HSE Audit and Risk Committee Meeting Minutes Friday 13 June 2025

Members Present

Yvonne Traynor (Chair), Anne Carrigy, Michael Cawley, Pat Kirwan, Éimear Fisher, John Moody and Sharon Keogh

HSE Executive Attendance

Joseph Duggan (Chief Internal Auditor), Stephen Mulvany (Chief Financial Officer), Mairead Dolan (Asst Chief Financial Officer), Brian O’Connell (ND, Head Strategic Health Infrastructure & Capital Delivery), Joe Ryan (ND Public Involvement, Culture and Risk Management/Chief Risk Officer), Tony Canavan (REO West & North West), Dara Purcell (Corporate Secretary), Niamh Drew (Deputy Corporate Secretary), Patricia Perry (Office of the Board)

Joined the Meeting

Pat Healy (National Director), Robert Morton (Director NAS), David Langton (AND Central Compliance Function,

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.

1. Conflicts of Interest

The Chair and Committee member Anne Carrigy briefed the Committee on their appointments to the Board of Children’s Health Ireland (CHI) by the Minister for Health, and that there were no conflicts of interest arising. No further conflicts of interest were declared.

2. Minutes

The Committee approved the minutes of the Special meeting of 19 May 2025, and approved the minutes of the meeting of 09 May 2025 subject to an amendment.

3. Action Log and Follow Up Items

The Chair advised that she had reviewed the ARC Action Log with the Board Office and all actions were being progressed as per the Update Report.

1. Chief Internal Auditor Quarterly Report - in private session

The Chief Internal Auditor joined the Committee in private session, and provided an update to the Committee.

1. Q1 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 Q2 2025; Audits Issued and Key control findings from Audit Reports in Q1 2025; advisory engagements; Implementation of audit recommendations at 31 March 2025; National Performance Indicator targets; and open, outstanding and overdue recommendations by area.

The Committee noted the update in relation to the Internal Audit Plan Status at 31 March 2025; with 19 audit reports issued in Q1 2025 and an outline of the key findings of those reports.

The Committee noted two advisory engagements requested by the CEO and separately two draft IA reports issued to management under HSE’s formal clearance process. Final reports are expected in the coming weeks and, due to the significance of their findings, will be presented to the Committee outside the regular quarterly cycle.

As highlighted by the Committee at previous meetings, the issue of outstanding and overdue audit recommendations was discussed. The Committee noted the high rated recommendations, and requested that management attend the July meeting to explain the overdue recommendations relating to IA Reports regarding Ill Health Retirements; and Waiting Lists – Speech & Language Therapy & Podiatry Services.

1. Draft Cash to Year-end 2025 (incl summary YTD April I/E)

The CFO provided an update to the Committee in relation to the draft Cash to Year-end 2025 (including summary YTD April I/E), which describes a foreseen overspend of €517m (excluding demand led schemes and excluding disability services) which is the mid-point of two forecasts. He advised that the higher of which assumes the same level of growth in cash utilisation in May to December as the average of the last 4 years (the range between the two forecasts is from €407m to €627m). The CFO advised that it may be reasonable to characterise the deficit as largely related to an inability to deliver sufficient savings rather than a lack of control over costs however the level of growth outside run rates currently forecast in our Q1 I/ E projections needs to be reduced if that is to continue to be reasonable characterization.

2. Summary consolidated report on YTD April Savings

The CFO provided and update to the Committee and presented a first draft summary consolidated report on YTD April Savings against initial regional and national savings plans at 30 May 2025, which covered YTD April reporting against initial 2025 savings plans - Pay including Agency plus Non pay & Income; Procurement contracts and net savings from same; Energy Savings; and Consultancy / Contractor savings.

The Committee noted subject to various caveats, reporting plans are in place with a total €138.6m of savings targeted delivery for 2025.

The Committee discussed the need for further reductions in consultancy costs, travel and postage savings and requested that a more detailed report be brought back to the July meeting which outlines a set of initiatives, savings and how they are being tracked.

3. Expenditure Approval Limits

The CFO provided the Committee with a draft proposal to amend the NFR non pay expenditure thresholds for their consideration, which follows the previous paper presented at the April meeting. It was noted that the aim is to improve the quality of non-pay expenditure approval decisions by involving more senior managers, who are typically budget holders or closely support budget holders, more directly in the process.

An outline was presented in the paper, based on the consideration of data from the IFMS ledger for the first quarter of 2024, and an outline of potential risks and opportunities arising from each of the four proposals (P1 – P4) were presented.

The CFO suggested to the Committee that a hybrid of proposals P3 and P4 should be chosen, and that a further analysis is required to assess and align the PO volumes and spend Value % to the final suggested threshold as outlined in the paper.

The Committee considered the proposal as presented and agreed with the CFO suggestion of hybrid of P3 and P4, and outlined that an associated metrics report would be required. The Committee welcomed the revision to the expenditure approval thresholds as set out in the paper, noting that this will improve control of non-pay expenditure.

4. Health Budget Oversight Group (HBOG)

The Committee noted the minutes of HBOG meetings of 23 January 2025 and 22 February 2025.

5. National Service Plan 2026: Estimates

The Committee noted the paper presented and the overall approach to budgetary planning including both Existing Levels of Service (ELS) and New Service Developments (NSDs) for 2026 and 2027, and noted that the Estimates for Disability Services will be managed through a parallel process. The Committee noted the priority areas and approach adopted, and that the total early view requirements are: 2026 - 3,345 WTEs, full year cost €479.12m and 2027 - 1,375 WTEs and full year cost €144.99m, which were submitted to the Department of Health on 04 June 2025.

6. Integrated Financial Management and Procurement System (IFMS) update

Valerie Plan, Asst CFO joined the meeting

An update was presented to the Committee by the CFO in relation to the IFMS Accelerated Plan which was approved by programme governance on the 29 February 2024. The Committee noted that following the implementation of IFMS in Implementation Group 1, full deployment of IFMS across the HSE (statutory) is underway in two remaining implementation groups (IG2 and IG3). Upon completion of IFMS deployment to the HSE, approximately 80% of all health expenditure will be transacted on IFMS. The CFO advised that under Phase 2, for which planning has commenced, IFMS will be rolled out to all voluntary organisations in scope, i.e. all Section 38 organisations, and Section 39 Voluntary Organisations in receipt of annual funding in excess of €10m. The Committee highlighted the need to closely monitor the roll out of IFMS to voluntary organisations.

7. Contract Approval Requests

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

1. Award of contract for the Supply & Delivery of 6 in 1 Vaccines
2. Award of contract for the Supply & Delivery of a Monoclonal Antibody for Respiratory Syncytial Virus (RSV) Passive Immunisation for Pathfinder Programme 2

The Committee considered the details of the proposed CARs and agreed to recommend to the Board for approval.

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

1. Climate Action Roadmap: Progress on the HSE Infrastructure Decarbonisation Roadmap

The ND, Head Strategic Health Infrastructure & Capital Delivery (NDSHICD) provided a report to the Committee in relation to the Capital Funding Memorandum of Understanding and Funding Agreement between the HSE and Sustainable Energy Authority of Ireland (SEAI); HSE Capital & Estates actions to Progress the updated Decarbonisation roadmap; and HSE progress towards achieving decarbonisation targets, which were noted by the Committee.

2. Quarterly Report on final account for completed construction projects

The ND, Head Strategic Health Infrastructure & Capital Delivery provided a report to the Committee comparing the contract amounts for major capital projects approved by the Board with the final outturn for those projects.

The Committee were advised that in the period between January 2020 to March 2025, 40 awards of construction contracts in excess of €10 million (excl VAT) were approved by the HSE Board. Of these, 10 projects had previously been presented to the Committee and 3 projects which have been completed and reached agreement on the final accounts were presented at meeting. Of the remaining projects, 2 Projects have been completed but the final account is not yet agreed; 23 projects are currently in construction and 2 projects have yet to commence. The Committee discussed the final costs of the 3 projects reported and the additional cost drivers identified as well as the mitigations outlined in relation to ongoing risks in the delivery of Capital Projects being progressed.

3. Building Contracts and Properties

The ND, Head Strategic Health Infrastructure & Capital Delivery presented to the Committee the following contracts.

1. Proposed lease of additional space at Navan Primary Care Centre, Balmoral Industrial Estate, Balmoral, Kells Rd, Navan, Co. Meath
2. Contract Award for HSE’s Climate Action Pilot Pathfinder Project at Clonakilty CNU, Clonakilty, Co Cork
3. Acquisition of 2 No. properties to Facilitate the continuation of Child Disability Services at ‘Clonbalt Lane’, Longford

The Committee considered the details of the proposed contracts and agreed to recommend items i and ii to the Board for approval.

The Committee considered item iii, noting that whilst the transaction is below the delegated threshold of €2m, as part of the recently updated delegated authority, proposed properties transactions that are considered to be outside the scope of a standard property transaction are to be brought to the Committee for consideration prior to entering into contract. The proposed transaction was noted and endorsed by ARC and agreed that no further Board approval was required.

4. National Maternity Hospital Business Case

The Committee noted the papers previously circulated relating to the Final Business Case Approval and request for the approval of the Contract Award for onward submission to Department of Health and ultimately for Government Decision for the relocation of the National Maternity Hospital to St Vincent’s University Hospital, Elm Park; and the Contract Award for the Pre Services Contract Agreement with the selected contractors while awaiting Government Decision on the contract award and Final Business Case Approval.

It was agreed that the Committee would hold a Special meeting on Monday 16 June 2025 to consider the Business Case in detail, and that Board members would be invited.

5. National Ambulance Service (NAS)

Pat Healy, National Director National Services and Schemes and Robert Morton, Director NAS joined the meeting

The National Director National Services and Schemes and Director NAS provided an update to the Committee in relation to the progress with the implementation of the recommendations of the Audit of the National Ambulance Service (Fleet Management) August 2024 and arising from the Audit findings and recommendations advised on the progress with the NAS fleet development over recent years and its future plans.

It was noted that the key findings of the audit report related to inefficiencies in the fleet management, insufficient resources in the NAS Fleet Management Division and in the HSE Capital Plan to deliver on NAS Policy objectives. The IA report made four recommendations in this regard with implementation dates ranging from August 2024 to March 2025. As outlined by the Committee, concern was made around delays in meeting the implementation dates and were advised on the current position, noting the key findings and the actions taken to address the issues and the associated recommendations and position to date.

The Committee noted that the risks relating to NAS fleet management have now been included in the NAS Corporate Risk Register; approval has been provided for the filling of posts, with further progress in regional level fleet management to be included in Estimates 2026; the outline of resourcing over the last 3 years, 2022 – 2024, and the position for 2025 together with plans for the next three years, which align with the HSE Corporate Plan.

The Committee highlighted that if risk are not being mitigated in relation to overdue IA recommendations due to lack of funding or prioritisation in place, that the Committee should be aware of same.

David Langton AND Central Compliance Function joined the meeting

1. Central Compliance Function - Compliance Reports

1) Children 1st Compliance Reporting – CARP returns vs PCOR Metric returns

The AND Central Compliance Function (AND CCF) provided an update to the Committee in relation to the Principal Compliance Obligations Register (PCOR) and Controls Assurance Review Process (CARP) returns on mandatory Children First training, previously discussed at the April meeting. The Committee noted the update in relation to the identified variances, and that a HSELand authentication project is ongoing to improve accuracy for online training statistics and assist improved regional reporting accuracy.

The Committee discussed mandatory training on HSELand, noting that a lens with regard to tracking accurate information and compliance be monitored, with the suggestion that this be covered via the Performance Committee.

2) KPMG Compliance Report Implementation Plan - update

3) Compliance Obligations Register (COR)

(a) COR Q1 2025

The AND CCF presented the Compliance Obligations Register (COR) Q1 2025 to the Committee, which included engagement with the Office of the CEO and the Office of Legal Services (OLA) to identify any new obligations that had arisen since the last update. It was noted that Internal Obligations have increased by 23 (3%) from 796 to 819; External Obligations have increased by 10 (2%) from 435 to 445; and that the Office of Legal Services (OLS) advised that there was reduced activity on the legislation front in Q1 2025 but that there is plenty of legislation tabled for enactment later in the year.

The Committee discussed the need to demonstrate compliance with the COR and managements responsibility to ensure that staff are aware of their obligations.

(b) Principal COR Metric reporting Q1 2025

The AND CCF presented the Principal Compliance Obligations Register (PCOR) Metric Reporting Q1 2025 to the Committee, with 12 obligations listed on the PCOR with an associated metric to demonstrate compliance and outlined the alignment to the CRR principal risks. The Committee noted that only one of twelve metrics analysed show a compliance rate within 10% of the target range set. All other metrics continue to be significantly off their targets which points to a compliance environment not operating as desired at present across the organisation. The Committee noted targets were high, and highlighted the benefit of including interim targets. It was agreed that the AND CCF would engage with the owners of the metrics.

4) Governance Pathway of PCRS Probity Unit

Further to the Committee meeting of 07 March 2025, where a paper presented highlighted a governance pathway gap in relation to PCRS, the AND CCF provided an update to the Committee. The Committee noted a decision has not been reached on the desired reporting pathway and that engagements between the AND CCF and the National Director of Schemes and Services are planned over the coming weeks to finalise an approach. A briefing note will be brought to the Committee at a future date once the approach is agreed.

2. Protected Disclosures – general update

The AND CCF provided an update to the Committee in relation to the National Office for Protected Disclosures (NOPD), which has seen a marked increase in activity during the first 4 months of 2025, both in terms of an increasing number of reports received, and closure activity across the system. The Committee noted that 53 reports were received in the period, circa 20% more than the same period in 2024; and 63 reports were closed during the period which equates to 75% of the total number of closures recorded during the entirety of 2024. It was noted that 58 reports remain open across the organisation as at 28 April 2025.

The long standing issue regarding legacy cases (i.e. pre-2023 cases that were under management before the establishment of the NOPD) is almost addressed with 7 further cases closed to date in 2025, 4 cases remain open, and the average time taken to close cases continues to fall. The Committee acknowledged the work of the NOPD with regard to the closure of legacy issues.

The Committee noted the report outlining the activity related to 2025 cases; activity related to pre-2025 cases; and the continuous Improvement Initiatives & Project work

The Committee noted that the Half Year Protected Disclosure Report is due to be tabled in the coming months.

3. R004 HealthCare acquired infections and anti–microbial resistance

Further to the Committee meeting of 09 May 2025, a request was asked for detail of the current status and progress of actions in relation to R004 Health Care Acquired Infections and Anti-microbial Resistance, and noted the update prepared by the Chief Clinical Officer.

The Committee noted that the Performance Committee monitors R004 HealthCare acquired infections and anti–microbial resistance.

8.1 Administrative Leave

The Committee noted the update in relation to Administrative Leave project, and that the issue would be discussed at the Board meeting in June 2025.

The Committee formally noted the conclusion of tenure as a Committee member of Mr Pat Kirwan and took the opportunity to acknowledge the work carried out by Mr Kirwan during his six years as a Committee member. It was noted that Mr Kirwan will join the HSE Performance Committee in July 2025.

The Chair thanked the Committee and SLT members. The meeting ended at 13.05pm.

Terms of Reference: Audit and Risk Committee