Does that culture involve an "us and them" attitude where we protect our spot and we will repel at all borders?
Bernard Durkan (Kildare North, Fine Gael)
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But it is there.
Mr. Ciar?n Devane:
Everybody is proud of their own hospital, service or whatever, but you can never do enough collaboration. We have to make sure operations and the clinical community cross-fertilise more.
I will give one example. When I was describing the committees, risk with regard to the organisation goes to one committee and clinical risk goes to another committee. That can be okay, but if it means there is not cross-pollination of how you manage risk well between the professionals who do risk management across the HSE and the clinicians who do clinical governance, as they would phrase it, across the HSE, then the sum is lesser than it might otherwise be. One of the things I hope we will be seeing is that we find ways of having the different interests, let us call it, in the room at the same time.
The third group we are beginning to get better at but have further to go is engaging the patient voice in that debate and making sure it is not the case of talking to the clinicians today and to the patients tomorrow. We need them all in the room at the same time.
Bernard Durkan (Kildare North, Fine Gael)
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Should it not be a given that the board represents patients or the patient voice in every aspect of it and that there is no suggestion in any quarter of somebody deciding to ignore a patient or a culture ignoring patients or patient's needs?
Mr. Ciar?n Devane:
I completely agree, and our board colleagues, not only those who came in with a specific brief around patient voice but more broadly, have been good at that, but we have to embed that in how the whole organisation operates. There is somebody now who is accountable for ensuring we embed those processes across the new organisation and we need to see that replicated in each of the regional health areas.
Bernard Durkan (Kildare North, Fine Gael)
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To what extent is Mr. Devane targeting the sensitive areas such as bed or trolley counts, and the number of persons on trolleys on any given day, which, of course, relates to patients in accident and emergency departments throughout the country? Is Mr. Devane satisfied that adequate attention is being given to each?
Mr. Ciar?n Devane:
I am satisfied that an awful lot of attention is being given to it, including by us as a board. At every meeting we will be talking about urgent and scheduled care and we will be looking at the data. We need to made sure some of the good practice that is out there is uniformly out there. If you read the minutes of the report on the Aoife Johnston case, it talks about the implementation of guidance, for example. One of the questions we have been asking is whether we are confident we have processes in place such that the best practice is not only in Limerick but is elsewhere as well.
We do not want to only be looking at Limerick and suddenly find we have a problem over there. Part of our role is to see if we can lift our heads for a minute and pose the same question of every other emergency department in the land, how many of the recommendations in the report would we be saying we have yet to implement?
Bernard Durkan (Kildare North, Fine Gael)
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We seem to have ongoing trouble attracting and retaining staff. Can Mr. Devane give some indication as to the main reasons for this? We know about the working conditions. That is understood, and we accept it as a given. Do we pay salaries and wages that are comparable or almost comparable with those available in other locations?
Mr. Ciar?n Devane:
Because it is topical, if we take the consultant contract, that stands up very well against international comparisons., including our near neighbours. Our retention rate is good. If we ask - and we do - colleagues across the HSE if they are proud of where they work, the answer broadly is "Yes".
There are two things we need to do. One is to make sure we have a workforce strategy that asks what capacity we are going to need for the future and whether we know where we are going to get those people from. If we have a strategy that says we need 200 occupational therapists and we do not see that the country has the ability to generate 200 occupational therapists for those roles going forward, then that is a debate we need to have. That debate is broader than just contemplating the area of health.
Bernard Durkan (Kildare North, Fine Gael)
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In terms of nurses, non-consultant hospital doctors or other staff, how do their pay and conditions compare with those available in other jurisdictions, including our next-door neighbours and various other locations, which continually draw from the qualified personnel that we have here?
Bernard Durkan (Kildare North, Fine Gael)
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That really was not the question, though. I did not say that.
Bernard Durkan (Kildare North, Fine Gael)
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I was inquiring about the difference, or whether there is a difference.
Mr. Ciar?n Devane:
The impression I have is broadly that we stand up well against our neighbours. In some areas - consultant contracts being an example - we are well ahead. One of the drivers of retention is the quality of the environment in which people are working, at least as much as the salary. That is much more under our control. I would say we have more to do on that.
Bernard Durkan (Kildare North, Fine Gael)
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Is Mr Devane happy that he has the ways and means of controlling the element to which he referred and that he is making progress?
Mr. Ciar?n Devane:
There is more progress to be made. I worry about the places we do not see or hear about. We all know bits of the system, but it is about creating an environment whereby people have the ability to speak up and be heard if there is something going wrong in a particular place. That it is uniformly the position. We have further to go on that, undoubtedly. There is much great work being done. There is more that can be done. However, if we look at many of the stories in other jurisdictions as much as ours, there is often somebody who will tell us they have been saying this for two years,. Listening to that person before things escalate is one of the things that keeps me awake at night, to be honest.
Seán Crowe (Dublin South West, Sinn Fein)
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Mr. Devane mentioned the whole area of capital projects and the priorities of his board. We have had discussion with various groups. People have appeared before the committee with regard to certain projects that were resolved around maybe the lack of beds in a particular area or whatever. One would imagine that there would be common agreement across the system. Whatever way we have our system, however, in the first instance people need to get approval - it may be political approval - within the system. There is a tendering process and there is a construction process.
With regard to the board, does Mr. Devane share the frustration of many members of the committee and many of the groups that come in here with regard to these projects? For instance, we have challenges around basic questions like how much it will cost and when it will be finished. One of the repeated frustrations people express is that we keep making the same mistakes we have made in the past. I am particularly talking about construction projects and so on. Again, the question is about whether Mr. Devane and the board share that frustration. Are there ways of improving? Do we look at other jurisdictions? I am thinking of the national children's hospital to give one example, but not exclusively so. We do not know when it is going to open and what the cost will be and so on. Representatives are appearing before the Committee of Public Accounts tomorrow. That is just one example, but there are others, for example, the local hospital in my area. We were told that the problem with the accident and emergency department is down to the lack of beds in the system. The hospital put forward proposals for an additional 72-bed unit that would not interfere with the running of the hospital. It seems a no-brainer, yet until it got approval, it seemed to be a very long process. Is there a way of the system itself speeding up the process for examples like that? That is really the question I am asking. Is the system capable of accommodating the change that needs to happen more quickly?
Mr. Ciar?n Devane:
I share the view that there are things we can do to speed up the process. One of the things we have done is to make sure the programmes that have to be signed off by the board get looked at by the audit and risk committee first. They come to the board with a recommendation. It is only a little bit of the time, but it takes that bit out of the time. That kind of re-engineering of the process is something at which we are looking at the moment. To say the obvious on the capital programme, we cannot give everybody everything they want because there is not the money to do that. It does take a great deal of negotiation to get the capital plan approved. There has been much engagement with the Department in recent weeks and days. The Cathaoirleach will have possibly seen a comment in the newspaper that we are expecting that imminently. The Minister will be at our board meeting this afternoon, so we will find out what the decisions are at that meeting.
The overall frustration overall about projects that feel like no-brainers and whether we can get them through quickly is something we need to look at. This means a couple of things. One is that they need to be grounded in the overall strategy rather than only a particular institution, wherever it is. It has to fit the direction of travel, obviously. Once those things are done, however, it would be good to be able to say here is a multiyear programme of what we are going to do in a particular area. I would be optimistic that we are getting there, but let us see what happens at the board meeting today.
Seán Crowe (Dublin South West, Sinn Fein)
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Deputy Shortall wants to come back in.
Róisín Shortall (Dublin North West, Social Democrats)
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I will raise a couple of issues before we finish up. Obviously, the employment pause or embargo is having a major impact on services. However, there are a few areas in which the board and the HSE can address some issues where there seems to be either confusion or a lack of action by the HSE. The first of those is on the workforce planning front.
It is hard to understand why the HSE has come to this so late. One would expect that would be a regular function of any major organisation. Anyway, there seems to be something happening there. However, where there are serious difficulties is on the HSE side, with the lack of clinical placements. That is something the HSE has control over. It would seem that in respect of providing additional third level places, there is a willingness to do that but not unless there are adequate clinical placements provided by the HSE. That is something that needs urgent attention.
There are two other areas that the committee has been involved in to some extent. We had the Neurological Alliance of Ireland in here recently and there was approval for specialist neurological nurses who could do incredible work with different patient groups who have neurological conditions. These posts were approved in various places across the country, 13 posts that were not filled. In response to a parliamentary question I tabled, the HSE said those 13 posts could not be filled because they were caught by the employment embargo. Last week in the Dáil, the Minister said that is not true. I ask that the board examine this. It would unlock a huge number of additional services for a very large number of patients. I ask for that to be clarified. The Minister said that those 13 posts were exempted.
Róisín Shortall (Dublin North West, Social Democrats)
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I have a letter from the HSE two weeks ago telling me that the posts were caught in the embargo.
Róisín Shortall (Dublin North West, Social Democrats)
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I thank Mr. Devane. The last area relates to public health nurses. There is a huge shortage of public health nurses, who provide a really important preventative service. Obviously, there is the whole area of screening for newborns and children. There are big tracts of the country in which those screenings are not taking place, especially in disadvantaged areas. There are also services for older people. They deal with people in the community at both ends of the age spectrum. They provide a really important service and it seems that the allowance that is payable by the HSE is less for the postgraduate training for PHNs than it is for other forms of nursing. Again, that is creating a dire shortage. I ask that those three employment areas be addressed at board level in the hope of clearing the logjam that seems to exist.
Neasa Hourigan (Dublin Central, Green Party)
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I will make a quick point relating to a committee meeting we had recently. The HSE is obviously going through a fairly significant restructuring in terms of more localised services and primary healthcare. One of the section 38 and 39 organisations made the point to us that whereas in the past the organisations would have negotiated the provision of services nationally, now they are looking at multiple contract negotiations with each regional organisation or a representative from the HSE. The organisation in question was concerned about that. It was concerned about the administrative load that might put on it, and also that there would be variations in contracts, which would probably serve no one, although the idea of regional provision absolutely adapted to that area is completely accepted. Could we get a view from the board on that structural issue? Is it now being proposed that section 38 and 39 service providers will negotiate fully tabula rasa contracts with each local area? That would be problematic.
Bernard Durkan (Kildare North, Fine Gael)
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I have a question on the filling of posts. It has been an issue as long as I have been around, which is a while. A number of us were previously members of the Eastern Health Board. We learned whatever skills we have there, or did not learn them as the case may be. Why is it not possible for the HSE to identify the most important and fundamental posts to be filled, so that we will not have this situation of it saying that it cannot operate anymore because of an embargo or go-slow? It is well known that the HSE and the delivery of services has considerably expanded in terms of employment of extra staff. It is huge. Some of the more important ones were not filled or were left aside. It is not a good strategy.
Mr. Ciar?n Devane:
We have said that a large number of roles are exempt from the controls. We have also said that if there is a role that a chief executive in the system thinks is more critical, they can absolutely recruit to that role internally or from across their organisation. As any other organisation would do, it would say that if this is a role it really needs, it would be very happy to move somebody into that role. We think we have exempted the really critical roles, such as consultants, for example. Let us hope we are right. I agree with the Deputy's premise. As we get more mature with the workforce strategy, it would be great to be able to say these are the critical roles, these are the succession plans for those roles, we know we have enough people being trained here who will ultimately be there if we have a vacancy, and we kind of know what we are going to do locally. We have to get to that point. It is entirely fair.
Bernard Durkan (Kildare North, Fine Gael)
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Is it possible to identify the pinch points at the beginning of the year and decide to deal with them first and talk about it afterwards, rather than not dealing with them until it becomes a talking point?
Mr. Ciar?n Devane:
I would like to think we mostly do that. We do not always do it, which is why it happens, and we do not always successfully do it, which is why it happens. On the principle that no good deed goes unpunished, that is where some of the problem last year came from. We thought we would have these 11,000 or 12,000 people leaving but in reality, it was 10,000. We had anticipated we were going to have to replace these people because there would be people leaving, as they always do. We do that to an extent. There are 145,000 whole-time equivalents, or close to 175,000 people, in the system. We are talking about large numbers here. However, the local organisations are usually good at trying to get their succession planning in place. They know who will be retiring next year or the year after that. That is where some of these vacancies come from. Can we be better? Absolutely.
Bernard Durkan (Kildare North, Fine Gael)
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And we will. I thank the Chair.
Seán Crowe (Dublin South West, Sinn Fein)
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We will end on that positive note. I really appreciate Mr. Devane coming before the committee.
Seán Crowe (Dublin South West, Sinn Fein)
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I wish him and his board well in their posts and also into the future. I again thank him for coming in. The meeting now stands suspended. We will resume very shortly with the next group.