Today’s session will consider significant recent developments and issues in the health service. This is a particularly timely session, given the recent revelations with regard to the public-only consultant contract, which is a core part of Sláintecare. It is important to say that implementation of the public-only contract is not optional. Individual hospitals cannot be allowed to implement this landmark contract on an à la carte basis, choosing to do so whenever they want. Every hospital must adhere to this public contract. It is as simple as that. It is refreshing that, as a result of these debates, Sláintecare has been put firmly back on the political agenda. To hear Sláintecare being debated in the media and Oireachtas is welcome. It is clear that there is strong momentum behind the Sláintecare reforms and delivery of the universal healthcare system. This is the vision that we must defend and address in all of our engagements going forward.

I particularly welcome the new Secretary General of the Department of Health, Mr. Derek Tierney, and the new CEO of the HSE, Ms Anne O’Connor. I look forward to the engagements we will have at this committee on policy analysis, public accountability on important issues in the health service and legislation. The committee has spotlighted a number of issues over recent times that we are keen to make progress on. We have produced a number of reports on a number of issues, including public dentistry and the assisted human reproduction Act. We are also working on reports in the area of sexual health. There are also many other issues we wish to seek progress on. I look forward to working with Mr. Tierney and Ms O’Connor and their officials on those matters.

I must read a note on privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against a 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 a 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 they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not criticise, comment on or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

In an attempt to put a focus on today’s proceedings, members were asked to identify key issues they want to address. We have a range of topics that have been identified to focus our discussions, including budgetary issues in the health service; National Treatment Purchase Fund, NTPF funding; staff recruitment and retention; the implementation of the public-only consultant contract; GP reform and strategic review; elective hospital and surgical hubs; an update on the Children’s Health Ireland, CHI, inquiry for those with spina bifida and scoliosis, as well as children in CHI more generally; and child and adolescent mental health services, CAMHS. Those are some of the issues that the committee wishes to address in this high-level session.

I invite Mr. Derek Tierney to make opening remarks on behalf of the Department of Health.

I thank the Chair and members of the committee for the invitation today. I am pleased to be here with my colleagues: Ms Tracey Conroy, assistant secretary for acute hospitals oversight and performance; Ms Siobhán McArdle, assistant secretary for social care, mental health and unscheduled care policy and oversight; Mr. Niall Redmond, assistant secretary for primary care performance and oversight; and Ms Rachel Kenna, chief nursing officer and assistant secretary for patient safety and workforce policy.

By way of introduction, this is my first appearance before the committee as Secretary General of the Department of Health, and I very much welcome the opportunity to engage with the committee. I recognise the important role it plays in examining health policy, governance, legislation and expenditure. I am committed to engaging with it in an open, constructive and transparent way. As Secretary General, my role is to support the Minister and Government on health policy, provide advice across the Department’s remit and work to ensure that the system is governed with clarity, discipline and accountability, while also delivering on the Department’s statement of strategy.

The direct delivery of services, as the committee will be aware, is carried out across the health service by the HSE and other service providers. What matters most is that, from the public’s perspective, the system works as it should, with services that are accessible, safe, timely and high quality. In that context, I work closely with Ms O’Connor and the HSE’s senior leadership team. That close engagement helps support shared priorities, alignment and a focus on delivery and performance.

It is important to be clear that the health service is currently operating under significant pressure. Those pressures are evident in rising demand, driven by demographic change and increasing complexity of care; access and waiting times; workforce constraints and morale; and the need to manage expenditure carefully while maintaining and improving services. These challenges are felt directly by people who use our services, as well as their families and staff. It is important to acknowledge that honestly. Equally, it is important to maintain a clear focus on what must be delivered.

In that regard, I highlight four areas of focus that will guide my approach as Secretary General. The first is to improve safe access, outcomes and public confidence. One of the ways that tells us we are delivering an effective health service is patient outcomes and experience. To impact positively, the focus needs to be on more timely access to safe care, more reliable pathways, better outcomes and a public health service people can understand and trust. Our health service as a whole must be underpinned by patient safety and grounded in a culture of openness and learning through listening to service users, patients and families. We must learn from incidents and ensure learnings are translated into practical improvements in care. Improving access and outcomes is not simply one priority among many. Rather, it must be the central organising principle for how the service operates.

My second area of focus is to support and strengthen the workforce. That includes front-line staff across all professions whose skill, commitment and compassion are central to the delivery of care and leadership at every level of the health service. We know there are real pressures on recruitment, retention, workload and morale. That is why the Government, the Minister for Health, Deputy Carroll MacNeill, the Department and the HSE have been clear that healthcare workers must be valued, supported and protected. Staff should expect to feel safe at work. Threats, abuse, intimidation or racist behaviour towards our staff are unacceptable. There must be a clear, sustained and practical response across the service. That response includes strengthening safe and respectful working environments, supporting our staff to manage difficult situations, maintaining clear policies on dignity at work and work-related aggression and violence and ensuring staff have access to appropriate training, supervision and well-being supports. Addressing those issues requires sustained focus on workforce planning, better deployment of staff, supportive working environments, strengthened leadership and accountability and an unequivocal commitment that racism, abuse and violence have no place in our health service.

My third area of focus is to deliver reform in a practical and disciplined way. A significant programme of reform is under way, as the Chair acknowledged earlier, including the Sláintecare agenda and a programme for Government that is driving the development of health regions, separation of scheduled and urgent care through our elective care strategy, the continued expansion of digital capability across the system and continued investment in cyber resilience, virtual beds and virtual care. Alongside this, we are advancing and enhancing the expansion of services in the community, including GP, pharmacy and wider primary care provision, to support earlier intervention, better chronic disease management, more timely access to new medicines and mobile diagnostics. We have our integrated care programme for older people, ICPOP, and we are strengthening the focus on vaccination, health prevention, screening, public health and more care delivered closer to home. There is also a substantial capital programme in delivery, including hospital developments and extensions, additional surgical capacity and the roll-out of primary care centres and community-based hub infrastructure. The key now is to ensure these reforms and investments continue to translate into tangible improvements in how services are organised, delivered and managed. That requires disciplined implementation, clear accountability and measurable results. Reform must be evident in people’s experience of our health service.

My fourth area of focus is to strengthen governance, performance and value for money. The health service operates at a significant scale, with substantial public investment. It is, therefore, essential that there is strong governance, robust oversight of expenditure and a clear focus on productivity and value. This is not solely a financial imperative; it is central to using resources in a way that maximises benefit for our service users, patients and the public. It underpins confidence that the system is being managed effectively and responsibly, while ensuring that funding is linked more clearly to activity, outputs and outcomes. Recent engagement by the Minister, the Government, the Department, the HSE board, the CEO of the HSE and her team and members of this committee has rightly placed emphasis on value for money. The implementation of the public-only consultant contract is one such example. It will ensure public consultant capacity is used fully and transparently, tighter control of agency and overtime expenditure, including conversion to direct employment, where appropriate, disciplined management of recruitment within affordable pay ceilings and continued scrutiny of non-pay costs, procurement and capital investment. Ensuring this focus is sustained and translated into practical delivery will be a key imperative for me as Secretary General.

In taking on this role, I bring a strong focus on evidence-informed decision-making, delivery and collective leadership across the Department, the wider health system and public service, as well as in close partnership with HSE leadership.

Looking ahead, Ireland will assume the Presidency of the Council of the European Union on 1 July. The health theme of our Presidency, investing in health to enable competitiveness, is both timely and closely aligned with the reform agenda at home. In both settings, the task is the same, namely, sustained reform that is grounded in evidence and delivered with discipline. I recognise the importance of the committee’s role in holding the system to account and helping to shape policy and reform. I reiterate my commitment to engage with the committee in an open and responsive way. I will provide clear and accurate information as we address these challenges. I look forward to working constructively with the committee in the period ahead.

I reiterate my commitment to engaging with the committee in an open and responsive way, and to providing clear and accurate information as we address these challenges. I look forward to working constructively with the committee in the period ahead.

I thank Mr. Tierney for that, and I welcome the commitment to positive engagement with the committee going forward.

I invite Ms O'Connor to make her opening remarks on behalf of the HSE.

Good morning, Chairman and members of the committee. I am joined here today by my colleagues: Mr. Damien McCallion, chief technology and transformation officer and deputy CEO, Mr. Pat Healy, national director for national services and schemes; Dr. Colm Henry, chief clinical officer; Ms Kate Killeen White, regional executive officer for the HSE Dublin Midlands; and Mr. Brian O Connell, head of strategic health infrastructure and capital delivery. I am also supported by Ms Nessa Lynch, general manager in my office. I thank the committee for the invitation to meet today and for the opportunity to outline my priorities, having taken up the role of CEO at the end of March this year. I spent many years working in the health service in this country and have worked across many services, from my front-line role as an occupational therapist to management roles in community services, mental health services and chief operations officer. It is truly an honour to be back again as CEO leading the HSE.

It is important to acknowledge the remarkable progress Ireland has made in the health of its population over the past 30 years. While much of the public discussion around health services is framed around crisis, including overcrowded emergency departments, waiting lists, seasonal overcrowding and winter pressures, it is clear we are living longer, healthier lives. Life expectancy has increased significantly, outcomes for many diseases have improved and advances in prevention, diagnosis and treatment have been transformative.

Vaccination programmes have greatly reduced once fatal illnesses and have led to major declines in child and infant mortality. Cancer survival has improved through screening and advanced treatments, while deaths from heart disease have fallen due to modern medications, interventions and surgery. Mortality and morbidity from stroke and other conditions have also decreased. This progress reflects sustained and very significant investment, scientific and clinical innovation, and, above all, the commitment and dedication of healthcare workers over many years.

However, we all acknowledge that success brings with it significant challenges. Ireland’s population is expected to grow from 5.3 million in 2023 to between 5.9 and 6.3 million by 2040. During this time, the share of the population aged 65 and over will increase from one in seven to one in five and the number of people aged over 85 will double. A growing and ageing population with increasingly complex health needs means people are living longer with multiple chronic conditions, requiring ongoing, co-ordinated care. Demand is not only increasing, but also changing in nature and becoming vastly more complex.

The HSE’s corporate plan and national service plan set out clear commitments on access, waiting times and equity of care. To understand the scale of the challenge and why reform continues to be essential, it is important to frame that commitment. Demand for our services continues to rise. In 2025, emergency department attendances increased by 4.1% compared with the previous year. Despite this, trolley numbers have reduced across the year, reflecting extraordinary work across the entire health system. However, sustaining that progress remains difficult when both attendances and admissions continue to grow. Planned or scheduled care shows a similar pattern. In 2025, more procedures were delivered than planned, and more than ever delivered before. Yet, by year-end, approximately 753,800 patients remained on waiting lists, which is an increase of 11.8%. Referrals for outpatient, inpatient and day case care also grew, rising by 6.3% over the year.

We are seeing across our acute hospitals not short-term impacts, but ongoing and sustained pressure on services, together with exceptionally high levels of activity. This sustained pressure is also evident in cancer services, where rising referral volumes and demand within rapid access cancer clinics require continuous pathway redesign aligned to the national cancer strategy, to ensure timely access and reduce clinical risk. The evidence is clear that demography alone does not explain the scale of demand we are seeing. We know non-demographic drivers, including service models, policy choices, patient expectations and social determinants, can account for over half of demand in some areas. These include the availability and accessibility of primary and community care; patterns of referral and clinical decision-making; social factors such as housing, isolation and deprivation; and the design of care pathways and where care is delivered. This matters because while we cannot change demographics, many of these drivers are within our influence. The public’s expectations are rightly higher and so our health service must continue to evolve to meet those expectations in a way that is safe and equitable.

People aged over 65 account for more than 60% of inpatient bed days, yet a health service that provides episodic, disease-specific care does not fully meet their needs, particularly for those with multiple conditions. Having a greater understanding of the needs of those we provide care to, while ensuring we are using our resources more effectively, will support a more sustainable health service. Ultimately, we need an age-friendly health system that delivers better outcomes and experiences for patients and families; greater efficiency with fewer emergency attendances, shorter stays and fewer readmissions, and improved staff experience through enhanced care planning and even stronger multidisciplinary working.

Against this backdrop, it is essential that we continue to reshape how we deliver our health services in Ireland. While additional acute capacity is important, it will not be sufficient on its own. Long-term sustainability depends on strengthening primary, community and social care as the foundation of the system. Sláintecare is not simply about expanding services; it is about fundamentally reorienting how care is delivered. Its core objective is to ensure people receive the right care, in the right place, at the right time, by the right team and, increasingly, that means care delivered closer to home and within communities. Our national clinical strategies, including the public health strategy, the rare disease strategy, the national cancer strategy and programmes in areas such as laboratory reform and cardiac services, provide a structured framework to guide the planning, organisation and delivery of services across the continuum of care. Continued implementation of these strategies supports evidence-based practice, improves patient outcomes and reduces unwarranted variation in care.

Significant progress has been made through the enhanced community care programme. We now have 96 community healthcare networks, providing the organisational foundation for integrated, locally delivered care. An investment of more than €300 million and 2,800 additional WTES has supported the development of 30 community specialist teams for older people and 30 community specialist teams for chronic disease, working with GPs and community healthcare networks to provide proactive, multidisciplinary care and reduce avoidable reliance on acute hospitals.

This shift towards community-based care is already delivering measurable improvements. In 2025, over 710,000 chronic disease reviews took place in general practice, alongside 474,000 patient contacts by community specialist teams. Today, 92% of chronic disease patients are managed in primary care, contributing to a 16% reduction in acute admissions for ambulatory care sensitive conditions between 2019 and 2023. The ICPOP delivered 143,000 patient contacts in 2025. In addition, innovation and digital transformation through the virtual care in the community initiative have undertaken 600 virtual consultations with patients in their homes including nursing homes. At the same time, access to community diagnostics continues to transform care pathways. More than 248,000 scans were delivered in community settings last year, resulting in an 84% reduction in referrals to emergency departments and acute medical units. Nearly 10,000 mobile X-rays were provided to older adults, with 96% of those patients treated at home.

A key priority under Sláintecare is improving access to community services. The primary care therapy waiting list initiative approved by the Minister for Health, had a target to remove 80,000 patients from waiting lists over a 12-month period, which commenced in October 2025 and, to date, 20,000 patients have been removed from waiting lists. We are also seeing important developments in elective care delivery. The establishment of surgical hubs is a significant step forward in reducing waiting times and improving patient flow. By separating scheduled and unscheduled care, these hubs enable greater efficiency, improved outcomes and a better experience for patients. This model is already making a tangible difference, and we intend to build on that progress.

Just this week, the HSE surgical hub in Swords opened. It is a modern, dedicated surgical facility that will treat thousands of people every year more quickly, more reliably, and more conveniently. When it operates at full capacity, it will deliver up to 10,000 day case procedures and 18,500 outpatient consultations annually. This is a significant increase in care for people right across the north east region. We have seen the hugely positive impact of the Reeves Centre in Tallaght and the South Dublin Surgical Hub, and we continue to work towards the completion of the remaining hubs.

Alongside these structural changes, digital innovation is beginning to transform how we deliver care. There is strong demand from both patients and healthcare staff for digital access to health information and services. Greater connectivity across community, primary and acute care would deliver significant benefits. There is now broad recognition across government and the health service of the need to implement core digital capabilities, including a shared care record, electronic health records, the HSE health app and expanded virtual care.

We continue to lay the digital foundations for a more modern, responsive and connected health system and, after many years of planning, the coming years will see significant progress in digital transformation across the HSE

Central to all of this progress is our workforce. Under Sláintecare reform, whole-time equivalent health service staff numbers have increased significantly. They are up by 27,437 since the end of December 2022 to 153,611 at the end of March 2026, which is an increase of 22%. Over 61,000 of these staff are employed in HSE community services. Across clinical, operational and support services, our teams demonstrate extraordinary commitment every day. The growth, specialisation and professionalism of our staff is one of the HSE's greatest strengths. This reflects both the complexity of modern healthcare and the commitment of our staff to continuous learning and improvement.

The implementation of the public-only consultant contract, POCC, is a critical enabler to the delivery of Sláintecare and wider health service reform, supporting improved access to services, enhanced productivity and more equitable care delivery. While significant progress has been made in implementing POCC, recent engagement has highlighted challenges relating to the consistency of implementation, variation across regions and the quality, clarity and comparability of POCC reporting. In response, the HSE has established a national programme focused on standardising and strengthening reporting on POCC implementation and accelerating and supporting effective implementation of POCC across regions and services.

We are committed to strengthening governance, improving performance management and embedding a culture of continuous improvement across the organisation. This includes better use of data, clearer lines of accountability, and a relentless focus on patient safety and quality of care. An equally important dimension of reform is how we engage with patients and service users.

There is increasing evidence that care designed with patients rather than for patients delivers better outcomes, safer services and improved experience. This is reflected in the greater involvement of patients and families in care planning and service design. While it is vital to recognise progress, it is equally important to acknowledge that we do not always get things right. We know that patients and families can experience delays and uncertainty. Our staff often work in services that can be fragmented uneven and over-complex. We are committed to learning from and taking whatever action is necessary to improve our services in the understanding that this is critical to maintaining the public’s trust.

I want to briefly speak about the current financial position. The HSE is facing a significant challenge this year. Demand-led pressures, inflationary costs, demographic growth and the ongoing requirement to sustain and expand services are all contributing to our financial challenge. This is not unique to Ireland, and health systems internationally are facing similar pressures. We continue to place a very significant focus on financial management and value for money. This includes strengthened controls, prioritisation of resources and ensuring that investment continues to be directed to those areas of greatest need and impact. We must work together to manage these financial challenges, ensuring that we are using public funds responsibly while continuing to provide safe, high-quality care.

Our health service has made extraordinary progress and there is much to build on. I am committed to working with the Minister and my colleagues in the Department, and to engaging with all committee members to ensure the HSE delivers health and social care services for the public that are safe, effective and timely. I again thank the committee for this opportunity and I look forward to this morning's discussion.

I thank Ms O'Connor and, once again, she is very welcome to the committee and I am looking forward to the ongoing engagement we will have in the period ahead. We will now take questions from members.

I welcome the Secretary General, Mr. Tierney, and the CEO, Ms O'Connor. I wish them the very best in their roles. They are tough positions but I know they have the capabilities to deal with them.

We get reports and I welcome the statements, which I have read a few times, but really it comes down to the individual patient experience. I will outline a case and let the witnesses draw their own conclusions on what I say. This is not always about resources but communication and organisation. Veronica Curley, a mother of two, was 39 years old when she suffered a haemorrhagic stroke outside a gym in Athlone on 27 December. This is on the record of the Dáil. I worked with Deputy Fitzmaurice on this case. She was airlifted and received exemplary treatment in Beaumont Hospital, the national neurosurgical unit. She was there for over two months. She obviously wanted to get back to her children locally in south Roscommon. They had insurance and tried to get into the National Rehabilitation Hospital, but there was a 12-month wait list for a 39-year-old woman who had had a stroke. She then tried to get private care, but no private care is available in this area and the insurance company was making an issue of it.

What comes next is the crucial point. In the new year we made representation to the stroke rehab unit in Merlin Park University Hospital in Galway to get someone from the west of Ireland, who has two small children, back there from Dublin. We were told she could not be admitted directly to the stroke rehab unit from the national neurosurgical unit in Beaumont Hospital, even with the assessment of a neurologist and a report to accompany her. She had to be admitted to either Roscommon University Hospital or Portiuncula University Hospital in Ballinasloe in order to make the transfer to the stroke unit. This is all in correspondence and it is a matter of fact. After a phone call from a politician to the manager in Portiuncula University Hospital, she was admitted. This should not be happening. There should be communication from clinician to clinician and from hospital manager to hospital manager. The manager of Portiuncula University Hospital very kindly arranged her admission for three days to allow the transfer to the stroke rehab unit in Merlin Park University Hospital in her own HSE West and North West region.

This is not simply about resources; it is about a lack of communication and goal keeping. It is not proactive. It is siloed and there is fragmentation. It should have been a matter of a simple phone call for the transfer of a 39-year-old mother with two small children. Do the witnesses have any reflection on this? I have not yet received a satisfactory answer from the HSE West and North West region. I may leave it with the witnesses. If it is emblematic of the dysfunction in our service, then we have a problem no matter how much money we throw at it. This is a cultural issue.

Clearly, I do not know the details of the case and I will have to look into it. In terms of how we deliver our care, my view is that we have to make it as streamlined as possible. What Deputy Daly has described seems to fall far short of this in terms of a co-ordinated and integrated care pathway.

Would Ms O'Connor say it is acceptable?

I do not know the details of it. It does sound unacceptable from what Deputy Daly has said.

I can state on the public record that the details are correct. In my view it is simply unacceptable.

I want to move on because I am on the clock. There is real concern about the regionalisation of our health services, and this goes to the Department mainly and the Secretary General. There is a real concern about our national strategies, which have been so effective in the past 20 years. These include the national cancer strategy, the national cardiovascular strategy and national stroke strategy. There is concern that, with regionalisation, we will lose this national focus in a small country the size of Ireland. Most especially in cancer care, we are beginning to drop off in some of the indices in terms of access to cancer diagnostics and the time between diagnosis and treatment, especially in the west of Ireland. We have some worrying trends there. Is the commitment there to have a national focus, which is so important with regard to clinical networks, research and the networks with the European Union which we should be using? I ask Mr. Tierney to comment on this, please.

With regard to the introduction of the health regions, we all recognise they represent a significant structural reform agenda, with the current position reflecting the Government's agreed approach to organising the services on a more population health-based regional needs basis. I do hear these concerns expressed myself. In establishing the regions, the whole purpose was to give regional autonomy supported by a strong centre, particular in the context of clinical programmes, planning and design services, performance and assurance. The challenge is to understand how we achieve this balance between national health service delivery through clinical programmes and, ultimately, service delivery.

That is at the front of our mind as we face into a revision to the cancer strategy and the maternity strategy. We have work to do in that space and I would be the first to acknowledge it.

It will require really strong leadership to ensure we do not get fragmentation. Huge political capital was expended on coalescing services 20 years ago. People lost their seats in this Oireachtas because they made the right decisions to centralise care and get specialised care. I hope that does not slip.

I will move on to a favourite topic of mine, which is digitalisation. I am still looking at these charts, the 2024 e-government benchmarks, and the digital decade indicator, showing Ireland not just in last place but off the chart with respect to digitalisation. I am on a tight timeframe here. I have spoken to the Minister for Health and the Minister for public expenditure and reform, Deputy Chambers, and emphasised that if we do not digitalise our health service, we can throw as much money as we like at the system but we will not get the commensurate productivity.

I will respond in the first instance and then hand over to Mr. McCallion on the HSE side, who is leading on digital reform. The Department is fully committed to delivering on the digital agenda. We recognised that almost three years ago. Since then, we have developed a strategy and vision. We are not lacking in vision or ambition. We fought hard to secure a funding line in the national development plan to support that. We have done that in two ways, to harden our infrastructure and to deliver on our digital programmes. We have now rolled out our app. We are in the middle of rolling out a shared care record. We are close to shortlisting vendors for our national digital electronic health programme. I want to give this committee confidence that I am fully committed. It is a passion of mine. I will be relentless on it. Mr. McCallion understands what relentless means when I am engaging on it.

I am short on time. I want to get last question in.

There are ten major programmes. The electronic health record is one of those. I was in Northern Ireland again yesterday talking to people there to make sure we learn from some of the things they have done. As Mr. Tierney said, we are now in the procurement stage. We have more than 100 people working on that. That is the system our staff will use. In parallel with that, the HSE app is live. We believe that is a mechanism to perhaps reduce postage costs and to allow that money to be reinvested in services. Our shared record is live in the south east and we have a range of other initiatives.

I take Mr. McCallion's reassurance. I visited the plastic surgery unit in Roscommon University Hospital with a number of Deputies yesterday. It is unbelievable that there is only one plastic surgeon serving Donegal, Mayo, Leitrim, Sligo and Roscommon. There are 8,000 referrals a year, 6,000 actively retreated, and one plastic surgeon, joined by a second plastic surgeon from Galway on a part-time basis. There are eight advanced nurse practitioners doing outstanding work in the area of skin cancer and the see-and-treat model of care. They only have two procedure rooms and they seem to have hit a stone wall. If you are looking for productivity, go to Ms Deirdre Jones in the plastic surgery unit in Roscommon University Hospital. That is productivity and the way the service should be run. There are people coming from the far reaches of Donegal to Roscommon to have their skin cancers removed.

I welcome all our witnesses and wish both Mr. Tierney and Ms O'Connor the very best in their respective roles. I genuinely wish them both very well. I have one question for Mr. Tierney about legislation. He might be aware that I brought forward legislation in the Dáil last week about ending the mandatory three-day wait. It is quite unusual that that could pass through the Dáil if the Minister is supportive of it. In that vein, I want to ask the Department if there is any opposition to the passing of that Bill from the Department's perspective.

No. To be succinct, the Minister has expressed her support, so I will make available resources to support any amendments. I know we have some forward commentary so we will lean in and support that. I know the HSE will be behind us on that too.

Is there any clinical reason as to why that Bill would not progress or any clinical reason ending the mandatory element of the three-day wait would be a problem from Dr. Henry's perspective?

No.

I will move on to the national children's hospital. We have dealt with this several times. It is under Mr. Tierney's purview and the Minister's to progress. We have had the board in very recently. The Minister has made comments. The last time the witnesses were in, they talked about the contractor not deploying the adequate resources needed to complete the project. Has there been any improvement in performance from the contractor on the ground since the witnesses have been in?

In March this year, both the Minister and Department met BAM Ireland and Royal BAM, the parent, to look for an assurance about performance and completion, and the need to increase resources and lean into the substantial completion date. The report back from the National Paediatric Hospital Development Board shows that those resources have not increased in any tangible way. I know the contractor will say that, given the stage of the programme, the technical commissioning, and so on, it would believe the resources are appropriate, but nonetheless we just see completion dates extending.

In short, because we are tight on time, is the answer to that question "No"?

Yes.

Why is that the case, from Mr. Tierney's perspective?

It is a good question. I presume the contractor is managing its own commercial position and cost base in the background. I do not want to get into that. That will be tested in a different forum. Our focus is on holding the contractor to account on two fronts, timely delivery-----

There has been lots of commentary that the contractor is potentially holding the State to ransom on that. If the performance is not what it should be, is it the case from Mr. Tierney's perspective that this is about all the claims and trying to extract as much as possible from the State? Is that why, from his perspective, performance is not what it should be?

The Deputy will appreciate I have to be careful what I say, but it is demonstrable that the contractor's programme has slipped 19 times to date. The contractor has given a commitment to reach completion by the end of August. We will wait to see. If we are judging past performance as an indicator of future performance, we will all draw our own conclusions. In parallel, we have pushed to get access to the hot block. We are taking every advantage and opportunity. We are now at level zero, level one, lower ground, and level six. It is a fully fitted hospital at this stage. Clearly, we would all like to see patients getting in. That is the whole purpose of delivering this transformation. I hope we will get access to level two by the end of the month, but we await that.

I want to turn to the financial controls, because it is a matter on which Ms O'Connor passed public commentary, and rightly so. We need to make sure we get adequate financial controls. She set out a number of responses she feels need to be put in place to make sure we can rein in spending and that we have proper controls in place for strengthening controls, prioritisation of resources and directing funds in areas of greatest need, all of which I would agree with. Up to the end of the first quarter, the overspend was in the region of €250 million. Has that carried over? Has it increased since then? What is the most up-to-date estimate of that overspend?

The figures from the end of May tell us that the overspend is currently at about €400 million.

A total of €400 million is a lot. Ms O'Connor said earlier that we have to make sure we use public funding responsibly. Given that we have a €400 million overspend, are there areas where we are using public funds irresponsibly?

We could spend it better. The challenges we face are in respect of our pay budget and our non-pay budget. We have significantly overspent on our pay budget. We saw very busy winter activity and a growth of our surge capacity to respond to that. Critically, we see a very significant use of agency staff. We know that agency staff are high cost. There is a significant programme of work under way to reduce our agency spend back to the cap that was agreed.

It has not reduced. The most recent figure, for last year, is over €900 million. I know there may have been some improvements in recent months, but in overall terms, it is still extremely high, both on the acute and non-acute side.

That is right, particularly on the acute side. When I came into the role at the end of March, the Deputy may recall that I brought in escalations at the end of April relating to the figures that had come through for March, and regions were put at different levels of escalation to reduce spend. While there is not a dramatic reduction in May, we have seen a turn. We have seen that the growth in the deficit has slowed. We are seeing the measures take effect. It will take some time and a number of months to see it through.

The problem I have is the previous Minister, previous Secretary General and previous head of the HSE made all the same points in previous years when we had overruns. A productivity and savings task force was established and all sorts of promises were made that we would rein in agency spending, deal with the efficiencies Ms O'Connor is talking about, and direct the money where it needs to be spent.

Here we are in 2026, close to the end of the second quarter, and there is an overspend of around €400 million. I fail to understand why we cannot make those changes that we need to make. If we are having the same conversation over and over again, something is not right and clearly something is failing.

In terms of pay we have a structural change where the use of agency has become a mainstream part of how we deliver our services. We have the public-only consultant, POC, contracts and driving that reform is a key part of what we need to do as well. For me it is about the effective use of all of our resources. We talked earlier about the growth and demand. We need to be doing as much as possible away from our acute hospitals. We see the largest deficits are in our acute hospitals. That is where we see unrelenting demand at the moment.

I agree with that and I think that putting a focus on community care is really important. The NTPF publishes the waiting lists for acute hospitals. We know at the moment that the total figure is 974,000. I know the officials cited the figures from the active waiting list but it is quite high, at almost 1 million. There are also about 250,000 people on community waiting lists. Only yesterday, I got data on the longest waits across areas. I just want to read them out because it really paints a picture. In audiology, it is 217 weeks; in dietetics, it is 709 weeks; in ophthalmology, it is 617 weeks; in occupational therapy, it 534 weeks; in physiotherapy, it is 354 weeks; in podiatry, it is 469 weeks; in psychology, of all things, it is 559 weeks; and in speech and language therapy, it is 344 weeks. Those are the longest waits in those areas. There are major problems with community waiting lists. That is the big promise of Sláintecare. If we want to try to fix the problems in our hospitals and access to care, and get Sláintecare delivered, the big piece of that was not just what is happening in the hospitals but also outside the hospitals. Why is it the case that those community waiting lists are so high and people are waiting for so long?

I might bring in my colleague, Mr. Healy, on the primary care waiting list initiative. There is an initiative under way to reduce primary care waiting lists. I completely share the Deputy's view. We have to provide more timely services in primary care to reduce the demand on our hospitals. The whole ethos underpinning our community health networks is that we provide services within our community services, but a very targeted initiative has commenced to reduce our primary care waiting list.

We have taken 20,000 people off the waiting list so far. That includes validation but over 7,000 people have been actually seen, with new treatments and so on. That is physiotherapy, occupational therapy and speech and language therapy. Our target is to achieve 80,000 within a 12-month period and I think we are on track to do that.

The officials are very welcome. It is always a pleasure to get an up-to-date account of where we are at. I wish Ms O'Connor well in her role. It is a huge job she has but one I am sure she is well and truly capable of fulfilling. I was interested in something from the opening statements regarding the primary care therapy waiting list initiative. The target was to remove 80,000 people from that waiting list in a year. That was last October's prediction, and here we are in June and the figure is just 20,000. Was that an over-ambitious plan? It is at 20,000 in June with only a few months left, and 80,000 was the target. Is there any reason that is the case?

I might ask my colleague. I think it started in pilot areas.

We have 20 integrated healthcare areas and we targeted ten of those that accounted for 75% of the issue. We are targeting those. It is important to say that reducing the waiting list is one thing, but the key thing we are trying to do is introduce a new model of how we run and implement waiting list management going forward. If we just do one waiting list initiative and reduce the waiting list, it will grow again. This is a reform programme where we will introduce a new model. That is starting to grip. Some areas are taking longer to get to it than others. One of our best areas is Dublin north city and west. It has substantially reduced its waiting list in the period of time. Those areas that are able to start this have made significant progress.

One of the issues that delayed us slightly at the beginning was that there was an issue with Fórsa. We are using external, private additional capacity on a once-off basis, so we can keep our own teams working at what they are doing. We are using external expertise and capacity to meet the backlog. There was an issue in terms of the level of consultation on that. We have addressed that through the joint implementation committee nationally. Further consultation is taking place with Fórsa, and hopefully that will clear the lines. That will help us then to have a more standardised, structured process across the whole system and we will see an improvement in terms of all areas being able to be involved.

My experience has always been positive when it comes to hospital admissions, I must admit. I am in the University Hospital Galway catchment area but had a surgery done recently in Roscommon. The way that system worked was fantastic, so my comments on it are very positive.

Yesterday, I had the privilege of meeting people from the nursing homes sector, private and public, across the road in Buswells Hotel. Following on from a retirement, the nursing home co-ordinator post in Galway has remained vacant. There is nobody identifying people who are ready for discharge and flagging them to nursing homes, private, public or otherwise. That person's retirement or exit was well flagged. This is not a criticism but I am trying to understand how long it takes in the general scheme of things to fill a post such as that. I asked the representative I spoke to if there was potential for bed-blocking to occur as a consequence of the person not being in that role. They were quite emphatic in suggesting that it potentially is happening. Do the officials anticipate that the role would be filled in the not-too-distant future? If there is a continued delay, it would not serve the hospital well as people are not being moved along when they are ready for discharge.

I do not know the details of that particular post, but it would be a key role in facilitating people to go to nursing homes. In terms of how we identify people for nursing home care within hospitals, it is often with the clinical team and the discharge planners. The nursing home co-ordinators then organise the actual transfer to nursing homes and so on, working with the nursing homes. I will have to come back to the Deputy in respect of that specific post, where it is at and how long it might take, if that is okay.

My final question is fundamentally important to me. I happen to be blessed or burdened with the title of mental health spokesperson for my party. One of the things I was really shocked to learn last week was that there were very tragically two suicides in the Ballinasloe area. Any suicide is one too many. I am anxious to understand what additional efforts are being made in terms of the national campaigns, advertising or encouraging people to reach out and get help, and giving them access.

The question is very timely. In the last month, the Minister of State, Deputy Butler, and the Minister for Health launched the Connecting for Life suicide reduction strategy. It is a national strategy that was developed based on the learning from the previous ten-year strategy. It was developed in partnership with people with lived and living experience, but also with our NGO sector and service providers.

There is a very strong focus on learning what will work from an evidence base but also what people need in timely access to supports. The focus is on reducing suicide and associated risks like self-harm.

In terms of what is available and what is happening, there is a continued focus, through the National Office for Suicide Prevention in the HSE, which has suicide reduction officers in every single part of the country. In addition, they work with all of our community partners to support vulnerable communities and ordinary communities in identifying initiatives and promotions that support mental health and well-being. When a crisis arises for an individual or in a family, there are clear pathways to service provision. One of the initiatives on the mental health side has been the provision of additional crisis support services across many of our regions. We have additional nurses in our emergency departments and the development of Solace, or crisis, cafés around the country. These services are available, provided and developed in partnership with local communities and NGOs, providing out-of-hours and evening services for people who may experience a mental health crisis. It is really about ensuring we move from a 9 a.m. to 5 p.m. service to a more expanded service into the weekends and that people have clarity on where supports are available and what works. We work closely with those who use our services and the staff who provide them to ensure the services are flexible and dynamic. We know there is still a continued need to roll out that information, which is part of the strategy. I am happy to speak to the Deputy separately on that strategy if there is anything else he would like to know.

In Galway, across the road from UHG, there is a crisis café in the building where the Mr. Waffle café is. We are already seeing a marked reduction in crisis attendances in the emergency department in Galway as a result.

The next slot is mine. I welcome in recent weeks the real focus on Sláintecare and the delivery of reform and a universal single-tier healthcare system. We need to keep a relentless focus on the reform agenda and on the creation of a healthcare system we can all rely and depend on. We need to work together to achieve that. My first question is for Mr. Tierney. When his predecessor, Mr. Watt, was before the committee, I asked him for updated costings on the 2017 Sláintecare report. Mr. Tierney may have been at that very meeting. He told me it would be provided to the committee and we still have not received it. When will we receive updated costings on Sláintecare?

I will get a return back to the Deputy shortly on that. I am trying to break out the Sláintecare Oireachtas committee report at the time into its various headings and show a tracked expenditure since 2017 to where we are now. A lot of the programmes set out originally in Sláintecare are now ingrained in the service and in reform programmes.

I know that but we need to know how much the reform will cost. If we are going to advocate for increased investment for these reforms, we as a committee need to know exactly how much it will cost. We heard this morning from the Department and the HSE that the service is under stress in terms of funding. I would appreciate if Mr. Tierney could give us a timeline for the committee receiving the updated costings. It has been some time since we asked for that.

I will have something back to the committee within the next two to three weeks.

I appreciate that. What is core to Sláintecare is the public-only consulting contract. I remain deeply concerned about the revelations in recent weeks and the ongoing practices and violation of those contracts. It must be put simply - it is not up to individual hospitals to pick and choose whether they will implement these contracts. They are landmark reforms and must be implemented by all hospitals across the State. We need to be really clear on that and take a really strong line with individual hospitals and consultants that these contracts cannot be violated or breached and must be implemented. What has changed on foot of the very shocking revelations in recent weeks? What has changed in reporting and governance?

I share the Cathaoirleach's view that it must be implemented. I issued a directive to the system two or three weeks ago on the implementation of POC in a standardised way. I have also established an oversight group chaired by Dr. Colm Henry as our chief clinical officer and Anne Marie Hoey, our head of people, in terms of driving that reform in a systematic and consistent way nationally because part of our challenge has been putting our arms around this. The visibility and transparency of data and all of that have been a challenge. I have been very clear with all of our regions in respect of the immediate need to report on DIME, our system of record. We are also enhancing it to ensure the data is better. We have a weekly report now. As part of our weekly reporting mechanisms, we see an update on where we are in implementation. I have been clear with all regions in respect of the need to review the work contracts to ensure they are compliant, not just having them on DIME but also ensuring compliance with Saturday working, extended hours and ensuring all services. This has to be implemented. The message has been very clear from me since I came in.

Up until now, what reporting was taking place other than uptake of the contract? What governance and monitoring occurred?

DIME is the system where people enter the work plans. Work plans are agreed with consultants and they are put up on the DIME system. The reality is it is not a very live system so we are making changes to that. Part of the challenge is the difference between seeing a work plan and if something changes in a hospital, being able to change all of that and reflect different working hours. I have seen there is far more local ownership of the implementation of POC and far more direction being given. The reporting we have now is weekly through the oversight group. I will ask Dr. Henry to comment as he chairs that group. It is visibility of what is going on side by side, consultants and all of that.

Do the clinical directors oversee the implementation of the contracts at a local level?

There are clinical directors within the site who develop the work plans with their consultants. The regional clinical directors also have a role in oversight at a regional level. They report to the regional-----

Does Ms O'Connor expect this national programme will result in changes and improvements?

Absolutely; it has to.

In relation to some of the pieces that have been exposed, has there been engagement with the Rotunda around weekend rostering practices? Has that changed?

There is ongoing engagement. I am aware the Rotunda will be in here next week. I am aware Dublin north city is in constant contact so it is working with it on the requirements to implement the contract as set out. My understanding is that that is progressing. A lot of proactive steps are being taken in implementing the contract.

We have heard from Cork University Maternity Hospital that it has changed its practice on foot of the revelations but we have not heard it confirmed from the Rotunda. Can it be confirmed whether the weekend rostering practice will change?

Yes.

It will change.

The way we measure is the work plan. The work plan needs to reflect what is actually happening on the ground. The CEO has already mentioned the work plan, as it is currently configured through DIME, does not always accurately do so. That said, we have seen regional variations. Looking at the core obligations of the contract, the extended working day and Saturdays, there is regional variation through an imperfect system which is going to be better, more sensitive and more reflective of what actually happens on the ground. For example, in the mid-west there are 70% of consultants in a planned working extended day and nearly 50% in a planned Saturday. We need to get that across all regions.

On the issue of private practice, we are very clear about this in the HSE. The contract is explicitly clear and we are explicitly clear with our clinical directors what that means for each consultant on a POC.

If we are to get to single-tier universal healthcare system, we have to remove private work from public hospitals. At the weekend, University Hospital Galway confirmed it will end its deal with Bon Secours to do laboratory work for private patients. Was the HSE or Department aware of this issue and the implications for the implementation of the public-only contract prior to the Social Democrats making this revelation in the Dáil last week?

I was not. On foot of the work with the Rotunda and all that happened, a directive was issued by Anne Marie Hoey, our national director for people, on examining any arrangements. In reality there have historically been many arrangements between public and private. In that instance, the Bon Secours has frail-elderly beds on behalf of University Hospital Galway. There has been an arrangement for many years. That was immediately ceased once this all emerged two or three weeks ago. A directive was issued by the regional executive officer to cease it. We are examining to see where any other such instances are happening.

Is Ms O'Connor satisfied by the response from the hospital that it will continue this until September, given that it had a number of years to implement this contract? It continues to do this and continues to require public-only consultants to do private work in the labs for most of the rest of this year.

There are patients currently in the Bon Secours sent by the public system.

We have to be very careful in terms of the ability to actually carry out the test. The Bon Secours has been put on notice in terms of building the capacity.

I do not think that is fair because we know there is a huge backlog and they are now being outsourced to a private company. The samples are coming from the Bon Secours to the public hospital and then being outsourced to a private entity. There is no reason why they cannot go directly from one private company to another and not have to be washed through the public system for what I am told is an eye-watering amount of money at a huge cost to the public system. There is no reason this cannot be ended immediately and it should be. We need to know if this is happening in other labs across the country. There needs to be an update on that.

On another matter, when will we see the long-promised strategic review of general practice? We were told it would start in 2023 and be done by the end of the year. There is still no sign of it. Any time I ask, I am told it is pending. When will we get a date?

We are working on it. We are at a particularly advanced stage.

When?

We will have it this year. Before the end of the year, it will be completed. We took additional time to do a much deeper dive into GP out-of-hours services. We put a significant programme of work into that which took longer than anticipated.

When will we see the programme for Government commitment that under-12s will get free GP care?

That will be considered in the context of the publication of the GP review and then in terms of budgetary-----

There will be another delay and further time before we see any progress. Core to universal healthcare is access to GP care in communities across the country.

I thank all the witnesses. I extend my congratulations to Ms O'Connor on her appointment as well as to Mr. Tierney. I know they are both veterans of the health system. I extend warm wishes to both of them in their challenging roles.

I welcome the focus on the expansion of primary and community-based care because that has got lost in the conversation, particularly over the last 12 months. We have fewer public health nurses than we had five years ago. Deputy Cullinane spoke about the very extensive lists - if you could call them lists because of the waiting times - in some parts of the country. I take it as a positive that there is a delay to the strategic review because perhaps the issue is with the massive gaps in access to GP care. It is not just about the supply; where the HSE puts GPs has to be part of the strategic review. It is supposed to be the summer, but hopefully by the end of the year we will have a really good review.

I will ask Ms O'Connor about the HSE's financial situation. This is the first year of the population-based resource allocation model. Did the HSE get the right amount of money at the start of the year? It has a deficit as of May of €400 million. Was there poor forecasting or poor management by the HSE or have the Department of Health and the Government simply given the HSE too little money?

The national service plan, NSP, for 2026 was framed before I came.

Yes, I appreciate that.

In terms of what I can see at the end of quarter 1, we certainly have been very challenged in terms of the level of activity. The level of activity has been very high during the winter period which has resulted in higher costs for hospitals for opening additional capacity and all that.

In terms of the framing of the NSP, there was a built-in assumption around savings that could and would be made, which did not quite materialise. There have also been other costs. We have seen significant increases, for example, in our drug costs. We have non-pay drivers in our deficit as well. We know that increased activity leads to increased costs in things like aids and appliances and diagnostics. I cannot speak about the forecasting; I was not party to that last year. However, at the minute we absolutely have to pull back to our NSP-funded level. We have a service plan that we are working to which has been signed off. At the minute, we are outside that. Very significant work is under way to bring that back.

I might jump in on that. We started 2026 with an overall budget of €27 billion but implicit in that was a requirement for total balance pay control and control around non-pay. As Ms O'Connor said, some external factors are driving pressures into our non-pay control. We have all recognised this. Even over the last few weeks we have had engagement around strengthening the financial control environment around that total balance pay budget and non-pay control. That extends right across key controls.

I might run through a few just to give an idea. As well as regional decision-making, there will be central recruitment approval. There will be a post-by-post review. We have to manage the payroll. We do not have an infinite resource available to us. There has to be pay control discipline. We have to ensure there is strong monitoring across that total pay control balance if we are to achieve post correction. As the Chair rightly pointed out, we have to pay particular attention to how agency is used as a structural recruitment piece and overtime. Obviously, everybody wants to see if we can achieve agency conversion into total recruitment, which would be ideal.

I might just answer two structural questions.

I am on the clock, but Mr. Tierney might go on quickly.

That is the in-year pressure. There is an expectation that we will take the system off framework agency by the end of September and establish a national staff bank. That is the structural reform that is needed, as well as working on the in-year pressures.

How will the €175 million levy that has been applied to the Department of Health be applied in turn? Will a cut be forced on the HSE or will it be absorbed elsewhere?

That is a decision that has already been taken by Government. We will have to understand how we achieve that saving.

What is the answer? Where will that cut happen?

I am sure we will negotiate that with both the Department of public expenditure and reform and the HSE in the coming months. We have to see how that settles in the context of the pressure we are seeing now. I cannot give the Deputy a straight answer on that today.

I take it the €181 million of savings set out in the NSP for this year will not happen at this stage. We have a €400 million deficit and there is an ambition for a €181 million saving. Surely that cannot happen at this stage, can it?

There are a number of work streams in place. As mentioned, there is pay and non-pay. We have a cost oversight group that Mr. McCallion is chairing on behalf of the organisation looking at very specific actions. I have been very clear with all the regions that we must bring our budget back. We are looking today at the May figures. We know that a huge amount of work is under way and it is very hard to say yet where we will end up.

At the moment, three regions are in tier 3 escalation. Does Ms O'Connor anticipate any of those regions going to tier 4 this year?

The May figures have shown that the growth in the deficit has stabilised and reduced. A couple of the areas that had the biggest deficit have come back the most in May. The May figures show that the actions that were put in place are taking effect in areas. It is a small turn, but it shows that the growth has slowed. I expect to see a very significant reduction in the coming months because we have brought in so many measures in terms of controlling our pay costs, as Mr. Tierney said, reducing our agency and critically also controlling our non-pay expenditure.

Are any of those three regions close to tier 4 escalation at this point in time?

At this minute, no, because we have stabilised in May.

There are all sorts of difficulties in the south-west region or whatever it is called now, but I am calling it the south west. I understand a letter of no-confidence in senior management was issued to Ms O'Connor. Can she confirm that is the case? What actions are being taken on foot of that?

First, I will not get into any specific HR matters or anything here within the south west or-----

I am not clear if it is HR or if it is to do with the financial situation. I am asking if the letter has been sent to Ms O'Connor with regard to no-confidence in the management.

I have received many letters from different people. In terms of the south west specifically, there have been concerns raised in respect of the south west that I am dealing with.

I want to ask about the POCC and insourcing. There is an ambition to reduce insourcing over time. When I look back at the health budget oversight group documents over recent months, one of the things that stands out to me is that the HSE is not able to disentangle the overtime paid by way of regular overtime and that paid through the National Treatment Purchase Fund, NTPF. Is that still the case? If it is, surely it is a reflection of very poor systems within the HSE that it is not able to identify what is regular overtime and what is procured through the NTPF.

I will have to come back to the Deputy. The integrated financial management system, IFMS, has been rolled out, so obviously we have made a big investment in financial management systems. I will come back to the Deputy specifically on that. I do not have the answer here.

Is Mr. McCallion not able to clarify if the HSE is able to separate out regular overtime from overtime procured through the NTPF?

The insourcing has ceased in most cases now anyway. The HBOG that the Deputy is referring to probably referred to where that was a more prevalent systems solution over recent years. There is very little of that remaining, so it is less of an issue than it was. I will have to come back to the Deputy on the system identification. I cannot answer that now.

We were told in the committee last year that people were confident that the POCC was working well, and then we saw what happened with the Rotunda. I would not be convinced that the approach to insourcing is working as well as might have been relayed here. We also have to be clear that if we are to get rid of insourcing, we need to be sure what is being paid for regular overtime.

A very clear direction went out on that previously. We are clear where that remains and how it is being phased out. That is not an issue going forward. I will come back to the Deputy on the specific point about the identification of the distinction on overtime.

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

I welcome the witnesses. Comhghairdeas leis Mr. Tierney on his appointment as Secretary General. I am also delighted to see Ms O'Connor in her new role. I hope Mr. Tierney does not mind if I call him Derek. As a fellow Christian Brothers graduate, I have noticed a trend among Secretaries General. I was talking about this to Robert Watt and others in London. A lot of Secretaries General are Christian Brothers graduates. I think we should form some sort of support group or mafia group - perhaps I do not want to use the word “mafia”. I wish him well. I note from his CV that he is a person who is well able to get his teeth into things and see things through. I congratulate him and wish him the very best on his appointment. I offer similar congratulations to Ms O'Connor.

My area of special interest is disability matters.

This is not a criticism of anybody here - it is an observation more than a criticism - to say that disability is in polycrisis for disabled citizens. If I was to focus on one ask of the witnesses today, it is on the area of mental health of intellectual disability, MHID. A national service plan was published in 2021, five years ago, and since then only one team in the State has been staffed and funded, on a pilot basis in Cavan. The other mental health of intellectual disability teams throughout the State do not have social workers, psychologists or occupational therapists. In many cases, they only have a consultant psychiatrist, and I would question whether they all have higher specialist training in MHID. The consequences of this affect these vulnerable adults, of whom there are thousands throughout the State, very often elderly and living at home with elderly parents. Four out of ten of these intellectually disabled citizens will develop a serious mental illness or disorder and all they can get is medication. I have been approached by many of the consultants in this area, executive clinical directors and the chair of the faculty of mental health of intellectual disability in the college of psychiatry, who tell me if they had those multidisciplinary teams they would be able to give these people occupational therapy and skills of daily living. In the case of a number of individuals who were able to avail of those sources, those consultants are able to de-prescribe and titrate their medication to the extent that one woman has been able to get up out of her wheelchair and walk. Another has been able to take up full-time employment in the community. Another has been able to feed herself for the first time in her adult life; again through the input of a multidisciplinary team, incomplete as it was. One family have reported that their adult child with an intellectual disability, having had support through an incomplete team, has recovered their personality and their sense of humour.

There are thousands of adults with intellectual disabilities in crisis throughout the State. They are out in the community. In the community, nobody can hear you scream. I refer to the moral distress for the clinicians who are trying to deal with them and the moral distress and injury to the parents who see their adult children deteriorate for lack of that intervention and who fear for their future. Some 55,000 disabled adults over the age of 25 are living at home with older parents over the age of 60. I will join that cohort on 26 August and there is no signpost, pathway or roadmap for us.

In their newly appointed roles, can the witnesses commit to funding those posts? The consultants tell me it is not a recruitment crisis among allied health professionals; it is in the regional health organisations that the REOs are telling them they are not funding them as they do not have the funding for them. It has been presented as a recruitment crisis but actually it is a refusal or an unwillingness to fund these posts. That is what I am being told by the hospital consultants and the executive clinical directors, ECDs, who are contacting me. I could say the same thing for CAMHS. I could say the same things for general adult psychiatry and for the CDNTs in broader disability. What is the plan? Do the witnesses accept it is a polycrisis or do they think everything is fine? I would be curious to know what their plan is.

I will open up and will ask Ms McArdle to come in before Ms O'Connor and the team. I fully agree with the Senator. Our role here is around providing services that protect dignity and safety as well as providing that support, particularly for people who are vulnerable and rely on complex supports. As Secretary General in the Department of Health, I engage with my counterpart in the Department of disability and children because we realise that many of the service pressures we see sit across those organisational boundaries. Therefore, if we are ever to truly deliver integrated care, we cannot let those boundaries separate us; we have to work across them. We have an inter-departmental forum where we share how we integrate or knit policy responses together across those boundaries. I will certainly take that point and engage with my counterpart on it.

The Senator is correct in identifying that people with disabilities are also people who may, during their lifetime, experience mental health difficulty. Our overall mental health service is available for all but there are a small number of people with moderate to severe intellectual disability who do need access to those more specialist services. In 2021, the HSE published a model of care for mental health and intellectual disability with a roadmap and ambition for multidisciplinary teams to be available, not to work in isolation but in conjunction with other disciplinary services, with residential services, with those places where people work or live, and with families. There are currently 20 such adult mental health intellectual disability teams around Ireland and there are ten CAMHS teams. The plan and the ambition is to roll out 31 of those teams and 16 specialist CAMHS teams. We know at the moment that there are areas where they are not fully developed. It is an incremental development because, as the Senator says, the psychiatrists who are specialists have to have the particular specialism in this area. Therefore, in 2026, the Minister of State, Deputy Butler, funded an additional two CAMHS mental health intellectual disability teams-----

Sorry, could Ms McArdle repeat that?

She funded an additional two CAMHS mental health teams.

I have just come down from the Seanad Chamber where I had a Commencement matter with the Minister of State, Deputy Butler, and we talked about this. Of those 20 teams that are dedicated for adults, she described them as "starters". They are not actually staffed. I say to the witnesses again that the clinicians are telling me it is not a recruitment problem; it is a refusal to fund. The Minister of State told me that she has ring-fenced a certain amount of funding, but the problem here is trying to get the HSE - excuse me - to proactively fund those and recruit them in the different regional health areas.

The canary is in the coal mine here. We had a highly publicised case last year of a lady in Cork who left her older daughter with Down's syndrome in the emergency department. She got a letter from the HSE, from the head of disability services in HSE South West saying she should be aware that she was legally responsible to look after and care for her child until she is 18, or 23 if she is in full-time education, but as a person with a child with a disability she was legally obliged to look after that child until she dies. I spoke to a very eminent senior counsel, a former Minister for justice, Attorney General and Tánaiste. I will not name him - Michael McDowell. He told me there is absolutely no basis in law for that. What it does reveal is a kind of ideological or philosophical position within the services that sees disabled citizens as charity cases, and see their parents, people like me, as a kind of a disposable asset, in that I will do this until I die. I have no idea what will happen after I die, however. I am sorry for burning up all the time. I am told by the clinicians that the CDNTs are advising older parents to leave their adult children in the emergency department, which is symptomatic of a broken system.

I thank all the witnesses for being here today. I have four points to make. The first is regarding orphan drugs and rare diseases. I welcome that the HSE senior leadership team, SLT, approved givinostat, but that was a week ago and the patients are waiting for the managed access programme to be agreed. They are looking for it to be agreed in line with the NICE recommendations. Anything else would be very disappointing for these people. To give a snapshot into their lives, because we do not have an early access programme, a lot of children who would have been ambulant and able to stand and who need access to givinostat and meet the requirements to access it, will not get early access. These are people at whose kitchen tables I have sat and I have talked to them at length. Do the witnesses understand the importance of an early access programme in Ireland for drugs? We also have the people with Friedreich’s ataxia who are waiting for Skyclarys. Do the witnesses understand the importance of being very speedy when making these decisions? Do they understand the need for an early access programme to make sure that humans do not lose what they have?

My second point is to do with accident and emergency departments. Is there a view on a policy, specifically for people with dementia, sensory issues or autism, for quiet rooms or secluded areas in accident and emergency departments?

When my father was very ill and had dementia, he was 74, so he was not of that age where he would have had really quick processing. He found the hustle and bustle of the accident and emergency department very distressing. Is consideration being given to this issue?

If there are psychiatric patients in Tallaght hospital, for example, with a long-term mental illness, such as schizophrenia, and they are being released against the wishes of their families, what care plan is in place? Are hospitals happy to release these people into homelessness? This happens. Are comprehensive care plans supposed to be in place? Why would a person with a major mental health illness, spanning 15 years, be released without a comprehensive care plan being in place? Why would they keep getting GP referrals, with the same thing repeating over and over and them never get the help they require?

I want to talk next about the procurement department. I do not know if anybody here is affiliated with it. What is going on? We are talking about overspending - money not really being a problem, but not reaching where it needs to either. I want to talk about the radiotherapy machines being at the end of their lives. I worked in procurement in an office. When the photocopier was on the way out, we replaced it with a new one. These radiotherapy machines are life-saving equipment.

I also want to refer to the fact that there is no positron emission tomography, PET, scanner in University Hospital Galway, which is a level 4 hospital. This issue has been raised by Councillor Michael Crowe on several occasions. Are there any plans to get such a scanner for the hospital?

I acknowledge the Reeves Day Surgery Centre and the south Dublin surgical hubs as well. They are great additions to the community. Has an impact been seen on waiting times so far because of these facilities?

I will come in first on access to medicines. There are two parts to the Senator’s question, one of which is the speed at which we can process pricing reimbursement applications. When we were heading into negotiations on the new framework agreements last summer, we got a very clear and explicit direction from the Minister on the 180 days, with that being a focal point of those negotiations. We spent quite a bit of time with industry representatives over the course of six months engaging on that particular issue. Coming out of that is a very real and tangible commitment in the framework agreement for the State to move towards 180 days progressively over the next couple of years. As part of that, the industry is committed to doing its best to bring pricing reimbursement applications----

May I just interject? With regard to givinostat processing, the timelines when the ball was in the HSE’s court were fast.

Yes, they were. Second, we recognise that, in terms of the process of meeting the 180-day commitment, there is a requirement for investment and process changes. Some of those have started already. More importantly, though, in terms of a structural change required, we went out to procurement recently on a review of the end-to-end process. This includes everything from the National Centre for Pharmacoeconomics, NCPE, process right through to the drugs group and senior leadership team, SLT. It is focused on looking at where we can speed up the process and how we can use digital enablement to support it. The ultimate aim is to get to 180 days.

There is a commitment to deliver early access programmes. We had discussions with industry in the context of the framework agreement. We have agreed to establish a strategic partnership around this. There is a very clear programme for Government commitment to deliver an early access programme, particularly in relation to rare diseases as a starting point. This is a body of work we are now working on within the Department. We are reaching out-----

The HSE acknowledged the need for the early access programme.

The Government has explicitly committed to it and we are actively working on that.

I thank Mr. Redmond.

In terms of accident and emergency departments, there is a quiet room and a mental health space. Modern emergency departments have more space available. I think there is less space in some of our older emergency departments. The reality is that, when an emergency department is extremely busy and it might be argued that it is even more important to have a quiet space for somebody, spaces sometimes get used. The answer, however, is “Yes”. Our emergency departments seek to support people who have particular needs, either due to mental health challenges or neurodiversity, in terms of quiet areas.

As to discharging people, this is always a tricky question in mental health. The only way we cannot let people leave hospital is if they are detained under the Mental Health Act 2001. If people are deemed to not be detainable, then they can leave a hospital. The reality is that, while every effort is made to develop a comprehensive care plan and we are required to have care plans for patients under our regulations and the Mental Health Commission, it is not always possible to support people when they leave hospital. People who are not detained under the Act will sometimes leave of their own volition against medical advice.

I find that very worrying and unacceptable in terms of the family's safety and so on.

Who would like to address the question on procurement?

On the radiotherapy aspect, the radiotherapy replacement programme is a key commitment under the current national cancer strategy. We have already allocated €120 million of direct investment in state-of-the-art radiation oncology centres in Cork and Galway to address radiotherapy needs. Funding has been allocated in the current capital plan for a linear accelerator, LINAC, replacement programme at St. Luke’s. The preliminary business case for the programme has been approved by the HSE.

In terms of future replacement needs, the Department and the HSE are developing the strategic infrastructure programme plan for replacement.

I am sorry for cutting across Ms Conroy, but would she accept that many of the machines are out of date by international standards?

Yes.

Who in procurement is answerable for that?

I will bring in Mr. O’Connell to get some more detail on this aspect. To address the future replacement needs, we have developed a strategic infrastructure programme to plan for replacement and, where appropriate, expansion at the public radiation oncology facilities. The first meeting of that with relevant stakeholders took place on 12 June. The whole intention there is centralised planning and oversight and implementation to enable cost-effective procurement, efficient delivery of enabling works and alignment with the cancer strategy, which has delivered significant outcomes for cancer patients in this country over the course of the last 30 years. Mr. O’Connell might want to come in here in terms of the recent detail.

There are 23 LINAC machines in the country across St. Luke’s, Beaumont Hospital, St. James’s Hospital, University Hospital Cork and University Hospital Galway. We have a significant replacement programme in this regard, including a phase 2 development in Beaumont Hospital. Of those machines, 12 are at an extended life stage, four are 18 years old, and another eight are between 15 and 16 years old. The ideal recommended situation is a shorter lifespan, but these machines are still being risk managed and serviced and are still safe to use.

I will flag that we will be having dedicated sessions on mental health, emergency departments and the cancer strategy where we will be able to tease out some of these issues in more detail in the coming weeks.

I extend my best wishes on the new roles. Quite a bit has been taken on, but I have no doubt about the witnesses being up to the task.

I want to ask questions about three areas, namely, capital, mental health and neurology. I will start with the capital question because it is the most straightforward. This is really a yes-no kind of question. Our sexual assault treatment unit, SATU, in Mullingar is the third busiest in the country. It consistently receives extremely complimentary reports from the service users and the staff. Where less than complimentary comments are made, however, they are about the actual unit itself. Has the SATU in Mullingar been included or reviewed for inclusion in any potential capital investment?

My understanding is that it is under review at the moment. There is a development control plan going on for Mullingar and the priority is for the development of a bed block there. That may free up space to expand the SATU, but it is in relation to the wider review as well.

That would be further down the line rather than any form of immediate work.

Yes.

That is disappointing, given the level of complimentary reports about the unit.

I want to move on to the area of mental health, particularly child and adolescent mental health services, CAMHS. This area is such a disappointment when it comes to the delivery of services. I heard the opening statements and what was said about access to services, being safe and sustainable, and best practice.

However, I cannot reconcile that with the 4,748 kids who have been identified as having a moderate to severe mental health illness and are sitting on CAMHS waiting lists. Those figures come out every three months and they are not going down. Rather, they are getting higher and higher. Bear in mind that this is CAMHS, not the community waiting lists. If I look at the community lists in my constituency, the long waiters are at 145 weeks. This question is specifically about CAMHS. At what point will the HSE react in a way it has not done to date to get those numbers down? I will give an example. In the Cork north and east integrated healthcare area, IHA, 53 children have been waiting over a year. In the Cork south and west IHA, 58 children have been waiting over a year. In the Louth and Meath IHA, 56 children have been waiting over a year to be seen by CAMHS.

I share the Deputy's concerns in respect of CAMHS, though a lot of work has been done. At the minute, there is a particular focus on long waiters. The national child and youth mental health office is working with the six regions on a focused action plan. We know the demand for CAMHS has gone up by about 33%. Our waiting lists have not gone up by that amount, but by about 3%. We can see that there is a proactive management of waiting lists in the context of the volume that is coming into CAMHS. Clearly, we do not want any child waiting a long time to be seen. We are struggling in certain areas in respect of recruitment to teams and this has been an issue with CAMHS for some time. There is a very targeted initiative now to drive the waiting list, with a particular focus on those who are waiting the longest nationally. I am aware that all areas are not equal in that. Some parts of the country are not as challenged, so we are targeting those that have the most significant demand.

When I look at the statistics, I can see the children waiting under three months. I see that figure reducing for the children who are waiting six months. There seems to be activity within those timeframes, but then I look further along and see the number of children waiting over 12 months increasing. Does Ms O'Connor understand the concerns I am raising? At what point does the HSE look at what it is doing currently and recognise that it simply is not working for these 640-odd kids?

There are two things. The waiting list initiative is under way. The other very important initiative going live in July is our single point of access for children who are being referred for CAMHS services, primary care services or disability services. In terms of the activity within our services, we know that many of the children are being referred and they may or may not need to be seen in CAMHS. What we find is that children end up waiting on lists. We need to ensure that we have the right service responding in a timely way. It may be CAMHS or it may be a primary care team, but we have to come at it from both sides, that is, the children coming in from referral and also the children who are the long waiters.

I happen to agree with that. It is about the right service for the child at the time the child needs it. However, my concern is about the single point of access. There will be children referred to teams that, as Ms O'Connor has said, are not fully staffed. Is the HSE actually going to be delivering the service or just moving the child from list A to list B?

We are increasing our staffing. Under our national service plan, we have over 200 posts in recruitment this year for our community disability teams for children. We are also increasing recruitment into our CAMHS services and are looking at other models. We are aware that there is a need for a more varied response in child and youth mental health in terms of crisis support and supporting families. Our national child and youth mental health office is working across the country on that.

I have an eye on the clock here and there is another area of mental health I want to move on to. Last October, the Minister of State, Deputy Butler, told the Dáil that a third crisis resolution team had been identified by the HSE for Tullamore-Westmeath. Has that been delivered? She went on to say that the funding would be in the region of €1 million.

I might check with Ms Killeen White as our regional executive officer in that area.

The funding for ten WTEs for the crisis resolution team for Tullamore was committed to. There is ongoing recruitment to resource that team and deliver the appropriate pathway.

Can we just nail down the location? Where is this Tullamore-Westmeath team going to be based?

It is affiliated to Tullamore but not the hospital. We will be basing it at a yet-to-be-identified location. Bear in mind that it will serve the broader midlands IHA. It is not specific to just Tullamore.

What are the criteria that Tullamore met and other larger towns in the region did not that led to it being chosen as the area to base this team?

I cannot answer that in the context of the specific criteria. There is ongoing recruitment for the ten WTEs to resource that much-needed team.

Can Ms Killeen White revert to me with the details of those criteria?

Yes. I can look into those.

The Minister of State could not answer when I put that question to her. It concerns me, given that we have St. Loman's Hospital in Mullingar and Tullamore to north Longford is a bit of a trek for any crisis team. Simple geography would have indicated more suitable towns for that team to be based in, with access to motorways and good-quality roads.

I am going to move on to the last issue. I will have to keep this really tight. I raised a Topical Issue this morning with the Minister of State, Deputy Dillon, on neurology services based out of Midland Regional Hospital, Mullingar. Is there a consultant neurologist in that hospital?

I do not have the answer to that. I will follow up on it for the Deputy.

Is the neurology team based in the hospital?

There is a community neurorehabilitation team that has been funded for the HSE Dublin and Midlands health region. That funding was secured to establish the community neurorehabilitation team to serve the broader region as part of the national-----

But is the team based out of the hospital?

No.

That was my understanding as well. It contradicts what was put on the Dáil record this morning, not by me, but by the Minister of State. I am raising it because there is no full-time neurologist in Tullamore hospital. There are three 90-minute phone calls available every week and every second week an inpatient clinic. A population of over 200,000 people is served by a part-time service. If I have a constituent who needs to go from Moyne to Tullamore, it is a 90-minute one-way trip of 105 km. We already know when it comes to the regions that there are gaps in the services provided. This is not unique to the health sector in any shape or form. Do the officials think it is safe, sustainable and best practice to have what is effectively a part-time consultant for a population of nearly 250,000 people?

Can we get a very brief answer because I have four other members who want to come in before we conclude the meeting?

Perhaps I will follow up with the Deputy directly on that in contacts-----

It is a "Yes" or a "No". Do the officials think it is safe, sustainable and best practice?

I might ask Dr. Henry as our chief clinical officer.

In short, it is not because we need more model 3 neurologists. We received-----

But it is part of the-----

If could answer the question, Deputy. There is a deficit of consultant neurologists in model 3 hospitals such as Tullamore. We received €5 million to appoint teams across model 3 hospitals in 2025. We need coverage across all of the model 3 hospitals.

That includes Mullingar, which is a model 3 hospital.

Yes.

Thank you, Chair.

Thanks very much. It will be tight to get everybody in, so if we could try to stick close to time, or if people do not want to use their full time, that would be great.

I congratulate Ms O'Connor and Mr. Tierney on their new roles and wish them all the best. I am looking forward to working with them and everybody who is here. I thank them for their information today.

My questions are mainly on University Hospital Limerick, UHL, and the mid-west area. The 96-bed block has been opened and I am thankful that the next 96-bed block project was awarded last week and is under way. There is to be a hospital development board established at UHL. Maybe I could get an update on that. When is the surgical hub in Limerick due to open? The current 96-bed block has made a difference but there was still a very high number of people on trolleys during May and into early June. Perhaps the officials will comment on that.

Another concern is GP shortages, especially in rural areas. A lot of GPs have retired with nobody to replace them. The doctor in the Moroe-Cappamore area retired and people now have to get a bus, if they can get one, to the next nearest place or into the city to see a GP. There is nobody to replace the doctor who retired. I am aware that there is a report due to come out.

To follow up on neurology, I know someone who was a patient recently in Cork University Hospital, CUH, and got fantastic care there before being transferred back to UHL.

When they were transferred back to UHL, there were not enough physios to carry out physio with them; it only happens two days a week. The witnesses might not be able to answer on this area today, but it is an area the HSE could look at. There are quite a few patients who need physio more than two days a week, but there are only sufficient funds at present for two days a week.

I reiterate the Government's commitment to addressing the challenges facing patients and families and the wider public in the mid-west. We are working through a programme for Government commitment to increase overall capacity in the region, guided by the advices received by HIQA at the time. The Minister is consulting a number of stakeholders, and she hopes when she concludes that to establish the strategic development board. I will let the Minister work through her stakeholder consultation but it is definitely at the top of my agenda to conclude arrangements for that and support the Minister in announcing that in due course.

The Senator is right, specifically in relation to University Hospital Limerick, that we have added capacity with our first 96-bed block and there is a contract under way to finish out the second. I know Mr. O'Connell is actively looking at all opportunities to build further capacity in Dooradoyle. In addition, we are looking at how we develop a new site that we recently acquired down the road. The plan is to build a two-hospital acute campus for Limerick within the wider region. We are trying to understand if there are services we can decant from Dooradoyle to our model 2 hospitals to put them on a sustainable footing. We have investment plans for the model 2 hospitals. We need to follow through on them.

Our goal is to open the surgical hub by the end of the year. I ask Mr. McCallion to confirm that. I will hand back to Ms O’Connor and the team on wider patient flow issues, pre-hospital avoidance, and community and GP capacity.

The surgical hub is on target for handover, contract-wise, by quarter 3 and for opening in quarter 4. There is a commissioning and equipping piece. It will be a gradual opening in terms of clinical safety.

Senator Costello asked a question earlier and I can give her the answer. There would be approximately 10,000 procedures a year for the four-theatre option, and just under 14,000 for the six-theatre option. It will grow gradually. Limerick will start at four and move to six later. That gives a sense that it will make a huge impact in relation to day cases. We have seen that in the Reeves centre and in south Dublin as well. There are 12 specialties. Initially, not all patients will be eligible for them, but there are 12 specialties and we will go through that.

There is real recognition of the need to increase the number of GPs. We increased the number from what was 120 more than a decade ago to 350 last year, and that will increase again to 400 this year. Some 1,044 graduated in 2024, and that will increase to 1,300. That is a 25% increase. Significant progress is being made in that area, even though we know more is needed. That is important.

The international medical graduate programme is a targeted programme of bringing doctors in from abroad in a structured way, with the support of the ICGP, the Irish Medical Council and the IMO. Some 113 graduates have come in, and after two years they can take up a full-time practice. That is targeted at rural areas. The western seaboard has benefited from that. That is also a positive initiative that is contributing to improvement.

The Senator is right that the emergency department continues to be extremely busy. The day before yesterday there were over 300 people there. The activity level is high. We saw a significant drop last week in terms of trolleys, etc., but it is extraordinarily busy there. The real focus is on using the model 2 hospitals nearby to ensure patient flows between units, but there is a high level of demand.

I acknowledge that the staff work phenomenally hard. It is very tough for everybody - the staff, but also the patients and their families. I will look at the model 2 hospitals, such as St. John's and Croom. I pay tribute to Ms Broderick and her team, who have done wonderful work to try to make better use of the different hospitals. Is the link with pharmacies and community-based clinics, where people can go for physio in their local community health centre or whatever, going to be expanded upon? Is there work going on to see how services can be increased in some of these areas to take people out of the hospital system?

Absolutely. The whole focus of what we are trying to achieve is to ensure people are seen in the best place. Already there has been a lot of work with pharmacies in terms of the common conditions and what pharmacies can now do. We are looking to expand that in the mid-west. That is going to be the first area leading on the community care record, which will be the first digital record, if you like, for community services. The pharmacies always work very closely in terms of trying to look at all other avenues to support people. The reality is that we need to continue to invest in our services outside the hospital. Limerick is a real example of that because of the very high attendances. A lot of work has gone on previously in that region in respect of the community intervention team and the older persons teams, etc., to support people to be at home and supported by GPs and pharmacists. That is where we want to go everywhere, not just in Limerick. Our focus is on our community health networks and trying to ensure we keep people as well as possible at home for as long as possible.

To follow up on that, is there a shortage of carers to go into homes? I know there are more than 5,000 people waiting on home care packages. It is very difficult to get people to become carers. Are there any incentives? Are we going to see any breakthrough shortly? When people are kept at home, they are more comfortable in their own home where possible.

Our focus is absolutely on supporting people to stay at home. There have been very targeted recruitment campaigns nationally and at regional level. We have seen some good results regionally in terms of targeting certain areas and geographies. It is a challenge to ensure we have enough carers nationally, but devolving that to regions to drive local recruitment campaigns seems to be delivering a better result.

I will raise my issues and I can get the answers at the end. I welcome our guests here today. I am aware that there are 162 unfilled positions at University Hospital Kerry, UHK, presently, which obviously brings its own issues. I have received reports of a number of cases in which senior citizens have been left waiting for care for up to 24 hours at the hospital's accident and emergency department. I am aware of cases in which people have fallen off chairs in the waiting room. I do not think that is acceptable. It is bordering on criminal, to be quite honest. What is an acceptable waiting time? I understand that priorities have to be given to different cases. I understand as well that the new 96-bed block will be part of the solution.

I have received complaints about the distance between the maternity unit and the theatre at UHK. This needs to be addressed. It is in the plans. It is a major health and safety issue for mothers and babies.

We need a new oncology and haematology unit in UHK. Over 5,000 patients were treated there last year. Patients from County Kerry are traveling to County Cork and elsewhere for treatment which could be done at home in County Kerry. We have a great organisation, Comfort for Chemo, which has raised close to €2 million. We should expedite this project. I have raised it a number of times in the Dáil and here. The new mayor of County Kerry, Councillor Mikey Sheehy, has been an advocate as well, to be fair.

There are beds in our community hospitals in County Kerry, in Dingle, Cahersiveen and Kenmare, which have never been opened and the reason is staffing. How much longer do we have to take that as an excuse? It cannot go on. Surely it cannot be allowed to go on much longer. There is huge demand.

Another issue I have been continuously raising is the idea of placing patients, when they are discharged, into long-term care in the furthest away nursing home or community hospital. It makes absolutely no sense. It is upsetting to the patient and his or her family. I am aware of cases where a person has to travel a five-hour round trip without even seeing their loved one, for example, from west Kerry down to Kenmare and vice versa.

That is something I think it can be sorted. I know that a patient must be allocated to the first available bed but this issue needs to be addressed as well.

We need to get the new Killarney community nursing unit open and fully operational as soon as possible. We have been given different dates all along. I hope that the unit will be opened sooner rather than later. I note that the unit will be opened in stages but we need to get the entire unit opened and operational as quickly as possible.

On primary care centres in both Killarney and Cahersiveen, these are ongoing for quite some time. I know that a decision is imminent in regard to Cahersiveen. I would like to see these projects developed as soon as possible because they will help, along with the minor injuries unit in Killarney. They will take a lot of pressure off the county hospital.

In regard to suicides, we need to do a lot more in that area. It is something I know about as we had a personal family event a number of years back. Sadly, there has been a spike in suicides in Kerry in recent weeks and months and there is a lot more we can be doing to get the message out that there is help available. I hope to organise a meeting after the summer and any help that the HSE and the Department can give in that regard would be most welcome.

To the Secretary General, is the Department clear and unequivocal in regard to the public-only consultant contract?

I will start with that question and leave all the questions on operational issues to colleagues in the HSE.

I want to be very clear about this. Not only is the Department clear but the Government is very clear about the established approach. The consultants on the POCC do not engage in private practice in public facilities. That is a key tenet in terms of separating public from private, enshrined in Sláintecare. Recent engagement with the Rotunda might suggest that this has not been on our agenda. This has been on our agenda since last year, with Ms O'Connor's predecessor and the Department engaging on how we drive compliance to develop work practice plans and rosters as part of the obligations under the contract so that there is transparency on whether the service maximising public-consultant capacity across the system. We started at a very low baseline, probably last August-September. The work has been about enforcing compliance with the provisions of the contract. Over 70%, I think, of all public-only consultants have uploaded their work practice plans to the doctors integrated management e-system, DIME. Now we need to drive that to 100%. That work is under way. Ms O'Connor has established a centralised programme to drive that home. Then it is around how we translate those work practice plans to rosters that work for patients who, ultimately, receive that care. That is our focus. It has been our focus for the last considerable while. In fairness, recent discussions with the Rotunda have brought that into view. I can assure the Deputy and committee members that we have started on this agenda well before. I can give that comfort to the committee.

I will answer the question on the ED and I will hand over to Mr. O'Connell to answer the questions on the capital projects.

The ED in Kerry, as the Deputy has advised, is very busy. It has become much busier. What we have seen in that emergency department is a growth in activity of over 7% since last year. Critically, it is a growth of over 11% in people aged over 75. The unit is seeing more older people than before. That leads to a lot more activity within the hospital.

We know that the service is challenged in terms of its activities. It tends to have a lot of people coming in. We also know that it is challenged at times in terms of its patient flow. That said, the service has put in place a number of initiatives. They are working in terms of addressing the challenges, particularly with older people. As a service, it is very integrated with the community. The hospital and community work, and have done for many years, very effectively in an integrated way in Kerry.

Mr. O'Connell will comment on the actual developments.

I will start with the hospital in Kerry. The bed block is in design and is progressing. That takes priority over the oncology development but one will follow the other. In the interim we have developed interim steps to develop beds. There are 30 beds in the vertical expansion, with seven being delivered this year and the remaining 23 next year. There were nine beds delivered last year to try and take the pressure off.

On the primary care centres, in terms of Killarney there was a disappointing decision by the council not to provide this as part of its previous scheme. We are reviewing the vacant sites that are coming available to progress the project through either the capital plan or, possibly, offering the site to private providers.

In terms of Cahersiveen, we are in the process of finalising the site along with the ambulance space.

I wish both Ms O'Connor and Mr. Tierney every success in their appointments. I am not sure how many chief executives have gone through since 2011. I wish Ms O'Connor well in her new job and I know she has a lot of experience. It is likewise with Mr. Tierney.

In the last four weeks, in my constituency of Cork North-Central, we opened an additional 24 beds in Mallow General Hospital. We also opened a 50-bed rehab facility in Tower in Blarney. These are two very welcome developments and I have a few questions on step-down facilities. The chief executive referred in her own report to 60% of patients at any one time being over 65. It is about the throughput in hospitals and the need for additional step-down facilities. In a lot of cases people are looking for nursing home beds. We need a planned approach from the HSE for step-down care for people who are well enough to be discharged but not well enough to go home. Are we going to work out a detailed plan on that across the country?

On the elective hospital for Cork, I spoke to a consultant recently who told me that, when starting off as a consultant, eight hours were allocated for operations in which anything up to 12 operations were done in a day. Now, because of the appointment of additional consultants, the eight hours are being shared with two other consultants. I know we are talking about hubs and the hub in Cork will be opened in September, but the elective hospital issue seems to have been put on the back burner and we still have not even gone for planning for the elective hospital in Cork. Even if we go for planning today, it will still be quite a distance away. If we want to keep people out of hospitals and we need elective facilities, why are we not fast-tracking that issue? On the one hand, I am talking about getting people out of hospital and step-down facilities. On the other hand, I am talking about trying to keep as many people as possible out of hospital in view of the increasing population but not an increase in real terms in respect of hospital beds. How will we deal with that over the next three to four years?

I will respond to the general point about the many people seeking a step-down service. Again, I completely share the view expressed by the Deputy. I am very committed to developing and driving the development of services to support people to stay at home and as close to home for as long as possible. I personally do not want to see people coming into hospital because there is no other option for them. People thrive better in their own homes. They can be supported by local communities. We know that, in general health terms, that is much better outcome.

In terms of the points made by the Deputy, the step-down beds are great to have. A worry I have is that they too end up with people not being able to move on. It is about having step-down and then step-out back to home. Earlier we talked about some of the challenges in respect of home care. It is that whole pathway, particularly for older people, that is really important.

A huge amount of work has been done in respect of the integrated care programme for older people and really looking at having an age-friendly health system because we know, in terms of the demographics, that they are the people who are coming to the health service more so than ever before. I would start with the home first and ask what we are doing to keep people at home, and doing everything there, and then building up in terms of supports such as home care, respite, step-down from acute beds and then the acute hospital.

On the question about a plan, I have already started looking at beds that are not acute beds, where they are and how we source them. We have our units and the units mentioned by the Deputy, and we source beds in other places. It is to have a clear view. Our population-based funding that is now coming in under Sláintecare will help us at a regional level to look at the capacity within geographies to support local populations so they can stay at home. That is a very big focus for us in mapping our demand, geographies and available capacity.

It will take a number of years for all of that to go through.

In the facility in Tower, Blarney, the idea is there will be a turnaround time of between 30 and 35 days from the time the person is discharged from hospital. Normally these people would be in hospital trying to get rehab there. Now, that will be provided in a state-of-the-art facility. This is so that they are then well enough to go home rather than half the work being achieved, they end up in a nursing home and then do not leave the nursing home. That is one thing we need to focus on.

Absolutely. On the elective hospital, I might hand that over to Mr. Tierney.

I will start and Mr. O'Connell can give an update. I acknowledge and thank the Deputy for raising the importance of increasing elective capacity. As the committee will understand, we are doing that in two ways. We are delivering a network of surgical hubs which is not insignificant. By the end of this year, we will have added 26 additional theatres to our capacity. We will have 12 minor operation rooms and significant outpatient department, OPD, capacity. The Deputy is right. Our response in Cork is a surgical hub on the CUH campus as we design and develop an elective hospital in parallel. It is important to recognise, when looking at the scale of what we will deliver in Cork with an elective hospital, that it is complex and requires careful progression. We have multiple stakeholders in the background. We have had support behind the scenes in our engagements with the local authority in understanding how to best access the site from the motorway. I had a personal engagement with the chief executive of TII to give a commitment that there will be no obstruction to making sure we link in with that infrastructure. Our focus at the moment is to get the surgical hub in Cork open in the first instance, drive the planning application for the elective hospital and then get on with procurement and construction.

Will a planning application be in before the end of 2026?

That is my expectation, or even before it. Mr. O'Connell is under a bit of pressure to have this done in quarter 3. He might want to comment.

By the end of the year, absolutely. We are trying to drive it back into quarter 3 but there is a balancing act. We are trying to make sure we get the best planning application that will have the best chance of success.

I wish to raise another issue. The national cancer strategy was touched on. Will a team be in place for planning and setting out how we go forward in the next national strategy? The current strategy expires on 31 December. Is a team in place to start planning for the next ten years? What stage is it at?

I will ask Ms Conroy to deal with that. I think our current strategy gets us into the middle of next year. We have already started to engage with how we will review our existing strategy and how that serves as a foundation for our next iteration.

As mentioned earlier, we have had 30 years of progress and achievement under our cancer strategy starting in 1996-----

The question is about the next ten years. What will we have in March or April next year if a plan is not in place?

The Minister has approved an external evaluation of the cancer strategy. We will commence that in the coming weeks. That will inform the development of the next national cancer strategy, which in policy terms we are deeply committed to.

If that evaluation is only taking place now, by the time it is completed it will be the end of the year.

We are in the last year of the cancer strategy. The current strategy was launched in June 2017. That brings us up to mid-year next year. The plan is to conduct the deep evaluation of the cancer strategy over the coming months, which will then inform the development of the new cancer strategy.

A number of changes are required. We are behind other countries in cancer care. We need to get up to date. I was at a conference in the Convention Centre Dublin with people from over 50 countries. It was clear that in some areas we are as far back as ten years behind other countries in relation to a cancer strategy.

The international evidence in relation to our approach to cancer control in the course of successive national cancer strategies is very strong. We continue to be internationally recognised for our robust strategic approach to cancer control. We have recent research that demonstrates the high quality. We rank at the top of a 20-country comparison of national cancer control plans. That is not to say there is not more to be done-----

Thank you, Ms Conroy.

We have work to do.

-----but we want to continue on that trajectory. When you look at the survival rate, as mentioned by the CEO earlier-----

Thank you, Ms Conroy.

-----we can demonstrate real achievement in that space.

We are pressed for time. There are two speakers remaining and I want to bring both in. With the agreement of witnesses, we might run slightly over.

I welcome the witnesses and congratulate them on their new roles. I wish them the best.

I was driving to Thurles on Sunday, on a nice sunny day, going to see Cork play Offaly. At that time I did not realise we were going to win quite handsomely, so I was happy coming out of the stadium. I was taken aback when I heard an interview on RTÉ Radio 1 by Paul Cunningham with a member of the NCPE. Let us just say it had a real dampener on my day. I am of the understanding that the programme for Government commitment is to have an early access scheme. It is quite clear the Minister is pushing in that direction. She has repeatedly said so in the Chamber but, for some reason, a member of the NCPE thought it was okay to go on national radio and basically comment about how he himself is against an early access scheme. What is the HSE's perspective? Ultimately, the HSE is the paymaster. It is up to the HSE to sign off on these drugs. What is the Department's position on it? How do we marry those two things, when a Minister clearly is pushing one way and a civil servant goes on the airwaves saying something contradictory?

As I said to Senator Costello, there is a very clear direction of travel in policy on early access with the 180 days and early access programmes for rare diseases. Professor Barry gave a wide-ranging interview on many aspects of the medicines process. It also raised legitimate concerns, risks and issues we know about in terms of earlier access. That is critical in the principles of design for early access.

Sorry, I really do value the time in here. I have been waiting for two hours to come in. Is it appropriate that a civil servant would go on the airwaves contradicting what the Minister has clearly stated is her objective? It was towards the tail end of it. Mr. Redmond is right that the interview covered a lot of bases but on that point, is that appropriate?

I think Professor Barry was on radio giving his view independent of the Department and the Minister. The Minister's direction of travel is very clear. The policy is very clear. The work we are doing in the Department in collaboration with the HSE and the sector is very clear. That is what we are turning our attention to.

I can start reading statements from patients' groups. Whatever about drugs companies, they felt disgust they felt over the past two days. I can start quoting YouCan Ireland, IPPOSI - I can keep going. They clearly are not happy with the intervention. I do not see how it can be deemed in any way appropriate. Perhaps the HSE wants to comment.

I will ask Mr. Healy or Dr. Henry to comment.

I did not hear the interview but I have the transcript. I am not here to defend or explain him. I have not spoken to him about this. He said he did not support early access for all drugs. He stated some support for early access for drugs that have a proven overall survival benefit. Rather than focus on an individual, the NCPE performs a very important function for the HSE, and drug reimbursement and drug application, which is underpinned by legislation within which it has to operate. It demands when it assesses drugs that there is a clinical need-----

The HSE is tasked with that not the NCPE. The NCPE has no statutory footing.

There is a process. The NCPE carries out this assessment on our behalf to deem whether a drug is clinically effective and cost-effective. That is laid down by legislation in the health Act 2013. It is not the NCPE contriving or making up a situation that it decides outside any legislative framework. It is laid down in legislation that it must advise us based on the cost-effectiveness and clinical effectiveness of a drug and on its overall budgetary impact and impact on overall HSE resources. That is what it is bound to do.

My understanding of the legislation is the NCPE is not mentioned anywhere in it.

The HSE has that duty, not the NCPE.

That is correct, Deputy. The NCPE provides us with advice, which goes to a drug group.

How often-----

Ultimately, the decision of that drug group is either accepted or not accepted by the senior leadership of the HSE. I remember in late 2020 when the HSE leadership team did not accept the advice. The decision goes through a governance process and then to the senior management team of the HSE.

I have concerns about the governance of the NCPE. I have asked parliamentary questions on this matter in the past, and Dr. Henry is probably aware of that. The NCPE is not accountable. There is no independent oversight, as far as I can see. There is no independent board of directors. I hope that all of this comes out in the wash during the review. I welcome that the Minister has commissioned one. I also welcome that the Minister is listening to patients and advocates in terms of the early access scheme. Dr. Henry can quote whatever Professor Barry technically said during the radio interview, but what he said was quite clear. I encourage Dr. Henry to listen back to it.

The drugs group, which provides advice, takes submissions from advocacy groups very seriously. When the drugs group is deciding, it considers not just the view of the NCPE, but also the views of advocacy groups.

As part of the Irish Pharmaceutical Healthcare Association, IPHA, agreement that was recently signed and much welcomed, the NCPE committed to 180 days. It will take time to get to that. Are we recognising that we have never adhered to the 180 days as per the legislation? For a long time, we failed to recognise that. I commend the likes of Senator Teresa Costello, the Minister and the families for their intervention on givinostat. It demonstrated that the process could be done relatively quickly at in or around 300 days, give or take. It can be done, but that 300-day period is still in breach of the 180 days as per the legislation.

Thirty drugs have come through the process this year so far. Of those, the applications for ten came from the companies within 90 days of authorisation by the EU, the applications for seven came within two years and seven others extended beyond two years. Fourteen of the 30 applications were submitted by the pharma companies within one or two years after authorisation. I think Professor Barry was probably trying to make that point. The HSE fully recognises that we have to improve our situation. We have committed to that. Mr. Redmond and I were involved in the negotiations with the pharma sector. We fully accept that and we agree. The Minister made it clear before we entered negotiations about meeting the 180-day period, and there is a process for that, but pharma companies also have to commit to improving their part of the process in terms of health technology assessments, HTAs, and the commercial negotiations.

I am not taking one side or the other. We just want timely access. We all talk about timely access, even if it is just for an appointment with a consultant. In the case of these patients, we want timely access to drugs. I am not interested in this charade of blaming one another, but I was very offended on behalf of all of the patients on Sunday. I needed to listen back to the interview. It was quite obvious from the tone of the interview what he was trying to do. When an end-to-end review had just commenced, he went out and did that type of interview. Will Professor Barry - maybe it is not fair to focus on him - or the NCPE more widely feed into this review? If so, the NCPE has quite clearly stated its belief about a fundamental part of what will inform that review.

Just on that point, I am happy to share a note afterwards on the scope of the review that is being commissioned. It is an independent review, so all stakeholders will have an opportunity to feed into it. It is focused on every part of the process, from the company stage and the pre-application stage right through to SLT stage in terms of-----

I have ten seconds left, but to be clear, Professor Barry is likely to feed into that review and his express aim was out for everybody to hear on Sunday.

I will say two things on that. All stakeholders will get an opportunity to feed into the review, but the review itself is looking at the processes from an evidence basis and from a data basis. We will be looking at all aspects of it from end to end and it will be independent.

I think the answer is "Yes".

I thank the witnesses for being here. When Ms O'Connor's predecessor, Mr. Bernard Gloster, attended this committee in May 2023, he identified addressing bullying in the HSE as one of his top three priorities and spoke about the need for the HSE's dignity at work policies and procedures to be matched by a real change in the culture of the organisation. When trade unions representatives were here on 20 May of this year for a session on staff morale, though, they painted a very grim picture of the current state of affairs. Ms Linda Kelly of Fórsa told us that the HSE had committed to resourcing the national investigations unit, which looks into the more serious dignity at work complaints, but that posts in the unit remained unfilled and had been "caught in the pay and numbers strategy". She said that the HSE was relying instead on private investigators at over €1,000 per day and that when it came to grievance procedure timelines, "those timelines are meaningless". Likewise, Mr. Tony Fitzpatrick of the Irish Nurses and Midwives Organisation, INMO, told us that when staff raised legitimate grievances, adherence to timelines for grievance hearings and resolutions was "not happening at all across the system." He described the grievance process as "totally dysfunctional".

That is a very serious indictment of the organisation's internal culture. Admin staff who have experienced bullying, harassment or mistreatment can be left languishing in limbo for months, sometimes still working alongside the person against whom they have made a complaint, and the process itself can become part of the harm. As the new CEO, how will Ms O'Connor do things differently? Will she commit to fully staffing and resourcing that national investigations unit? Will she publish data on compliance with timelines for grievances and dignity at work complaints across the regions? Will she give interim protections to workers who have made complaints so that they are not left exposed while the process drags on?

At the outset, I want to say that our staff are our greatest asset in our health service and I personally would hate to think that anybody comes into work any day feeling like they have been bullied or are not being supported when they have a particular concern in the workplace. Huge strides have been made in terms of supporting staff over many years. As the Deputy referenced, we have a dignity at work policy. We have certainly worked very hard to create an environment where people feel that they can disclose all sorts of things to us as their employer.

I do not know the specifics of the filling of those posts in the national investigations unit, NIU, but I will revert to the Deputy on that and on the data that we publish. I will do everything I can to support our staff, particularly those who have a concern or issue in respect of anything to do with the workplace.

Are there any concrete commitments Ms O'Connor can make in that regard today?

I do not have the detail of the NIU or any of that, but I will take the point away and look at it in terms of what vacancies there are and what the story is, and I will revert to the Deputy.

I thank Ms O'Connor. That concludes our speaker list this morning. I thank the Department of Health and HSE for their engagement. There are a number of questions and outstanding issues from members that we would like correspondence on, so the witnesses might follow up with us on those.

Next week, we will have a session about the public-only contract with representatives of the Rotunda Hospital, Cork University Maternity Hospital, CUMH, the Department and the HSE. If there are any particular actions - I know I had questions about the action taken in respect of the Rotunda - or developments in advance of the session, I would appreciate if the witnesses could send a note or letter to give an update on them and on investigations before next weeks' session, as I am not satisfied with the answers there. If that is possible, I would appreciate it. The meeting is concluded and we will resume on 1 July.