We will now go into private session to consider some housekeeping matters.

The health committee will consider the HSE's national service plan for 2026. This is an important document and is essentially an agreement between the HSE and the Minister for Health that sets out how this year's multibillion euro budget will be spent. The committee is keen to examine the commitments made in the plan and, more importantly, how they will be delivered this year. We are also very conscious of the overarching priorities that should guide this plan, in particular Sláintecare and the programme for Government commitments. I think we all accept, however, that the traditional 12-month budget cycle does not serve the needs of patients and staff well. A multi-annual approach to health service funding is long overdue and the committee is eager to see the programme for Government commitment progressed.

To assist the committee's consideration of these matters, I welcome from the Health Service Executive Mr. Bernard Gloster, chief executive, Ms Sara Long, regional executive officer, Dr. Colm Henry, chief clinical officer, Mr. Patrick Lynch, national director of planning and performance, Ms Anne Marie Hoey, chief people officer, and Mr. Pat Healy, director general of the CAWT Partnership.

Witnesses are reminding of the long-standing parliamentary practice to the effect that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that may be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person outside the House or an official either by name or in such a way as to make him, her or it identifiable. I remind members they are required to be physically present within the confines of the Leinster House complex in order to participate in meetings. I will not allow a member to participate from outside Parliament.

I invite Mr. Gloster to make his opening remarks on behalf of the HSE.

I thank the Chair and members for the invitation to meet with the committee to discuss the national service plan for the Health Service Executive for 2026. The Chair has already introduced my colleagues and I am supported by Ms Sara Maxwell, the general manager in my office.

The national service plan for 2026 sets out an ambitious programme of work to build on the progress of 2025 and is set within a resource allocation to the HSE of €29 billion and 160,270 whole-time equivalent, WTE, positions, of which disability services comprise €3.8 billion and 23,664 WTE.

Members will be aware the HSE now has two line Departments, recognising the transfer of functions in 2023 in respect of disability services. The focus of my appearance before this committee is in respect of the health and social care services aspects of the service plan, which are under the auspices of the Minister for Health, Deputy Jennifer Carroll MacNeill, and supported by the Ministers of State, Deputies Mary Butler, Jennifer Murnane O’Connor and Kieran O’Donnell.

Directed by the Minister through the letter of determination, the plan provides extensive resources for the delivery and development of health and social care services. In the 2026 provision, the WTE aspect of the health service is 136,606, with Revenue funding of €25.2 billion and funding in capital of €1.54 billion. There is an error in the circulated opening statement stating that the figure is €1.56 billion, but it is €1.54 billion.

The scale of demand for services continues to grow. Our population is now greater than 5.3 million people, is older and is living longer than ever before. This welcome position brings particular health considerations, with the population aged over 65 years projected to grow from 780,000 in 2022 to over 1.3 million by 2040, increasing their share of the total population from 15% to 21%. The over-85 age group, at circa 85,000, is likely to quadruple over the next 30 years and this is a particular marker for healthcare planning. With an expected prevalence of chronic disease of 53.8% among adults aged over 50 years, the number of people with chronic disease in Ireland could increase from approximately 778,000 people in 2016 to over 1 million by 2030.

In recent months, we can see the impact of this demographic trend in the demand for both scheduled and unscheduled care services, and in particular the demand from older people. The recently published HSE Corporate Plan 2025-2027 is of assistance to us in strategically planning for this scale of challenge through five key pillars: healthy communities, the right care, the right place, the right time and supported by strong foundations.

It is in this context that we have approached 2026 in our in-year planning. As the result of significant work in 2025, we now have a strong foundation of resources, reforms of practice and improved methodologies for delivering services. The plan is detailed and focused, with a heavy emphasis on both the population-wide focus of our six new regions and the use of measurable performance to drive improvement in a way that is fair but accountable and transparent.

In terms of capacity, the plan will build on recent years by adding a further 428 community beds and 177 acute hospital beds. In addition, an increase in virtual beds across our acute hospital network will reflect the capacity that can be created by merging clinical efficacy with technology. Five new surgical hubs will become operational and two more will commence development to design stage. Mental health, paediatric, maternity, elective and primary care projects will all advance. Use of existing built capacity is as important as new capacity, and 2026 will see additional focus on evening and weekend options, particularly for outpatients. This, added to the now commenced outpatient department toolkit, will ensure we achieve maximum benefit from what we have already available to us.

A new workforce of 3,300 whole-time equivalents will be added to the already approved and funded resource of 133,000. The principal focus in 2026 will be on five-over-seven working, further full maximisation of the benefit of the public-only consultant contact, POCC, in particular agency change in dependency, and also a chance for regions to balance the different levels of services that are underperforming compared with their peers.

I want to address timely access to scheduled care. The national service plan is supported by the recently published waiting time action plan. Despite some challenges on parts of the internal targets in 2025, reductions in waiting times remain the focus and continue to show a very strong position compared with the position of a short few years ago. It is of note that some 82% of people on one of the lists measured by the National Treatment Purchase Fund, NTPF, at the start of 2025 were not on that list at the end of the year. To understand the volume of this, the end of December concluded a year in which 1.928 million patients had been added and 1.84 million patients removed from these lists. By any measure, this is enormous turnover in a system known to experience the impact of the dominant emergency care demand against which these lists have traditionally competed.

In 2026, the HSE will see 4.33 million attendances at outpatient departments and outsource 2,500 and the NTPF will provide for a further 100,000. Approximately 1.32 million of these people will be new patients being attended to and seen, as reported by the NTPF. Regarding inpatient day cases and scopes, a further 1.46 million people will be seen and treated, with fewer than 50,000 of those reliant on HSE or NTPF outsourcing. This rises to over 2 million procedures when chemotherapy and dialysis procedures are included.

Improvements will continue to be made in seeing patients waiting 48 months and 24 months, and figures for these have already seen improvements of 20% and 30%, respectively. We are also seeking to move beyond the number of people within the Sláintecare timeframe from over 31% to 50%. We fully appreciate that is a target we had in 2025 that we did not achieve. This will be a year when the combined effect of the use of existing resources, new resources, surgical hubs, performance managed transparent reform, virtual care, targeted toolkits and clinical leadership and innovation will see further significant improvements in response to increasing demand of approximately 4.5% on standard outpatient and elective lists. More people continuing to wait less time is the only measure of success in this context.

The Minister has given specific directions to move beyond the traditional NTPF lists and tackle the challenge of those needing access to primary care services. A recently commenced programmatic approach to primary care waiting times will see, in 2026, a reduction of 60,000 people in the standard three therapies lists and, critically, a sustainable model of moving to inside 39 weeks waiting for these services.

On unscheduled care, I am very much aware of the significant challenge for the public, particularly patients admitted via emergency departments, who spend time on a trolley waiting for more suitable care. In 2025, we saw 1.6 million people attend our emergency departments. This was a national growth of 4.3%, or approximately 200 extra people a day, which was higher at many individual sites. Yet, in that context, we have reduced the trolley waiting numbers by 10%, which, again, was higher at many individual sites. Early 2026 saw an unprecedented growth in emergency department, ED, attendances compared with the same period in 2025. In the first 27 days of January, we recorded growth factors of between 13% and 18%, or an additional 700 a day attending emergency departments. This resulted in a challenging month but, again, one in which some improvements were achieved overall. A total of 29 ED sites now report having a green status in a more sustainable way, which is a significant indicator of improvement in how patient flow is managed and experienced. I am aware that this remains a challenge for the public in some locations. Again, reform in 2026, building on 2025, will be essential to mitigate the impact of this phenomenon.

The response to challenges in all aspects of access to care is the focus of ongoing engagements since September, and again this month and this week, where regions participate in detailed, data-driven and qualitative-focused workshops chaired jointly by the Minister and me as CEO. This oversight, in addition to all performance management processes, will continue in 2026.

The plan also provides for key service focus, some of which I have highlighted in my opening statement. The improvements include: 223,000 women, or more than 36% growth on 2025, will have mammogram testing and 240,000 women, which is a growth of 18%, will have cervical screening; all maternity units will implement the maternity early warning score system, which is an increase of 22%; 73,000 more people will be covered by a GP visit card; home support hours for older people will increase by 5%; over 2,000 more children will be seen in child and adolescent mental health services, CAMHS, and 3,700 more adults will be seen in adult mental health services; GP out-of-hours contacts will increase by 12.% to 1.2 million; 95% of patients referred to rapid access breast clinics will be seen in two weeks, which is an improvement of 30% on last year; and similar improvements in terms of the most appropriate location to treat stroke patients, medicines management, pharmacy reform, industry contract reform and high standards of probity, which will all allow for continued access to new drugs and medicines.

These are some of the key aspects of the 2026 national service plan, which comes off the end of the first year when we achieved the financial and workforce resource targets set by the Government to enable a sustainable health service into the future. That means we have achieved an effective break-even position for the first time in a very long time. It is within that context that we have seen that control, productivity, reform and effective management mean we can now combine new resources, and how we use the resources we already have, to deliver safer and better healthcare. As this is my final scheduled appearance, I want to express my sincere thanks to the Chair, the members of this committee and, indeed, members of all of the Oireachtas committees with whom I have engaged over the course of my career, and particularly as CEO of the HSE. I wish the committee well in its future work. I am happy, with my colleagues, to take any questions.

I thank Mr. Gloster. I invite members to discuss these matters with the witnesses. Members have eight minutes each and we will start with Deputy Daly from Fianna Fáil.

As today is the last time Mr. Gloster will appear before this committee, I want to recognise his service to the HSE and to public health in Ireland. In all my dealings with him, both in my previous life as an advocate for the Irish Medical Organisation and as a Deputy, he has been honest and transparent in all our dealings. He is a very straight man. I wish him well in his retirement and a long life, health and happiness.

I thank the Deputy.

I will now reflect on the report.

I thank Mr. Gloster and his team for coming here today. We appreciate that. The report reflects a population getting older, more comorbidities, a rising population and a more sophisticated population that is well travelled and informed by its experiences of other health services around the world while expecting more from our health service. I will reflect on a meeting I had yesterday with a self-employed mother of three in Ballinasloe who came back from Australia 12 years ago. She is hard-pressed and is spending €4,000 on private health insurance because she feels she needs that to give her family cover in addition to quite expensive childcare. That is the context. When we talk about services, we have to bring it down to individual people.

I will try and keep the questions short and direct. Mr. Gloster referred to scheduled care and the lack of consistency around the country in regard to some of the waiting times for people in emergency rooms, etc. Could he reflect on that briefly?

Sure. I can do it in respect of as recently as last weekend. I was on all weekend because we are obviously coming off the back of an accelerated growth in demand and the end of the traditional flu season. When I look at how the demand for unscheduled care presses on every region, some more than others, and at how regions have changed in order to manage their patient flow systems, that is where the lack of consistency frustrates me. People in regions will argue about history, resources and different things and all of those are factors but they affect everybody. The regional executive officer for HSE Dublin and north east is with me today. Dublin and north east is a region that has achieved one of the most consistent performances inside its green marker threshold for trolleys. When a site goes red like the Mater did on Tuesday, it recovers very quickly. That is very consistent, whereas when I go to the Deputy's region, it is quite an unpredictable scenario. It is very difficult to predict the unscheduled care performance in the west with any certainty. It is something I am quite concerned about. I will be meeting those involved along with the Minister next week at one of the scheduled workshops. I have a national team that has travelled to the west today for three days to help me form a deeper view as to-----

It is something the Minister has reflected on publicly, so I am not trying to target anyone, However, there is no doubt-----

No. There is a reality of experience for the people in the west and the north west-----

To learn from other parts of the organisation nationally.

Yes, that is correct.

A significant amount of effort has obviously gone into the management of unscheduled care in other parts of the country. We should have the same level of efficiency in the west and the north west. It is just a reflection, and I appreciate Mr. Gloster's answer.

I fully agree.

It is a bit like a sinking ship at times. I noted that for scheduled care, in spite of 1.84 million people being removed from waiting lists, we saw 1.928 million added to them. That is a considerable challenge for our health services in terms of our capacity to respond. I will move on. That is more of a statement and I accept what Mr. Gloster has stated.

In primary care, we have in our area of Roscommon-Galway the town of Ballaghaderreen, which has significant challenges in term of poverty and deprivation. In the national school there, 22 different languages are spoken. They were promised a primary care centre for a long number of years. Could Mr. Gloster reflect again - I asked this question before - on the model of developer-led primary care provision? Should it not be the purview of the State to provide these builds directly?

I was around when we had no developer-led model and we built health centres, as we called them then.

Yes.

I was around for the public-private partnership, PPP, model, which gave us a certain number, but it would not be a model I favour. The lease model has delivered well in many parts of the country, and I am glad to see that. We are going to continue to pursue it this year. The policy question that arises - I know it is one the Minister is reflecting on - is that when the lease model simply does not give a community what it needs within a reasonable timeframe, the State should consider proceeding to direct capital build and investment. That would seem to be the best position.

I am old enough to remember the first batch of primary care centres in Donegal.

That is right.

For some reason, Donegal built a number of them in the north west. They were very successful models. In communities where there is significant need, the State should be taking the lead in providing those centres.

While the capital plan has many demands on it, I certainly know from my most recent discussions with the Minister that she is not locked in to the developer model solely. She wants to see the infrastructure for communities, however it is achieved.

I just feel Ballaghaderreen has been failed by this model. It is the model that has failed.

I would not dispute that.

On the doctor visit-only card scheme, why is there such a poor uptake in spite of-----

I might ask Mr. Healy, who is deeply soaked in that, to give an insight.

It is actually difficult to say because there are people who should be taking it up. What we have tried to do with the Department and the HSE is to do significant communication campaigns. We have also focused on our primary care reimbursement service, PCRS, system in the context of making it as simple as possible for people to apply. We have another campaign on that this year. There is an issue about encouraging everybody to take it up.

Have we profiled the types of people who are not taking it up? I can see families taking it up. Is it single people who are working and on low incomes who do not see the value in the doctor visit card?

It appears to be a mix but definitely, more single people are a part of that, particularly younger, male, single people. What we have been doing then is quite a bit in regard to research to try to target, go out and research why and who.

I am sorry, but I am tight on time. What capacity is there for it to be delivered if everyone took up the entitlement?

Between the medical card and the GP visit card-----

No, just the GP visit card.

We have 700,000 at the moment.

Of the cohort that comprised the additional amount, was it 350,000 extra?

That is right. We have not reached that. We have not reached 50%-----

Is it 50,000 or 60,000?

Yes.

So it is a pretty poor uptake. It would be important to have an idea of why that has happened. That is not an attack or anything but we should learn the reasons why someone would not take up what is a valuable entitlement to primary care.

On breast cancer, I was happy to see that 95% of women are offered urgent breast cancer assessments within two weeks if their cases are marked urgent. One of the issues arising in the west and north west, from a number of representations, is a lengthening interval between a diagnosis of breast cancer after assessment and the offer of treatment. Could the witnesses reflect on that?

We will just get a quick answer on that because we are running out of time.

I will answer that if we have time. We are putting more resources into the whole breast screening and treatment pathway. As the Deputy knows, the screening identifies women who then need timely treatment. There have been some delays in some areas. Part of the remit of the national cancer control programme for 2026 will be working with the regions to ensure the end-to-end pathway is delivered in a timely way consistent with the screening programme.

I will start by wishing Mr. Gloster well and thanking him for all the work he has done and the support he has given to every member of this committee and to the Oireachtas. If I was asked to identify a good, competent, professional public servant, I would say Bernard Gloster. I say that sincerely. He has been outstanding. In the context of the issues we raise at this committee in relation to culture and governance, he has been to the fore in tackling many of them. I again thank him for the work he has done and wish him well.

There are lots of issues we want to get through and we have a very short period to do so. I want to start with an issue that has arisen in the past number of weeks in relation to clinical measurement physiologists. Mr. Gloster might have seen some of the commentary on that. Has the HSE required that any clinical measurement physiologist, CMP, trained outside of Ireland must obtain recognition of equivalence from the Irish Institute Clinical Measurement Physiology, IICMP?

Could the Deputy repeat the question? I missed it. I am sorry.

Is it a HSE requirement that any clinical measurement physiologist trained outside of Ireland must obtain recognition of equivalence from the IICMP?

That body is not a regulatory body but we are engaging with it to look at courses that are offered, for example in University College Cork, UCC, to see if they can be validated through a process that is usually done in other professions by the Medical Council or the Nursing and Midwifery Board of Ireland

Is it a requirement?

It is not. It informs us in making the decision.

It is not, Deputy.

I have two memos that were sent to me recently. One was sent by the HSE to hospitals in 2023 and the other was sent in 2025.

The memos that were sent seem to suggest that it is a requirement. In fact, they are comprehensive. They were sent out by Ms Hoey. The do not distinguish between permanent, temporary and agency staff. They state that it is a requirement. The also state that the standards, which were reviewed and approved by the HSE clinical measurement oversight group, would apply to the practice of clinical measurement physiology in this State in the context of the disciplines that are set out.

I will ask Ms Hoey to clarify.

At the moment, we would be familiar with regulation by a body such as CORU. The CMPs are not regulated by CORU. We are working with the IICMP towards standards and accreditation. As my colleague,Dr. Henry stated, we are working with it in terms of the course in UCC, for example, and that is towards standards for proficiency.

What I am talking about here is a requirement. I want to give a synopsis of what was stated in both memos. They refer to: the finalisation of national processes for recognition of overseas qualifications; approval and monitoring of education programmes; formal endorsement of the IICMP standard suite, which, it is made clear, has to be done; and reliance on the IICMP as the professional body advising on eligibility. The memos that were sent out by the HSE clearly set out that this should be done. However, information that has appeared in the public domain indicates that hospitals have bypassed those memos and have hired physiologists that do not meet those standards. Is that Ms Hoey's understanding of what happened?

We entered into a service level agreement, SLA, with the IICMP in 2024. It is working with us to process overseas applications and to establish and publish standards of proficiency and progress to be accredited.

Ms Hoey is not getting to the root of the issue I am raising. I am looking at, and I have read from in detail, two memos that were issued by Ms Hoey on behalf of the HSE. Those members make clear that eligibility has to be based on the standards to which I refer. What those standards are is set out in both. What is stated is very clear and unequivocal, but it seems that the memos were bypassed. In fact, the IICMP wrote to the HSE in 2024 raising concerns. Is that correct?

We continue to work with the IICMP towards that-----

No. That is not what I asked. I have asked Ms Hoey-----

Notwithstanding this, we have----

With respect, I am asking questions and I want the answers to them. I asked whether the IICMP formally raised concerns with the HSE in relation to these matters in November 2024.

It did. Since then, we have entered-----

What concerns did it raise?

It raised concerns, if you like, in relation to having accreditation in place. We acknowledge and accept that. We have been working with the IICMP since 2024 under, by means of an SLA, to achieve that accreditation. Notwithstanding that, we have employed this very important cohort of staff for a number of years now. They continue to provide their services while we continue to engage and work with the IICMP to achieve the standards and accreditation.

Mr. Gloster, there are issues here that need to be fully examined. My understanding is that an audit was meant to be carried out to establish how many of these physiologists were operating without meeting what would be seen as the acceptable standard. I am asking that this be looked at.

It is a fair call. I saw the weekly reports. There are also industrial relations issues going on, but it is a fair call.

I will go back to the point that Dr. Henry made. Fundamentally, the real resolution to that issue is making sure that there is a regulatory standard applied to the profession, be that by CORU or by any other registering body. It is helpful that the IICMP, as an association, is helping us but, fundamentally, it is not a regulatory body. It is fair to say that when a direction like that issues and where the body involved is not a regulatory body, there is no doubt that local services will depart from it. We have to put our hands up and say that. My fundamental view is nobody should be offering any type of a service in respect of a patient unless they are qualified to a standard that we accept as being the standard.

My quarrel is not with Mr. Gloster, Ms Hoey or anybody sitting here.

I understand that.

In fairness, those memos were sent out. Ms Hoey did her job, as far as I can see, in setting out the position and giving a clear direction. Unfortunately, it was not followed. That is wrong. We cannot accept that because there are patient issues potentially if that happens. As I stated earlier when I was talking about Mr. Gloster's role as the head of the HSE, these are issues he takes very seriously-----

Absolutely.

-----and I would hope that the incoming CEO will do so as well.

I want to ask a question of Mr. Gloster in relation to healthcare assistants. As Mr. Gloster will be aware, there is potential industrial action. A number of them in different parts of the country have voted for industrial action. They are important members of the health service, a view Mr. Gloster would support. They do good work, important work. It is regrettable it has got to this point. I ask that every effort be made to resolve this issue and that we do not have strike action or industrial action from people who do not want to strike but have raised with me - I have met many of them - genuine issues that they see have not been dealt with by the HSE.

I have stated publicly that the most important people in that equation are those who receive the service and those who provide it. I am of the view sensible resolutions can be found.

I would say, to be fair, that after I came into this job, we reset the rates that we pay all the providers for home help services to a very substantially improved level and it was up to them to apply that to their staff to make sure at least there was a living wage. Some did, some did not and some have sought to try to come in under the banner of a different agreement, which is the section 39 workers, and that is not going to happen because the precedental impact for the State would absolute destroy its ability to have any type of relationship. I absolutely agree with the Deputy. Sensible solutions need to be found. I believe that they will be.

The next slot is for Fine Gael. I call Deputy Burke.

Like my colleagues, I thank Mr. Gloster for the work he has done and for driving forward the change that was necessary in the HSE. I wish him well, no matter what position he takes on into the future.

Mr. Gloster raised the issue about staff allocations. One of the issues that I found in the HSE is that sometimes we have half a team trying to provide a service and there is a part of it missing. In Cork, for example, we had a problem where there was a shortage of ten radiation therapists. Now, that issue is resolved. I wonder has there been an overall review of services, making sure we are appointing people where the service can be delivered. Has there been an audit done in each individual area, looking at that issue to make sure that we are carefully planning and where we are positioning people to take on new roles?

Long-term workforce planning is something that has improved substantially, but it has a way to go. I would say that the intervention that was made in this year's service plan is the greatest opportunity of addressing exactly the point the Deputy has spoken about because what we have done is given each region an allocation of posts. We have not prescribed what they are for, but we have stipulated that they must identify where the service deficits and gaps are and utilise them to fill those.

The reason I raise it is that in the next hour a research report by the Swedish Institute of Health Economics on our cancer services will be launched. I ask, when that is published, that the HSE would look at it because it has clearly identified where there are glitches in the cancer services. It is in relation to where we have a particular problem in one area of the country where we do not have the same number of consultants per head of population.

We also have an issue in relation to cancer, say, with the lower socioeconomic group, as regards the need for education. Of course, the whole idea is about prevention rather than trying to deal with care, if we can do a lot more in relation to education in that group. I am merely saying that the report is worth looking at.

In relation to the provision for additional beds in community care, the HSE is talking about 426 additional community beds. Can we have a breakdown as to where they will be? Mr. Gloster may not have it today, but it could be sent on.

We have that available. We can send it to the Deputy.

On the issue of HSE nursing home beds, 33% of the funding under the fair deal scheme is looking after 18% of the patients. On the question of value for money, there is now huge pressure on the private sector. For instance, a nursing home in my constituency, Blair's Hill, is closing. As a result, 35 residents will have to find alternative accommodation.

That will be a challenge in the future. Mr. Gloster raised the issue about the increase in the population of the over-65s to over 1 million. Are we doing enough planning in that whole area? Are we getting value for money in the planning we are doing?

We are somewhat better at it. The Deputy has raised with me many times the difference between the cost of running a public bed versus a private bed. I must say that I also have issues with some parts of the private sector and how they conduct their business. The difficulty we have as a State is that our dependence on the private sector is too high. There is absolutely room for private provision, and we should have it, but our dependence on it is so high that we become very vulnerable when any one of the entities collapses, for whatever reason.

Does Mr. Gloster accept that there is going to be a huge increase in demand in this area over the next four-----

Four things need to happen. To be fair to the Minister of State, Deputy O'Donnell, and the Minister, Deputy Carroll MacNeill, all four are receiving adequate attention. The first is the amount of things that are keeping people more healthy so that we reduce their dependence on going into care. The second is the proposal to move to a regulated home care service, followed, we hope, by a statutory home care scheme. The third is to improve the standard of residential care so that people can depend on it without the risk of it closing. The fourth is increasing capacity. We need to do work in all four of those areas.

Does Mr. Gloster accept that we also need to increase capacity in step-down facilities?

Yes, 100%.

We want to get people out of hospital because they are occupying a bed when they do not need to be in hospital-----

That is right.

-----but need a level of care to get them back home.

Sometimes the private sector chooses not to give us credit for this but we buy a phenomenal amount of step-down care from the private sector. It is, I would say, one of the things that is quite significant for the private sector in its business model. The only way we are going to get people out of acute hospitals in time and appropriately, and give them the best possible chance of going home again, is by having appropriate step-down facilities and various levels of rehabilitative intervention in the step-down models of care that we have. That is ultimately-----

Are we going to increase the number of step-down beds for 2026?

Yes.

What additional numbers are we talking about?

This is one of the reasons that we have given regions flexibility. Let us consider the 436 community beds. I recently visited Louth, where Ms Long is shortly to open a new community nursing unit under the public-private partnership model. When it was built, it was built for 50 long-stay beds. She has now chosen to make 20 of the beds long stay and 30 step-down or rehabilitation beds. Those beds will produce enormously positive outcomes and allow people to go home, as opposed to going into care and decondition, which I know Dr. Henry and Deputy Daly would give you ten rounds on. Each region will now have flexibility on what it does with its bed stock.

There is one other issue I want to raise. Mr. Gloster talks about the numbers of people going into accident and emergency departments. The minor injuries unit in on St. Mary's campus in Cork, for example, is a fantastic facility.

It is super.

The average turnover there from the time a person comes in the door to the time he or she is leaving is approximately two hours.

That is right.

That is huge. Are there any proposals to increase the number of minor injuries units across the country, rather than relying on accident and emergency departments?

Yes. They are slow to develop because when they develop first, you do not have either public or clinical confidence in them. I will take the example of the one I am familiar with, which is in Ennis. It is now humming. It is absolutely hopping. However, for two or three years, we could not get people to go there. It is about confidence. The Minister most recently approved a unit in Ballina, Mayo. That is a large rural domain with a single dependency on Castlebar hospital. I expect that will pull approximately 8,000 emergency departments attendances per year from Sligo and Mayo hospitals. It will mean that people in Mayo have to travel a shorter distance. That will bring us to 15 or 16 local injury units. Once we get beyond developing surgical hubs this year, the amount of local injury units will start to increase exponentially.

Mr. Gloster might be able to get the figures for what the minor injury units are doing. It is important that those figures get out. In relation to a minor injuries unit in Dublin, is there any proposal to deal with that issue?

I ask Mr. Gloster to give a brief answer to that question.

We have Smithfield in Dublin, but I am not sure beyond that.

Where there is a large population, we should be looking at-----

Yes, that is a fair point.

Appendix 2 to the service plan has a list of where all the beds are going, if members want to get that from the HSE website. We will, in any event, write to the committee.

I have a number of questions at this point. I, too, would like to thank Mr. Gloster for his engagement, openness and frankness. It has always been a pleasure to have him before the committee. I thank him for his work and service.

I will pick up on two points from earlier. Deputy Daly asked about the GP visit card. I recently heard from a third level student who was applying for it but gave up because the process was too cumbersome. There is a level of bureaucracy that we need to tackle. Similarly, a person attending my constituency clinic last Friday applied for a medical card. He really struggled to apply. He was engaging with social welfare and had provided all his information to the Department of social welfare quite recently. He found the process far too difficult and cumbersome. We need to make it simpler for people to engage and to apply for the services to which they are entitled.

One thing I find is that it can sometimes be quite hard to figure out what is new, which are additional services, and where the real improvements are, year on year, when we look at the service plans. It is not just an issue for the HSE but applies to all public services. I note that in 2026, 177 acute hospital beds are to be delivered, which is a significant reduction on last year's target of 297 beds. In November, 112 of the 297 beds had still not opened. How many of the 2025 beds are still outstanding?

Is the Cathaoirleach referring to the ones that are built and open?

Of last year's 297 beds, how many are still outstanding? In November, there were 112.

Some 228 have been constructed. An additional 12 were funded from revenue, so 240 of the 297 have been constructed. The latest figures I have show that 198 of them are operational. For some, it is a matter of the timing between construction finishing and-----

That is 198 of the 297.

Yes, those are operational but then 240 beds have been constructed. There is a commitment in the service plan this year that there will be a closing of the time between beds being constructed and becoming operational so we are not leaving beds that are constructed-----

Are some of the beds announced in the 2026 service plan just a repackaging of the undelivered beds from 2025?

No.

As for the beds in the 2025 plan that might not yet be open at the time the plan is published, they are all in recruitment or going into recruitment. I made the point at my most recent attendance at the committee that the staffing allocations have now been made to the regions. The only outcome required of them is that they commission and open all of their capital facilities, such as the surgical hubs and the beds. It is based on the Frank Clarke recommendation in Limerick, where we staffed the beds before the builder finished. We are now moving to that model.

There are, for example, 24 beds listed for Mallow General Hospital and 12 beds for the oncology unit in the Mater were listed in last year's plan and again-----

The beds in Mallow are opening at the end of this quarter. They are not included in this year's figures, however.

They are not included in this year's figures. They were a part of last year's figures.

They are separate beds, yes.

On community beds, the new service plan states that 428 community beds will be delivered in 2026. There are undelivered community beds under the public-private partnership project that was due to deliver 530 community beds by 2024. Are they some of the same beds or are they different?

This is on the public-private partnership beds that are coming on.

The community side was slower last year, particularly because of some of the public-private partnership ones. The biggest ones will come on stream early this year, however.

Are those included in the numbers for this year?

Yes.

Those beds were due by 2024 but are in the service plan for 2026-----

There was an interminable delay on the public-private partnership model.

Is there a repackaging of beds that were announced previously? Those beds were due by 2024. They are now in the service plan for 2026. They have been re-announced or repackaged. Do the witnesses agree?

I would need to check. I know that some of the three biggest ones were delayed, comprising those in St. Finbarr's in Cork, Killarney community nursing unit, CNU, and Clonmel CNU. They will all come on stream in quarter 1.

Are they included in the 428?

I would need to go back-----

We need to clarify that.

There is a concern that they will be repackaged and re-announced continuously.

St. Finbarr's Hospital is in my own constituency and like the rest it was due to be delivered in 2024 but the builders are still on site there and I understand it is to be handed over to the HSE at the end of March.

Whether they are part of the number this year in the service plan or not, my focus and emphasis is that they were too slow coming on the PPP model. They are now coming on and we need to get them open for the people of the constituency, no matter which year we count them in. That is where the focus is.

I would urge against this repackaging and re-announcing of things.

I take that point.

On surgical hubs, the service plan says that five surgical hubs will be delivered this year, in Cork, Galway, Limerick, north Dublin and Waterford. Other than the surgical hub in north Dublin, I understand that the other four are still under construction. Is that the case?

Yes, they are but progressing at a very rapid pace.

The service plan says that the four still under construction will be open and operational by quarter 3. Are you confident to meet this target?

I would put the Limerick one last at quarter 4 but the stretch target is quarter 3 for all of them.

What is the position in respect of staffing and funding for the surgical hubs?

All provided for at the start of the year. The regions can now proceed to recruit for them.

Is recruitment under way?

All of the 3,300 jobs approved for this year - unlike last year when some of them got held up because of overspends on agency - have to go into recruitment in the first quarter of the year to be ready for their various commitments, yes.

In relation to the elective hospitals, are you confident that the planning application for the elective hospital in Cork will be submitted this year, given the road access issues with the St. Stephen's Hospital site?

I am confident we will do what we need to do to submit the planning application. I think there was some improvement in the level of engagement with the local authority as to how the road issue might get resolved in a planning application. How that will finally play out we are going to have to see. There is a question of whether we apply for the road or somebody else applies for the road but I am confident that the application for the elective hospital will be resolved and submitted.

This year.

At what point was the access issue identified? Was it flagged before the site was chosen?

I am not sure exactly at what point the formal issue was documented as being a showstopper. Going back two years when I was talking about the mental health aspect of that site in Glanmire I certainly had an awareness that the road access was going to be an issue. I think it just became a bit more acute in the last year as to whose issue it is to resolve.

Is this one of those things where it is a blame game between the council and the HSE?

I would want to be fair to the local authority as much as I would want to be fair to my own people. The public should not be interested in or occupied by whose row it is. We are all public servants funded by the State and we just need to sort the thing out and move it on. That is why I am confident the planning application will be moved on. If we all work together, it should not become a spat between us. It would be an unsightly thing for two public bodies to be spatting and holding up something as significant as the development of a hospital.

We hope the application goes in this year and it gets delivered as soon as possible, because it is urgently required. Deputy Sherlock is next.

I thank Mr. Gloster for all his work over many years in the public sector. He has brought very honest and transparent leadership to the HSE By its very nature, health is a very opaque system but on behalf of the Labour Party, I thank him for all the work he has done and for his generosity with his time in answering our questions when we posed them to him. I want to wish him all the very best and to echo Deputy Cullinane's comments about what a public servant should look like.

Just under half of all the over-75s who are attending emergency departments were waiting nine hours or more last year. When we look at the figures in the previous year, there was no change. There has been no improvement over the past year. Obviously, part of that is because of the acute hospital capacity and the step-down beds. Some of the conversation on the step-down beds has already been covered but I want to ask about the commitment to 134 new acute beds in the service plan. When we look at the bed expansion capacity plan in 2024, just short of 3,000 beds were being committed to between 2025 and 2031 and yet we seeing only a commitment to 134 beds this year. Is the 2024 plan now redundant? I look at the Minister's letter of determination to Mr. Gloster and I see very little emphasis on expanding capacity. While we are all very supportive of greater productivity within the health system, building additional capacity is critical. I want to hear what is the plan to meet that critical bed need over the coming years?

We put an enormous emphasis on the over-75 cohort. When I came into this job, people over 75 were waiting regularly more than 24 hours on trolleys. With Dr. Henry's help, we really drove a major shift in emphasis. We now tag people over 75 in emergency departments and we have dedicated staff keeping an eye on them and advocating for them. Does it work everywhere? No, there is always more to do. To any family who have found themselves in that situation, it is one of the things that will always be to my greatest regret that it ever happened even once and that is the truth. It is shame on us that that happens.

In relation to the bed plan, the Minister has not dispensed with the 2024 intentions or plans by any means. What has happened since, as the Deputy will have seen in the latter part of last year is the national development plan. This provides an envelope for the Minister and the Minister has instructed the HSE to keep bringing forward shovel-ready projects, which will be funded and supported. This applies in the surgical hubs and the new maternity hospital. The beds we are finishing out are from a programme from five years ago really. The instruction is to keep bringing forward the elective hospitals, where there is a lot of bed capacity. This is more than an aspiration. I think there is a shared view that we need to build a large scale of capacity between now and 2031, both in actual physical beds and in the use of virtual care capacity.

I am looking at a document here which says that Beaumont Hospital is supposed to have 232 extra beds by 2031. Cork is supposed to have 341 extra beds. Are the wheels in motion now to deliver that by 2031? I does not seem to me that they are when I look at the service plan and when I consider everything that has been said over the past year.

The local planning and local commissioning of design teams are all at different stages and they are all moving. In any one year we have to look at what is shovel-ready to go into building and be done. The Deputy saw the 96 beds in Limerick last year. We would probably have built another 96 in Limerick by next year had we not met with a major planning application. We are now clear of the planning and that building is literally flying up out of the ground. That is another 96 and in all of the different projects, we are pursuing those. However, we cannot arrive at a point yet where we can say that every project will be ready and finished by 2031.

I appreciate that but what I want to be clear on is that we saw the Minister get a lot less last year in the NDP allocation than any of us would have liked. The critical question now is, in terms of improving patient flow through the hospital - and we know that 145,000 beds were lost because of delayed transfers of care last year - is the money available and is the planning happening for that bed capacity to happen to the extent that we will see 3,000 more beds in the system over the next five years?

In the capital plan, which the Minister will publish shortly for this year, the Deputy will see the range of those projects that are at various stages of design and at various stages of progress. Ms Long might want come in on this.

I will pick up on Beaumont Hospital. Regarding its capital development, its third CT scanner was completed this year and its 20-bed cystic fibrosis unit is going to be operational-----

Sorry, I am just asking about the expansion in the coming years as opposed to what has been previously. I appreciate everything that has been done but looking ahead is the question. I am conscious of the time ticking away.

There are either enabling works taking place, projects are at feasibility study stage or projects are at design stage. Particularly on the Beaumont site, there is a lot of enabling works. We have to do one thing before we can do another thing before we can do the next thing.

On the public-only consultant contracts, the deadline was the end of 2025. There is an issue with obstetrics and we heard what the master of the National Maternity Hospital, Holles Street, had to say a number of weeks ago. Are obstetricians getting a by or a pass or what is happening?

Definitively not. The public-only contract is now the only contract in Ireland for consultant doctors in any specialty.

There is not going to be a by or pass, and maternity and obstetric care will be delivered under the public contract in all our maternity units. We will fund that.

Has action been taken to ask all the current obstetricians?

No. They are all entitled to stay on the contract they have until they retire. I think what the-----

The leadership in a particular hospital is questioning whether it should happen at all. Is that an issue?

The leadership in the hospital is entitled to question whether it should happen or not, but that is different from the decision. The decision is that every obstetrician hired in Ireland from now on will be hired under the public-only consultant contract.

Regarding GP care, in parts of my constituency, there is one GP per 3,500 people. The numbers vary wildly across the country. In other parts, it is one GP per 1,500 people. Does the HSE see this as a problem?

Yes.

What is it doing about it?

We have increased the number of training places to 350 this year. The first- and second-year cohort of GP trainees now stands at 350. In another two years, we will have an output of 350. We have then done two supplementary things. First, we brought in a cohort of doctors from South Africa who were trained to a very high standard. They can practice here for two years and then be registered as GPs. We have targeted them at areas of rural isolation or social deprivation, where it is harder to get GPs.

The final piece is the supports for different GP-type practice models and group models, which is making it more attractive. The Deputy is probably familiar with the GP Care For All story in Summerhill.

Thank you, Mr. Gloster.

A lot of effort is being made there.

The strategic review is obviously late. It has been promised for over a year now. I do not know why that is the case.

The Deputy will see it shortly.

The location of GPs has to be a critical part of that plan, not just the numbers.

I agree 100%.

Next is the Fianna Fáil slot, with Deputy Cahill.

I also extend my best wishes to Mr. Gloster and wish him every good health and happiness. I thank him for his help at all times during my short time here. His effectiveness and ability have not gone unnoticed. Nationally, he has done our country proud.

There have been hiccups with the primary care centres in Cahersiveen and Killarney. Can we get a timeframe for those?

I do not have the detail, but some of the issues there are being resolved through our estates teams. We can get the detail of those two for the Deputy.

Rather than going into the minutiae of the issues, which can occur in that particular developer model, which we discussed earlier, I will say that we are not going to leave any stone unturned to make those happen.

Both centres are really needed.

When I visit Kerry hospital, which is often do, I look at it as a health service and the health service in Kerry needs that additional support.

Is there an opening date for the new community hospital in Killarney?

That is in quarter 1.

It is in quarter 1, in the next few weeks.

It is developed and ready to open.

It will be opened in a few weeks.

On opening beds that remain closed in Dingle, Kenmare and Cahersiveen, I know staffing has been an issue there. Is there any way to incentivise staff to come to these areas and, in particular, peninsulas?

The short answer is I cannot do so. How would the State incentivise gardaí to come to Dublin? How would I incentivise public health nurses to work where Deputy Sherlock is? It would fracture the entire public service model to try to incentivise. I would hope the beauty of Dingle alone would attract some people. That is the best I can do.

Respite for children and adults with profound disabilities is something I have raised many times as a TD here and as a councillor at home in Kerry for many years. There is a chronic shortage of respite beds. Parents tell me they are waiting six and seven months. We have a fabulous centre, St. Mary of the Angels, in Whitefield in Beaufort, where St. Francis Special School is also located. I keep saying this is an ideal location. It was donated for children by the Doyle family many years ago and there is plenty of development land there. We really need to do something on respite. People are on their knees and begging for help. It is not fair. They are not getting a wink of sleep 24-7. Is there any light at the end of the tunnel for these families?

The Minister, Deputy Foley, and Minister of State, Deputy Emer Higgins, are certainly very focused on this issue, as is the Cabinet committee on disability which I attend. There has been substantial investment this year.

As regards respite across the different categories, this year, day-only respite will increase from 66,000 to 91,000 instances, the number of people in receipt of disability and respite services will increase from 6,300 to 7,300 and the number of overnights will increase from 164,000 to 175,000. We are investing an additional €25 million in respite, targeting children in particular. What we have said to all our regions, supported by the disability capital plan and revenue plan, is we want to see the HSE itself directly take on more provision, rather than relying on the traditional models, by buying houses, staffing them with social care staff and providing constant respite. There is progress being made on that.

My office has been contacted by families with regard to the cut in respite from four weeks back to two weeks, which is causing a lot of hardship. Can this be reversed any time soon?

Where is that?

In Kerry.

I will certainly look at that. I did not authorise anyone to cut anything. I will have to go behind-----

If he could, Mr. Gloster might look at that and come back to me.

I am a bit surprised to hear that, being honest.

We have a number of cases.

I will certainly look at that.

At University Hospital Kerry, oncology numbers are sadly increasing all the time and patients are travelling to Cork and Limerick, etc. Can the new oncology unit at the hospital be pushed forward? There is a great organisation locally which has done a lot of fundraising, etc.

With the estates team, both in the south west and nationally, we are genuinely trying to see how we can expedite the development and utilisation of all the capacity of Kerry general hospital. We are in trouble there as regards capacity, and we know that.

I have raised the CAMHS scandal in north and south Kerry many times. When will the long-awaited look-back review be published? How are we faring as regards compensation and services for the children in question, many of whom are young adults now? We need to get this right and ensure it never happens again.

There are two parts to that. First, when there is a problem, if you spend too much time looking back at it and not enough time correcting it, you are in trouble. A lot of time has gone into correcting and improving CAMHS service provision. This is being led nationally by Dr. Amanda Burke, one of our outstanding clinical directors. That work is ongoing and I have a lot of confidence in the service today compared to what it was several years ago. There is more to do.

As the Deputy will know, the south Kerry piece and the compensatory aspect have been dealt with. The north Kerry audit is finished. It is going through some final engagement between my team in the south west and the Department to process the implications of it. I expect we will hear more on that shortly. There are a lot of complications behind it, including legal complications which I am not in a position to go into, but the matter is receiving much attention.

Will the ambulance base to serve the Killorglin and mid-Kerry area be in place any time soon? I have been calling for it for many years. What is the status of the relocation of the ambulance base in Cahersiveen?

We are looking at both of those this year. With our estates, we have a good capital allocation. There are a number of local issues, which the Deputy will be aware of, and there is a question of what exactly we would put into Cahersiveen and Killorglin. We are looking at it this year. I will come back to the Deputy specifically on this issue, which is on our agenda for 2026.

When will the pause on recruitment of physician associates be lifted? When will the physician associate review be published? How does the HSE intend to utilise physician associates within the national service plan 2026, particularly in understaffed and underserved services?

We have finalised the report and are in discussions with our colleagues in the Department as to the next steps. What we want to do is ensure that there is a clear definition of the role of the healthcare context and that this role is safe, supportive and works within a multidisciplinary team. Primary among our concerns when we are looking at any discipline, whether it is doctors, nurses, health and social care professionals or, indeed, physician associates, is the provision of safe, appropriate care within a multidisciplinary team. That report is finalised, and it is the subject of a discussion with the Department.

I submitted it to the Department two weeks ago.

I suggest we take a quick break. Is that agreed? Agreed.

I wish Mr. Gloster well in whatever his future may hold. I also thank him for the service he has given to the public over many a long year. I wish him the very best of luck. I hope there is a warm and sunny climate on his horizon for a while. He has definitely earned it.

I will start with mental health, specifically CAMHS. I read the document that was provided to members. A total of 2,205 additional children and young people will be seen, which is a 19% increase. I am struggling with these figures because I also read that there are now 4,375 children on the waiting list compared to 2,115 in 2020. There has been a massive increase in the number of children waiting over a year. How does the HSE plan to achieve that increase of 19%? When I ask about it, I am told there is pressure on services, staff cannot be recruited and the teams are not full. Will Mr. Gloster talk me through how the HSE intends to reach that 19% increase?

There are two things that I believe will help. I want to be honest and, in fairness to the Deputy, every time I have come before the committee, she has articulated that concern well. It is one I share. I am not going to fool anyone by saying that I think we are going to have it all cracked and sorted. However, there are the additional mental health development posts this year and also the improvements that have been made in services, which have been led by Dr. Amanda Burke and the team across the country.

I will put two things together that I think will fundamentally help. On 9 February, the new autism protocol goes live for use in the health service. I believe that will respond to a cohort of people who previously, in the absence of other pathways, were finding themselves referred and then waiting in the CAMHS space for quite a while. That is one point. The second is that of the 4,000 children who are waiting, I believe a number can be well supported and responded to by either primary care or disability services. With the single point of access model I introduced in October, we have gone from a multitude of referral forms - I think there were 47 different forms - to one referral form for children. That model will go live very shortly and under it, CAMHS, disability services and primary care services will work together to see who is best placed to respond to the child.

Those two things will help. They will not resolve everything.

In the context of CAMHS, no doubt the witnesses have been following some of the issues the committee has been looking at in recent times, one of which is eating disorders. A very real concern was put to the committee by Cared Ireland and Bodywhys about the lack of a national transition pathway between CAMHS and YAMHS for young adults who are transitioning out. There is a cliff edge in this regard. In terms of the 19% increase in CAMHS provision, is a transition pathway being examined as part of the service plan pathway for 2026 and will it be implemented?

The team will be before the committee in the next two or three weeks for a detailed session on CAMHS. I have asked that it specifically address that and go into the detail of it for the committee. The team will explain it better than I could. There are a lot of clinical dimensions to it. The focus now is not just on looking at CAMHS but looking at the subset of conditions like eating disorders. Not every child who requires an eating disorder response from CAMHS is the same as those children who require other responses.

No two children are the same.

We need to stream the response to make sure those types of different transitions can happen. No more than 20 years ago, I and others struggled to try to bring clarity to children leaving CAMHS and going into adult mental health services. All of those transitions are better, but we are not there yet by any means.

What measures does the service plan for 2026 contain to address the fact that there are no specialist eating disorder teams at all in 14 counties?

We have more eating disorder teams now than we had before.

Are they staffed?

To varying degrees.

I am glad Mr. Gloster admits that because it was one of the issues that came up at the committee engagement, and nobody could say whether this model of care had ever been fully resourced and staffed. There is a real concern in this regard. It is a mental health condition that involves the highest level of mortality.

The Deputy has landed on an important square. Apart from eating disorder teams, I have the same with children's disability network teams, with CAMHS teams in general and with multidisciplinary teams across services, whether they relate to stroke or other forms of care. Every service wants the highest bar when it comes to multidisciplinary teams. To be fair to successive Ministers, there is a notion that if they resource them or approve the resources for them - the Minister of State, Deputy Butler has not been short in that regard - we can fill every multidisciplinary team with the professionals we want despite the fact that we only have a limited supply of professionals. We have to find better ways and different models. That is why you end up with the binary thing whereby not every team is fully staffed.

They are not functioning as a result.

The issue of dental care, particularly for children, gave rise to one of the most frustrating committee engagements I have been involved. There is a really excellent example of how it is working very well in Galway. However, the latter seems to be despite the system that is in place as opposed to because of it. There is no mention of dental hygienists at all in the service plan or of expanding the scope of work they do. This is despite the fact that a diminishing number of children are being seen through the screening programme, and there are growing delays. Where did this go wrong and how do we fix it? It went wrong somewhere, and it needs to be fixed.

The probable reason it is not mentioned in the service plan is that we are working with the Department to shortly bring forward an implementation plan for the strategy we talked about when we came before the committee previously. The Minister has been talking with the Department specifically about hygienists, and that will be part of that plan. The Department and the HSE recognised from the meeting we had with the joint committee that there was a necessity to do something about that urgently. We hope we will bring forward proposals in the implementation plan that will be creative and innovative as to how we manage the immediate situation relating to children. There was a sense that the dental treatment services scheme has stabilised, but there is a clear recognition that there are significant waiting lists for children-----

I hope that will not involve removing the entitlement to this service.

No, not at all.

Because that would be deeply concerning. There is reference in the document to mobile dental clinics. What are mobile dental clinics? How does the HSE intend to use them?

There is an innovation whereby we are looking at how we would use them. We used mobile dental clinics in the past. We are looking at how we could roll out the demonstration site to try to do that. That is one of the initiatives. It is not the complete situation, but it would contribute to people being able to go to particular areas with their children and gain access to examination and treatment.

Why would such clinics be preferable to primary care centres?

It is not that they is preferable. It is just an additional and innovative solution that may be beneficial in contributing to meeting the overall requirement.

I thank the CEO and his team for coming in today. I listened with interest to the comprehensive statement he made. There was a lot of good news and a lot of what one might call aspirational news. That is mixed with the bit of sadness or celebration in the final paragraph, I do know what you would call it. Mr. Gloster mentioned that this will be his final appearance before an Oireachtas committee. During my short term here and in the years during which I watched "Oireachtas Report", he has been an exemplary civil servant in many ways. He did his job with care, compassion, honesty and efficiency. Indeed, he did it with frankness. I like that in anyone because we sometimes hear what we do not want to hear. It is that honesty that makes him a huge loss. I wish him very well in the future.

I have a particular passion for assessments of need, CAMHS and CDNTs. I say that in the context where, while I know this plan is a vision for 2026, one thing that concerns me is that we know the target for CAMHS is to have 78% seen within 12 weeks and that in CDNTs, there is a reduction of 25%. My question on CAMHS concerns the 22% who will not be lucky. I am always reminded, and let us not forget, that these are the formidable years in anyone's life. I hope and expect that if we were to review this document in a year's time, we could look back and say that we achieved those targets. In the context of addressing the need that exists, 78% is absolutely fine. Is Mr. Gloster confident that what he outlined in his statement can be achieved?

When discussing something as complex as children's disability services, I am always reticent to frame it as being purely binary in terms of numbers. I understand that numbers matter. I have listened with interest to and participated in the discourse over a number of years whereby we are talking about the number of people waiting. It is important that we talk about this and recognise it. In disability services, if you listened to some of the commentary, you would think it is the one area where there has been no improvement at all. The number of children's disability network teams that are now functioning well is light years away from what was the case even three years ago. The number of children being seen by children's disability network teams is light years away from where it was as well. There are people waiting, and that is the worry.

On assessments of need - and the Government is looking at the legislative aspect - the truth is that the way it is currently structured and used means it is impossible for us to comply with the law.

It will remain impossible because we are performing against an outdated construct in assessments of need. Of the children being referred for assessments of need, about one third go through that process and come out the far end with no indication of a disability. That is not good for the children, not good for their families and, quite frankly, not good in the context of the resources we are trying to apply. There are people who think they need an assessment of need in order to access services. Maybe that is our fault. People think they do, but they do not. The truth is that we are tying up an enormous amount of effort in just trying to do the assessments. If even a proportion of that resource was available to provide actual services after the assessments, children would be far better off. That part is changing. It is changing rapidly this year. I had a conversation with the Minister of State, Deputy Emer Higgins, in the past few days. I met young Cara Darmody again this week. I have met her three times now. We will make substantial improvements in both assessments and the provision of therapy services to children. Unless we reform the process relating to assessments of need, however, it will just become the type of very negative story that does not help anybody.

In recent times, Portiuncula hospital has referred high-risk cases to other centres.

That is correct.

That was done for very good reason and was based on solid clinical advice. In terms of where we are now and when the HSE anticipates normal services will resume, is it fair to say that we are well on the road to getting to where we want to be?

We took part in a lengthy committee hearing on Portiuncula hospital recently. Perhaps Dr. Henry can assist me with this. Can I simply say this: my concentration on Portiuncula hospital is in the context of making it the best possible service it can be for the 80% of people who continue to be booked there and who receive services there. My focus on Portiuncula hospital is to make sure that it is considered in the same way as the other 19 units across the country in the new maternity strategy, the approach to which the Minister for Health, Deputy Jennifer Carroll MacNeill, is contemplating because the current one is going to run out this year . If the clinical advice given to me tomorrow is X,Y or Z, that is what I rely on. I do not hide behind clinical advice. The accusation is that we are trying to close Portiuncula hospital by stealth. The Minister has no desire whatsoever to close any part of the health service, but we are obliged to make it safe. Right now, we are continuing to book higher risk women into Galway or into other centres of their choice. We will continue to improve the service for the other women. That is where I see it being for them.

Understandably, there is focus on the diversion of high-risk women. However, there is much more to this. Twelve reviews have been completed and five remain to be completed. There are 52 recommendations pertaining to clinical care, communication between teams or within teams, communication with patients, training and follow-up to adverse events. The external team is working on those, but they do not grab as much attention. It is not just about the diversion of those who are deemed to have high-risk pregnancies. It is about improving care on the foot of the recommendations coming out of the 12 reviews that have been completed. As stated, there are five reviews yet to come.

Go raibh maith agaibh. Once again I wish the CEO the very best of good luck.

I thank the Deputy.

The committee will come back to the provision of maternity services and the national maternity strategy. There is a strong interest among members in respect of that area of women's health. We will be looking at it in more detail next time.

I will start the by thanking Mr. Gloster for his hard work, honesty and straight talking, and for his straight answers when he has been here. I appreciate that.

The first matter I want to raise is symptomatic breast screening and diagnostic breast screening. I have raised this previously. When a girl visits her GP and is referred urgently, or even non-urgently, with signs of breast cancer to a symptomatic breast clinic, I do not understand how she is not scanned on the day she attends the clinic. I was diagnosed 13 years ago. I had a triple assessment. Had I been sent away to wait six months, I probably would not be sitting here. My cancer was extremely aggressive. In younger women, it is particularly aggressive. I have huge concerns about women being effectively triaged on two occasions, because they are triaged when they get there as well. Even if they are part of the worried well, I do not think anybody should be walking around with a tumour in their body not knowing whether it is cancerous or non-cancerous. Will there be a focus on improving matters in this regard?

To distinguish, there are two issues. There is screening, and I know the Senator understands this distinction. There is the mammogram, as people will know. Our aim is to return to a two-year screening programme. We have had a shortage of radiographers over the past few years. Then there are what the Senator referred to as the urgent breast clinics where we need to see people within ten working days. The Senator is quite correct. It is not just a question of being seen, it is about having access to the proper diagnostics. Of course, we face difficulties with diagnoses right across all cancer services because we are becoming more highly reliant on diagnostics and more refined imaging is required. It is an essential part of us delivering on the commitment to see people within ten working days in an urgent breast clinic so that from the moment they attend they have access to appropriate and timely diagnostics to enable a rapid diagnosis, bearing in mind that over half of breast cancers are diagnosed through these urgent breast clinics, and so they can enter treatment pathways as soon as possible. We are concerned with the whole end-to-end pathway, which is good screening, the timeliness of urgent breast clinic attendance, the diagnostics to follow, the surgery to follow and the chemotherapy or radiotherapy to follow for those who receive an unfortunate diagnosis. It should be one seamless pathway. There are problems with diagnostics and they reflect the increased referrals we are seeing to these clinics. It also refers to the way that the treatments change and expectations change, and the need for more refined diagnostics. It is something we are focusing on not just through our cancer strategy but also through our national imaging strategy.

I just feel something changed over the years. At the time I was diagnosed, I would have known a lot of girls under the age of 40 who were also diagnosed. They all got triple assessments at their first appointments. I cannot say enough about how aggressive cancer is in younger women. Six months is too long for a girl to wait.

Reference was also made to waiting times in accident and emergency departments for people over the age of 75. I would like to see people who are 70 years of age and older being tagged, and maybe people who have dementia and those who have autism and are in accident and emergency departments. My father, who passed away in October, was 74 and had dementia. We were waiting in an accident and emergency department, which was very traumatic, but he did not fall under the age range to be tagged. I was waiting with him for over 30 hours. I had just been elected to the Seanad. I will acknowledge, however, that a few months later, the waiting time was between four to six hours. The new chief executive in Tallaght hospital obviously acknowledged the issue, she made changes and used her expertise. I did notice a positive change there, and I want to acknowledge that. However, I would like to see people-----

We have made a change, and that change is welcome. While we have had a couple of days where that has slipped, just because of the sheer volume, I think we have made a consistent change. We started with people who were admitted and were waiting on trolleys because they are the people who can decondition most quickly. We are now focused on the experience of older people coming into our accident and emergency departments. I met a family recently who have given me feedback and have given me a particular suggestion as to how we can particularly tag, and I mean that in a caring way, those people who present with questionable levels of dementia or cognitive impairment in order that they are not lost in our system and, at the same time, are not stereotyped. I know my successor will be focused on that.

The Minister, Deputy Carroll MacNeill, never fails to remind me how struck she is every time she goes into an emergency department if there is an older person waiting even for a moment without the apparent signs of their being fully attended to. We have to keep that micro focus if we are really going to improve as a health service. We can do that with those extra resources. That is the truth.

The focus on older people comes not just from the self-evident poor experience that might happen with a long wait but also from the immeasurable harm associated with that. There is evidence accumulating on this in the context of older people.

It is quite arbitrary to have a cut-off for what is considered to be older but there has to be a cut-off somewhere and it is 75. There is accumulating evidence that measurable harm is associated with protracted stays in emergency departments for older people compared with younger people.

I hope we do not go back to those days because there were stories and experiences. There is nothing more shameful than seeing an older person on their own, disorientated, on a trolley or in a chair, with difficulties with toileting and eating, and the entire trauma this brings, apart from the reason they are there. We have been intent on improving this but we can never ever relax on this focus.

I totally agree. To see somebody vulnerable in a very humiliating state is difficult, especially if they do not have family with them.

With regard to dental services, will there be a return to observing children in school? Things took a dip when nurses stopped going into schools to check children's teeth. That is probably where a lot of things went wrong. Mobile clinics were mentioned. Would they be a way of getting back into schools?

During the pandemic we stopped but now we continue to do examinations. One of the challenges for us is that we are not seeing all of the children. We do second, fourth and sixth classes and the predominant focus is on sixth class at the moment. Last year, across second, fourth and sixth classes and special classes, we did 147,000 examinations. We should have done 216,000 examinations in the school academic year. We continue to follow up on those. The plan we are bringing forward will hopefully address how we might target some of these waiting lists.

I echo the sentiments of all of my colleagues and wish Mr. Gloster the best of luck in his retirement and wish him many happy years ahead. I have a few questions. The plan states that 100% of maternity units will implement the Irish maternity early warning system in 2026. What consequences will apply to units that fail to meet the targets? How will the implementation be audited?

They will implement it. It is ingrained in maternity safety in the units. It follows some high-profile events where the findings following investigations showed failures to track and identify deterioration in women, particularly sepsis. It is a critical part of our safety work in maternity units.

To answer the fundamental question, and I do not want to be disparaging, this is a case of joining the army and wearing the boots. They do not have a choice and they do not get to opt out. This is mandatory, they have to implement it and that is it.

How will it be audited?

Each unit is led through a clinical governance structure that goes right up to the clinical directors and REOs, such as Ms Long who is here. We consider this to be core not only for individual practitioners but for the management of any maternity unit. It is a core safety requirement.

If there are issues with the implementation of it, will the public be aware of it? Will the public see the data or see which hospitals are not as good as others at implementing this?

In recent months we published the latest round of our maternity safety data and other metrics. For the first time we deanonymised the list and named by site, and that will be a feature of it. To be fair to maternity units, most of them want to do the right thing and to do it well. The national women and infants health programme under Dr. Henry supports them to achieve it. This is not something I am worried about. I am worried about other things but I am not worried about this.

How has the HSE embedded the lived experience of women into the strategy, as opposed to just referencing it in policy?

The original maternity strategy, which is coming to a close, was commissioned by the then Minister for Health, Leo Varadkar. My recollection is that patient representatives were involved. I cannot remember the detail exactly but there was broad representation in the strategy. Now that it is coming to an end, there may be a new strategy and that will be completely up to the Minister and the Department. I would expect, as with any such strategy, that there would be public and patient participation, inclusion and input into it.

We now have, for the first time ever, full-time paid patient participation managers' representatives in each region. Part of their job is to ensure we get the engagement of the public to influence how we plan and design services. I will give the example of endometriosis. The Minister held a patient forum last September, which I attended with her, and we had a subsequent meeting with the forum in October at which we launched the framework. She will bring them all back together on 5 March to review our progress and test us to see how we have done on the inclusion of the patient voice. That type of approach is the modern way of designing healthcare.

That is brilliant. The Minister has directed a move beyond hospital waiting lists to primary care access. What accountability mechanism exists if a region fails to meet the therapy wait time targets?

In the service plan for this year we have a new iteration of what we call the performance and accountability framework. Each region gets a resource and an outcome it is expected to achieve, which includes adopting the primary care waiting list initiative that Mr. Healy is supporting. The regions will no longer report through a complex system but directly to me. The data of the performance is used in this engagement. It is published. There is an accountability framework through which a region can be escalated if it is underperforming. This can go right up to and include interventions by me.

The plan emphasises greater autonomy of health regions alongside stronger accountability. What specific consequences will follow a region if it consistently underperforms?

This is the performance accountability framework. Again, I do not want to start from the negative construct that they underperform. A lot of people we have working are very good people who aspire to and do achieve great results. There are a couple of levels of intervention. We can support and we can put in place specific corrective action plans. We can progress right up to removing executive control of the region and replacing it with direct executive control by me or somebody I would appoint. Quite significant steps can be taken.

I thank everybody for coming before the committee. I want to be associated with the kind wishes to Mr. Gloster. Since I first came here a number of months ago, he has been nothing but kind and courteous. The first question he always asks me is how my wife is, and that is the sign of a good man. I thank him very much.

We spoke earlier about surgical hubs. It is Letterkenny on schedule?

In my opening statement I said that five would open this year. Mount Carmel opened last year and Tallaght is pre-existing, and these will bring us to seven. I said two more would go to the next stage of the development and these are Letterkenny and Sligo, which we only announced a short few months ago. The design work is starting on these now.

As we are speaking about Letterkenny, Mr. Gloster said that he would visit the dialysis unit there. Has there been any movement on this? The building is there and it is just a matter of kitting it out. Is there any movement on getting this pushed forward?

Everybody is pushing to get to the right place with it and to do the right thing with it. I am just not 100% up to date with where it is at today. To be fair to Senator Boyle, because he has asked me twice, I will come back to him with a formal position on it in writing. It is a fair question.

I thank Mr. Gloster. Every day we receive phone calls about community hospitals and beds not opening. What is the update specifically on Killybegs and Ballyshannon? Will they be open soon? These are the beds that older people want to have near their homes.

These beds face a number of challenges. I have made it clear to the region that it already has the resources available to it, historically and in the resources received this year. There are recruitment challenges in particular counties with staffing units such as these and agreeing staffing levels but I do not think this is a showstopper. Another element is that I am just not happy generally with the rate of opening or reopening community beds, particularly on the western seaboard.

We are particularly slow when we either close a bed to rebuild it or when we build a new one. That is why the target this year is that any new bed, any bed available and commissioned, has to be staffed and opened this year.

We were getting word back that HIQA was in the hospitals making changes.

Yes, and there can be a HIQA intervention where it believes the refurbished building has a particular deficit. There was one in Senator Maria Byrne's area in St. Camillus's Hospital when we rebuilt it. It had a particular issue. The point is that if HIQA has an issue, our job is to fix it quickly. Usually it is something to do with a door or a staircase. It is Bob the Builder stuff; it is not rocket science. We should be able to do these things faster. I am not that happy about that attitude of "Ah well, it's HIQA and sure that's grand then, we'll leave it closed for another six months". That is just not good enough.

In my area, in Killybegs, there have been serious delays. I cannot fathom how long it has taken, to be honest.

In the modern era, whatever about old beds and HIQA having concerns about them, when we take steps to either close, rebuild or provide new beds, we should be well out the gate with HIQA before we finish the building of those beds. Those are the basics of good, effective management of a project. It is on us. They are too slow. For as long as I am in the chair for the next few weeks, we will still go after it.

One issue I keep taking up is the ambulance service in Donegal. Mr. Healy is probably tired of listening to me. One of the most important things in a rural county is to have a good ambulance service. A couple of weeks ago, there was a flu epidemic. Everybody knows about that but ambulances were waiting at the hospitals. On local radio it was said there were nine or 12 queuing up at a time. Can we have a patient handover service that would free things up? I keep coming back to Killybegs and I apologise for that, but it would be a real game-changer for Killybegs to get the second ambulance back. There are cruise ships coming in now. This year alone, 20,000 extra people are coming in through the port. Next year, they are looking to have 35,000 and we have one ambulance. Twenty years ago, we had two and it was working well. Given where Killybegs is, it really needs the second one. It covers a large area from Glencolmcille up to Inver Bridge and down to Fintown. I do not know why it was taken away. I suppose it was all cost saving. It really needs to be reinstated.

Before Mr. Healy comes in on the resourcing of Donegal, I might say two things briefly. The ambulance service particularly, if not exclusively, in rural Ireland, like on the Inishowen Peninsula and other places, is one of the most important services and one of the highest risk jobs. I send my good wishes to two paramedics who were injured in a serious road traffic accident up there just before the winter. I hope we will see them back to full health. On the issue of ambulances standing on ramp in Letterkenny Hospital, I was on every day over Christmas that the hospital where I am most concerned about ambulance delays is Letterkenny. We have a hospital-ambulance liaison person at the back door of the hospital. I appreciate demand can mean ambulances have to wait a bit longer but the delays in wait times there are wholly unacceptable. They are no fault of the National Ambulance Service. It is an unacceptable position. I have made that clear. I have seen some improvements there but daily, seven days a week, we are following it to improve it because it is not acceptable. Mr. Healy might comment on the resources.

Castlebar and Letterkenny are getting a full hospital-ambulance liaison service. We have worked closely with the REO and the teams there. We are putting additional resources in. There will be two in Castlebar and two in Letterkenny. That will provide a full service. In addition, the REO is working with us and looking at Galway and Portiuncula. In relation to the overall ambulance service, the Senator raised it specifically when we were here in October to discuss the National Ambulance Service and has done so since on a few other occasions. I am glad to be able to say that in 2026, there are additional ambulances going into the north west and one going into Killybegs. The Senator will be glad to hear that. That is approved for the year. The other important thing for the north west, which we spoke about previously, is the HEM service. The HEM service will come into play and eight additional staff are approved for it. It will go ahead. It will be an important service for that whole north-west area and rural areas. I am glad to be able to report that both of those will be of benefit to the Senator's area.