HSE Audit and Risk Committee meeting minutes 12 December 2025

Members Present

Anne Carrigy (Chair), Michael Cawley, Patrick Bailey, John Moody, Éimear Fisher, Sharon Keogh and Peter Lynch

Apologies

Yvonne Traynor

HSE Executive Attendance

Joseph Duggan (Chief Internal Auditor), Stephen Mulvany (Chief Financial Officer), Joe Ryan (ND Public Involvement, Culture and Risk Management/Chief Risk Officer), Tony Canavan (REO West and North West), Dara Purcell (Corporate Secretary), Niamh Drew (Deputy Corporate Secretary), Patricia Perry (Office of the Board)

Joined the Meeting

Anne Marie Hoey (Chief People Officer), Dr Grant Jeffrey (Director Workplace Health & Wellbeing Unit), Dr Hugh Brady, AND HR, Corporate Compliance & Resource Optimisation), Dr Colm Henry (Chief Clinical Officer), Ronan Buckley (Business Manager, Office of CCO), Kieran O’Brien (Partner KPMG), Brian O’Connell (ND, Head Strategic Health Infrastructure & Capital Delivery), Gareth Morton (ND Procurement), Leonard Clinton (Asst CFO Finance Shared Services), Elaine Kilroe (AND ERM), David Langton (AND CCF)

Minutes reflect the order in which items were considered and are numbered in accordance with the original agenda. All performance/activity data used in this document refers to the latest information available at the time.

The Chairperson held a private session to consider the agenda, papers and the approach to conducting the meeting.

2.1 Conflicts of Interest

No conflicts of interest were declared.

2.2 Minutes

The Committee approved the minutes of the 14 November 2025 and 27 November 2025.

2.3 Action Log and Follow Up Items

The Committee noted the action log.

2.4 Committee Workplan 2026

The Committee noted the Committee Workplan 2026.

2.5 Terms of Reference

The amended Terms of Reference were reviewed and deemed appropriate to be sent to the Board for consideration and approval.

2.6 HSE Code of Governance

The Committee reviewed the revised Code of Governance, and recommended approval to the Board for adoption.

Ms Anne Marie Hoey, Chief People Officer; Dr Grant Jeffrey, Director Workplace Health and Wellbeing Unit; and Dr Hugh Brady, AND HR Corporate Compliance and Resource Optimisation joined the meeting.

3.1 Ill Health Retirements

The Committee noted the update relating to the comparison of the number of ill health retirement cases in the HSE with an external benchmark; stress related ill health retirements and the average age of employees retiring on the grounds of permanent infirmity, which was provided by the Chief People Officer (CPO) and Director Workplace Health & Wellbeing Unit in response to queries raised by the Committee at a previous meeting.

The Committee asked that consideration be taking in relation to the increase in the number of Occupational Health Physicians (OHP) who conduct assessments; and that an analysis of how often the full amount of additional years are granted if an employee retires on the grounds of ill health based on actual years’ service and for what criteria they are awarded, be provided to the Committee.

3.2 Podiatric medicine

The Committee noted the update provided by the CPO regarding the monitoring and management of additional training placements for podiatrists to enhance resource capacity, which had been requested at a previous meeting. The Committee welcomed the initiatives presented to increase the resourcing capacity and highlighted that consideration be taking for discussions with the Department of Further and Higher Education Research Innovation to further increase resources for Universities. The Committee asked for a comparison of the number of podiatrists per population in Ireland versus the UK be brought back to the Committee.

3.3 Pay Related Overpayments

Leonard Clinton, Asst CFO Finance Shared Services joined the meeting.

The Committee noted the update provided by the CPO and the AND HR Corporate Compliance & Resource Optimisation regarding the continued work to mitigate/avoid pay related overpayments and increase repayments, which had been requested at a previous meeting.

The Committee discussed the need for prevention of overpayments, the support of the overpayment process to a recovery agency, the potential application of the DEPR circular 07/18 for civil servants in relation to the recovery of overpayments which is currently being explored for progressing for the HSE, the fraud policy, ethics in public office and the understanding of the statute of limitations.

The Committee asked that the CPO and AND HR Corporate Compliance & Resource Optimisation consider the options discussed and provide a quarterly update to the Committee noting that the report should include timings implemented and tasks completed.

Dr Colm Henry, CCO and Ronan Buckley, Business Manager, Office of CCO joined the meeting.

Leonard Clinton, Asst CFO Finance Shared Services left the meeting.

3.4 Non Specialist Division of the Register (SDR) of Medical Practitioners of the Medical Council

The Committee noted the update provided by the CPO and Chief Clinical Officer (CCO), which had been requested at a previous meeting. The CPO outlined to the Committee the information broken down by Health Region on each of the Non SDR consultants identified in the data report, including the number and categories of Non SDR Consultants employed; the confirmation of risk assessments and clinical governance arrangements in place; and the details on plans for exit arrangements.

The Committee discussed the process of quarterly reporting from the HSE Regions to ensure compliance with the recommendations of the Internal Audit on Non SDR Consultants; the recruitment policy to employ consultants with the appropriate qualifications; and the tracking of employment of consultants who are not registered on the SDR, and it was agreed that a quarterly report would be provided to the Committee going forward.

Chief People Officer, Director Workplace Health and Wellbeing Unit, and AND HR Corporate Compliance and Resource Optimisation left the meeting.

4.1 Quarterly report HSE National Centre for Clinical Audit (NCCA) - Update on National Clinical Audit Programme/Plan

The CCO provided an update to the Committee in relation to the National Clinical Audit Plan, National Clinical Audits and Registries. The report provided updates in relation to: five new National Audits approved by the National Steering Group for Clinical Audit which are in progress or commencing; one new National Registry approved; eight published National Clinical Audits, Database and Registry Reports; the NCCA Annual Report 2024, (completed and due for publication December 2025); HSE National Clinical Audit Strategy 2025-2030; Clinical Audit Prioritisation and Commissioning; HSE NCCA Clinical Audit Portal; and Local clinical audit enablers.

The Committee noted that the NCCA report focussed on published National audits, key findings, regional variations and recommendations, ensuring that the National Clinical Audit Programme evolves from a primarily responsive model to one that is strategic, risk-informed, and forward-looking, aligned with national patient safety priorities and system learning.

The Committee discussed the tracking of recommendations and how recommendations inform the allocation of funds when the National Service Plan and Capital Plans are being developed. The Committee highlighted the absence of recommendations from the audit report regarding Out of Hospital Cardiac Arrest Register (OHCAR), which the CCO agreed to follow up with the Clinical Lead.

CCO and Business Manager, Office of CCO left the meeting.

This Committee’s discussion, in private session with the Chief Internal Auditor (CIA) was deferred.

5.1 Q3 2025 Report (IA Reports and IA Recommendations Monitoring)

The CIA provided a report to the Committee which included Audit Activity and Plan Status and Planned Audits Q4 2025; Audits Issued and Key control findings from Audit Reports in Q3 2025; Implementation of audit recommendations at 30 September 2025 and National Performance Indicator; and open recommendations by area.

The Committee noted the update in relation to the Internal Audit Plan Status at 30 November 2025; with 7 audit reports issued in Q3 2025 and a summary of their key findings, and noted audits deferred, postponed and removed from the 2025 Plan. The Committee acknowledged the improvement in the management response rate of 90% relating to the implementation of audit recommendations.

5.2 IA Report Summaries (out of session)

The CIA advised the Committee that due to the topical nature of the content, two internal audit reports issued in November were being presented to the Committee outside of the regular quarterly reporting schedule. The Committee held a discussion in relation to the following audit reports:

5.3 Internal Audit Plan 2026

The CIA presented to the Committee the draft Internal Audit Plan 2026 which proposed 52 operational and 16 ICT topics, totalling 68 engagements. He advised that the draft Plan reviewed by the Committee at the November meeting had been amended with the removal of two audits: National Oversight of Patient Private Property and Decommissioning of Petty Cash; and the addition of one audit: Discharge of Elderly Patients to Private Nursing Homes.

The CIA noted that the final number of deliverable topics will also be contingent upon the successful recruitment to vacancies in early 2026 and that based on current projections, Internal Audit anticipated delivering approximately 45 operational topics, prioritised in the Plan and allowing capacity to respond to management requests throughout the year.

The Committee noted that the Plan continues to increase focus on risk areas at a more strategic regional and national level, looking particularly at topics of significance which have not been previously or regularly reviewed; the number of audits by functional area; the key topics as highlighted by the CIA; and the Risk Assessment Heatmap and Audit-Risk Incidence Heatmap.

The Committee commended the CIA and team on the comprehensive plan and endorsed approval of the draft Internal Audit Plan for 2026 for the Board at the December Board meeting.

5.4 Internal Audit Effectiveness Review and Balanced Scorecard Development

The CIA advised the Committee that as identified in the Internal Quality Assessment (IQA) which was brought to the November meeting, there is a requirement for the Committee to undertake a formal effectiveness review of the Internal Audit function and implement a Balanced Scorecard.

To support the Committee in fulfilling its requirement to evaluate the effectiveness of the Internal Audit function, the CIA outlined the proposed approach using interim performance indicators, a structured assessment tool, and an Internal Audit effectiveness review checklist, which the Committee discussed. It was agreed that the Internal Audit effectiveness review checklist would be reviewed by the Committee with the support of the Office of the Board and the CIA and scheduled for early in the New Year.

The CIA noted that further to the endorsement of the Balanced Scorecard approach and measurement at the February 2025 meeting, it was not yet ready for Committee approval and outlined the reasons for same. The Committee endorsed the deferral of the full Internal Audit Balanced Scorecard and agreed that Internal Audit will return to the Committee by June 2026 with a proposal.

5.5 Updated assurance ratings

The CIA advised the Committee that a review in relation to assurance ratings was carried out which was prompted by the implementation of the Global Internal Audit Standards (GIAS, 2024), HSE Enterprise Risk Management (ERM) Framework and limitations in the current model. He outlined to the Committee the proposed changes in the rating approach applied to Internal Audit reports and issues identified in Internal Audit Reports. The CIA proposed to the Committee that Internal Audit adopt the Chartered Institute of Public Finance and Accountancy (CIPFA) four tier model which better reflects an assurance opinion and offers clearer and more objective definitions than the current model; and a set of revised issue-level ratings that apply a broader organisational risk perspective consistent with the HSE ERM Framework, which reflects Internal Audit’s remit beyond financial controls, and provides clearer differentiation of severity.

The Committee considered the proposal and agreed to approve the adoption of the new rating framework.

Elaine Kilroe, AND Enterprise Risk Management (ERM) and David Langton (AND CCF) joined the meeting.

6.1 National Records Retention Policy

The National Director Public Involvement, Culture & Risk Management, (ND PICRM) presented to the Committee the reviewed National Records Retention Policy for noting, which was approved by the Senior Leadership Team.

The Committee noted the policy and asked that a update be brought back to the Committee in relation to the pilot programme and the adherence by staff to the policy.

6.2 Corporate Risk Update

The CRO provided an update to the Committee in relation to an AI Risk Assessment which was undertaken by the CTTO office and ERM Unit following a series of engagements with relevant stakeholders. The Committee noted the update and that the determination that the risk will be managed at the Chief Data and Analytics Officer level and that any change in the materiality of AI-related activities will prompt a reassessment for corporate risk register entry.

The AND ERM provided the Committee with the corporate risk update noting that short and medium term deliverables have significantly progressed with the establishment of the risk information system and engagement at SLT, REO and senior levels on the risk reporting processes. She advised that the key element now of the strategic plan is to focus on continued support and facilitation of ERM risk management practices throughout the newly established regional structures. The Committee noted that an internal audit recommendation to have an external review is being progressed, the recommendations from which will inform the ERM’s work programme.

6.3 Risk Based Compliance Assurance Monitoring Plan 2026 - Approval

The AND CCF presented to the Committee the draft Risk Based Compliance Assurance Monitoring Plan which is to direct compliance assurance activities within the HSE during the 12 month period to December 2026, to which the Committee considered and approved.

AND ERM and AND CCF left the meeting.

Mr Kieran O’Brien, Partner KPMG joined the meeting.

7.1 KPMG Report - Finance Operating Model

The CFO introduced to the Committee Mr Kieran O’Brien, Partner KPMG who provided a presentation to the Committee in relation to the implementation of a redesigned Finance and Procurement Operating Model to ensure the organisation is strategically equipped to deliver high quality financial management, aligned to the National Integrated Financial Management System (IFMS) rollout and Sláintecare, which was approved by the Health Regions Steering group, consisting of the CEO, SLT members, DoH and DCDE and voluntary organisations.

Mr O’Brien provided to the Committee an overview of the project including the Finance Operating Model Design Principles & Drivers for Change; Benchmarking Summary relating to Sourcing and Finance; the Future State Operating Model relating to National and Regional Finance; the Strategic Benefits of Change; and the next steps.

The Committee held a discussion with the CFO and Mr O’Brien noting the need for a requirement for a change in culture in the HSE, the need to have the right people in the positions of business partnering, the need to drive efficiency, options to yield savings, consideration of AI in terms of recommendations made, and the reasons the project was not done prior to the implementation of IFMS.

The Committee thanked Mr O’Brien for the presentation and asked that he come back to the Committee with an update to questions raised.

Mr O’Brien left the meeting.

7.2 YTD Expenditure and Financial position to year end and Non Pay Savings 2025

The CFO provided a briefing to the Committee on the YTD Financial Position as at 31 October 2025, noting that the breakeven plan line is flagged with a positive variance of €218.6m / 1.5% within the DoH funded non-Demand Led Scheme spend areas, which is made up of a total Health Region surplus of €85.3m and a total Corporate and National non-DLS surplus of €133.3m. Outside of the breakeven plan, total Corporate and National DLS have a deficit of €43.5m, leading to an overall DoH funded surplus of €175.1m. The Department of Children, Disability and Equality (DCDE) have a deficit of €182.7m and overall the HSE is reporting an October YTD deficit of €7.6m.

The Committee noted that the current cash position for the HSE is €452.6m over profile as at 30 November, where DoH is over profile by €300m and DCDE over profile by €152.6m. In relation to YTD savings, it was reported as at 30 September 2025, €108.2m savings against a YTD target of €94.9m, with an over delivery against savings target of €13.3m.

7.3 ED charges at point of presentation – update and action plan

Leonard Clinton, Asst CFO joined the meeting.

The CFO referred to the update provided to the Committee at the October meeting and presented the report in relation to the follow up Survey on Collection of Emergency Department Charges at Point of Attendance to the Committee.

The CFO outlined to the Committee the approach to the survey and the Committee discussed the key findings and the areas where improvement needs to be achieved. It was agreed that a further update would be brought back to Committee which includes the movement to 100% for locations to facilitate payment, improvements in collection of payment at time of ED attendance, and the inclusion of KPIs to track delivery. The Committee noted that the CFO via Finance Shared Services and IFMS / SAP CoE will work with regions around support for staff communications with patients around payment at point of attendance and training.

REO West and North West left the meeting.

7.4 2026 Budget Setting for services including for the main voluntary bodies

The CFO provided a brief to the Committee in relation to the 2026 budget setting for services including the Section 38 and Section 39 agencies, noting that engagement is ongoing and nearing finalisation with the Centre and each Health Region.

7.5 Health Budget Oversight Group (HBOG)

The Committee noted that there were no minutes of HBOG available.

7.6 Contract Approval Requests

Gareth Morton (ND Procurement) joined the meeting.

The CFO and ND Procurement presented to the Committee the following Contract Approval Requests (CARs):

The Committee considered the details of the proposed CAR and agreed to recommend to the Board for approval, and requested information be brought back in relation to whether there is a service risk in brining dispersed sites back into the Centre of Excellence once opened and cost comparisons between SLRON v private health site services.

CFO and ND Procurement left the meeting.

Brian O’Connell, ND, Head Strategic Health Infrastructure & Capital Delivery (ND SHICD) joined the meeting.

8.1 Update on Property Disposals Programme

The National Director, Head of Strategic Health Infrastructure and Capital Delivery (ND SHICD) provided an update to the Committee in relation to the accelerated disposal process implemented in 2025 to streamline the release of surplus or underutilised properties.

The Committee noted that 25 properties have transacted to date in 2025, with an increase to circa 40 properties anticipated by year end, and welcomed the process which aims to optimise the value of non-essential assets, reduce ongoing operational and maintenance costs ensuring that resources are focused on fit-for-purpose healthcare facilities.

8.2 Building Contracts & Properties

The Committee considered the details of the following proposed contracts which was presented by the ND SHICD.

The Committee agreed to recommend to the Board for approval the following contract:

The Committee approved the following contracts:

The Committee noted the updates relating to the following contracts:

1. 1. 1. Proposed clarification on Market Valuation interpretation in the context of delegated authority with reference to Acquisition of 6.8 Acres, Roscrea, Co Tipperary
      2. Contract awarded for 75 bed Community Nursing Unit to replace long stay beds at St. Camillus Hospital, Limerick

The Committee asked that the National Director of Communications attend a future meeting to discuss communications plan for the HSE for 2026.

The Chair thanked the Committee and SLT members. The meeting ended at 1.43pm.

Terms of Reference: Audit and Risk Committee