COMMITTEE OF PUBLIC ACCOUNTS debate -
Thursday, 24 Oct 2024

Apologies have been received from Deputy John Brady. As this is my first meeting as Cathaoirleach, I must make the following declaration in attend in accordance with Standing Order 104(3)(a). Dearbhaím go sollúnta go ndéanfaidh mé, go cuí agus go dílis agus a mhéid is eol agus is cumas dom, oifig Chathaoirleach an Choiste um Chuntais Phoiblí a fheidhmiú gan scáth gan fabhar, na rialacha mar atá siad leagtha síos ag an Teach seo a chur i bhfeidhm go cothrom neamhchlaonta, ord a choimeád agus cearta agus pribhléidí comhaltaí a chaomhnú de réir an Bhunreachta agus na mBuan-Orduithe.

All in attendance are very welcome. I remind those in attendance to ensure their mobile phones are in silent mode or switched off. I wish to explain some limitations to parliamentary privilege and the practice of the Houses as regards references witnesses may make to other persons in their evidence. The evidence of witnesses physically present or who give evidence from within the parliamentary precincts is protected, pursuant to both the Constitution and statute, by absolute privilege. This means they have an absolute defence against any defamation action for anything they say at the meeting. However, they are expected not to abuse this privilege and it is my duty as Cathaoirleach to ensure that this privilege is not abused. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members and witnesses are reminded of the long-standing parliamentary practice 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 that makes him or her identifiable. Members are also reminded of the provisions within Standing Order 218, that the committee shall refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policies.

The Comptroller and Auditor General, Mr. Seamus McCarthy, is a permanent witness to the committee. He is accompanied by Mr. John Crean, deputy director of the Office of the Comptroller and Auditor General.

This morning, we will engage with representatives from the Health Service Executive to examine the 2023 financial statements of the Health Service Executive and the Report on the Accounts of the Public Services 2023 - Chapter 17: The Health Service Executive’s integrated financial management system.

We are joined by the following representatives from the HSE agus go raibh míle maith acu as teacht os comhair an choiste. Is iad: Mr Bernard Gloster, chief executive officer; Mr. Stephen Mulvany, chief financial officer; Dr. Colm Henry, chief clinical officer; Ms Sandra Broderick, regional executive officer HSE Mid-West; and Dr. Andy Phillips, regional executive officer HSE South West. We are joined by the following officials from the Department of Health: Ms Louise McGirr, assistant secretary; and Mr. Patrick McGlynn, principal officer. Tá fáilte rompu ar fad.

I call the Comptroller and Auditor General, Mr. Seamus McCarthy, to make his opening statement.

The Health Service Executive’s financial statements for 2023 record total expenditure of €25.8 billion. This comprises capital spending of €1.1 billion and non-capital or recurrent spending of €24.7 billion. Some €21.8 billion of the HSE’s funding for 2023 was from the health Vote. Funding for specialist disability services of €2.7 billion was provided to the HSE by the Vote for the Department of Children, Equality, Disability, Integration and Youth. Other funding, including charges for treatment, amounted to €888 million.

Non-capital expenditure in 2023 exceeded income by €575 million and this deficit was carried forward to be met from the funding provided from the health Vote in 2024. On the capital side, there was a surplus of €68 million.

I issued a clear audit opinion in relation to the financial statements. However, in my report, I drew attention to a number of matters disclosed by the HSE. First, Covid-19 vaccines that had been acquired at a cost of €86.5 million were written off in the 2023 financial statements. The cumulative Covid-19 write-off to 31 December 2023 is €181 million, representing 40% of the total cost incurred on Covid-19 vaccines.

The HSE also held stocks of antigen tests that cost €12.5 million at year end which were expected to reach their expiry date before they could be used. In 2023, the HSE incurred storage costs amounting to €2.3 million in respect of stocks of obsolete personal protective equipment and hand gel.

Health insurance claims to the value of an estimated €3.5 million were rejected by a private health insurer during 2023 because HSE hospitals had not submitted the claims within the agreed timeframe. Separately, the HSE committed to refund €30 million to a private health insurer in respect of the application of private patient treatment charges in the past.

Once again, my audit report for 2023 draws attention to non-compliant procurement which remains a significant issue for the HSE. A self-assessment exercise carried out by the HSE estimated that non-compliant procurement in 2023 was around 12% but I consider that this figure may not accurately represent the scale of the underlying problem.

In 2023, the HSE provided non-capital grant funding of €6.8 billion to voluntary hospitals and community sector agencies. Even by the year end, only 83% of the funding issued to such agencies for 2023 was covered by a completed bilateral agreement of the appropriate type.

The statement on internal control discloses weaknesses around the control and management of fixed assets in the HSE. I refer in my report to audit findings of inconsistencies in the treatment of assets across the HSE, including some capital project costs not included on asset registers and assets no longer in use remaining on registers.

I once again drew attention in my report to the highest remunerated staff member who received almost €1 million in total remuneration in 2023.

This included almost €700,000 for treating patients outside normal hours, under non-standard contract terms.

Finally, I drew attention to a termination settlement in one case of €1.6 million. This included €1.4 million in compensation for loss of potential private earnings during the period while the individual was suspended.

Chapter 17 of my report on the accounts of the public services for 2023 reviews progress and costs to date in the roll-out by the HSE of an integrated financial management and procurement system, IFMS. Once fully deployed, the IFMS will replace multiple legacy financial management systems in use in the HSE and in other in scope health bodies. The chapter also looks at how the IFMS has or will impact on the HSE's financial and other reporting processes, including HSE reporting to the Department of Health and production of the annual financial statements. The HSE submitted a detailed ICT business case for the IFMS to the Department in May 2015. The proposed project budget at the time was €82 million for capital and once-off costs and €50 million in recurrent spending for system support over an 11-year period. In late 2022, the HSE informed the Department that additional capital funding would be required, probably from around 2026, to complete the roll-out of the IFMS as the previously approved €82 million did not include VAT and was based on pre-tender estimates.

The 2015 business plan envisaged that the phased roll-out of the IFMS would commence in 2017 and would be fully rolled out in the HSE and the other in-scope health bodies by 2020. However, the IFMS only went live for the first phase implementation group in July 2023. Additional funding was provided in the health Vote for 2024 to accelerate the project. The HSE now plans to complete the roll-out of the system across the HSE in two phases, to be completed in 2025, with work on the roll-out to other health bodies to commence thereafter. By the end of June 2024, the HSE had recorded that a total of around €136 million had been incurred on the IFMS project, of which €60.2 million related to capital costs, €50.75 million for IFMS project in-house current expenditure, and €24.8 million in current software and operating costs. The full budget required to complete the deployment of the IFMS to the rest of the HSE and to the in scope health bodies has yet to be developed by the HSE.

Good morning. I thank the committee for the invitation to discuss the HSE financial statements for 2023. I have noted in the invitation the specific reference to the requests to focus on the roll-out of IFMS, non-compliant procurement, staffing and remuneration, and capacity at University Hospital Limerick and the University of Limerick Hospitals Group. I am joined by my colleagues, who have already been introduced by the Chair, and I am supported by Sara Maxwell from my office.

The financial details of the HSE for the year 2023 are set out in the annual report and financial statements. In a service context, using those resources, 2023 saw unprecedented levels of demand for almost all health and social care services. Despite growth in key demand areas of scheduled and unscheduled care, the second half of 2023 saw significant improvements in waiting times and waiting numbers in scheduled care, and also in the emergency department trolley position, which is unscheduled care. I am pleased to be able to report to the committee that in 2024, despite continued additional growth in demand, with outpatient department scheduled care demand being up by 7.5% and unscheduled care emergency department attendances being up by 8.4% in the year to date to the end of September compared with the same period last year, we have continued to see reductions in waiting times and trolleys compared with 2023. We remain challenged in a number of sites for unscheduled care and this continues to be a priority for the whole of the HSE.

Members will be familiar with the improving financial position as set out prior to the summer economic statement and budget 2025. This is the first year when we have had early sight of our in-year closing cash position and our existing level of service position for next year. The cash management of the organisation is now more clearly set out and aligned to planned expenditure than it has been for some time. The focus of the pay and numbers strategy has resulted in a better control environment and the 2023 moratorium has ended with no future requirement for this type of blanket measure. In non-pay control, we have a plan in place until the end of 2025 to achieve better value and efficiency from the significant resources we have. Managing the variables of demand and inflation requires a clear plan that is comprised of new resource, productivity and control. I am satisfied we have progress in all of these three fronts.

I will address the integrated financial management system, IFMS. Replacing fragmented and outdated systems has long been talked about in the HSE, since its foundation. Clear benefits can be achieved by using a single national modern system. These benefits include better and more timely financial reporting and forecasting, improved financial management, governance, compliance and transparency and better overall financial control. IFMS went live on schedule in July 2023 in what is referred to as implementation group 1, which includes the HSE in the east, the HSE nationally, in corporate and national services, the primary care reimbursement service, and Tusla, the Child and Family Agency, to which we continue to provide financial services. Roll-out of the solution to the remainder is under way with go-live scheduled for 1 April 2025 and 1 July 2025, respectively, in two tranches, at which point all HSE expenditure, which is about 80% of the total health budget, will be transacted on IFMS. Implementation to voluntary organisations in scope, which are predominantly section 38 agencies, will follow subject to further planning. That is anticipated to go live potentially from 2026 onwards. That latter point requires further discussion with those organisations and the Government.

I am advised that while still on track to achieve the planned go-live dates for the two tranches in 2025, some challenges have been encountered. The project is currently reported as behind schedule but at a minor level. By way of external oversight, the Comptroller and Auditor General published chapter 17 of his report which relates to the HSE's IFMS. The Comptroller and Auditor General noted this in his opening statement. The chapter notes the challenges experienced by the HSE in relation to the first go-live phase and the measures undertaken by the HSE, which are factored into the roadmap for the rest. I consider it helpful that the committee has asked the HSE to provide it with a quarterly update on the progress of the IFMS project and the HSE is happy to commit to same.

On compliance with procurement rules, HSE procurement estimates addressable current expenditure of approximately €4.9 billion in respect of goods and services that are subject to procurement regulations. The HSE is required to report on compliance in accordance with the requirements of the revised Code of Practice for the Governance of State Bodies. The HSE's statement of internal control acknowledges the challenges in respect of its monitoring and reporting of non-compliance, but equally it reflects the significant work that is progressing to improve this reporting. Prior to 2020, the HSE was not in a position to report annually on procurement non-compliance. In 2020, the HSE introduced an internal self-assessment process, which has been conducted on a quarterly basis since 2022. This self-assessment incorporates a review of all invoices greater than €25,000, which represents 38% of the estimated procurable expenditure for 2023. This assessment indicates a compliance level in the order of 88%. The current up-to-date estimate at the end of quarter 2 2024 puts it at 90%.

The HSE has acknowledged in the 2023 statement of control that not all expenditure is assessed in this context, which is a limitation. The HSE’s corporate procurement plan details the efforts under way to improve compliance. Spend under management, where contracts or frameworks with all of the terms agreed are in place, is an important driver of compliance. Our corporate procurement plan included a target to have 75% of spend under management for 2023, which was achieved. It is currently 82.7%, indicating that we are on track to achieve 85% by the end of 2024.

The implementation of IFMS, which I have mentioned, will make further improvements to this.

Staffing in the HSE continues to be at its highest in the history of the services. In 2023, a pause aimed at slowing down the growth in unfunded workforce was introduced. Despite this, the HSE and section 38 partners recruited 8,000 net extra whole-time equivalent, WTE, staff in that year against a funded level of 6,000. At the end of August 2024, there were 147,714 whole-time equivalents occupied by 166,000 people. The WTE growth is 23.3% since December 2019. When adjusted to exclude certain categories such as students, it is 21.9% up on the same period. Remuneration and the rules pertaining to it are set externally to the HSE by the Department of public expenditure. Pay scales and the new consultant contract will contribute to the number of higher earners over time. However, the primary concern of the organisation, and I believe this committee, will be the reference in the Comptroller and Auditor General's report and the HSE’s own financial statements regarding those ten employees paid in excess of €500,000 in 2023. It is clear that there is a contractual provision for consultants in respect of call outs that can lead to payments. In my assessment, these were never intended to accumulate to the level that they have, even where there may be a shortage of consultants to provide services. The majority of very hard-working staff, including consultants, who provide on call services do not come into this category of earning.

I am very conscious of the significant and ongoing commentary in respect of University Hospital Limerick, UHL, and the overall provision of emergency care in the mid-west region. There are important balancing factors on the commentary regarding services in the region. I have been clear in my public statements on the issues of capacity, pace of reform, process, best use of resources and the important issue of errors and failures. Where warranted, I have been unequivocal in some of the more difficult issues there. However, again, I stress that there are many positive aspects and strengths to the services in UHL. It is of concern to me that this balance often loses out to an either-or "good or bad" discourse. I pay tribute to our many fine staff in our hospitals and services in the mid-west, who come to work to care for the public every day. We are absolutely determined to overcome the challenges that are experienced there, particularly at the point of emergency access to service. There is now in place a strong programme board under the direction of the regional executive officer, Sandra Broderick, who is here today, bringing together all of our capability. In the coming months, we will see more beds in addition to what has been added, more staff in addition to the growth of more than 1,000 in recent years and more options for people to pursue their care needs, all of which will be underpinned by excellence in leadership and governance. Capacity at UHL will continue to be expanded and we will await and work with government on the outcome of the HIQA review of emergency department capacity in the region.

This January, the HSE approaches the 20-year mark of its foundation. In 2023 and 2024, we have put in place the long-awaited Sláintecare structures, improved governance and transparency, delivered the highest levels of service ever and we have record resources. We also have unprecedented demand. I am very conscious that for many people today we still have more improvements to make to either restore or build their confidence. I assure the committee of the absolute focus of the board and leadership of the HSE in that continuous improvement.

I congratulate Deputy Farrell on assuming the role of Chair of the Committee of Public Accounts. I think she will be excellent, and I wish her every success.

I thank our witnesses for joining us this morning for what I hope will be an enlightening and helpful discussion on how manage the significant resources that we invest in our health service on the part of our taxpayers. I also thank them for the work they do every day in an exceptionally challenging environment.

To start, I will tell two stories, both of which are interactions with the health service in this country. From those interactions, I will give my suggestions as to how we could and should make it much better. In July 2021, to be frank, a driver ran over me in Moycullen just outside Galway city. I suffered a serious injury to my leg. I was taken immediately by ambulance to University Hospital Galway, UHG, and I received world-class care from the surgeons, clinicians, nursing staff and physiotherapy staff there. I have recovered to an excellent extent as a result of the expert, kind and supportive care but in the post-operative phase of that experience, I had to attend the orthopaedic clinic in Merlin Park on four or five occasions. I had to meet the surgeon and see how progress was going. First, I got a letter in the post each time, which stated when my appointment was. I then walked into the orthopaedic centre in Merlin Park, queued up at the lovely little reception area and eventually a very helpful member of staff rolled back the glass window and asked my name. I handed in the letter and the staff member fumbled about in a filing cabinet and my file was taken out. The very helpful person wrote a note on a piece of paper, handed it to me and instructed me to walk across the campus from there to the X-ray clinic in Merlin Park, at which point another person rolled back another glass screen. I handed the person the piece of paper, who handed me another piece of paper and told me to queue for the X-ray, which did not take long and was an exceptionally efficient part of the service. The result of that X-ray was sent electronically back to the orthopaedic clinic, and I walked across the campus and waited in the queue for my interaction. I received very supportive advice from my surgeon, and indeed the physiotherapist, and then I went home. Approximately three weeks later, another letter would arrive in the post and the whole process of slips of paper and walking over and back in Merlin Park would reoccur. That was one interaction.

A previous interaction was when a close member of my family was diagnosed with cancer. Thankfully, she is now fully recovered, again as a result of the world-class expert care provided by our clinicians and nurses in our health system. She became violently ill five times during the chemotherapy regime. Each time she did, I travelled with her into UHG. We had to present at the emergency department. There was no other way of accessing the oncology service other than to go through the emergency department, which I question in terms of the person's compromised immunity as a result of the chemotherapy, but in we went. The person at the little front desk rolled back the glass window and asked for her name, address and PPS number, all of which was taken down. We then sat for two, three, four, sometimes five hours in the emergency department, awaiting assessment, only to be told she was being referred to the oncology department, which was in the same building on the third floor. We then got into a lift, went up to the oncology department and presented at another desk. On the first occasion, just as this was happening, the very helpful woman behind the desk asked for the details. Halfway through the process of this information being handed over, I questioned the person behind the desk and told her that we gave this information four hours ago downstairs. She told me they use a different computer system. This is the same building, the same patient and on the same day. She had to give all of her personal information, which she did not have a problem doing, to be input into two different computer systems working and operating within the same building. That happened each time on the five occasions in the subsequent months. She had to give that information over and over again.

We have a fundamental problem in this country with how we manage our patients' health records and how we have studiously avoided the use of technology for many years in making our health system much more efficient, more cost-effective and safer in how we care for and interact with our patients. We had at one point, not very long ago, a world-renowned expert in patient management, Professor Martin Curley, and the establishment of a patient electronic health record system. He lasted a year in the role.

He resigned in early 2023 out of sheer frustration from his experience of not alone an inability to reform or innovate, but an absolute opposition to reform or innovate how we use technology in the management of our interaction with our population and people every day.

I am also a patient of my local GP and dentist. As most people do, I have had several interactions with them during the past year or two. Every time I do that, I get a message on my phone stating that my appointment with Dr. X is next Friday at 10.30 a.m., for example. I go to Dr. X. It is a great service. When Dr. X opens his computer, he can see every single interaction he has had with me for the past 15 years. I know that because I asked him. Every other GP operating in that practice has access to that exact same service. When I leave that building, Dr. X sends my prescription electronically to my chosen pharmacy. The same happens when I interact with my dentist. Again, it is all done electronically, and it is very efficient and time effective.

When Martin Curley left the HSE, he said that he thought "he had died and gone to hell". When he began working with the HSE, he said: "I think we can safely say many people have died, many people have had extended stays in ... circumstances because the doctors and nurses don’t have access to the information they need [at their fingertips] to make the right decision." Countries such as Denmark, Estonia, Finland and, increasingly, Spain, figured this out a very long time ago. We position ourselves internationally, rightly so, as being leading edge when it comes to innovation and technology. That is why some of the world's foremost technology companies base themselves here. Why has our national health service yet to figure out how to do something that most other countries of similar resources and expertise have done a very long time ago? I would like somebody to tell me why that is the case.

I thank the Deputy. I do not propose to disagree with his observation that we are so far behind the curve on this, and have been for many years. There is no point in me attempting to dispute that. We could go into lots of analysis as to why that is. I am sure it would cross everything from culture to resistance to money and lots of things. We all, as healthcare professionals and providers of State services, share a responsibility in that.

We have some increasing advances, thankfully. The new digital framework for healthcare, which the Government agreed this year, is credible and comprehensive. Rather than expect the country to wait for the entire full EHR to be everywhere, which is really something that will take several years, we have committed to producing the first nationwide patient app at the end of this year and from that start to build a patient summary record. It will take a bit of time to build up all of the records that are potentially available for somebody.

We also have some discrete projects going on, about which I previously advised the committee. The new children's hospital, despite all of its challenges, will be the first completely all-digital hospital. St. James's Hospital has a good EHR system. The Mater has one but it is coming to end of life; we will focus on the priority of that. We will go by the six regions to build up the EHR but, as I said, rather than waiting for a big bang, four of the maternity hospitals, for example, are now completing the implementation of EHR. All of the maternity network will be done next year. All of the palliative care network will be done after that. We are building it.

The GPs' own systems are quite good and the interfaces with ours are not bad. I will not convince the Deputy that they are anywhere near where we want them to be. We have previously done very good records on the introduction of the national imaging system, which is quite successful. I do not want to be disparaging of anybody, but our problem in the past was that we allowed for too much opt-in or opt-out of what are and should be national mandated positions. I really feel, as a health system on behalf of the people, that whoever we fund, whether it is our own hospitals or section 38 hospitals, the simple reality is everybody will have to accept decisions will be made and implemented consistently or we will not continue to fund them. That is the approach that will be taken to it.

As I said, the critical thing for me was not to wait for the big bang at the end, which will probably outlive my career, but to start with real, nationwide, comprehensive measures. The patient app is a very good start to that. I look forward to people seeing that in the coming weeks.

It is closer to 700. That is right across hardware, digital and networking because our system was obviously very old. Quite a bit has gone into that. Within that, there is a digital team and a digital focus. This year, I appointed a full-time chief technology and transformation officer. We have just appointed - in fact, he is just starting this week - a chief information security officer, which has been a huge challenge. The fallout from the cyberattack made it very obvious what that was. Where we do not have the capability, because digital projects require very specific capability, we partner with the bigger firms who do EHR. There are two or three big providers of EHR across the world. We partner with those on a procured basis for the different provisions that we have.

I am not in any doubt that the majority of the capability and structure of our approach to digital, and our resourcing of it, is unrecognisable from what it was before I came into this job, when I left the HSE a few years ago to go to Tusla. It is now unrecognisable, largely due to colleagues over the three years of Covid. The Deputy saw some of the innovations that were done during Covid. For all of the slagging that was done, the app-----

Have the people who are leading that change in that unit of 700 people ever contemplated visiting places such as Denmark - maybe they already have - which is not dissimilar to us in terms of its demographics and population? Estonia is a very small, agile country that has been doing extraordinary things in the use of technology for how a citizen interacts with the state. Have we visited these places? Have we studied how they have done this? It is complex but it is not rocket science. Countries such as Spain, particularly in some regional areas, are leading the way in how a patient can carry a card that literally moves with them throughout the whole system. All the records move with the patient throughout the system.

When I was a junior Minister in the Department of Education a very long time ago, I was asked to go to an ehealth conference in Boston. Two people from the Spanish health system were there, and this was in 2012, describing how they were going to completely transform their health system, and they are doing it. Is it the case right now that the HSE does not have the resources and expertise? Is it the case, as we are led to believe by people who have immersed themselves and then withdrawn very quickly, including Martin Curley and others, that there is massive opposition to the kind of cultural change required to adopt a system like this?

In fairness to Professor Curley, he departed just before I came. I hope my arrival was not anything to do with that. I know Martin and have met him since. I will not comment on his departure. Traditionally, we would be planning for next year. We have a capital and ICT budget. The ICT budget was predominantly about buying computers and hardware. We now have, increasingly year-on-year, a digital budget with proper allocation for digital technology, digital expertise and digital implementation. Ms McGirr, who is in charge of the resourcing in the Department, will be very clear that is our increasing focus.

We also do international peer collaboration.

We will start by building it up by the networks and then we will plug all the networks into one another rather than trying to do it all at once. This is why the maternity facet is being done and so on. What will bring much more benefit in the meantime will be the summary records we will build up about people and the app. This will give people much more control. We know, for example, that people are much more likely to attend appointments or to cancel and not be DNA if they are on an app and their appointments are app-based. It is as simple as that. We are building it and in seven years' time we will be at a current-state EHR system. Our problem then will be the retrospective element, because the question will be how far to go back to load everyone's records. We have millions of them.

I acknowledge the Cathaoirleach's new position. I have no doubt but that she will continue the good work of the previous Chair in chairing this committee and doing it in a cross-party way. Our work in this committee is very important, but so is the way we do our work. It is important and different from other committees. I acknowledge this point.

I thank Mr. Gloster and all the team for being with us today. Before I go to my line of questioning, I will comment on something Deputy Cannon said. The quality of data held about people also improves the quality of the interactions that people have. It is not all just about medical outcomes. As we all are now, I was out knocking on a door in Beaumont three weeks ago. I was chatting away with a lady. She had received a letter from Beaumont Hospital regarding the neurology outpatient and an appointment for her husband. It asked if the outpatient appointment was still required. Extremely sadly and unfortunately, her husband had passed away 11 years earlier.

Look, we all have databases and we have all sent emails where the data might not have been correct. Whatever infrastructure or architecture, though, is being put in place around this context, we must also be very cognisant about tying in data around people passing away. This has such an impact on people. Even getting a letter regarding the voter register can really set people back in their grief and so on. As the HSE, then, is building this system, I ask that it would fold in the available data. I know this can come from different sources. I do not say this to criticise Beaumont Hospital. The question that did arise for me was how much of our outpatient waiting lists would be in this category of inactive activity, if we wish to put it in this way. Has the HSE done an audit or any sort of deep dive concerning our outpatient lists?

"Validating the waiting lists" was a very famous phrase used some years ago. Every couple of years, the list would be built up and then there would be pressure on the system to respond to it. A validation exercise would take place and the result would be to get exactly what that lady saw in respect of Beaumont. I shudder every time I think we go to conduct an exercise of that kind that we will write a letter to even one person who is deceased. In 2024, we should be better than that. There is no point in me even trying to explain that.

We are now less likely to do it for the following reasons. In the last year and half, we have concentrated on the time people have been waiting on waiting lists. We have reduced the majority of long waiters and by serious numbers. If we go across the whole waiting list, we come up with the average waiting time. It was ten months and now it is 7.1 months. I am very confident that it will go below seven months. About 16,000 people, though, are still in the category of being very long waiters. This is for lots of reasons.

This year alone, we have taken off 5% more people than we took off last year. We are seeing people, but more people are coming on. That is a different issue, however. The reason I am saying it is less likely that what was referred to will happen now is because by this time next year, 50% of people will be inside the Sláintecare timeframe, which is only weeks.

Some 50% of people will be inside the Sláintecare waiting time by next year, which is only weeks. The point I am making, however, is that the shorter the time people are on the waiting list, the less likelihood there will be for a validation exercise of that type being required and therefore the less the likelihood of a letter of that type arriving to anyone. Could I promise that did not happen somewhere today? I could not.

I am very much cognisant of the volume of money associated with this hearing. We are talking about €23.5 billion. Many Government Departments could be folded into that figure. In 2019, the figure was €16 billion. Essentially, there has been a 46% increase in the funding of the HSE over the past four years, that is, the lifetime of this Government. In 60 seconds, can Mr. Gloster tell us what we are getting for this 46% increase?

Yes. To go back to the waiting lists for a second, just to give an idea of the quantum we are talking about, as of 10 October, which is, effectively, right up to date at week 41, the total number of patients waiting for acute hospital care was 702,000 people. This is just 33,000 behind target, which in the context of the volume is quite low. In that time, what we have done is if people are on an outpatient waiting list, the weighted average waiting time is down to seven months. If people are on an inpatient waiting list, the time has come down to 6.6 weeks. For people on a scope list, the waiting time has come down to three months.

Fundamentally, what we are getting is a far higher volume of people being seen and treated. A major exercise was done in the health service in 2018 called the capacity review and it projected out to 2031. What I have been saying to everyone for the last year is that the activity we are doing this year means that 2031 is here already. The demographic demand is enormous. We have not been able to predict for the last two years the number of people who will be coming onto our outpatient waiting lists because they are growing by such a rate. What we are getting, then, is a higher and faster level of service. I would argue that, fundamentally, when we look at this in the round, there has been a major improvement in the quality of outcomes for people. If we look at the quality of outcomes in Irish healthcare, it will be seen that, despite our problems with access, they are right up there at the top of the EU 27. This is what we get for the money.

I would love to explore that point more but I just do not have the time. Turning to the non-compliant procurement, this is the first thing we look at in this committee. The HSE estimated that the total expenditure on goods and services subject to procurement rules was €4.2 billion. Again, this amount is multiples of an entire Government Department in some cases. The idea that anywhere close to 12%, and I think there is a big question around this figure, of this amount is non-compliant is highly significant. Serious questions must also be asked in the context of the self-assessed project that was done. These include the level of co-operation with it and the lack of data on who procured documents, etc. Perhaps Mr. Gloster could talk us through this aspect a little and what is being done in this area, because it is particularly concerning.

I thank the Deputy. Procurement is clearly a significant challenge for the HSE. It is one we have been working on for some time. We estimate that the addressable spending, in other words what is subject to procurement rules, for this year is more like €4.9 billion. Obviously, the figure goes up every year. We are trying to do two things. First, we are trying to increase the number of contracts and frameworks in place that make it easier for people to comply. This gives us a competitive procurement base. As the CEO said in the opening statement, we had about 75% last year, which meant we hit the target of getting about 75% of that addressable spending covered by contracts and frameworks. Now, we only count contracts and frameworks where all the terms are complete. In other words, it would be possible to state the price is settled and just issue an order. We have another 5% or 6% where we have frameworks in place but where an element of competition or mini-competition is still required. This year, therefore, we are trying to move on and drive this figure up from 75% from the end of last year up to 85%. As we said, we are on track to get there.

The figure of 12% includes those who did not respond. There are two big areas where we have technical challenges around responding and they make up about a third of that non-response. We count the non-responses as non-compliant. We accept the point of the C and AG that this is a sample of just under 40% of our total spend because we look at overpayments over €25,000. That means looking at approximately 8,000 or 9,000 invoices a year. We have gone from an annual process that we could not do before 2020 to one we started doing in 2020. It is now a quarterly process since 2022. Every quarter, we do a retrospective self-assessment. It is not completely self-assessment. It is a guided self-assessment and there is an external validation of a random sample which has high-----

Just to return to that point, Mr. Mulvany is saying the figure of 12% does include the 13% of invoices within the scope of the exercise where either the manager responsible could not be identified or where the manager failed to respond to the exercise. He is saying that 13% is deemed non-compliant and is included in the 12%.

I can give the Cathaoirleach the exact figure but more than 90% was confirmed as valid. Actually, when they looked at colleagues who may have declared something as non-compliant, in some cases the external validation said they were compliant. In some cases people are overly cautious in saying something was non-compliant.

Okay. It is just clearly an issue of concern when it is under 40% of what is actually being assessed and then there is also the amount that is not assessed.

I will bring in the next speaker.

We agree that it is a limitation that it is a 40% sample. The issue is volume. Our intent, as we roll out the integrated financial management and procurement system, IFMS, is to move from a manual retrospective self-assessment to one that over the coming years will be more automated and will be able to go to progressively lower levels of value.

I thank the Cathaoirleach and wish her the best of luck. She will be a fantastic Chair. I welcome everyone, particularly those who have been appointed in the last period of time. Best of luck to them. We need them all to be successful so I hope that they will be. I welcome those who have been around for a while as well. In fairness to the CEO, one thing about Mr. Gloster is that his frankness is refreshing. Whether you agree or disagree with him, what he says, he means. The frankness is refreshing.

Deputy Cannon was fantastic earlier. He took the time to explain something that has been bugging me for years. I have raised this thing for a decade about ehealth. In a previous life, for both Bord Fáilte and Fáilte Ireland, I was tasked with building the national tourism database. I would love somebody in the next Government to be appointed within Government as a junior Minister for ehealth and to take it over.

I have spoken publicly about my own father being in the UHL Nenagh unit. He is into his fifth week there. I will be going to see him later. On the day he was admitted I happened to be in Dublin and I got a call from the emergency department going through all his history, which I gave. I will never forget it. I had to leave my phone on during the night because of the situation. At 3.37 in the morning I got a phone call from another doctor in the hospital asking me the exact same thing. I am not saying that is anyone's fault. That is what is there. Over the past four odd weeks, I have had eight calls from doctors where I tell them the exact same thing, except I keep adding on to it because of my father's situation. I have written in down in a note and I keep it with me. I add on things all the time because he has had different issues and I have to explain the imaging on the scans and all of that. We have a real problem. From an efficiency point of view, I do not need to tell the witnesses that this is causing such inefficiencies. It creates such costs and, without a shadow of a doubt, it affects outcomes. We need to address it. I saw the table and I respect the outcomes in our health system. They are quite good. I do not want to dwell on that but I wanted to add my personal experience to what Deputy Cannon said, because it was excellent.

I have limited time but I have an issue with the whole mid-west and UHL. I am not going to get into the Aoife Johnston reports and all of that. We are in desperate need of a decision about a model 3 hospital. I refer to the reconfiguration and all of that. I have a sign on the Hanly report up my office which predates my time in politics where I campaigned against it. I accept that the care, once people get into the system, is good. I listed off nurses, doctors, medical attendants in Limerick and Nenagh in the Dáil yesterday who were fantastic. They were incredible, brilliant. As I am sitting here, I am thinking of Ray who is the healthcare attendant in UHL who is probably looking after my father as I speak. However, we have an issue. We also have a narrative problem which can have counterproductive outcomes. I really encourage and ask the HSE, in fact I am begging it, to engage in a campaign in the mid-west to the public about the services that are available and how people should attend. In some cases, they are not attending. I have said publicly I had to get my father to attend. I do not want to get into it because I will get emotional but I had to get my father to attend. Will the HSE please engage in that? The MAUs have vacancies in the evenings and at weekends. That would stop people from ending up in accident and emergency departments. Will the witnesses engage and please put some campaign and thought towards all the services and into encouraging people to attend? People have to and should attend, as bad as the narrative and the situation is and all the problems. Will they do that?

They provide outstanding care once you get past that overcrowded emergency department. I also agree with the Deputy that we need to engage in a campaign because I am concerned that people are delaying coming to the emergency department. We have a wonderful patient advocate who is working with us. We have been out and doing media interviews together. We have been encouraging people to come to the emergency department. They will be seen, they will be treated and they will looked after. Yes, there will be delays in getting from the emergency department up into the ward but they will be looked after. We have a lot to do in getting the public to rebuild their confidence in us as a hospital. We are doing that. We are trying to reach out to people all the time.

In respect of the MAUs, just yesterday the regional clinical director, Dr. Catherine Peters, and the IHA manager, Maria Bridgeman, met the GP leads to explain the extending MAU hours. The Deputy is right. In Nenagh, we are not seeing the increased number of referrals but we are in Ennis. We are getting huge volumes in Ennis but not in Nenagh. They are due to meet with the GP leads again, I think in two weeks' time. That will be really important because if we do not see the uptake of those appointments-----

I could not agree with the Deputy more. There are two issues. First, part of the narrative problem since Christmas is what people choose to take out of what we are saying. I have done many radio interviews talking about very difficult subject matters in Limerick and all of the time underpinning that by the fact that that is my local hospital, that is where I go and if people need emergency care, they should go there and they will be cared for. I attempted this year to issue a statement when I felt people were making correlations between outcomes in one case and another that are not appropriate or well informed. I could not agree more with the Deputy and, yes, I will take very much to heart what has been said.

Mr. Gloster will see my questions coming from a mile away because I have asked them twice this week. When will the 96-bed block be opened? Through accident or misspeaking, as he said yesterday, I take Mr. Gloster at his word. I see it. I have been inside in UHL for more than a month. I have actually seen floors go up since I was in there. They are flying it and I accept that. What date and what month will the block be opened? Broadly speaking I am not going to, to use Mr. Gloster's phrase, hang him on it.

Second, I presume, and it is one thing on which I fundamentally disagree with Mr. Gloster, the famous nursing home in Nenagh, for which I fought very hard, will be opened in correlation with that. I think that the REO has committed to that.

We are on target with construction for the facility, which is the update from the HSE capital and estates.  We have commenced recruitment. We are in stage 2 of the process in respect of getting staff. All going to plan, which is on track, we should have the facility opened by the end of June 2025. That is the plan. I am 100% committed to handing the-----

The MAUs will first move to midnight. Depending on the success of getting the GP community, doctors and staff to use the uptake on that, we are happy to go beyond that but we want to see that there is an appetite to use the service, because, as the Deputy will appreciate, the worst thing we could do is have an open service not working.

I ask that because, as Mr. Gloster will know, it is contract staff rather than full-time staff.

An issue jumped out at me from the report. How can one consultant be paid 24 hours pay for one hour's work? I know from looking at Mr. Gloster that he is as shocked as I am about this. A consultant was paid 24 hours pay and is paid nearly €1 million a year. The example being given is that for one hour, presuming that four patients are seen, a consultant is paid a premium of six hours pay, which equates to 24 hours pay in one hour. Has the practice been discontinued? How did it happen? Are there other instances where contracts like that are in place? I ask these questions because such a practice is insane.

Unfortunately, it is a contractual provision and the contract is still there.

Second, has it reduced this year? Yes. It is reduced two ways. One, we have added to the consultants in the particular unit where that person was working. Second, they have changed the rostering arrangements. That particular earner has not featured yet in the highest earnings this year, which is positive, but I will not make a promise until I see what the end-of-year outturn looks like.

Go raibh maith agat, an Teachta Kelly. We have heard two personal experiences today and they have been very powerful. We wish the Deputy's father a very speedy recovery. It is very difficult for people watching and listening to hear that, despite their own personal experiences and difficulties within the healthcare system and accessing healthcare, that one consultant would be paid such an extraordinary amount. It is mind-boggling and something that we should not tolerate long term.

An Teachta Catherine Murphy, an chéad chainteoir eile.

Yes. The hours went up in 2013 and the hours went down following the change last year. They net each other off in how the hours are counted, yes. I am very satisfied that the WTE counting is accurate and correct. The INMO has raised this issue with me. I have had the WTE accounting looked to make sure that it is fair, balanced and takes account of the same approach that was applied when the hours went up as it does to when the hours went down.

There would not be a shared agreement among us that that figure is the figure we would believe because the growth of nursing over the past four years has been the highest, in terms of actual WTE number growth. The WTE in December 2019 was 119,800. The WTE in December 2023 was 145,900. As I said, the WTE in August this year was 147,714.

I, too, picked up on the overtime payment and wonder how it happened. During a weekend night call-out in 2023, the employee was paid a rate of six hours' pay per patient for each of the four patients treated in a single period of 60 minutes. That same point was made by Deputy Kelly. It cost in excess of €2,800 for the call, which is an extraordinary amount. I can see the HSE's methodology in dealing with that by going after the areas where this occurs. As acknowledged earlier, when a person has any engagement with a hospital, he or she will see consultants there morning, afternoon and evening. I also understand that the vast majority of staff work very hard. Mr. Gloster said that the payment was not intended to be made in this way even though it is within the contract. Is there any way to challenge the contract or paying per patient as opposed for the time? I ask that because there seems to be a real flaw in the contract.

I will let the officials from Department talk about that in the context of the new contract. Ms McGirr was part of the team that negotiated it. Before I do so, I want to be unequivocally clear about what I was pointing to in my opening statement. I do not think it was even extraordinary. It was abhorrent that somebody's contractual provision, which might be legally, technically correct, is interpreted to that level of application where four patients would be seen in less than 60 minutes and each would attract the six-hour payment the contract allows for when someone comes in, off their rest day, on call. In terms of the new contract, which is fundamentally the way of dealing with those issues, Ms McGirr may want to comment.

In the new contract, there are new limits, as there are in most contracts, in respect of on-call duties. A consultant can have up to €40,000 in total for the year in the context of being on call. Issues around compensatory rest are involved in this particular case. Where consultants are working on a very challenging rota of 1:1 or 1:2, they will get compensatory rest for time off, and there are issues with how that is being applied.

The overall solution is the significant increase in the number of consultants. This really reduces the amount of intensive rostering that allows for additional payments for compensatory rest. On call is limited. On-call duties should be reduced through the new contract because the core hours of the contract are from 8 a.m. until 10 p.m. and over weekends. We now have well over 4,500 consultants in the system, and with that growth they should be rostered around times that mean the need to be on call as a reliance for the provision of service is really reduced. I know the HSE has done a great deal of work on looking at that reduction of those 1:1 rosters. They should not be in place anywhere. That is the solution.

The entitlement under the contract is that if a consultant is called in from home, having been on call, to see one or more patients on a weekday before midnight, they are entitled to a two-hour compensatory rest period, and if they do not get to take that within a period, they are entitled to payment for it. They have to do the call-out, claim it and not be able to take it for operational reasons, and then they get a payment in lieu of those compensatory rest days. If that is after midnight during the week, it is three hours, and if it is at the weekend, the two hours becomes four or the three becomes six.

The second item I want to deal with - I hope I will be able to come back in on a few other matters later - relates to the settlement of the employment case. This cropped up in the C and AG's report. It jumped out to us. I understand that there is a mediated situation and that this constrains what can be said. The settlement comprised €1.37 million for a loss of potential private earnings during the period. This person had been paid in full while they were under suspension and then they claimed for the loss of private earnings. It seems that all the power is one side, and the power is almost in the inadequacy of the person. Obviously, they were not suspended for no reason - I presume it was because they had not been able to do the job - and then they get this kind of compensation. Is that not encouraging a particular type of behaviour? It seems extraordinary that the legal advice would not be to challenge this and, at all costs, to make sure this person was gone.

I provided a note to the committee yesterday with a description of this case, and I think I even stretched the boundaries, to be fair, in doing so. When a mediation of this type is carried out, it includes a risk assessment of the alternative, and the alternative is likely to be a combination of two things. One is several years of not working and being paid while litigation goes on, and the other is the risk of the cost of the litigation, which, as the Deputy knows, is significant. Consultant contracts are one of the most disputed contracts in the country in employment law. Most consultant contract disputes are litigated in the High Court and they are very complex and significant. It depends on which of the three consultant contracts the person holds. A very considered view is taken to settle as to opposed to the alternative. The alternative would have been set out in the business case that would have gone to the Department of Health and the Department of public expenditure. It would have been very clear what the options were. Even so, it is very significant.

-----and it indicates that the power was all on one side here.

I asked a question some time ago about the contractor that is building the national children's hospital and contracts over the past ten years for the same entity. There were seven of them, totalling €93 million, in different locations. What was the profile for looking at how they had worked out and whether they were on time and on budget? Was there a profile of tendering low and claiming? Does the HSE carry out an analysis post completion of how a contract went, if it did not go to plan?

I did not specifically do an analysis of those projects. I saw the answer that issued to the Deputy. I am told the €96 million on the projects was generally within a good range of time and anticipated costs, but we would have to go back behind each one. Last week in the Dáil, the Cathaoirleach raised the issue of six HSE projects where there was a stated overshoot of €17 million, although I can correct that later. In general, however, and I checked this with the head of capital and estates, the overall satisfaction rating in a good sample of our total number of capital projects would be that they are within the range of the margin that is allowed for and the time for completion but-----

Comhghaideas leis an gCathaoirleach. I do not intend to dwell on this but I have one question about that high earner. Mr. Gloster used the word "abhorrent", with which I think most of us would agree. Are we going to face a similar scenario? He talked about the new consultant contracts and the employment of more consultants, which is the ultimate aim, but are legacy contracts in place such that will be back here in the next Dáil session, or whoever happens to sit on the committee at that time, dealing with another such abhorrent incident?

I do not believe we will be to the same extent. There are going to be high earners, and I think I said in my opening statement that the base for counting high earners has traditionally been about €300,000-plus. The new consultant contract, if we apply that to an academic appointment, takes us up to that already. The number at €300,000, therefore, is going to change. To be fair to the Comptroller and Auditor General at this committee, the focus has tended to be on the ones over €500,000. There certainly are signs of that improving and there are a lot of reasons it might do, but the highest projected earnings we are seeing at this point in 2024 seem to be somewhere between €600,000 and €700,000, so it is a reducing phenomenon, if you like.

Completely. I would have to say that while there might be a row about it, we will have to get better at how much we are prepared to defend our interpretation of the contract when we come to those individual instances of that significance. I cannot stress enough, however, that every consultant in the country is entitled to claim for when they are called, and we are talking about one here in this number.

The majority of consultants who come in when they are on call probably come in for one patient and see seven, and you would not see anything like this.

In the recent past, my family has been very glad to have access to consultants out of hours. I will touch on that. My father is 80 years of age. He still rides vintage motorcycles around the place, which is great for our collective family blood pressure. He gave us a bit of a scare recently. He came off the bike. We were in hospital with him. This goes back to Deputy Cannon's point about the electronic records. It is one of the things that strikes me as low-hanging fruit. My father was in hospital about to undergo a procedure and the question that arose related to the medication is he on. He was not in a position to answer. I had to drive out to the family home, which, thankfully, is not far from University Hospital Waterford, UHW, rummage around until I found the relevant box - I had to hope that the necessary prescriptions and all the rest were inside - and bring it back in. In our case, somebody was around who could do that. Many people who present at a hospital are not in a position to outline the medication they are on. As stated, this is low-hanging fruit. Are we making any progress in respect of that matter?

Yes. Deputies Kelly and Cannon mentioned how unsafe healthcare can be in the absence of electronic healthcare records. One of the areas in that regard is medication safety. Traditionally, people who arrive at emergency departments would usually bring GP letters with them - unless they are directly conveyed to the hospital - and those letters would have their medication lists. We have links with GPs through Healthlink through referral to hospitals. GPs, as part of their normal communication with hospitals for scheduled care, would list someone's medication.

What the Deputy says highlights the urgency for focus, as the CEO said earlier, on not waiting for everything to be perfect but to focus on the areas of greatest impact and safety. One example of that is digitalisation of radiology procedures, which has been in place for most hospitals under the NIMIS system for many years and has resulted in safe transfer of images in real time between hospitals in a way that facilitates safe patient care. Medication safety is one area of focus that does not need everything to be perfectly lined up but it does need matters to be expedited in the way the CEO outlined earlier.

I will ask one more quick question and I will then move on to non-compliance. We are lucky with UHW. There are fights to be had about the provision of health services in Waterford. People will know well about the fight for 24-7 and the second cath lab. That has been well documented, but we are very lucky in that ours is one of the model 4 hospitals that does not have people on trolleys. It has not had people on trolleys for a long time. I know that there was an information-sharing exercise between UHW and UHL and that a team travelled down from UHW to advise on the processes. Keeping the senior decision-makers on the floor of the hospital is one of the real big things. Where did that exercise go? Were there learnings? Were there outcomes? Was there positive engagement between the two parties? Can Mr. Gloster give me a brief update on that?

Some of our staff went down to Waterford. That was some time ago. Of course, Grace Rothwell was in with the director of nursing from Waterford during the summer. They made lots of observations about how we could potentially improve some of our processes that were very helpful and we are setting about implementing some of those changes that were recommended by that expert team. It would be remiss of me not to point out that Waterford and Limerick are very different in terms of the challenges and all the rest of it, but the ideas from Grace and her team were really excellent. We are working to implement them.

I want to deal with non-compliant procurement in the short time remaining. We are talking about a spend of €4.2 billion. The HSE has put the estimate for non-compliant spending at 12%. We have difference there because, apparently, the exercise only covered 38% of the overall spend. Could Mr. Mulvany put a monetary value on it for me because I am making an assumption - it may be incorrect - that the non-compliant spend might be at the lower end of the spend spectrum? When I say 12%, am I talking about 12% of the money - probably not - or 12% of the cases?

To correct the record, I said earlier that the non-assessed - the 13% that we did not get returns back on - was counted as non-compliant. That is incorrect. It is not part of the calculation. Apologies, just to correct the record on that.

On the €4.2 billion for 2022 or €4.9 billion for the current year, the Deputy is correct that approximately 38% or, I think, €1.6 billion of that €4.2 billion is what goes through the total exercise. I can get the Deputy the actual number. Of that €1.6 billion, we are saying the 12% came back as not being compliant.

The number, which is staggering, troubles me. Something that worries me more is that one of the reasons we get back for not having that information, on the one hand, is the manager responsible for the expenditure could not be identified centrally. That would very much worry me. Then the flip side is that the identified managers failed to respond to the exercise. When they were asked about their compliance, they stonewalled the auditors. Both of those really concern me, and the latter more so. If somebody does not comply with that exercise or if there are trends in terms of non-compliant procurement in specific areas, are there sanctions? They have approached people and asked could they explain certain procurements and were informed by these individuals that they could not, that they did not see that email or whatever. Is there a sanction in place whereby they go back and demand the information?

I am not aware of any actual sanction that has taken place. I can check the specific follow-ups. It is followed up and we seek to maximise the level of returns. It may not be that individual managers are not returning. It is just that they have not sent back a return in respect of all areas of their spend.

The fact that we either cannot identify or get the information we need on these types of matters is descriptive of aspects of how distributed our own system is and how chaotic aspects of our own system can be. We have to be honest about that, and that is improving. In the context of the managers who are sitting below me now and the new governance structures we have in the organisation, I would not tolerate anyone refusing to answer a question that they are paid to answer and there would be a pursuit of that. If that were brought to my attention, I can assure the Deputy it would be pursued.

I am not aware, but no one has brought to my attention that someone is willfully belligerently standing in front of an auditor telling them to go away because they are not going to answer the question. What the CFO is explaining is it is a much more complex process than that but the Deputy's general question is a fair one.

Go raibh maith agat, a Chathaoirligh, agus comhghairdeas.

I want to follow up on the issue of one individual who earned over €1 million, with €700,000 of that being an addition in their salary, and the instance whereby a significant portion of that was for a single shift where the person was paid at a rate of six hours per patient for each of four patients who were actually treated within an hour. Mr. Gloster described that as "abhorrent". I do not think anybody would argue with that. Ms McGirr outlined how the new contracts would not allow for that scenario to arise. Are there consultants or other staff on old contracts for whom such a scenario would be possible today?

About 42% of our consultants today are on either what is called the Buckley contract or the 2008 contract. They would all have an entitlement to make those types of claims and, indeed, in the public-only contract, there is an entitlement to claim for call, albeit it is much more defined. The risk of that happening is much lower because traditionally these very high call-outs were associated with circumstances where one or two practitioners were working a rota and they had to be on call either all the time or at least every second day. Therefore, the chance of them getting to take their rest hours for coming in on call was less likely, leading to the payment. The Deputy can see from the very fact that a small number of people are on that list of high earners that it is not common practice in the way consultants go about their work, are rostered or make a claim when they are called in.

I will come in on that. It is, and it is closely monitored. We are aware of the figures in terms of where those high earners are now. It can be region-specific, so if it is a location in which it is difficult to get another consultant or more consultants regionally. We do have that issue in some cases. It is also clearly specialism-specific, so where there is a difficulty recruiting to a particular specialism, consultants are on call more and there is more compensatory rest involved. Those are the areas. The way to solve it is by ensuring that they are adequately staffed to improve the rostering. There are a few things the HSE is monitoring much more closely. The level of consultants needs to be targeted around those hard-to-fill posts.

Ms McGirr mentioned that the first option in these instances is for rest leave to be provided in lieu. I am not sure of any worker in any scenario who, given a choice of getting six hours pay for 15 minutes, essentially, or an alternative hour off, would not take the former. In this instance, the witnesses indicated that monitoring may be in place now. When a member of staff works these hours, is there now a mechanism in place within the HSE that would essentially force that person to take their leave as opposed to receiving six hours' pay for 15 minutes work?

I would say again, because of the number of consultants now available to staff most rosters, that there is a better chance of hospital managers and clinical directors being able to monitor and enforce that and make sure. I suggest to the Deputy that, while the figures are just outrageous, the number of earners in that category for 2023 is so small compared to the totality of the consultant body as to be a good indicator of the level of control and level of use that is in place.

In terms of the monitoring, Mr. Gloster is right that it may be a small number but the figures are astronomical. How far up the line does the monitoring go? Is the CFO, for example, informed that there could be a potential outlay as a result of a member of staff having worked these hours and provision not being in place to prevent him or her with a rest period in lieu?

The expectation in the contract is that people will take compensatory rest days. That is for the hospital manager and clinical director on the site level, supported by medical manpower, which is local HR, to manage. The call-out has to have happened. The rest days are expected to actually be taken under the contract in the majority of cases. As colleagues have said, in cases where operational and clinical reasons do not allow for that, there is provision to then claim the actual payment if people have not taken the days within two months.

Our HR colleagues have issued and periodically re-issue guidance to the system around the active management of all aspects of our contract. One of those is monitoring and management around compensatory rest days. The preference is that colleagues will be able to take those as the rosters become less and less onerous. In this case, the roster is now a one-in-five roster, having been a one-in-three roster at the time. That is not a particularly onerous roster anymore and, therefore, the risk reduces. It is still a risk, however.

I am conscious of time. I want to touch on what might be a fringe issue. It was reported during the summer that the Workplace Relations Commission, WRC, made a finding in favour of an administrative worker in the HSE being allocated the pandemic bonus payment during the summer. Are any of the witnesses aware of that?

The reason I asked the question is that I am relying on media reports to find out that an administrative worker who had been denied the pandemic bonus payment brought a case to the WRC, which found in that person's favour. Has that result led to a reconsideration of the pandemic bonus payment actually being paid? I take it that none of the witnesses are even aware there was a WRC finding against the HSE, the Department cannot answer that either and that the answer is, in fact, that the HSE is not re-evaluating who the payment was made to.

I can certainly say, in case anybody thinks we have all taken leave of our senses and we are not doing our jobs, that I have 166,000 staff. The frequency of grievances and pursuit of cases to the WRC and so on is that they happen all the time. I am not aware of that case, but I will certainly look into it. What I can definitively say to the Deputy is that I have had no cause since I came into this role 18 months ago to revisit pandemic payment issues in terms of either the people entitled or categories entitled to it.

There were very strong criteria around the fact that people had no choice with regard to who they saw at the time of the pandemic, which was pre-vaccination. We prioritised our acute hospitals and staff working with those people who were the most exposed and at risk.

The other piece is that there has been a great number of claims about widening this to public sector workers more broadly, to prison officers and to those in the many public services where people were exposed. There had to be borders or some areas-----

Rather than just getting the detail, I would ask that the Department fully review that situation. As I said, these were people who carried out what in my view was essential work. It was as risky as other types of work within the health services who fall under the scope of the scheme. These are employees who we need to continue to do very important work. I just have a fear that we could end up in a situation whereby resistance from the Department ends up costing us more than the payments would in the first instance. I just wanted to make that point through the Chair.

Beidh mise mar an chéad cainteoir eile. One issue that has annoyed me for some time, even previously in my role as a city councillor on Galway City Council, is that of agency spend. We have seen that it has gone from a spend of €350 million to €650 million in a four to five year period. If we look at that trend and the figures that we had up until August, it seems that if the trend up to August is maintained, that figure of €650 million will be exceeded. In fact, it looks as though a figure of €700 million will be exceeded with regard to agency spend. Does Mr. Mulvany concur with that figure? Does he think we will go higher than last year's figure and could it exceed €700 million?

The Deputy is right. Agency spend tax increased substantially in the past five years. In 2019 it was €423 million and in 2022, it was closer to €720 million. Last year it was just over €780 million. It has increased substantially with the biggest part of the increase occurring before and during the pandemic. The key issue is that it has not reduced. There are efforts under way to reduce it. Our first target is to hold it steady this year against June to August levels of last year. I need the exact figure but we are 3% or 4% beyond that. We are above steady compared with last year but most of that can be accounted for in terms of price. The cost per hour of agency goes up as wages generally go up. Our overall aim is to reduce agency spend substantially. We have-----

It would be hard to see the impact on this year's accounts in a significant way. That is why the Deputy is right. We will either be close to or exceed last year's spend, because both of price increase and as the CFO said, we now hold steady. We will see a reduction in agency over the next 12 months, back to the level it was at before quarter 3 of last year.

For some time. I can see from the spend on the management and administration that the HSE has gone from €29 million to €86 million in those areas. One of the frustrations for people - and it is not always a frustration that is based on facts, it can be based on experience and we have heard quite powerfully from an Teachta Cannon his own experience of getting the piece of paper and going around – is that for administration and management, that seems like quite a lot within the HSE. Can Mr. Gloster confirm that has been the increase for management and administration?

Broadly speaking yes, there has been an increase in management and administration of the order the Deputy is talking about. Back in 2019 it was approximately €32 million.

Extrapolating for last year, it is approximately €80 million, so there has been a substantial increase. It comes down to what we mean by management and administration, who those people are and what they do.

Mr. Gloster stated that he had a staff of approximately 166,000. There is considerable frustration about agency spend in general, particularly given that there are many people who want to get good jobs in the HSE. This expenditure on agency and management and administration basically represents a trebling of the previous amount. Why has it increased to this level in such a short period?

The HSE also wants to recruit people permanently into directly employed jobs. That is our preference and is generally what we offer. We only use agency staff when we cannot get people for jobs or only need them for short-term filling. Some level of agency staffing – probably 3% or 4% in an organisation as large as ours – will always be necessary. There will always be short-term gaps that we cannot fill-----

When 7% of one’s total spend on pay is on agency staffing – in some services, it is even more – that is more of a problem. That is the over-reliance we are trying to reduce. The level increased during Covid in particular. Much of the additional processing during Covid, including around vaccinations, saw many administrative staff involved. The level has decreased by approximately 20% since the height of Covid. We would like to drive it down further.

-----but we are discussing a large amount of spending. I understand that the HSE has an aim, but it does not seem that the aim and what the HSE is doing correlate at all.

The Minister created a productivity and savings task force, which set a target of reduced spending. Who sits on that task force?

The task force is chaired by Mr. Gloster and Mr. Robert Watt, Secretary General of the Department. There is senior management from the Department’s management board and the HSE’s senior executive team. There is now a productivity unit within the HSE that is a national focal point for driving productivity. We published our review to the Minister. It is on the website. We also publish all of our minutes and agendas. The focus and priority-----

The measures to reduce agency spend include staffing, roster changes and agency conversion. Limits are now in place and there are targets for savings, which are the responsibility of the regional executive officers via Mr. Gloster, to be achieved. They are not related to the work being done on the productivity side of the task force. The reason for having external assistance on the productivity side is because we are considering matters like OPD, digitisation and other issues that were discussed earlier in terms of how to improve operating efficiencies.

I accept that. The external consultancy firms are not typically the providers of agency services. A different range of firms provide the bulk of our agency nurses, physios, administrators, etc. The equivalent of three external people on the seven-person unit in the productivity and savings task force are there for their external expertise, adding to the internal expertise of HSE staff. There is no conflict there. They are different. That is part of the overall effort the CEO has led to reduce our reliance on management consultancy. Where the specific type of management consultancy we are discussing is concerned, the target was to drop it by 30% against the quarter 1 2023 baseline and keep it reduced. We have hit that target. We got most of it done in 2023 and have hit it and maintained the decrease in 2024. While we are using a small amount of extra consultancy for the productivity and savings task force, it is part of dropping the overall reliance-----

We agree that agency spending is too high. There are targets to bring it down. The conversion that Mr. Gloster mentioned is one of the key ways. We have invested more than €50 million in safe staffing and nursing to reduce the agency cost of nursing in hospitals. The consultants’ contract, which is in the evenings and daytime, is there to reduce reliance on bringing people in outside the 9 a.m. to 5 p.m. schedule. In recent years, we have increased the workforce on the health side by just under 28,000, never mind the Department of Children, Equality, Disability, Integration and Youth side. These are all measures that should reduce agency spending. We agree that there is an excessive reliance on agency staffing. This is the focus of the task force. There is no-----

They are predominantly – 99%, I believe – front-line workers. There are a further 400 separate conversions in nursing for safe staffing, so there are 900 conversions in total. They are everything from temporary allied health professionals working on the front line to nursing staff. If there are agency administrative staff like receptionists in a health centre, we are talking about converting front-line workers.

I welcome more people being able to get jobs in the HSE. I did my leaving certificate in 2008 and most of my friends who studied health went abroad. They are coming back but find it impossible to get full-time permanent jobs. This has a major impact on being able to get a mortgage, move out of the family home, etc. The embargo impacted on them further.

Regarding private consultancy firms, we have heard that the unions have argued that the money spent in 2023 alone – €80 million – could have been used to recruit people to a significant number of posts in areas that were badly understaffed. Mr. Gloster hopes to get 500 conversions under way. When it appeared before the health committee yesterday, Fórsa stated that the 2023 spend would have funded 1,865 therapy posts, 2,354 medical secretary posts or 1,334 psychology posts. Most people will be concerned by this, given how many people looking for assistance are on waiting lists and the number of people who are not getting full-time permanent jobs.

As has already been said, when many people get into the system, it is fantastic and they could not ask for better. Is it an area of concern if unions like Fórsa are coming out and saying the HSE has €80 million? We would like to see people being hired to keep staff within the sector. What is Mr. Gloster's view?

To avoid confusion, there are three components. There is agency staffing, which is temporary staffing. If we look at the profile of our agency staffing, a substantial number do not want to be HSE employees because they like to be able to pick the hours they work, they work shorter time and some are people who have retired early and come back to do various pieces. We have to reduce our dependency on agency staffing. That is the first point.

On management consulting, I said when I came into this job that the HSE spend on management consultants, but more importantly its culture of dependency on management consultants, had outgrown any reasonable sense of what was needed. In essence, we were almost subsidising our workforce with it. We have reduced that by over 30%, as the CFO said, which is a very substantial reduction and saving. Any consulting we now take on is much more competitively priced, is for a much shorter time and much fewer people are linked to that expertise.

Fórsa has a job to do, which is to represent its members, and I do not for one minute propose to be disparaging about that. However, there is no connection between what we spend on management consulting and hiring health and social care professionals. My only issue with hiring health and social care professionals is that I cannot get enough of them. There are several hundred vacancies in physiotherapy, occupational therapy and speech and language therapy in disability services alone that I would fill today in a heartbeat if the people were there, but the supply is not there. There is no connection between what we spend on management consulting expertise in one part of the organisation and filling health and social care professional jobs in another. That is simply not the case.

I fully share Fórsa's overall concern about our reliance on management consulting. I hope Fórsa continues to co-operate with us and work with us when we take out that management consulting in different parts of the organisation, and that we can continue to ensure the work is done.

When the embargo happened, I was contacted not by a lot of people, given that not that many would contact me directly, but by a number of people, in particular young women who had worked in the healthcare profession and hoped to come back. Either they were in Britain and they were trying to come back, or they were living here and not on a full-time contract and were maybe working one or two days a week. This had a very serious knock-on impact on them. While I appreciate Mr. Gloster is telling me there are jobs available, at the same time, many people are finding it difficult to move home because they cannot be guaranteed they will get into a workplace. That age group of people, those in their 30s, want to have a full-time job so they can settle down.

Deputy Murphy raised the issue of the posts that were advertised on 31 December 2023 and then cancelled overnight. I understand there is a dispute about the figure. The unions are saying it is 2,000 posts and my colleague, Deputy David Cullinane, has tried to get a response from the Minister with regard to exactly how many it is. How many would Mr. Gloster say were there on 31 December and then, overnight, were no longer there? What figure would he put on that?

We have 147,000 full-time equivalent posts currently occupied by 165,000 individual people. Our turnover rate last year was 8% and if we break that down into quarters, we get 2% of the workforce per quarter. That is the type of number we are talking about. That is outside of new developments because we carry vacancies in new developments. However, in our core workforce, I would imagine that on any one day, we could be in the territory of 2,000 to 3,000.

To be fair, I have tried to make this point to everybody who wants to discuss these figures. Despite the moratorium at the end of the last quarter of 2023, there were more resources in the HSE at the end of 2023 than there were at the start. There have been more nurses in the HSE every single year since the end of 2019.

Yes, there was a nurse missing in the community nursing unit in Limerick. Of course, there was. Yes, there was a social worker missing somewhere. Of course, there was. On any given day, that happens. However, that was overtaken by the fact we kept 4,000 jobs and we added 2,000 more jobs than we were funded to do last year and got to keep them. This year, we are again adding several thousand jobs.

That is not the question. If Mr. Gloster does not have the figures to hand, he might provide them. It is a disputed figure. It is something we are trying to get to the bottom of but we cannot get to the bottom of it if only one side is telling us an exact figure.

I am conscious of time because other members are offering. I want to ask a question in regard to primary care centres, in particular the Carraroe centre in County Galway. Carraroe is on the list to get a primary care centre. We want to make sure people are able to access healthcare locally, especially in a rural area like Connemara, from where it can take well over an hour to get to Galway city, even forgetting about the traffic issues. It is a long-standing demand to have a primary medical centre. At this point, does Mr. Gloster know what the estimated timeframe is for delivery of that and what costs are associated with it?

I got confirmation at the break from Tony Canavan, the regional officer. My understanding from him is that they are working to develop a business case to deliver a primary care centre in south Connemara, which will cover Carraroe as well. I do not have an indication of what indicative cost might be associated with developing a primary care centre.

I thank the witnesses for attending. There are many different areas that we could focus on. One of the things that really jumps out at me is the climb in expenditure from 2019 to 2023. Obviously, that is taking Covid into account but it seems the expenditure has not dropped back. To give context to my comments, we are looking at the figures coming from south of €20 billion, at approximately €17 billion in 2019, and climbing to over €25 billion now.

One of the things I want to feed back to the witnesses, as somebody who has been elected to the Dáil for four and a half years in a rural constituency, is that we know that 1.6 million of Ireland's population are deemed to live in rural areas. The lack of access to GP services is extraordinarily bad and it is getting worse. Lack of access to out-of-hours services is at crisis level. I do not want to get too parochial but I can speak to my constituency because I know about it from meeting constituents. When people want to see a GP but perhaps cannot do so or they have to wait for a period, their health worsens. That potentially requires an emergency solution, with people going to an emergency department. The consequence is that they may end up on a hospital bed or on a trolley. This clogs up our hospital system.

I have raised this before. It is staggering that 25% of GPs are now over the age of 60, if I am not mistaken. What has Mr. Gloster done in the past years in his role to address this? Where are we with it? The expenditure in the HSE is climbing rapidly. We are lucky to live in a sound economy but I am fearful of what may happen if circumstances change internationally. Can we sustain paying Mr. Gloster's organisation such a sum of money annually?

There are two aspects to the GP matter and one specific to rural matters. My colleague, Dr. Colm Henry, might add to that because he plays quite a part in that. The fundamental structural change that we have made, which has commenced this year, is that we have increased the number of GP training places to 350, which is quite significant. The graduate numbers over the next four years will exceed the predicted retirements. The plan is to supplement that. One part of the world, South Africa, has a particularly skilled workforce of doctors, who have come to Ireland and under an arrangement with the Irish College of General Practitioners, they can do two years of supervised practice here and then register as GPs. We have tried to target those specifically where there is either deprivation in cities or rural access challenges. Dr. Henry might want to address GP development in rural Ireland.

As the CEO said, we have increased the number of trainees. We have a national level of GPs to population which is suboptimal, frankly. It is six or seven per 10,000 people. We need to get to about 11 per 10,000. As the Deputy pointed out, looking at a population level and even a regional level fails to address the particular exposure we have in rural, single-handed and isolated practices. I attended a conference of that group of general practitioners last weekend. Through the GP agreement in 2023, money has been set aside to support specific general practices which are stand-alone with locum support and linking them to a hub GP practice, in addition to the measures the CEO referenced, under which we have 121 international graduates supporting these kinds of practices. We hope to raise that to 250 per year right through to 2031 so we can go from our current suboptimal provision of GP cover, with, as the Deputy points out, an ageing GP workforce, to having the additional 350 trainees per year bring us to the ratio we would like to see, of 11 per 10,000 people. That special care needs to take place for those isolated, stand-alone, single-handed practices because of the particular vulnerability.

I refer to north Cork since this came up so much during the local elections. People cannot get in the door to see GPs in Mitchelstown and Fermoy. This is replicated in other parts of the country. I am not even going near the SouthDoc issue but it is extraordinarily worrying that even when people require a consultation with a doctor in an emergency or a call-out to a home that the service is collapsing. It comes back to people ending up in the hospital system. It is having a significant impact on costs. I come from a family of healthcare professionals. All my siblings are working in healthcare settings.

I look at the primary care system as a positive development. As Mr. Gloster knows, I have been working hard to try to get the primary care centre up and running in east Cork. I think it was granted conditional planning by the county council this morning. I am also interested in the ambulance training unit that is being built in Youghal in the south of the country, as set out in the 2024 capital plan. What is the timeframe for the roll-out of new ambulance training colleges and funding being made available to progress them? We have done these successfully in other parts of the country. I think there is one in Ballinasloe in the midlands. How quickly is that being done?

I thank the Deputy for the opportunity to address that. I know the last time I was here, he was quite frustrated at our level of responsiveness. I know the team worked with him and others in the area. Three positive and exciting things are happening. There is planning permission for the primary care centre. There was a request from the local authority for additional information which has gone in and I do not envisage any major challenge to that. Planning permission for the community nursing unit has gone in and there is an additional information requirement for that. In the case of the ambulance training base, we need additional training capacity. We are planning to grow the number of paramedics in training every year. A feasibility study, which needs to be done first, is currently being done on the possibility of locating that in the St. Raphael's campus.

It operates, for want of a better word, like a third level college. There is a group of students, which could be 30, 40 or 50, and there is a group of tutors. The students go out on placement with ambulance crews on the road. It is a full cycle of training and has to operate like a full-time college.

We are 12 months on from Storm Babet, which took place in 2023. Enormous damage was done to Midleton. I was talking about this with the Office of Public Works earlier in the week. Midleton hospital experienced devastating flooding. The Owenacurra Centre there, which has been much-discussed over the current Dáil term, was damaged too. I want to get insight on where the HSE is with rolling out the new capital infrastructure both for psychiatric care in Midleton and the Midleton hospital development. That has been dragging on for a long time. I am more than concerned about it. Where are we with it?

I know there is a lot of community solidarity about the Owenacurra Centre. That centre was not fit for purpose. We are developing a much better facility for people on that side. As to the timescale, I apologise, because I will need to get back to the Deputy on that. Midleton hospital is a much-loved facility in the community. I know a number of things are happening there. We need to get back to the Deputy on the specifics of the timescales.

I understand that. To be fair about Owenacurra, regarding the time to get it out of the ground, before I came, it was much disputed. I went there and met staff, some of the residents and the mental health service in Cork. After that visit, I made the formal decision that we would build on the same site so that the future users of those services would have access to the town and all of the support systems there. That decision has been made. I understand the design work has been well drafted. We will come back to the Deputy with a more definitive answer.

I thank both our Leas-Chathaoirleach and former Cathaoirleach for their inputs to the Committee on Public Accounts during my term. I thank the witnesses for their attendance. I will start with a quick question about capital infrastructure. What is the update on to the 97-bed block for Wexford General Hospital? Will Ms McGirr answer?

I thank Ms McGirr. I do not know who is responsible with regard to the home care support services but I am very concerned about the volume of calls I am getting whereby those in receipt of the care and their home carers are being informed they are no longer allowed to feed those they are supporting. While this has been sent out in the form of an email with the guidelines set down in a HSE document, the document pertains to 65-year-olds. I have the case of a mother who cares for two people, one of whom is a very seriously disabled and intellectually challenged individual as well as another son who has cerebral palsy and she cannot operate in an environment whereby the home care support worker does not feed her 22-year-old son, as an assistance to her. The reason I have been given is that when the client starts to choke that is something the home care support worker cannot cope with. Surely we are not sending in people who are not trained in this regard. Will Mr. Gloster look into that? I am not sure if this has been sanctioned at local level, constituency level or CHO 5 level but I certainly want a categoric answer because I know there are people who are seriously struggling with regard to this. I do not know if Mr. Gloster can answer this question now.

We have sent the information. We will re-send it. If it is that and there should be a reassessment, the HSE should not be writing to parents and putting the fear of God into them that this is no longer a part of the care that is provided because it is a very stressful environment already. I will take that up with Ms Broderick.

I know that and I appreciate that but it is very concerning and upsetting.

My other question might also be for Ms McGirr. Will she give an update on a medical centre for New Ross, County Wexford? The latest proposal was turned down as it was no longer viable, apparently. Can I have an update on that please?

I have a question for Mr. Mulvany. How much does it cost to keep a public patient in a public bed in a public hospital for one night?

The last time Mr. Mulvany appeared before the committee I put it to him that there had been a young girl with anorexia in University Hospital Waterford for 30 days. I was incorrect. I am stating on the record that it was actually 91 days. There was no clinical intervention that she should be moved until I got involved, and there was no administrative intervention to ask why she was there. The hospital neither had a paediatric dietician or any consultant come to see her. She moved out of the care of the CAMHS consultant into the care of the hospital consultant who failed to see her in the hospital, at her bedside, for 90 days until I got involved. Has that been investigated since Mr. Mulvany was last before the committee?

Yes, to deal with her disorder. She spent almost nine months there, during which time her father passed away. The tragedy is that when she left that setting she was referred back to CAMHS, which had neglected her in the first place. She is back to the same weight she was when she was admitted to the hospital in the first place. We are failing, and failing miserably. While the girl is back at school, her mother attends school every day to ensure she eats her lunch. In a year and a half, no inroads have been made in her mental healthcare except to put her back to where she started. There was no intervention in the 90 days she was in University Hospital Waterford. She lost more than 7 kg in weight and no questions were raised. That is failure and I do not care who is responsible but I want it to be addressed. I may never be back here again and I understand Mr. Gloster has a serious task on his hands. I watched his progress because I told him I would give him a chance. He is making progress but it is a mammoth task he has. For all the good we do, this child could have died but will spend her lifetime, if ever, trying to recover because we failed during the 90 days she was in a hospital for no reason with virtually no help.

We are failing our staff also because the hospital was not able to deal with it. The staff had no training. There was an adult dietician who clearly was doing her best but was out of her depth because this was a 15-year-old. I find it incredible that this has not been addressed even though Mr. Gloster was aware of it from the last day here. Not only that, the only provision she could be offered when she was released from the mental health setting that dealt with the anorexia in the first place was to put her back to a CAMHS service that was not fully staffed and did not provide fully for her care in the first place, which is how she ended up in hospital. It is value for money-----

I would like to say it is impossible but I sat in the hospital for a day with the patient. When it was discovered who I was, I was asked to leave. Not until then was there an intervention. Not until then did the psychologist come to the hospital and address the situation. Then it all had to happen as an emergency because the girl was in organ failure. This is crisis. For all the good work that has been undertaken, one death of this nature would be catastrophic for all of us. We still have failed because even though she is no longer at death's door, she is back to the very same position she was in the first place.

No, I am still in the same position when it comes to eating disorders because we have not addressed the situation of either CAMHS units or CDNT units being staffed.

We have 817 vacant positions in CDNTs. We are servicing nobody. The situation with CAMHS is almost identical. I will have to come back in later because I am out of time Will Dr. Henry prepare an answer in the interim? CAMHS Wexford south, as it has to be identified - because if it is not, it discredits CAMHS north - has refused to take on hundreds of children on the basis that they may also have attention deficit hyperactivity disorder. We are really failing poorly.

Before Deputy Catherine Murphy comes in, I wish to address the Deputy Murphy from the south east. I have the update on the 97-bed block for her. The enabling works to clear the site are being done. There is also work towards finalising the design to get it out to tender. It will go out to tender in quarter 1 of next year. The commencement of works on site is scheduled for quarter 3 of next year.

I wish to pick up on the point my colleague Deputy Verona Murphy made on the CDNTs. This comes up repeatedly. I hear from people who had services when they were being looked after by Enable Ireland but who have no services now because they were switched to a CDNT. The vacancy rate in Kildare south is 16.7%. In Kildare north, it is 35.2%. In mid-Kildare it is 15.3%. Some 250,000 people live in Kildare. Looking at the demographics, it is one of the locations with the largest number of young people. This is a brass-plate service for most people. It just does not exist.

I spoke dad who described his home as a care home rather than a family home. When he did end up getting some sort of engagement with the CDNT, it was an absolute emergency situation. There would be quite a number of injuries in the house because one child has a particular behavioural problem. I am just using this as an example. The man in question was told he could go on a course. That is what he was offered. We are totally failing here.

Is the HSE making progress on the number of vacancies? I do not see it. Is CHO 7 different? Is it worse? Is this a problem right across the country?

It certainly is a problem right across the country. We appointed a senior HR professional to support recruitment into CDNTs. It remains an issue, and we need to make more progress. I am very conscious of the small number of children who are having their assessments and therapy within the appropriate time. It remains an issue we will need to work on, particularly as REOs.

There is just not a service for most people. It is the one area that is very out of control, from what I am hearing. It is repeatedly raised in the most tragic situations. We are talking about emergency situations, where you go with an emergency and are told to come back in 12 months. It is outrageous. I just wanted to highlight that as the kind of thing that really needs attention.

Mr. Gloster talked about a staff turnover rate of 8%. In addition to staff turnover, a huge number of women work in the health service. Some will have to take maternity leave and deal with other kinds of situations. In addition to the vacancies, do we know the numbers on maternity or sick leave?

We do have absenteeism. We have tracking in that regard. It can run anywhere between 5% and 6.5%, depending on the different discipline or speciality. I would have to check the position regarding maternity leave. The Deputy is quite right that maternity leave is a significant feature, hence the reference earlier, in reply to the Cathaoirleach, to the need to retain a certain number of agency staff.

In the short time I have left, I will focus on one matter. We make recommendations to the HSE when we compile a report. One of those recommendations was that the reports from internal audits be published on the executive's website. Will the HSE be doing that? Does it see the internal audits and the reports from audits relating to the more than 60% of other publicly funded health agencies?

I wish the Cathaoirleach well in her new role. I mark the fact she is the first female to serve in her position. I also thank Deputy Catherine Murphy for her work recently and throughout the term as Leas-Chathaoirleach.

Returning to the capital development side of things, I wish to ask another question. In the context of land relinquished during 2023 – this is a specific question – did the HSE do much community engagement with sports clubs or other organisations throughout 2023 where additional lands it may have had were given back to communities or made available for sale for community organisations?

I would be misleading the Deputy if I said that we did. The disposal of property follows a specific trajectory. We are obliged first to offer it to other Government agencies that may have an interest or requirement, particularly local authorities. It would not be unusual for us to dispose of a premises and for a local authority to take it for use. The second thing which has been an increasing feature over the past two years is we have offered certain premises - some of them very high profile, unfortunately, because they were torched – to the Department of integration to service the needs of international protection applicants. Regarding vacant land that is not built on, the primary focus of the dispersal of that or not is the Land Development Agency. It operates on behalf of the State and expresses an interest in our lands. Some we have transferred to it and some we are arguing to keep for our own future plans. With regard to dispensing with land to local communities, that would be very much on the margins. It might be where we actually own the ground and a soccer pitch might have been there for the past 30 years. We certainly would not be-----

It is interesting Mr. Gloster says that because I have one situation I wish to raise with him. I was trying to get a conversation without prejudice between a local GAA club and a facility where the HSE owned the ground but there was that instance where the field was used for GAA purposes. I was wondering about the mechanisms around that.

Yes. It is a huge site. There are vast lands with it.

I refer to the feasibility study on the ambulance training unit going into the old building in St. Raphael's. It is a beautiful building. It is almost like one of the old buildings you see in Trinity College but it has been left derelict and vacant for some time. It is sealed and contained. It is not as run down as some other empty derelict units would be.

I would encourage usage of older buildings where possible, particularly around an education campus. That will serve its purpose for decades if it were reinvested in rather than going through the hoops of trying to attain planning and trying to go down the road of a new greenfield site and all the trouble and hardship that can come with that. I know the witnesses will be coming back to me about the ambulance training college but on that feasibility study, there is a building sitting there.

We are not averse to using our old building stock. If you go to Monaghan, the former psychiatric hospital there is now probably one of the largest primary care centres in Ireland. It is a super facility. The St. Joseph's psychiatric hospital in Limerick is a multi-occupant site with a beautiful presentation of the old building, albeit for modern purposes. I would have no wish not to use them, but there is a practical point about the feasibility of doing the building if it is a protected structure or with regard to the energy rating and so on.

That is good to hear. The primary care centre is moving along. I also ask about the chronic pain management suites the HSE is working on. Dr. Henry might know a little more about this but it is looking at locating some of them in primary care facilities around the country. I have another question about small injury units and to see what is involved in locating those within the new primary care settings being developed. I ask because there is obviously an ongoing development where I believe a contract has been given to Axis Healthcare group as the appointed contractor. I want to get feedback to see what is involved in securing a location.

Pain units tend to be located in hospital settings, but there are also some units in palliative care units like Marymount in Cork where we have a theatre. It tends to be a subset of anaesthetic care usually provided in a hospital setting but strongly linked to palliative care. Local injury units are located on specific sites such as Gurranebraher and elsewhere. They provide care from 8 a.m. to 8 p.m. for defined clinical incidents up to a certain threshold. They have been quite successful in siphoning off cases that would otherwise present to emergency departments. Is the question related to primary care centres?

The Cornmarket project in County Wexford is a support service for individuals with a history of addictions. A co-ordinator in the services has contacted me to say that the HSE is set to slash 26 front-line positions in social inclusion services at the end of this year. Twelve of those positions are specific to addiction-related services, and at a time when the demand for services is spiralling into a drugs crisis, this would be detrimental. There is a serious potential outcome if these positions are lost, and we are facing a public health emergency with regard to the current spate of drugs in villages and communities in County Wexford. Most recent figures show a massive increase of 23% in drug use across the south east between 2021 and 2023. It is an educated guess that that will go up in 2024 if this is to happen. We need investment in drug treatments and services to reduce wider costs to the taxpayer, and this is where we join the dots. The Cornmarket project believes that for every €1 spent, there is a €3 saving to the taxpayer across the sector. Will the witnesses clarify the current status of the 29 vacant positions across the south east? Because it feels like the south east is continuously being hit and discriminated against with regard to health supports. The HSE substance misuse services manager position has been vacant for more than 18 months in County Wexford. Will they please address that? We are in the throes of a drug misuse pandemic.

I am not familiar with Cornmarket. I will say two things to the Deputy. I was in Ashleigh House in Coolmine, Dublin, the other day where women recovering from addiction have their children with them during their residential treatment. I have seen the fantastic outcomes there, which will save thousands for each person into the future. My plan with respect to addiction services is certainly not to cut any spending. I only see it going one way, and that is up. I will have to come back on the specifics of what the Deputy is saying because I do not know-----

I would say it makes no sense at all given that every rural community in this country is facing an existential crisis with drugs. It is no longer the pastime of those who should be avoided. It is every village and community, and every young person I am acquainted with can tell me of friends or themselves being accosted and how it is being used in different environments. Now, this is not Mr. Gloster's fault, but this is most certainly not a time when we can take the eye off the ball. It ultimately leads to chronic.

I turn to the Deputy's question on capital funding for Wexford. This year €2.2 million was allocated in the capital profile for it. I obviously do not have the capital plan for next year yet, but on the basis the €2.2 million was done, the enabling works and planning is going to happen. It is hard to see why it would not be in it. We are pressing ahead.

Yes, it relates to the Deputy's question in the first round. The model of care for eating disorders is largely community based. Our plan is for 16 teams across the country. It is true that the Deputy's area is one of those not covered, but we are hopeful. There are 11 teams of the 16 in place. Eight are for adults and eight are for CAMHS. We have 11 in place, one recruiting, and we are hopeful for two more in the coming financial year, which will include coverage of Wexford and Waterford.

I turn to the reality of what is happening in our mental health services across the board. I do not know what kind of key performance indicators the HSE is using, but I can tell the witnesses of an adult who has been separated from her children for a couple of weeks, inflicted by her mother, who took her in because she is not coping mentally. She visited local mental health services where the doctor told her to go home and cop herself on. They are probably not the words, but they were to that effect, and he said that he would see her in three months when she had been away from her small children for two weeks. Her mother was with her and intervened, at which point he conceded that he would see her in a month. Where are we going, and what kind of monitoring are we doing? Another doctor told a woman he did not believe in menopause and took her off her medication. I could be here forever. I can tell you that I am proof menopause exists if anybody wants to drive at me, no problem at all. It is not something a doctor should use as a throwaway remark.

I thank the witnesses again. I thank the staff of the HSE and the Department of Health for the work involved in preparing for today's meeting. I thank the Comptroller and Auditor General and his staff for attending and assisting the committee today. Is it agreed that the clerk will seek any follow-up information and carry out any agreed action arising from the meeting? Agreed.