Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)

I thank the Deputies for their questions and contributions. I will answer as many questions as I can and I can provide a further briefing for Deputies on a technical basis. I am very happy to come to the committee where we can do more back and forth. It is important Deputies have the opportunity to contribute in the House and, as I always try to do, I will answer as many questions as I possibly can, recognising there is some duplication in those questions.

With regard to the questions on 2010, it is simply on the point of skeletal maturity. This was the initial look back to account for the children who are still children. I do not think it should necessarily be cut off at that point but I do think we should prioritise the children first before people who are now adults. I have a transitional model of care for those aged 16, 17 and 18 who are moving into adult care. I will discuss it with the CEO of the HSE. There is no desire to exclude and there never is.

In relation to the age of seven brought up by two Deputies, this was a clinical audit of children between the ages of 12 months and seven years. It was designed to try to capture the experience between 2021 and 2023. Again, it does not seek to exclude the other experience. It is about a clinical audit within these parameters. It is not limited to this. I have to be very clear it was an anonymised audit. I said this on Friday but please allow me to say again that there is no way a parent can ring up and ask whether their child was in the audit. I do not know and CHI does not know. By definition, it was an anonymised clinical audit.

While we are prioritising this, the follow up and the care is most important. Let me say several things. I completely respect that parents should not have to walk into a hospital where they have had, or feel they have had or worry they have had, a negative experience. We need to provide follow up but there has to be a measure of flexibility in it. I will discuss this with the HSE and CHI. I do not expect parents to have to go back to the same clinician or go through the same process. This will require us to have more flexibility.

Deputies also referenced the impact on service delivery, which has to be taken into account. We have a finite number of healthcare professionals. We are trying to grow more. There is an interplay between these different things.

The other expert review panel necessarily must be independent and external. I appreciate there are different perspectives on when I should have commissioned it but having received the report it is very important to get the recommendations and act on them expeditiously. I appreciate some Deputies would have taken a different approach. That is as may be; the important thing is that it is done as quickly as possible.

On the letter from Cappagh, I have confirmed with the CEO of the HSE that it went to approximately 20 people. It was the same group but for a different reason. It is slightly different. The letters have not yet issued, either to Cappagh or anywhere else, as I understand it. To be clear, those parents got a call this morning to say they could, of course, bring both parents or additional guardians or whatever else. That is something slightly different and not related to this.

I recognise the limitations with the phone line. It really was an effort to provide some answers to people over the weekend. The people answering those questions do not have any more information than I do. It was an initial signposting opportunity to have a clinical ear for parents at the earliest stage over the weekend, rather than leaving them in total silence.

Other questions have been raised regarding the accountability and the why. Many different questions have been asked on this. My broad view on accountability in relation to the individual clinicians is that there really are two mechanisms available for it. These are within the employment law structure and within the professional registration regulations. I do not have the capacity to fire a consultant in any context. Even if we think about the circumstances relating to Limerick, where the CEO of the HSE took various steps against people working in the healthcare system, those issues went through a court process. That is well publicised. This is with regard to even taking those different steps.

There is an imbalance with regard to the fair procedures individuals have the protection of in all cases, not only in the criminal process but in employment law processes and other accountability processes. This is with regard to the balance of protection given to the individual and their fair procedures, which are constitutional protections, versus the balance of the broad public good and getting information out there. We have to go through fair processes and behave in the correct way. There are good reasons for this but I wonder about the interplay over time and it is something the House should reflect on more broadly.

To answer a question asked by Deputy Rice, it is the case that explanations were advanced by surgeons which were discounted by the auditor. It is, therefore, the case that surgeons were contesting, at least within the audit process, the findings and advancing alternative explanations, which did not stand up. I am not aware of legal proceedings but this does not mean they will not be taken.

In relation to trust in the running of CHI more broadly, I have said clearly, and let me say again, this is something I am looking at in the round. There is a way to go on this and I will work with Deputies, particularly those on the health committee, on this.

The question of why has come up in a range of ways, with regard to motive and financial issues. There is a range of questions.

The straight answer is that I do not know the answer to that at this point, nor was it investigated in the clinical audit, although it is an exceptionally important question, as the Taoiseach articulated this morning. I would like to take steps to reflect on how we might get to the bottom of it, recognising that it is important that we also get the Nayagam report, which is linked to these different issues within orthopaedic surgery. Perhaps Deputies would allow me to get that report also and then reflect on those questions about motivation and how we might get better answers about it. I am not discounting anything about motivation and I am always interested in hearing Deputies' perspectives on it. However, let us perhaps get the Nayagam report and then reflect on how to think about the mechanism for that as well.

On the public-private system more broadly, I want it to be clear that I am an advocate of the public health system. If people want to have private health insurance and go to private hospitals, they are welcome to do so. This is a free country. However, I am a Minister trying to implement a public system with no other interest in it. I am an advocate of the full implementation of the public-only consultant contract. I will be taking further steps to remove the perverse incentives, or whatever people want to call them, that feature today because of the overhanging mix of public and private activity. I will not be dissuaded from that. That is important. However, it is also important that we use the levers we have to address the waiting lists where we can because that means our constituents, our people, getting operations today instead of some other time, while we all go on this transition together. I am an advocate of a public healthcare system. There is no advantage to having insurance in the paediatric system in particular and I do not want to see hospitals asking people whether they have insurance ever again. It is not important or relevant in a public hospital. I wanted to clarify that in case it needed clarification.

While I have tried to answer as many questions as I can on this report, I appreciate that I have spoken for almost 25 minutes between the beginning and the end of the debate in a very governance-focused, executive way, trying to answer the questions that were rightly asked and to set a direction of policy change and accountability. I will use my last two minutes to just speak about it as a public representative.

In the same way as others have very personal concerns about what has happened, I am aware of the impact of surgeries that were not warranted being done on children. I am aware of the feeling parents will have had when they heard that a surgery was warranted and made a decision either to have it or not have it as the case may be. The responsibility parents take upon themselves to follow clinical advice and the lack of alternative information available to them is like a Chinese sign being on the wall and the doctor the only person who can read Chinese. People have no choice in many ways but to follow the guidance. The responsibility a clinician holds is enormous and where it has been used in a way that is wrong, it is problematic, but where it is used in a way that is casually wrong and has implications for the small bodies of small children is unconscionable. I wanted to take the time to say that, so my response is not removed from the feeling of these things and overly focused on the executive response, which is appropriate and necessary. It is important that I am held accountable, but I wanted to take the opportunity to recognise that this is deeply hurtful. It has caused enormous worry to many parents who thought they were taking the right steps on behalf of their children in a properly governed, properly functional system with professional consultants making correct decisions. I want that other perspective also to be heard clearly. Ministers of State have articulated it. Deputies on both sides of the House have articulated it. We do so as a collective and I wanted to take the time to make sure it was done by me as well.

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