Select Committee on Health debate -
Wednesday, 16 Oct 2024

The meeting has been convened to consider the 2024 Supplementary Estimate for Vote 38 for the Department of Health, amounting to €1.749 billion for current expenditure and €5 million for capital expenditure. I welcome the Minister for Health, Deputy Stephen Donnelly, and the Minister of State at the Department of Health, Deputy Colm Burke, who is a former member of the committee. The Minister of State is very welcome back. The Minister of State, Deputy Butler, is on her way. The Minister and Minister of State are accompanied by their officials, Ms Louise McGirr, assistant secretary, Mr. Patrick McGlynn and Mr. Daniel Curry, principal officers. I thank the officials for providing the briefing material on the Supplementary Estimate, which has been circulated to members.

Witnesses are 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 as 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. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise, or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate when they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I will ask any member participating via Microsoft Teams, prior to making their contribution to the meeting, that they confirm they are on the grounds of the Leinster House campus.

I invite the Minister to make his opening remarks.

I thank the Chair and the members of the select committee for the opportunity to bring the Supplementary Estimate for Vote 38 before them. I am seeking an additional total for 2024 of €1.754 billion. It comprises €1.749 billion for the HSE's current expenditure and €5 million for capital expenditure. For clarity, while I am seeking the committee's approval for this Supplementary Estimate on a one-off basis, €1.5 billion of this funding is already in the health budget for 2025. This was agreed as part of the summer economic statement in July. I will come to that shortly.

First, I want to outline the main drivers of the Supplementary Estimate. Approximately 60% of it is required for pay costs, excluding pensions. This covers: staffing roles that had previously been provided from temporary Covid funds along with funding for staff hired in excess of funded levels of recruitment; higher agency, over-time and staff allowances due to increased level of demand, especially in acute settings, as well as difficulties in recruiting specialist staff in certain geographic locations; and additional funding for the national pay deal.

During the year, the health sector has experienced significant increases in demand across all areas, with average volume increases of between 5% and 10% being seen in our hospitals. The increase in demand is driven largely by demographic changes - population growth that has outstripped previous projections, as well as the fact that the number of those aged 65 and over has increased significantly, placing additional demands and costs on the health sector.

The population has increased by an average of 2% every year since 2019. That is an average of 84,000 people annually. This means the cumulative population growth between 2019 and 2024 is in excess of 422,000. One third of this growth has occurred in the part of the population aged over 65, with an additional 132,000 people in this age category since 2019. The number of people in the part of the population aged 75 or over increased by 26% between 2019 and 2024. There are an estimated 367,300 people in this age group, amounting to 7% of the national population.

Another driver of the deficits is the impact of inflation on the health sector. Although this year has seen a moderation in inflation, the increases in previous years are now part of the cost base. This leads to higher costs in providing ongoing services.

Despite these demand and expenditure pressures, I am very happy to report to colleagues that the health service has been able to deliver important improvements for patients this year. In hospitals, the number of patients on trolleys has fallen. It is down 11%, by more than 9,000 people, compared with the same period last year, that is, the first eight months of the year. The number of people aged 75 years and over, who were waiting more than 24 hours in emergency departments, has fallen by 13%, or 1,600. The average outpatient waiting time has continued to fall from a high of 13.1 months in 2021 to the current level of 7.1 months, and it is continuing to fall. That represents a nearly 50% fall in the amount of time people are waiting for their first outpatient appointment. I acknowledge the remarkable reduction that has been achieved by healthcare workers, which will undoubtedly save countless thousands of lives and lead to better health outcomes for many.

Much progress has also been made towards the goal of universal healthcare, including what is envisaged under Sláintecare. This includes: abolishing inpatient hospital charges; rolling out free contraception up to the age of 35; expanding free GP care to another 500,000 people; introducing State-funded IVF; reducing the drug payment threshold per month to €80; and providing free diagnostic access by GPs to hundreds of thousands of people.

In the past four years, as committee members are aware, this Government has delivered record levels of investment in health. We have increased the workforce by nearly 28,000 people. We have increased hospital bed capacity by more than 1,200. We have also built more than 1,000 new and replacement community-based beds. We have continued to roll out the national network of primary care centres. This level of investment is helping the health sector to meet the increasing level of demand. The additional funding requested in the Supplementary Estimate will ensure that the health service has sufficient resources to continue to deliver on these improvements through to the end of this year.

I want to turn now to the agreement I reached with the Minister for Public Expenditure, National Development Plan Delivery and Reform in July on HSE funding. This was published as part of the summer economic statement and included substantial additional funding for the health service. The additional funding is comprised of two parts: there is a permanent increase in funding of €1.5 billion, and a further €1.2 billion for 2025 to maintain existing levels of service. Essentially, that is a €2.7 billion adjustment to the base, to recognise existing levels of service, inflation costs, demographic pressures and the other issues I have outlined.

It was agreed that the Supplementary Estimate for current expenditure would not exceed €1.7 billion for this year. The Supplementary Estimate of €1.7 billion is inclusive of, not additional to, the permanent increase in funding of €1.5 billion for 2025. The reason for the difference between the €1.7 billion, which is the supplementary, and the €1.5 billion, which is the permanent recurring allocation, reflects the fact that following the allocation mid-year, important and stronger cost controls and expenditure limits have been introduced. Given the size of the increase in health investment this year, the tighter budgetary control and the full-year savings impact for 2025, the €1.5 billion figure reflects underlying budgetary pressures that will continue into 2025. That is probably an overly complex way of me saying that the €1.5 billion is the run rate structural adjustment that was needed for this year.

There is an additional approximately €200 million to €250 million, which reflects the fact the run rate and savings in productivity achieved through the year do not apply to the full year. We are satisfied the €1.5 billion accurately reflects the ongoing recurrent cost requirement. While progress is being made on cost containment and productivity, there is a long way to go. Next year must deliver better value for taxpayer money for investment, along with stronger budgetary control, which I am happy to say the chief executive and board are taking seriously and acting on.

We are all aware that during the pandemic significant but temporary additional funding was made available to the health service to respond to Covid. As well as supporting the vaccine programme, it helped fund responses to the wider impact of Covid, for example, tackling the big increases in our waiting lists and the impact on mental health and social inclusion. It supported provision of care away from acute hospitals, where appropriate. I am happy to report that €900 million of the funding has been allocated permanently to health. It did not get much attention when the Minister, Deputy Donohoe, announced the settlement reached earlier this year, but it is a significant benefit to the health service that €900 million of Covid-related funding has been agreed by Government to be put on a permanent basis. That is relevant to a long list of important initiatives in our communities and hospitals, things that are making access quicker for patients and providing new services for patients. That money is being moved from one-off funding to temporary funding. It has been very welcome.

The overall current expenditure allocation of €24.3 billion announced in budget 2025, including the additional permanent funding provided for in July, puts the health service on a sustainable financial footing for the coming years and will provide for continued improvements in services and outcomes for patients. It has secured permanent funding for an additional 4,000 HSE staff. These were previously unfunded in our acute hospitals. This includes 2,000 consultants, doctors and nurses and more than 400 health and social care professionals. It includes high medical inflation experienced immediately post Covid in Ireland and around the world. It includes increases in activity levels experienced by the health service post Covid and it includes the services provided on a one-off basis this year that can now continue - for example, funding to increase activity and reduce waiting lists and times. Critically, in the area for which the Minister of State, Deputy Burke, is responsible, funding for homelessness and various social inclusion services, which we were providing on a post-Covid year-by-year basis, have been transferred to recurrent permanent funding. These are incredibly valuable services which were stood up during Covid but on which we never had agreement for a permanent roll-out. The Minister of State now has allocation to continue those services on a permanent basis and they are making a big difference.

At this point, I will be guided by the Chair. I have detail on the subheads, which I can go through. There is about another five minutes' worth. If the Chair wants, we can revert to members. What would the Chair like to do?

Subhead 1 relates to net pensions costs of €83 million. Pensions is an area that is difficult to predict with accuracy as it is demand-led and once people retire they are entitled to claim superannuation benefits. As well as the demand element, the additional €83 million is driven by the public sector pay deal and a reduction in retained superannuation contributions because of the single public service pension scheme.

Subhead J1, HSE €1.347 billion, covers all main HSE core operations service areas, including acute hospitals, primary care, social inclusion, palliative care, mental health, older persons, community services and national support services. The subhead requires a Supplementary Estimate of €1.347 billion for 2024. This comprises €1.615 billion of additional expenditure, partly offset by a €268 million movement in HSE cash and working capital. While there are deficits across a range of core services, most of the supplementary ask, €1.544 billion, relates to acute hospitals. These deficits in core services are offset somewhat by other operations expenditure, which is forecast to be in surplus by €281 million. This primarily comprises an underspend in the office of the chief clinical officer of €121 million and an underspend in national support services of €135 million. The support services surplus partially reflects the fact that funding is held centrally by the HSE for certain measures, such as new development, and some of it is yet to be allocated to relevant service areas. When the budget is distributed, the surplus in support services will be lower and the deficits in those service areas will be reduced.

Subhead K4 concerns payments to the State Claims Agency regarding clinical negligence. The State Claims Agency supplementary requirement for this year is €50 million with a final allocation of €485 million. This is attributed to an increase in the number of claims and the value of settlements awarded, particularly claims arising from catastrophic birth injury. A sum of €50 million is required to fund the total cost of claims which will be settled this year.

Subhead L1 is the primary care reimbursement service, PCRS, and local demand-led schemes, €269 million. The PCRS administers a number of demand-led schemes, including general medical services schemes, community demand-led schemes and the national drug management scheme. A projected shortfall in PCRS funding of €186 million is related to overspends in these areas. A portion of the shortfall is driven by expanded eligibility to medical and GP card visits and cost-of-living measures, the drug payment scheme, for example. The local demand-led scheme deficit of €83 million is largely attributable to a combination of the increase in demographics, and therefore increased activity under the eligibility schemes, and price inflation, predominantly across high-tech medicines, long-term illness scheme and hardship medicines.

Subhead M2 is capital, which is €5 million. Supplementary capital funding of €5 million is being provided in respect of the Brexit capital apportioned for the OPW phase 1 and phase 2 projects, which relate to storage facilities in Dublin and Rosslare ports and Dublin Airport. The supplementary funding is based on figures presented to my Department by the OPW.

This year has seen a continued increase in demand for health services. This is driven by demographic factors, greater longevity and increased provision of services. As a result, the amount sought will bring the total Department of Health expenditure this year to €24.577 billion. The value of this investment in delivering crucial services to our people is immeasurable. I seek the committee's approval of the Supplementary Estimate of €1.754 billion for Vote 38.

The Minister spoke of subhead J1. Maybe it is the language he is using but it is not very clear. I am conscious people are probably listening at home as well. Maybe other members understand it. The Minister stated:

While there are deficits across a range of core services, most of the supplementary ask, €1.544 billion, relates to acute hospitals. These deficits in core services are offset somewhat by other operations expenditure, which is forecast to be in surplus by €281 million.

Will he explain what exactly he means by that?

I referenced two funds in the speech, the chief clinical officer's area and the services area. Essentially, the money goes into central departments in the HSE and, as new developments are rolled out, it gets transferred. For example, regarding the national cancer strategy, the money is allocated from the Department to the HSE, sits with the chief clinical officer and his unit and, as the national cancer strategy gets rolled out, money is transferred as new services begin. At this point in the year, there are still new services to be rolled out over the coming months. As they are rolled out, the money held in the chief clinical officer's budget line will go out to the national cancer control programme, the national women and infants health programme and other groups who use it to roll out the new services.

I thank the Minister, the Ministers of State and the officials for attending.

There are just a couple of things that come to mind. It would appear that a better picture is emerging in the context of funding for health service that will lead to improvements for consumers right across the country. That is to be welcomed.

How did the underspends to which the Minister referred come about? Did they affect areas where there was an obvious need and could the moneys involved have been used effectively somewhere else in anticipation of the fact that underspends were going to occur? In other words, could the people responsible not have said that it was likely that the funds in question were not going to be needed and asked if, with the permission of the Minister or whomever, they could be transferred elsewhere?

I thank the Deputy. The two big areas of underspend which we have shown in the document circulated to the committee are those the Chair and I have just discussed. They relate to the chief clinical officer and national support services. They are not really underspends. That is to the Chair's point. We call them underspends but, in fact, they are lump sums that are transferred across and, within the HSE, are released out to the service lines, such as hospitals, the cancer control programme and the national women and infants programme, as they roll out new services and hire new people. The big chunky amounts, which are in here as overspends, are, in fairness, not really underspends. Those are sums that gets released throughout the year, but there are individual service lines where that might be the case. In terms of the total HSE amount, that is then netted off overspends in terms of the money that the Oireachtas votes to the HSE.

Moving slightly away from the Deputy's question, we have obviously got a big focus now on productivity and cost containment. My preference is that where they can find savings, they should be able to reinvest the moneys locally. A quick example I will give the Deputy relates to the medicines budget. We started the latter for this year and are continuing it into next year. What we said to the various groups, Professor Barry and the others who are involved in that, is that any money saved can be reinvested in new medicines. In that context, they have aggressively gone after biosimilars and generics. They are well ahead of target for this year, and that money is beings reinvested. My view is that if an individual hospital can roll out a productivity programme and get better at cost containment in the context of its various spends within reason - it might not always be the case - it should have some ownership of the moneys saved and should be able to reinvest them locally. This lines up the incentives in a way that works.

There should be an alteration in the description. The Minister has explained that. It should be done in order prevent people being misled and to enable those who may expect the moneys to be sent in their direction to know that this is or is not a possibility. They have to plan as well.

In relation to the State Claims Agency and negligence claims, the total allocation of €485 million can be attributed to an increase in the number of claims and the value of settlements awarded, particularly in the context of claims arising from catastrophic birth injuries. What steps are being taken to limit the extent to which incidents or accidents can occur? Such incidents and accidents seem to occur repeatedly and the same issues seem to arise. What steps have been or are likely to be taken to minimise the risks both from the point of view of the patients - the children and their mothers - and when it comes to liability in respect of the cost of health services?

I thank the Deputy. The core part of this is patient safety. There is a financial cost involved for the State as well, but, first and foremost, this is about reducing and, where possible, eliminating harm to patients. A few different things have happened. In terms of catastrophic birth injuries, there is now a review group. It was set up, I believe, two years ago by an eminent obstetrician who had led national women and infants health programme. They are now doing what I would call root-cause-analysis reviews where there are catastrophic birth injuries.

The other thing that has been done this year is that Dr. Rhona Mahony led really important work in terms of looking at this, first and foremost, from a patient safety perspective, but then with a knock-on effect on claims. There were 30 recommendations and six themes in her report. We launched the report, I believe, four weeks ago, and it is now being actioned. Certainly, it is Dr. Mahony's view and it is stated in the report that there are further improvements that can and must be made.

Have these been quantified? Have the areas where positive changes can be made with obvious beneficial results from the point of view of patients and in the context of the risk and cost to the health service been flagged? To what extent has a breakdown of the €485 million referred to, including legal fees, been obtained and what were the extent of the legal fees involved, if known?

I am sure we can get that information for the Deputy. What we are seeing in the profile is that there was a significant escalation, as we see from the figures provided to the committee, from €205 million in 2015 up to €465 million in 2021. It more than doubled. In 2022, it went up €530 million. It has stabilised over the past four years.

There would be various reasons. The payments being made this year will, for example, relate to cases from quite some time ago. We will get the Deputy a more detailed note in terms of legal fees versus payments.

We want to achieve a few things. First and foremost, we want to maximise patient safety. Second, where there is a mistake or where there is a catastrophic birth injury or something else in respect of which payment is required, we want non-judicial processes. Dr. Mahony's report looks into this as well. Litigation is obviously always available but it should be a last resort as opposed to sometimes being the only thing that patients and families can opt for. Third, we want to bring costs down. Given the time between when something happens and a payment being made, it will be a number of years before patient safety improvements that have been made over the past two to three years will result in a reduction in the level of payment made.

In terms of a reduction in the number of incidents, how will be able to monitor the extent to which potential catastrophic incidents can arise? What evidence exists which shows that the prevention of incidents is well in hand, as needs to be the case? The follow-on from that is the financial liability. How quickly will we see the effect of and be able to judge the preventative measures that have been put in place?

They are measured each year. There is an accurate understanding of the number of catastrophic birth injuries and, indeed, other patient safety issues. It is taken very seriously. The patient safety office in my Department is very involved in this. The HSE is also very involved.

We can certainly provide some detail in terms of the numbers. For example, the legal fees relating to the €485 million for this year are believed to be €10 million to €15 million.

All I will say is that this Department specialises in health. Insofar as possible, we need to prevent as many accidents or errors in procedures as possible in every way possible to ensure the money in the health budget is spent on health as opposed to legal fees.

I saw something about the OPW. I have had some interaction with the OPW recently. While I cannot find it at the moment, the OPW was mentioned as being-----

I welcome the Minister, the Ministers of State and the officials who are here. I wish to make one point or observation, which is important for me to make. The Minister might recall that when we had discussions about Supplementary Estimates last year, which was also after budget 2024, this committee clearly set out our concern that the health service was not properly funded for existing levels of service, ELS, not just for one year, but for a number of years, and that this was leading to a growing deficit which would require money being put into the base. We cited three reasons that were given at the time by the Department and the HSE and which the Minister actually restated in his opening statement today, namely, the growing demand, pay costs and all of those issues, and health inflation. This committee estimated and put on record that €1.5 billion was needed to be put into the base. We received very strong pushback. We had meetings of this committee in which we received very strong pushback from officials. In fact, we received even stronger pushback from the Secretary General of the Department of public expenditure and reform who certainly was not of the view that any deficit existed or any Supplementary Estimate was required. In fact, I went before the finance committee and had a very robust exchange with the then Minister for public expenditure where I was told I was raising alarm and that the figure would be nowhere near €1 billion, never mind €1.5 billion. I am making the point that here we are 12 months later and the figure is €1.7 billion. Everything said to us by officials in the Department of the Minister present and by the head of the HSE has turned out to be correct: the deficit was real and has now been put into the base. It is important to set the record straight because we had lengthy discussions on this matter. I am not attributing blame to the Minister on this one; the fault lies elsewhere. It was very unhelpful and a chaotic way to fund healthcare. I hope, going forward, we will not see that anymore. Whatever the estimate is for existing levels of service, it must be scientific and real and it has to be funded to end the madness of what we have seen in recent years. I am just making that observation.

My first question relates to the productivity and savings task force the Minister established. Deputy Durkan talked about State claims. I agree that patient safety is the main reason we should try to limit claims in that space. The legal cost is one thing, but there are also the volume of claims and the amount being paid out. That is only one area, however. Agency spend, management consultancy, overtime, outsourcing and all of that are areas where we can save money. Will the Minister outline how much money has been saved to date and in what areas? It is important for us to understand that. Given we are seeing changes in work practices, and we need to see more, is there any scientific financial evaluation or data that demonstrates how savings and efficiencies can be achieved through changes in work practices and as we roll out more advanced technologies, such as virtual beds and all of those kinds of areas? That is something we are being told can happen. I am interested and curious to hear from the Minister’s response whether this has been quantified. Separate from that, what savings that have actually been achieved have been quantified to date?

I thank Deputy Cullinane for that. I will answer his second question first. Ms McGirr is on the task force and is well placed to give the Deputy an update on his first question.

On the changes to work practices, what we are doing is pursuing what was called for in Sláintecare. For me, there are three pieces to this, namely, structural changes to get better productivity, operational changes and technological changes. The main structural change is moving from hospital care to community care. We all know that and are all signed up to treating people in the least expensive setting possible, which, obviously, still has to be clinically appropriate. For me, that is one of the big structural changes. The move to the six regions is a structural change. We have been involved in large changes in the past four or five years in health to create a more cost-effective model of care. That is the first thing.

The second thing is operational changes. We have a way to go in this regard. For example, operational changes include increasing theatre utilisation, which to my mind is too low, and increasing outpatient clinic utilisation and other day-to-day operational changes that are being made, in some hospitals more than others, to drive day-to-day productivity. Are we treating as many patients as possible every day in our operating theatres? Are we seeing as many patients as possible every day in our outpatient clinics? Are we scanning as many as patients as possible every day with whatever radiology facilities we have? That is a big change. We have brought in the new HPVP productivity platform, and we are in the middle of a fundamental change in culture, approach and performance management. The new consultant contract is part of that. There is a day-to-day operational productivity.

The third one is technological productivity. We cannot ask our health professionals to run a modern service from a productivity perspective unless we give them the tools to do that. We all know Ireland has a long way to go in terms of e-health and digital health services. Shortly, we will have our first patient app, which will have basic records. By the end of next year, we will have a shared care record which will be a big leap forward. The third thing we are doing is rolling out e-health or a digital health service.

In fairness, I have given the Minister a lot of my time to respond to that question. I want to get on to a second point as quickly as I can as well. I just want a figure for my first question. How much has been achieved by way of productivity and savings since the task force was established? The breakdown, if there is one, can be provided to us in writing. Second, what scientific analysis is being done to estimate what savings can be achieved through technology? Is there a percentage, a figure or something we can look at? We all want to achieve savings and efficiencies in healthcare where we can. Has a figure been identified by the Department that, for example, over the course of five years, a specific percentage of spending can be achieved through better use of technology?

We are on target with our savings to date. This document has been published and we will send a link after the committee meeting with the details of it. I am also happy to take any questions on it. We are on target for a total of €100 million of savings by the end of the year. That includes high performance in medicine savings and management consultancy. Both of those areas are on track. Medicine savings are ahead of where it is supposed to be. There are also savings in terms of some of the pay elements forecast for later in the year. We are on track for those. The pay targets are now actually part of the overall HSE limits and expenditure after the mid-year settlement. Once the HSE lives within the €1.7 billion, it will actually have changed the trajectory of spend in the beginning of the year significantly to reduce its spend.

Of course, there is more to do. Some €100 million is nowhere near what can and should be saved. Even in respect of the issues the Minister raised regarding how money can be saved, €100 million does not stack up. We have not even got to agency spend, where I argue a lot more can be saved. If a note can be given on exactly that, it would be important. I am sure we will debate these issues out in due course over the next number of weeks.

I will come to the pay and numbers strategy. The healthcare trade unions were before the committee last week, as the Minister might recall. One line from the INMO's opening statement reads, "Over 2,000 nursing and midwifery posts have been effectively abolished as they were vacant on December 31st 2023." We heard similar claims from SIPTU. We will hear from Fórsa next week. Their central charge is that what we have now is an embargo by another name, and very limited recruitment, because of the limitations of the pay and numbers strategy. Will the Minister respond to that charge of 2,000 nursing and midwifery posts that have effectively been abolished and the fact that we are now looking at industrial action by healthcare trade unions? All of this arises from the reckless way in which we approached health spending last year, which led to an embargo that caused all of this unnecessary tension in the first place.

The figure of 2,000 is contested. My Department has written to the INMO seeking the figures. It has not provided those to us. We wrote again to the INMO this week seeking those figures. Nobody has cited these 2,000 roles. If and when we get the list of those posts, we will of course take that very seriously.

Let us park that for one second. That is a figure. Is the Minister contending that no posts have been abolished that were vacant on 31 December 2023? Is it his contention that no posts have been abolished or is he simply saying that the figure of 2,000 is something he wants verification on? That is an important distinction.

We know that. It is my last question, and the Minister did not answer it, with respect. I accept what he said. That is not in dispute. What is in dispute is that there were vacant posts on 31 December 2023 that were abolished. If the Minister is disputing the figure from the INMO, has he the HSE's figure? I am asking him a very straight question. He is the Minister. Have posts been abolished? If so, how many? If he is disputing the INMO figure, I am sure he has his own figure. Is it his contention that no posts were abolished? Does he contend that the 2,000 figure is unverified? What is the real number, from his perspective? I am not alleging the INMO figure is wrong. That is the Minister's contention.

I will answer the Deputy's question. We need to see the INMO or Fórsa figure of 2,000. We will verify it. It is the case that there are teams, be they in the community or in hospitals, which are under a lot of pressure. There are teams that might have had one or two vacant posts in January, where they do not currently have agreement to hire into those posts so I-----

The point is there are thousands more posts now than there were. What can be done? Hospital managers and regional executive officers can redeploy. Ultimately, there are thousands more posts today than there were this time last year. We are talking about an overrun of €1.7 billion. We have to get away from a world where individual hospitals, and it is mainly the hospitals rather than communities, feel that they can just hire any number of staff they want, regardless of how many they are funded for. We simply cannot do that.

What we need is a workforce plan that is aligned with recruitment, if we are training healthcare professionals. That is why we have training targets. We are training them to come to work in the public system. Every graduate should be offered a job in the public system. That is not runaway recruitment. It is common sense. If the Minister is able to furnish figures for vacancies that were abolished, he might do so. If he is disputing the INMO figures, he should at least put onto the public record what the HSE's estimated figures are. I will leave it at that.

I thank the Minister, the Ministers of State and their teams. I will take up the same theme. The Minister is talking about 6,500 appointments, essentially. These are new positions between this year and what is projected for next year, yet the INMO and Fórsa are protesting today. What does the Minister say to them?

It is very disappointing. I absolutely acknowledge that there are teams. There are community-based teams in primary care, for example, and teams in our hospitals, where they really are under pressure. There were vacancies in their teams through the embargo and they no longer have sanction to immediately hire into those. However, as envisaged under Sláintecare, we are pushing accountability and decision-making out. Individual hospitals, where they have far more staff than they did even a year ago, have the authority to deploy into those roles, as do the regional executive officers.

To try to make this real, three of the hospitals where I believe there are protests this week are Our Lady of Lourdes, Drogheda, Cork University Hospital and Connolly hospital. My understanding is healthcare workers are outside their own hospitals protesting about the lack of staff. In Our Lady of Lourdes, the increase in the nursing and midwifery workforce over the lifetime of this Government is nearly 30%. Critically, it has gone up every year, including this year. There has been an increase of 37% in nursing and midwifery in Cork University Hospital. That is 600 more nurses and midwives working in Cork University Hospital than there were when this Government was appointed. Again, the number has gone up every year, including this year. There has been a 32% increase in the nursing and midwifery workforce at Connolly hospital and, again, the number has gone up every year, including this year. That is why the protests are very disappointing.

If there is industrial action, all that will do is serve to lengthen waiting times for patients. It has an effect on services - it is designed to have an effect on services - which has an effect on patients. If protests were happening in the context of reductions in the workforce, that would be one thing, but we have just seen an unprecedented increase in workforce across all categories, including consultants, NCHDs, nursing and midwifery, health and social care professionals, and general administration. Right across the board, there has been an unprecedented increase. We have 28,000 more people working in the service today than we did when this Government was appointed. As I just shared, in addition to that, there are approximately 6,500 vacant, fully funded posts between now and the end of next year that the HSE can hire into. In the context of unprecedented hiring and staffing, it is just hard to understand.

However, I fully accept and acknowledge there are individual teams that are under huge pressure. The hospital managers and regional executive officers have authority to deploy into those areas. For example, it is estimated that safe staffing, which we are all fully signed up to, requires approximately 2,000 additional nurses. Some 1,500 of those are in situ so it is three quarters rolled out. The remaining number has been fully agreed and is now funded. In light of an unprecedented increase in the professions like that, quite rightly, which was hard fought for by their members and championed by this Government, it is really disappointing, notwithstanding the very real pressures for individual teams.

I will move on to a few quick questions. I will briefly note the comparison of health spending in Ireland with other European countries. We are about halfway up or down the league table, depending what way you look at it.

Are there any statistics available on international comparisons in regard to getting bang for the buck, outcomes and so on? I do not need the Minister to answer this now but it would be useful to know where we stand. It seems we are better than most southern European countries. We are ranking mid-table and we are better than the Danes and Finns in terms of expenditure. Have we any data on outcomes or how is that measured? I do not want to take too much time on this but I am interested in those statistics. People in the Opposition often throw out terms like "Third World health service". I have been in Third World countries, which I will not name. We have a First World health system. Expenditure certainly is one indicator of that but it is not the only one. Is there other data that would point to that?

If the Deputy searches for "HSPA" or "health service performance assessment tool", he will get it. There is a lot of information there. The short version of it is, looking at western Europe, which really is our comparative group, in some areas, we are around average but getting better, we are below average in some areas, and we are doing really well in some areas. In areas like women's healthcare, palliative care and cancer care, we are getting better and doing so quite quickly. There are other areas that need investment. We really tried to highlight and push those areas in the budget this year. Cardiovascular disease is a big one. It is one of the major killers in Ireland. That was the case 100 years ago and it still is the case today. We have provided funding for the stroke strategy, the Irish Heart Foundation and a new cardiovascular strategy, which will come out of the report by Professor Philip Nolan. Deputy Lahart has championed, with me, action on lung fibrosis, which is another area where we need investment and where there has not been that investment. We are now investing in those areas.

In terms of the cost base, when comparing Ireland with western Europe, one factor is that our wages are high. I could be wrong on this but I think the new consultant contract offers the highest public sector consultant pay anywhere in Europe. There might be a country where it is higher but I am not sure there is. Our healthcare wages compared with some other European countries are in the middle and higher.

I want to raise an issue that is good news and a matter of continuing interest. It is relevant to the Minister of State, Deputy Butler, who is here. One of the most interesting points the Minister mentioned in his opening statement concerns the demographic challenge, which is alarming. The statistics are really interesting. Our population is at its largest since 1850, with an increase of close to 400,000 people in five years. The highest percentage increase was in the older age groups, with a 28% increase among those aged 75 to 84 and the older-than-85 age group having the second highest percentage growth of 25%. These figures are in contrast to an average growth rate of 3.5% for the same age profiles across the European Union. People over the age of 65, which is the common threshold for old age, now make up 15% of the population, which is an increase from 12%. Population ageing is having significant impacts on both the demand for and flexibility of healthcare provision. Will the Minister of State comment on that? I ask that she leave me 30 seconds at the end for a small rider question.

Yes, in the EU 27, as deemed by the World Health Organization. A really interesting statistic is that we have 400 fewer people in nursing homes under the fair deal scheme this year than we had in 2019. This shows that the investment in home care, day care and meals-on-wheels services is working. When Sláintecare was being devised, it was estimated that we would need 30,000 fair deal beds by 2025. Today, there are 23,200 people in fair deal beds, which is 400 fewer than in 2019. People are presenting to nursing homes with far more complex needs than was the case previously because they want to stay at home for longer. This year, we will deliver 23.4 million hours of home care. Between July of last year and July 2024, we delivered 1 million more home care hours. I have secured enough funding for next year to get to 24 million hours. We will support approximately 59,000 people. The triangle of supports, comprising home care, day care and meals-on-wheels services, is paying dividends. It is people's will and preference to stay in their own home for as long as possible.

A note on that would be worth getting.

My final question is one concerning what may be the smallest sum in the Supplementary Estimate, namely, the dormant account funding of €2 million. I am interested in why the Dormant Accounts Fund was raided and for what purpose. I am being dramatic in using the word "raided". Does the Minister have a note on the specific uses of that funding?

Yes, there is an annual allocation to the Department of about €2 million. There is an application process by which various community groups can apply for funding. There is a limit on the amount of funding in each case. I think it is €50,000 but I am not sure. The provision involves small amounts of funding for small organisations. There is a transparent application process that can be accessed on the HSE website.

I welcome all the attendees. The Minister of State, Deputy Butler, mentioned there are 400 fewer people in nursing homes under the fair deal scheme. That is a really welcome figure. It is the first time I have heard it. I hope that trend will continue.

The Minister referenced in his opening statement the demographic changes, which are very significant in terms of population size and the ageing nature of the population. The question must be asked as to why these figures were not used last year to ensure an adequate budget was provided. There is no point in raking over old coals but it is an important point, which I will get to in a moment. Interestingly, the Irish Fiscal Advisory Council, IFAC, criticised the budget on the basis that insufficient funding was provided to health. It is very unusual for the council to do that. Normally, it is complaining about too much money being spent. IFAC was very critical of the fact that the health budget last year did not take account of the significant demographic changes. That raises questions about the ability of the Minister's Department to make the case based on the facts of the situation in regard to population. That is on the one hand. On the other hand, it also raises questions about the ability of the Department of Public Expenditure, National Development Plan Delivery and Reform to hear cases being made.

The primary responsibility of senior officials in a Department, and of the Minister, is to ensure they secure adequate funding. It was not secured last year. We have to be clear that this is why we are getting this supplementary allocation. We can talk about this as if it just concerns figures on a page. Of course, it does not just do that. The impact of the inadequate funding that was secured last year was very significant for patients and, in addition, it put additional pressure on staff because the recruitment freeze came into force as a result of that inadequate funding. There are questions in this about the ability of the Department to make a proper case for funding.

I agree with the Deputy that there is probably nothing to be served by going back over this matter. It was a fairly well ventilated budget discussion last year.

The settlement this year is significant, with €1.5 billion for ELS this year, €1.2 billion for next year and €900 million for one-off to core. Critically, as well as that, there is now a very clear workforce allocation in terms of numbers and pay, which will help for next year. If I could just make one quick point, the embargo had nothing to do with the ELS settlement. The embargo was because last year the HSE was funded to hire about 6,000 staff. It hired 8,000 and it was not showing any signs of slowing down. We signalled through the year that it had to stop with the accelerated hiring and unfortunately it did not happen. We were left with no choice other than to press stop. Last year was the biggest year of hiring in the 20 years that the HSE has existed. Regardless of any settlement for this year, the point is last year they hired 2,000 staff that they had no funding for.

There is a great deal of inaccurate information being thrown around on all sides. I am not saying it is inaccurate, but confusing information and claims being made from all sides in respect of this. I would not say for a moment that hospitals should be allowed to recruit as many staff; that would be ridiculous. They were allowed to do that in the past and there were serious problems as a result. I fully support an approach that is about getting better value for money and achieving efficiencies. However, there is another factor that comes into play here in respect of nurses and midwives, which is the safe staffing levels. The figures the Minister has set out do not account fully for the agreed safe staffing levels of 1:4. There are a number of points here that need to be made. The INMO was at the WRC and there was an acceptance by the WRC that the way the numbers were calculated did not reflect the reduced working hours. My understanding is that people are still waiting for the HSE or the Department to come back with the recalibrated numbers. What is the Minister's position on that and when can we expect to see those figures?

I will talk to the chief nurse about that. The very clear advice I have from the Department is that the figure of 2,000 additional nurses is what is required for phase 1 and phase 2, that is, all the medical and surgical wards and the emergency departments. I am advised that 1,500 of those are in situ and another 500, which are fully funded, are to be hired. If there are additional issues we will find them. I will give one quick example. There was a claim made in UHL that they were short, I think, 200 nurses for safe staffing. The chief nurse is also head of patient safety and leads on safe staffing. I asked her to go to UHL and do a quick audit to find out, because I was very concerned at this. What she found was that they were sufficiently staffed for safe staffing but it was not being implemented consistently. There were some wards where they were understaffed but, critically, there were other wards where they were overstaffed. Really what it required was consistency in application in the hospital. The claim of 200 staff was shown not to be the case.

That is fine and it sounds like a plausible explanation. There are claims that you have not recalibrated the numbers for safe staffing based on a reduced working week. I am not expecting the Minister to have that detail today but I would ask him to provide a note on it, specifically on the recalibration.

I agree. If I could add one point, all of us listening to some of the narrative would be forgiven for thinking that we have a deficit of nurses in the country. In fact, the OECD figures show that we have the second highest level of nurses per head of population of anywhere in Europe. The safe staffing framework is seen around the world now as one of the highest levels of staffing.

This is heavily disputed. That is why we need to see the facts of the matter. The other point you made on efficiency and so on was to fully utilise the expensive equipment we have. There are many issues around that. I want to raise specifically the issue of radiation therapists. I have raised this umpteen times by way of parliamentary questions. It is claimed by SIPTU in particular that the number of radiation therapists is 30% below what is needed across the five public radiotherapy centres. As a result of this staff shortage, four of those important machines are closed and three CT scanners are not in use. That just does not make any sense whatsoever. I have raised this. There is a need for additional radiation therapists. In order for them to start training in Trinity and have clinical placements within the service, there is a need for additional tutors. That is the key to unlocking this logjam. Will you address that issue, please, so that we can have additional therapists, use all the equipment that is there, and stop spending additional money on outsourcing services? There is €10 million being spent on outsourcing radiotherapy services.

The funding is allocated now on the basis that it takes time to hire. They can essentially get on and start recruiting them now. There was an ask in from the university that was completely over the top. Had a reasonable ask been made, it would have been sorted much quicker. The ask was to move from half a whole-time equivalent to six and a half whole-time equivalents for what was about a 50% increase in the posts.

I want to go back to the issue of outsourcing. The latter is currently rampant across the health and social care service. I am concerned that we could reach a tipping point with this. So many services, particularly in social care, are outsourced. We have got all of the private nursing homes, something like 80% of home care staff. We are increasingly outsourcing other diagnostics and nursing services. The latter are being outsourced through the widespread use of agency staff. There are many other areas as well. I spoke about radiation therapy. What is going to be done about that, Minister? Part of the answer is to have an up-to-date comprehensive workforce plan which we have lacked for a very long time. The other part of it is an ideological thing. What examination is being given to looking at the relative costs of outsourcing? On the surface, it can look cheaper because of lack of commitment to pension obligations and so on. Has the Minister undertaken any kind of study to look at the relative costs of that, irrespective of the other impacts?

In some areas, yes. Some outsourcing, if one could call it that, works very well, such as with GPs, pharmacies and so forth. We are all happy with that. From an ideological perspective, my view is that core services within the HSE should be delivered by it.

The Minister of State, Deputy Butler, may speak to it, but neither she nor I are happy with the percentage of private nursing home beds. It has increased dramatically. There needs to be a reset, and the commission that started earlier this year is looking at exactly that.

In the operational areas, agency is a big one. An agency is basically outsourced labour, mainly within the hospitals. It is a combination of medical, nursing and support. The Deputy mentioned radiology. I do not want these things to be outsourced. I would prefer that our agency bill was very minor and just used to plug holes where necessary. Part of using agency is we want to grow the services for patients quicker than we can scale-up the HSE. I will give one example and then I will stop. I refer to State-funded IVF. What was proposed to me was that we would build up new IVF clinics or assisted human reproduction clinics within the HSE and then make that available to patients as and when they became available. I took a different approach. I said we should make it available now. We use the existing private capacity while we build up the public capacity, and then transition across. The minor injury units is another example. There are a few privately run minor injury units but we want them to be publicly run. For me, it is less about cost effectiveness and more about speed of scale-up.

That is fine, but the problem is that if we continue in that vein, we create a strong incentive for staff to work in the private sector instead of the public sector. The private sector becomes the place where the jobs are available. Many things need to be looked at with regard to the speed, or lack of speed, in recruitment processes, centralised recruitment in the HSE and all of that kind of stuff.

My last question is on the RHAs. Will they get separate budgets next year?

There is discretion now. At this meeting next year or at the budget meeting, we will start reporting region by region, which will allow for some important comparisons between the different regions. There is discretion within the regions. It is nuanced. We cannot provide full discretion because there are things we all want to roll out. If we fund the national cancer strategy, it is not up to the region to decide whether or not it will roll it out. Where the new regional executive officers are already beginning to apply that discretion is in individual hospitals, and between acute and community. For example, if there are very high-priority teams that are understaffed, perhaps there are lower priority areas that could be looked at in terms of redeployment.

I wish to come in on community beds. In next year’s budget, there will be an additional 174 community beds. I asked the HSE, when we were going through the CNUs, that instead of just replacing the beds, we start turning the dial. For example, in Clonmel CNU, 50 beds will be provided, of which 32 are additional. In St. Columba’s in Thomastown, there will be 95 beds, of which 50 are additional. We are turning the dial ever so slightly. It will take a long time, but we have made a start.

The Minister of State indicated that earlier in the year and it is very welcome. I hope other parts of the health service emulate that.

Please excuse me as I have to speak in the Chamber. I am sorry.

Yes, he mentioned that later on. He also raised some of the key drivers of the supplementary budget. The Minister said that 60% of the Supplementary Estimate is required for pay costs, excluding pension costs. He mentioned “staffing roles that had previously been provided from temporary Covid funds along with funding for staff hired in excess of funded levels of recruitment”. What type of staff is he talking about?

In the agreement with the Minister, Deputy Donohoe, earlier this year, we got agreement to permanently fund about 4,000 staff for whom there were no wages allocated by Government. They fall into two groups. The first is the extra 2,000 the HSE hired last year. There was no funding for that. The HSE obviously paid their wages, but it was not funded to pay their wages. Therefore, we have an agreement now for all 2,000 of those staff. The gap between the 6,000 and the 8,000 that were hired are now permanent roles.

The second is there were another 2,000 staff who were hired during Covid. They were meant to be hired for just a few years in response to Covid. Many more were hired and subsequently left, for example, those who worked at the vaccination centres and many others. However, there was a group of 2,000 who were still in the system. The individual hospitals and the community organisations – mainly the hospitals – were saying that the services those people provide are now core to what we do. In addition, there were some structural differences. For example, most of the hospitals now have isolation areas and different, bigger footprints. Infection prevention and control has not gone back to pre-Covid levels. It is not at the enhanced emergency level but the level that it has settled back to is still higher than the pre-Covid level. Maintaining that required staff. The HSE’s view was that these 2,000 staff are central to the ongoing operations of patient care. To the credit of the Minister, Deputy Donohoe, it funded all 4,000 of those.

I am trying to get at the nub of why. The Minister also mentioned “higher agency, overtime and staff allowances due to increased level of demand, especially in acute settings”. He is saying that the people who came in from the Covid funds who were working in the system are needed in the health system.

The impression at one stage was that people were being hired willy-nilly and there was no real need for those staff. The Minister is saying that the Covid staff are needed. There was a recruitment embargo and we all get that you cannot just hire staff. However, I do not think that anyone is saying that these staff are not needed within the health system. Are there any staff that the Minister is aware of, where if he was in the position of Bernard Gloster, he would not have hired?

Again, staff are needed. We had witnesses in the committee. We heard about the radiologists. We have machines sitting there, lying idle, that would be able to be used. That is just one example, but we have been given other examples over the years related to staff. People are waiting on waiting lists. Last night disability was talked about, for instance. Some 4,000 children are waiting on assessment in the CHO 7 area. That is up 30%. In that area, if we had people to do the assessments, that waiting list would go down and the system would move much more easily. Similarly, the Minister mentioned access to GP services. The challenge for many people is that they get free GP care cannot access a GP in their area. They cannot get on a list. If you have a medical card, in many areas, it is almost impossible to get a GP. That is not just in rural areas; it is in city and urban areas. There is a challenge there. We had dental association representatives in. They were saying reduce the number of people. In the public sector, people and children have to wait sometimes years for key access to a dentist. They have free access to it, but they cannot get a dentist. It is the same with older people who have free access to a dentist and a medical card - they cannot get a dentist. People cannot get chiropodists.

Many key personnel are missing from the system, and that is where it falls down. The Minister talks about additional beds in the system. That is really positive, but the beds have to be in the right place. Does the Minister accept that? He stated that we led off in respect of claims. Recently, there was one issue - I presume it will be a claim in the future; I will not even get into that - whereby they were talking about safe staffing levels and saying that in one hospital where a young woman died there were three nurses to 80 patients. That is clearly a problem within that hospital system. That is an example of the challenges facing some people.

The Minister mentioned the reduction in the number of patients on trolleys over eight months by 11%, or more than 9,000 people, but that leaves 81,000 people who have been on trolleys. I am putting things in context, although it is really good that these things are happening. The number of patients over 75 who have been waiting more than 24 hours in an emergency department has fallen by 13%, or 1,600 patients. On the basis of my figures, this means that 12,500 people who are over the age of 75 were on 24-hour waiting lists in emergency departments. I am just putting things in context.

There are also the challenges people talk about as regards step-down beds and not having the right beds in the right place. Many people's lived experience is that the quality of our care services is decreasing rather than increasing. If you cannot get a doctor, that is a key component in your health. If you cannot get a dentist, that is vital to oral health. Where do you go? If you cannot get a doctor, you will go to the accident and emergency department. If you cannot get there, the lists get longer. That is the challenge. Talking about a shortage of staff is all very well, but if we do not have key personnel in key areas, the system fails, and that is what is happening for many people. We could give examples of people waiting on lists.

I have raised the issue of people with obesity having to wait five to seven years. Children who are non-verbal wait possibly two years for assessments. The list is going the wrong way. I am just putting things in context as regards some of the challenges we have. This is not a criticism. I am saying that this is the lived experience of many people as regards the challenges we face. They will probably ask after this Supplementary Estimate what will change as regards their life, whether it will be easier to get into the hospital, whether it will be easier to get a doctor, whether it will be easier to get a dentist and all those basic things. There are all the positive things the Minister says about what is happening, but those are the challenges that face us all. I am not blaming him or any particular party for this. Collectively, we all need to come up with solutions to this.

I thank the Chair. I agree with everything he said, particularly when we look at the challenges the Government faced coming into office. As he very fairly stated, many of those challenges still exist. What we have been working on every day is to address them and to do a small number of important things, namely make it quicker for people to access a doctor, a nurse or a therapist, make it affordable for people to be able to do that and make sure that the services people need are available. Important progress has been made, but we are probably halfway through what needs to be done. We have been working on this for a little over four years. The first year and a half were completely dominated by Covid, but as to what our healthcare workers are achieving because they have had this record level of investment, the number of healthcare professionals has increased at a level that has just never happened before, and they have achieved a great deal.

We have a way to go. For example, as stated earlier, in the context of the average length of time someone waits to see a hospital consultant, three years ago it was more than 13 months. It is now just a little over seven months and falling. Our agreed target is no more than three months. To get from 13 months to seven months, on our way to three months, is important, but we are not there yet.

An area we look at an awful lot, quite rightly, is children's spinal services. We focus a great deal on the surgical waiting times, but what very rarely got much mention was the outpatient waiting time. This year, the team in CHI has reduced that so far from five years to 18 months, and it is falling rapidly. We are now well on our way to what we have agreed, which is three months.

Access to GPs in many parts of the country is a big issue. That has not resolved but will begin to resolve from now on in that the simple answer is that we need many more GPs, so we have been increasing the number of GPs in training. It is, however, a several-year training course, obviously. They are beginning to come out now, so now and into the future years it will get a bit easier.

As regards dental services, we are in discussions with the Irish Dental Association. The orthodontic list was one I was particularly concerned about, partly because it was too long and partly because it is too expensive. It is thousands of euro for parents. It is falling and it needs to fall further.

Is Tallaght University Hospital the Chair's local hospital?

In Tallaght University Hospital, just in the lifetime of this Government, the increase in the nursing workforce has been over 50%. There are an extra 620 nurses working in Tallaght University Hospital today who were not there four years ago. That is a vast increase, and they are doing great work. As a result of this increase, the waiting times at the hospital are falling and the surgical waiting times are falling, but what the Chair said is completely on the money. We are only halfway through, and it is not everywhere. For example, a woman referred for gynaecology in Sligo four years ago would have waited four years. She is now waiting about six weeks because there are new services in place, but it is not universal. There are other services where we still have a long way to go.

Coming back to where we started as regards the staff, I have no doubt that the extra 2,000 staff the HSE hired - it hired 8,000 - are doing good work. I also have no doubt that every principal in Ireland could hire more teachers, and if they could, they would provide better education to their pupils, and that if every Garda inspector in Ireland could hire as many gardaí as he or she wanted locally, crime rates would fall further. It is the same in healthcare: if you can hire more and more people, you should be able to provide more and more services. However, you have to say, "This is what the taxpayer has funded", and you have to do your best within that, particularly in a world where there has been unprecedented growth. That is why the productivity agenda is so important. My view - and I think it is a view shared by colleagues on the committee - is that there is definitely more patient care that can be delivered for the current level of resource. Some parts of our service are really productive, and some parts of it just are not. The theatre utilisation rates in some of the hospitals just is not acceptable. The lack of outpatient clinics being run on Saturdays in some of our hospitals is not acceptable, given that so many of our consultants are now on the new public-only contract and we are paying them a lot more money to be available on Saturdays. That is not to have a go at the consultant. The consultant will quite fairly say, "Well, hang on a second. I need the administrator, the therapist and access to diagnostics." There is much more we can get out of what we already have. At the same time, obviously, we have to continue to expand.

Could I come in briefly on two things we have done as regards older people that have made a big difference?

Earlier this year we completed the nationwide roll-out of mobile X-rays to people in nursing homes. It makes no difference which nursing home you are in - public, private or voluntary. We started on a pilot project but we have used it across the whole country now over 10,000 times. When a person has a fall in a nursing home, the mobile X-ray unit will be there within four hours. It has been used over 10,000 times, as I said. The nursing home will get in touch with the local GP. We have started to roll it out in the community as well, albeit we are in the very early stages of it. There is a ratio of approximately 90:10 between nursing homes and the community at the minute. We plan to do more and more of that in order to prevent people having to go to the emergency department. The other piece we are doing, again in a roll-out phase, is the National Ambulance Service pathfinder project. This project is specifically for instances where there is a 999 call and when they triage the call they realise this may be an older person who may need, for example, fluids, or just the support of the team going to the house. They may not need to have to go to the emergency department. That is starting to turn the dial as well. That is really important in rural areas.

I thank everybody for their statements thus far. I have a question for the Minister of State, Deputy Burke, regarding the additional funding this year. Will he give a breakdown on this? I am reading a breakdown of the additional funding in the press release and it gives a breakdown but the drugs task forces in the country will say that funding has been reduced, particularly in the last ten years. In 2012, €20 million was put towards harm reduction and so forth in drug task forces across the country. Now, the figure is less than €20 million. Will the Minister of State give a breakdown on the additional funding and where it is going?

The additional funding in budget 2025 is €4.2 million. An additional 34 whole-time-equivalents will be employed. Some €2 million will be allocated to expand community-based drug services. Some €1 million will be allocated for the national roll-out of the community alcohol service, and that includes the employment of 24 whole-time equivalents. There is €500,000 for drug prevention and public health awareness, and €3 million for research evaluation and international collaboration. The total in real terms will be €5.4 million when we roll it out. That is in the drugs area and is for 2025. It is not the 2024 budget, it is the additional funding for 2025.

Does the Minister of State accept that in terms of the overall harm reduction budget and the money that is given towards task forces across the country, there has been a reduction, particularly in the last 12 years? Obviously, he is only in the position a number of months but does he accept that in 2012 more money was being allocated towards task forces than there is now?

There is a substantial increase in the overall budget for 2025. It is going to be the biggest budget ever in real terms. I will get the correct figure for the Deputy but the increase in total is the biggest figure. For instance, the total increase in funding is €40.5 million for the coming year. There is a €10.1 million increase for pay awards agreements. Some €5 million has been allocated for homeless services, including Housing First. The total additional funding in this particular area is €40.5 million. Some €1.5 million is being allocated for the drug and alcohol task force. This funding will support the co-ordination role of the 24 drug and alcohol task forces across the country, including the increased demand for services, especially cocaine use services. Therefore, there is an increase in the budget and it is substantial in real terms.

As the Deputy knows, we hope to have the supervised injection facility in Merchants Quay opened by the end of the year. I have been there and I have seen the progress being made in the building work. The target is to have it opened by early to mid-December. That is a really important facility that needs to be open. As the Deputy knows, the initial proposal on that was going back to 2019. It went through various planning difficulties but now we have everyone on board. I will have to sign the licence for that to be opened. There is co-ordination between An Garda Síochána and the health services right across the board to make sure we have everyone in support of this facility.

I will come in there as it is something that overlaps both our briefs. As the Deputy would know, in 2023, I launched the clinical programme for dual diagnosis, which supports service users who present with mental health and a substance use disorder. In the mental health budget, there were 210 new whole-time equivalents. Ten of those posts are specifically for dual diagnosis to start up two teams. We want to move on the Keltoi programme as well in Dublin. It is a day centre at the moment but we want to move it to have inpatient beds. There is a lot of work being done on this programme to get it over the line. As I said, we only rolled out the clinical model of care in 2023 so I was delighted to secure the funding to invest ten whole-time equivalents into it in budget 2025. It will be a huge interaction going forward between the addiction and the mental health pieces.

The Deputy should remember that 422 different centres around the country provide support for people with alcohol or drug addiction. Last year, 13,000 people received treatment for drug addiction and 8,000 people received treatment for alcohol addiction. Those figures are likely to go up. I have visited many of those centres over the last three to four months and each one of them is doing a very good job. We need to roll out additional services in some areas. I am working with the HSE and, in some cases, the local authorities in those areas to try to improve and develop new services where they are required.

The target date is for early to mid-December and the construction work has really progressed. I was down there recently - in the last three weeks - and I have seen the work that has been done. The people involved in it are doing everything possible to make sure we can reach that target date of somewhere in the first two weeks of December.

My understanding is that wastewater can be analysed to see the issue regarding the use of drugs. I am not into the detail of it but it is a mechanism that can be used to identify and to evaluate.

Regarding the figures we have, we rely on centres such as all the HSE treatment centres around the country but we do not have a full picture in real terms of the people who are using substances. It is about getting a bigger picture so that we can plan for the future, and that is what that analysis is about.

We should have them because it gives a slanted impression. For instance, I do not see the number of people over 75 coming into the country as being in any way of the level referred to here but, by comparison, I see a huge number of young people coming in. I would say the ratio is very different from what these figures suggest. As well as that, I heard on a radio programme this morning confirmation of inward growth in the number of young people in the lower income bracket and that they do not put a huge strain on our economy. They will obviously graduate and qualify for higher incomes as time goes on. I would like that looked at in a way that might be of more benefit when calculating what we are at. I have been listening to it for a long number of years. The year 2038 was to be the crash-out year where everything was to go awry, but the balancing factor is the number of young people. There are the indigenous young people who do not emigrate automatically, who are staying here and who can travel if they want to, which they do for experience, and so on, in comparison with the past when all those young people booked their flight to London, New York, Sydney or wherever else they wanted to go because they had no option. They were economic emigrants. We were economic emigrants in this country for at least 150 years. That is coming to a halt, and rightly so, but we need to acknowledge it in the calculations we are making. I certainly believe it should be included.

Regarding addiction services, I believe in a combination of two ways and means. We have to detox and we have to have drug treatment centres. We have to have a means of the urgent cases being able to get to a hospital treatment area or a treatment area that will give them the equivalent of hospital attention in the shortest possible time. I mentioned previously at these meetings the extent to which people requiring treatment for drug and alcohol addiction are appearing at the accident and emergency departments in our hospitals. It is widespread. It is not only one or two hospitals; it is all over the place. As to the effect that has, it is disruptive to the staff and it is intimidating to some of those who are there for a different purpose, such as various health reasons. I suggest there be a dedicated place for drug and alcohol treatment adjacent to or nearby accident and emergency departments without infiltrating the accident and emergency departments and making them unworkable. Some of what I have seen in accident and emergency departments over the past 12 months is undesirable. The amount of abuse being hurled at staff, foul language and threats to staff at all levels is appalling. It is not possible to run a service in that kind of atmosphere and we should not try to do it. I would ask that there be some arrangement made for that separation, not that there would be a diminution in attention but that at least would have the two types of patient in a place that is more geared to their requirements. It is urgent.

I visited a couple of the drug treatment centres in recent times and they are doing a good job. I agree with the concept of medication and restriction of the flow and access to drugs. There is a strong lobby within the services that says we must concentrate on the medication and forget about the rest of it. That is not dealing with the situation. As a former member of a drugs task force, we found out that methadone is instrumental in helping people who have a drug addiction, but it should not be as a means of supplementing the illegal drugs industry which is fairly rampant in this country. Anybody will tell you that in all schools - second-level schools and, in many cases, primary level - in any area in the country, drugs are being foisted on students and pupils in a way that makes them impossible to avoid. Students will tell you they can have a ready supply any time they want. There should be no correlation between the illicit drug trade and methadone because methadone is deemed to wean the patient or addict off the drugs - detox for a start and then onward treatment in a way that leaves the patient less dependent on drugs. I have in recent times met many, mostly guys, who are willing to help themselves when they get the opportunity, but if we lead them into a situation whereby we put them on a programme now and it will be forever, that is not the way to deal with the serious and worsening drugs problem we have in this country. Eventually, we will be in a situation whereby a very large segment of the population will be unemployable or will be a burden on their families and themselves and the State forever. It is not necessary because there is the science and the technology and the medication there now to treat their particular addiction, whatever it is.

I have spoken about this many times before, and some people in the House do not agree with me on the matter, but there is a need to come down on one side or other. I live in a part of the country, as do many of our members at present, where drug barons are kingpins and they supply on demand anything the addict or would-be addict wants. If they do not have an addict in mind, they will soon create them because they create the problem by feeding the population with an appetite for drugs. Some people will say that alcohol is bad. I agree, but at least we do not treat alcoholism by giving the alcoholic a bottle of whiskey today and two bottles in a week's time or whatever the case may be. That is not treatment and we know that. For those who say drug addiction is different, it is not, and we need to recognise that.

We need to give the drug treatment centres greater recognition for the work that they do. I have seen the sparseness of some of their centres, including one in my constituency. They need sufficient funding and facilities to deal with the problem as presented to them. There is no good in us saying here that we have the facilities. We do not have facilities that are sufficiently geared to deal with the magnitude of the growing problem. Can that be emphasised in a particular way and could there be some follow-up action to it that we can at least see for ourselves?

On that point, many of the drug treatment centres are helping people to get access to medical services. I visited a number of centres. In one centre, for instance, a GP and nurses are going into the street and getting people into the centre for medical treatment. Many people who have had an adverse event in an accident and emergency department are now afraid of going to an accident and emergency department but need medical treatment. The facility I am talking about, which is in Limerick, is doing a lot of work with people who need that medical care.

In Cork, for instance, I know the HSE is providing medical support, both nurses and doctors, in some of the residential centres and night facilities that are available so that people in those institutions are getting access to medical treatment. We are working towards having a day centre to which people can come to access medical services. Many areas of the country have such a facility. We need to do more, but there is a co-ordinated approach being adopted by the drug treatment centres, the HSE and all the people in healthcare who are working in the communities. A lot of good work is being done. We need to grow that work. It is not just about dealing with the issue of drug addiction. It is also about dealing with other medical issues that arise. One of the housing bodies has identified an issue to me. It has got people through drug rehabilitation and people are no longer dependent on drugs but still require support. That body is providing housing. Those people now have new challenges. People as young as 40, as a result of their addiction problems, are now showing signs of dementia or Alzheimer's. That is a new challenge for that housing organisation. The issues are complex. It is important we have a good support team in place in every area to give support to deal with drug or alcohol addiction and to deal with other medical issues a person may have.

To pick up where I left off before I had to leave, regarding the handling of the budget going forward, the whole principle of the RHAs is that the area is to be profiled. There would be an allocation of funding based on established need, population size, socioeconomic profile and so on. I know there is a huge amount of work under way in the Department on that. We have not had a briefing since before the summer on that. It would be good to get one soon. Where are we with regard to building that objective resource allocation model? Is the Minister aware of where we are at? Is there going to be any change next year in terms of allocation to the regions? The idea of the RHAs is that there would be a single management team and a single budget and then there would be discretion to spend that budget where it makes the most sense locally, given the age profile, socioeconomic profile, etc. Are there transitionary arrangements for that? Are we going to see any changes next year?

We are going to see changes next year. The budget for next year will have a subheading for each of the six regions. We are moving to regional reporting, which is only one thing, but it is an important change in the system and in how everybody thinks about it. Work is ongoing on healthcare econometrics and what the demand is region by region. There will be adjustments over time on that. One area where we have already done it is on the 3,000-bed plan, in which the mid-west region will go from having the lowest number of beds per head of population to the second highest. When those 3,000 beds are rolled out, the regions will not be perfectly equal, but they will be pretty close. There is a very wide discrepancy there now. There is an ongoing discussion about the level of local autonomy, because there has to be some central direction as well, obviously. There is a level of local discretion, both at a hospital level and at a regional level. That will be an iterative process. Inevitably there will be things done there that work, and some things that do not work. It needs to be flexible. Ms McGirr can speak in terms of some more detail regarding the resource allocation as well if that is useful.

The regional executive officers have already been given that authority. It marks a substantial shift. I will give one example to illustrate it. The Wicklow town primary care centre urgently needs therapists. During the embargo, one of the major hospitals in the same region hired quite a number of staff. Not only did the hospital have no money and no sanction to hire those staff, it was explicitly told not to do so. The hospital went ahead and did it anyway. As I said to Martina Queally, regional executive officer for that region, she now has to have, and has probably started, a very difficult conversation with that hospital, telling the hospital it hired 80 or 90 people whom the hospital was told it was not allowed to hire. The Wicklow town primary care team is badly in need of people. It is easy for us to say it here. On the ground it is obviously very difficult, but it is already going exactly the way Deputy Shortall referred to. It is going to take some time, but it is going there.

I am seeing the structures changing. I would have always dealt with the head of older persons, the head of mental health and the head of disabilities across each area. They have changed now already. There is a new integrated healthcare area, IHA. Our area, which was CHO 5 and CHO 6 combined, is now called Dublin and South East. There are now three IHAs there and they have broken up the counties between them. I have seen it from dealing with something in my own area regarding mental health and a package that needed to be signed off, that it is the regional executive officer, Martina Queally in this case, who is making that final decision when there is significant funding there. It is already starting to roll out.

My understanding is that the role of chief officer will be gone very shortly as well. They will be doing another role within the pyramid structures. It is actually happening on the ground. There is a bit of getting used to the changes. From my perspective as Minister of State with responsibility for mental health, it is important to make sure mental health does not get kind of sidelined. It is important that it is front and centre within the structures. I have had that conversation with Bernard Gloster, and I will meet the various regional executive officers to have that conversation. One of the challenges is that when funding is specifically ring-fenced, such as for mental health posts, for example, there has to be discretion, but we also want to make sure that those posts are hard won at budget are allocated down to the six RHOs.

That is exactly the discussion that is ongoing in terms of the movement between community acute settings and care groups such as mental health and older persons. In terms of the budget, the budget for 2025 will be allocated in the same way we allocate it now, but a shadow budget will be done by regions. We will see what it looks likes on a regional level in preparation for the following year. There is also quite a lot of work going on in terms of the population-based resource allocation model, which I think is what is being talked about, in terms of expertise, the group on that and recommendations. That is being developed to be applied fully in 2026. It will be part of the shadow budget and how we look at it. We can give a written update if the Deputy wants to know where that is at.

It would be important to organise that. I will go back to the issue of nursing numbers. I am thinking specifically about community and public health nurses, who are vital, whether it is for older people, infants or others. There are major shortages there in terms of unfilled posts. Is anything being done to address that issue? Is anything being done to take it out of the rest of nursing and give priority to it, given its importance in the context of developmental tests and various checks which are not taking place at the moment? The other day I heard that parents in some areas are being told how to do the developmental checks themselves. In terms of prevention and early intervention, that just does not make any sense whatsoever.

I am taking it very seriously. We have had several debates in the Dáil on exactly this, which I think the Deputy might have been involved in. I wrote to the Chief Medical Officer recently to ask for a full review. There are certain areas, particularly in more disadvantaged communities, where they simply do not have enough staff. There are other areas where they are well resourced. It is simply not acceptable to tell parents, particularly when it is based on the average income of a community, to do the checks themselves. It is not acceptable. It is the inverse care law at work. In some cases, the communities that need it the most are not getting it. I have asked the Chief Medical Officer to engage across public health, in the first instance with a view to making sure we are getting the most out of what we have. If that means moving some nurses on a temporary basis, we have to do that. I funded an additional 25 public health nurse places in the budget. If the Chief Medical Officer comes back and says there is a need for additional resourcing, we can certainly look to reallocate within existing resources. I share the Deputy's concern in that regard.

It is the ultimate early intervention service. It is madness and very wrong if there are widespread vacancies. The presentation referred to facilitated access to hundreds of thousands of diagnostic scans for GP patients. Will the Minister clarify how that system works at the moment? I am hearing mixed views on it. In some cases, people are saying they can no longer go to a hospital for an MRI. What is the arrangement in terms of reimbursement for the private providers relative to hospitals doing the diagnostic testing?

The scheme is GP access to diagnostics. I will get the exact figure for the Deputy but I think it is approximately €46 million this year. It is very expensive.

It is brand new. We started it in 2021. It is very expensive but has been very popular with GPs. To be honest, it is probably one of the reasons we see such an increase in referrals to the outpatient lists because more people are being caught more quickly. The deal is that a person's GP can refer him or her for radiology, that is, for X-rays, CT, DEXA, MRI and ultrasound scans. I am sure there are more. It is a combination of hospital capacity - for example, some of the hospitals are doing them at the weekends - and private capacity.

Chair, can I have two minutes to discuss the drugs services? I will be very quick on this. There is a lot of concern across the board about community drugs task forces - local and regional drugs task forces. The allocation to them has more or less stayed static for several years. I think it is €4.2 million this year.

I gave the figures earlier. The drugs budget is €4.2 million and this is for new initiatives in the whole drugs area. The budget for 2025 will be €4.2 million in addition to what is in 2024. The total social inclusion budget is €40.5 million of an increase. It has increased from €220 million to €260 million.

There is €1.5 million additional funding for task forces. The funding will support a co-ordination role of 24 drugs and alcohol task forces across the country including the increased demand for services, especially for due to the use of cocaine. There is an increase but other initiatives are being started.

We are working on a number of projects. For instance, I am working on one project where we talk about transferring a whole lot of services out from night support facilities to a day centre. We are talking about doing that. As I outlined earlier, the supervised injection facility will open in December. There are a number-----

A point I want to make about the task forces is that increasingly they are aiming to be partners in the provision of community services, whether that is family support or bringing together education partners. The task forces are facilitating a lot of that joined-up thinking and activity to have a comprehensive response in areas where drug use is very prevalent. The task forces are saying they desperately need multi-annual funding because as part of the outreach work they are doing they are trying to employ therapists and other workers such as family support workers. It is very difficult to do that unless they can guarantee a medium-term contract. Now it is just annual funding and they do not know how they will be fixed the following year.

That is a fair point because I met someone else yesterday who is in a totally different area and again it is annual rather than multi-annual funding and it is something we need to look at. I have only been in the Department for the last six months and this is an issue that has come up in a number of cases and is something we need to look at, how we can make that decision about it being multi-annual funding. A lot of the contracts people are able to give then are only 12-month contracts, or six-month contracts in some cases.

On the same issue, it relates to the supplementary budget but the Minister of State spoke about additional money being put forward. It is a drop in the ocean. My local task force, which I have been a member of practically since it was established, looked for an additional €1 million-plus for the roll-out of services. That was for community engagement with young people who were at risk, and for additional services due to emerging trends. That is just one task force.

The Minister of State is talking about the additional funding across the country. It is a drop in the ocean. With the volume of drugs out there, we get a sense of it in our own communities. Where can one go that drugs are not being sold or consumed? There are very few places one can go in this city where drugs are not being sold. There is a normalisation of the drug scene. Many of those who are working in the services, the section 39 workers, have not had an increase since 2008. There is talk about that increase. Deputy Shortall talked about holding on to staff in order to hold on to management of the services. The funding is not there in terms of what has been allocated to them. Front-line services are losing staff to other services, the likes of the HSE and so on. That is the common theme. I hope that in a number of weeks' time, we will have the drugs task forces before the committee as well as the Minister of State but the funding is a drop in the ocean compared with the challenges they face out there.

There is the issue of nitrous oxide being consumed everywhere. One can see the canisters everywhere. They are like thermos flasks. One sees them at the side of the road, at beauty spots, on GAA pitches, in car parks, in shopping centres and elsewhere. That is the drug of choice. It is children - literally children of eight, nine or ten years of age - who are taking it. There is talk of possibly giving out balloons so the children will not burn their mouths or their lungs will not collapse. That is just one drug.

Drug intimidation is a huge issue across all of the task force areas. The Minister of State is only new to the job but the problem has been there for a number of years. The problem is getting worse. There is crack cocaine in many of our areas now. That was the big fear. Other drugs are coming down the track. We still have heroin users and cocaine users. If one talks to any of the hospitals, one hears of the challenges they face related to this and it is not just young people, people in their seventies are presenting at the weekends due to cocaine use. We will have the Minister of State at this committee in a number of weeks but there is a huge challenge. He has the support of the Oireachtas with regard to additional funding but we need to wake up to the reality facing our communities. Young people are dying because there is not enough support out there. Young people are committing suicide. Young people are being intimidated by drug dealers. These are young people who have to go to school. They are trying to get supports and services but there is drug dealing going on outside those services. There is a huge problem. We do not have time to deal with it this morning as we are dealing with a Supplementary Estimate but I hope we will have a session with the Minister of State to discuss the real problems facing out population out there.

I fully accept what the Chair is saying. For instance, with regard to the issue of intimidation the Garda has now appointed more than 30 inspectors throughout the country specifically to deal with the issue of intimidation. In my constituency people have come in to me who are being intimidated by drug dealers. We have appointed 30 Garda inspectors specifically to deal with that issue.

The growth of the illegal drug trade is huge and there is no question about that. There is the increase of the social inclusion budget of €40.5 million.

It is about doing a whole lot of different things and working with communities. One of the big complaints is the number of people who are staying in night shelters overnight and are back on the streets in the morning. It is about having the appropriate level of day centres to deal with them in which we can offer a whole lot of services. That is something we need to develop, as well as working with the HSE and the drug and alcohol addiction treatment facilities. A lot of good work is being done that we do not see in the newspapers or media. People have made huge commitments and are dedicated to delivering those services and giving that support.

Another interesting point is the number of people who have come through rehabilitation and are being employed by different agencies because they know what it is like to sleep on the streets and to be involved in drug addiction. Depaul Housing has employed a number of people who were addicted to drugs and living on the street but have since come through a programme and are now working with the organisation to help others. Take the example of someone who is addicted to drugs and is living on the street, and who has a medical appointment. Depaul Housing makes sure that such people keep their appointments and turn up on time so they can be assisted. It also helps people to get more stable accommodation. All of that is happening. A lot of good work is being done by a considerable number of agencies, as well as by the HSE and local authorities. The Deputy is right that we need to work towards a comprehensive programme in every area. We also need to get out the message. Someone made the point to me recently that we constantly talk about physical health and do not talk about brain health. If you drink excessively or take drugs, you are likely to suffer brain damage. We do not talk enough about that. Young people start experimenting with drugs and find, within a very short period of time, that they are addicted. The big challenge is trying to get them away from the addiction.