The purpose of this meeting is to consider Committee Stage of the Health (Amendment) Bill 2025. I welcome the Minister for Health, Deputy Jennifer Carroll MacNeill, who is accompanied by officials from the Department of Health at today's meeting. I will read a note on presence in Leinster House. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precinct will be asked to leave the meeting. In this regard, I ask any members partaking on Microsoft Teams that, prior to making their contribution, they confirm they are on the grounds of the Leinster House complex.

Before we move to detailed consideration of the Bill, I understand the Minister wishes to make some brief opening remarks.

I thank the Cathaoirleach. I am very pleased to be here today and I thank the committee for facilitating Committee Stage of the Bill. As the committee knows, the Health (Amendment) Bill is intended to amend the Health Act 2004. We brought it to Second Stage in July 2025. The purpose of the Bill is to introduce a number of reforms to strengthen planning and accountability in the HSE. The reforms arise from the Sláintecare implementation plan, which highlights the need to move away from the previous directorate structure of the HSE towards an independent board overseeing a chief executive officer. We have already seen some legislative measures in a number of areas - strategic direction statements, performance delivery plans, corrective action proposals and so on - but, together, the provisions in the Bill will ensure the priorities of the HSE continue to align with those of the elected Government and that accountability is strengthened. Crucially, it will ensure maximum value for money is achieved in carrying out its functions.

Overall, the Bill will enhance the governance of the HSE and strengthen the relationship between the HSE executive and the Government and therefore, the Oireachtas. Since the establishment of the HSE board, the Department of Health has engaged and consulted extensively with the HSE and, more recently, the Department of children and disability. The provisions in this Bill build upon those structures to further enhance the HSE's accountability while retaining the independence and autonomy of the HSE board. As the Cathaoirleach is aware, today's amendments relate to the regional health forums and multi-annual budgeting.

I thank the Minister. A total of six amendments have been tabled which will be discussed individually, except for amendment Nos. 4 and 5 which will be discussed together. We will now consider the amendments and each section of the Bill in turn.

I move amendment No. 1:

In page 5, after line 27, to insert the following:

“Report on outsourcing and agency spending

4.(1) The Minister and the Executive shall, not later than 6 months following the passage of this Act, prepare and cause to be laid before the Houses of the Oireachtas a report on agency spending and outsourcing spending, that being any expenditure on private providers for services which are and can be provided by the Executive including but not limited to clinical, human resources, and administrative functions.

(2) The report shall set out year-to-year expenditure by service providing units of the Executive on such matters for the years 2016-2026, and shall set out targets for a reduction in such expenditures over the years 2027-2031.”.

I welcome the Minister. I fully support the Bill and all of the provisions in the Bill. I think the Minister would agree there is a lot more that needs to be done in relation to governance changes, oversight and accountability within the HSE. It is a big organisation and I accept that. It has a huge number of staff and there is a huge amount of management involved in the HSE. Value for money is one part of governance and accountability and we will get into some of that, but decision-making, how we deal with issues that arise and whether people are truly held to account is something that always surfaces and is part of an ongoing debate about the healthcare system.

I will make a wider point before I go into the substance of the amendment. When we have a discussion on healthcare, the amount of money we spend on healthcare is obviously a big issue because it is a huge budget. There is a responsibility on all of us, including this committee, to focus on value for money, outputs, efficiency and making sure we are getting bang for our buck. In a few moments when we consider the amendments I will deal with some of the areas where we are not achieving that. Obviously, there is a responsibility on the Government but there is a role for the health committee as well. We try to play a role in relation to Revised Estimates but we do not always get the opportunity to have those debates on accountability and transparency that we maybe should. This Bill gives us an opportunity to have some of those discussions. I do welcome all of the provisions in the Bill and I will support all of them.

The first amendment deals with agency spending. It references outsourcing but it is mainly about agency spending. I have engaged with several different heads of the HSE, as well as others in the Department and HSE, on this since I became health spokesperson. I have heard plenty of goodwill and good intentions on this. The previous head of the HSE said he wanted to make sure there were really substantial changes made to agency spending, clamping down, enforcement and making sure we had high rates of conversion from agency spend into whole-time equivalents and getting tough with the healthcare system. We cannot have a healthcare system that relies on very high levels of agency spend. It is simply not sustainable and not good value for money. As we know, there is a premium we have to pay for agency staff. For example, I know many nurses have no choice but to work for an agency because they cannot get contracts. I can understand why it happens. From a health service point of view and for the local managers in different healthcare services in hospitals, I understand why they may feel forced into hiring agency staff because they cannot recruit the staff they need.

The most recent figures I received - they never cease to shock me when I get them - are up again. In acute hospitals in 2025, the total amount that was spent on agencies was €420 million. Outside of acute care, which would look at disabilities, health and well-being, non-acute, non-community funding in health regions, which was quite small, mental health, older persons and primary care, we spent €536 million last year in agency spend. That is almost €1 billion between the two of them, which is a doubling of the investment over a very short period. It is clear there is a problem and more needs to be done. What is the Minister's plan? How do we bring accountability?

My amendment deals with one of the few ways in which I thought we could have some level of accountability. It calls on the Minister to lay before the House a plan to address the issues around agency spending and outsourcing - for her to tell us what we are spending and how we will rein it in. We could then have statements in the House. We could do it through the Oireachtas health committee; there are various ways in which we could do it. I have to make the point to the Minister that previous Ministers sat where she is sitting, along with previous Secretaries General and heads of the HSE, all of whom said this is a runaway train that needs to be dealt with, yet it is going up rather than going down. I ask the Minister to set out her plan and the time frame for converting as much of that agency spend as possible into whole-time equivalent positions. How can we rein in what is an outrageous figure, in my view, of almost €1 billion on agency spend?

While I agree with what Deputy Cullinane has said, I do not think it is necessary to put it into the Bill. However, I believe there needs to be a structure put in place as regards how we can reduce the cost of agency staff. One of the areas I have consistently raised over the past 12 years is forward planning within the HSE, especially when consultant posts are coming up because people were due to retire. We do not appear to be taking any decisive action before a person retires. We tend to allow the person to retire. They then come back in as a locum and we then advertise the job. We should be advertising those jobs at least 12 months in advance.

I know the HSE has taken this on board and I know it intends to do it proactively now, but it is unfortunate that we have missed a decade where forward planning was not done on that whole area. If we had that forward planning, it would reduce the number of locum doctors we have to employ. That would reduce the whole issue of the cost of non-HSE people being paid. In many cases, when the HSE takes on a locum doctor it is paying nearly double the amount of money. It is important that we plan forward.

Another issue that needs to be looked at is how at any one time on, say, the nursing side or the care assistant side, there are going to be people who are out on sick leave for very genuine reasons. We do not appear to be planning for that. Another issue relates to people having to take maternity leave. We do not appear to be planning for that in individual hospitals. That is something we need to look at.

While I agree with what Deputy Cullinane said about the need to reduce the cost of agency staff, I do not believe it is necessary to put it into the Bill itself.

I also agree with the comments made by Deputy Cullinane around the reliance on agency staff, outsourcing and insourcing, which really just reflects a lack of capacity in our health service. Part of it is capacity. There was a lost decade after the financial crash where we just could not properly fund what we wanted to fund. We are playing catch-up. We need to have a more planned approach. I will not labour the point but we need a more planned approach in relation to capacity. I agree with the stance on the public money contract because that will allow a more consolidated approach within hospitals where people are working in teams rather than just in silos.

Regarding outsourcing and agency staff, we need some flexibility in the system while we develop capacity but we also must be conscious of the cost of agency and the cost of outsourcing. We also need to be aware, as we know from our discussions previously on Children's Health Ireland, of the moral hazard in the system if we have people where work is being insourced or outsourced who are already in the public system and are supposed to be providing service there. However, I do not think this is the place for this amendment.

First, I need to immediately correct myself by saying the multi-annual budgeting amendments are to be introduced on Report Stage. I had that confused so forgive me. I do not want to mislead the committee.

In relation to agency, I thank Deputy Cullinane for the amendment and the opportunity to discuss it. I totally understand the way in which he has structured the amendment and the purpose of it to have better accountability around this. I do not believe it is for legislation because I think we should be doing it anyway. I might suggest a couple of ways of doing that.

First, I will give members my reflection on what we have been trying to do on agency over the past period. I believe I updated the committee on this previously, but last September or October I met with the HSE director of people, Ms Anne Marie Hoey, and expressed my very strong concern around agency use and also the slowness with which many people in the health system are recruited. Deputy Cullinane has referred to that just now. It takes an inordinately long time to recruit a nurse. The structure and use of panels, for example, is something of a complexity that one certainly would not start with but we seem to be here with it and I do not believe it results in faster recruitment. Some days one feels it is quicker to recruit the CEO of the HSE than it is to recruit a specific nurse. I am being a little bit facetious but only a little bit. The structures that have grown over time do not necessarily serve quick recruitment, which is what this committee wants. We want people recruited into whole-time positions and a massive reduction in the role of agency.

We are trying to do some different things and I will suggest to the committee how we can take it forward together. The first is tightening authorisation controls, including removing delegated approval for agency bookings at site level when required. The second is formal directions by the regional executive officer to sites on agency limits, controls and required actions. The third is restrictions of agency use to defined exception areas and also direct recruitment and agency conversion, which is by far the most important aspect.

I really want to establish our own HSE agency. I am tired of paying agency fees to third parties. I do not see any value in it. I believe there is a role for agency in the future of the health system insofar as we will need a certain measure of flexibility, as Deputies Daly and Cullinane have said. However, where we need that measure of flexibility, I do not want to pay a third-party entity for the privilege of it. It is reasonable that we establish our own HSE staff bank. It is something I asked for last October and it is now being progressed in the HSE. It should be possible if someone wants to do extra hours or is available to do extra hours to apply to our own agency and say they are available for additional hours. It is also important that where we are using agency staff, the site is directing the hours that are done and people are not signing up for the most advantageous shifts, as it were. I mean that the site is in control when we are using agency to cover what the site needs as opposed to any situation where agency is controlling the hours. That is something I have seen in different places and we need to be very careful.

We need our own HSE staff bank to reduce the reliance on third parties while still allowing some measure of flexibility but we need better conditionality on the use of agency staff as well. That might result in some kickback from people who have been used to working in this way and I ask for the committee's support if that is the case. We also need to get to the point where, if we establish a staff bank in the way I am describing, we end the off-framework model. That is going to result in a sort of rupture. I ask the committee for support when that happens if we do that and take that important step. Rather than saying the situation is fine in perpetuity and "fix it when you can, lads", at some point we are going to have to say "this is our staff bank" and thereafter not do it outside of this structure. That will result in some disruption and I ask for the committee members' support when that happens.

Deputy Cullinane said he has been talking about this with many Ministers, executive officers and members of the HSE who have all the time been trying to get down the budget on agency, recruit the permanent positions and change the site-by-site culture that has built up over time. If we are going to make the kind of change that, I think, is the one that is necessary to be effective, I am going to need the support of the committee members. I ask that they help me with that. Let me describe what we are thinking, the parameters we want to put on it in 2026 and where I think there might be difficulties, and ask for the committee's support in making that transition.

I suggest, rather boldly, that the Chair invite the regional executive officers, the regional directors of people and the regional clinical directors in to describe to the committee what they are doing in terms of agency conversion and the speeding up of recruitment of permanent positions. They can describe to the committee what is happening in their areas in relation to the establishment of a staff bank.

There is a directed programme by the CEO at the moment in relation to agency conversions. We are seeing that it is more difficult in some regions For example, the hospitals in Dublin Mid-Leinster have a much higher proportional reliance on agency than hospitals in other areas. That is a huge cost. The bulk of it is a huge significant cost and is also not the right way to be working. However, the other side of it is smaller in numbers but very expensive and that is consultants being recruited on agency in temporary and locum positions. We have about 450 consultants who are on temporary or locum positions. That is expensive. My question to the regions and sites is: are they sure there is nobody within the hospital who is already qualified? With positions that are not filled for maybe a year or 18 months, are they sure that is necessary? We have to be rigorous, site by site, about the different vacancies and the different positions.

Given the Sláintecare support for the regional structure, it would be reasonable for the committee to look at it region by region, seeing how the regions have been tasked with this very activity, so I can come back and describe to members a systematic change that will last, one that is going to have an important budgetary implication and, more importantly, is going to give the health system much more predictability about rostering and who is available. I suggest that the committee, without needing to legislate for it, should take control of this and bring in the different regions to have that detailed conversation. I ask the committee to support me on the establishment of a HSE staff bank and the necessary change that will come from it, and to say "this is the new way, we have to end the old way" and help us through the different issues that will come as consequence of that. That is my suggestion for how we collectively deal with this issue that we collectively have.

Is the amendment being pressed?

I want to come back in as we are on Committee Stage. Ireland is a very small country and we had a very similar discussion on insourcing and outsourcing where it is riven with conflicts of interest.

The political system had made a decision to move not just to a fully public system when it comes to taxpayers' money, but also a seven-day-a-week health service. Any impediment to achieving that has to be challenged. I will support whatever measures need to be put in place to manage and deal with that because we have to get to a point where we have a public system and a seven-day-a-week health service. That means changes. Some people do not like change but that is an issue for the Oireachtas to deal with and set out the policy. When the Minister says the health committee should take control, I appreciate that she meant we could play a role.

Yes.

Obviously, the Minister has the ultimate responsibility along with the Department, the Secretary General and the head of the HSE. Some of what the Minister said in her response means she is looking under the bonnet, which is important. I agree with lots of what she said but I want to balance it. It is important to establish how much of the over €950 million agency spend is recurring. There was a time when this was seen as one-off spending, it was needed because there was an emergency, we needed staff in certain areas where we were understaffed, people were out sick or all sorts of other reasons. We have to accept that this spend has now become a permanent feature. It is recurring spending year on year. Worse than that, it is increasing. The first job and responsibility of decision-makers is to work out how much of that spend is recurring and how much needs to be converted into whole-time equivalent posts, with a strategy then around that.

I agree with the Minister fully on consultants. I got a further breakdown of this. I did a piece of work with a journalist on it because we had taken an interest in this whole area of agency spend. I looked for a list of all the companies that provided services. It is a cottage industry. There is no other way to describe it. It is like the wild west. There was any amount of these companies being formed. When I say we are a small country and there are conflicts of interest, some of these companies are owned by people who work in the health service. It is rife with conflicts of interest. A huge amount of money is being made.

It makes complete sense that the HSE would have its own panels. In private hospitals, for example, they have bank hours. We need to be very careful about the workers' rights and employment rights side of this because lots of private hospitals also have zero-hour contracts. While I agree with flexibility, it is important for some staff members in the health service and a form of such contract is what suits them, many are forced into taking these contracts because permanent contracts are not available. If there is a public agency within the HSE, we have to make sure that it does not infringe on employment rights and the right of staff to seek permanent contracts, which the vast majority of people in the health service have. That balance has to be struck.

It also has to be about need because there is an issue in relation to controls, which the Minister mentioned. We have to make sure that proper controls are in place when overtime is sanctioned. We will invite in the regional executive officers, REOs, because they have a responsibility. The health regions and REOs are accountable for budgets in their areas and I fully accept that we need to hold them to account, but I have heard from hospital managers and other elements of the health service that they have no option but to hire agency staff because they cannot recruit staff and this is the only option for them. If they do not, they cannot provide a safe service.

There is a strong balance to be struck on this issue. It is difficult but that does not mean we do not deal with the issue. I am willing to work with the Minister and anybody in the Department or the HSE on this to get to a better point where I am not submitting parliamentary questions and seeing that the spend is now €1.1 billion and increasing, more companies are being established and more elements of the health service are engaging in this. It has crept into the non-acute side in recent times and it is massive. It has to be reined it. I accept a lot of what the Minister said.

I support everything that has been said. It is an enormous concern that it has been persistent in the Irish health service and there has been a tolerance for it across so many hospitals. Some hospitals have up to 20% of their staff from agencies, which falls to 2% or 3% in some of the larger hospitals. There is a conversation to be had about why some level 2 hospitals in particular rely on agencies to such an extent and the degree to which they are supported by the nearby level 3 and level 4 hospitals but also the functions of those hospitals. That is a very controversial subject for any political party - we were there 20 years ago with the Hanly report - but it is one we cannot shy away from in terms of why some hospitals are unable to attract staff. There are a variety of reasons, but there are very real issues when a consultant in particular operates on their own as opposed to in a team. It is important when we are having that conversation about agency spend that we recognise that factors are different between hospitals. It is an important conversation in the context of the regions, some of the level 2 and level 3 hospitals and their functions.

For many years, the NHS has had a kind of locum staff bank within its services. It is astonishing that has not been developed in the Irish health system. It needs to be. There will always be a need for a locum service. We all accept that but who profits from it is the critical issue. As Deputy Cullinane said, there is a cottage industry. There are people who have decided that agency work suits them. I am all for flexible work arrangements but the reality is this is public money, which needs to be spent well as opposed to just facilitating the flexible work arrangements some people desire. Those arrangements can be facilitated as direct employees in the health service but a much greater push needs to happen. The Minister's leadership is critical here. We as a committee will of course play our role but it is ultimately for the Minister to lay down the law and make very clear what the priority should be.

It was the Minister and the wider Government who took the strongest stance on defending the public-only contract in relation to the Rotunda. I commend her for that because those issues would have unravelled Sláintecare. While the Minister has pushed it down to the REOs, she has shown leadership in a lot of areas such as insourcing, outsourcing, Children's Health Ireland, CHI, and the public-only contract. It will take her leadership and the Department's direction to set policy in relation to this.

It seems inexplicable to the average person that when we know a post is coming up in the HSE - a consultant, nurse, midwife, admin staff - the day the HSE starts looking for a replacement appears to be the day the incumbent leaves the job and there is a gap. I cannot understand that; I do not think any right-minded person can understand the inefficiency of that system.

The issue on public-only contracts is coming up under amendment No. 3. We might discuss them under that.

I totally agree with Deputy Cullinane that "control" was the wrong word. It is of course my responsibility. I know what the Deputy is saying, it is just that I think this committee has a strong role because it can bring people in and spend time speaking in a public way that I do not necessarily have the facility to do. It is more that sort of partnership that I mean.

I have required that I get a week-by-week update on how this is going region by region. The regions are important because the detailed conversation is there. For example, my most recent update was the week ending 12 June. Under the, "Deliver on target to convert maximum agency conversion" section, all of the regions were red except the west and north west, which is doing quite well. Off-framework agency reduction will be crucial because we said that there would be the elimination of off-framework agency use on a phased basis by September. All of the regions are red in that regard. When it comes to September and I say that the regions had been given three months' notice to get themselves off framework and they now have to be off framework, that is when I will need the committee's help to back this change.

On flexible contracting and the establishment of a staff bank, Deputy Sherlock is right.

If private hospitals want to recruit agency through private companies that is a matter for them. That is not my business, but we need a measure of the HSE and recruitment agencies and I want the HSE to recruit from itself. I do not want the idea that there is someone working in the HSE who is also employed in the HSE but through a third-party agent. That does not make any sense to me. This is the question I asked last September: tell me the number of people who are working in the HSE who are also working in the HSE except through a third-party agency. We are paying fees for that and a heightened price for it so please explain that to me. Why can we not have our own HSE agency? I have required that this agency be set up. On that, the progress so far is that four regions are in red and two regions, Dublin and South East and South West, are seeing some progress in relation to it.

In terms of absence management, all the six regions are in red. However, we have a week-by-week rolling update of this over the summer period. That is the only way I can see to implement this. That level of granularity is necessary rather than just coming in and saying, “This is what I want to do and I have tasked the HSE CEO with it”. This is a detailed week-by-week plan to try to do that. That is why I suggest it would be augmented by the committee’s role in that and engaging with the regions, not only on how they are doing it and the way in which they are engaging with it, but the real challenges there are for them in different ways. These are tangible, site-by-site challenges that are meaningful. The committee could draw that out a great deal as well.

Of course, what we want is people working in permanent positions. That is our goal. We have far too many permanent positions that are funded that are not filled. I want them hired permanently and for people to work in the HSE on a public basis.

Deputy Sherlock mentioned model 2 hospitals but where we see the real difficulty is with the model 3 hospitals. What it needs is a cultural shift to make sure people, consultants in particular, who are working in a model 4 hospital, regard the model 3 role as just as important as the model 4 role. That is our structure. There is a question of whether people want to work in model 3 hospitals or not. There is a reasonable structure between working in a model 4 and a model 3. It gives very good cover and the opportunity to still do some of the more specialist work in a model 4 and then bring that specialist experience to a model 3, but it does actually have to happen and that relationship needs to happen every week. It needs to happen culturally in a totally integrated way. We are seeing our biggest challenge with the model 3 hospitals. That redeployment between the model 3 and model 4, and that balance, is really important. I thank the Deputy for flagging it.

I do not wish to stifle discussion but we are still on amendment No. 1. We are on section 4 of 28 sections and I am keen to make progress. If people want to come in, I ask they keep it brief so we can make some progress and get this done. We will do our business in an efficient way, if we can.

Coming back to the issue of forward planning, the HSE has said it will do that where consultants or any staff members are due to retire out. This has been discussed for years but it still does not appear to be in place. The person retires and there is then a vacancy for anything up to 12 to 18 months because of recruitment whereas recruitment should be happening 12 months before the person retires out. I have not seen that there is a structure put in place. Going back some years, I saw where all the consultants in a hospital in a particular area were locums because people were retiring and there was no forward planning done.

I fully agree with having the regional executive officers come before the health committee. It should have been done by now, to be honest, because they have been in place for some time now and they all have a very important role to play. Value for money and efficiency are issues we would want to talk to them about as well as outcomes. There is also investments. I am sure they will come in and say they need investments in certain areas. They have a responsibility for budgets but also for the running and providing of services. It would be very useful to have a meeting on agency spend and public-only contracts, which we will deal with later. There are lots of issues we would like to talk to them about. Productivity in the health service is really important and the REOs have an important role to play so that would be useful.

I will make one final point on agency spend. I hope a message goes out to the entire system and the HSE that we are serious about reining in agency spend. That needs to be a very clear message. When we say we will take action then we have to take action, but we also have to balance that and understand the pressures and the reasons some areas of the health service are recruiting. There are geographical issues. I have the breakdown myself and I can see some hospitals where it is very high and others where it is not as high. I am conscious there are good reasons why we outsource and use agency. I do not like that there are so many companies, why they have set up and there being a premium and so on but there is a good reason behind it. What we have to do is get the balance right. Where there is good reason, let us convert posts into whole-time equivalents where that is appropriate. If there is need for more flexibility around what the HSE can do let us do that, and where there is fat, waste or inefficiency let us ruthlessly deal with that. That is how we should approach it. That should be the message that goes out from this committee. If that is the message that goes out from this committee then maybe the amendment was worthwhile even though it will not be accepted.

The amendment is fantastic because it gives us the opportunity to discuss this. That is the purpose of it, I assume. It is fantastic that we have the opportunity to discuss this. I am driven demented trying to get it changed. It is really important that I can describe the steps we are taking.

When the committee brings in the REOs, I strongly recommend bringing in the people directors and the clinical directors because both have a similarly important role. There is huge variation. I am not trying to put them in any difficult position. They are all working on this. It is just important to establish the practicalities involved and the practical difficulties in relation to it. With the new model, each region is responsible for its own funding. There is only so much that can be said for calls for more funding from central government. We are trying our best to invest in it but at the same time it has to be managed within each region. That will create tension in the finite resources environment we all work in.

On the proactive hiring of consultants, Deputy Burke is entirely right. The most important piece of that is multi-annual funding so that people know what is needed over time. It is also important to say that we should assume every position needs to be directly replaced. Specialisms are changing and needs are changing. While it is often the case that a post needs to be replaced, it may also be that a region needs something different. That is one of the new shifts towards the regional model. The region needs to consider what it needs best, what it needs best this year and how it can plan for that over time. That is important as well.

On agency, the things that have the big spend are healthcare assistants, which is a big driver of agency spend, mental health and older people, which is also very high in terms of scale. In terms of the individual expense, the consultant piece is an obvious one to look to. I thank the Deputy for the opportunity to be able to update him on what is happening.

I move amendment No. 2:

In page 5, after line 27, to insert the following:

“Multi-annual funding frameworks

4.The Minister shall, not later than 6 months following the passage of this Act, prepare and cause to be laid before the Houses of the Oireachtas a report on multi-annual funding frameworks for the Executive for the purposes of outlining indicative funding for the Executive in particular on capital expenditure and on national strategies.”.

In her opening remarks, the Minister has said that she will come back on Report Stage with amendments on multi-annual funding and frameworks. That is really important. I would have preferred for it to have been in the legislation at the beginning because it is a big part of the reform needed in the healthcare system.

I have looked at what we actually mean by multi-annual funding in detail over many years. Taking capital, in some respects, there is capital expenditure over a reasonable time period, which it could be argued is multi-annual funding. The issue is the allocation of that funding and where that money goes. In areas such as new drugs and cancer care, there needs to be funding certainty over a reasonable time period to allow the system to plan. What was happening previously, particularly when it came to new money or new investment, was this was at the whim of the Minister or government of the day and the budget, where people would be looking at the budget to see what new money was coming and where that money was going. Sometimes, the money would not come and funding programmes would not get the money they hoped for and that then became a political issue and so on. It just was not efficient. It is much better if we can set out funding over a reasonable time period, particularly in those areas, and say, “Here is the budget. Where is the plan?”. We can then measure the implementation of that plan. That is the space I want us to get into.

The Minister will give her view and we will have amendments on Report Stage. I know this was a commitment in the programme for Government so I know the Minister is committed to it as is the Government, but it is an issue where I hope there is universal agreement across this committee and the Oireachtas that we need to get to that space in healthcare, and we will be in a much stronger position.

It would be remiss of me not to point out that we do not have enough capital funding for the health service. The Minister will say she has got increased funding beyond what was maybe offered but I know the big challenges in health and the big developments that need to happen, such as the elective hospitals, the new national maternity strategy and digitisation, and all the other pieces that go with it. There needs to be accountability as well, by the way, around bed plans that were announced by the Minister's predecessor, how they are going to be delivered and when. I do not see that they will. There are a lot of issues around accountability when it comes to announcements that are made and follow-through in the absence of multi-annual funding that underpins them.

For all of those reasons, it would be much better for the political system to have funding certainty in place and multi-annual frameworks, notwithstanding the fact that budgets are budgets and Ministers like to be able to make announcements. I get that the Ministers for Finance and public expenditure want to be able to make decisions in real time about additional investments. There are areas in healthcare where we can very quickly move to multi-annual frameworks and budgeting, and I hope that is where we go.

I will bring amendments in relation to creating the structure for multi-annual funding on Report Stage. We will enable it and phase it, essentially. We will bring in a measure that enables multi-annual funding and then we will see. Hopefully, we can do it as quickly as possible. The detailed design and implementation of multi-annual budgeting for health is being progressed separately through a dedicated workstream with the Department of Health, the Department of public expenditure and the HSE. We really are trying to work towards that. How we come in on the money is a big part of that, too.

I thank the Deputy for his comments on capital. I always think that I should have a bigger capital budget. I am doing my best to spend every penny of that. I would also like to tell the committee that the Department of public expenditure has informed me that I am the best of all the Departments at spending the capital budget, way ahead of housing and education. We are spending our money as best we can. That is the right investment. I can confirm that I will be trying to take everybody else's leftover capital budget if they leave anything within the 2026 allocation. I will be doing my best to spend not just my capital budget, but their capital budgets, because that is the kind of investment we need in health. We just need to spend it. We really are doing our best.

We will be opening the Waterford surgical hub, which is a fantastic measure. We had somebody else announcing it but us delivering it. I look forward to opening the surgical hub in north Dublin this month. There is quite a lot happening. I was down with Deputy Colm Burke two weeks ago in Mallow opening the new 24 beds there. I think Mallow hospital has gone from 37 beds to 96 in a reasonably short period, along with a very substantial annual current, recurring budget increase. We were also in Blarney, where the Mercy hospital has taken over the hotel beside the golf club to turn it into rehab and step-down beds, including very high-level neuro-rehab beds. It was a pleasure to be there. It is great to see all of those capital projects advancing and, indeed, opening.

I cannot tell the Deputy how delighted I am to hear his approach to the budget. He will recall that I did not make any announcements of the ministerial kind in relation to the budget in October last year. I had a reasonably boring presentation, I believe, saying what the uplift was and that we would distribute it to the regions. I do recall direct and specific criticism from the Deputy's excellent self about not having allocated a specific budget for cancer. I maintained a position that it was not for the Minister do be doing that and that it was in fact better to be delivering an overall uplift and for it to be allocated. I also remember a specific campaign by Sinn Féin in relation to endometriosis and the fact that I had not tagged specific money for it. I recall a video by Deputy Mairéad Farrell, for example, going viral and being brought to my attention by many different endometriosis activists for my failure to allocate money for endometriosis in the budget, notwithstanding that Deputy Cullinane and I both know that was to happen in the broader context. The very last thing any Minister should be doing is standing up and making self-regarding announcements in relation to what is in the budget. The job of the Minister for Health is to try to secure the best budget they can to increase funding for the following year, to deliver multi-annual funding for exactly the sort of predictability the health system needs, and to take the politics out of health as best as possible. I look forward to trying my best to do that this year, to make sure that we come in on the money and to make the best case to the Department of public expenditure and reform.

I have to say that the Minister, Deputy Jack Chambers, is really working with me on the implementation of the public-only consultant contract and on productivity, which the Deputy highlights as being very important, as well as on delivering a more sustainable, structured budget that helps to bring health out of the politics of the annual into something that is much more structured and sustained, which I think reflects Sláintecare better. It reflects multi-party co-operation better, and that is what we are trying to get to.

I commend the Minister on the endometriosis framework and the new service. It is a huge improvement and a recognition of a need that was there. Many women who will avail of that service are very grateful for the Minister's leadership in relation to that.

I will raise two issues about capital. The first is digitalisation, which I am going to keep hammering on about.

The Deputy is right.

I have spoken to the Department of public expenditure as well. We have an archaic system. If we keep throwing money at this system, we will not get the commensurate productivity because it is simply not fit for purpose. We are so far off the charts. This is not a criticism of the Minister but it is a reality of where we are. In the 2030 Digital Compass project, we are in last place in the European Union in relation to digitalisation. I will keep hammering that because we will not make progress until we get there.

The second issue is in respect of the emphasis on primary care. We have had this mantra for the last 25 or 30 years about primary care, yet the money is not going to primary care. We are seeing places like Ballaghaderreen in County Roscommon, where poorer communities in a rural area, with a national school that has 22 different languages, are being asked to find a public-private partnership to provide a primary care centre after 15 years. That has failed. It is patently obvious that the HSE, the State or the Department - I do not care who - should be directly building primary care centres in deprived rural and urban areas and populating them with health professionals. Otherwise, we are going to make no progress on the recruitment and retention of general practitioners, public health nurses, primary care and allied health professionals and nursing professionals. I will continue to make that point. It would be like asking consultants on a public-only contract to go out and build a public hospital and fund the infrastructure, and then see the first patient. It is not exactly the same thing but it is pretty close. When you are down in places like Ballaghaderreen, Roscommon more widely or east Galway, or deprived urban areas, the vast majority of income comes from public patients.

We are discussing the multi-annual framework. If we could stay on track, that would be appreciated.

I want to come back on some of the points the Minister raised. She correctly said that I had asked questions about allocation of funding arising from the last budget. I fully stand over that and maybe I will refresh the Minister's memory in relation to the point I was making. It is a valid point that I will be making again this year, next year and the year after. When we allocate funding to healthcare or to any Department, there are a number of elements to it. The Minister talked about an uplift in the budget, that the money was allocated to the regions and that the regions had to figure out how best to spend that. I do not have a quarrel with that. I supported the development of the health regions. However, we also have national strategies and there are certain line items and issues, such as new drugs, that have to be controlled as well. The point I was making was that a big element of what was in the health budget were existing levels of service funding to enable the health service to stand still. We know it is around pay, demographics and all of those issues. That has to be provided for. In previous meetings, Secretaries General have said that they do not have enough money for existing levels of service to enable the health service to stand still, which means we actually go backwards and end up with Revised Estimates and so on. What I was looking for at the time was not a line-by-line breakdown of every single case. It was about how much was new money, how much was new development, how much was an existing level of service. There is a need for a level of transparency about the amount of new money that is going into the health regions or elsewhere. There should not be any quarrel between me and the Minister, I hope, on that point because it is a very simple breakdown of what is money for existing levels of service and what is new money.

I welcome the Minister's recollection of the campaign that Sinn Féin ran on endometriosis, the public meetings that we held and the voices we listened to. It was an important issue. I am not sure about the other issues the Minister raised. For example, I am not across the issue she raised about Deputy Farrell, who is not here to defend herself. Endometriosis is an important issue and it was an important campaign that we ran. We brought an important motion before the Dáil. I recognise the framework that was put in place, which I have also supported.

On the capital side, we can all recite individual capital projects that have happened. I fully support all of them, including in my own constituency. I pass the new building almost every second day and, in fact, have family members who are trying to get employment in it.

They are applying for positions in it as well. I know it will be vital for Waterford.

I am making a broader point about the capital budget, which the Minister has accepted, that there are big demands in the healthcare space. I want to make sure that when we make investments, we are making smart decisions and smart investments. Where we need to have efficiencies, we have to have them and we have to get value for money. We also have to invest, however. We know that on the capital side, some projects require big expenditure. I do not want to open up the discussion on the children's hospital - I will not do so - but that is an example of a project costing a lot of money. The national maternity hospital will cost a lot of money. I am concerned about the elective hospitals. I am concerned about how quickly we will deliver them. I am not saying that as a criticism of the Minister; I am just concerned, and that is an issue for me.

Thank you, Deputy.

I will finish, but there is no specific time limit we have on Committee Stage.

Yes, but-----

I am sticking to the issue-----

Sorry. We do need to get through this Bill-----

I understand that.

We are on amendment No. 2. We have spent an hour-----

I know we are on amendment No. 2, but-----

If you will allow me to speak, Deputy, we are on amendment No. 2 to section 4 . There are 28 sections in the Bill. I am just keen to make progress in order to ensure that we get through this today and that we get to your other amendments and to those of other Deputies. The other members of the committee wish to have their amendments debated as well. I ask you to conclude and to stick to the discussion.

I am respectful of that, but, equally, these are important issues for us to have a discussion on. It is not often we have an opportunity to have discussions of this nature on these issues.

I was finishing on the capital spend. There are big projects that require big expenditure. Then there are lots of other smaller projects that may not be as big but are important for local hospitals and local healthcare. I refer, for example, to projects relating to mental health provision. I do have a concern about the overall capital envelope that is available for coming years and whether we can do all that we need to do. That is just my view; it is not a criticism at all of the Minister, who I know has fought for additional capital and will continue to fight for it.

When we get to Report Stage and see the Minister's amendments, we can come back to have maybe a further discussion on the framework for multi-annual funding. I thank the Minister for her response.

I am conscious of the committee's time.

Is the amendment being pressed?

Yes.

I move amendment No. 3:

In page 5, after line 27, to insert the following:

“Report on removal of private practice from public hospitals and implementation of public only contracts

4.(1) The Minister shall, not later than 6 months following the passage of this Act, prepare and cause to be laid before the Houses of the Oireachtas a report on the removal of private practice from public hospitals, which shall detail the level of remaining private activity in each public hospital, including statutory hospitals and relevant section 38 organisations, and outline the steps being taken and timeframes for the full and total removal of private practice from public hospitals.

(2) The report referred to in subsection (1) shall include details on the rate of uptake of the public only consultant contract and the deployment of said contract by site and by weekday, and shall include anonymised or pseudonymised details on the level of private practice conducted by consultants on public and public-only contracts in public hospitals or otherwise during contracted hours.”.

This is on the public-only contracts. The Minister will certainly agree that this is an issue we need to deal with. It has been in the media for the past number of weeks in relation to the Rotunda Hospital. I am also conscious that since then we have had an audit published by the HSE that has raised concerns about enforceability, accountability and transparency in relation to public-only contracts.

I will make this point, if I may, because there are lots of different issues which have surfaced which have really concerned us, and I know the Chair has spoken about them as well. The Rotunda was one in relation to the consultants on public-only contracts doing private work. That is now resolved and the board has reversed its decision, which we all accept. We then heard about payments of up to €1,500 being made to some consultants in the Rotunda, but there are also wider issues across the system in relation to consultants not being rostered at weekends. One of the reasons I have heard, which, by the way, I refuted on national radio, is to the effect that "We are on call". I am sorry, but I was one of those who supported the public-only contracts when they were in place. In fact, I remember meeting with the previous Minister for Health and saying, "We are going to get some flak and some pushback." That happened, and we have to make sure that we defend the decision collectively that we make. I met with consultants leading up to that contract and I disagreed with them on lots of stuff, but one area where I did agree with them was that maybe there should be some flexibility in relation to private work. I was satisfied that as long as it was done off-site and in a private hospital, then so be it, once they were abiding by the terms of their contract. That was a flexibility we accepted.

Since then, what we have seen, in my view, are examples of individual consultants, maybe facilitated by some hospital managers or the health system, allowing flexibilities which were not agreed. That is unacceptable and should not be happening. Again, all of us signed up to Sláintecare. We all made that very clear. From the minute I got into politics, my view was "Public money, public hospitals, public contracts". If people have private health insurance - many do but I do not - good luck to them. They feel they need it. They get private care in private hospitals, and that is not my business. In fact, if anything, we need to be using private hospitals more for public patients and looking at that in a more strategic way. On the public-only contracts, though, there was a focus on one particular issue - the Minister was very strong on it, and I commend her on that - in relation to the Rotunda. It seems that there are much bigger issues here, however. I am conscious of the audit published by the HSE which pointed to those issues. I know the Chair has been very strong and vocal on this. There is a need for the committee and its members to be equally strong and to send out a message that we are standing by these contracts. Any attempt to undermine or unravel them has to be challenged, confronted and dealt with. That, again, is a message that has to come from this committee today.

I am hopeful that message will be sent out on foot of this amendment being moved. For anyone who works in the system, be they management or consultants, who believe they can try to engineer something that skirts or tries to get around contracts that were put in place in good faith - and they are well-paid contracts - they have to be faced down. I hope we all accept that.

That is the spirit in which I have moved this amendment. It is about having this debate year on year in order to see where we are and whether we are getting value for money. On the weekend aspect, it is really important to go back to what I said at the start about the seven-days-a-week health service. Nobody who works in the health service can be an impediment or a block to our getting to that point, including, I would argue, hospital consultants.

The Minister has already dealt with this issue over recent weeks. I do not believe there is a need for an amendment like this because the Minister has made hospitals fully account for what is happening, and the satisfaction has been taken on it. It is already on the record as regards work done.

In relation to the seven-days-a-week contract, it is important as well that it is not just totally reliant on medical consultants; it is also about having the required number of support staff. That is an issue that has not been looked at in real terms by hospitals. A clinic can be run on a Saturday, but it is on the basis that there are support staff in place to work with the consultant or the senior registrar in charge of operating the clinic. That is an issue that hospitals also need to look at. One of the complaints I am coming across - and I am working with one or two hospitals on this issue - is where they have the staff but do not have the space to run some of the clinics. One hospital, for instance, has to take on additional space because we have recruited all these additional staff but we then do not have the clinic space for them to operate in. We need to look at that as well in order to ensure that we get maximum value out of the people we are employing. It should be remembered that the number of consultants we have has literally dramatically over the past five to six years. That is all very fine, but, for example, I had a consultant who was able to do eight hours of operations in a hospital every week. Then two other consultants were appointed, so there are now three consultants sharing those same eight hours. That is the kind of thing we need to start looking at to make sure that they have the availability of space and of theatre time to do the work they want to do.

I know one consultant who was doing two days of operations a week when they worked in the United States. They came back to Ireland and ended up in a hospital where all they were getting was a half day - and it was an afternoon - to perform operations. Then they were advised that unless the patient was in theatre by 4 p.m., no one else would be allowed in. Those are the kinds of issues we need to look at as regards the use of space and making sure that space is available to allow clinics to be held and throughput to happen.

While this amendment probably does not have a place here, it gives rise to many pertinent points. I support what Deputies Cullinane and Burke have said, but I want to reflect on the fact that the person who took the strongest stance on the public-only contract - I include the Taoiseach, the Minister, Deputy Chambers, and a number of others in government in this regard - was the Minister. Her stance was unequivocal.

I cannot say the same for the Opposition in all cases. The Minister showed leadership. There was no equivocation or talk about talks and compromise. The Minister realised the importance of upholding the public-only contract because otherwise Sláintecare and the Government policy that has received all-party support for the past number of years would unravel. That was extremely important.

In saying that, what has happened in this transition period is that anomalies have been exposed. Practices have been exposed that were built into the system culturally. We need to ensure it is not just about maternity hospitals but that, right throughout our system, hospital by hospital and place by place, these anomalies and practices that built up are now to be seen off the pitch, if there is going to be an even pitch for everyone. At the end of the day, this is about taxpayers' money and a contract that was freely entered into. It is also about the citizen and patient who goes to receive the service.

As we know from all the reports around maternity care, there is no difference in the safety of care between public and private practice. We have very good maternity outcomes because we have a hugely supported public service that supports those outcomes. The same applies to many of our other hospitals but we need to see those. That is where some of the insourcing and outsourcing ran into trouble. The insourcing certainly ran into trouble because it created this moral hazard and conflicts of interest, and we need to see that off the pitch.

While I do not believe the amendment is appropriate, I accept what Deputies Cullinane and Burke said. Deputy Burke made a very good point. If we are going to appoint more consultants, we have to look at the infrastructure too, so that we get the commensurate productivity. That means health and human resources, physical infrastructure and digitalisation.

I thank the Deputy for raising the insourcing because it allows me to thank the committee for its support for ending that model at the time. That was a necessary step but one we all needed to do together. I thank the committee for its support on that and on the implementation of the public-only consultant contract.

I see this in two ways. The first is that what happened with the Rotunda was, in my view, a direct breach of the terms of the contract. However, I will separate the broader issue, which is essentially a tacit non-implementation. To my mind, that is just as big a problem. It may not be a direct offence to the contract as such, but the non-implementation of the contract is, in my view, an offence to the taxpayer generally, who is paying for it. If I had signed a contract in 2023 that had a specific salary and working hours and, in the following two or three years, I had never been asked to work those hours, I would have asked when I was working on Saturday because I had signed a contract that says I will be available to work on Saturday. I am perfectly happy to receive the salary, and if I was not receiving the salary, I am sure I would be in touch with somebody pretty quickly, but what about the actual fulfilling of the terms of the contract and knowing what that change meant?

There are a couple of different elements to this that Deputies have highlighted, and I think it is important to bring them all together. The first is the consultant roster generally. It is to be available until 10 p.m. and on Saturdays. I do not ever want to hear again the argument that this means consultants cannot work on Wednesday. Yes, we know that. Everybody here is able to count and if someone works on Saturday, that means they do not work on a different day. As I think Mr. Bernard Gloster said in this committee, if there are ten consultants, it is better to have eight working during the week and two at the weekend than to have ten working during the week. That balance is important, so I ask that we please stop hearing the argument repeated to us, from various quarters, that this is difficult because it means people will not be there on a Wednesday.

I also do not want to hear that this is difficult because the support staff need to be there. The unions agreed to work five days over seven. They have stated explicitly that the staff will be there to support the implementation of the public-only consultant contract, which needs to be stood up, managed, led and organised by clinicians. Everybody needs to play their part in that. To give the committee some side examples, one hospital manager told me the support staff are there but she has a difficulty with the consultants where they have a different site because the consultants want to work theatre hours on Saturday but they do not have the nursing support. There is a little bit of implementation to be done and it is everybody's responsibility to be there and implement this.

We have a unique opportunity in that we have a 41% uplift in consultants, we have the consultant roster and we have had union agreement in the public service agreement since 2008, and the unions committed to implementing it more than 12 months ago. It is a unique opportunity and there is an overwhelming moral obligation on every single person working in health to implement that and get this State to a full six-day system in the first instance, recognising that it is twice as expensive on Sundays and the contract is a six-day contract. If we could get to a full, working six-day system, that would transform healthcare in Ireland forever and we would never go back.

One of the hospital managers told me that a consultant recently asked her: "Do you remember when we used to just leave people on Fridays?" The culture in that model 4 hospital in Dublin has already changed so much because the consultants in that hospital are being rostered on Saturdays, not to come in and do rounds but to do a full, eight-hour shift and a full, proper working day. What does that mean? It means that if somebody comes into the accident and emergency unit and need to see one of the "ologies", for want of a better description, they see them on Saturday morning. Then they are either admitted and there is a plan for them or they are discharged in an appropriate way. That keeps the hospital flowing better but also applies the terms of the contract.

As regards space, Deputy Burke is absolutely right. As we grow the system, we are going to need space but we do not necessarily need that space yet. There are two reasons we know that. One is the outpatient toolkit, which did a baseline analysis of the use of every room in all of the outpatient clinics right around the country, in 41 hospitals. It showed us the room vacancy rate and how that changes over time. In one model 4 hospital in the south west, we saw that the room vacancy rate during the week was between 4% and 9%, but it was 24% on a Friday afternoon. That is not a hospital that needs more rooms. It is a hospital that needs to use the rooms on a Friday afternoon. I have not even seen what the figures are for Tuesday night at 9 p.m. I have been in that hospital on Tuesday night at 9 p.m. and I can tell members that it is not as busy as it was 9 a.m., so the rooms are not being used. In the same way, the outpatient clinic at Merlin Park hospital moved from two clinics per day to three clinics per day and the rooms are being used much better. Naas General Hospital has implemented the outpatient toolkit and is using its rooms much better.

On theatre utilisation, I do not want to hear again of theatre nurses, consultants and porters starting their shifts at different times because it means you do not get knife to skin until 8.30 a.m. or 9.15 a.m. when it could have been at 7.30 a.m. How can you stand over that? There is a certain measure of logical organisation that means you get into theatre as early as possible. How surgeons does it take? Why do we not fully use every single theatre? Deputy Burke is correct about the idea of a theatre not being available after 4 p.m. or that it only operates from 9 a.m. to 5 p.m. Why? The hospital is still there. We have contracts that enable people to work in those hours. Why is it not running from 7 a.m. or 8 a.m. until 10 p.m. or 11 p.m., six days a week? We have all of these theatre, which have been fitted out all over the country, and we are building more. We are also building surgical hubs and elective hospitals. The Deputy is right about elective hospitals but we cannot build them for them to sit idle for eight hours of the day when they could be used. The public-only consultant contract gave us the route to a public system but also massively extended hours, so we need to fill the rooms we have with activity before accepting the argument that we would do it if we could get the staff around us or if we could only get the room. The rooms are there.

Look at the baseline data on the outpatient toolkit, hospital by hospital. Look at the utilisation of diagnostics, and I am having a specific project done on the national integrated medical imaging system, NIMIS, so we can look at the utilisation of the diagnostic equipment that is there. Look at the utilisation of the theatres around the country. I remember, in the case of endometriosis, a project to have additional surgeries. I was pushing for an extra 100 surgeries in the final quarter of 2025 and we got 142, for which I thank the clinical community. However, at one point I was told elective surgeries could not be done in the Coombe after 5 p.m. Sorry, but why? It was because the theatre manager said so. I am sorry but none of that makes sense.

We have more than we think we have. We have more resources and infrastructure than we think we have. We now have a contract that enables us to use those in a structured and important way. We have it with outpatients, rooms and theatres. We have it everywhere but we need to utilise the contract.

I thank members for highlighting the audit, which was done in a period up to August 2025. Members will recall that Bernard Gloster and I gave a direction, I think in April 2025, to say we were giving three months notice, which is required in the contract, that the public-only consultant contract was to be implemented, that is, rosters on Saturday and in the evenings.

I ask the Minister to conclude.

We have spent all year doing regional forums to investigate how that is being implemented. It is not just the disappointing figures by the end of August. My figures, which have not been formally published, show that now that the doctors integrated management e-system, DIME, has been stood up, which should have been done years ago, and the work plans are being uploaded to it, with nearly 90% now uploaded, the level of planning to work in the evenings and at weekends is woefully low. I have required that it be changed, essentially, within the next four weeks. It is not okay.

Certainly, from our perspective, we support all efforts to ensure the maximisation of the capacity that exists within acute hospitals. The point I would make to the Minister, though, is that we know there is a dire shortage of step-down care to get people out of our acute hospitals. It is important to say in terms of the utilisation of space within our acute hospitals. I fully support everything the Minister is doing, but we know there are very serious issues around the country with regard to step-down care where people are basically languishing who should be discharged from hospital but cannot be because of the lack of step-down care. That is important to say.

In relation to this amendment, which we support, Deputy Daly has made a number of attempts now to try to goad the Opposition. It is important to say that the Labour Party has been unequivocal about the public-only consultant contract and getting private care out of public hospitals. What I will say, though, and somebody might be able to shed light on this because it is important and relevant to the amendment, is that there is a specific clause within the contract. We can talk about the spirit and intent of the public-only contract and then look at the actual terminology that is included. There is a provision there and I do not understand why it is there and I do not support its existence within the contract. I refer to clause 24.10. Obviously, the Rotunda got itself into a shocking amount of trouble, which it should never have got itself into, with regard to the use of this particular clause within the public-only consultant contract. I have a very real concern that other hospitals away from the gaze of public scrutiny or, indeed, the scrutiny of this committee will end up using that clause at times in the future and I believe that is wrong. I want to hear why that clause is there, why it is being justified and whether there is any effort being made to actually take it out because for as long as it is there, there is a real question mark about the extent to which we can fully stand over and say that a public-only contract is a public-only contract.

I thank the Deputy very much. So people are aware, in two weeks' time, we are going to have a full session on this for two and a half hours to discuss the public-only contract and operation of maternity services with officials from the HSE, the Department of Health, the Rotunda Hospital and Cork University Maternity Hospital. We will have a full and frank discussion on many of these issues.

Of course, but it is important when the Minister is here that we have that conversation.

If I may come in, I can add to that.

I am sorry, Minister. There is a list and we will stick to it. I will very briefly echo Deputy Sherlock's comments. There are many people who have been quite strong on that issue over the last number of weeks.

I call Deputy Cullinane.

We can have a debate any time about hospital beds, step-down facilities and step-down beds and all the other issues that can be raised in relation to capacity in the health service. In my opinion, and I am just giving my opinion, none of that is an excuse for the non-implementation of a contract that was signed in good faith by consultants. What we are talking about here, as far as I can see, are well-paid contracts and well-paid consultants who signed up in good faith. That contract was negotiated, by the way, by the IMO, which is the representative body, with consultants to put in place a contract that had flexibilities and could have support and, in fact, did have support because many switched over to those contracts and, of course, all new contracts now are public only.

The easier part to deal with is where there are breaches. I commend the Minister, by the way, for dealing with the easier parts initially. We saw that with the Rotunda Hospital. We need to be very strong and very robust when we have breaches that are being stood over by either voluntary hospitals, which are funded almost exclusively by the State and by the taxpayer, or by any other hospital. Where we have those breaches, that obviously needs to be dealt with very strongly and very robustly. It is probably the easier part. The more difficult part is the non-implementation.

That brings me to the HSE audit because it is a bit like the debate we are having about the children's hospital and how we hold the contractor to account. Maybe the legal levers were not strong enough in the first place and now we are at the mercy of a contractor. I do not know what legal levers or other levers are available to the Minister in relation to the non-implementation of the contracts. Maybe she can set that out because it will be important for us when we are actually having that session in a couple of weeks' time. Whatever levers exist that the Minister has to deal with this need to be exercised and used. I am heartened by her very robust and strong contributions today in relation to all of that, so I have no doubt that the Minister will deal with this in a very direct and robust way. I anticipated, as many of us did, that what would happen when the contracts were put in place was that any and every attempt would be made to not implement the contracts, slow it down and then bring in all sorts of erroneous arguments. They are genuine in their own right - we need more beds, more space and more step-down facilities. These are all issues we can debate at any time, but nobody is going to convince me that any of those issues are the reason we have non-implementation of those contracts. It is for other reasons that consultants are doing that. We know why it is and it has to be stamped out and faced down. I will be fully supporting whatever way the Minister does that because I stand foursquare behind those public-only contracts. It is the best way.

I am not giving the Minister a free pass while she is here. I am also conscious that we have over 1 million people in some form of health waiting list if we look at acute, primary and community care. I am very concerned about community waiting lists. There are lists in mental health, older people and all of those areas where we have lots of challenges. The Minister has a responsibility, of course, to be dealing with those issues as well, absolutely, but we are never dealing with waiting lists, the situation of patients on trolleys or all the other pressures we have in the health service unless we are getting bang for buck with the health service working seven days per week and we are utilising the very expensive equipment, buildings and staff we have and getting value for money. I want to get to that place. I will work with anybody and everybody, including the Minister, to get to that place, which is one of the reasons I tabled all of the amendments I tabled today. It is to have that discussion with the Minister and put on record my very strong view that this is where we need to get to.

I thank the Deputy. Hopefully, we will get some other observations on this as well.

I thank the Deputy very much. That is exactly the point. Everything else, including all of the inpatient day cases and the surgical lists, needs the implementation of the public-only consultant contract. The outpatient tool kit in reducing those numbers needs the implementation of the public-only contract. I will add the step-down facilities to the list of reasons why the public-only consultant contract is difficult along with how we need the people around us and we need more rooms. Step-down facilities are important. I just outlined two in Cork that we saw last week. There is no question that there are delayed transfers of care. In Letterkenny, for example, they have about 30 at the moment. There is also a 100-bed community nursing unit across the road. Let us stop, as health leaders, giving excuses or explanations as to why it cannot work, including never hearing again that means it is difficult on Wednesday. It just has to stop. This is the contract and it has to be implemented.

Deputy Sherlock referred to the section 24 clause. I have heard her refer to it in the media. I would ask her to stop bringing this ambiguity into it. That clause was there to get rid of some post-Covid lists and in the case of an emergency. I appreciate that the Rotunda brought this ambiguity in relation to it. It actively used clause 24.10 for the purpose that it wanted to. It did not come and say that it thought there was something wrong with this contract and that we might need to reflect and think about it. No, it said it would like to continue doing this and this is how it has decided to do it, in essence. I am paraphrasing but, in essence, that is what it said. The contract very specifically states, for example, in that instance, that the Rotunda was the employer directly. Obviously, a contract does not live in isolation. A contract does not override statute law. It certainly does not override a service level agreement, SLA, with the State, which very clearly states that you must comply with Government policy. Section 24, at a contractual level, states that it is only in circumstances where a derogation can be given with the express permission of the Minister and the HSE. I have said that repeatedly. We need to set aside that red herring, which came from what source? The Rotunda itself. I ask the Deputy to set that aside. She is entitled-----

It is there in black and white.

She is entitled to raise questions with me. I ask her to reflect on the legal advice she has received. I ask her to stop reflecting the language of the different interests and to take the State's position sometimes. That is the argument that was advanced by the Rotunda, which I refuted and which is incorrect. It is incorrect at contractual level, SLA level and Government policy level. It is not correct and I ask that we end that piece of dialogue. It is also not correct in the context of the contract that has been signed by individual leaders. Apart from anything else, not only is it incorrect in law but it is incorrect in the spirit of it as well. We have an opportunity to deliver a public-only consultant contract, POCC. That is the only way of delivering a six-day and, ultimately, if we get to it, a seven-day system. There are different examples of where it is being used really well, for example, in the mid-west in Limerick. I want to call out Dr. Catherine Peters as a clinical director of excellence who, with the lowest POCC uptake, has delivered the best Saturday rostering and the best use of that. Now, they are doing it with a lot of a lot of overtime as well because they have such a low POCC uptake, so it is the contract B holders. They are doing it in a way that delivers for patients much better than they were before.

Meanwhile Dublin north-east is not doing it at the same level. We are seeing the implementation now. It is something the committee can track. The work practice plans are so important. This means the consultant and clinical director sitting down together and agreeing the plan, for example, that the consultant will be available on whatever night of the week until 10 p.m. and every fourth or sixth Saturday, or whatever, and the clinical director can plan the hospital on that basis. Imagine if all 3,500 people who signed their work practice plan, having signed the public-only consultant contract, did not then reflect the terms of that contract. What was worse is that the clinical leadership, both at clinical director level and regional clinical director level, during a period of focused implementation of this contract, at regional meeting after regional meeting to discuss how this was being done, for instance, who was getting an extra Saturday clinic and what was being done about extra diagnostics, accepted so many contracts that do not reflect that implementation. I really struggle with that. We will fix it; we have to get it fixed. The clinical community and clinical leadership need to understand the level of importance we place on this from the perspective of the patient, the taxpayer and the system more broadly. I thank Deputies for their support for that today.

Does Deputy Sherlock wish to come back in?

No.

I welcome the robustness of the Minister's approach to this issue. It is really refreshing. The approach of previous health Ministers I have dealt with was not so robust. That very direct, hands-on approach is necessary and we should not be afraid, as Opposition spokespersons, to say we will stand behind the State, whether it is the Minister, the head of the HSE or the head of the Department, because we are all, collectively, signed up to this and have a vested interest in making sure it works. If this works, it will benefit the health service. Whatever benefits the health service benefits patients, which is a good thing for all of us. I want to get to that point.

We will have a session next week, I think.

It is in two weeks' time. Next week is the meeting with the Secretary General.

I do not think we will have time to meet again before the summer recess. After the session in two weeks, it will be important to have the Minister in again later in the year for a fuller discussion on this issue and an update on progress and how we are getting on. I hope we will learn a lot from the session we have. The committee in its work will look under the bonnet of this. That would be a very useful session.

This is the last of my amendments. I hope the issues we raised will bring some clarity to the areas where we need more accountability in the health service. I thank the Minister for the directness of her approach to this particular issue and other issues.

There are people in the Gallery from Waterford. Waterford hospital is also one of the hospitals that performs very well. Consultants were working at weekends for a long number of years. This is one of the reasons we had no patients on trolleys for many years. Grace Rothwell, who was the manager of the hospital, was instrumental in that. That story and those good examples need to be told over and over.

I suggest we take a short break.

Amendments Nos. 4 and 5 are related and may be discussed together.

I move amendment No. 4:

In page 10, between lines 19 and 20, to insert the following:

“(f) indicate the extent to which the Executive is able, within the level of resources it considers likely to be available to it for the period to which the corporate plan relates, to—

(i) discharge all of its functions under and in accordance with this Act, including maintaining the type and volume of health and personal social services provided at the commencement of the plan period, and

(ii) implement the priorities and achieve the goals and outcomes specified in the strategic direction statement in respect of health services priorities provided under section 28A and the strategic direction statement in respect of specialist community-based disability services priorities provided under section 28B,

(g) where the Executive considers it would not be able to fully discharge its functions or fully implement those priorities or achieve those goals and outcomes within those resources, identify—

(i) the services, priorities, goals or outcomes which it considers cannot be so provided, implemented or achieved,

(ii) the constraints arising from the level of resources likely to be available to the Executive which would prevent full discharge, implementation or achievement, and

(iii) the measures, if any, which the Executive proposes to take to mitigate those constraints,

and

(h) specify the level of resources which the Executive considers would be required to—

(i) discharge its functions in the manner described in paragraph (f)(i), and

(ii) implement the priorities and achieve the goals and outcomes referred to in paragraph (f)(ii).”.

We are all very supportive of this Bill. The need to strengthen accountability in the HSE is very clearly recognised and I support everything this Bill is trying to achieve and do. However, I think there is scope to push the Bill a little further on the transparency of health budgeting. While we all have a shared ambition regarding the cost-effectiveness of what the public purse is spending on health and accountability, there is a very real issue. The health budget is resource hungry. Some would say it has an insatiable appetite for money. The Minister engages in negotiations with the Minister for public expenditure and reform and a certain figure comes out of those.

There is an issue because we have seen both in 2024 and this year that what is agreed ends up, for perhaps a number of reasons, not being sufficient nor well spent. Amendments Nos. 4 and 5 seek to introduce reporting at the point at which both the corporate plan and, in particular, the performance delivery plan are adopted. It is not just about setting out whether the HSE has enough but also specifies the specific service, why it does not have enough if it does not have enough, and what budget is required to meet the ministerial priorities as set out by the Minister for Health in her letter of determination to the HSE.

It is very important to say that section 23 talks about the corrective action proposal. That is fine. These amendments do not seek to duplicate or seek to cut across that in any shape or form. The amendments seek to insert a process at the start of the budgeting, just after the budget is announced and after the Minister has sent her letter of determination to the HSE. They do not confer a right to the HSE to seek additional resources. The amendments seek to introduce a duty of disclosure and transparency on the HSE regarding whether it can work with the resources that it has been given.

Let us look at what happened in 2024 when the HSE, in its national service plan, set out that what it was being given in the budget was not sufficient or that running the existing level of service would exceed the funding that had been made available. There is a political problem there because that was approved in that form. Subsequently, there was an overrun of €1.1 billion and the Government had to approve a supplementary budget of €1.5 billion. Supplementary Estimates have now been banned but we are into a situation where, in the first quarter of 2026, the HSE was €250 million over budget and three regions were in tier 3 escalations. There are very serious questions about what will happen with that plus the €175 million levy, which is effectively a cut, that is being applied to the health budget because of the spend in education.

There are very serious issues with the HSE costs overrun and how that will be dealt with. That might be differently dealt with if it is known at the start of the year that the cost of maintaining the existing level of services will be more than what the HSE is being given. In that regard, amendment No. 4 seeks the insertion of an additional requirement in the mandatory content of the corporate plan to ensure that the HSE sets out whether it can provide the services, as set out by the Minister in her ministerial priorities, with the allocated funding. As I say, it is not just to say whether it can or cannot. It has to specific the which, why and the what.

Similarly, amendment No. 5 relates to the mandatory element of the performance delivery plan. Amendment No. 5 is probably the more important of the two amendments because that process takes place immediately after the HSE gets the Minister's letter of determination.

The amendments seek a resource adequacy process be put in place at the start of the accounting period to ensure that we have an open and transparent conversation about whether the HSE is getting enough to match the ministerial priorities. None of us wants to see a situation where the HSE overruns its budget and controls must be put in place. An honest conversation must happen after the Government has made its budgetary allocation. I say this in support of the Minister saying that she needs to be given more than what she is given, in particular with regard to the capital budget. To be clear, these two amendments only relate to the current spending, not the capital spend. Ultimately, they seek to ensure that honest and transparent disclosure takes places on the part of the HSE to say whether it can work with the allocated resources.

The Government agrees the budget within the resources of the day and that changes over time, as the Deputy is aware. I will make the strongest case that I can for the strongest portion of that for the health budget but thereafter that is the health budget. Amendment No. 4 is the greatest free pass that I have ever seen for poor performance management. We get a budget and the HSE is responsible for delivering it. By the way, Sláintecare says that there should be regions that are responsible for the allocation of funding and that they should set their own priorities within the allocated funding. We are creating a structure for multi-annual funding, which I know the Deputy supports, to plan over a period for a longer term structure.

Amendment No. 4 states:

(f) indicate the extent to which the Executive is able, within the level of resources it considers likely to be available to ...

(i) discharge all of its functions ... and

(ii) implement the priorities and achieve the goals ...

How does that work in practice? The HSE will come back and say that it will be able to do this but not that. What about the other elements? What about productivity, activity-based funding and holding people to account? We have literally just had a conversation about agency. Is it a case of saying "Sorry" to the Minister because the HSE is just not able to do that because it does not have enough, and when asked what it is doing about agency conversion, it says that we just did not give it enough? The amendment is a complete free pass for poor budgeting and poor budgetary management. The Deputy assumes in this amendment that everybody is running the service as well as they can. The Deputy assumes that, for example, the investment that we have put in is being utilised. This Oireachtas has funded additional virtual beds around the country. There are 40 in Limerick and 40 in St. Vincent's. Limerick has a utilisation of about 25. Last week, I visited the Mercy hospital. It has ten beds but only one to three of them are routinely used. After allocating money, what about the conversation about how the HSE is using it? Where is the accountability? The amendment outlines the worst possible way to structure a health budget. I would rather talk about the granular detail of accountability and asking why, after we funded a hospital's virtual beds, it had only used three of them when it could have used ten and there were 18 people on trolleys. The measure of granularity is how resources are used. That is what is important.

Amendment No. 4 states: "the extent to which the Executive is able". Where is the Oireachtas in that? Where is the accountability by the extremely well-paid managers within the HSE whose job it is to implement exactly what we have been talking about, namely, the public-only consultant contract to achieve better productivity? People may apologise and say that they do not have enough money to get additional rooms, but they should use their rooms better.

Let us have an amendment that deals with productivity and activity-based funding and seeks accountability for how taxpayers' money is used, not one that creates a structure whereby there is a political conversation about how the Government of the day did not give the HSE enough resources to meet its obligations.

No, that is not right, Minister.

I do not accept the amendment, nor the premise behind it. I am here all day every day for a conversation about accountability for the way in which money is used and how we are trying to deliver productivity by consultants. We have put a great deal of money into the health system but it has not been matched by increases in activity or improvements in access. Across the acute hospitals services, very significant increases in funding have been delivered but the growth has been modest. Staffing in model 4 hospitals has increased by 36% between 2019 and 2025, with a 10% increase in activity. Let us table an amendment on that - not on whether the HSE can do it within the resources, but on whether it is doing it and why it has not. Activity levels have risen but output has not increased with additional staff employed. There is already more scope to increase productivity. Why has it not been done? Let us have that conversation.

We need to get more from the capacity we already have. We have had this conversation. We all agreed to it 25 minutes ago. We discussed extended hours, better deployment of workforce and maximising the use of the existing infrastructure. Let us use what we have that the taxpayers' of this State have already paid for and then go further and do it in a really intelligent way that gets the best for every penny.

Amendment No. 4 commences with the words: "indicate the extent to which the Executive is able". I view that as a total free pass for bad budgeting. I would rather talk about the granularity of budget accountability and the use of resources that have already been paid for.

Regretfully, there is a lot of detail in the amendments that is not reflected in the response by the Minister. Clearly, these amendments are about trying to have that productivity and state in black and white why the HSE cannot deliver with resources that are being allocated to it by the Government.

It is not just about not getting enough money. It is about specifically setting out what, why and which services will be impacted because they cannot spend. Why is the funding not sufficient? To the contrary, this goes to the heart of how we have a conversation about transparent productivity.

Another key point to make is that I am not clear as to why the HSE has overspent by €250 million this year. What I hear from the Minister is that it is poor management performance. Will the Minister clarify whether it is this or whether there are also other factors?. We have not had an explanation and, hopefully, we will have it next week from the head of the HSE. What is the Minister's perspective as to why the HSE has gone so far over budget? None of us want to see a situation where corrective measures are being taken because that has a very real impact on patients. Is it poor performance by the senior leadership of the HSE or are there other factors?

To be very clear, I did not say that this year's was as a result of that. What I said was that I believe Deputy Sherlock's amendment will give a free pass for bad budgeting management in the future. This year the budget overrun, and the committee can discuss this in more detail at its upcoming meeting with the HSE, arises from two things in particular. One is the purchase of private beds and private supports to support discharge out of acute hospitals, particularly during a very busy flu season and extremely high presentations, especially in the first three months of the year. We are moving to a better and more standardised process for the purchase of private beds and this is a very important budgetary change. It is a necessary reform and is a reform that should deliver savings and not go over. This is not encompassed in Deputy Sherlock's amendment. Another issue is the over-reliance on agency, as we have discussed, particularly in the mid-west and south west. This is something that requires reform and performance management and not more money. It requires doing it in the resources that were allocated in last year's budget. These are the two big drivers and that is my perspective.

There is also an overwhelmingly increasing drugs budget. It has increased by 11% this year. This is not something we can control; it is demand. It is increased population and people being prescribed drugs. While we would have argued for an 11% uplift in the drugs budget, we got 8% or 9%. Certainly, we knew the drugs budget was going to be bigger than the allocation we got. This is something that is a little bit out of our control. It is not a reform measure; it is a cost measure. The other two are very definitely reform measures.

I do not accept what Deputy Sherlock said regarding her amendment being about productivity. The amendment proposes:

(g) where the Executive considers it would not be able to fully discharge its functions or fully implement those priorities or achieve those goals and outcomes within those resources, identify—

(i) the services, priorities, goals or outcomes which it considers cannot be so provided, implemented or achieved,

(ii) the constraints arising from the level of resources likely to be available to the Executive which would prevent full discharge, implementation or achievement, and

(iii) the measures, if any, which the Executive proposes to take to mitigate those constraints,

and

(h) specify the level of resources which the Executive considers would be required to—

(i) discharge its functions in the manner described in paragraph (f)

The amendment does not talk about reform; it only talks about more money and it only talks about a complaint. I have had this with different regions wanting to do something and getting an indicative figure of €1 million or whatever it happens to be. It is about reorganisation. We have increased our health budget over ten years and particularly in the past five years we have increased it by 36% on the acute side and 25% to 30% overall. What are we getting for it? Where is the productivity? Let us have an amendment that focuses on productivity and not on explanations for why things cannot be done. I have just given three reasons for why the budget has increased this year, two of which are based on reform and one of which is something that is just going to continue to increase in cost, which is the drugs budget, and there is no question that this is difficult for us. The other issues are to do with performance.

When we do not have a room vacancy rate of 24% on a Friday afternoon, when we have theatre utilisation so we are not building up waiting lists and using the NTPF to fund procedures that could be done were our theatres used differently, and our public only consultant contracts are used differently, then let us have that conversation. However, on the basis that we have already put in all of this additional money and we have not seen the output or the productivity from it, let us keep focused on the productivity and the essence of Sláintecare, which is delivering that and delivering activity-based funding. Let us have this transparent conversation.

With regard to requiring accountability from the HSE, and why it cannot actually-----

It is not politically realistic.

The Minister raised the drugs budget. Demographics are obviously a huge part of the drugs budget, as is the increasing complexity of care. From memory, in previous health budgets there was normally a line on a provision for demographics. I do not believe we saw this in budget 2026. There is a lack of transparency in terms of the amount of money the Minister has been allocated-----

There was a clear uplift in the drugs budget.

We are not having a back and forth. Deputy Sherlock is speaking and we will then go back to the Minister.

The point is the Department got less for the drugs budget this year than what is required. What are we going to do about that? Are we going to have a conversation about the demographic factors that are driving demand in certain areas and then make sure it is either provided for or that there are reforms? At the moment we do not have this transparency. There is an element that we know there is a shortfall and none of us are going to be any the wiser at the end of the year as to who precisely has lost out because not enough money has been allocated to the drugs budget. I want to have that transparent conversation.

I want to see our budget on health well-spent. This is the motive and intent behind these amendments. It is about making sure that when the Minister sends the letter of determination, the HSE then makes clear what it will deliver because, frankly, we should not have a situation where we have cost overruns. Reorganisation is a critical part of this but it is about making sure we have accountability from the HSE at the start of the year as opposed to saying halfway through the year that we are €250 million over budget. That should not be happening. This is to try to help the political system and the public to understand what the HSE is doing and to provide answers as to why it is not doing enough on agency spend and all of the other inefficiencies that exist. The motivation, spirit and detail here are not, as the Minister describes, a free pass but to set out what and why it cannot deliver with the resourcing it has been given.

I do not accept that at all. The national service plan sets out exactly what the HSE is going to do in the budget allocation it has received. With regard to the drugs budget, we do not want anybody to be prejudiced. Nobody has been prejudiced because we have spent the money. It is also true that within the allocation people are required to make non-pay savings - let us see the detail of that - to reduce their reliance on agency and to streamline procurement and other measures in order to come within the overall budget envelope, which is set by the State and the Government of which I am a member. I have to agree collectively on the amount of money available and the allocation the health budget will receive.

We received an uplift of €1.5 billion, which is 5% to 6%, last year. It is a huge uplift but we have to get something for it. Yes, we need more money for drugs and we are going to continue to need more money for drugs but we are not going to prejudice the drugs budget because somebody has not got their act together on agency conversion. We have to do both. It is not an either-or conversation. I am sorry to say that I think Deputy Sherlock's amendment is a free pass. We should be having a more detailed productivity conversation and if we have a disagreement on that point then we will have a disagreement on that point.

I move amendment No. 5:

In page 16, between lines 7 and 8, to insert the following:

"(k) indicate the extent to which the Executive is able, within the section 30A(1) determination and, where applicable, the section 30B(1) determination for the period to which the plan relates, to—

(i) provide the type and volume of health and personal social services indicated under paragraph (a), and

(ii) implement the priorities and performance targets specified in the statement of health services priorities provided to the Board under section 30C and the statement of priorities for specialist community-based disability services provided to the Board under section 30D,

(l) where the Executive is not able to fully achieve the matters referred to in paragraph (k) within those determinations, identify—

(i) the services, priorities or performance targets which cannot be so provided or implemented,

(ii) the constraints arising from the level of those determinations which prevent full provision or implementation, and

(iii) the measures, if any, which the Executive proposes to take to mitigate those constraints,

and

(m) specify the level of resources which the Executive considers would be required to—

(i) provide the type and volume of health and personal social services indicated under paragraph (a), and

(ii) fully implement the priorities and performance targets referred to in paragraph (k)(ii).".

I move amendment No. 6:

In page 24, between lines 19 and 20, to insert the following new section:

"Amendment of section 42(1) of Principal Act

26. Section 42(1) of the Principal Act is amended by the substitution of the following paragraph for paragraph (a):

"(a) establish such number (not exceeding 6) of regional health forums as the Minister considers appropriate, and".".

This amendment updates the legislative provision governing the HSE's regional health forums. Under the Health Act 2004 the number of forums is capped at four but, of course, there are now six HSE regions. The amendment aligns the forums with the health regions.

It increases the maximum number from four to six. It is a straightforward update to keep pace with legislation and reform. The statutory role and functions of the forums will remain unchanged. We all know that the forums provide a mechanism for elected representatives from city and county councils to raise local service matters with the HSE aligning it. The forum is really important as it keeps it more local and provides the option for local management to be asked local questions. The amendment is consistent with Sláintecare and aligning the forums with the regional structures, including regional patient and service user councils and regional voluntary forums. That is the purpose of it.

Did I mention I would table amendments on multi-annual funding on Report Stage?

Yes. Does anybody else wish to flag their wish to table amendments on Report Stage? I may also table some amendments on Report Stage.

I may table a necessary amendment to the Health Information Act.

There is consideration under way as to the adequacy and robustness of the existing legal basis for the accountability and performance oversight that the Minister exercises. Our current plight is that it is adequate but we are engaging with the Attorney General-----

Just to flag up a possible amendment on Report Stage.

-----to ensure the legal basis for the Minister requesting and receiving information.

Yes, that is great. I wish to flag a possible amendment.

Work is under way.

I make members aware that there may be additional amendments on Report Stage.

I thank the Minister for Health and her officials for attending today's meeting and for the considerable work done on this matter and other business. Do Members have any other business they wish to raise at this point? No. The meeting is concluded.