Oireachtas Joint and Select Committees
Thursday, 23 April 2026
Public Accounts Committee
Hospital Insourcing Funding Arrangements: Discussion
2:00 am
John Brady (Wicklow, Sinn Fein)
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This morning, we will engage with the Mater and Tallaght hospitals to examine insourcing funding arrangements. On behalf of the committee, I welcome officials from the Mater Misericordiae University Hospital: Ms Josephine Ryan Leacy, chief executive officer, Ms Maria Creed, chief operating officer, Professor Jim Egan, executive clinical director, and Mr. Adam O'Hare, executive clinical director. From Tallaght University Hospital, TUH, I welcome Professor Anne-Marie Brady, chair of the TUH board, Ms Barbara Keogh Dunne, chief executive officer, Mr. Dermot Carter, director of finance, Professor Peter Lavin, lead clinical director, and Ms Sharon Larkin, director of HR.
We are also joined by the following witnesses from the National Treatment Purchase Fund, NTPF, who are attending in a representative capacity: Ms Fiona Brady, chief executive officer, and Mr. Seán Flood, director of finance. We are also joined by Mr. Robert Kidd, integrated healthcare area manager, and Mr. Joe Campbell, regional director of finance, Dublin and midlands, both from the HSE. They are attending the meeting in a representative capacity. Finally, we are joined by officials from the Office of the Comptroller and Auditor General, including the Comptroller and Auditor General, Mr. Seamus McCarthy, who is a permanent witness to the committee, and Ms Irena Grzebieniak, deputy director of audit. They are all very welcome.
Before we begin, I wish to explain some limitations to parliamentary privilege and the practice of the Houses as regards references the 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. This means they have an absolute defence against any defamation action for anything they say at the meeting. Witnesses are, however, expected not to abuse this privilege, and it is my duty as Cathaoirleach to ensure that it is not abused. Therefore, if witnesses' statements are potentially defamatory in relation to an identifiable person or entity they will be directed to discontinue their remarks, and it is imperative that they comply with any such direction. Witnesses are also reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity, by name or in such a way to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity.
I now call on the Comptroller and Auditor General, Mr. Seamus McCarthy, to make his opening statement.
Mr. Seamus McCarthy:
As Members are aware, I do not have an audit remit in relation to the financial statements of the three public hospitals appearing before the committee today. Accordingly, I do not reference their financial statements in these opening comments. Instead, I will briefly refer to information provided by bodies whose financial statements I do audit.
The Mater, St. Vincent’s and Tallaght university hospitals are all grant funded by the HSE under the provisions of section 38 of the Health Act 2004. The HSE’s financial statements indicate that it provided funding totalling €1.54 billion to the three hospitals in 2024. This comprised €558 million in recurrent funding and €28 million in capital grants to the Mater, €468 million in recurrent funding and €45 million in capital grants to St. Vincent’s, and €433 million in recurrent funding and €11 million in capital grants to Tallaght hospital.
Employees of section 38 funded bodies are regarded as public servants whose employment terms and conditions and pension benefits are directly linked to those of their HSE equivalents. The same obligations in relation to declarations of interest also apply.
The HSE requires agencies funded under section 38 of the 2004 Act to adopt individual annual service agreements which link the level of service to be delivered with the level of funding provided. In my report on the audit of the HSE, I drew attention to the continuing general delays in the finalisation of the annual service agreements and to reservations expressed by some of the funded bodies about their capacity to deliver the service levels specified in the agreements with the funding levels provided.
Separately, the hospitals also receive grant funding each year from the NTPF. The level of funding fluctuates from year to year. According to correspondence by the fund to this committee, in 2024 the fund paid amounts totalling €9.9 million to the Mater university hospital, just over €2 million to St. Vincent’ hospital and almost €2.5 million to Tallaght hospital. Individual memorandums of understanding between the fund and the hospitals specify the controls to be applied around patient selection and payments for treatment.
John Brady (Wicklow, Sinn Fein)
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I thank Mr. McCarthy for that. I now ask the chief executive officer of the Mater hospital, Ms Josephine Ryan Leacy, to deliver the opening statement. As set out in the letter of invitation, she has five minutes in which to do so.
Ms Josephine Ryan Leacy:
I thank the Chair and committee members for their invitation to today’s meeting, the aim being to assist them in their examination of the public funding of voluntary hospitals. I am the CEO of the Mater. I am joined here today by Professor Jim Egan, my executive clinical director, Ms Maria Creed, my chief operating officer, and Mr. Adam O’Hare, my chief financial officer.
Founded by the Sisters of Mercy, the Mater opened in 1861. It is a publicly funded hospital operating under charitable status as a designated activity company. The primary governance frameworks are company law, charity legislation, HSE service arrangements and clinical governance. The Mater is a key part of Ireland’s integrated healthcare system. As a publicly funded hospital, we take great pride in delivering patient-centred excellence in healthcare in a cost-effective, accountable and efficient manner. We employ 4,847 staff, of 63 nationalities. Our staff are the heart of our operation, demonstrating a high commitment to our patients. We currently provide services across 745 inpatient beds, 225 day beds and 14 operating theatres.
The Mater serves three functions within the Irish health system: providing local acute hospital services; providing regional services; and serving as a national referral centre for 17 national specialist services. It is also designated as one of the State’s two major trauma centres.
The Mater is located within one of the most socially diverse demographic areas in the State, with high levels of social disadvantage, chronic illness and homelessness. Approximately 13% of all emergency department, ED, attendances in the Mater relate to people experiencing homelessness.
Like all Irish public hospitals, we face the challenges of an ageing population, increasing numbers of presentations and complexity. This, coupled with our unique demographic, presents a significant demand. There is a documented life expectancy gap of five to eight years between the hospital’s north-inner-city catchment and that of south County Dublin. The hospital’s patient profile, with the social complexity outlined, has a direct operational and financial impact on it. However, our demand continues to rise year on year. In 2025 alone, we delivered 300,000 outpatient attendances, 105,000 ED attendances, 89,000 day-case procedures and 32,000 inpatient admissions. Despite the increase in activity, measurable improvements have been delivered in respect of the patient experience, including a 30% reduction in our 8 a.m. TrolleyGAR number, a 10% reduction in our average length of stay, and a move to a six-day working model. According to the Irish Government Economic and Evaluation Service analytical review, the Mater was seen in 2024 as the most efficient model 4 hospital on a cost-acuity index basis.
The NTPF has brought about a significant improvement in outpatient and day-case access. We take our oversight, fiduciary and accountability responsibilities to the public taxpayer extremely seriously and operate within the governance framework established by the NTPF. We have entered into insourcing arrangements with the NTPF over many years, providing a safe, closed-loop system of access for long-waiting public patients, and better value for money for the Exchequer and taxpayer. The Mater confirms that all NTPF-related activity is fully compliant with NTPF processes and requirements. It further confirms that no conflicts of interest have been identified involving any grade of staff in relation to NTPF-funded activity.
There has been a significant financial increase in the Mater’s annual allocation of around €300 million from 2019 to 2025. Just over one third of this relates to national pay awards. The remaining drivers for the budget increase were the addition of 100 extra beds, the commencement of trauma activity, a significant increase in patient activity, and a 54% increase in staffing.
In April 2025, the hospital entered into a risk-sharing agreement with the HSE that was critical to restore a break-even position, ensure essential patient services did not need to be reduced or suspended, and avoid adding to our historical deficit of €48.7 million, which would have raised the potential for director exposure under company law. In addition to separate HSE and Charities Regulator governance, the Mater is subject to independent external audit and robust company law corporate governance arrangements.
The HSE annual service arrangement process, with its single-year focus, is in need of reform. Negotiations frequently begin from the previous year’s baseline, despite clear growth in activity and demand.
Agreements are often not concluded until late in the financial year undermining effective financial planning. On top of this, we continue to face cash-flow pressures arising from HSE drawdown arrangements, where approximately 10% of approved funding is effectively deferred each year, forcing a reliance on an overdraft facility. There is a strong case for moving to multi-annual, activity-based funding linked not only to volume but also to patient complexity, acuity, age profile and national referral responsibilities. This would provide greater transparency, improved multiyear capacity planning, better value for money and improved accountability. We will continue to work collaboratively with the HSE to implement financial and reporting systems. We would welcome the opportunity to be a pilot site for activity-based funding.
The Mater hospital is proud in delivering increased levels of complex, high-quality care efficiently and transparently. However, the current funding model is not keeping pace with the evolving nature of the demand or increased complexity of patient needs. The current HSE arrangement and funding processes are in urgent need of reform in order to enable hospitals to operate with improved longer term service delivery focus and transparency. In relation to voluntary hospitals, this would provide an integrated framework to facilitate the proper management of financial and fiduciary risks. Our first priority, however, remains the delivery of safe, high-quality patient care. We welcome the opportunity to assist the committee in examining how an improved funding framework can better support the objective with the necessary transparency and accountability.
We are happy to answer any questions that members may have.
John Brady (Wicklow, Sinn Fein)
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I thank Ms Ryan Leacy. I ask the chief executive officer, Ms Barbara Keogh Dunne, to deliver the opening statement on behalf of Tallaght University Hospital, TUH. As set out in the letter of invitation, Ms Keogh Dunne has five minutes to make her opening statement.
Ms Barbara Keogh Dunne:
Gabhaim buíochas le comhaltaí an choiste as an deis labhairt inniu. I am the chief executive at Tallaght University Hospital since July 2025. I am joined by my colleagues, Professor Anne-Marie Brady, chair of the hospital board; Dr. Peter Lavin, lead clinical director; Mr. Dermot Carter, chief financial officer; and Ms Sharon Larkin, director of HR. They join me to provide clarity on their respective areas of responsibility and expertise. It is our role to ensure we uphold the trust placed in us by patients, staff, the Department of Health, the HSE and the wider community.
Based on the briefing document already submitted to members, I will provide an overview of the scale of services we deliver, governance and funding structures in place, funding challenges and how we can provide assurances in relation to our regulatory, professional and statutory obligations. Supported by a workforce of over 4,000 staff, we work closely in partnership with the HSE, the National Treatment Purchase Fund, NTPF, community and other healthcare providers. Our mission is to deliver excellent patient-centred care, while continuously improving how we operate and use our public resources in line with our hospital strategy. TUH is a model 4 voluntary hospital, serving a population of greater than 800,000 people across Dublin and the wider region. We provide a broad range of services - national and regional - including specialist, surgical, medical, diagnostic and emergency services and are the second largest site providing dialysis services nationally.
The hospital accommodation includes 476 inpatient beds, 125 day case beds, 65 treatment spaces within the emergency department and access to over 200 step-down beds off-site. Regarding activity, 63,000 patients attended our emergency department in 2025, which was an increase of 8% on the previous year and an increase of 11% in the number of patients who presented who are over the age of 75 within that timeframe. This trend continued into quarter 1 2026 with a 12% increase in attendances and a 6% increase in admissions compared to the previous year. Despite improvements in patient flow, the hospital runs at an occupancy rate of 110% to 115%, resulting in delayed admissions through the emergency department and growing waiting lists for scheduled care. There were almost 205,000 outpatient attendances in 2025. That is an increase of 5.5% on the previous year. In tandem, almost 83,000 patients were admitted for elective inpatient or day case procedures within that timeframe.
As a voluntary hospital, TUH is mainly funded by the HSE through the annual service level agreement. The cost of running the hospital in 2025 was €438 million. The projected out-turn for 2026 is €471 million. The hospital carries a historical deficit of €25 million. Other funding sources include HSE capital funding, the NTPF and HSE access to care funding. Additional revenue sources include income from private health insurance, the hospital car park, retail outlets and the private clinic. Funding received from our three foundations support the implementation of the hospital strategy in relation to patient care, research and innovation, the arts and education.
TUH operates within a governance and accountability framework providing assurances in relation to our statutory, regulatory and professional obligations. This is implemented through national and local policies. A set of internal and external controls are in place that demonstrate financial probity and operational effectiveness, with appropriate risk management procedures in place to deliver safe, effective patient care.
A number of challenges are outlined in our submitted briefing document inclusive of the HSE annual budgeting process, reliance on short-term funding sources, such as the NTPF, a reoccurring funding requirement to support ongoing IT and capital infrastructure developments and the availability of inpatient bed capacity.
I assure the committee that the board and the executive team are deeply committed to ensuring the hospital is managed responsibly and transparently. We recognise the trust placed in us to use funds wisely and that responsibility guides every decision we make. My colleagues and I are here to provide clarity, contribute proactively to the committee's deliberations and to ensure that the public can have confidence in the service we deliver. I thank members for listening and we look forward to addressing any questions they may have.
John Brady (Wicklow, Sinn Fein)
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I thank Ms Keogh Dunne. We will suspend our meeting at about 12.30 p.m. for a 30-minute break. We will resume in session two afterwards, when we will have St. Vincent's University Hospital before the committee. I now open the floor to members. The lead speaker is Deputy Byrne. Due to the time constraints, the lead speaker has 12 minutes and all other members have eight minutes afterwards. If times permits on the conclusion of that, I will allow members back in for a second round. I am conscious that we are scheduled to finish the first session by 12.30 p.m.
Joanna Byrne (Louth, Sinn Fein)
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The witnesses are very welcome. I will start on insourcing. It is something that this committee has focused on before. Although it not unique to the witnesses, it is very clear that the Government's failure to reform the health service has led to costly insourcing efficiencies where we see spending of huge money with no bang for buck. That naturally sets a platform for conflicts of interest and perverse incentives. To tackle that, we have the Government coming in with arbitrary measures and targets and then missing them, when what is needed is investment in capacity, beds, seven-day rostering, new contracts, elective hospitals, rapid access for everyone and an end to the two-tier health system that we all know.
Problems in all of this create long waiting lists. Long waiting lists create fear. Fear provides a market for the private sector. Private health insurance is an extra tax on those who can afford it. It is understandable why people want it. Why would they not if they can afford it, even if I do not have it myself? The level of private health insurance is an indictment on public failures. That is all a consequence of government failures over decades, such as reactive initiatives and a make it up as you go along approach, which is evidently not working.
I seek an update on the progress against targets set by the Minister and the HSE CEO to end third-party insourcing completely as a practice by June of this year. That is for all the witnesses or whoever is best placed to answer it.
Ms Josephine Ryan Leacy:
I am happy to come in. We never bring in third party for any insourcing. All insourcing that was done in the Mater was done in line with the NTPF process and guideline where we brought in staff. They were temporary staff for NTPF funding for a specific purpose and to deliver that activity. There was never a third-party company brought into the Mater to support insourcing for the NTPF.
Joanna Byrne (Louth, Sinn Fein)
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What about Tallaght University Hospital?
Ms Barbara Keogh Dunne:
We do not have any at the moment.
We do have an unusual arrangement with a private facility. We use that facility to carry out specific procedures, but we use our own consultants within their own work practice plan to carry those out. The reason for that is that we do not have the physical capacity, namely the space, within our endoscopy department to carry them out.
Joanna Byrne (Louth, Sinn Fein)
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Can Ms Keogh Dunne name the facility that the hospital uses?
Joanna Byrne (Louth, Sinn Fein)
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That is all right.
On the back of that, where are we at in the context of progress on the public-only consultant contract and the implementation of six-day rostering and activity on Saturdays? Is the level of that in both hospitals matching the activity from Monday to Friday, so to speak?
Ms Josephine Ryan Leacy:
We are very fortunate in the Mater. Out of our 394 consultants, we have had a 75.8% uptake on our public-only consultant contract, which equates to 298 consultants. I am delighted to have Professor Jim Egan here because he spearheaded the six-day working in relation to Saturday working, with the caveat that there are obviously resources that are still required to fully implement a six-day working model. We have done what we can with the resources we have. I might hand over to Professor Egan, if that is okay, to go through this.
Professor Jim Egan:
The Mater concurs with the Oireachtas that there is considerable value in Saturday working, and this is on top of the standard on-call rosters. We brought additional consultants in on Saturdays beginning in January 2024 and we witnessed an improvement in the quality of patient care. We have seen a drop in the length of stay and we have seen enhanced discharges at the weekend. There are challenges in delivering this, particularly with regard to NCHD capacity, because we have to ensure that they are compliant with the European working time directive and that they are able to have their statutory rest days, but it is certainly of considerable value to patient care, and we are very committed to growing that.
Joanna Byrne (Louth, Sinn Fein)
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And Tallaght?
Ms Barbara Keogh Dunne:
From a TUH perspective, 73% of our consultants have transferred over to the public-only contract. That is 165 consultants. Similar to the Mater hospital, some of our staff do work on the Saturdays, not exactly 100% compared with Monday to Friday, because they do need support services such as administrative support, non-consultant hospital doctor support and nursing support to run specific clinics, procedures or surgeries.
I will hand over to Professor Lavin to clarify exactly on the same thing.
Dr. Peter Lavin:
Similar to what Professor Egan's said, we have increased the amount of Saturday working, and it is particularly evident where we are looking at unscheduled care. Where it is more challenging is where we need more resources for efficient working on a Saturday and we have to balance replacing a very well-resourced activity during the week with making the resource less well resourced and less efficient at the weekend until it is fully resourced. However, we would be fully committed to having a fully active State service. Ideally, it would be equally resourced six days per week.
Joanna Byrne (Louth, Sinn Fein)
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That brings me to my next question. What capacity do both hospitals need to replace insourcing and outsourcing and private work entirely yet still reduce waiting lists? Where do they see the challenges? Dr. Lavin talks about being fully resourced. What are the specific challenges for both hospitals?
Dr. Peter Lavin:
If I were to give an example of an outpatient clinic operating on a weekday at present, I would say that there may be a consultant and there might be two to three non-consultant hospital doctors, there would be administrative staff and there may also even be some clinical nurse specialists who are supervised. You would like to be able to replicate that full service-----
Joanna Byrne (Louth, Sinn Fein)
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Into the weekends.
Dr. Peter Lavin:
-----on the weekend. It is never as simple as that. During the week, the non-consultant hospital doctors are probably also rounding on inpatients. There may be an on-call component as well. It is the complexity of managing your full team across the six or seven days, really, and that you need the numbers of staff to make all the services run at full efficiency every day they are there. If we are stretching it to the weekends, it means we may be moving someone from an efficient service on a Monday or a Tuesday to potentially a consultant-only clinic at the weekend and that we would see fewer patients.
Professor Jim Egan:
It is important for folk to understand that to run the weekend service, you need appropriate rosters. It is not about one individual. For example, if I am on call on a Friday and I come in on a Saturday, I can see about 60 emergency admissions, when I have a full team, in about three and a half hours. If I come in on the Sunday on my own, without the NCHDs and so on, it might take me close to two hours to see three people. You need the infrastructure to drive the productivity and turn over as many patients as you can. You need six people, and that is six consultants to run a roster, six SHOs or house officers, and six registrars to build that team. We are very committed to doing that because there is considerable added value from a patient perspective.
Joanna Byrne (Louth, Sinn Fein)
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There is an expectation that hospital waiting lists will exceed 1 million, and we already see some hospitals expressing concern over the clampdown on insourcing and the ultimate eradication of that process. Is there any evidence in either or both hospitals of a go-slow or a non-co-operation campaign by those who may have benefited from the insourcing model?
Ms Josephine Ryan Leacy:
I am happy to come in there. Insourcing has absolutely shown massive value for us. Just to put it in context, last year we got over €11 million through the NTPF, but we saw 11,000 outpatients and 2,500 patients had procedures. Those patients would have stayed on our waiting list if we did not have the facility from insourcing. If we had a recurring revenue model that was built into our base, we would be able to do that activity, but that is the number of patients we are talking about. I will put it in context. We always have a waiting list of over 40,000. That is probably the number we will always have. We are seeing a 57% increase in our referrals in outpatients. Our waiting over 12 months, we were at, was it-----
Ms Maria Creed:
We were at 15,000 in 2019. We are down to just about 7,000 at the moment, which is a significant drop. That is very much thanks to the NTPF insourcing initiatives. We did additional clinics with staff going to specific departments and areas to do specific NTPF-funded work, but they were taking people, long waiters, from our waiting list. The impact has been that reduction in the time on the waiting list, although it is acknowledged that it is very difficult to get the number on the waiting list down. If you are on a waiting list, the time is as important as the number.
Joanna Byrne (Louth, Sinn Fein)
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I appreciate that, but my question was specifically about consultants who operate within the insourcing model. Are the witnesses seeing a reluctance, a go-slow or non-co-operation on the public lists, and is there-----
Ms Josephine Ryan Leacy:
No. Our waiting list continues to grow. We continue to increase our outpatients year on year. I know there would be the perception that there would be such a campaign; there is not. If we do not get the insourcing, that will have an impact because we will have to stop those clinics, but then it is about how we continue to support our public and our patients. We would have to reduce the activity of the consultants who are not operating through the NTPF. With specific services, we would have consultants who were brought in for the NTPF. If insourcing went, they would go.
Joanna Byrne (Louth, Sinn Fein)
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Insourcing is ultimately going to go, however. That is the goal, so-----
Ms Barbara Keogh Dunne:
I do not believe there is any go-slow or non-co-operation at all. We review all our clinics, make sure that every clinic is properly booked up as per work practice plans and ensure that there is efficiency. The additional clinics are run all the time outside of those four working hours.
Joanna Byrne (Louth, Sinn Fein)
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It is kind of measured like a key performance indicator model in that regard.
Ms Barbara Keogh Dunne:
Exactly, and, similar to the Mater hospital, if we did not have the NTPF, we do not have the facility to treat all the patients. The referral demand is bigger than our capacity to manage and put through those patients. We have reduced our outpatient wait list by 9% compared with last year in total, so we had 30,000 down to 27,000 by the end of last year. If we did not have those 4,000 extra patients per year funded by the NTPF to do that insourcing, they would be back on the list.
Joanna Byrne (Louth, Sinn Fein)
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How will the hospitals meet that when the eradication of insourcing comes in if the targets are met? How will they continue on-----
Joanna Byrne (Louth, Sinn Fein)
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And coming back to my opening comment.
Eoghan Kenny (Cork North-Central, Labour)
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I welcome our witnesses from the NTPF, the HSE and both hospitals. I will start off by asking why the Mater Misericordiae University Hospital does not publish its financial statements online?
Mr. Adam O'Hare:
The financial statements themselves are sent in to the Companies Registration Office on the basis that we are set up as a designated activity company. However, the annual report for the hospital is published online. Within that - I believe it is on page 32, if I remember correctly - there is the income and expenditure account and the balance sheet, but it is not the full set of financial statements that is there.
Eoghan Kenny (Cork North-Central, Labour)
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As compared with St. Vincent's and Tallaght hospitals, why does the Mater not publish its full accounts online?
Eoghan Kenny (Cork North-Central, Labour)
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Within that income and expenditure that is posted online, is the CEO's payment posted on that?
Eoghan Kenny (Cork North-Central, Labour)
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Is the payment to the CEO of Tallaght hospital published on its website?
Eoghan Kenny (Cork North-Central, Labour)
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What are the payments for the CEOs of both hospitals, please?
Eoghan Kenny (Cork North-Central, Labour)
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And Tallaght?
Eoghan Kenny (Cork North-Central, Labour)
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Does the Mater have any possibility in the future of posting its whole public financial statements online?
Eoghan Kenny (Cork North-Central, Labour)
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It is something to be considered really. Regarding the insourcing, no third-party insourcing was referenced. I may have a lack of understanding in that. What does that mean?
Eoghan Kenny (Cork North-Central, Labour)
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That was just last year, was it?
Eoghan Kenny (Cork North-Central, Labour)
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How does the insourcing work?
Ms Maria Creed:
The NTPF offered the facility to provide funding for additional work to get people off the waiting lists. Getting long-waiters off the waiting lists for the Irish public is, to my understanding, its primary function. We have identified a number of areas where we may have redundant infrastructure. We had a CV lab that was not in use. This was redundancy that was built in when we refurbished a particular part of the hospital over a decade ago. In that instance, we had the infrastructure but we did not have the staff and we did not have the non-pay costs. We applied to the NTPF, giving it a business and a proposal as to what activity we could do and at what cost. It reviewed that through its internal processing and it approved it for us. In that particular instance we provided the service at 45% of the cost that would be applicable in the private sector, exhibiting very good value for money for the Exchequer.
Eoghan Kenny (Cork North-Central, Labour)
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However, who carries out the work?
Eoghan Kenny (Cork North-Central, Labour)
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Are the staff who carry out that work currently staff within the same hospital?
Eoghan Kenny (Cork North-Central, Labour)
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Are there staff who are working in the public system while also working in that private system, who have done the insourcing work?
Eoghan Kenny (Cork North-Central, Labour)
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I know that, but are there staff who are receiving NTPF funding for the private work they are doing for the insourcing?
Eoghan Kenny (Cork North-Central, Labour)
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How is that getting waiting lists down, so?
Ms Maria Creed:
The patients who go through that lab come from our public waiting list. They could be from our local catchment. They could be part of the national specialty services we provide. We take patients off our waiting list, in line with the NTPF criteria that are set in terms of the timelines for-----
Eoghan Kenny (Cork North-Central, Labour)
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So all of the staff who are coming in are brand new staff?
Eoghan Kenny (Cork North-Central, Labour)
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And in Tallaght? Is there a third party that comes in?
John Brady (Wicklow, Sinn Fein)
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Professor Egan wanted to get in.
Professor Jim Egan:
Just to explain, we had an empty cath lab, and with the NTPF we were able to take 500 people off the cardiac waiting list based on the NTPF funding which spread everybody thinner. There was no private element to it. For example, of those 500, 128 underwent a procedure called transcatheter aortic valve implantation, TAVI, where you run a tube up into the heart and pop in a new valve in a life-threatening condition. That has enabled us to turn patients over. They can go home the next day. Back in the day, that was done by open-heart surgery where patients would be in for seven to ten days. We used that empty facility-----
Eoghan Kenny (Cork North-Central, Labour)
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In that business case the hospital presented to the NTPF, did it make comparisons between how that would be cheaper compared with bringing in a private company?
Eoghan Kenny (Cork North-Central, Labour)
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Does Ms Creed think it would have been cheaper to bring in a third-party company?
Eoghan Kenny (Cork North-Central, Labour)
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Okay, and in relation to Tallaght?
Eoghan Kenny (Cork North-Central, Labour)
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In both hospitals, do the witnesses know of any of their staff who work for a third party for any insourcing in another hospital?
Ms Josephine Ryan Leacy:
This comes back to the SIPOs the Deputy is talking about in relation to declarations. When we get our SIPOs, we would get a clarification of anybody who is a director and then we would have that on a procurement list, so if we were going to use a third party, we would have that. Again, what happens outside the hospital is that, with NTPF outsourcing, it goes into the discussions and the tender with the private institutions.
Eoghan Kenny (Cork North-Central, Labour)
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Does Ms Ryan Leacy know if any of her staff are directors of third-party companies?
Eoghan Kenny (Cork North-Central, Labour)
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So there are staff within the hospital who are directors of insourcing-----
Eoghan Kenny (Cork North-Central, Labour)
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Not within the Mater. I mean they could be insourcing into other hospitals, for example.
Ms Josephine Ryan Leacy:
Again, that would be through the NTPF. If there was any insourcing, it would be able to clarify that question. I can only give visibility of my consultants who are directors of companies and I know, because they disclose it to me, how that is disclosed through the NTPF process. It might be best to ask the NTPF how it manages the insourcing in other hospitals.
Eoghan Kenny (Cork North-Central, Labour)
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Are any of those staff on restricted hours? Are any of those staff currently on sick leave?
Eoghan Kenny (Cork North-Central, Labour)
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Yes.
Eoghan Kenny (Cork North-Central, Labour)
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Sorry, not the NTPF staff. I mean the directors of the companies who have made declarations in relation the statement. Are any of those staff?
Ms Josephine Ryan Leacy:
As I have said, I can only clarify what companies they are directors of. It would be remiss of me to tell the Deputy that I could tell him that they are part of any NTPF insourcing in any other hospital because I would not be aware of what companies what hospitals are using.
John Brady (Wicklow, Sinn Fein)
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We do have Ms Brady and Mr. Flood here from the NTPF so it might be helpful for the committee just to-----
Eoghan Kenny (Cork North-Central, Labour)
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Absolutely.
Ms Fiona Brady:
I thank the Deputy. Regarding to third-party insourcing, there are only nine hospitals nationally that the NTPF is funding, and the Mater and Tallaght, as already indicated, are not any of these. We are not aware of any other third parties in use other than the nine that have been declared when they applied for an insourcing initiative.
Eoghan Kenny (Cork North-Central, Labour)
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Are there any staff within the Mater who are directors of companies? Are any of those directors working on behalf of those companies in relation to insourcing in other hospitals?
Eoghan Kenny (Cork North-Central, Labour)
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Does Ms Creed agree with that?
Eoghan Kenny (Cork North-Central, Labour)
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The NTPF is suggesting that the governance lies with the hospital itself. I think the hospital itself is saying the governance lies with the NTPF.
Ms Josephine Ryan Leacy:
For clarity, what we are saying is that if our consultants say they are a director of a company, we do not do any insourcing in our hospital so we do not bring any companies in.
If any other hospital brings in a company, I do not have visibility of that, so I suppose I cannot answer for them.
Eoghan Kenny (Cork North-Central, Labour)
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I suppose the NTPF would.
Eoghan Kenny (Cork North-Central, Labour)
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There is such a lack of oversight.
Mr. Robert Kidd:
The former CEO issued very clear control requirements within the HSE last year around third-party insourcing. To the point the Deputy is making, one of the conditions of use that he made very clear - we have put controls in place within our region of Dublin north east and the Mater is part of our region - is that for any application for an initiative of third-party insourcing, and to satisfy ourselves, we must be able to demonstrate that where a third-party provider is using employees of the HSE or HSE-funded agencies, which include Tallaght and the Mater, that the rates of pay applicable do not exceed HSE pay rates. The requirement is on us to satisfy. He put further conditions before that, which make it very clear that we can only use those entities in very limited circumstances. We have very limited use-----
John Brady (Wicklow, Sinn Fein)
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I am just conscious that we are way over time on this. Could Mr. Campbell be brief if at all possible?
Mr. Joe Campbell:
I just want to confirm as well that in HSE Dublin and Midlands, similar to Mr. Kidd's area, there are very strict conditions. We have very low numbers, only in one hospital, where we look at third-party insourcing. That has been virtually eliminated. We also have a derogation process in place where a derogation is sought from the region itself before anything is agreed.
James Geoghegan (Dublin Bay South, Fine Gael)
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I thank all of the witnesses for being here. I am going to start with the Mater if I may, with Ms Ryan Leacy, because to my mind she put things very clearly. It is very helpful in comparing the governance of how her hospital operates versus some other hospitals that have been before this committee, and perhaps are currently before this committee.
To be absolutely clear, the Mater took a decision, for whatever reason, that no existing hospital employees would effectively be carrying out work that was funded by the NTPF. Is that correct?
James Geoghegan (Dublin Bay South, Fine Gael)
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I think Ms Ryan Leacy said the Mater received €11 million in 2025. In his letter, the Comptroller and Auditor General reminded us of what the NTPF told us, which is that in 2024 the hospital received around €9 million.
James Geoghegan (Dublin Bay South, Fine Gael)
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All of that funding has gone out to new employees the hospital has hired. Have they been hired on a temporary contract basis?
James Geoghegan (Dublin Bay South, Fine Gael)
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Okay.
James Geoghegan (Dublin Bay South, Fine Gael)
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Okay. Ms Ryan Leacy said something very interesting about SIPO. She will be aware that this is an issue that has arisen in this committee and will likely arise again when we have another hospital coming before us. She made clear that when consultants make their SIPO declarations to the hospital they go on a procurement list, so then when the hospital is carrying out a procurement it is aware of where those conflicts arise.
James Geoghegan (Dublin Bay South, Fine Gael)
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That is the governance model.
James Geoghegan (Dublin Bay South, Fine Gael)
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Is Ms Ryan Leacy surprised at some of the governance issues she has heard in other hospitals on these same issues?
Ms Josephine Ryan Leacy:
I am not here to comment on other hospitals. What I am here to do is assure the committee and to provide guarantees that we have very tight governance and oversight in the Mater in relation to it. We all need to be very careful. There must be 100% compliance with SIPO in hospitals. There should be clear visibility. Anybody who is a director should be disclosing it. I would have to disclose if I was, so everybody should have an obligation to do that. I have taken it upon myself. I am in my position 16 months and I have taken it upon myself to have visibility, so I know every return and I can break it down to who is a director or not.
James Geoghegan (Dublin Bay South, Fine Gael)
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Would Ms Ryan Leacy say that the system she has, in terms of how she uses the NTPF funding, was led by a governance approach or ultimately when the board or whoever in the hospital was carrying out its assessment of how this could be done best, that it was done on a pragmatic basis and that this was the best way for the hospital, or was it a combination of both? Was governance a factor in making the decision that it would not be third parties or current hospital employees but that it would be new employees? How would she characterise how she arrived at that decision?
Ms Josephine Ryan Leacy:
The starting point was the patient. We had a massive volume of patients waiting for over 12 months on our waiting list. When the NTPF was set up, which was a really good initiative, it was an opportunity for us, because we did not have funding, to support patients coming in as long waiters. What we did then was we identified where the need was. We have 17 different specialties in which we do outpatients, from an insourcing perspective. We looked at the critical need for the patient to get access. We work very collectively with the NTPF. We set down a specific business case for every specialty. We look at how much it would cost to deliver an outpatient, so it was a fee for outpatients. We would then factor in the pay and non-pay to be covered within that, and then employ the staff appropriately for that. We always felt it was cleaner to have the governance so that we knew who we were bringing in, we were managing it and we did not have any third-party vendor. What we did internally from a governance point of view was HR, finance and operations met monthly to ensure that, first, we were doing the activities we said we would do, to make sure that we were getting the income in to cover the cost of the staff and the non-pay to support the NTPF initiative.
James Geoghegan (Dublin Bay South, Fine Gael)
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Does Ms Ryan Leacy think that if there is a model, which is not in her hospital, where employees of the hospital are carrying out the lists that are available to them, and then are being supplemented by the NTPF to fund other people on their waiting lists, that there is at least a risk of that creating inefficiencies in how they carry out their public contract hours?
James Geoghegan (Dublin Bay South, Fine Gael)
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Perhaps it is easy sitting at this side of the desk, but what Ms Ryan Leacy has just said seems so blindingly obvious, yet in very many hospitals that is not the case.
Ms Josephine Ryan Leacy:
As I said in my opening statement, we take pride in taking taxpayers' money really seriously. This is a really good initiative. There is a value for the patient but there has to be tight governance. We met with the NTPF on a yearly basis to go through everything, cross-reference and make sure we achieved our targets. We also look at the cost for next year. If there was a price increase we looked at whether it was commensurate to inflationary costs or the non-pay costs. Everything would have been done in line. A really good example to showcase is that insourcing our cath lab is 45% cheaper per procedure than if we outsource it to a private hospital.
James Geoghegan (Dublin Bay South, Fine Gael)
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I thank Ms Ryan Leacy. I will turn to Ms Keogh Dunne. If I understood what she said correctly, in Tallaght Hospital it is in gastro-enterology and endoscopy that insourcing is used. That was €2 million in 2024. I do not know what the figure was for last year for NTPF funding. Is all of the NTPF funding going to endoscopies or is it in other areas of the hospital?
James Geoghegan (Dublin Bay South, Fine Gael)
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No. What is the NTPF funding used for?
James Geoghegan (Dublin Bay South, Fine Gael)
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Ms Keogh Dunne mentioned that she has this-----
James Geoghegan (Dublin Bay South, Fine Gael)
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I think she called it an unusual arrangement.
James Geoghegan (Dublin Bay South, Fine Gael)
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How much funding is going towards the unusual arrangement?
Ms Barbara Keogh Dunne:
It is in the report. In 2024, it was 834. That would be a mix of outpatient insourcing but also scopes, which is a procedure carried out. We do not have the facility because of the unscheduled care demand of patients coming through the ED taking up beds, so we do not have that capacity.
James Geoghegan (Dublin Bay South, Fine Gael)
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The system in Tallaght is different to the Mater.
James Geoghegan (Dublin Bay South, Fine Gael)
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Are the existing consultants who then receive NTPF funding on the public-only contract?
James Geoghegan (Dublin Bay South, Fine Gael)
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There is a top-up essentially of NTPF funding to carry out-----
James Geoghegan (Dublin Bay South, Fine Gael)
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Are they being paid above what they are-----
James Geoghegan (Dublin Bay South, Fine Gael)
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Is there any double pay in Tallaght Hospital?
James Geoghegan (Dublin Bay South, Fine Gael)
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Of any form?
James Geoghegan (Dublin Bay South, Fine Gael)
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Who carries out the NTPF-funded service?
James Geoghegan (Dublin Bay South, Fine Gael)
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Does the NTPF go towards funding the overtime?
James Geoghegan (Dublin Bay South, Fine Gael)
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I see Dr. Lavin wants to interject.
James Geoghegan (Dublin Bay South, Fine Gael)
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There are additional staff as well.
James Geoghegan (Dublin Bay South, Fine Gael)
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In Tallaght hospital then, there is a similar enough governance model. Is that correct?
James Geoghegan (Dublin Bay South, Fine Gael)
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I understand that. I am sure the other hospitals that have been before us did too. However, at least there is the perception that there would be a conflict if an existing clinician is carrying out work with public patients through a company providing more overtime. There is no risk of a clinician relying on NTPF funding while he or she is also relying on a public waiting list because, as Dr. Lavin said, they are using the NTPF to fund overtime of existing clinicians. In addition, Dr. Lavin has indicated that the hospital is hiring a few, presumably on temporary contracts-----
James Geoghegan (Dublin Bay South, Fine Gael)
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At the risk of there being, let us say-----
James Geoghegan (Dublin Bay South, Fine Gael)
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Yes, an effective go-slow-----
James Geoghegan (Dublin Bay South, Fine Gael)
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Is Dr. Lavin surprised at some of the governance models we have heard in other hospitals in relation to these issues?
Dr. Peter Lavin:
Again, it is difficult for me to comment on other hospitals. As a clinician, I want to get a solution to see the patients. For us, this represented the best value and also best reliability in that when you are doing it effectively in-house by hiring additional staff, you have control over this and you have consistency with the same person seeing all the patients.
James Geoghegan (Dublin Bay South, Fine Gael)
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What is the hospital's process for Standards In Public Office Commission, SIPO, declarations?
Ms Barbara Keogh Dunne:
It is very similar. On an annual basis, before 31 January, we retrospectively correct the previous year. We had 98% compliance in 2024. There were three consultants who were actually on leave and who we could not contact. That was the remaining piece. Then, for 2025, we are at 95% today, so we have ten more patient consultants-----
James Geoghegan (Dublin Bay South, Fine Gael)
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Does the hospital have a similar system that the person who is carrying out procurement-----
James Geoghegan (Dublin Bay South, Fine Gael)
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----- in the hospital is aware of the conflicts through the declarations.
James Geoghegan (Dublin Bay South, Fine Gael)
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Again, it seems blindingly obvious sitting on this side of the desk that the hospital would have a governance system like this, yet in other hospitals, it was not the same governance system. I thank Ms Keogh Dunne.
Aidan Farrelly (Kildare North, Social Democrats)
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I thank everybody very much for being here. I will start with Ms Ryan Leacy. In reading the financial statements, €18.7 million accrued in 2024, which, if I read it right, gives a total close to €50 million of debt. Is any of this related to the Mater private network or any workings of the Mater private at all?
Aidan Farrelly (Kildare North, Social Democrats)
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I understand.
Aidan Farrelly (Kildare North, Social Democrats)
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There is nothing; there is no relationship there whatsoever.
Aidan Farrelly (Kildare North, Social Democrats)
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There is no interaction in terms of------
Ms Josephine Ryan Leacy:
We have shared care with MOUs and service level agreements, SLAs, and staff, if they come up to look at multidisciplinary teams, MDTs, but there is no correlation between the two. We work very closely with them. They were absolutely a game-saver to us during Covid when they supported access of surgical capacity to make sure patients with cancer during Covid still got their surgery. We have a really strong relationship with them but there is absolutely no correlation. We are two separate hospitals.
Aidan Farrelly (Kildare North, Social Democrats)
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Within that relationship, would there be payment interactions or transactions at all for surgeries for patients moving from one to the other? Is there any relationship there? Are there any outstanding payments in that relationship?
Ms Josephine Ryan Leacy:
I will get my director of finance to come in if the Deputy wants specifics. Safetynet was a really good example of where we sent patients down to the private hospital. The Deputy will remember that during Covid, there were four iterations of Safetynet. We sent patients down. Initially, we actually were invoiced by the private hospitals and then we got paid by the State for it, but they realised that was really not a clean way to have it. Therefore, from Safetynet 2 onwards, the privates actually paid directly to the State. We try to avoid, where possible, not having to have any financial interactions because it is very complex and you want to make sure you have tight scrutiny in relation to that.
Aidan Farrelly (Kildare North, Social Democrats)
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So there is nil now. That is-----
Mr. Adam O'Hare:
I can come in there. There would be services that both hospitals would avail of from each other, probably on a monthly basis. Invoicing does go back and forth. At any given point in time, moneys would be outstanding from one entity to the other. I do not have the exact amount outstanding as of today but that is something I can get and come back with.
Aidan Farrelly (Kildare North, Social Democrats)
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Please, yes. Des Mr. O'Hare have that monthly figure overall? Does he have an average of the sum of financial transactions between the two?
Aidan Farrelly (Kildare North, Social Democrats)
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I thank Mr. O'Hare. Is it Ms Ryan Leacy's ambition to see the hospital debt free and see that €50 million reduced to zero? What is causing that annually? What is the plan to eradicate that debt?
Ms Josephine Ryan Leacy:
To allay fears, when people say €50 million debt, it is actually €50 million due to the fact that we deliver services for which we were not funded proportionately to deliver. As the Deputy knows, we go into a service agreement with the HSE to deliver funding based on a budget allocation. Every year, year-on-year, we have exceeded that. When we have had any kind of, as we call it, deficit in the papers, it is because we were not funded for the services we deliver. Obviously, we cannot close the door so it is an underfunding model. It looks like debt but it is actually underfunding. As I said in my statement, however, we cannot build on that because of company law and our director's fiduciary responsibilities. I know we cannot build on that. That is why, last year, we broke even and we absolutely have to do that again this year because €48.9 million is a significant sum that is still outstanding. To reassure people, however, it was all about patients getting access and it was because we were not funded for the services we delivered. We pride ourselves because, actually, the Mater could do more and will do more, but we need the funding to be commensurate with the activity that we deliver.
Mr. Adam O'Hare:
I will come in as well. To add to what our CEO said, we are currently going through the finalisation of our annual financial statement audit for 2025. From my conversations with the audit partner, he is not able to commit to a figure but he has been very clear that we do not build on our direct deficit through the underfunding that we have seen to date.
Aidan Farrelly (Kildare North, Social Democrats)
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Does Mr. O'Hare expect that for 2025, there will not be an increase on that deficit of €50 million?
Aidan Farrelly (Kildare North, Social Democrats)
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In practice then, how would that have manifested itself in terms of difference in the service offered? If that figure has stayed the same, is it unfair to assume that the service level then has reduced in some way, shape or form?
Ms Josephine Ryan Leacy:
As I said, as part of the risk sharing agreement we went into last year with the HSE, we were actually able to forecast. We were forecasting last year a €33.3 million deficit that would have added on to the historical deficit, which would have made us insolvent or not a going concern so we had to make really harsh decisions. I am a nurse by background. It is very hard when you are balancing the ethical and financial, but we obviously have to do that every day. We were actually looking at option appraisals last year when we would have been reducing services, closing wards, reducing access to cancer treatments and reducing outpatients. Thankfully, with the HSE, because we had started, we opened our Rock Wing, which is something of which we are really proud. We opened all four wards and we were only funded for two. We had been told we would get the funding, so we opened in good faith. When we came back and had that deficit, we realised that if we did not get funded by the State as part of the HSE risk sharing, we had to close two wards of the Rock Wing. Thankfully, we did not have to do that because we never want to have to reduce services. It is that continuous balance act. My priority, as CEO, unfortunately, is to make sure we do not build on the historical deficit but maintain access for the patients as well. It is a really hard juggling act.
Aidan Farrelly (Kildare North, Social Democrats)
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With the cash acceleration then from 2024, were any conditions attached to that payment from the HSE?
Mr. Adam O'Hare:
No, there were no conditions in relation to it. To be fair to the HSE, it has always been very supportive of the hospital meeting its liabilities as they fall due. During 2025, for example, we put in two cash acceleration set-up profiles. What that means is that it becomes first call on our cash drawdown for 2026. The total of it then was about €40.5 million, so that brought us fully up to date with any payments to suppliers and any other liabilities we had at the time.
Aidan Farrelly (Kildare North, Social Democrats)
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The 2024 statements stated that the ambition for the cash acceleration was to pay most of the suppliers. What was the sum left unpaid ?
Are there still suppliers left unpaid or is that just coming from somewhere else?
Aidan Farrelly (Kildare North, Social Democrats)
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It was stated that if expected funding is not made available, the hospital would work with the HSE to establish what kinds of services might be curtailed. What services are envisaged to be curtailed if funding does not match what the hospital needs to operate?
Ms Josephine Ryan Leacy:
Our emergency department is open 365 days, 24-7, so we cannot close the unscheduled demand. We would be looking at our elective activity and predicting that, scheduled surgical activity for complex cancer cases, and outpatient procedures. We would have to try to pare back activity in these areas. We are working very closely with our region to come up with a funding model for this year that allows us to continue to deliver, because we take such pride in actually delivering the service.
Aidan Farrelly (Kildare North, Social Democrats)
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I should have said at the outset that it is commendable in that context. If the Chair does not mind, I will squeeze in one more question. It was said that a principal risk in the financial statements for 2024 was the constraints of the EU working time directive. How does that manifest itself in the hospital's work, and has it sought a derogation from the directive?
Professor Jim Egan:
We are constantly challenged in terms of our NCHD cohort because the demand from the patients in terms of coming in the door is enormous. Our compliance with the EU working time directive has improved compared with the time before Covid. Then, we were at 54% and we are up to 65% currently. We need to continue to strive to achieve a standard of 90%, but it goes back to that issue that we need six people 24-7, 365 days a year to run the services productively and safely for patients.
Aidan Farrelly (Kildare North, Social Democrats)
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Would Professor Egan expect that to improve this year?
Albert Dolan (Galway East, Fianna Fail)
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I will start with the Mater. Its opening statement and the briefing we received asserted that, "No conflicts of interest have been identified involving any grade of staff." That is obviously in relation to NTPF-funded activity. What process was used to identify whether there were conflicts or not?
Ms Josephine Ryan Leacy:
Because we were not bringing in any companies for any insourcing, and were not bringing in any third-party vendors, there was no conflict. We were bringing in staff who were being employed as nurses or doctors and that was their primary purpose. They were coming in on a full contract of 35 hours or 37 hours to deliver the NTPF.
Albert Dolan (Galway East, Fianna Fail)
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They were not Mater staff, were they?
Albert Dolan (Galway East, Fianna Fail)
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They were additional staff brought into the Mater, though.
Albert Dolan (Galway East, Fianna Fail)
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The reason I ask is that from 2020 to 2025, as per the briefing document, the insourcing receipts grew from €929,000 to €11.4 million. In the space of five years, this has become a significant method of funding for the hospital. Is the hospital now dependent on insourcing funding?
Ms Maria Creed:
As the Deputy mentioned, our reliance on, or our capacity to use NTPF funding, has increased incrementally over the years to the point now where we saw almost 14,000 patients off the waiting list last year with it. That has been identified activity across 17 different specialties and without it, we would have those 14,000 patients from last year, and indeed all the patients from the year before, on our waiting list. These staff are providing extra and additional capacity, without which we would be at a significant loss and we would be then in the position where we would have empty infrastructure unused in the organisation.
Albert Dolan (Galway East, Fianna Fail)
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All the hospital's funding is agreed with the HSE based on a service level agreement. Is that correct?
Albert Dolan (Galway East, Fianna Fail)
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Does the hospital run a deficit on that or is it ever the case that the funding is insufficient?
Mr. Adam O'Hare:
I think it is fair to say that generally it would be insufficient, so we do look and see that it is a case of underfunding. As we have said already, in 2025, the hospital achieved a break-even position. However, if we go back one more year to 2024, we were left with a deficit for that year in isolation of €18.7 million as a result of underfunding.
Albert Dolan (Galway East, Fianna Fail)
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The reason I ask about this is the hospital is given a service level agreement and signs it. Subsequent to the hospital agreeing what is in that agreement - the amount of funding and the levels of service that are expected to be delivered under it - does the hospital send a side letter to the HSE saying that the amount is not sufficient? How quickly after signing the service level agreement does the hospital have to go back to the HSE to say it has signed the document but it is not sufficient?
Ms Josephine Ryan Leacy:
The ideal model would be that we would have a service level agreement and we would know in January what our funding allocation is and what the activities are expected to be delivered. Then, as we went through the year, if we saw we were going above it, there should be a process whereby we could say we were going to incur an extra cost. That process does not occur at the moment. We get an agreement-----
Albert Dolan (Galway East, Fianna Fail)
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Do negotiations take place? At the start of the year, there is a clear expectation of what the service levels will be. This is set out with the HSE and a service level agreement is signed. How quickly afterwards is the hospital going back to the HSE to advise it of cost overruns? I understand that the hospital has to keep its doors open. It has to make sure the patients get seen and it offers an incredible service, which I appreciate it does, but is it a case of a blank cheque here? Can the hospital just keep going back every time?
Ms Josephine Ryan Leacy:
No. For us it is frustrating. This is why I say there needs to be a reform in relation to the process. We need to be involved and we are starting to work collaboratively with the HSE. We can forecast, based on our activity, our pay and non-pay, what we would require to run the hospital for the next year, but what happens is we get an allocation that is quite significantly lower than that. This is where the SLA debacle comes in. We are seen to be delaying signing an SLA, but we cannot sign it if we know we do not have the funding to deliver what we need to deliver. This is what we need to be looking at and that is why I go back to the multi-annual activity-based funding. That model would allow-----
Albert Dolan (Galway East, Fianna Fail)
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Just on that topic, does the hospital send a side letter afterwards saying it is not enough?
Ms Josephine Ryan Leacy:
We signed our last SLA last year in November, which is farcical because we were signing at the end of the year for the year just delivered. As part of the side letter, we always say that there needs to be an acknowledgement of how we would factor in inclusive activity, be it winter surge or other planned activity. We would also have a side letter that would go in.
Albert Dolan (Galway East, Fianna Fail)
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How quickly after signing does the side letter go?
Albert Dolan (Galway East, Fianna Fail)
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That is definitely something that needs to be looked at. As a section 38 organisation, if the hospital is going almost the whole year without signing its service level agreement, that may run a risk. How is the hospital able to draw down payments throughout the year if it does not have a service level agreement in place with HSE?
Ms Josephine Ryan Leacy:
I might get my financial officer to come in on that, but I will just say that I totally agree. I would love to have my service level agreement signed in January for this year and then be able to financially plan and look at activity openly and transparently. As things stand, it is too late in the year when we sign the SLA. This is where we need to be involved. We need to have collaboration with the HSE to look at the funding.
Albert Dolan (Galway East, Fianna Fail)
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Is there anyone from the HSE here? How many hospitals only sign their SLA agreements by the end of the year?
Albert Dolan (Galway East, Fianna Fail)
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I am saying that if an agreement is going to be made about how much money is going to be budgeted for 2026, I would assume all of those documents should be well signed by now, in April. At the moment are there many hospitals with signatures outstanding on their SLA?
Albert Dolan (Galway East, Fianna Fail)
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The Mater is the only one that has not signed?
Mr. Robert Kidd:
It is not the only one, but it is the most significant in terms of value. We would have a value of about €2 billion for service level arrangements. We have about €1.1 billion or €1.2 billion signed, so the Mater is about €600 million, so that would bring us up to a value of about €1.8 billion.
Albert Dolan (Galway East, Fianna Fail)
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What is holding the Mater back from signing an agreement with the HSE right now, given that we are in April? The hospital is basically saying to me that it will not sign this until December because it will have to. I want an answer from the CFO as well. How are payments drawn down when there is no agreement in place? That has to be a huge governance risk for the HSE, the State and the hospital, because it is drawing down payments with no underlying agreement.
Mr. Adam O'Hare:
In terms of the payments we draw down, we are given a cash profile from the HSE for the year. It bases that on the current budget we have been allocated. For 2026, for example, we currently have an allocation of €597.2 million. Just for context for the committee, we finished out 2025 with a final allocation of €614.8 million, so we are effectively €17 million behind our final position for last year before we factor in any of the additional payments, such as €15 million for pay awards under the national agreements for 2026. However, the cash-----
Albert Dolan (Galway East, Fianna Fail)
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The private auditors had warned hospital directors that the accumulated deficits were so large that they were at risk of trading recklessly under company law. How does the hospital manage that? It is a fairly hard-hitting statement from the auditor to suggest people could be trading recklessly under company law. I do not think auditors would say that lightly, so I am just asking how the hospital is managing its budgets such that it is ending up with such deficits. I understand it is delivering a massive service and that it has to be funded, but it is quite shocking that there is no SLA in place to underpin all this activity, even allowing the hospital some headroom for overrun.
Ms Josephine Ryan Leacy:
Last year with the risk-sharing agreement, we absolutely broke even. We identified what we needed. We set out with the HSE the identified areas it had not funded. We cannot build on the €48.7 million deficit. What we hoped for this year was to start off with the budget we had forecast, and to have discussions on how to get as near as possible to that. Then what we would have to do is map our services accordingly. We absolutely want to get the SLA signed.
Albert Dolan (Galway East, Fianna Fail)
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I will ask my last question because I am conscious of the time.
John Brady (Wicklow, Sinn Fein)
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Very briefly.
Albert Dolan (Galway East, Fianna Fail)
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How is the hospital managing its costs? Are they getting out of control? Is there waste in the hospital?
Ms Josephine Ryan Leacy:
No. To reassure the Deputy, we have management accounts for every director within the hospital. Whether it is a matter of surgery or the ED, we can look at both pay and non-pay. We view that on a monthly basis and we see where the trends are. A lot of our funding is actually fixed and outside our remit, because it is a matter of pay. We look at what we can manage. Our non-pay element is quite tight. We absolutely have very tight processes. We go through the frameworks that we can go through in relation to non-pay, so we do not feel there is a lot of meat left on the bones in relation to non-pay. To put it in context, our medication cost has risen from €42 million in 2019. We are now spending €82 million per year on medications alone. If you put an implantable device into somebody’s heart, you will note the cost has gone up 43% with inflation. I refer to non-pay costs. However, to reassure the committee, we absolutely scrutinise our pay and non-pay.
Albert Dolan (Galway East, Fianna Fail)
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I thank the witnesses.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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I thank everybody for coming in today. I want to be clear in my own head about how both hospitals are funded. We will start with Ms Keogh Dunne.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Who gives that money?
Ms Barbara Keogh Dunne:
This year, it has transitioned from the central HSE to the regions, so the region actually allocated it for this year.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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So it is the HSE. How much did it allocate?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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What is the total budget?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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So the HSE gives the hospital €438 million out of €471 million. Is that correct?
Ms Barbara Keogh Dunne:
We project that it is going to be €471 million. The HSE has allocated a budget that is €40 million short of that. Therefore, the funding allocation is about €40 million short.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Where else does the hospital's funding come from?
Ms Barbara Keogh Dunne:
First of all, we have been working closely with the HSE to try to fund the gap and identify exactly what was not funded. We have had numerous negotiations and engagements with the Dublin midlands region to try to close the gap. We are working together on that.
With regard to other ways, we have our car park income, our private income-----
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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How much does the hospital get in car park income?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Could the Comptroller and Auditor General explain to me again what we discussed earlier in respect of section 38 organisations? Are these hospitals not completely funded by the Government?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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So why are they not under the control of the Comptroller and Auditor General? Why do we not have oversight of these hospitals?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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The Comptroller and Auditor General referred to the amount being over 50%, but it is way over 50%.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Okay. How could we correct that to make sure the hospitals would come under our remit?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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I thank the Comptroller and Auditor General.
Could Ms Ryan Leacy state how much her hospital receives in car park income?
Ms Josephine Ryan Leacy:
We do not have car park income. The car park comes under a separate company. It actually comes under the parent board. When our building, the Whitty, was built, there was a shell but the HSE could not fund a car park, so the parent board took out a significant loan to build one. The income from it is paying off the loan, but I would not have visibility of the financial accounts.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Who owns the car park? Who does the land belong to?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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How much is it making?
Ms Josephine Ryan Leacy:
I do not know; I do not have visibility. The Deputy would have to ask it directly. The charges have not increased since it opened in 2009, which is a good thing. We are conscious that it is in the city so we are trying to make sure people in the street are not using it so there is access for patients.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Okay. The witnesses from Tallaght hospital highlighted in their opening statement that the occupancy rate was between 110% and 115%. What kind of impact does that have on patient care, patient outcomes, staff morale and retention?
Ms Barbara Keogh Dunne:
It has a significant impact. Today the hospital is decongested somewhat, as there are probably two patients waiting for beds, but for the last three or four months the congestion has been very significant. That impacts on patient safety in relation to getting patients through the emergency department as fast as possible. There is a negative impact if patients are delayed there.
The second area on which there is an impact is our scheduled care. We actually have to limit our intake of scheduled-care patients, for surgery day cases who need to come directly into the hospital, and we also limit our scheduled intake of inpatients. Our waiting lists start to grow, especially during the winter, in both of those areas. We also have other areas that are congested in the hospital, such as our acute medical assessment unit, our surgical assessment unit. These are areas patients should flow through, but patients are stagnant there and waiting for inpatient bed accommodation.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Is the occupancy rate in the Mater the same? Has it the same issues?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Okay.
Ms Maria Creed:
It is similar to what Tallaght experiences. Our occupancy rate is significantly and frequently above 100%. Also in line with what the witnesses from Tallaght have said, our doors are always open and attendances at our emergency department have increased by 25% over the past six years. They increased by 10% in March 2026 by comparison with March 2025. Therefore, we are experiencing huge popularity among the public.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Is this having an effect on retaining staff in each of the hospitals? It could be an issue in relation to the insourcing or outsourcing. Maybe we would have more staff in our hospitals if staff were not working in such bad conditions, with higher occupancy------
Ms Josephine Ryan Leacy:
Additionally, you have the pressure of working in a pressurised environment with high volumes, and the antisocial behaviour has increased exponentially. We have had massive incidents of antisocial behaviour where staff were getting attacked. It is really hard to maintain morale and protect the staff. This is at the core of what we do. We have a very good working relationship with the gardaí in Mountjoy. We are very fortunate to have that but it is becoming really hard to retain staff in an environment that is so difficult. For us in the Mater, we are so proud. We are very open and we are all about protecting our staff. We really take pride in our staff, so we try to protect them as much as we can with wellness initiatives and employee assistance. You are trying to see how you can support them but it is extremely challenging.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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It was said in the Mater hospital's opening statement that there is a documented life expectancy gap of five to eight years between the hospital's north inner city catchment and that of south County Dublin.
Where did that data come from?
Ms Josephine Ryan Leacy:
It is available on pobal.ie. It comes back to the complexity of what we are looking at and, as I said during my opening statement, 13% of the people who come through our front door are homeless. We have 1,800 homeless people living on Gardiner Street, which is literally just up from our door, and we have 1,800 IPAS applicants around us. These people rely on us and we absolutely have to be there to support them but somebody who is experiencing homelessness they are four times more likely to present to the ED. There is complexity and they will be three times more likely to require admission. It is not as easy as just discharging them. We cannot just discharge people out on to the street, so I do not know-----
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Has the HSE made any targeted interventions on the issues arising related to underfunding and staff morale and retention within the hospitals?
Ms Josephine Ryan Leacy:
We are very lucky we have a really good social inclusion consultant in the Mater hospital so we have set up a hub. We go down to Summerhill. We have two peer supporters who have gone through homelessness and have experiences of addiction so that is an element we are looking at trying to support people at the front door because these are a cohort of people who are very vulnerable and we need to be there to support them. Does Professor Egan have anything to add?
Professor Jim Egan:
Definitely, and I thank the Deputy for that question. The profile of patients since pre-Covid has changed radically. When I was on call last week, out of 55 emergency admissions, a third of the individuals were either homeless, IPAS candidates or very elderly people. I was delighted to meet four people over the age of 90. Complex support is involved in getting them discharged and maintaining that flow through the ED. It is extremely challenging because of the complexity of demand.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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It is all down to complete underfunding by the HSE. Neither hospital is getting enough funding to provide its best service.
Joe Neville (Kildare North, Fine Gael)
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I thank the witnesses for coming in today. I appreciate everything they do on our behalf and that of the State. I want to speak quickly to my one hospital experience during the past few years, or ever. I tore my Achilles and attended the Mater hospital. All I can say is that it was amazing. I went to the Smithfield clinic first and they sent me to the orthopaedics unit in the Mater. All of the team, and everyone I dealt with through to the operation stage, were amazing. I know we often hear of the negative stories, and rightly so because they have to be highlighted, but I want to give my own positive impressions of what was a difficult time. I had to have an operation and could not walk properly for four or five months and I found the team and the aftercare team brilliant. I wanted to share that and thank the Mater hospital's as I have the opportunity.
Moving on to what we are discussing today, I want to try to bring it up a level, even to help my own understanding of funding and the arrangements the hospitals have. In regard to the Mater hospital, what are the current funding arrangements with the HSE? What is the amount of funding it receives each year and what are the main KPIs or elements of the SLA the Mater has to adhere to each year, and how they are monitored?
Joe Neville (Kildare North, Fine Gael)
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It is probably a question for him.
Mr. Adam O'Hare:
In terms of our funding at the moment, the Mater has an allocation of €597.8 million for 2026. Based on our level of activity, in terms of patient throughput and our spend, there is a significant shortfall forecast for the year. It will be in the region of €48.8 million if we were to continue at these rates, which to be honest, is not sustainable-----
Joe Neville (Kildare North, Fine Gael)
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Is that for 2026?
Joe Neville (Kildare North, Fine Gael)
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Will Mr. O'Hare say that again? He thinks the Mater hospital will exceed by €48 million-----
Joe Neville (Kildare North, Fine Gael)
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Yes.
Joe Neville (Kildare North, Fine Gael)
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That is timely because we had the quarter 1 review of the accounts from this perspective and we can see where we overshot in education, and obviously sightly here, and that was part of the national conversation. Just for the Mater hospital alone, there will be about a €50 million overspent. It is quite early in the year to have that figure. Is it the same element of spending that Mr. O'Hare feels the run rate will continue or was there one specific loss already in the quarter?
Mr. Adam O'Hare:
No. To be honest, when we look at the accounts as a whole, it is spread across the board. We have two primary areas that are causing difficulties. One is pay and the other is the income generation targets set for us. It is to do with the underfunding. For context, when we finished out 2025, and we had a break-even position, our final allocation was €614.8 million. As is stands at the moment, we are €17 million behind that final position of last year, just starting this year, and that is before we factor in any of the significant pay awards we are predicting for the year ahead. They are underpinned by the public service stability agreement that finishes this year. That, in isolation, will account for about €15 million.
Ms Josephine Ryan Leacy:
To clarify, when we say a €50 million deficit, we cannot incur that. We cannot build on what we have historically. This is why we are working with the region to try to get a figure so we have a final one. This is what we are forecasting, because we know from our activity, but we cannot actually have that, significantly, so we cannot build on the historical deficit and this is where the challenge is. I know representatives of the region are here, so we are working with them to try to get a funding model that works for us and actually allows us to deliver but not build on a historical deficit.
Joe Neville (Kildare North, Fine Gael)
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Does the HSE have visibility on what the hospitals spend or how does that work? I know there was a lot of conversation about the IFMS as well in the non-voluntary hospitals and then there were conversations regarding yourselves. Where has that landed with the IFMS?
Joe Neville (Kildare North, Fine Gael)
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Tallaght hospital is on target.
Joe Neville (Kildare North, Fine Gael)
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Tallaght hospital will be 1 August. It is funny that there are so many different groups and we only have eight minutes. It is gas. I risk focusing in on one group, so apologies. IFMS is going live on 1 August in Tallaght hospital.
Joe Neville (Kildare North, Fine Gael)
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Okay.
Mr. Adam O'Hare:
To go back to the Deputy's earlier question about the visibility of information, the Mater sends what is called the information management report to the HSE every month, so that does detail out our actual spend against our budget across pay and non-pay. It is something the HSE can see. In addition, we have already started the IFMS process and our information is mapped into that system, so it is already there via an upload. So that is three times per year.
Joe Neville (Kildare North, Fine Gael)
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It is almost like a monthly P and L that the Mater hospital issues.
Joe Neville (Kildare North, Fine Gael)
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I will ask the same question of Mr. Carter, if he does not mind. As regards the level of funding and the position after quarter 1, where does he think-----
Joe Neville (Kildare North, Fine Gael)
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That is €470 million.
Joe Neville (Kildare North, Fine Gael)
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Tallaght has gap of €40 million.
Joe Neville (Kildare North, Fine Gael)
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Yes, Tallaght hospital has a funding shortfall. So €40 million and €48 million is essentially €90 million between two hospitals. That is not in a lot of the hospitals, I would have thought. What is the situation with the rest of the hospitals?
Mr. Joe Campbell:
In relation to TUH, clearly the gap of €40 million is significant. It is not the largest gap we have had over the years. Two years ago we had a gap of €89 million. We worked with the hospital to get that down to break even. In fact, if we look at our funding for the hospital, and I am sure Mr. Carter will agree with it anyway, between 2021 and 2025 there was a growth in funding from €237 million to €409 million, which is 73%. When we look at the quarter-----
Joe Neville (Kildare North, Fine Gael)
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Sorry, the increase of 73% was where?
Joe Neville (Kildare North, Fine Gael)
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In Tallaght alone.
Joe Neville (Kildare North, Fine Gael)
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Apologies, I am conscious I have 30 seconds left. I know the Chair will give me an extra minute or two.
Dr. Lavin has indicated that he wants to jump in.
Joe Neville (Kildare North, Fine Gael)
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It is activity led.
Joe Neville (Kildare North, Fine Gael)
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I am an accountant. You do your budgets and you have a sense, and obviously there can be increases. To go back to Mr. Campbell, if we are at 88 for two hospitals, what is the run rate around the rest of the hospitals? What is the overall figure? I know it is not about the groups here today, but where do we think it is? Eighty-eight is a lot for two hospitals.
Joe Neville (Kildare North, Fine Gael)
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How many hospitals are there in total?
Joe Neville (Kildare North, Fine Gael)
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Yes, even the nine.
Mr. Joe Campbell:
If we look at our overall projected overspend, it is somewhere between 4% and 5% at the moment, but clearly we are working with hospitals to get that number down. We have boundaries and challenges. We have a responsibility in terms of compliance, control and stewardship over public funds, so that really-----
Joe Neville (Kildare North, Fine Gael)
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Is that 4% or 5% over about €4 billion?
Joe Neville (Kildare North, Fine Gael)
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It is €4.3 billion. Is it about €160 million?
Mr. Joe Campbell:
Approximately, yes. That is an initial position. Obviously, we have to go through our quarter 1 projections with the hospitals, so I would expect to get that down. The target would be to get to a break even. That is our ambition to do this but obviously we have to go through the projections. We have to look at areas where we can save money. Each of the hospitals have detailed savings and efficiency plans for the rest of the year. We also have national service plan money, which the regions hold until such time as those particular plans are put in place in individual hospitals and the funding is released. We have a trajectory and an ambition to get close if not to break even. That is our stated position.
Joe Neville (Kildare North, Fine Gael)
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I thank everyone for all their clear answers.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Go raibh maith agat, a Chathaoirligh. I will also avail of the additional two minutes that everybody is getting.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Like Deputy Neville, I acknowledge the really positive work that is being done. It is the nature of our committee that we tend to focus on perhaps where things are going wrong. I just wanted to acknowledge that. I had an unexpected stay in the Mater last year where I had access to top-quality diagnostic equipment and top-quality consultants. I had a bit of bumpy entry at accident and emergency, but I know that accident and emergency is a challenge for everybody.
I will focus on insourcing for a moment. In their opening statements, the witnesses talked about multi-annual activity-centred funding. In essence, on the face of it, insourcing is essentially that. It is additional funding to a public hospital to carry out additional work and, in the normal course of events, we would welcome that. The issue that arises for this committee is in two areas. Is the funding double spending? Is it focusing on work that is already being done or should already have been done? Second, are the people who are managing that core work benefiting financially from the NTPF funding? Will witnesses from the two hospitals address those two questions and whether they believe that to be the case?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Are the witnesses satisfied that the register of any conflicts of interest is both transparent and available?
Ms Josephine Ryan Leacy:
We thankfully have never brought in any third-party company as part of our insourcing, so we never had to have that, but we do have a very tight and stringent process in relation to any procurement. We have our own procurement team that highlights any conflict of interest. Anybody who would go for tender for any company for a hospital would also provide conflicts of interest. We have a very tight scrutiny but we did not bring in any third party for insourcing.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Along with that, it then highlights the issue of the funding that is already received. I will talk about the consultant contract and the delivery of what is expected under that contract in the different specialties in the witnesses' areas. Is that a challenge, Ms Ryan Leacy? Can she tell us where she is at in ensuring that is being delivered?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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All consultant contracts.
Ms Josephine Ryan Leacy:
We would have visibility of work plans for all our consultants. I sign off on individual work plans for every consultant that is actually in the institution, be they public only or if they have different types of contracts. We have visibility. Obviously, we are uploading them onto the national system, the doctors integrated management esystem, DIME, so there is visibility and transparency. I might hand over to Professor Jim Egan.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Of course, yes.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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From the Mater's perspective, are the witnesses satisfied with that?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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I know that Ms Keogh Dunne joined Tallaght hospital relatively recently. Can she talk to the committee about the situation with that hospital?
Ms Barbara Keogh Dunne:
I would say it is similar. I would add that as consultants start their employment, the work practice plan is outlined from the very beginning. It is agreed with the service and the clinical director and then signed off by myself. It is then reviewed on a three yearly basis or sooner, if needed, if they are changing to a different contract.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Historically, was that a challenge at Tallaght hospital?
Dr. Peter Lavin:
I might come in here. We would review of all of the work plans either on a three yearly basis, or if there is a new person to the service and therefore the work plans may change accordingly. We also then have oversight from the business managers and we can see the utilisation that the clinic capacity has fulfilled. I have regular interaction with these consultants where we would see them on post-take rounds, and we do a daily intake so we see them on the ground. There is communication. I am confident that the consultants on the ground are delivering their contract.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Significant funding in terms of staff has been provided for the acute medical assessment unit, AMAU, and the surgical version of that, which is the acute surgical assessment unit, ASAU. Is the hospital seeing an impact from that in reducing waiting times?
Dr. Peter Lavin:
We had initially. Unfortunately, in the last 12 months, the occupancy levels in Tallaght University Hospital have been at 110% to 115%, which has meant that the AMAU has inpatients in it because there are patients in a lot of surge areas in the hospital. However, the AMAU consultants continue to work into the emergency department and they do a lot of admission avoidance work. Certainly, we can see there has been a dramatic decrease in the patient experience time which is a really important marker. That-----
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Is it perhaps not what the witnesses might have expected?
Dr. Peter Lavin:
There could be more. Having said that, there is still a very dramatic decrease in that time. It has gone down by almost 12 hours in the last 12 months. That is very significant. I am very confident that the consultants who are there are working to the spirit and ethos of their contract and fulfilling at least the hours in it.
Professor Jim Egan:
I thank the Deputy for that question. Again, I will clarify the kind of operational issues that we face in terms of productivity. On unscheduled emergency care, we might have 50 admissions on average, but there will be nights when we have 79 admissions and that results in what I call the M50 effect. Those patients get distributed all around the hospital and everything slows down. If we look at what we call the time taken to do a "safari round" - walking around the hospital to see the 80 people that were distributed - it takes three and a half to four hours. In contrast, if we have sufficient beds in terms of occupancy, we know we can cohort patients in one particular area, say, all the heart candidates in one area and the cancer patients in another. Those ward runs take about an hour and a half. The lack of beds results in what I call the M50 effect, which reduces the productivity just when we are having a surge.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Where there is concentration, it provides a manpower benefit, or woman power.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Reference was made earlier to no third party for insourcing. Does that include additional overtime for consultants being funded by NTPF?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Is Ms Ryan Leacy satisfied the people managing what should be done in core hours are not in any way creating an artificial list to avail of that via overtime? I am asking because that is the concern.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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What about Tallaght?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Is MedModus the company delivering the IT service Ms Keogh Dunne mentioned?
Paul McAuliffe (Dublin North-West, Fianna Fail)
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How does that interact with the HSE patient tracking IT?
Ms Barbara Keogh Dunne:
It is a business intelligence platform with real-time visibility of all our activity in relation to scheduled and unscheduled care. We have used it for a significant number of years. We are trying to transfer into our own so we can have internal expertise, but that takes training and a transition period.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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Will Ms Keogh Dunne provide details of the overall cost of that? She can do it in writing afterwards.
Mr. Robert Kidd:
It might be helpful to add to what the Mater said. Within the HSE we have theatre efficiency and OPD efficiency and productivity programmes. I know the Mater has engaged in both. That is looking at the issue the Deputy raised: what we have in core, how we use that and can we use it better.
Paul McAuliffe (Dublin North-West, Fianna Fail)
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That is the core criticism, as the Chair will agree. The fear is people managing the core activity may in some way financially benefit from additional funding or that there is not transparency on that. The witnesses' answers here are clear. That is the core concern the committee has.
Séamus McGrath (Cork South-Central, Fianna Fail)
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I thank the witnesses for being here and for their answers so far. I will follow up on some of the questioning and seek further clarifications, starting with insourcing. In the case of both hospitals, there is no third-party insourcing at present.
Séamus McGrath (Cork South-Central, Fianna Fail)
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That has been the case for a number of years, with the exception, as has been clarified, of a facility in Tallaght. The insourcing that is taking place, not including third parties, is seen by both hospitals as an essential source of funding for the operation of the hospitals.
Séamus McGrath (Cork South-Central, Fianna Fail)
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They need to see that continue.
Séamus McGrath (Cork South-Central, Fianna Fail)
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I think the Mater made the point that it is a combination of additional staff and overtime.
Ms Josephine Ryan Leacy:
For all the outpatient activity, it was additional staff. For the radiology that has been stopped for the past few years, that would have been done on a Saturday as overtime. Thankfully, we are looking at bringing radiology in as core working on a Saturday. NTPF is no longer for radiology and has not been since it got pulled from NTPF.
Séamus McGrath (Cork South-Central, Fianna Fail)
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So it is generally additional staff in the Mater's case.
Séamus McGrath (Cork South-Central, Fianna Fail)
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How many additional staff are funded through the insourcing model?
Séamus McGrath (Cork South-Central, Fianna Fail)
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What is that as a percentage of overall staff?
Séamus McGrath (Cork South-Central, Fianna Fail)
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It is a couple of percent. In relation to Tallaght, is it-----
Séamus McGrath (Cork South-Central, Fianna Fail)
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Tallaght tends to use more overtime, as I am hearing.
Séamus McGrath (Cork South-Central, Fianna Fail)
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What is the overtime rate in both cases? Is it an hour and a half, two hours, in terms of the rate that is applied?
Séamus McGrath (Cork South-Central, Fianna Fail)
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What is that rate?
Séamus McGrath (Cork South-Central, Fianna Fail)
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In terms of employment of staff, we know it is difficult to recruit specialist medical staff. Why would medical professionals take up employment through the insourcing model on a temporary basis, not having the certainty and so on, as opposed to becoming permanent members of staff? Can the witnesses explain that?
Ms Josephine Ryan Leacy:
For us in NTPF it is predominantly admin and nursing. They would all love to be coming in on permanent but it is an opportunity to get into the hospital and provide visibility of their skill set. We see natural attrition of people moving from temporary funded posts to permanent positions that come up in the hospital. That is beneficial for us but it is very uncertain for people on temporary contracts.
Séamus McGrath (Cork South-Central, Fianna Fail)
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Going back to overtime, what is the total weekly hours in the public contract at present for consultants?
Séamus McGrath (Cork South-Central, Fianna Fail)
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Typically, what level of overtime would be done through the insourcing model?
Séamus McGrath (Cork South-Central, Fianna Fail)
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The Mater has nobody but Tallaght does, as I understand it.
Séamus McGrath (Cork South-Central, Fianna Fail)
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How many hours would typically be done? What would it vary from?
Séamus McGrath (Cork South-Central, Fianna Fail)
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It would not be a significant top-up to basic salary.
Séamus McGrath (Cork South-Central, Fianna Fail)
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I understand that point but I am trying to get a sense of the level of overtime. Dr. Lavin is saying it is not a high level of overtime.
Séamus McGrath (Cork South-Central, Fianna Fail)
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Both hospitals gave figures in terms of the public-only contracts and the rate at which they have been taken up. Consultants who are not on public-only contracts carry out private work. Is that done outside the campuses of both hospitals or is some work undertaken within the campuses of the hospitals?
Séamus McGrath (Cork South-Central, Fianna Fail)
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There is a private clinic on-site but it is nothing to do with the public facility. It is entirely private.
Séamus McGrath (Cork South-Central, Fianna Fail)
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Would both hospitals describe their register of declarable interests to be in good state?
Séamus McGrath (Cork South-Central, Fianna Fail)
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Have there been any instances in recent years where issues have had to be clarified or corrected?
Séamus McGrath (Cork South-Central, Fianna Fail)
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Was it a correction or a clarification?
Séamus McGrath (Cork South-Central, Fianna Fail)
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I will turn to the NTPF. We hear of the reliance on non-third-party insourcing. Where are we as a whole with the third-party insourcing currently taking place?
Ms Fiona Brady:
I mentioned last October when I was here that the NTPF does not deal directly with third-party insourcing but is aware the insourcing money we give to public hospitals is used in nine different hospitals to fund third-party insourcing. Last year we spent €69.1 million on insourcing; €23 million of that was on third party. This year we have reduced our insourcing funding significantly in line with the public money consulting contract. We are very aware hospitals are looking for more productivity from consultants in that regard and have reduced our insourcing to €48 million this year. One third of that is third-party insourcing, only till the end of June. That will all stop at the end of June, as per Mr. Gloster's directive. Insourcing from a payroll overtime perspective will continue. It is only the third-party insourcing that is stopping at the end of June.
Séamus McGrath (Cork South-Central, Fianna Fail)
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It is due to end by June but for this year it is a third of €48 million, so it is somewhere around €16 million.
Séamus McGrath (Cork South-Central, Fianna Fail)
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That will absolutely come to an end in June.
Séamus McGrath (Cork South-Central, Fianna Fail)
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What are the implications of that for waiting lists? A significant amount is being spent through that avenue.
Ms Fiona Brady:
I might hand over to Mr. Kidd on this one but I think from Mr. Gloster's review of third-party insourcing last year, it only came out at 4% of the activity at a national level. It is quite small though the payroll - as in the overtime - insourcing is quite significant and does a huge amount of good.
Mr. Robert Kidd:
The CEO's report, as Ms Brady said, identified about 4%. I can only speak to our region. We have very limited use and have stuck rigidly to the controls the CEO put in place last August. We are lucky to have had investment this year and hope to open a surgical hub this June in Swords on the northside of Dublin that will support additional activity for us. We are hoping additional theatres-----
Séamus McGrath (Cork South-Central, Fianna Fail)
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Is it fair to say the ending of third-party insourcing, which I agree with, will result in waiting lists increasing in the near term?
Séamus McGrath (Cork South-Central, Fianna Fail)
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Would Mr. Kidd not see a knock-on effect in his region?
Mr. Robert Kidd:
There are specific pockets where we use it. I think it was mentioned earlier that there was a derogation given for BowelScreen in particular, for scopes, at a central level within the HSE, so that was-----
Séamus McGrath (Cork South-Central, Fianna Fail)
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So, within certain activities.
Séamus McGrath (Cork South-Central, Fianna Fail)
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Given what we have heard today about the underfunding in both cases coming to close to €90 million in the wider region, and obviously that is replicated other hospitals, it is quite a chaotic way to be funding a health service. Have the HSE witnesses any comment to make on that? How do hospitals plan in the medium to long term when they are constantly dealing with underfunding and a model that does not give them the funding requirements they clearly need?
Mr. Robert Kidd:
I am happy to come in first on that and then perhaps Mr. Campbell will come in. There are two aspects from our perspective as a region. As members will have seen from the Mater opening statement, last year was the first year we engaged with the Mater. We had a sort of risk-sharing engagement in terms of what its allocation was last year. It was facing into a similar scenario. As we heard from the Mater, it broke even last year. We are in a similar space this year and we are engaging with the Mater collaboratively again. We would expect the outcome to be similar. The Mater referenced in its opening statement-----
Séamus McGrath (Cork South-Central, Fianna Fail)
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How does Mr. Kidd go from a projected underfunding of €48 million to breaking even? How does that happen?
Mr. Robert Kidd:
There are some elements within the allocation that were once off last year. Second, there are savings included in all allocations for all hospitals and all entities in the overall region. We look at our capacity within the overall region. We need to look at our overall forecast, as Mr. Campbell mentioned earlier. It is a forecast and we will have our first quarter results. Again, similar to last year, we will be working with the Mater-----
Séamus McGrath (Cork South-Central, Fianna Fail)
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Is it the case that a bailout of additional funding will be required?
Séamus McGrath (Cork South-Central, Fianna Fail)
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Some €48 million does not disappear. It has to be made up and services have to be provided. That additional money has to be forthcoming.
Mr. Joe Campbell:
In terms of the reference to it being chaotic, there are struggles. Each year the increase in volumes obviously creates strains and pressures on the system. As I said before, there are boundaries and we have to meet those particular challenges. The HSE does give additional funding for activities, which is clearly outlined in the budgets that are delivered each year. I can only talk to our own region but looking at our current challenge of around 4% to 5%, that is early days. We have to look at the forecasting and the first quarter projections with all of our hospitals. The savings plans start to kick in. The national service plan 2026 money in particular starts to be delivered out to the hospitals. We are also looking at areas such as continuation of funding for bed capacity that existed from last year. All of those matters have to be addressed. The move should help us and reduce some of the chaos in terms of the funding. The move to activity based funding, ABF, and multi-year budgeting will be really important. ABF is a stated goal for budget setting for next year.
Grace Boland (Dublin Fingal West, Fine Gael)
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I apologise as I have been going between two between two committees, so I may have missed something. I just wanted to pick up a point with the Mater and Ms Ryan Leacy. Did I miss the reason the Mater has not signed the service level agreement, SLA, and the reason it was so late in signing it last year.
Ms Josephine Ryan Leacy:
The reason we have not signed the SLA this year is that we actually started off this year with a budget allocation of €592 million, which was €17 million less than what we finished last year with. Based on our forecasted activity for this year and our expenditure, and on top of pay awards, we would be looking at needing another uplift of just under the €50 million. We cannot sign an SLA until I know what my budget allocation is because I need to mark my activity based on that. The deficit that we have from underfunding-----
Grace Boland (Dublin Fingal West, Fine Gael)
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So it is a row over the budget funding, is that it?
Grace Boland (Dublin Fingal West, Fine Gael)
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Was that not the same last year?
Grace Boland (Dublin Fingal West, Fine Gael)
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I want to move on to the National Treatment Purchase Fund, NTPF, and the insourcing. As the witnesses will have heard, we struggle to understand what the hell is going on here. I am trying to get a bit of clarity. With regard to the NTPF, in Ms Brady's view, is in sourcing being used to compensate for a lack of core-funded capacity?
Ms Fiona Brady:
My HSE colleagues here are probably best to answer that. No, I do not believe so. As Ms Keogh Dunne and Mr. Campbell have already said, the unscheduled care activity within the organisation is so unpredictable. It runs at nearly 100% so one cannot predict that but we also cannot leave our patients just sitting and lounging on a waiting list because they will simply deteriorate. The Mater and Tallaght hospitals are very proactive in how they manage their waiting lists and how they use the NTPF funding.
Grace Boland (Dublin Fingal West, Fine Gael)
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Would it not be cheaper for the State to give funding directly to the hospitals rather than having yet another organisation, the NTPF, added into the whole system? Is Ms Brady aware of any cost-benefit analysis being done? I will ask this of the HSE as well.
Grace Boland (Dublin Fingal West, Fine Gael)
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Mr. Kidd or Mr. Campbell?
Grace Boland (Dublin Fingal West, Fine Gael)
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But it is a known issue. In terms of carrying out a cost-benefit analysis where would that lie? Is it with the Department?
Grace Boland (Dublin Fingal West, Fine Gael)
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Yes. I am wondering do we do we need to continue to have the NTPF or should more funding be given to the hospitals directly.
Grace Boland (Dublin Fingal West, Fine Gael)
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What is the benefit of using the NTPF rather than trusting the hospitals with the funding?
Mr. Robert Kidd:
I mention the guardians of that funding and the flexibility of use of that funding. This is what I see based on my engagement with the NTPF. If there is a multiplicity of hospitals with those backlog issues, over time one might use that funding in one hospital this year, this month or for the next six months but then there is the flexibility to use that funding with the NTPF in a different hospital next year, if that makes sense.
Grace Boland (Dublin Fingal West, Fine Gael)
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In the context of the NTPF and knowing there will not be any third party insourcing, Ms Brady mentioned that from June the NTPF will not be funding overtime insourcing. Is that it?
Grace Boland (Dublin Fingal West, Fine Gael)
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So in the case of the Mater where it takes on temporary people to carry out the NTPF-----
Grace Boland (Dublin Fingal West, Fine Gael)
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That will continue to be funded.
Ms Fiona Brady:
Yes. In light of the Deputy's previous question to the HSE, these consultants and these additional staff come in on a targeted basis. They target a specialty. If that was a permanent member of a consultant's staff, he or she is not simply just going to do outpatients. They will get involved in on-call and post-call and all the other things that go with the consultant contract. This is why the NTPF targeted insourcing initiatives work so well, particularly with the Mater and Tallaght hospitals.
Grace Boland (Dublin Fingal West, Fine Gael)
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Ms Keogh Dunne mentioned €2 million. Is all of that €2 million spent on overtime and paying payroll overtime?
Grace Boland (Dublin Fingal West, Fine Gael)
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Yes.
Grace Boland (Dublin Fingal West, Fine Gael)
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The NTPF figure provided to us by the NTPF for the Mater is different from the figure that the Mater provided to us. This is not unique to the Mater but it is across all three of the hospitals that we are examining today. I cannot understand whether that is a systemic issue or why the figures differ. In the case of the Mater, we are looking at a difference of €730,000. With the increase in NTPF funding for 2025, I would be concerned if that difference is even greater this year. Can someone please explain to me why there is a difference between the figures provided?
Ms Fiona Brady:
I can confirm we reconciled the numbers. We also worked with the Mater in that regard.
It is just an understanding of how we defined the process because there were winter beds that the NTPF funded during the Covid phase, during 2019. That looked like it was an outsourced model for the Mater but-----
Grace Boland (Dublin Fingal West, Fine Gael)
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Do the hospitals get confused themselves?
Grace Boland (Dublin Fingal West, Fine Gael)
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Is Ms Brady satisfied that there is not a €730,000 difference for the Mater?
Ms Josephine Ryan Leacy:
We had a meeting with the NTPF two days ago to cross-reference. I can clarify that where there were discrepancies. We accounted for them. As Deputy Boland says, we factored that as outsourcing because we were sending to a hospital. This was during the pre-Covid time where we had access to emergency beds, and it was deferment. We have a clear breakdown. Every penny is clearly accounted for. Every penny given by the NTPF has been used solely for the NTPF.
Grace Boland (Dublin Fingal West, Fine Gael)
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I thank the witnesses.
Paul Murphy (Dublin South West, Solidarity)
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I thank the witnesses for coming before us. I will start with Tallaght hospital. My first question is not related to insourcing. In the briefing, it was mentioned that the hospital did a pilot with a kind of single sign-on for access to all the different systems. A staff member might have to access 17 different systems over the course of a shift, and the time saved per clinician was 58 minutes on average per shift, which is incredible. If I am not wrong, it suggests that the average clinician is spending an hour every shift, presuming the shifts are eight hours, signing on to different systems. Is that right?
Paul Murphy (Dublin South West, Solidarity)
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I presume that also goes for the Mater.
Ms Josephine Ryan Leacy:
We have a patient centre at the minute. We have a legacy. We are very excited about the new electronic health record, EHR, that is coming on board because when our patient centre was set up it was a legacy but we have it all compatible in one service, so it has always been really efficient from that perspective.
Paul Murphy (Dublin South West, Solidarity)
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From the point of view of Tallaght, effectively we are saying that the equivalent of one out of every clinician is just logging on to various systems full time.
Dr. Peter Lavin:
As user of the system, I might give the experience. We would have an electronic patient record, a radiology system and a lab system. It is like if you log on to your laptop, there is a few minutes where the laptop logs on and it gets your different passwords, whereas with this one system you tap your identity card to the sensor beside the laptop or PC and it effectively logs you into all of the systems that you would normally use automatically so that it saves you time. That time accumulated over an eight-hour, ten-hour or 12-hour shift or whatever it is, and that was the average time gained back. It is really good.
Paul Murphy (Dublin South West, Solidarity)
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It is incredible. Therefore, if we move to a single sign-on system, there is effectively a 10% increase in time available for clinicians to do work.
Paul Murphy (Dublin South West, Solidarity)
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Yes. I will move to the issue of insourcing. In the briefing, it was stated by Ms Keogh Dunne - I agree with it - that it is basically a short-term solution but it is not a sustainable solution to waiting lists. It depends on repeated use of overtime by existing staff rather than recurrent investment in core work and capacity. It places an unhealthy burden on those staff members and creates operational risk for the hospital. Could she expand on what she means by that in terms of the unhealthy burden and the operational risk for the hospital?
Ms Barbara Keogh Dunne:
In terms of health and well-being, everybody needs to work a certain amount and is entitled to their time to disconnect and to take time off. For anybody who works over their hours it can potentially impact on their efficiency in work. So while it is a really good solution and it addresses our waitlists directly, the long-term sustainable solution would be preferred where we have permanent consultants, staff, administration and nursing staff to carry out the procedures on the outpatients within our existing facility because we do not have 12-over-seven working. We do not have 12-hour shifts from Monday to Sunday, so some areas lie idle because we do not have the resources on Saturdays and Sundays. We are working towards that but we need it incrementally and we need the support to be put in place to do that.
Paul Murphy (Dublin South West, Solidarity)
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Are some staff working an unsafe number of hours because of the insourcing arrangements?
Paul Murphy (Dublin South West, Solidarity)
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Could I just dig in a little bit into the story about Naas General Hospital consultants being paid on a per-patient basis rather than on an overtime basis? A HSE audit found that they were basically paid over the odds as a result of that. One thing I did not fully understand when reading the story was why Tallaght hospital was involved in this. Tallaght hospital was somehow in the middle of this and making payments. It was converting per-patient payments into overtime payments and then paying the consultants on that basis, which was a fee worked out on a per-patient basis but then transposed into being overtime, and then it got the money back from Naas. Why was Naas not just directly paying the consultants' company?
Ms Barbara Keogh Dunne:
A lot of consultants work over more than one site. That is not just particular to Tallaght hospital, it is every hospital in the country. The paymaster is usually one hospital. In that report of the internal audit, while no findings were made against Tallaght hospital and all the recommendations were implemented as outlined, by Naas, we were the paymaster so Naas General Hospital converted the hours into overtime hours and its general manager signed off. That was transferred to the Tallaght University Hospital payroll system and then we issued the payment, as requested.
Paul Murphy (Dublin South West, Solidarity)
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Is Ms Keogh Dunne saying that these consultants were getting paid via a company because they had a company set up? No.
Paul Murphy (Dublin South West, Solidarity)
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Okay, so the ones that were paid through Tallaght hospital were not in a company.
Paul Murphy (Dublin South West, Solidarity)
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Was Tallaght hospital aware that what was coming to it as payments be paid for overtime was actually a kind of converted figure from a per-patient basis?
Paul Murphy (Dublin South West, Solidarity)
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Does the hospital simply get the overtime amounts?
Paul Murphy (Dublin South West, Solidarity)
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Did Mr. Carter have no awareness of that or no involvement in the creation of this way of paying for them?
Paul Murphy (Dublin South West, Solidarity)
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I thank Mr. Campbell. In the opening statement Ms Keogh Dunne makes the point that the hospital runs at an occupancy rate of approximately 110% to 115%, resulting in delays in the admission of patients through the emergency department. Is there a recommended bed occupancy rate either for Tallaght or for hospitals in general?
Paul Murphy (Dublin South West, Solidarity)
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I saw that across the OECD countries they also operate on the basis of 85%. The average bed occupancy rate in 2023 was 72%. The rate was higher than 85% in only two of the 29 countries with comparable data - Ireland and Canada. We are definitely an outlier in this sense.
Paul Murphy (Dublin South West, Solidarity)
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There are also studies in Britain. Effectively, for every 82 patients delayed for longer than six hours in emergency departments, there was one excess death. Does Ms Keogh Dunne have any assessment of excess deaths that result in Tallaght hospital as a consequence of these sometimes quite long waiting lists?
Paul Murphy (Dublin South West, Solidarity)
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Does Dr. Lavin mean the normal parameters in Ireland?
Paul Murphy (Dublin South West, Solidarity)
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But they often also have long waiting lists or long waiting times.
Dr. Peter Lavin:
Absolutely. We are very aware and very conscious of that data. I am also even more conscious of the patient experience time data from the time the patient arrives in the emergency department to when they ultimately leave it to a bed in a ward or whether they go come.
What is not captured in that data is the fact that we are at this occupancy and all of this activity effectively comes through the front door and it is the other activity that we suppress, you know, the planned operations that we need to get for people. That is probably not captured because it is activity almost not planned because we know that we do not have the capacity. That is one of my concerns.
Ultimately, there is a plan for additional hospital beds. Hopefully, that can be expedited as well because that is really what we need.
Paul Murphy (Dublin South West, Solidarity)
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I thank Dr. Lavin.
John Brady (Wicklow, Sinn Fein)
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I thank Deputy Murphy. I have a few questions and comments.
I thank everyone for being here, this morning and into this afternoon now.
I will comment, in the first instance, on the opening statement from Ms Ryan Leacy. There are many elements to it but one line that struck me there was life expectancy of the patients the hospital looks after. Ms Ryan Leacy states that there was a well-documented "life expectancy gap of five to eight years between the hospital's north-inner-city catchment and that of south County Dublin." That speaks volumes to deprivation, to poverty and to the challenges. I am not looking for Ms Ryan Leacy to comment. I know that was research. I know Trinity College, in 2019, did research.
John Brady (Wicklow, Sinn Fein)
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It is probably dated. That is based on-----
John Brady (Wicklow, Sinn Fein)
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It is stark.
John Brady (Wicklow, Sinn Fein)
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Absolutely. I wanted to comment on that.
I want to turn to Tallaght about the third party in-sourcing. The Mater has a policy from the get-go. There was no third-party in-sourcing. Ms Keogh Dunne said that there was not at this point. At what point did that third-party in-sourcing stop?
Ms Barbara Keogh Dunne:
There was a third-party but it was not funded by the NTPF; it was funded by Access to Care. That took place for approximately a year, between 2023 and 2024. It was where a company came in and carried out procedures within the hospital. It was in response to a wait list requirement at the time. It ceased in 2024.
John Brady (Wicklow, Sinn Fein)
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Access to Care was an outside-----
John Brady (Wicklow, Sinn Fein)
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Were there any staff members working within Vincent's?
John Brady (Wicklow, Sinn Fein)
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There was no conflict.
John Brady (Wicklow, Sinn Fein)
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What was the value of that over that timeframe?
John Brady (Wicklow, Sinn Fein)
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Okay. I want to touch on the issue of staffing. In the opening statement from the Mater, thankfully, we have seen a huge increase in staffing. There has been an increase of 54% from 2019. In terms of the break-up of that, there is huge dependency on agency staff. Currently, what percentage of the staff complement within the Mater are agency staff?
John Brady (Wicklow, Sinn Fein)
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A figure of 3.8%.
John Brady (Wicklow, Sinn Fein)
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Okay. What does that look like in terms of staff numbers?
Ms Josephine Ryan Leacy:
Our staffing number, as we said, is 4,847. The Cathaoirleach is correct. We have had a 57% increase in our staffing.
I anticipated this question might come up. To give a breakdown, it requires six nurses to run one ICU bed. We have increased our ICU bed base by 12 in the last four years. We will increase it by another four. Actually, 154 of that increase in staff was purely for ICU. Our Rock Wing, which is absolutely a very nice success of ours, has 306 staff because we opened up eight new wards there. We have got 92 posts for our trauma, that we have become designated for.
John Brady (Wicklow, Sinn Fein)
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I appreciate all of that. I am trying to get to what is the dependency on agencies providing these staff as opposed to HSE contracts.
Ms Josephine Ryan Leacy:
We are still dependent on agency. We try not to. We obviously like to have our own regular staff because we have a bank office but we rely on agency when we are in these unprecedented levels where we currently are with escalation. When we are opening up extra beds, which are called "surge beds", we rely on agency, but then we have to balance the challenge between agency and regular staff to make sure continuity of safety for our patients. We have tried to reduce our agency and convert as much agency as possible to full-time posts because there is a better value add in that for continuity.
John Brady (Wicklow, Sinn Fein)
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Absolutely. In relation Tallaght, what is the dependency on agency staff?
Ms Sharon Larkin:
We do not use any agency in nursing and have not in the last two or three years. Where we have a usage is for our healthcare assistants in terms of providing enhanced care to our patients. That is where a patient needs a one-to-one special. At the moment, we have a reliance on agency of approximately 50 WTEs per week for that.
We have submitted a business case in terms of converting that agency use to WTEs and employing the staff directly, which would have a cost saving of approximately 27% on what we are spending. That has been supported with the region. We are just working through the detail of that.
One of the directives, obviously, at the moment, is to try to reduce agency pay within the HSE. From a value-for-money exercise, we want to employ the healthcare assistants directly.
John Brady (Wicklow, Sinn Fein)
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Okay. I want to touch on the issue of private health insurance claims. We have had a number of engagements with a number of other hospitals and there are huge figures that are not being collected from private health insurance providers. On Tallaght's situation, in the first instance, do we have uncollected figures for 2024?
Ms Barbara Keogh Dunne:
We have. It is €74,000 in total. Twenty thousand euro of that is related to patients not signing their private insurance and the other €50,000 was related to consultants not signing. However, we have a clear process in place to ensure that we capture that as much as possible. I might defer to the chief officer.
John Brady (Wicklow, Sinn Fein)
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When did that process come into being?
John Brady (Wicklow, Sinn Fein)
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It was €250,000 in-----
Mr. Dermot Carter:
Yes, in 2024. That was split between €77,000 where we could not get the patient to sign and €172,000 where we were unable to get the consultant to sign.
Obviously, we have debt that is due to us from private health insurers. At the end of 2024, we had €7.2 million submitted and waiting payment, and unsigned claims of another €3.9 million. We are working through the process on the latter.
John Brady (Wicklow, Sinn Fein)
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It is still significant and there are serious failures there. I might ask the same question of the Mater.
John Brady (Wicklow, Sinn Fein)
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Was it solely down to the patient?
John Brady (Wicklow, Sinn Fein)
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Was that for similar reasons of patient or patient and consultant not signing?
John Brady (Wicklow, Sinn Fein)
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When the consultant does not sign it, does that have any financial implications for the consultant? Do they still continue to get paid?
John Brady (Wicklow, Sinn Fein)
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I would ask for a full briefing note from both hospitals, and maybe, dating back over the past five years, what figures have been uncollected and written off. It is deeply concerning, not only in terms of themselves but right across the hospital sector.
The final area I want to touch on briefly goes back to Tallaght University Hospital. Paediatric services are catered for within Tallaght hospital. I know that falls under CHI, but Ms Keogh Dunne obviously has a role and remit as the CEO for the entire campus. She might talk briefly about that. What percentage or what paediatric services are provided within Tallaght hospital?
Ms Barbara Keogh Dunne:
As soon as the children's hospital opens, that inpatient service will transfer over. At the moment, that is approximately a 50-bed inpatient capacity. When that is reconfigured for adult beds, however, it will reduce to about 35 beds for the hospital itself to maintain. In terms of the urgent care centre on site, we have an agreement that service will stay on site. We have a service level agreement with CHI to maintain that.
John Brady (Wicklow, Sinn Fein)
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Ms Keogh Dunne mentioned the private element that is availed of within Tallaght. What services does that provide there?
Ms Barbara Keogh Dunne:
There is a private clinic with a capacity of 800 sq. m. We have an agreement with each of the consultants who use that. Since the public only consultant contract, POCC, was implemented in 2023, that has reduced significantly to approximately four or five consulting rooms. That is still there, and we have an SLA in place with the consultants.
John Brady (Wicklow, Sinn Fein)
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Are there plans to bring that back in under the fully public side of things?
Ms Barbara Keogh Dunne:
Under contract, each consultant is entitled to private activity depending on his or her contract. Therefore, we are obliged to provide a space for that. However, we are looking at all of our footprint to see what we can reconfigure in terms of inpatient capacity. At the moment, we are obliged under their contract to provide that service.
John Brady (Wicklow, Sinn Fein)
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In terms of going back to CHI, the move to the national children's hospital and the continued delays with that process, what are the real impacts for Tallaght in terms of that plan and the creation of 35 new beds, as Ms Keogh Dunne outlined? Surely it is very difficult, if not impossible, to plan for that. I am sure procurement processes and everything else are left hanging. What is the real impact of the delays in the delivery of the children's hospital?
Ms Barbara Keogh Dunne:
It is 35 more patients who could be accommodated if that service was transferred out. Plus, we also have an outpatient area for the paediatric services, so that will be an expansion of the adult outpatient department when that transfer happens as well. We are planning for both of those and we will have to reconfigure that area. That will be at a cost of about €1.5 million to reconfigure that area of the inpatient space. The outpatient space will be a lot less because it is consulting rooms only.
John Brady (Wicklow, Sinn Fein)
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Obviously, there is an impact on patient care that cannot be provided. In terms of the planning and timeframe for that, I would imagine that it is impossible to plan, but-----
John Brady (Wicklow, Sinn Fein)
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Has the board been able to move to procurement or tender for any of that?
John Brady (Wicklow, Sinn Fein)
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Is there a financial impact arising from the delays in moving to a national-----
Ms Barbara Keogh Dunne:
Yes. At the moment, we have an integrated finance management system between us. We have, for example, people who work on the switchboard. Some of our posts are funded by CHI. When they split, we will need those resources to continue. That will be a significant uplift requirement for us to maintain those services and staff those beds then.
John Brady (Wicklow, Sinn Fein)
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Obviously, that is going forward. The board will have to address all of those when CHI moves-----
John Brady (Wicklow, Sinn Fein)
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-----but there are immediate financial impacts of those paediatric services not moving to the new hospital. Is there any other financial impact?
John Brady (Wicklow, Sinn Fein)
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I thank Ms Keogh Dunne for that. That concludes our engagement for today. I thank the chief executives and their officials from the Mater and Tallaght hospitals for attending today. I also thank the officials from the HSE, the National Treatment Purchase Fund and the C and AG for their attendance once again. Is it agreed that the clerk will seek any follow-up information and carry out any agreed actions stemming from our first session today? Agreed.
An Cathaoirleach:This afternoon, we engage with St. Vincent's University Hospital to examine insourcing funding arrangements. On behalf of the committee, I welcome from Ms Pauline McGrath, chief executive officer, Ms Stefanie O'Brien, chief financial officer; Mr. John Keane, HR director; Professor Michael Keane, chief medical officer, CMO; and Mr. Cathal Flynn, chief operating officer. We are again joined by Ms Fiona Brady, chief executive officer; Mr. Seán Flood, director of finance; and Ms Bernadette Weir, director of commissioning from the National Treatment Purchase Fund. We are joined by Ms Aisling Heffernan, integrated healthcare manager for Dublin and the midlands from the HSE, who is also attend this meeting in a representative capacity. We are also joined by officials from the Office of the Comptroller and Auditor General, including the Comptroller and Auditor General, Mr. Seamus McCarthy, who is a permanent witness to the committee, and Ms. Irena Grzebieniak, deputy director of audit. They are all very welcome this afternoon. I will ask the secretary general to deliver the opening statement now on behalf of St. Vincent's University Hospital. As set out in the letter of invitation, Ms McGrath has five minutes to make her opening statement.
Ms Pauline McGrath:
I thank the Chairman for the opportunity to attend this afternoon. I am the CEO of St. Vincent's University Hospital. I am joined by Ms Stefanie O'Brien, our director of finance; Professor Michael Keane, group clinical director; Mr. John Keane, HR director; and Mr. Cathal Flynn, our chief operating officer.
St. Vincent's University Hospital is a voluntary hospital, which for over 192 years has played a leading role in the delivery of healthcare in Ireland. We are part of the St. Vincent's Healthcare Group, a private, independent company with charitable status that invests all our funds in the treatment and care of our patients.
St. Vincent's University Hospital is one of the largest and busiest acute level 4 hospitals in the country. We have over 4,000 staff who delivered exceptional care to nearly 400,000 patients over the past year. We provide front-line, acute, chronic and emergency care across 50 different medical specialties and more than five national specialties. We are located in a catchment area with the largest population of people over 75 years of age in the country. The patients we treat are older, generally in poorer health with complex health needs, and often do not have the supports needed to enable them to be treated at home or in the community. They come not just from the immediate catchment, but from communities across Ireland. We truly deliver a lot of services nationally for the people of Ireland. Our patients receive the highest standards of care from the most experienced healthcare professionals and have access to the most modern equipment. We are proud that the quality of care delivered by our consultants and staff has been internationally recognised. As a premier academic teaching hospital, we have Joint Commission International accreditation and lead national programmes in liver and pancreas transplants, cystic fibrosis, neuroendocrine tumours and respiratory medicine and we are one of eight national cancer centres.
Our emergency department is the major referral centre for the east region for patients with strokes and major trauma. We are at the international forefront of innovative, translational healthcare bench to bedside research with our partners in University College Dublin. Our education and research laboratories complement the work of our clinicians in the diagnosis and treatment of disease.
As a voluntary hospital operating in a community with the oldest age profile in the country, the demands on our services are intense, and they will continue to grow in the future. St. Vincent’s University Hospital is under sustained pressure to meet patient demand, driven by continuing growth in activity within a funding framework that has not kept pace with that demand. Operating under section 38 of the Health Act 2004, St. Vincent's University Hospital receives funding to provide health services under a service arrangement with the HSE. A key challenge has been the annual budget-setting process. In recent years, the opening budget issued by the HSE has not fully reflected the actual levels of activity or known cost pressures, including pay agreements, inflation and increasing demand. While supplementary funding was traditionally used to address this gap, it did not consistently cover the full cost of services delivered. In 2023 and 2024, supplementary budgets were provided. However, the hospital was still left with a funding shortfall despite delivering the services under the agreement. This amounted to €26 million over the two years. In 2025, the hospital is reporting a break-even position as the HSE issued revised spending limits that aligned to hospital forecasts. However, this year we are once again in a position where we have been provided with an opening budget that does not meet the service requirements. Therefore, we have not been in a position to sign off on the service agreement with the HSE at this point, but we are actively engaged with the regional HSE team on this issue.
We understand the pressures that the HSE and the region are under and, to be clear, we all have the same objective, which is to provide excellent care to the patients who need it in an efficient and impactful way. We accept that there are limitations to funding but the increased demand we are under, and that the whole sector is seeing, is driven by the growing and ageing population. This will not abate, and we need to work together to ensure the health sector is resourced to meet that demand. We have worked to develop services that provide our patients with safe and effective care while reducing the need for hospitalisations where we can. We look forward to continuing to work with all our partners to find ways to better serve our communities. I am happy to provide more details of those innovations to the committee. Notwithstanding these challenges, St. Vincent’s University Hospital will continue to make its contribution to the Irish healthcare system. We are proud of our record, and we are committed to working together with our funders in the best interests of our patients and service users. We hope our presence today will assist the committee as legislators.
John Brady (Wicklow, Sinn Fein)
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I open the floor to members. The lead speaker is Deputy Bennett, who has taken over from Deputy Joanna Byrne. She has 12 minutes, thereafter everybody will have eight minutes each. On conclusion, if time permits, we might allow members back in for supplementary questions.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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I thank the witnesses for coming in today. Tallaght and Mater hospitals were with the committee earlier today, but the same message is coming across to me from all of them. All of the hospitals are underfunded and central funding is not coming from the HSE and the Government. They have not been getting enough money to run their hospitals since 2023 or 2024. Will the witnesses let me know if 2026 is going to be the same with regard to underfunding? What has been done about this? Has the health Minister been approached about this, and why is there such underfunding?
Ms Pauline McGrath:
I will pass to Ms O’Brien, but we are projecting a deficit of €41.9 million this year. We are in active negotiations with our region and the HSE since the funding envelope was issued to us in January. Ms O'Brien will give a breakdown of where those pressure points are, but the HSE is aligned with us on our forecast and is in agreement that these are genuine pressures on us delivering those services. We are actively working with the HSE to come to a resolution.
Ms Stefanie O'Brien:
Our actual expenditure for 2025 was €492 million, excluding pension costs. The initial operational budget for this year was €488.9 million, so there is an immediate gap of €3.3 million. However, when we do our forecasting, we have to consider pay awards that will happen this year, which are significant at over €11 million. There are increments, inflation and increased costs due to the increased activity we are forecasting as well as income reduction and hospital specific pressures. We had a forecast of €531 million for 2026. As our CEO has outlined, this has been gone through in detail with HSE regional, so we are all in agreement on the components of that. At a high level, the breakdown is that €14.7 million is the shortfall in funding, where we have received less in relation to pay awards and activity than we are forecasting. The other half is predominantly made up of service-impacting pressures. We are under constant pressure in terms of capacity and that is the second half of the gap. Since the opening budget was received, we have engaged with the regional team, which has confirmed a further €9.8 million for approved developments and surge initiatives. Our current forecasted gap is €31.9 million.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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It seems extreme to me that every hospital that comes in here is underfunded. It is the HSE that gives them the money, but that money comes from central government to start with. Has St. Vincent's met with the health Minister? Is she across this? Three hospitals have come in today and they are extremely underfunded. Is the health Minister aware of this with regard to St. Vincent's University Hospital specifically?
Ms Pauline McGrath:
I cannot answer for the health Minister, but last year we hit a break-even point and had constructive conversations early in the year. I was not in the CEO position at the time. The commitment of the HSE was that we were to continue at that service-level agreement level. We do not want to cut any services to our patients. We had a productive conversation earlier in the year. While we did not sign the service-level agreement until later, we got funded to what we needed.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Has the hospital signed it now?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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What are the witnesses looking for to have it resolved so that the hospital would sign it?
Ms Pauline McGrath:
We need to identify the funding gaps. If there have to be some discussions about service reductions, we will have to have those if we do not get the appropriate funding. That is not what the mission of St. Vincent's University Hospital is. We are 100% committed to delivering healthcare to the populations that need it. For our national specialties, those patients have nowhere else to go but St. Vincent's University Hospital. That is the truth of it. We are extremely committed to that.
There is a tension. We know that there are fiscal constraints and we have to be responsible for public money. I also pay taxes, and I want to make those assurances to the committee that we have the governance in place. We can show that we have taken a lot of initiatives, which have created savings. We have been given a savings target of just under €2 million and have already identified nearly €900,000 that we think we can save on the non-pay side.
However, 70% of our costs are driven by pay. A lot of the underfunding is for pay awards and things we do not have any control over, and service growth. The tension is there. Our mission and our commitment is to deliver healthcare. The HSE is committed to that so we will continue to work with it because it was effective in our negotiations last year and we go in in good faith to say it will be productive this year.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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I thank Ms McGrath.
In the C and AG's opinion, is it good budgetary practice for there to continue to be a deficit every year?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Okay. In the HSE representatives' view, is it good budgetary practice that every year, all the hospitals that are here this morning are underfunded?
Ms Aisling Heffernan:
I can say we are working closely with St. Vincent's University Hospital. On that specific question, a lot of the funding gap is driven by an increase in activity that we need to understand year on year. That is why the quarter 1 projections are particularly important. We have done a lot of work on them with St. Vincent's University Hospital so we are clear and aligned on the funding gap for 2026.
We see that there are four key steps to addressing the funding gap at present. Step 1, as Ms McGrath and Ms O'Brien outlined, is around savings of €1.9 million, which St. Vincent's is confident it will achieve. It will get approximately €10 million in support from the region and that has already been agreed, which leaves us with approximately €30 million outstanding, of which €15 million is for egress beds to support St. Vincent's University Hospital. It received the funding for those in quarter 1 so it is about agreeing the extension of that funding throughout the year. That leaves €15 million relating to a resulting issue we need to have a conversation about. We are looking at what potential savings we can use across the region to support that gap. We are also speaking closely to HSE centre and the Department of Health about that. The big thing is that we have regular engagements and monthly performance meetings. It is a very transparent and collaborative working relationship.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Ms O'Brien said the hospital is €15 million short after all the cost-saving measures. Did it go to the Department of Health and Minister for that? What was the response?
Ms Aisling Heffernan:
We have just completed our quarter 1 projections and we have communicated the funding gap for the year to HSE centre. A lot of the funding gaps are similar to those in Tallaght and Mater hospitals. They relate to a drop in income, increased pay costs and so on and we are highlighting those issues and engaging with HSE centre on them.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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What is the hospital's occupancy rate?
Ms Pauline McGrath:
The occupancy rate can go up to 116% or 118% because we use a lot of surge capacity and some of those are extra beds. We have a good bank system. Our agency costs are well under control. We have been noted as being one of the best in the country at managing our agency costs. When I say we are lean, we have done a lot around savings and agency staff has been an area we have been particularly active in. However, there is still a cost associated with it because we have a bank of nurses who will do extra shifts. There are also non-pay costs, such as for linen and food, for those surge beds that are not in our base funding.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Does Ms McGrath think it has an impact on patient care and staff?
Ms Pauline McGrath:
I would have to say it does because overcrowding happens in our emergency department and we do not want that for our patients. It is not good enough, but there are pressures. We have done a lot. In the first quarter of the year, we significantly improved our trolley numbers and patient experience time. However, we have seen another surge. We are consistently seeing over 220 patients per day in our emergency department so it does have an impact, but-----
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Ms McGrath said an additional 220 patients are being seen daily. Is that right?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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On that uplift, has the hospital insourced?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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That is additional money that is not in the hospital's budget. Is that right? The HSE or the Department pays for the insourcing.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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That is an additional budget. How much has the hospital spent on insourcing?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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That was €1.8 million on top of the budget.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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The consultants or doctors employed under the insourcing are new people. They are not working in the hospital.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Okay. They are all completely new staff.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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The Minister has set a target of ending insourcing by 30 June. What will the hospital do then? It will mean the hospital will be down €1.8 million because it will not be able to-----
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Okay, so fixed-term contracts will still be there. How does that work? Do the people insourced with the €1.8 million have proper contracts? What is the difference between them and the people working in the hospital?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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After 30 June, we will continue with these contracts. To enlighten me again, what has the Minister promised will end on 30 June?
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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It is only 4%.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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We are really not ending anything on 30 June. It will only be 4%.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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It is only 4% of contracts, though.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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How much are we spending in total on insourcing? How much does the 4% that will stop equate to? I was under the illusion that all insourcing was going to stop, but it is only 4%.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Then it is not the insourcing. Are all the hospitals doing their own insourcing?
Ms Fiona Brady:
What typically happens is that hospitals apply to the NTPF - it is through the regions now - looking for initiative. As I mentioned this morning, the reason it works so well for the hospitals is that they have locums to take a targeted approach to a specific initiative and the locums do not get caught up in all the unscheduled care the acute hospitals have to manage. They come in for a few months, target a specific waiting list and then go.
Cathy Bennett (Cavan-Monaghan, Sinn Fein)
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Again, to put it on the record, what the Minister has offered is just a 4% reduction in insourcing.
James Geoghegan (Dublin Bay South, Fine Gael)
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I thank the witnesses, including those who have been here since this morning. I will start with Ms McGrath. It sounds like the approach St. Vincent's hospital has adopted to how it does insourcing is similar, if not identical, to how the Mater hospital carries out insourcing. Ms McGrath is new to her role so others might care to offer to respond. What were the thought processes that went into how St. Vincent's hospital was going to avail of insourced funding? Why did it not use the third party route? Why did it go this route? Were there governance or other considerations?
Ms Pauline McGrath:
It was a mixture of clinical need and governance. It is obviously good governance to have people, as Ms Brady outlined, who come in for a fixed purpose. They are not caught up in anything else in the hospital and they address a specific clinical need.
I will pass over to Professor Keane because he will say what we do with the wait lists on a clinic need is to base it on our long waiters and the need that we have for specific specialties.
Professor Michael Keane:
It was our preference to have the extra work carried out in-house and to hire additional people. For example, we are the national centre for sleep medicine. A lot of that expertise and the ability to test is based on campus. We felt that it was better in terms of overall provision for that to be provided by hiring in a locum, for example, in that particular speciality.
James Geoghegan (Dublin Bay South, Fine Gael)
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The witnesses will be aware with other hospitals that issues have arisen in relation to the third-party companies that have been employed and the failure to the disclose as part of their SIPO obligations. How does SIPO work in St. Vincent's in terms of the obligation of declarations? Has the hospital done reviews on this? What does the governance look like?
James Geoghegan (Dublin Bay South, Fine Gael)
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Is Ms McGrath satisfied that all the hospital's employees had filled out their SIPO declarations in the manner that they were supposed to have done?
James Geoghegan (Dublin Bay South, Fine Gael)
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Did the hospital do this on foot of what has emerged publicly or was this something that was being looked at on an ongoing basis?
James Geoghegan (Dublin Bay South, Fine Gael)
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Ms McGrath did a review.
Ms Pauline McGrath:
I did a review. I have brought our compliance levels as high as we can with the few people who are off at the moment. We have looked through the ones with the conflict. If there is anybody who is a director of company, we make sure if there is anything in our procurement, that they are not involved in it and they are kept completely separate. We manage that conflict of interest.
James Geoghegan (Dublin Bay South, Fine Gael)
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The Mater and Tallaght hospitals said that for the procurement there is effectively a list when they are carrying out procurement. Is that similar?
James Geoghegan (Dublin Bay South, Fine Gael)
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The Comptroller and Auditor General can correct me on this. The only reason we knew that were governance mismanagements in relation to SIPO declarations - let us say in St. James's or Beaumont Hospital - is because they are both audited by the Comptroller and Auditor General. They carried out a special audit in relation to this particular issue. They came across it and then they looked it in Beaumont. It seems that there were issues there too. They are going to come before the committee. Questions were asked in relation to it. Was Ms McGrath surprised that in other hospitals those types of governance failings existed?
James Geoghegan (Dublin Bay South, Fine Gael)
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In response to that question, the CEO of the Mater Hospital gave a very clear understanding as to what she viewed the importance of these SIPO declarations. What is Ms McGrath's own perspective?
Ms Pauline McGrath:
My own perspective is that I equally view them as a key part of our governance. We need to be aware. We need all our declarations. We are at 94%. We will be at 100% as soon as we resolve our few doctors and clinical consultants that we need to. It is an absolutely empirical part of governance.
James Geoghegan (Dublin Bay South, Fine Gael)
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On another matter, the hospital has not signed the service level agreement with the HSE. When does Ms McGrath expect to sign that?
Ms Pauline McGrath:
When we reach an agreement with the HSE that we can deliver within the service agreement parameters and we can deliver the level of service that we need, we then will be in a position. I cannot in good faith ask the board to sanction and sign that service level agreement if I know that there is a deficit.
James Geoghegan (Dublin Bay South, Fine Gael)
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Will Ms McGrath give the public an understanding of it? A lot of the public find it very difficult to understand how a hospital like St. Vincent's is funded by the taxpayer and somehow there is an ongoing dispute over how the hospital is going to deliver the services that are being funded by the State. What are the sticking points as to why the voluntary board has determined it is not going to sign the service level agreement it is funded to deliver?
Ms Pauline McGrath:
It would be remiss of us because we need to have come to a landing and understanding. There is always that tension between us delivering care and the funding that is there. However, we are committed to continued working. We did get to a landing last year. We know that if we move towards annual multiyear funding and activity-based costing that we would overcome that. There is a group within the HSE that is looking at moving towards an activity-based costing. I have worked extensively with it in Australia and New Zealand. I am only back six months from New Zealand. It is a much better process because it follows the patient complexity. It takes into account things like the complexity of national services. It would be welcome in the voluntaries, particularly the large level fours, if we moved towards activity and multiyear funding because we could plan and be much more involved in the discussions around the forecast and service delivery.
James Geoghegan (Dublin Bay South, Fine Gael)
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Will Ms McGrath give a flavour or insight into how rows play out? Is the hospital hiring lawyers to represent it in discussions with the HSE? Is it looking for legal advice on any issues that the HSE wants the hospital to deliver and that there are disputes about? How does this in practice play out?
Ms Pauline McGrath:
We would not be going down any legal route or seeking any of that advice. We have a very collaborative relationship with our region. Budgets have been devolved down to region within the HSE. Our approach has always been to work in partnership and collaboratively. At the end of the day, both the HSE and St. Vincent's University Hospital want the same outcome. They want to deliver the best possible maximum care that we can to our population.
James Geoghegan (Dublin Bay South, Fine Gael)
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In which month does Ms McGrath think this thing will be signed? We are in April now.
Ms Pauline McGrath:
I will hand that across. The HSE might be able to answer that question better than me.
James Geoghegan (Dublin Bay South, Fine Gael)
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We can have the witnesses back for another committee meeting in about a month if we think it will speed up the signature of the agreement.
James Geoghegan (Dublin Bay South, Fine Gael)
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I apologise. I only have one minute left. On the time, is it going to May, June or July? When is it going to happen?
James Geoghegan (Dublin Bay South, Fine Gael)
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It will be signed in the next one or two months.
Due to the time constraints, my next questions are for Ms Brady. This third-party insourcing issue certainly shocked a lot of members of the committee in terms of how some of this funding was managed, how it was used and how declarations were not properly done. I am a little bit heartened by how different hospitals that were here today had a totally different governance model, different approach and a very different system when it comes to the SIPO declarations and the management of it. Where does the NTPF stand on all of this? When the NTPF was funding hospitals that were then using that funding and paying third-party companies where there were SIPO declarations that were not properly made, was that a breach of their agreement with the NTPF and memorandums of understanding, MOUs, and documents that the NTPF had done?
James Geoghegan (Dublin Bay South, Fine Gael)
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That was not my question. The question was very clear. Was the fact that they did not make SIPO declarations a breach of the terms and conditions that the NTPF has with the hospital for the purpose of providing NTPF funding?
James Geoghegan (Dublin Bay South, Fine Gael)
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How is that possible? How can the NTPF be providing funding to a hospital and not even have the most basic governance guidelines written into the memorandums of understanding that it would have? I cannot understand that. The NTPF board is the guardian, ultimately, of all these moneys that were being dispersed. Yes, it relies on the good faith of all these hospitals that it is providing, but it cannot just hand out this money willy-nilly with no governance controls.
James Geoghegan (Dublin Bay South, Fine Gael)
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Does Ms Brady accept now that there was a clear failing in respect of those hospitals that did not have their SIPO declarations properly done and used moneys that the NTPF provided to them to third parties where SIPO declarations were not properly made? Does she at least accept that very basic fact?
James Geoghegan (Dublin Bay South, Fine Gael)
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Does it disturb Ms Brady that moneys that the NTPF provided to a hospital were provided to a third party where SIPO declarations were not properly made and where proper procurement was not done? Does that disturb Ms Brady as a public servant?
Ms Fiona Brady:
It does as a public servant, absolutely. I found out about it at the same time as the Deputy, to be honest. When I was managing in Drogheda, the SIPO declarations were under the governance of myself and the clinical director. The NTPF does not manage consultants. We agree agreements with the public hospitals. We agreed those initiatives with the hospitals that used third party. It was their decision to outsource to a third party. It was not a NTPF decision.
James Geoghegan (Dublin Bay South, Fine Gael)
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At a very basic level, I cannot understand why it would not be wound up within a memorandum of understanding or level of agreement that all disclosures would be properly done in any funding that would be provided. That seems like a very basic level of a governance standard that could have been included in a memorandum of understanding. Does Ms Brady accept that in retrospect?
James Geoghegan (Dublin Bay South, Fine Gael)
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It is a bit late now because we have got rid of the third party funding.
Aidan Farrelly (Kildare North, Social Democrats)
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I thank the various witnesses for being with us today. On the conversation about the service agreement, when was the service agreement signed with the HSE in 2023 or 2024? When would service agreements usually be signed? In what period of the year would that usually be?
Ms Stefanie O'Brien:
It would depend on the funding situation. Last year, it was later in the year - I would say in quarter 3. I do not have the specific dates for previous years. As outlined in our briefing document, the underlying reason for this delay is due to the existing funding model. We are often given a budget at the beginning of the year, which is clearly not manageable within. When we are making our estimates it is a very clear process. We look at our prior year cost base and we increase that through known increments such as pay awards, activities and inflation. We would hope that that would be the basis for how budgets would be set but, frequently, the budget at the beginning of the year is far less than that.
Aidan Farrelly (Kildare North, Social Democrats)
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At what point would the hospital receive a first idea of what the budget will be for the following year?
Aidan Farrelly (Kildare North, Social Democrats)
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Last year, for example, the hospital did not sign the service agreement until quarter 3. Is it a trend that most service agreements are nearly retrospective in their use? By the time an agreement is signed, negotiations begin almost straightaway on the following one? Are there risks involved in not having an agreement in place?
Ms Pauline McGrath:
I think there are some risks. The Deputy is correct that we sign them much later in the year. In reality, if we were to go to multi-year agreements, that would be fantastic. However, even if we were to change the current process to start looking maybe in October or September of the previous year, at least we would have a few months in which to start the process. We would like to be more engaged in the decisions around what the allocation is. We would welcome that moving forward. It is less than ideal that we would be signing a service agreement late in the year.
Aidan Farrelly (Kildare North, Social Democrats)
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Does Ms McGrath agree that it is nearly dysfunctional? Alongside the annual funding process, the annual service arrangement piece seems to be performative or almost like a dance between to institutions.
Ms Pauline McGrath:
"Dysfunctional" might be stretching it a bit because we do end up, in good faith, getting funding. The HSE does, through the course of the year, fund us for most of the activity that we deliver but I think there is a better way to do it, as I have outlined.
Aidan Farrelly (Kildare North, Social Democrats)
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Would that be a three- to five-year model for a service agreement?
Aidan Farrelly (Kildare North, Social Democrats)
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Will Ms McGrath posit a guess as to why there is some resistance to that?
Aidan Farrelly (Kildare North, Social Democrats)
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From the perspective of the HSE, is there a possibility in the short to medium term that we might see level 4 hospitals being in a position to sign an agreement that allows them to be a little more strategic in their planning? I have the idea that somebody is always either negotiating the previous arrangement or getting ready to negotiate. It is almost like a job title in itself to be constantly in the battle with the HSE but it always gets solved. What are we really achieving?
Ms Aisling Heffernan:
I am aware that the HSE centre and the Minister for Health are working towards a multi-annual budget across the entirety of the health service. They are working with the Department of public expenditure on that. I agree that would really help from a strategic perspective. The devolving of budgets to the regions and our closer working relationships with the hospitals will improve the process and inform budgetary requirements on an earlier basis, moving forward.
On the service level arrangement, the funding gap is the primary issue. The service level arrangement covers the entire balanced scorecard, looking at our people, access and quality. We have performance meetings every month with the site, at which we look at the full range of parameters with it.
Aidan Farrelly (Kildare North, Social Democrats)
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Does the HSE look at that as an unsigned document or does the previous year's arrangement follow through? Does the HSE keep going based on last year's arrangement-----
Aidan Farrelly (Kildare North, Social Democrats)
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-----so that from a financial perspective, it is not signed off, and that is clear. From everything else that is involved in that arrangement, is the HSE obliged to follow through on those objectives if the document has not been signed?
Aidan Farrelly (Kildare North, Social Democrats)
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I am not challenging any body's good faith.
Aidan Farrelly (Kildare North, Social Democrats)
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It is a leap.
Aidan Farrelly (Kildare North, Social Democrats)
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It seems dysfunctional. I am not laying blame on anybody in this room. I suppose it is inherited from a culture. We have heard from three hospitals about a similar process whereby they need more money, they kick up a bit of a fuss and they end up getting a little bit or a lot of what they need. This involves need as there is no profit being made. They are either breaking even or recording a loss. It seems like a dance and a waste of time.
Aidan Farrelly (Kildare North, Social Democrats)
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On the shortfalls in 2023 and 2024, the financial statement indicated there are ongoing negotiations with the HSE as to who will-----
Aidan Farrelly (Kildare North, Social Democrats)
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-----foot the bill for that. Do tensions exist? Are any of the shortfalls being contested?
Ms Pauline McGrath:
I will pass the Deputy's question to Ms O'Brien but my understanding is that there is a group within the HSE looking at some of those historical shortfalls.
Ms Stefanie O'Brien:
As the Deputy outlined, our financial statements show an accumulated deficit of €28.4 million. This primarily relates to 2023 and 2024 when we were not fully funded for service provision. We would consider that to be still owing to the hospital. We continue to follow up regularly with the HSE as to when that can be resolved. As the CEO mentioned, we understand a group has been formed to discuss this with the Department of Health.
Aidan Farrelly (Kildare North, Social Democrats)
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Does that form any part of the negotiations on the current service arrangement?
Aidan Farrelly (Kildare North, Social Democrats)
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Are there outstanding liabilities as part of that? Has the hospital paid all the bills associated with that? Did it take that cost on itself?
Ms Stefanie O'Brien:
It predominantly causes challenges in relation to working capital. As I think is the case in other sites, we need to apply for cash accelerations. We did so last June and we have just had a cash acceleration approved by the HSE this month. What that means is that we are asking to draw down on cash that should be profiled for later in the year. What drives that is the accumulated deficit.
Aidan Farrelly (Kildare North, Social Democrats)
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Sorry, I do not understand that. I will come back in later. I thank all the witnesses.
Joe Neville (Kildare North, Fine Gael)
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What is the annual funding for St. Vincent's Hospital? I asked this the last time.
Joe Neville (Kildare North, Fine Gael)
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It is now €498 million. Is that €488 million and then another €10 million?
Joe Neville (Kildare North, Fine Gael)
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What is the financial trend for the year?
Joe Neville (Kildare North, Fine Gael)
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Will the gap end up at that figure or will it continue to grow?
Joe Neville (Kildare North, Fine Gael)
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Is the €8 million a function of the first three months? Is that sum related to one issue, one specific item in quarter 1 or will the number trend out across all four quarters?
Joe Neville (Kildare North, Fine Gael)
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The gap will be €32 million.
Joe Neville (Kildare North, Fine Gael)
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Perhaps my next question has already been answered. What is the carried forward loss?
Joe Neville (Kildare North, Fine Gael)
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It is €28.4 million and this will effectively double. Has St. Vincent's faced issues like this in the past at this time of year?
Joe Neville (Kildare North, Fine Gael)
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What happens? Does the Government, which includes my party, give the money afterwards?
Joe Neville (Kildare North, Fine Gael)
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Even if I just bring it back to 2024 - I am not sure if Ms O'Brien was there and I know Ms McGrath was not - was there a question around the level of increase in staffing and increase in funding given to the hospital, yet there was a lack of increase in performance. Is that correct?
Mr. Cahal Flynn:
The Deputy is right. The Department of Health issued a report which looked at value for money and productivity versus funding. It detailed St. Vincent's at 3% return, the same as St. James's. We met with the Department of Health and it became apparent there was three months of activity that was not included in our activity for the year. The Department of Health estimated that our 3% would rise to 9%. Once we got into the detail of it, it became apparent that we thought the complexity of the patients was not being truly identified in that mechanism of the report.
Joe Neville (Kildare North, Fine Gael)
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Is that a 3% increase in staff numbers? Not in staff numbers, apologies. Is the increase in patient numbers?
Joe Neville (Kildare North, Fine Gael)
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Was it a case that St. Vincent's was one of the lowest returns?
Joe Neville (Kildare North, Fine Gael)
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What was driving that?
Joe Neville (Kildare North, Fine Gael)
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I do not want to go down a rabbit hole of comparing the level of patients in one hospital versus the level in another one, and I feel that is where we will probably go. What levels of increases were seen versus levels of return? On the 3%, to an outsider, there is no way of measuring. I have no clue what is being measured. No one else would. You could ask what was the increased level of funding and what was the increase in patient-----
Joe Neville (Kildare North, Fine Gael)
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Exactly. That is the number I want.
Joe Neville (Kildare North, Fine Gael)
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I know and I get that. I can imagine exactly what Mr. Flynn is going to do there but at the same time, that calculation is not measurable from an outside perspective because 3% means nothing. What was the level of increase in funding the hospital got versus the level of activity?
Ms Stefanie O'Brien:
Year-on-year, the increase in funding from 2023 to 2024 was 11%. However, there was a significant increase in some areas. Pay awards cost €12 million. We also had a significant increase in funding because of the public-only consultant contract and new development posts. There was also significant inflation in 2024.
Joe Neville (Kildare North, Fine Gael)
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There is a real concern about public spending just increasing and increasing. If we keep giving the money, we will keep finding ways to spend it. It is a bit like the more time we have, the more we will talk. It is the same element and that would be the fear. Here we are, and we had the two hospitals here earlier and they already have funding gaps. We will have to look at how we fix them. There is that concern. We are here as the Committee of Public Accounts and, typically, we look backwards. Obviously, we have an opportunity to look forward.
With the hospitals, and Deputy Geoghegan touched on it earlier, do they get supports from the HSE outside of the funding it gives? Do the hospitals get supports for things like legal costs or any other elements or do the hospitals fully go their own way? Is it a case of here is the money and that is done or how does it work?
Ms Pauline McGrath:
Within the funding envelope the HSE gives us, we cover all of those costs ourselves.
Joe Neville (Kildare North, Fine Gael)
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How much is that?
Joe Neville (Kildare North, Fine Gael)
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Just as an example. I might pick another.
Ms Stefanie O'Brien:
Most of our funding comes from the HSE. Obviously, there is private health insurance income and there is a small number of donations as well.
Joe Neville (Kildare North, Fine Gael)
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Are there any voluntary or umbrella groups that might support the hospital? Is it part of an umbrella organisation? Is there an umbrella organisation for voluntary hospitals?
Joe Neville (Kildare North, Fine Gael)
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How much does St. Vincent's give to that?
Joe Neville (Kildare North, Fine Gael)
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Could that be sent back afterwards?
Joe Neville (Kildare North, Fine Gael)
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Cool. To rectify the gap we are seeing of €30 million towards the end of the year, how much do the witnesses feel they will be able to cover by changing the activity? Maybe that is a question for Ms Heffernan and the HSE, although I am not sure. Ultimately, how much might they work on it together? How much of the €32 million gap does Ms McGrath think will be able to be changed by activity versus, ultimately, what extra will be looked for?
Joe Neville (Kildare North, Fine Gael)
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Or improvement in service delivery.
Joe Neville (Kildare North, Fine Gael)
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Does Ms McGrath feel the hospital is operating at 110%?
Joe Neville (Kildare North, Fine Gael)
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That is what I would have thought.
Ms Pauline McGrath:
Some of the initiatives that St. Vincent's has run have been exemplar initiatives. For example, we have a vertical ward where we have 35 people who are supported in their home. We have received outstanding feedback from our patients. It is better for the patients. It leads to admission avoidance. It is overseen by clinicians and nurses. The cost of running that would be a fraction of running a 35-bed ward in the hospital, which would be in excess of €10 million to run 365 days a year. That initiative only costs about €1 million or €1.5 million a year. Immediately, that saves us about €7.5 million or €8 million a year.
Joe Neville (Kildare North, Fine Gael)
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Okay.
Ms Pauline McGrath:
We have an emergency department in the home initiative and we have extended that to aged residential care. We put 400 patients through that, which means that is 400 patients who did not come to our emergency department and we have a very small admission rate from the initiative. We are constantly doing these things to take the pressure off the system and they are value for money initiatives.
Joe Neville (Kildare North, Fine Gael)
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That is something from a national perspective and in our committee that we are so conscious of - there is €27 billion poured into health every year. Obviously, the run rate now possibly might change but €27 billion is a huge amount of money. We need to get the value for money for it. I know the integrated financial management system, IFMS, has been rolled out and there is increased visibility form a HSE perspective. Where is the hospital with that?
Joe Neville (Kildare North, Fine Gael)
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When is that coming? Is it August?
Joe Neville (Kildare North, Fine Gael)
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The hospital has not been given a date but it is committed to it.
Joe Neville (Kildare North, Fine Gael)
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That was something where the voluntary hospitals were a little bit behind so it is good to hear they are catching up.
Joe Neville (Kildare North, Fine Gael)
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I thank Ms McGrath for coming back from New Zealand to help. We need good people operating the system so I give my best wishes for the next period. I thank everyone else for coming.
John Brady (Wicklow, Sinn Fein)
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I have a number of questions. This has been a really important engagement over the course of the day. One of the main themes coming out of it is obviously the issue of insourcing but across the three hospitals, the issue of underfunding comes out. Across the three hospitals here, we have heard there was underfunding of up to €130 million to maintain services over the course of this year. That has to ring alarm bells. There was a lot of hype a couple of years ago when a number of our hospitals in Dublin received a bailout of €200 million to ensure their staff were paid. That is no way to operate a health service. I just have to say that. To me, that is what is coming across here. When I hear members of this committee talk about the chaotic funding of our health service and hospitals, I absolutely agree. That is the standout from this to me.
Just to pick up on the point Deputy Neville made, there was a newspaper article citing St. Vincent's and the Minister talking about not getting bang for buck in terms of the huge funding increases in St. Vincent's and only hitting a 3% increase. I hear what was said about the analysis and that the piece of work was not done by the Department but, for me, for a Minister to come out and name a hospital and be very critical is reckless without having that piece of homework done in terms of having the proper metrics and analysis done. I do not know if the witnesses want to make a comment about it. I am sure they are aware and have seen the negative commentary from the Minister for Health.
Ms Pauline McGrath:
Obviously, we saw it as a poor reflection on us but we corrected that and we did go back. We were surprised ourselves that we would not have appeared to have better productivity than that. We did find the source of the error and we wrote and corrected it. That is as much as we can do, to say this does not look correct to us. Mistakes can be made in data and it was not correct. There is no blame game here. It is just that errors can be made and we found the source.
John Brady (Wicklow, Sinn Fein)
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Errors were made but it is reckless to name a hospital without having the correct information to hand. I just want to touch on the whole area of insourcing----
Joe Neville (Kildare North, Fine Gael)
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There were not loads of performance at the time.
John Brady (Wicklow, Sinn Fein)
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Well, 9%----
Joe Neville (Kildare North, Fine Gael)
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They were responding to a direct question, in fairness.
John Brady (Wicklow, Sinn Fein)
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Just in terms of the insourcing, I know you had said currently the hospital does not use third parties. Has that always been the case with St. Vincent's or was there a case in the past where third parties were used?
John Brady (Wicklow, Sinn Fein)
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It was off site.
John Brady (Wicklow, Sinn Fein)
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Were any current staff on contracts within St. Vincent's?
John Brady (Wicklow, Sinn Fein)
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I just want to touch on the whole issue of agency staff. I know recruitment and retention is a major issue. Ms McGrath said attempts have been made to reduce the dependency on agency.
Ms Pauline McGrath:
We actually have a really good track record with agency. We have one of the lowest spends. Nursing is generally the biggest pressure with agency because we have to keep the wards open 24-7. If we have a shortfall, hospitals do have to use agency to buffer those numbers so that we have safe nursing staffing. We have done extremely well. We have got a really good bank, which is much cheaper to run. We have some small pockets of specialties that we use agency for. Laboratories are one of them and there are a few other areas. Ms O'Brien might comment on the good work we have done on our agency spend.
John Brady (Wicklow, Sinn Fein)
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What kind of percentage?
Ms Stefanie O'Brien:
In 2024, we spent €3.6 million on agency, which was a reduction of €4 million versus 2023. This is because we had significant vacancies at the end of 2023. We hired staff in 2024, predominantly nursing staff, and that enabled us to reduce our agency spend. However, with the pay and numbers strategy and the headcount numbers given to us, it will be a challenge for us to maintain that now going forward.
John Brady (Wicklow, Sinn Fein)
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The board foresees that increasing from €3.6 million upwards.
John Brady (Wicklow, Sinn Fein)
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I want to touch on private health insurance claims. We have heard from a number of hospitals in previous hearings and the C and AG has highlighted other hospitals in terms of uncollected health insurance claims. Do we have a figure for uncollected health insurance claims?
John Brady (Wicklow, Sinn Fein)
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If you can, and backdate it over the last five years as well.
I want to touch on the relationship with St. Vincent's Private Hospital, which is close by. How does that structure work? What dependency is there and what kind of interactions exist between the private and the public?
Ms Pauline McGrath:
They are both independent branches of the St. Vincent's Hospital Group. We function with our own CEO, our own budget, our own executive management team and our own governance structures in St. Vincent's University Hospital, as does the private hospital. We do co-operate on a number of patient pathways and there are services between both sides in that we have service level agreements in place with the private, but they are both still independent branches of the St. Vincent's Hospital Group.
John Brady (Wicklow, Sinn Fein)
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On those agreements in place for 2024, what was the value of that? How much was paid to the private hospital for those services?
John Brady (Wicklow, Sinn Fein)
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If you want to come back to us on that, yes. I have different examples of people who may have been on a ward within St. Vincent's for a couple of days, and a day before they are due to be released, they are moved over to the private hospital, which to me is nonsensical.
Ms Pauline McGrath:
I can clarify that. We have, due to measures to manage our unscheduled care and address our emergency department, we did work off a HSE framework to purchase private beds to help acute capacity. We worked off that up to June last year. It dissolved last June. The previous CEO of the HSE, Bernard Gloster, gave us the authority to commission 26 beds from the private hospital. Ten of them were in relation to the National Maternity Hospital enabling works, which were going to be out of action for three to four months. The rest were to deal with the capacity demands. As we put in our briefing document, the Department of Health report on acute bed capacity has indicated that St. Vincent's needs 220 more beds. We have had no investment in beds in the last ten years. We are still sitting at only 610 beds, except for the six ICU beds we got that opened in January. That covered 26 beds. That basically means we are purchasing a ward. They are like another ward.
John Brady (Wicklow, Sinn Fein)
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What value is that?
John Brady (Wicklow, Sinn Fein)
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Do you have the costings of that to hand?
John Brady (Wicklow, Sinn Fein)
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The other area I want to touch on before allowing members back in is car parking charges. This is a serious bone of contention. I know there have been different political initiatives over previous years to try to reduce, abolish or harmonise and cap them. Looking at the three hospitals we have had in here today, St. Vincent's has the highest daily rate. I think it stands at €17 a day, which is €7 more than the lowest that we had in today, which is capped at €10. How can you explain that? These are patients and people going in to visit loved ones. That, to me, is extortion. I do not think there should be any parking charges for patients or for people going in to see them. Can you stand over that or give a justification for those exceptionally high charges?
Mr. Cahal Flynn:
From 2012 to 2025, we did not increase the charge at all. We increased it in 2025. We have 500 spaces that are made available to the public. We absolutely need to have access for patients to get to the hospital. If you think about the train and bus lines and so on, a lot of people rely on being able to drive in but we only have so many spaces on site. The price point----
John Brady (Wicklow, Sinn Fein)
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You said it increased in 2025. What was that increase?
John Brady (Wicklow, Sinn Fein)
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That was in the face of the political focus and the fact the previous Minister said he was embarking on a review in terms of capping the charges. Despite those political utterances, there has been no real movement and despite that, St. Vincent's, rather than scaling back, increased charges.
Mr. Cahal Flynn:
We do a reduced parking rate on compassionate grounds for cancer and dialysis patients. If someone comes to the hospital and finds that it is very expensive, they can speak to us. We have a process they can avail of if they are cancer patients, for instance, with repeat attendances. It is a 50%----
John Brady (Wicklow, Sinn Fein)
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What was the revenue for 2024?
John Brady (Wicklow, Sinn Fein)
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Rather than it being a control mechanism, as Mr. Flynn outlined, it is an invaluable source of revenue for the hospital, it has to be said. Was the increase driven by a need for additional revenue? What was the rationale for increasing it?
John Brady (Wicklow, Sinn Fein)
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Most people who go on site-----
John Brady (Wicklow, Sinn Fein)
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-----go there because they have to.
John Brady (Wicklow, Sinn Fein)
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It is not by choice. It is nowhere to go and hang out for the afternoon.
John Brady (Wicklow, Sinn Fein)
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It is somewhere they go out of necessity. Unfortunately, the hospital is penalising the people who really cannot afford to be penalised. I ask the hospital to have a look at this.
John Brady (Wicklow, Sinn Fein)
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In comparison to the other hospitals before the committee today, St. Vincent's hospital is way out of kilter. As I have said, I do not think there should be any charge for car parking at hospitals. I ask the witnesses to go back and review it. I will open it up for a second round of questions.
James Geoghegan (Dublin Bay South, Fine Gael)
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I thank the witnesses for staying on. The briefing we got states St. Vincent's hospital will report a financial break-even position for 2025. Is this correct?
James Geoghegan (Dublin Bay South, Fine Gael)
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What happens to the 2023 and 2024 structural deficit issues?
James Geoghegan (Dublin Bay South, Fine Gael)
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When the hospital says it is in a break-even position-----
James Geoghegan (Dublin Bay South, Fine Gael)
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But overall in the statement the hospital will still be carrying a deficit.
James Geoghegan (Dublin Bay South, Fine Gael)
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What will that deficit look like in 2025?
James Geoghegan (Dublin Bay South, Fine Gael)
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Remind me what is the figure.
James Geoghegan (Dublin Bay South, Fine Gael)
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There will still be a €28.4 million deficit in the accounts.
James Geoghegan (Dublin Bay South, Fine Gael)
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That is not an anomaly. When Ms O'Brien speaks about financially breaking even, how do these two things compute? How can she say the hospital will financially break even if it is carrying €28.4 million of a deficit?
James Geoghegan (Dublin Bay South, Fine Gael)
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I heard what Ms O'Brien said about the €28 million of spending, and that it is the hospital's position that this was spending on services it had expected to be funded. Is that the position?
James Geoghegan (Dublin Bay South, Fine Gael)
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I know it is spending on services that were provided but I thought it was said that they were services the hospital expected to be funded.
James Geoghegan (Dublin Bay South, Fine Gael)
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I know it is expected now but at that time the hospital was delivering those services, did it expect them to be funded?
James Geoghegan (Dublin Bay South, Fine Gael)
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What is the HSE's position on this?
James Geoghegan (Dublin Bay South, Fine Gael)
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Will Ms Heffernan give me anything more than this?
James Geoghegan (Dublin Bay South, Fine Gael)
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This has been going on for how many years? Is it three years?
James Geoghegan (Dublin Bay South, Fine Gael)
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What can Ms Heffernan tell us? We are talking about €28 million of taxpayers' money. What can she tell us more than that it is under discussion at the Department of Health?
Ms Aisling Heffernan:
All I can say from a regional perspective is that we are constantly advocating for the need for a solution to address this. We have raised it with the HSE centre and we are informed it is under review with the Department of Health.
James Geoghegan (Dublin Bay South, Fine Gael)
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Will Ms McGrath shed a little bit more light on this?
Ms Pauline McGrath:
We raise it through the region and through every forum. A bit like the Mater, we probably need to start going directly to the Department through the region to say we need to start looking at this. We were informed that a group was being formed to look at historical shortfalls. As Deputy Geoghegan alluded to, the Mater is in the same position as us.
James Geoghegan (Dublin Bay South, Fine Gael)
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In very simple terms, what does the HSE say to the hospital in its communications? The hospital says it has spent all of this money and asks to have this money. What does the HSE say?
James Geoghegan (Dublin Bay South, Fine Gael)
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Obviously it is in dispute with the hospital. What is the nature of that dispute? It says the hospital spent money on things it did not fund it for. Is it as simple as that?
James Geoghegan (Dublin Bay South, Fine Gael)
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Will Ms McGrath illustrate it a little bit better for the benefit of the committee?
James Geoghegan (Dublin Bay South, Fine Gael)
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Yes.
James Geoghegan (Dublin Bay South, Fine Gael)
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I presume these issues came up at board meetings in terms of governance issues.
James Geoghegan (Dublin Bay South, Fine Gael)
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How quickly, as the hospital was spending the moneys, did it become aware that they may not be ultimately funded by the HSE? What do the board minutes reflect over this time period?
Ms Stefanie O'Brien:
We report monthly to the HSE and we do quarterly forecasts based on the run rates. The level of spend is visible throughout the year and the end position is noted.
James Geoghegan (Dublin Bay South, Fine Gael)
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In terms of governance, obviously the directors of the board were presumably quite concerned if it was at any point a risk that the services the hospital was spending money on might not ultimately be funded. My question is if we were to peruse the board minutes, what would they give us? I do not think we have any board member here.
James Geoghegan (Dublin Bay South, Fine Gael)
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Is it something the witnesses can share with the committee in terms of the board minutes in dealing with this issue of the accumulated deficit and the discussions around that time of the spending? Is it something the witnesses are aware of? Was this an issue for the board? Was the financial risk committee looking at it?
James Geoghegan (Dublin Bay South, Fine Gael)
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Did the board have to make decisions to keep providing these services in the absence of certainty of funding?
Ms Pauline McGrath:
Last year there was a productive meeting with the outgoing HSE CEO, Bernard Gloster. This is how we agreed and it funded us to the break-even point. The board is constantly aware of it. We have an audit committee and it is aware of the deficit and it is well recorded. The board directors are aware of their fiduciary duty and their exposure. Like ourselves, they do not want to have to reduce any services so we still continue to work in good faith with the HSE to be able to close it.
James Geoghegan (Dublin Bay South, Fine Gael)
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Is Ms McGrath confident about the SLA, which it sounds like will be signed in a month or two?
James Geoghegan (Dublin Bay South, Fine Gael)
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My question is whether Ms McGrath is confident that in the SLA, which will be signed in a month or two, this issue of the hospital being put in a position whereby it is providing services where there is uncertainty in relation to the funding of these services would not arise again in the next period of time, over the lifetime of the SLA?
James Geoghegan (Dublin Bay South, Fine Gael)
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Ms McGrath can see-----
James Geoghegan (Dublin Bay South, Fine Gael)
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People outside of the system, who have never worked in a public hospital, and who have just had the benefit of the great nurses and doctors who work in our hospital system, look at this and do not really understand how it is we have the HSE over there and the hospitals providing services. They are all supposed to be providing services pursuant to agreements and that is how we manage the flow of money one way or another and yet there is this huge wall of cash of €28 million that is unfunded. Ms McGrath is saying that maybe even with the SLA these problems could persist and there will be a governance structure. How do we overcome these issues? Will it be just the multi-funding issues in future?
James Geoghegan (Dublin Bay South, Fine Gael)
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Has the hospital agreed to sign up to the new financial management system? Is the hospital already there?
James Geoghegan (Dublin Bay South, Fine Gael)
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I think it is the first quarter in 2027 for the Mater but Ms McGrath does not know when-----
James Geoghegan (Dublin Bay South, Fine Gael)
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Is that related to the SLA or how does it work?
Aidan Farrelly (Kildare North, Social Democrats)
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I will build on this because the set-up in this regard is the interesting bit for me as a layman. It is about where the good faith begins to unravel a little bit. I presume in 2023 and 2024 the good faith was there yet the deficit ran up. I am curious about when the forecasted budget went in. Am I correct that the hospital puts in a projection of what it would take and then the HSE comes back and agrees or disagrees. Was the cumulative deficit part of an underbudget, an overspend or under-resourcing? How would the witnesses categorise the deficit?
Aidan Farrelly (Kildare North, Social Democrats)
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St. Vincent's Hospital sets its forecast but it does not-----
Aidan Farrelly (Kildare North, Social Democrats)
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I am going to make a wild guess that the allocation from the HSE is never over what the forecast is.
Aidan Farrelly (Kildare North, Social Democrats)
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In layman's terms, who is standing there with their hand out waiting? For this deficit, is there anybody unpaid? If the HSE gave the hospital a cheque to write off this debt, where does that money go?
Aidan Farrelly (Kildare North, Social Democrats)
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A cash acceleration is not written off against the debt that is accrued though.
James Geoghegan (Dublin Bay South, Fine Gael)
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Can we get the Comptroller and Auditor General in on all of these financial management practices for any observations on this?
Mr. Seamus McCarthy:
A number of years ago I did report on the HSE's deficit, which it is carrying forward. It all rolls back to the Vote. Earlier, the Deputy was asking why there cannot be multi-annual funding. There is a difficulty because every year the funding has to be voted. It starts from there and then it has an implication on the HSE, which, in turn, has an implication on the deficits that are being carried by the acute hospitals.
Aidan Farrelly (Kildare North, Social Democrats)
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The cash acceleration is an acknowledgement almost by the HSE that the hospital requires this.
Aidan Farrelly (Kildare North, Social Democrats)
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It is advanced payment they will then take off the hospital. Is that how the deficit accruing? Is its ongoing cost-----
Mr. Seamus McCarthy:
One example of this, which we see in Votes as well, is well-known, which is when a pay agreement is in place for three years. Looking forward one can see there has to be a pay increase on, say, 1 February and 1 June in 2026 but the budgeting and the allocations that are made in 2025 for 2026 do not necessarily include provision for those pay increases. There was a reference to increments. What you might find with increments is that you have leavers and joiners so the average increment does not change. There would not be a grade drift but that can be there. It can be quite significant. There are many things.
Again, in putting together a budget for the year, the hospital will be able to make a projection that it will have a pay increase and what the implication will be with X number of staff. You are trying to price what the 2026 outlay is on the existing level of service or existing level of staff. It is a difficult process. There is a difference between the amount that is allocated for the year and how it is actually funded. One is a budget, which is the amount you have to spend for the services that you provide but then there is a separate question as to how much cash do you need when. The two things are very complex.
Aidan Farrelly (Kildare North, Social Democrats)
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It is becoming clear to me. Today I am learning a lot about cash accelerations. Does the HSE have a cash acceleration fund or pot that it goes to when these requests come in or does the hospital have to go to the Department of Health or the Department of public expenditure to seek approval for them? How do they work?
Ms Aisling Heffernan:
There is a cash acceleration process. There is formal paperwork to be completed. My awareness is that it gets signed off at my level. Our regional director of finance reviews it. The regional executive officer reviews it. My understanding is that it goes to the chief financial officer in the HSE centre.
Aidan Farrelly (Kildare North, Social Democrats)
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I thank everyone for their time.
John Brady (Wicklow, Sinn Fein)
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I have a few concluding questions. There has been an awful lot about the finances, which is understandable as we are the Committee of Public Accounts. I want to ask about the capacity issues. Earlier, reference was made to working at 110% or 116% of capacity. What does that look like in real terms for nursing care and from the patient's perspective?
Ms Pauline McGrath:
We have a funded bed base. We have some additional bed capacity that we are unfunded for. We open those additional beds and we use other spaces. For example, we keep our admission and discharge lounge open to about nine patients and we have a sleep lab that only functions one week out of four, so we use those spaces. We go into spaces temporarily on a surge capacity but there is a cost to that. We have to nurse it and there are non-pay costs associated.
We purchase the beds from the private sector in line with the HSE agreement. We are constantly under pressure because we do not have enough acute beds. We also purchase additional step-down beds and we have permission to go to additional step-down beds this year from the HSE. We went from a base of about 45 to about 85 in one of our subacute providers. We got some additional capacity in Leopardstown Park Hospital. However, some of those beds still do not address the need for the acute bed capacity.
As I said, the Department of Health bed capacity report stated the St. Vincent's Hospital needs 220. It is over ten years since we have had any capital investment in that. The impact of that is we are constantly in that space of trying to keep the flow going and that is challenging. We also have some egress pathways or step down such as rehab and community beds. Again, they are under pressure. We often have up to 40 or 50 patients who are medically fit for discharge but who do not have either packages of care or community beds. That is another ward and a half or almost two wards we can have at any one time.
We work closely with community services. We work closely with community hubs with our rehab partners but it is a system-wide pressure because we are demand-led. It does mean that the operational wing of the hospital is constantly on a wheel and they are working every day at 110% steam to keep the patients because our ultimate aim is safe care for our patients and we do not want to have our emergency department overcrowded. We have mitigations in place to make sure our patients are safe but it is a constant battle.
We have a commitment from the HSE to give us those 220 beds and it is looking at building us a ward block. We are finalising some details. We have not got the final approval. We are looking at maybe 2029 or 2030 for the first ward block of about 98 or 100 beds. The mitigations I have outlined is what we do to try to address that. It is less than ideal but we do keep patient safety at the centre of it.
John Brady (Wicklow, Sinn Fein)
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Earlier Ms McGrath provided some figures in terms of the accident and emergency department of up to 220 patients a day which is up from 170. I am from the Wicklow constituency and our local accident and emergency department closed in St. Columcille's Hospital in 2013. I am sure the vast majority, if not all, of those people are now in on top of what was already an overwhelmed system in St. Vincent's back in 2013. I am sure some of those increases are captured by the closure and the knock-on impact of it. How would Ms McGrath describe the reality of the accident and emergency department in St. Vincent's from a patient perspective?
Ms Pauline McGrath:
From a patient perspective, I have never met such a high-quality performing team as we have in the emergency department. If we look at our patient experience times, it is six hours. We are one of the higher performing of the level 4 hospitals, similar to our ourselves, on our six-hour discharge. Our emergency physicians and nurses actually discharge the patients that can go home. The issue with the cohort we see is that they are very elderly and very sick. We do not necessarily see the ones the lower triage categories. We are seeing a lot of what are called priority 1 and priority 2, a lot of whom need admissions. That creates a huge pressure. We have a good emergency department. We have a good layout in it and we have quite a lot of individual cubicles.
Some of the patients who wait for beds is not just around bed capacity. I will pass this across to Professor Keane because he can describe some of the other issues we have to take into account for our patients.
Professor Michael Keane:
It is a challenging environment because there is a fundamental capacity problem. There are two major problems: one is flow and the other is capacity. We have done a lot in terms of optimising flow of patients to other facilities, to nursing homes or to step-down units with the co-operation of the HSE, but we are still left with a fundamental capacity problem. There are large numbers of patients presenting to the emergency department, with over 70,000 last year. We are consistently over 220 or 230 a day and we have the highest number of patients over the age of 75 in the country presenting to our emergency department, so we do have an ageing demographic. The number of emergency admissions has, I would say, doubled in the past 15 years. It is an ongoing challenge. Our challenge is being able to get admitted patients out of the emergency department. Hence, our trolley count has been high over the past year. Even within those constraints, however, it is a risk, but we manage the risk, we keep that under control and we are cognisant of it.
John Brady (Wicklow, Sinn Fein)
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I get that. All these services are obviously demand-led, and there is that increase in demand.
From a patient's perspective, I was critical of the hospital last week when a constituent of mine was referred to the accident and emergency department in St. Vincent's presenting with a suspected stroke. He was seen last Friday. He was sent home after seeing some medical team. He was told to go home over the course of the weekend and to come back on the Monday just gone, which he did. He again sat in the accident and emergency department, from Monday morning right up until midnight, before finally being taken in, given a chair within the department, put in what he described as a shower room along with five other patients - four men and a woman - and left in there for a further number of hours. In all of this, bear in mind, he had a suspected mild stroke. That, to me, lacks compassion, lacks dignity and lacks, as I would see it, proper medical supervision. As he said, when he was waiting in accident and emergency, because of the policy whereby no family members and no one else can go in and sit along with them, you have some of the most vulnerable people sitting in accident and emergency - Ms McGrath said for six hours, but in this case and many other cases people are sitting in there-----
John Brady (Wicklow, Sinn Fein)
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-----all day long, on their own, very vulnerable. Then, ultimately, to be given a chair and to be put sitting in what this man described as a shower room is not right.
Professor Michael Keane:
We obviously apologise to anyone who has a bad experience when they present to our hospital, either electively or through the emergency department. We are challenged with space. I do not have all of the clinical details of the case the Cathaoirleach has alluded to, but we will take a look at that.
John Brady (Wicklow, Sinn Fein)
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I know there are issues.
Ms Pauline McGrath:
Yes, we know the issues and we have highlighted them. Coming in as the new CEO, I have looked at what my top five areas of priority and risk are. At the top of the list is my emergency department and the second is bed capacity, and they are both intrinsically linked. If I had bed capacity, I would not have the overcrowding. Sometimes, the trolley count does not reflect the busyness of the hospital because I might go in in the morning and there might be only 40 patients but 25 might be waiting to be admitted, whereas another time I could come in and there could be 70. Then we know and we put our escalation policy in place. We have other levers we pull to be able to clear the emergency department. We have an escalation policy. Some days, the department does get overwhelmed in a short period of time, which, potentially, could have been what happened on Monday. Monday was a particularly busy day for us.
John Brady (Wicklow, Sinn Fein)
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I have been in with family members in accident and emergency, and there is the policy of not allowing families into the accident and emergency waiting area, where it is patients only. These are some of the most vulnerable people experiencing a lot of pain; otherwise they would not be in there. They are left sitting isolated for hours and hours on end. Is that a capacity issue, or what is driving that policy of only patients being allowed in the accident and emergency waiting area?
John Brady (Wicklow, Sinn Fein)
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This is in the waiting area before they get-----
John Brady (Wicklow, Sinn Fein)
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But you appreciate that these people are vulnerable and-----
John Brady (Wicklow, Sinn Fein)
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-----very much in need of that support.
John Brady (Wicklow, Sinn Fein)
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Can that be looked at? Can that be reviewed, or is there capacity to review and change that policy, even at that level?
Ms Pauline McGrath:
We are exploring some extra space where we can take a couple of areas out of the emergency department. There is a little bit of capital funding, and we have put that proposal through to the HSE. We hope that maybe before we come into this winter, we will be able to get those two areas refurbished. There is an older persons' rapid assessment unit we have that sits in the emergency department and we can move that out. Then there are returns that come into the emergency department, so we have two areas. We are well aware of the kinds of capacity issue within the emergency department. That could be a short-term measure. There are plans in the future to extend the emergency department, but that would at least give us some temporary relief.
John Brady (Wicklow, Sinn Fein)
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I ask the witnesses to go back and have a look at that policy. In that particular case on Monday, after going home at the weekend and coming back, as he was told on Monday, he sat there from early morning until midnight and later and then was put sitting on a chair within a shower cubicle. That is not right.
John Brady (Wicklow, Sinn Fein)
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I ask you to have a look at that and have a look around the policies that allowed a scandalous situation like that to arise. Six people put sitting in a shower cubicle for a number of hours before eventually being given a trolley or a bed is not right, even with the constraints and the issues.
John Brady (Wicklow, Sinn Fein)
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The last thing I want to touch on is the national maternity hospital. Ms McGrath might give me an overview as to what role, if any, St. Vincent's is playing in it, what kind of governance or structures are around it, what involvement, if any, she has in that or-----
Ms Pauline McGrath:
Ultimately, this is a HSE project. Currently, it is going to be on the St. Vincent's University site. The HSE works very collaboratively. We have people who are assigned to this project from a St. Vincent's perspective because, obviously, it involves major disruption to the site. It will be beneficial to our population, including the women and babies in our area, to have a fantastic facility like the national maternity hospital. To be co-located with an adult hospital is the right model, so we are 100% behind that. We have governance structures. There is an overarching governance board and I sit on that, and what we are doing at this stage are the enabling works. A lot of that involves a lot of issues on our sites and moving forward. At this point, we are tracking the enabling works through our capital books. All those enabling works will not come through St. Vincent's University Hospital. My understanding today is that everything is on budget and on target and all is working really well, but we work very closely and collaboratively. Obviously, we have to step through, and our own facilities and estates work very closely. We have had upgrades of our electrical services because we had to get another power substation in to facilitate this. When we add another hospital to the site, there is going to be a significant increase in power. We have had roads. We are managing all of that really closely.
John Brady (Wicklow, Sinn Fein)
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Is Ms McGrath across how much has been spent so far? Is that all through her?
John Brady (Wicklow, Sinn Fein)
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I think there have been reports of over €150 million being spent on enabling-----
John Brady (Wicklow, Sinn Fein)
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Is that for the enabling works?
John Brady (Wicklow, Sinn Fein)
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When do we expect those enabling works to be completed and construction proper to start?
John Brady (Wicklow, Sinn Fein)
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Would our HSE representative have any idea?
Ms Aisling Heffernan:
Again, apologies, but I do not. I will revert. Similar to Ms McGrath, I do not have a direct role in relation to it. It is about ensuring that the impact on the public hospital is minimised as much as possible. I am working with Ms McGrath on a plan to decant staff from St. Vincent's campus to the Seamark and Avista buildings that are adjacent to the campus as well to facilitate the enabling works.
John Brady (Wicklow, Sinn Fein)
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To conclude, as regards some of those enabling works, there is that impact. I have seen some of the hoarding go up on the campus and so on. It seems to be an older section of the hospital. Is there any-----
Ms Pauline McGrath:
We have people who are managing this. We work closely with the HSE team that is overseeing this project and we have staff who are assigned to deal with that because, ultimately, the management of the site sits with us at St. Vincent's University Hospital. We work very closely, we get method statements, we know what works are going to be done, we know the phasing, we have Gantt charts that tell us what is happening and when, we keep an eye through the town halls and we keep the staff updated as to the progress and what is happening and when.
John Brady (Wicklow, Sinn Fein)
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So, again, when does Ms McGrath think those enabling works will be concluded?
Ms Pauline McGrath:
That is what I am saying. I am not 100%. Some of them already have been, including the substation. There are some other enabling works there. We have to move the kitchen. We have a new kitchen. That will happen later in the year. There is the move of the dermatology services to the Seamark building. That is going to happen towards quarter 2 or quarter 3.
John Brady (Wicklow, Sinn Fein)
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Are we not going to see the same cock-ups and mess-ups we have seen with the national children's hospital? That is probably not for Ms McGrath to comment on but-----
John Brady (Wicklow, Sinn Fein)
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That is it from me, so that concludes our engagement for today. I thank the chief executive officer and her officials from St. Vincent's University Hospital for attending. I also thank the officials from the NTPF and the HSE along with the C and AG for their attendance once again.
Is it agreed that the clerk to the committee will seek any follow-up information and carry out any agreed actions arising from the meeting? Agreed.
The committee will next meet on 30 April 2026 with the National Paediatric Hospital Development Board and Children's Health Ireland to discuss the National Paediatric Hospital Development Board's financial statements for 2024 and CHI's financial statements for 2024.