Dáil Éireann debate -
Thursday, 2 Feb 2012

Vol. 754 No. 1

Health Service Plan 2012: Statements (Resumed)

Deputy Patrick O’Donovan

I welcome the opportunity to speak on this topic, in which there is much interest. There is concern in various sectors about the development of health services and associated policies. I will restrict my remarks to three areas that do not get attention and in which I have a personal interest - carers, orthodontic care and childhood obesity. I have raised the latter with the Minister previously. I represent a constituency in the midwest and while there has been negative criticism recently about acute services in the midwest, the vast majority of services in the midwest are operating very well. I have had the misfortune from a family point of view to have to use the acute services in the Mid-Western Regional Hospital and the ambulance services in the midwest region. We are very fortunate to have the Mid-Western Regional Hospital in Dooradoyle, County Limerick, along with the support services available. One cannot understand the impact of the health services or the work people do until it comes to one's own door. On 29 November 2010 I was working as a primary school teacher and within an hour of taking the roll of children in my care, I was sitting in the back of an ambulance with my father, who had experienced a number of strokes and heart and lung related problems. That day changed my life and the life of my family. It left us with someone in permanent need of care.

Many of these discussions forget the carer. It is not just the life of one person that changes with this sort of incident, where someone's independence is removed. It also affects the person who looks after these people, in many cases the partner, spouse or wife. I had no real understanding of the work carers do until I started to live with one. It is a difficult, silent role and it goes unnoticed. The reason is that carers are withdrawn from their daily lives and contact with the outside world and their lives suddenly change. Their lives revolve around the people they care for, as they are there 24 hours a day, seven days a week without a break. The hours provided by the State, not-for-profit organisations or profit-making organisations, in looking after the person and giving the carer an hour to collect the pension, go to the shops or just get a bit of downtime, are invaluable. It would be easy to say that home care packages and home help cost the State a certain amount of money but we cannot put a monetary value on it unless one experiences the impact the removal has on a person's life. I understand the country is in dire financial circumstances, as has been well enunciated. For the people who built the country and on whose backs the country was founded, it is a sad reflection on where we have come from and where we are going that we must examine the services available to a group of vulnerable people who have lost the right to have a say because, in many cases, they are unable to exercise the franchise.

There has been much talk about the community hospital network in this country in recent weeks. It is very easy to throw out the idea that hospital care and care of the elderly within the community hospital network is expensive compared to private nursing homes. Examining it on the basis of the number of patients and the amount of money going into each sector, is a fair comparison. However, when one peels back the money and looks at the patient or resident, many of them have complicated medical needs and have been discharged from acute general hospitals. They are in need of ongoing care, including rehabilitation, physiotherapy, occupational therapy, speech and language therapy or intensive care following a stroke or serious head injuries. In my area, we talk about bed numbers, trolley numbers and the occupancy of beds while there is a network of community hospitals around the country that are not being used to their true potential. There is a temptation to look at them only in terms of longstay beds when, as the Minister said, the best thing for community hospitals is to focus attention on getting the person back to independence or semi-independence and capable of returning to the home, with ongoing care from the State services. This should include home care packages in order to restore someone's dignity. The loss of someone's dignity is something that cannot be quantified. It leaves a huge mark on a family when it happens.

I refer to orthodontic care of children. It is a shame the Dental Act was passed in 1985 and allowed persons to be appointed as dental technicians to clear the waiting lists but it has not been advanced. The legislation has been passed but we have not made regulations that allow it to be rolled out. We can contrast what is happening in Ireland with Wales, Bulgaria and other European countries. We are light years behind them because reforming the Dental Council has not happened fast enough, there is no chief dental officer and we need a joined-up strategy on how this will be delivered.

One can talk about the cosmetic element of orthodontic care and it boils down to a cosmetic function for some people but it is a huge problem for young people of 14 or 15 years of age. It is not the only problem because there are complicating factors. Young people are exposed to all sorts of peer pressure and families must spend thousands of euro every year to try to avoid waiting lists to get braces. The Minister and the Minister of State have responded to me on this point and are conscious of the efforts required but it needs to be prioritised, particularly for families struggling to make ends meet. The cost of braces and ongoing care can be between €10,000 and €13,000 and people cannot afford this crazy money.

I refer to childhood obesity. We have a national advocate in the Road Safety Authority in the person of Gay Byrne, who took on, without fear of control from Government, politics or State agencies, the need to drive down the number of people being killed in road fatalities, which has worked successfully. We now need to consider the appointment of a personality outside politics and the public arena who young people, in particular, would have an appreciation and respect for to drive a national campaign in this country to address the massive issue of obesity.

It is like a timebomb waiting to explode in this country in terms of the illnesses that are being stored up such as diabetes, obesity-related cancers, heart disease, asthma and others. For a health service developing in the future, one of the largest problems we have buried beneath the carpet waiting to cause huge problems for the Exchequer and the long-term ongoing health needs of the country is obesity. If I could make one proposal, it is that the Government consider the creation of a post of national obesity advocate to drive national policy and the implementation of same, and hold the Government to account.

In five years time we should be able to say we have achieved something and are taking the issue seriously, as is happening in the United States . I again thank the Minister for the opportunity to speak today. The implementation of the health service plan is dear to all our hearts. Much has been said in the past 24 hours and if the Minister takes it on board we will have a much stronger and more vibrant health service.

Deputy Clare Daly

This is an important topic. Given the title Health Service Plan 2012, one might think this is a great step forward and strategic advance to reform the health service, but it is patently obvious on any reading of it that is not the case and underneath inoffensive sounding words such as "amalgamation", "synergies", "cost efficiencies" and so on the reality is that this is a continuation of the butchering and decimation of the health service.

The document does not hide that. The so-called plan will clearly have a major impact on front line services. We have to consider the points made by the Minister, Deputy Reilly, when he was in opposition. He said: "It is outrageous for the Minister or the HSE to suggest that there will be any improvement in capacity or service quality in light of the cutbacks that have already been implemented and the further cutbacks to come." The same man, in his ministerial robes, is doing exactly that. He is making cuts to cuts that he is on record as opposing and is making the situation worse. It is a real problem for hospitals and service providers.

Things were pared back to the bone and now the bone is being eaten away. When we talk about a reduction of 4.4%, we have to consider it in the context of the cut's that have been made and the deficits being carried forward by many hospitals which already could not cope. In that sense the cutbacks are more like a doubling of the figure. We completely reject the inference that the health service is bloated and that there is a fundamental problem.

The health service has already lost almost 9,000 employees since 2007. We are not talking about bloated fat cats at managerial level losing their jobs. In the Minister's plan, 1,600 nurses will exit the system, compared to 200 administrative staff. I am not saying the administrative staff do not deserve to keep their jobs but where is the serious analysis? Many hospital consultants are already on the record as saying that people will die as a result of these measures and cutbacks. To listen to the Minister speak on the Private Members' debate yesterday about how we will deliver better services with fewer employees was nonsense. No squaring of any circle could be completed.

When the document refers to activity levels falling by 6%, what the Minister is really talking about is longer waiting lists and people being kicked to touch. It is not a solution, it is a kind of cover-up. It is the same mentality that says the numbers on trolleys can be reduced if people are taken out of accident and emergency wards and moved to different corridors, which means they do not count in the figures.

While this is happening in the centre of the health service, home supports are being cut back. The document refers to a 4.5% cut in home support hours. When that is aligned with the chronic difficulties people have in accessing carer's allowance, one can see it will result in the worst of all worlds. There is a slash and burn policy across the board.

Everybody knows there is a crisis in the health service. Rather than taking the opportunity to develop and review our approach, we are being served up a diet of more of the same. It has often been said that we can judge a society by the way it treats its most vulnerable, elderly and sick. If that is the case this Government would face indictment for crimes in that regard.

The situation that is unfolding with regard to care for the elderly is disgraceful. Like all aspects of health service, it is not that we are not spending enough money, rather it is that huge amounts of money are being siphoned off into the private sector and private medicine in an unfair and unequitable situation that sees those who need care most being penalised. It is scandalous. This Government should be ashamed of the situation facing nursing homes.

Hardly anybody was in private nursing home care 20 years ago in Ireland. We now have a situation where two out of every three elderly people in nursing homes are in the private sector. The Government wants to further that trend by axing another 1,000 beds from the public nursing home sector. It is a ridiculous situation. We have seen figures bandied about to the effect that the private sector is much more efficient and it only costs €850 a week to keep somebody in a nursing home. Public nursing homes can cost anything from €1300 to €1800 a week.

Those flippant figures have been categorically exposed by the Ombudsman. Like with like is not being compared. The service provided by public nursing homes is far more comprehensive whereas the private sector cherry picks people and turns away those with high dependency needs because they are not profitable. The fact that the Government stands over a situation where there are no minimum staffing requirements in nursing homes is a disgrace. Private nursing homes can recruit fewer of the more highly skilled, higher paid nursing staff and have more low paid carers, which benefits them financially. It is scandalous.

The level of service being given to elderly people is far more comprehensive. The Minister should answer on some of these points. Why are we going in that direction? Let us look at what is provided. The Crooksling nursing home in Brittas has the highest number of high-level dependency patients. Some 84% of the elderly residents in the Minister's constituency require the maximum level of care. Medical staff in Tallaght Hospital would say the alternative for such people would be a hospital, such is the level of care they need.

They are getting excellent care in the facility and the Minister will say it will not be closed. The residents in the area know full well that is a lie. People are positioning themselves strategically to continue to undermine the facility by ordering Tallaght Hospital not to refer patients to the nursing home in order that a situation can be orchestrated whereby as the current elderly patients exit the system nobody will be there to replace them. It will make it look like the facility is more expensive and it will be shut down. Meanwhile, private nursing homes which have been given massive tax breaks and subsidies by the Irish taxpayer, which are operated by the likes of Dermot Desmond and friends, earn millions in profits. It is a crazy situation. The net result is not only the lining of the pockets of private individuals and reduced care for citizens; it is also causing problems for hospitals. Since Tallaght hospital, for example, cannot refer patients to Crooksling, it must accommodate 22 maximum-dependency patients who really should be in the nursing home. The Government will not let them go there. This is more of the same.

While many people celebrated the ring-fencing of the €35 million for mental health services, it is quite clear that there has been a cut in this area. We all acknowledge that, with the extra strain and stress of the current economic crisis, any failure to increase the budget for mental health services represents a cut because a considerable number of citizens need to gain access to those services. This needs to be attended to very carefully.

My last point is on private health care. We need a single-tier public health service. Many citizens can no longer afford private health insurance; some 47% of people have had it. The only reason people have private health cover is because they do not believe their families will receive adequate care without using it to jump the queue or enter the system. The system is completely wrong. We should use our tax system to have a proper publicly funded health service, and we should not give moneys to private insurance companies or adopt the Dutch model, which has cost citizens a considerable sum of money over the years. Our health service is excellent when people get into it but we are not joining the dots, however. A significant aspect of the ongoing problem is the lack of adequate investment at public level. The Minister is missing a valuable opportunity to use this debate to transform circumstances. In reality, he is doing exactly what he criticised his predecessor for doing; he is cutting further into the bone.

Deputy Ciara Conway

I concede that, in the past, the dots were definitely not joined up. Consequently, we are facing one of the biggest crises to have challenged society. In the programme for Government, there is a plan for the health service. There is more planning now than ever before. A plan was absolutely lacking under the last Government because it threw bad money after bad decisions.

For the first time, we have a clear agenda for the development of community-based services. We all know there are considerable constraints and that all the reform will have to be cognisant of the target of cutting costs by €750 million. I acknowledge the difficulty but welcome the developments concerning children and families, mental health and primary care. The Government failed absolutely in the latter area, including in my constituency, Waterford.

Of the pilot projects that were supposed to have been rolled out under the last Government, a measly 11 were carried out successfully. There is a continuing problem with access to acute hospital services because primary care is not being offered as it should be. I have every faith in the ability of the Minister of State, Deputy Shortall, to make progress in this area throughout the lifetime of the Government.

Yesterday, the Minister, Deputy Reilly, outlined some of the goals of the plan. They are very ambitious. It is hoped that no hospital will have a waiting period of more than 12 months. As a new Deputy, I realise this is one of the most serious issues to be placed on Deputies' desks. Deputy Daly touched on it when she said the system is second to none when one gets into it but that the problem is trying to access it. I welcome the Minister's ambitious targets in this regard.

With regard to reform, I welcome the decision to establish a separate agency to deal with child protection and family services. These have been an issue for many years. The previous Government failed to deal with it and, unfortunately, there have been some very serious and unfortunate deaths of young people because of the failures in the system. I do not blame the workers in the system. I worked on the front line as a social worker but noted the system itself is broken. The Government has acknowledged that this is the case and it is willing to take a chance and put €40 million towards establishing child protection and welfare services to ensure best practice regarding these serious matters, which affect some of the most vulnerable children and families.

It would be remiss of me, as a Waterford Deputy, not to outline my very serious concerns about the south east and Waterford Regional Hospital. Last week the details on the forthcoming cuts that are to affect Waterford were made known in my constituency. We must wait for another couple of weeks, or perhaps one week, before they are made official. A few years ago, Waterford Regional Hospital was lauded for its value-for-money approach. It has the lowest staff-patient ratio of any major hospital. Recently, it passed with flying colours in respect of all the HIQA standards.

Waterford Regional Hospital has been neglected over the years in terms of funding for the development of services. Annually the hospital treats up to 200,000 patients on a budget of €145 million. St. Vincent's Hospital in Dublin treats approximately 184,000 patients on a budget of €250 million. Cork University Hospital, which is just down the road from Waterford, treats a very similar number on a budget of €277 million. What does this mean for the people of Waterford? In 2010, a decision was made to split the administration of the south-east area. There are now two integrated service areas which is a mistake because south Tipperary, Kilkenny, Waterford and Wexford are all vying for the same pot of money. Consequently, Waterford Regional Hospital has a lower number of staff and a smaller opportunity to treat people. The split across four sites gives rise to an issue of hospital governance. I am eager to hear from the Minister his plan to address the administration of health care in the south east.

At present, Waterford Regional Hospital is facing considerable cutbacks. Acute medicine, above all, is under serious pressure. The facility in Waterford, which is not well funded owing to a historical problem which I acknowledge, is to suffer from the same cuts as other hospitals with vast resources. Therein lies the inequality and my dissatisfaction.

The problem is such that Cork University Hospital, which treats the same number of patients as Waterford Regional Hospital annually, has five pain consultants while Waterford Regional Hospital has one. In St. Vincent's hospital, there are six cardiologists while Waterford Regional Hospital has two. I ask the Minister to consider this. A crude cut of 3% or 4% across the board will mean Waterford Regional Hospital will be further punished for delivering in respect of good practice and savings. It was asked to achieve the savings but it is now being punished for doing so.

Waterford Regional Hospital is facing the closure of wards and theatres. This reinforces regional inequality because those living closest to Dublin and Cork have a vast number of services on their doorsteps by comparison with those in the south east, which is facing very serious difficulties owing to high unemployment rates and job creation difficulties. This problem, on top of everything else, is of great concern.

Waterford Regional Hospital, despite its cost-saving measures and low number of staff, was one of the hospitals that met all the HIQA standards. If the cuts go ahead, where will it leave the hospital and its patients, my constituents, in terms of their being able to gain access to safe health care?

The welfare of people in the south east is under threat. I implore the Minister to examine this because of the manner in which Waterford Regional Hospital was disregarded by previous Governments. This needs to be put in context by the HSE and the Minister when implementing the plan over the coming 12 months. The south-east region, served by Waterford Regional Hospital, is the only region in the country that has no palliative care services. I have seen a letter written prior to the 2007 election, and signed by Mr. Bertie Ahern, promising the people of Waterford a palliative care centre but that was never delivered upon. I ask the Minister to consider the grave need of people who face challenges in regard to looking after very sick people. Nobody needs to be told how emotive it is to have somebody in one's family challenged with a very serious illness and faced with death while not having a palliative care service or unit in the area. I make that plea to the Minister.

Deputy Dara Calleary

I welcome the chance to speak on a number of issues around the HSE health service plan for 2012. I will begin by considering the whole area of medical cards. All of us in our constituency offices are dealing with the unbelievable backlog that has arisen whereby an anticipated and targeted 15-day turnaround is now close to 15 to 20 weeks. While the staff in Finglas are doing a very good job in very difficult circumstances, I want to give an example of what we are dealing with. A constituent of mine, an elderly gentleman, through diabetes was forced to have a leg amputation, although he was lucky enough to have a good family around him. He submitted a medical card application last September. I checked the details with my office earlier today. Since September, we have exchanged 20 pieces of correspondence with the central processing unit's client registration office about this gentleman. On five separate occasions, his family and ourselves submitted information that had been previously submitted and then once again requested. This man is missing a leg and is dealing with consequences of that as well as being diabetic and suffering from other conditions. Yet, we cannot sort out a medical card for him.

Everybody in the House probably has similar stories as to what is happening in this regard. With a local office, at least there was some element of local intervention in such a case. Under the Croke Park agreement, I have always felt there should be a core of staff who would move into areas where there are shortages, demands and pressures, such as in this case, to address backlogs before moving away to another office - we would almost have a small army of people to address backlogs in given areas. None of us can stand over a system that waits five or six months to issue a medical card to a person with diabetes. The plan anticipates that 100,000 extra medical cards will be issued this year, which is probably inevitable given the economic circumstances. If the delays continue as at present, what system is in place to deal with this extra avalanche of applications that will come during 2012? The HSE attended the Committee of Public Accounts and made all sorts of commitments. The proof will be in the pudding. I ask that urgent attention is paid to this issue.

There are many ambitions and aspirations within the plan in regard to care for the elderly. Again, the plan often contradicts itself, as the Minister in his public statements often contradicts himself. He said at the health committee that community nursing homes with less than 50 beds are not viable, despite the fact this would include the majority of such homes in the country. We are cutting back on community nursing homes and the number of beds within them. The fair deal is apparently funded until the end of March. What happens beyond that date? If a person cannot get a community bed, he or she may not be able to afford a private bed. We are cutting home help hours and home care packages.

What message is being sent out to elderly people who may need a bed, perhaps temporarily, or may have to make the choice to move into a home? There are so many different messages. We are cutting every kind of supply to them. Many Deputies have spoken about the role of community nursing homes and community hospitals. The fear among all Deputies and the community generally is that many will close because of the policies the Minister seems intent on pursuing. Before this plan was published, I questioned him on several occasions on this model he has of money following the patient. What does that mean for community nursing homes and district hospitals which do not have the necessary throughput of patients because they are going to the general hospitals?

I pay tribute to the management and staff of Mayo General Hospital who have put enormous work into transforming the services and the standard of delivery at the hospital in recent years. We have a hospital we can all be very proud of. However, it only works, and the standards and transformation only work, on the basis of having very good step-down hospitals in Ballina, Belmullet and Swinford and having community nursing homes across the county where people can be stepped down into beds instead of having them occupy beds in the general hospital. There have been 70 bed closures in the district hospitals and the community nursing homes since last September. How can the management of Mayo General Hospital continue to step people down to beds that no longer exist? This will put the pressure back on the general hospital, waiting lists will increase and we will be back into the same ring-around.

Deputy Conway spoke about joined-up thinking. There is no joined-up thinking when one cuts off the funding to feeder hospitals. I come back to my earlier point. This all fits clearly into the model in terms of addressing backlogs in our major, general hospitals. However, the model the Minister is pursuing of money following the patient will cut the legs from the ability of the feeder hospitals to form part of that model in time to come.

I have spoken previously in the House about services at St. Joseph's Hospital in Ballina. I understand the Minister is involved in putting together a plan to save beds through the use of home helps in the hospital, although I gather this is still subject to union approval. I ask everybody involved to knock their heads together in order to protect the beds there. I have not seen anything proposed in regard to the psychiatric unit at the hospital or, indeed, psychiatric services generally in Mayo.

Deputy O'Donovan spoke earlier about the need for a national champion on obesity, and he is right that we must have such a person. Far more fundamentally, however, we need a national conversation or debate about mental health. We need people to stand up and say that they may have a mental health condition. I pay tribute to the many people whom we have seen come out in recent weeks and months to say they have had depression. Mental health is the same as physical health. As a country, we are great at running to people when they get physically sick and great at providing support, talking to them, praying for them and so on. However, we are still stand-offish and reluctant to talk about mental health as an issue.

Mental health is the number one challenge facing this country. When one considers the rates of suicide and depression, we have to put it out there and start talking about it. To be fair, the Minister of State, Deputy Kathleen Lynch, has done a good job ring fencing money and positions. Again, however, the issue of joined-up thinking reappears in that the senior Minister does not get it. Some 400 extra positions have been ring-fenced for mental health teams throughout the country, which is great and something we all welcome, but how many people are retiring or announced yesterday their plans to retire by the end of February from mental health services?

We were able to run to get Mr. Paul Appleby sorted out and put a package in place for him to wait on to finish his work. Surely, the 400 positions could be brought forward to make sure there are no gaps in our mental health services when that investment is going to be made later in the year in any case. It would be a shame to think the investment and the genuine commitment on the part of the Minister of State, Deputy Kathleen Lynch, would be undermined by someone failing to knock heads together in regard to sequencing retirements and appointments across the service.

The Minister, Deputy Reilly, when he was on this side of the House, was a great man for throwing every kind of abuse, indeed, much personal abuse, at the former Minister, Ms Harney. I do not see that much has changed since he came into office except that he is not as voluble as he used to be. I genuinely wish him well. Never mind the political issue, health is an issue that affects us all. However, mighty mouse, as he was when he was on this side of the House, is kind of quiet now as he deals with the realities of being Minister and having to deal with the issues.

I am willing to give him a chance in regard to this plan. I emphasise that it is his plan. I love the reference to the "HSE health service plan". The HSE is in the control of the Minister now. It is his body, his creation and he intends during 2012 to dismantle it and put up a James Reilly version. I will give him a chance on this but next year he had better deliver on the targets. We must see reform that involves better services and better access for people. We would then see the colour of his money before he starts to bring in his new, Dutch, one-size-fits-all system that has been promised to all as the nirvana of health care. However, the more one looks into it the less realistic it is.

An Leas-Cheann Comhairle

I call Deputy Paudie Coffey, who is sharing time with Deputy Brian Walsh. He has five minutes.

Deputy Paudie Coffey

I too welcome the opportunity to contribute to this very important debate. It is essential we maintain a health service that can meet the needs of every citizen, young, old and in-between. There are new challenges in the current economic climate that must be met; there are cuts across many services. This raises the bar for all of us, politicians, the HSE and the clinicians and management teams in our hospitals, as we try to protect the vital services that our people depend on so much in the area of health.

I wish to acknowledge the massive contribution of the health professionals in our health service. In debates such as this we often hear the negative stories but there are many thousands of positive stories coming out of our hospitals and primary care teams on a daily basis. There are positive outcomes to health problems with which our citizens suffer. We often do not hear enough or talk enough about those positive outcomes.

Being from Waterford and the south-east region, my main concern is Waterford Regional Hospital. I heard Deputy Conway's contribution. Recently, some Opposition politicians have made serious charges about the cuts in the services at this hospital. Some of these charges are of a scaremongering type and they worry people who are already vulnerable because they are sick. I do not include Deputy Halligan whose contribution I heard yesterday. Although he expressed his concerns in a very measured and forceful way to the Minister, he did not engage in the scaremongering other politicians have engaged in in my constituency.

There are genuine concerns about the status of Waterford Regional Hospital which serves a region with a population of more than 500,000. We cannot have a regional hospital in every county. We hear about re-configuration, re-ordering and reform within the health system but it is important to prioritise our regional hospitals and give them the essential resources they require to meet the demands and needs of the citizens they serve. Politicians - I include myself - must be very careful because we can be used by vested interests to put forward their often hidden agendas. Sometimes people are opposed to reform and change. Lately documents have been leaked from Waterford Regional Hospital. These were merely unapproved draft documents but they are really worrying the citizens of the south east.

Our hospital services need strategic investment and there must be capacity building in the other hospitals that do less acute work. I understand consultations have taken place between HSE management and leading clinical managers in Waterford Regional Hospital regarding the health service plan 2012. That will mean reform and change and the re-ordering of services. However, it should also mean re-emphasis, re-enforcement and re-investment in new services. The accident and emergency unit in Waterford, which is always held up as an example of excellence, will get two new consultants, a new cardiologist, a new endocrinologist and an acute medicine physician. That is a great investment which I wish to acknowledge in the Dáil, especially at a time of recession. I hope we will see further investment of this kind.

There are challenges for all of us in this economic climate. I include clinical managers, hospital managers and politicians who must step up to the mark and not resist reform that is for the betterment of our citizens. We have less money now and more tightened resources and we must make better use of both to protect as far as possible the health service. The Minister has outlined his priorities. The special delivery units have already achieved good targets, raising the bar even further. The Minister has, for the first time, appointed a director within the HSE who will focus on mental health. I applaud and encourage this. He is focusing on greater access to primary care and, within a few years, free access to general practitioners for all. Ultimately, there will be universal health care access for all. It will be difficult but it is achievable. We need everybody to row in so we can have a more sustainable health system that is accessible and fair for all our people.

I have a final point. A palliative care unit for the south-east region is essential. Ours is the only region without one. More than €2 million has been raised locally. I appeal to the Minister and the HSE to try to make provision for a palliative care unit which has been promised for many years. It is an essential part of our health service.

Deputy Brian Walsh

It is important to recognise from the outset the scale of the challenges faced by the Minister, the Department of Health and the HSE in framing this service plan against the backdrop of required savings of €750 million. I agree with the Minister's analysis that this level of saving can be achieved this year without a reduction in the level of service activity. From this perspective the service plan is to be commended. I also commend the Minister on the progress he has made in the short term in which he has held office, especially in reducing the time people spend on waiting lists and reducing the numbers of patients on trolleys in accident and emergency units throughout the country. His initiative to introduce special delivery units has assisted greatly in this regard.

Let there be no doubt, however. We are not going to solve the problems of our health service in one year. I respectfully suggest that notwithstanding his expertise in the area of health care and his obvious competence in health provision, the Minister is not going to be in a position to fix the health service in one term, especially given the legacy he has inherited and the challenges presented by that legacy. There can be no doubt that the scale of budgetary reduction our economic circumstances demand will impact on delivery of services in certain areas of our health service. In particular, the imposition of savings outlined in the service plan will have serious consequences for organisations reliant on HSE funding to deliver services in communities to those who can be counted among the most vulnerable in our society. For these invaluable organisations the true extent of these cuts is in many ways disguised within the pages of the action plan because, by virtue of the Croke Park agreement, they are very much constrained in determining which areas of the budget should sustain these required cuts. The care provided by these organisations, such as the Brothers of Charity in Galway, with which the Leas-Cheann Comhairle will be familiar, is by nature labour intensive. As much as 80% of their budgets can be pay-related. On the face of it, therefore, a 3.7% reduction in funding for such an organisation may seem manageable or even modest but if 80% of that organisation's budget is protected by the terms of the Croke Park agreement, that 3.7% cut must be applied to non-pay items. It then becomes a cut of in excess of 18% in non-pay expenditure which will have grave implications for the ability of that organisation to continue providing services.

There is no fat left for these organisations to trim. The HSE cleaver is already touching the bone for many. If the terms of the Croke Park agreement continue to protect the pay packets of public servants without any of the promised efficiency improvements the totality of the burden will be shifted to the non-pay element of these organisations' budgets. Vital services will be compromised. The reality is that the Croke Park agreement is not achieving the efficiencies promised. I hear regularly from health care professionals and consultants in my area, Galway, as I am sure other Deputies do in theirs. They provide us with examples of archaic procedures which are still being used, for example, in document management. There appears to be a resistance among some staff in the HSE in our hospital services to embrace new technologies which would encourage and introduce the efficiencies that are required under the agreement.

Separately, I wish to highlight a measure contained in the service plan which is likely to pose serious difficulties for one organisation that is very close to the hearts of many of my constituents. A 3.7% reduction in funding for palliative care in 2012 will impact severely on the Galway Hospice Foundation which already receives a lower proportion of funding per bed than any other hospice in the State.

I previously outlined to the House the inequitable distribution of funding for palliative care services across the country which has resulted in an historic core funding deficit for Galway Hospice Foundation, an issue with which the Leas-Cheann Comhairle is familiar and about which he has been active. The shortfall in the State subsidy to the Galway hospice has been supplemented traditionally by generous donations from the public, a testament to the high regard in which this facility is held in the west. However, a 10% fall in fund-raising last year, coupled with a 7.3% reduction in HSE funding over the past two years, has left the Galway hospice in a position where any further cuts to its budget could result in the undermining of the viability of its services.

On a positive note, the health service plan notes it will be necessary this year to prioritise some services over others to meet the most urgent needs. I hope the Minister will agree the Galway Hospice Foundation, as well as the Brothers of Charity operating in the west, are two such services. It is also noted in the plan that HSE managers will have the scope to vary the level of reduction that will apply to individual care providers to achieve overall savings. I hope due cognisance will be taken in the case of those providers which have already made significant efficiency savings in recent years and are less well able to sustain further budget cuts.

Deputy Jonathan O’Brien

I welcome the opportunity to give my thoughts on this year's health service plan. However, this two-day debate is concerned with statements. There are now only four Members in the Chamber. This is not the proper use of our time. The health service plan is an important issue which should be debated in committee with HSE officials and the Minister present. Members should be able to pose questions and get answers on the plan. If we are to debate the plan, then it should be with those who have the answers and make the decisions on it. This would mean a proper debate rather than this nonsense of four of us in the Chamber making five or ten-minute statements. It is not as if we do not have enough legislation to be getting through in the Chamber. Earlier, we spent just 50 minutes on the Legal Services Regulation Bill, important legislation which the Government tells us must be passed by a certain date because the troika has put down a deadline. Yet despite spending only 50 minutes on that legislation, we will spend another three hours speaking to ourselves in an empty Chamber with no interaction with Ministers or officials on the health service plan. That is not what people put us in here for.

Yesterday my constituency colleague, Deputy Dara Murphy, and a little earlier Deputy Brian Walsh spoke about how they believed it is possible the level of cuts implemented by the Minister in the health budget will not impact on front line health services. Deputy Dara Murphy spoke about the Minister's attempts to address problems in the health service. I do not doubt the sincerity of Ministers when they talk about reforming the health service to reduce waiting lists, achieve a more cost-effective service and create a responsive one-tier system.

I doubt the Minister's ability, however, to achieve that vision because of the policies contained in this plan and the wider health strategy that he is implementing. Deputy Dara Murphy stated the Government's target was to have no patient waiting for more than nine hours on a hospital trolley, making it out it would be some sort of an achievement. Who are we codding with a target of nine hours? The target should be zero. That attitude depresses people listening to debates like this.

I know we are all entrenched in our own political views but we all are passionate about health care and education. I have no problem with others criticising Sinn Féin's policies or the Government's. The defensive attitude taken by Members opposite, however, that the Government is right and everyone else is wrong does not help the debate. We all have good ideas on health care. If we started working together, we could start moving forward. Retreating into the trenches and criticising every single alternative put forward by the Opposition does not help. Yesterday and today, I listened to Government Deputies criticising the Opposition's alternatives. We do not have all the answers but neither do they. We must stop this political posturing when it comes to such important issues such as front line services in health and education. We must get down to brass tacks to do the job for which we were elected, namely reform our political system, get the country back on its feet, create jobs, instead of criticising people for the sake of it.

Last week, I had the unfortunate experience of ending up in Cork University Hospital, CUH, accident and emergency department with my son. When we went in, staff there were already stretched with full waiting rooms and a minimum four-hour wait to see a doctor. After three hours waiting, another trauma case went in which meant it was another seven hours' wait, a total of 11 hours in the CUH. Not only is this unacceptable but I cannot see how the Government's policies can address these problems.

Government Deputies, along with the Minister, believe they can achieve cuts to the health budget without impacting on front line services. It cannot be done. Even the HSE's health service plan states, "Some reductions in services will be unavoidable even with such efficiencies. These will arise in day service, residential and respite services". It is about how we prioritise spending our health budget.

For example, the medical card system is a fiasco. I recently had to make representations on behalf of an individual who needed to renew his medical card but did not complete the necessary paperwork in time. Accordingly, his medical card was cut off. The individual in question requires medication every day. However, he has gone several days without his medication because he cannot afford to buy it. This morning I received an e-mail from the medical card unit informing me it had received the additional paperwork and will revert to us in a couple of weeks. How can a man who cannot afford the medication he needs to take every day be told he must wait another couple of weeks to get his medical card back? We all have heard the radio advertisements that a response on a medical card will be made in 15 days but it is not happening. There is no point in Government Deputies claiming the system is being reformed when the reality on the ground tells us differently.

The service plan states HSE south will lose 170,000 home-help hours when the same plan estimates the number of people requiring home-help hours in the region will increase. Yet the Minister and Government Deputies continue to claim budgetary cuts will not impact on front line services.

It is not credible to suggest that front line services will not be hit when more people are looking for services and services are being reduced. I do not know how anybody could try to justify that argument.

There are alternatives, however, and it is a question of how we prioritise them. For whatever reason, this Government prioritised bondholders over ordinary citizens. The Deputies sitting opposite will say they had no choice in paying unguaranteed bondholders but show me the evidence if that is the case.

Deputy Dan Neville

Nineteen thirty two.

Deputy Jonathan O’Brien

I have yet to see a document that states the Government did not have a choice in paying unguaranteed bondholders. It could put this argument to rest once and for all but it cannot do so because it does not have the evidence or legal advice stating that unguaranteed bondholders have to be paid. It was a political choice and vulnerable people who rely on front line services are suffering as a result.

Prior to Christmas the Taoiseach told the people it was not their fault but then he went to Davos to tell the world it is our fault. The Minister of State, Deputy O'Dowd, can shake his head but that is the reality. The Taoiseach got a pat on the head from Europe for his comments. That type of cynical politics drives people crazy. Four Deputies are in this Chamber to listen to statements on health.

Deputy Fergus O’Dowd

I am surprised there are more than one.

Deputy Jonathan O’Brien

Irrespective of what we say, it is not productive. We should be questioning the officials in committee.

Deputy Jonathan O’Brien

Invite them before the committee.

Deputy Dan Neville

I welcome the opportunity to speak on mental health services in the context of this debate on the health service plan. Mental ill-health is damaging not only sufferers, their families and communities, but also the economy. Many of the debates held in this Chamber deal with important economic issues but the current economic crisis also includes social elements. In 2008, the Mental Health Commission published a report which estimated the direct annual cost of mental health at a staggering €3 billion in 2006. This is the cost to the taxpayer of decades of Government neglect and isolation of services. Mental health is central in building a healthy, inclusive and productive society. Illnesses like depression and schizophrenia can be treated successfully for the vast majority of sufferers and with early intervention people can live healthy lives and fulfil their individual potential.

In January 2006, the Government adopted A Vision for Change as the basis for the development of mental health services in Ireland. The policy framework set out in A Vision for Change, which built upon the recommendations of the 1984 report, Planning for the Future, received nearly universal approval as the best model for a modern, comprehensive and world-class service to meet the mental health challenges facing our society. However, five years since its announcement there is a lack of progress in implementing the A Vision for Change. The independent monitoring group reported last July that the specialist services promised as part of the strategy have not been developed. These include forensic mental health care services, rehabilitation and recovery eating disorder services, psychiatric services for older people, services for co-morbid severe mental illness and substance abuse problems and intellectual disability services.

A Vision for Change set out a policy framework for the mental health of the entire population. In addition to recognising the importance of mental health promotion and primary care, it called for a person-centred, recovery orientated and holistic approach to mental health services. This was a vital recommendation. It also called for a shift from the current system, which is excessively reliant on institutional care and medication, to a system centred on community-based care provided by multidisciplinary mental health teams. These teams would include psychologists, social workers, occupational therapists and service users, who would work alongside psychiatrists, mental health nurses, psychotherapists and counsellors. It is that important people with mental health problems are allowed to access the services and supports they choose while continuing to live in their communities, as is their right.

Ireland is more reliant on institutional mental health care than any other country in Europe. While there are examples of good practice in certain areas, implementation of the plan has been inadequate overall. Services remain deficient with few complete multidisciplinary mental health teams in place and limited access to community care for the full range of psychological supports that should form part of a modern mental health service. In 2009, only one in five staff in the mental health service was working in a community setting. Inpatient facilities remain completely unsuitable, with 15 of the 63 approved inpatient centres dating from the Victorian era or earlier. St. Joseph's in Limerick was built in 1825. The Inspectorate of Mental Health Services has described some of these facilities as entirely unacceptable and inhumane. The position in respect of older people and people with intellectual disabilities is even worse because specialist mental health services in these areas are in need of comprehensive reform.

The Ministers for Finance, Public Expenditure and Reform and Health have honoured their commitment to allocate €35 million this year for community care services. For the first time there will be a full director of mental health services. In respect of the €35 million in funding, it is vital that the director is appointed at the earliest opportunity. In 2006, the then Minister for Health and Children, Mary Harney, allocated €25 million for the implementation of A Vision for Change but the HSE only spent €17 million and hived off the rest of the money for other areas. Only €10 million of the €25 million allocated in 2007 was spent on mental health services, with the rest being used to address deficits elsewhere in the health service. This was discovered by a health service NGO. If a director is not appointed immediately, management of the promised €35 million will again be left to the health services and I am not confident it will be used for its intended purpose. An early appointment of a director of mental health services is required. Under the present structure of the HSE provision of mental health services is fragmented. There is an assistant national director with responsibility for mental health policy. However, the budget for the delivery of mental health services is split across the four regional directors of operations. The National Office for Suicide Prevention which reports to the assistant national director for mental health has a budget of €4.2 million, yet a further €4.5 million is split across the four regional directors of operations for suicide prevention activities.

The Government has promised an increase in the direct allocation to the National Office for Suicide Prevention in addition to the €4.5 million. We believe that an additional €3 million out of the €35 million should go to it. The €4.5 million that is split across the four regional directors of operations should also come under the auspices of the office so that we have full co-ordination in the area of suicide prevention.

Ireland has one of the fastest-growing rates of suicide in the world. As a cause of death among young people, suicide exceeds deaths from cancer and road traffic accidents. We have the fourth-highest rate owing to neglect over the years, therefore it is important that this area is prioritised within the €35 million allocation. We are not asking for extra funding at this stage. Some €3 million to €4 million of that should be allocated to the National Office for Suicide Prevention.

The HSE should immediately produce a detailed plan for the spending of the €35 million to be debated in this House in order to prevent the hiving off of money as happened during the tenure of the former Minister for Health and Children, Ms Mary Harney. There should be a single HSE director in charge of this €35 million and that director should progressively move to controlling the full mental health budget, which is €705 million at present. The mental health services need to have a dedicated management control with the efficiencies the Minister for Health is proposing for the general health services.

Deputy Michael Healy-Rae

I acknowledge the presence of the Minister of State, Deputy Kathleen Lynch. I also put on record my admiration for the great work done by Deputy Neville over the years in the area of mental illness. He is well known and respected throughout the length and breadth of the country for his great contribution, which I acknowledge.

Acting Chairman (Deputy Peter Mathews)

Those are very kind remarks. I thank the Deputy.

Deputy Michael Healy-Rae

I thank the Whip of the Technical Group for allowing me the opportunity to speak on the health service plan. I wish to quote:

No one knows more about the changes that need to take place in the Health Service than the experts on the ground ... and they are the managers, staff and their representatives who deal with the day-to-day realities of hospitals, health boards, support services, outpatient clinics, day care and other facilities.

We are now in an era of rapid development in health care and increasing consumer awareness. To deliver the service we need in the 21st century, we need a new way of working together, a way to cross the dividing lines and pool our resources...

Each local issue that is resolved, each short-term goal reached, is a solid advance in the journey toward a high-quality service for all who receive health care and treatment, and genuine job satisfaction for those who deliver that service.

These are not my words, but come from a document published by the former Minister of Health and Children, Deputy Martin, in 2001. These words give the sense that everything will be fine, but alas not much has changed since 2001.

Nobody will ever but have the highest praise for the front line staff of our hospitals. One need only read the letters page of any newspaper to see praise rightly heaped upon these doctors and nurses. Everyone seems to be very happy with the service in our hospitals, once there are admitted. So where is the problem? Every day we hear of long waiting times at accident and emergency departments throughout the country, people on trolleys, long waiting lists for procedures to be carried out and morale among staff at an all time low.

It must be asked, therefore, what is wrong with our health service and why does it not work for the benefit of those it is trying to serve? Having listened to the speakers from all sides the problem, I believe is not as complex as HSE managers make out. I put it simply with the acronym BEDS. I use this term because it is what everyone around this country is telling us and it also stands for better early diagnostic services.

We need a better community health service. County Kerry has a network of excellent community hospitals, in Caherciveen, Killarney, Kenmare, Dingle and Listowel with one which remains to be opened in Tralee. These community hospitals, working with the local GPs, can provide a great service to their locality. A few extra beds in these facilities used for non-critical medical conditions would immediately relive the pressure on our bigger hospitals. GPs, who have spoken to me on this subject, have informed me that many procedures could be carried out by the GPs themselves if they had access to these facilities. All community hospitals should be able to boast of having digital X-ray and video-conference links to their general hospitals in order to enable staff in the wider community to have direct access to consultants and specialists in whatever field may be necessary to carry out a proper diagnosis and treatment schedule.

However, community hospitals will have to provide a wide range of services for all ages from the youngest to the oldest, including child and family clinics along with physiotherapy, occupational therapy, speech therapy, psychiatric clinics, breast-care clinics and other carers' supports as required. Along with the upgrading of our network of community hospitals, further goals must be put in place for our general hospitals. The feeble excuses offered for recent ward closures include staff retirements and maternity leave, both of which are well within the bounds of forward planning and should have been flagged earlier so that action could have been taken to deal with the situation.

A new approach will need to be agreed with all managers on admittance to hospital. There needs to be co-operation between all hospitals whether they are community or private so that wherever a bed is available it should and must be availed of. The provision of these community services is the first step in ensuring a health service of which we can and should be proud. It is only by working from the bottom up that any progress will be made.

When the Minister for Health was in opposition he used to berate the then Minister for always claiming an issue about which she was asked was a matter for the HSE and not her responsibility. No Minister for Health who is asked a question in this House should hide behind the HSE - the buck stops with the Minister. I would like to see the Minister adopt a more responsible and hands-on approach when dealing with questions.

The issue of medical cards was raised earlier. There is chaos with medical card processing at present. I compliment in a special way the people who are working on trying to process the cards here in Dublin. I am not pointing any finger of blame whatsoever on them because they are dealing with thousands of applications. However, I have a problem with the policy of dealing with applications from all around the country in a central location. We had excellent staff dealing with medical card applications throughout the country. Local representatives and doctors had direct access to the people dealing with the applications and public representatives had direct contact as well. We knew the names of the people working on the processing of the cards.

However, a policy was introduced to centralise the processing of the cards with chaos resulting. There are people who have repeatedly sent in information by registered post only to be told afterwards that there is no record of the application. I have the PPS numbers of people to prove this fact if the Minister or anyone else wishes me to back up the claim. The Minister of State is aware of this and would have encountered the problem herself as would the Minister, Deputy Reilly. Constituents are being driven to the point of distraction when it comes to applying for a medical card. I place no blame on those involved in the processing of them as they are simply overwhelmed. We should go back to the system we had in place for dealing with medical card applications county by county.

I wish to highlight the position of carers. What has happened recently whereby carers' hours have been slashed and cut is wrong. The people providing care for elderly people in their homes save the State thousands of euro every week. If these people were not being cared for in their homes, they could end up falling and then they would end up in a community hospital or in an acute bed in a general hospital. Keeping elderly people at home is better than having them as patients in a hospital.

Orthodontic delays should be addressed, especially procedures that young people wish to have carried out. We are all aware that when a young person is developing and if they have a problem with their teeth, it is preferable for it to be dealt with at a young age because as the young person gets older it is more difficult to deal with the problem. There are considerable delays not only in my constituency but throughout the country. I wish to see the matter being given the consideration it deserves.

There are certain situations in hospitals such as that prevailing at the community hospital in Dingle. I appreciate the Minister will officially open Dingle Community Hospital tomorrow and to turn the sod for the new community hospital in Kenmare. Progress has begun there. It is ridiculous to have a new community hospital in Tralee with the doors shut, to be paying security guards to mind it and having wards in the magnificent hospital in Dingle which I visited recently. I compliment everyone on the great work they carry out there and in all our community hospitals. However, it is nonsensical and penny-wise and pound foolish to have massive infrastructure in place but not to open the beds.

Deputy Neville spoke about suicide prevention. I believe no one in the House or in the country has not been touched or affected by suicide and if it did not involve a family member it may have been involved a friend. Sadly, we have all had these experiences and in my case it has occurred in the recent past. Resources must be pumped into the issue of suicide prevention to ensure that everyone will talk about the problem. Ultimately, there is a critical timeframe whereby if a person is in danger and if there is intervention, talk and openness, that person may be taken to a better place and what they might have considered today they would not dare consider at another time.

Deputy Paschal Donohoe

I wish to share time with Deputy Joe McHugh. We will take five minutes each.

Acting Chairman (Deputy Peter Mathews)

I will let you know when there is one minute remaining.

Deputy Paschal Donohoe

I agree with one point Deputy Healy-Rae made on the processing of medical cards. This is a universal experience. Nothing is more difficult to deal with than the case of a constituent who come to a Member and who is only applying for a medical card in the first place because they need it from an income point of view or because they need it from a health point of view. Such a person is already in a situation of reliance and sometimes they will be in a state of upset. They put in the application form and, too frequently, I have had to deal with the issue of an application that either has not been received or, if it has been received, the correct use has not be made of it and those involved are unable to track it in the system and cannot give a prompt answer.

I disagree with Deputy Healy-Rae's comments in respect of the strategy. I believe the right thing to do is to centralise the system so that one group of people deals with all of it and this group has a system that they can use. Like Deputy Healy-Rae, I have found that the individuals working in that department are undoubtedly doing their best and are always full of compassion for the people with whom they are dealing and for the circumstances they are managing. Yet, it is still not working.

The Minister has acknowledged that more must be done and more will be done to give people a prompt and a more efficient service than they experience at the moment. It is most important that we do this. For many people, the main symbol of their involvement with our health system is the fact that they have a medical card and the fact that this confers on them certain benefits to which they are fully entitled. A speedier resolution of claims and applications would make a considerable difference to the lives of many people in the State.

I refer to three points related to the HSE action plan under discussion. There is provision in the plan for the measurement of the number of people waiting for more than nine months for scheduled care. This provision is acknowledged in a section of the report. The target laid out in the report for this year is that no one will be waiting for more than nine months for scheduled care. This is laid out explicitly. A total of zero people will be waiting and 0% of those who apply and who are on a waiting list will have to wait for more than nine months. It is necessary to set this target because no one should be in a system in which they must wait for more than nine months for necessary care. It is also an ambitious target in the context of the waiting lists and delays in place at the moment.

This is the singular measure in a long document with a considerable array of indicators and various measures to be tracked. If progress was made in this respect it would have a significant effect on people's perception of our health system and their ability to get into the system in the time they need. As other Deputies have acknowledged, the problem in many cases is not people's difficulty with the health system but the difficulty they face getting into it. I emphasise that this single measurement and the clarity of the objective set down is of considerable value this year.

Another issue dear to my heart because of the number of times it occurs in my constituency is the matter of children who are homeless, especially youths who are homeless, who have no place to go and who are reliant on the care of the State to ensure they are safe and not exposed to danger. Unfortunately, we have forfeited this responsibility in the past. However, I am pleased to see that targets are laid down for what we must do this year and there are several other plans that must be delivered upon. I was concerned to learn that the main reference beside this target or plan is to establish a base line in 2012. I would have thought that was already in place and I hope we can establish the ambitious targets in this area and deliver them.

I acknowledge the many good things in the report. I welcome the final agreement on the building of the new national children's hospital which will start soon and I welcome the completion of the extension of the Mater Misericordiae University Hospital, which will provide even better facilities for people seeking to access it.

Deputy Joe McHugh

I welcome the Minister of State to the House. I will be parochial in my contribution and I hope it will be of value. I refer to the Donegal model of community service, assessment and intervention, of which the Minister of State will be well aware. The model is worth pursuing at a national level. Having spoken to practitioners within the sector and to stakeholders we should consider the all-encompassing model involving 11 community hospitals. While one provides community care, the remaining ten provide rehabilitation, assessment, respite and palliative care. There is so much evidence of good work that sometimes it goes unnoticed in the public domain. If there is one deficit, it is the lack of recognition of that good work. I would encourage some reflection on the Donegal model and an intervention by the Minister of State to add value to the national set-up.

With regard to assessment, each case is treated individually. Within the ten community hospitals, we have occupational therapists, public health nurse teams and multidisciplinary teams. We should emphasise the key statistic in this regard. Donegal has the highest percentage of people over 65 in the country but the lowest number of people in long-term care. This illustrates that we have a conveyor belt of continuity, whereby patients from Letterkenny General Hospital move on to convalescence, where the idea is not for them to convalesce in a community hospital ad nauseam, but to get them back into their homes. This is done through rehabilitation, assessment and working with the families, and that system is working well.

I want the Minister of State to intervene and examine the designation of long-term beds. There is no flexibility with regard to these beds and under the fair deal programme, the situation has arisen where community hospitals are losing money when these beds are not being used for long-term patients. There must be some intervention with regard to the flexibility of the designation of these beds. This is not about competition between private and community nursing homes. Private nursing homes probably accommodate about 75% of the needs of older people for long-term care. However, the community nursing home is vital to the attempt to keep patients moving within the system. It is not just about taking them from Letterkenny General Hospital and letting them convalesce in a community nursing home. If they need long-term care, that will be provided and it is right that flexibility should be there. However, if they need to come home, they need the support systems at home. They need the support packages through the public health nurse and other community supports. They should also have the option of returning to the community home for respite care, which they have in Donegal.

I know the Minister of State is well aware of the Donegal model and that she is up to speed on it. She must intervene with regard to the flexibility of redesignating long-term beds. If the onus is not put on the community hospital to move people on, the whole system will become clogged. Currently, the incentive is to keep them in long-term care in the community hospital and if that is the case, what will happen with regard to the convalescent potential from Letterkenny General Hospital? What will happen on that journey from broken leg, to hospital, to convalescence, to community hospital, back to the home and return to respite if necessary is that the whole continuum will break down. I have spoken to the Minister, Deputy Reilly, about this, but I make a specific request to the Minister of State today to re-examine the designation of long-term beds. The incentive should be to keep the system fluid, but that is being prevented currently.

Deputy Joan Collins

I am pleased to be able to contribute to this discussion because it is an issue on which there has been significant debate. Much attention has been given to the issue of health services and the Government has made much of its commitment to primary care services and to reducing the demand for acute hospital services by developing community care.

I would like to point out one example of how far there is to go in this regard and I base my remarks on information provided to me by the Irish Heart Foundation. I am sure the Minister and Minister of State must be aware of this information but we need to put it on the record to make people aware of the situation and of how far we need to move to solve the problems within this particular community. Stroke is one of the main causes of acquired disability and up to 50,000 people with disabilities resulting from stroke live in the community. Survivors should have access to physiotherapy, occupational therapy, clinical psychology, speech and language therapy and nutrition and dietetic information provided by both hospital and community-based stroke teams.

In 2008, the Irish Heart Foundation's national audit of stroke care indicated the almost complete lack of stroke rehabilitation services. The audit showed that putative rehabilitation was only available to one-in-four patients or was delayed beyond the point at which it was most effective; continual care and long-term recovery programmes were haphazardly organised or did not exist; the quality of care was determined by chance, location and a haphazard combination of circumstances; and too many survivors were left with unavoidable and unduly prolonged disability. In 2010, the foundation showed that the direct cause of stroke to the economy amounts to €557 million per annum. Of this, as much as €440 million, almost 80%, is spent on nursing home accommodation. Less than €7 million is spent on community-based rehabilitation, which is barely enough to pay for one physiotherapy session per each of the 50,000 stroke survivors. At least one out of every six nursing home residents has had a stroke. The lack of rehabilitation services means that we are failing the survivors of stroke and as a result, people who with the right care and support could live independently require ongoing care. This is an issue that must be examined and addressed, but it cannot be addressed with the huge cuts we face in the health area.

Respite care is also a significant issue, particularly for young people in a respite home in Dublin where staff will have been cut from nine in 2010 to five by the end of February. This will leave five staff struggling to provide 24-hour respite care seven days a week to 27 families. They do not have the capacity to do that. These areas of the health service are being cut right across the board and the situation is not getting any better. The same is true for the home help service, which is already very thinly spread. The proposed cuts to this service of 4.5% will soon have the service on life support. This reduction of 4.5% will mean that 5,000 fewer people will receive home help than in 2008, a cut of 2 million hours from then.

I fail to see how we can make progress with these and other services. The ones I have mentioned are just the few that came to mind when I thought about my contribution to this debate. How can we change this when there is to be a cut of €2.5 billion in funding over three years and a reduction of staff of 8,700? This reduction in staff has affected primary and community-based care in particular. Home help hours will be cut by 500,000 in the plan. The IMO and midwives say that 10% of public health nurses will leave under the early retirement scheme. We face a chaotic situation. I was very distressed recently when people came to my office in Crumlin seeking my intervention to get them the surgery they need, a hip replacement or to find out why they are waiting so long for this care. It is a terrible state of affairs when people must come in to ask their Deputies to write to hospitals for them. It is terrible that people feel they must come to a Deputy because they are not getting the care they need from the hospitals.

I was also horrified recently to hear from people who came to me about the difficulties they are having with regard to their loved ones in hospitals waiting for places in nursing homes. They are having difficulty finding nursing home places and have been told by the hospitals that they will now be charged €1,000 a day for the hospital bed while they are waiting for nursing home care. That is wrong. It is horrific that people whose loved ones are already in a stressful situation waiting for nursing home care, and who through no fault of their own cannot get that care due to lack of space, face this. Then we see that beds in public nursing homes are to be reduced by 500. It is horrific to think of where we must start from and get to with our health service.

Talk of reform is just talk and our historically underfunded, unequal, two-tier, consultant dominated system has never been fit for purpose. It will be less fit for purpose after these cuts. The task of creating a properly funded public health system, with an emphasis on primary and community care and with free, equal access at all levels, can only be achieved when we have a Government which puts people before the profit of these consultants and many private hospitals.

The Minister's health plan will not deliver what is needed in the community, and there needs to be a complete change of tack on how we deliver our health service both in the community and in hospitals.

Acting Chairman (Deputy Peter Mathews)

I believe Deputy Seán Kenny is sharing ten minutes with Deputy Spring.

Deputy Seán Kenny

Thank you Cathaoirleach. This is a very difficult year for the health services. A Sinn Féin Deputy said in the House yesterday that the Labour backbenchers were staying silent on the health service plan. I am not a Trappist monk. The Government has to face up to the terms negotiated with the troika by the previous Administration. The challenge for the Government is to mitigate the impact on front line health care services. There are things in the plan which are to be welcomed, such as the development of proposals to protect the viability of community nursing units; increases in intermediate and community care capacity; a significant strengthening of primary care services; the enhancement of community mental health teams; progression of the clinical care programmes and a more tailored approach to disability services.

The plan requires an outline of the type and volume of services to be provided. It has to manage the health services in a manner which will mitigate as best it can the impact staff reductions will have on services. It is essential, therefore, that the focus should now switch to implementing the many reforms which are outlined in the plan and to managing the risks facing the health services.

In terms of staff numbers and pay savings, HSE target numbers were about 104,500 at the end of 2011, which is around 800 under the ceiling. The ceiling for the end of 2012 is about 102,100, which is a reduction of 3,200 compared to the 2011 target. I understand these figures are still being finalised.

The scale of the financial challenges facing the HSE, and the resulting staffing challenges, means there will be an inevitable and unavoidable reduction in services. The plan commits the HSE to minimising this impact by fast tracking new, innovative and more efficient ways of using the reducing resources. It reflects the need to move to models of care across all services and care groups which treat patients at the lowest level of complexity and provide services at the least possible unit cost. It also includes a commitment to addressing staffing levels, skill mix and staff attendance patterns and rosters within the context of the public service agreement.

Under the plan, hospitals will work closely with the special delivery unit to ensure that nobody waits longer than nine months for an elective procedure. Indeed, nine months can be a long time for somebody in pain. I certainly hope that their projections are accurate. I hope there will not be a repeat of the accident and emergency trolley crisis reported to me by constituents late last year, where old people lay on trolleys in Beaumont Hospital for long periods before being moved. I wish to pay tribute to the Beaumont Hospital staff and to accident and emergency staff in particular, who make heroic efforts to cope with the demands placed upon them.

In line with the commitment in the programme for Government to a significant strengthening of primary care services, additional funding of €20 million is being allocated to fill as many vacancies as possible. This will be increased to €25 million if it can be established that there is scope for further savings of €5 million in demand-led schemes. Funds have also been prioritised for the HPV vaccine programme and the catch-up measles vaccination campaign. GP visit cards will be issued to long-term illness claimants in line with the programme for Government. Based on the projected 2012 outturn, an increase of 105,000 medical cards is anticipated.

It is also intended to roll out a national chronic disease management programme for diabetes in 2012. Preparations will be made for the roll out of similar initiatives for other chronic diseases including stroke, asthma and heart failure. Outside of the fair deal scheme, home care packages which allow the most dependent older people to remain in their own homes will not be reduced in 2012. An additional estimated 1,270 clients will be supported under the fair deal scheme. The HSE will also work with the Department to increase intermediate care capacity by reallocating funding from long-term residential care and potential other sources such as acute hospitals.

An additional €35 million will be allocated to mental health services in 2012, targeted at improving child, adolescent and adult community mental health teams, as well as suicide prevention and counselling services. In addition, a number of inpatient child and adolescent units will open during 2012.

This country faces stark choices. It was the actions of the previous Administration that led us to this point. Despite all of that, this Government is investing as much as it can, where it can. There are adjustments in some areas, along with investments in other areas, in order to improve on services and increase provision of services. This Government is doing its very best to weather this very difficult storm.

Deputy Arthur Spring

I thank Deputy Kenny for sharing time. Being the son of a doctor and a nurse, I will not lecture anybody as an expert in medicine, considering I never studied it myself. However, I feel the public health service should be called the public ill health service. The problems arise when people with ill health have to access services that heretofore they did not have to do. I want to take a different slant on this today. I prefer to deal with rehabilitation and also the prevention of ill health in respect of mental health, obesity, the effects of alcohol, as well as the orthodontic waiting lists in the country.

The medical profession builds up tacit knowledge through practical experience, in the same way we do as politicians. One of the good elements of the Croke Park agreement is that the profession is now in a position to bring that knowledge to the table and say that this is how it needs to be reformed. Even though an enormous financial mess was created in the country, good money was spent on health, but it could have been spent a little bit better. Not only are we going to have to do things better, but we are going to have to do them better with less money. I will not get into the intricacies of bonds, as some other people did. There is a deficit and bonds have a minuscule part to play in that. I will not lecture the Acting Chairman on this, whatever about anyone else. The health service is going to have to get more bang for its buck.

The Croke Park agreement allows the stakeholders to arrange an implementation process on what we can do better. One improvement I would like to see is in the use of community hospitals and the ability to rehabilitate people and put them back into their homes where they want to be. We currently have one such hospital in Tralee with 50 beds that needs to be opened. I have spoken to the Minister of State about this on numerous occasions.

It is fairly crazy when health and education are not working together. If we can inform kids on how to keep their weight down and live a healthy and happy lifestyle, that would be a very proactive step. The Department can work on this. The fact that some children are not allowed to run in a school yard is the most bizarre thing to comprehend. It is like putting shackles on children. Medics believe that not only parents but also children do not have the knowledge about this. There is no point in knowing what year Cromwell arrived in Ireland if they cannot look after their health. The education system under the Minister, Deputy Quinn, has the capacity to develop projects that will allow people to develop self help in respect of obesity and mental health.

I noticed a few encouraging things at the Young Scientist exhibition at the RDS. Two Kerry schools - Coláiste na Sceilge and Mount Mercy Tralee - identified that confidence levels among Irish kids were not good and that mental health issues arose as a result. Doctors have told me that if kids are involved in clubs and have interests and hobbies, they are less likely to have social problems, alcohol and drug problems and, more important, mental health problems. The students identified ways of making themselves see potential problems and how to help themselves without needing to go to counsellors and the like.

If one buys a packet of paracetamol, the side effects will be listed. However, if, on a visit to the supermarket to buy a box of cornflakes, one walks past a promotion for alcohol, which is a lethal substance in some cases, one is not informed about its side effects. People need to be given such information from a younger age to enable them to make conscious decisions and live healthier lifestyles.

The Carers Association of Ireland is an integral part of the health service. Carers have looked after members of my family. They perform an onerous task and save the country a fortune. It is important, therefore, that they are protected.

Reform will be introduced and must take account of the knowledge of doctors, consultants, nurses and patients. One of the more enjoyable aspects of my job is being able to respond to members of the public because we have access to the Cabinet and are able to provide Ministers with information on how to make reforms better. I wish we had more money to fix the health service.

Deputy Richard Boyd Barrett

Deputy Spring stated that the overall financial context in which the health service plan has been introduced is not related to the payment of bonds. The implication is that the problem to be resolved is the deficit. It is important to challenge this notion. While many of the bonds have been paid, the cost of doing so has been transferred to the sovereign debt. Nationalising bankers' gambling debts was a mistake and it is the reason the deficit is so bad. While we also have what is known as a structural deficit, the decision to socialise more than €100 billion of bankers' debts spells disaster for the economy and society. I still believe we should repudiate these debts. We must challenge the European authorities and fight on this issue because it is simply not fair or sustainable, either socially or economically, to assume the debts of bankers. I reject as a starting point the notion that we must accept these parameters. We must resist them and I will explain the reason it is necessary to do so by referring to one the most important elements of our society, the health service.

If the cost of taking on the gambling debts of bankers is to inflict serious damage on the ability of the State to provide adequate health care to its citizens - the sick, vulnerable, elderly and young - that price is not acceptable. It is clear that this is the case as an examination of this year's service plan for the Health Service Executive makes clear the terrible price we will have to pay for this decision.

Health is one of a number of very important areas. Before I address the health plan, I will first place on record the position as regards the so-called structural deficit. If we repudiated the socialised banking debt, our deficit would be at manageable levels and we would almost certainly be able to access funds on the international markets because they would consider Ireland a reasonable bet in terms of our ability to repay our debt. It is precisely because our deficit has been compounded by the gambling debts of bankers following a decision that effectively doubled the deficit that the international markets do not believe we are not in a position to repay our debts and will not lend us money.

We also have the matter of the depleted tax base, which is almost entirely a consequence of the policy pursued for a decade by the Fianna Fáil Party of reducing taxes on wealth and big business to unsustainable levels. Previous Governments conned people into believing this policy was good for the country because most people did not examine the detail of the Fianna Fáil approach during the boom. As it transpired, the boom was a bubble for which we are now paying the price. The way to address this problem is not to slash services but to reform the taxation system to ensure those at the top of society pay their fair share, as they are well capable of doing.

Having set out my complete rejection of the economic and financial justification for the cutbacks and austerity measures the Government will visit on the health service, I will focus now on the health service plan for 2012. In summary, the plan attempts to spin and justify terrible cutbacks in the health service which will cause great suffering for the most vulnerable sections of society. The Government is trying to spin it as reform in summing it up with the ludicrous slogan, "more for less". Neither the Government nor the Minister for Health believe their own slogan, which is merely an attempt to put a brave face on a savage attack on the health service. Let us be honest, this is a plan to further slash vital health services for ordinary, vulnerable citizens. I hope the Government will make a clean break by desisting from the type of play-acting the previous Government engaged in when terrible things occurred in the health service as a result of inadequate funds and resources. At that time, the Minister and his Department blamed the nasty Health Service Executive for everything that went wrong as if the Government could distance itself from the HSE. Last month, RTE's health correspondent, Fergal Bowers, put it well when he described the Minister for Health's rejection of the initial draft of the health service plan for 2012 as akin to sending a letter to oneself to complain about oneself given that departmental officials make up half the board of the HSE. The Government should not attempt to abdicate responsibility for the health service. We are familiar with this policy from the Fianna Fáil and Progressive Democrats parties. Let us have none of that. Responsibility for the delivery of health services lies with the Government and Minister.

The key issue in the health service is whether we have sufficient numbers of doctors, nurses, administrators, cleaners and other professionals required to make the service work. The crucial element of the health service is to have people with skills in place to help sick people, although resources and infrastructure are clearly also necessary. If the number of health service workers is cut to the extent set out in the plan, it is utterly preposterous to suggest we will get a better health service. The "more for less" slogan is dishonest and should be dropped.

Since 2008, the number of health service staff has been reduced by 7,000 and the plan envisages reducing it further, from a current level of 104,000 to 95,000. This will result in a worse health service. As the HSE plan acknowledges, cutting €750 million from severely overstretched and inadequate services will result in a serious decline in the quality of the service provided. HSE management does not believe one can get more for less. According to the plan, "The issue most directly impacting on the levels of services to which the HSE can commit is the number of staff who will be available next year to deliver our frontline services".

It is clear it will not be possible to deliver all services at the same levels as previous years. It only promises to deliver the maximum level of safe services possible for the reduced funding and employment levels, including addressing, in so far as possible, the unstructured nature of downsizing. In other words, it will do its best but the level of service provision will be considerably less. It states clearly that efficiencies, about which the Government talks along with restructuring and so on, will not compensate for the loss of front line health care delivery staff in such large numbers. The estimates here may not even be accurate. There are already indications, as reported on RTE recently, that rather than the 3,000 whole-time equivalents by the end of 2012 suggested in the plan, it may be 3,500.

The Health Management Institute said recently that it believes continuing to provide services with the reduced resources available in certain areas will compromise the quality of services provided and will also impact on risk. That is the reality.

We are talking about a health service in which, with fewer resources and fewer staff, there will be less service provision, more suffering and people unnecessarily dying. That is true also in the mental health area. If one looks at the situation with Louise Bayliss before Christmas, what was that ultimately about? Ultimately, it was about cuts in staff and in resources in mental health services.

We are sacrificing the quality of our health service, which is there to protect the sick, the vulnerable and the elderly in our society, to pay back the gambling debts of bankers and bondholders. That is the truth and it is a shame on any Government that it would allow that to happen. The United Left Alliance will continue to robustly resist that agenda.

Deputy Paul J. Connaughton

I welcome the opportunity to speak on this very important issue. The provision of health services in what is a very difficult economic situation must be the top priority of this Government and, to this end, there are many initiatives contained in the HSE service plan introduced by the Minister which must be welcomed but concerns remain at a local level as to how these changes will impact on the day to day working of our health service.

The plan provides for the spending of just over €13 billion, a reduction of €750 million in the health spend. As the Minister said previously, the removal of that money will result in an inevitable and unavoidable reduction in services but great efforts have been made to shelter front line services from the full impact of these savings and instead focus on cost-saving across all sectors.

Welcome initiatives in the plan include proposals to protect the viability of community nursing homes, to strengthen primary care services and to enhance community mental health. Mental health, in particular measures in terms of suicide prevention, is especially important at this present juncture given the high rates of suicide and self-harm.

Any householder or small business owner will tell one of the importance of ensuring all income is collected and thus the increased focus on tackling uncollected hospital income is very welcome. I note that very ambitious targets have been set in this respect and an increased rate of collection will result in great savings in the health service generally.

One very successful initiative introduced by the Minister is the special delivery unit, SDU. It is hoped the success experienced to date, where the number of people on trolleys has fallen by 27% since the introduction of the SDU, will be mirrored throughout the country, including in University College Hospital Galway where patients have experienced long delays due to the high volume of patients presenting at its emergency department. The change instituted in emergency departments by the SDU is one example of how harnessing the knowledge and expertise of the medical personnel at the coalface can result in common sense and cost effective changes to what are long-term practices.

This is a very difficult time for people working in the health service and that fact must be recognised. A large number of staff will leave the health service this year and remaining staff will be faced with requirements for greater flexibility in terms of work practices and work rosters. To this end, implementing the public service agreement will be crucial.

In terms of health service provision in the west of Ireland, great care must be taken in respect of changes instituted only last year. The downgrading of the accident and emergency department in Roscommon County Hospital has created great difficulty for many people in east Galway and Roscommon and has put considerable increased pressure on the services in Portiuncula hospital in Ballinasloe with no increased resources. Hospitals, such as Portiuncula hospital in Ballinasloe and UCHG, must be strengthened to ensure they can provide the type of service demanded in the current HSE plan. I very much welcome the Minister's recent appointment of a new CEO to cover the four hospitals in the region but, as someone who is very clearly linked to one of the smaller regional hospitals, we want to see a very clear plan on how Roscommon, Portiuncula and Merlin Park hospitals will work with the larger UCHG to provide the best care possible for the patient, which is what this is all about. UCHG is a fantastic facility but it is suffering from delays. We are sending too many people there when we have these other hospitals which have management and staff who are more than willing to change their work practices to keep those hospitals viable. That is crucial in terms of the way forward.

I note that hospital budgets for this year will be down by an average of 4% on last year's allocation. This, added to existing deficits, will mean a reduction in expenditure of 7.8% as the hospitals endeavour to get their spending back on track and yet it is expected that inpatient numbers will reduce by only 3% on the 2011 figures.

Cancer continues to be a scourge faced by thousands of families and individuals in 2012. It is disappointing to see an anticipated increase of 3% in the incidence of cancer but it must be remembered that an element of this increase relates to better and earlier detection of cancers which, in turn, results better outcomes. However, dealing with an increase of 3% at a time when cancer care services are already extremely busy will create more pressure on oncology services.

I welcome the fact home care packages, which allow dependent older people to remain at home, will not experience any reduction, even though the cost reduction for the budget for older persons, excluding the fair deal scheme, is 2.3%. Of much greater significance is the reduction of 4.5% in home help hours, even if this reduction will only see a number of people in receipt of home help hours have their allocation reduced by 1.2%. For those critically ill older people who are being cared for at home, the level of home help available could be a determining factor in whether the family members feel able to cope with caring at home. Such cuts could put even greater pressure on the fair deal scheme in the future.

Often dry facts and figures mask the real impact the reductions will have. One example of this is the provision for disability services. I note the allocation will be reduced by 3.7% nationally and that it is hoped that this will be achieved through greater efficiencies, procurement changes and pay reduction savings as well as the rationalisation of back office costs. In recent weeks, I have met many people in regard to this issue, among them members of Ballinasloe Advocates Group, a group of parents concerned about the level of services their children will receive in 2012 and in the future. Members of this group have been understandably very anxious about the consequences those cost reductions may have on the lives of their loved ones, whether in the provision of leisure activities or transport. They are very anxious that the huge progress made in the area of services for disabled persons is not damaged by the cuts the country must make in order to balance its budgets.

The Minister stated that this reduction will result in some small reduction in day and respite services but I urge him, in conjunction with HSE management, to ensure that any such measures are kept to an absolute minimum, in particular cuts to respite services which provide an invaluable service to parents, such as those in the Ballinasloe Advocates Group.

At a time when cuts are being instituted right across the board in terms of health, education and other vital services, it is very welcome to see an additional spend of €35 million on improving child, adolescent and adult community mental health teams as well as suicide prevention and counselling services. The opening of a number of inpatient child and adolescent units is also welcome.

While the switch away from psychiatric inpatient beds to care in the community is very welcome, it has reflected a historical model of the psychiatric services which had become outmoded. I note the loss of staff in the mental health services in recent years will result in a further reduction of inpatient beds but this needs further investigation. Increased use of psychotropic drugs and recreational drugs has led to increased incidents of psychosis and, in many cases, inpatient services are the appropriate way to deal with patients who present with psychosis as opposed to sending them home in the company of family members who have neither the professional knowledge nor skill to deal with such situations. This issue may require further discussion in future years as we see an increased number of patients presenting with psychosis as people, young and old, continue to purchase psychotropic drugs from illicit sources, including over the Internet.

I again welcome the extra spend of €35 million which has been ring-fenced for this area. However, for many years, we always considered the health service could be fixed by increasing funding to it. That was the only way for the Government to prove it was fixing the health service. We need to see how this €35 million will be spent, whether in the community or through hospitals or organisations. That is the key here. It is welcome news but now we need to see how the Minister will spell it out. How will it affect such people and their families to fight the problem of suicide in the community? At a time when social workers face immense workloads and the public becomes increasingly aware of child protection issues, a reduction of 7% in child and family services is disappointing. Social workers are dealing directly with the children most in need in our society. Every care should be taken to ensure that children are not endangered by this significant funding cut.

A reduction of €750 million in this budget will cause great difficulty for people using the health service, as well as those working in it and others making the difficult decisions on funding cuts. Given the country's financial situation, such cuts are unfortunately unavoidable. I note that every effort has been made in this service plan to achieve a significant proportion through increased efficiencies and changes to procurement processes.

Deputy Tom Fleming

The €750 million reduction in this year's budget from the 2011 budget allocation is a dramatic shortfall, which imposes a great challenge to delivering an adequate service in 2012. Of immediate concern is the anticipated loss of 3,500 workers under the redundancy scheme by the 29 February deadline. A huge mistake was made when the redundancy package was announced because guidelines were not specified and neither were the numbers of people being allowed to avail of the package in each health care discipline. It seems we will have deficiencies in some hospital sectors. For example, rumour has it that a disproportionate amount of nurses in some specialties are applying for redundancy. There is also an overdraw in midwifery. The HSE report admits to the unstructured nature of exits for different services. The report also refers to a replacement factor pay model of €16 million for critical posts. The report admits that this represents a very limited capacity to address what will no doubt be critical gaps in the health service.

Existing staff will be overloaded and thus under strain in coping with additional demands. The HSE report also states that agency staffing is to be reduced by up to 50%. It is clear that the Minister for Health will have to devise some contingency plan for this situation. Due to the negative impact on health services, there is an urgent need to review the embargo on recruiting graduate nursing staff. Even if they were only to be employed on a part-time basis to deal with what I predict will be a mini-crisis, it would ease the dilemma as well as giving these graduates with excellent qualifications an opportunity to pursue their careers in their own country.

I welcome the additional €55 million for nursing homes, which is additional to the sum of €1.049 million already provided for the nursing home support scheme, which is better known as the Fair Deal. This sum should be concentrated on public care homes, rather than private ones, as well as semi-public and voluntary care establishments. Valentia Community Hospital, which is in receipt of financial support from the HSE, should also benefit from this additional allocation. It would enable it to continue its high quality service to that island community and the surrounding catchment area.

There are rumours circulating that a disproportionate number of long-term beds for the elderly will be taken out of service. This is causing widespread anger and concern among people in County Kerry, so the Minister should clarify the matter. District community hospitals, including St. Columbanus's nursing home in Killarney, have provided sterling service to the senior citizens of the county over many years. Following improvements to upgrade such facilities, it would be totally out of order to interfere with these institutions.

It is estimated that some 23,611 clients will be supported by the nursing home scheme by the end of this year. This is an increase of 1,270 from 2011. We definitely have adequate beds in our public institutions, such as those I mentioned earlier, but there should be no further drift of spending to private hospitals at the expense of public ones. I welcome the fact that Kerry General Hospital in Tralee and Kerry community hospitals combined with St. Columbanus in Killarney, had no budget deficits last year. This merits enhanced funding based on their performance and high standards.

The allocation for disability services is being reduced this year by 3%, which is downright uncivilised. It will lead to further neglect and deprivation of essential back-up services for the most needful in society. The 14-month waiting time for appliances for such people in the Kerry-Cork region is unwarranted and unacceptable. It should be dramatically reduced as it is inconvenient and stressful for people waiting for prostheses or second skins, for instance.

I welcome the €1 million for autism services, which for a long time were deprived of necessary funding. These moneys should be further increased next year to develop early intervention teams. Autism needs to be addressed step by step in the coming years in order to provide the attention it deserves.

The additional €35 million for mental health services is also welcome. The recruitment of 400 staff nationwide is most positive for these services, which are faced with increasing demands daily. The Minister should proceed with the closure of St. Finian's Hospital in Killarney and finalise arrangements for alternative accommodation at an early date.

I commend the development of primary care services, which are wonderful, progressive developments throughout the country. I ask the Minister to progress with the HSE the further provision of primary care services, which are most beneficial for rural communities and particularly for people living alone in isolated areas.

Deputy John Paul Phelan

I am glad of the opportunity to discuss health funding. It is the first health debate in which I have participated since being elected to this House. I want to make a couple of points to the three Ministers in the Department of Health. In our current economic crisis, most publicity is placed on the difficulties facing Ministers in the Department of Finance. The job of Ministers in the Department of Health, however, is an onerous one and it is all the more difficult given reductions in expenditure across the board. I wish them well in what is a very difficult task.

I wish to comment specifically on a couple of areas concerning the HSE's national service plan for 2012. I echo what was said earlier by Deputy Paul Connaughton who welcomed the extra funding for mental health services. The inclusion of additional funding for the mental health sector is highly appropriate given the economic crossroads we are at and the commitments given by Fine Gael and the Labour Party in opposition. Increased funding for this sector has been found at a time of great difficulty to ensure services can be improved across the country. There has been a change in emphasis in the past ten years in how mental health services are delivered. Thankfully, more services are delivered outside acute hospital facilities nowadays. Extra funding will help in this regard.

I agree with Deputy Tom Fleming's point on increased funding for autism and primary care centres across the country. Many people present at acute hospital facilities who could be treated closer to where they live. They need not become involved in the acute hospital service. I welcome the additional funding for primary care.

The service plan provides for a reduction in cancer funding. In my region and others, there has been centralisation of services in the regional hospital, which will result in some savings. Hopefully the impact on the delivery of service will be positive. In response to the debate, perhaps the Minister of State can refer to colorectal screening, an issue that has been raised with me. The HSE, the Department, the Minister and the Minister of State are anxious that this can be rolled out in 2012. Are there concrete proposals for when it will be rolled out?

Care of the elderly is close to my heart. We saw harrowing scenes in Laois where proposed closures of public beds for elderly people led to protests before Christmas. There is the prospect of a significant reduction in public geriatric beds. It is not something I support. I refer to the policy pursued by the previous Government in promoting the private provision of nursing home beds. It is without doubt that the provision of beds is necessary in dealing with the number of elderly people who require residential care. I urge the Department and the HSE to do everything in their power not to close 555 public beds in the coming 12 months. When 75% of the health funding is spent on pay and pensions, it is unjustifiable that savings from the other 25% lead to elderly people and their families becoming involved in protests. I have regard for the people involved in my local hospital, St. Columba's Hospital, Thomastown, County Kilkenny. This fantastic public facility provides a home for close to 100 people. There is no private facility in the region that can match it. We need to ensure these public facilities are retained. Whatever savings are made in the overall health budget, I ask that we ensure elderly people are kept in these facilities. For many people, these facilities are their homes rather than just a hospital. They live there and build bonds of friendship and affection with fellow patients and staff.

I welcome the initial steps taken by the Minister and Minister of State in the overhaul of the HSE. We often speak of the economic difficulties passed by the previous Government to the current Government. One of the unmitigated disasters passed by Fianna Fáil and its friends of various colours in government over the past 15 years is the HSE. When first proposed, the HSE was in a very different form to the form it has taken in the years of its existence. We have a bureaucracy that is not delivering a proper service across the country.

In the response to this debate, the Minister of State can provide information on how the HSE will be further overhauled in the coming months. As a Member of the Seanad, I remember discussing legislation and hearing that savings would be made because the HSE would deliver a unified service across the 26 counties. Instead, we saw the creation of extra levels of management and bureaucracy and decisions being taken out of the hands of local decision-makers and centralised, with the result of mass frustration. This applied to public representatives like me and the general public but also those involved in the service. People in the south-east region used to make decisions for the south east but they now have their hands tied behind their backs because of an extra series of management levels created above them. They cannot look after the service in the local area.

Over the years, there was a problem with the delivery of funding for health services in the south east. The region consistently lagged behind the rest of the country in capital expenditure. There have been welcome announcements about the provision of accident and emergency facilities in Wexford General Hospital and St. Luke's Hospital in Kilkenny but the south east receives less capital funding per capita and substantially lower current funding per patient treated. That is unacceptable and is not part of what we were told the HSE would be. We were told there would be the same level of care and the same level of funding across regions of the country. This has not been delivered.

I am not sure funding for rural GPs comes under the HSE national service plan. I welcome primary care centres but GPs in rural areas operate alone or in practices with one other GP. There are proposals to reduce substantially the funding for GPs and this will have a serious impact on the delivery of vital health care services in rural areas. Perhaps the Minister or Minister of State can comment on this in response to the debate.

Deputy Thomas Pringle

I propose to share time with Deputy Mick Wallace. The HSE service plan should be renamed the lack of service plan. It is being prepared to meet the €750 million reduction in the HSE budget, amounting to a total reduction of €2.5 billion in the past three years. It is past the point where we should ask ourselves whether we will have a health service in the future. We cannot continue to keep cutting and the Government cannot expect more efficiencies can be found. Efficiencies mean treating more people with less every year. It simply does not add up.

The executive summary of the service plan puts things in black and white. It is certainly true that it will be impossible to avoid an impact on front line service delivery in 2012. We all know we cannot continue to cut services and staff, yet operate a service safely. In the past few days we have learned the plan is out of date. The announcement that almost 4,000 staff will leave the health service by the end of February and the news that 47 out of 200 midwives will leave maternity services shows the real effect of the embargo and the continued reduction in front line staff. The public have known since day one that the front line was the target and now at least HSE management is recognising it.

It appears the removal of staff has not been planned for. In the past few days the Minister said the plan will be put in place, four weeks before staff are due to leave. There is no doubt the HSE will not act as quickly as the Cabinet did when the Office of the Director of the Corporate Enforcement announced his retirement because front line staff are leaving and only treat ordinary working people. More and more of the elites are the only people who will have health insurance and will continue to get preferential treatment. At least the service plan has recognised some of this in trying to address the unstructured nature of the downsizing, but it clearly shows no thought has been put into it.

Much has been made of the ring-fencing of €35 million for mental health services but in real terms this is a reduction of 1% in the overall budget for mental health services. Once again they will be the poor relation of the health service and the most distressed people will continue to suffer.

In terms of services for older people, we will see the closure of over 550 beds in community nursing homes across the country. In Donegal many beds in community hospitals are under threat, from Lifford to Dunloe and Ballyshannon.

The plan refers to maximising elderly people's ability to live in the community rather than taking up closed beds. The number of home support packages will be maintained at the same levels as last year. Where will people denied a bed get support? The number of home help hours will be cut in HSE west by 115,000. There will be no home help for those who cannot get home support. This makes a lie of the plans of the Minister and HSE.

Letterkenny General Hospital is the second most efficient hospital in the State. Over 90% of its patients are non-elective. Yet, the Government still cut its budget by millions of euro. There will be reduced service levels this year which will mean waiting lists will grow and non-elective patients will not be treated. What incentive is there for a hospital to be efficient? Last year the Minister announced Tallaght hospital will have its deficit written off but what about Letterkenny?

With the reduction in activity levels in hospital services large numbers of staff will also leave primary care. The service plan states patients should be treated in primary care rather than hospitals. How does the HSE expect this to happen? Surely staff are needed somewhere if one area is needed to pick up the slack when another service is reduced.

The HSE is already cutting out of hours GP services in Donegal and a reduction in primary care will be caused by retirements. This is combined with the cuts in home support, which is servicing the same number of patients as last year. The burden of home help hours will have to be taken up somewhere. We will see the blocking of hospital beds because many patients will simply have nowhere to go. This will lead to further reductions in treatments and place a bigger burden on primary care. The vicious cycle will continue. There is no doubt the HSE service plan and lack of services will take up many hours of debate in this House as the full effects of the cuts are felt across the country.

Deputy Mick Wallace

The general nature of the plan is difficult, given that so much money is being cut from it. It will be very difficult to provide the same services with fewer people. A strong unknown element is involved. It must have been difficult to plan for how many people were going to avail of the opportunity to avoid pension cuts. It appears that 3,500 people will leave the medical profession, a figure made up mostly of nurses and midwives. Front line staff seem to be getting a hammering more than others.

One of the priorities for 2012 is to deliver the maximum level of safe services possible. How will that be achieved in a maternity unit if there are not enough midwives to deal with the number of women coming in? Given that we have a rising population and there are more births every year but fewer midwives, I do not know how things will work out. I would not like to be a woman going into hospital not being sure how many midwives were available. I have never had such an opportunity.

I heard there will be a review of the situation when the HSE knows exactly how many people are leaving. It is clear that extra people have to be recruited to certain sections, especially midwifery. I do not see how the State can take a gamble on not having enough staff on the floor to deal with patients.

The Government's plan to treat patients at the lowest level of complexity and provide services at the lowest possible unit cost is fair enough. The policy of keeping more people in their homes is good and I agree with keeping people out of hospital if they do not need to be there. However, I am surprised that home care support hours were cut. The carer's allowance has come under threat through the welfare system. This is a backward step. The Government is right to start working towards more home care but I do not understand how it can cut home care services through changes introduced in the budget.

The Law Reform Commission made recommendations on Monday. It stated that HIQA should be given additional regulatory and inspection powers to ensure that appropriate legal standards are in place for undertakings providing professional home care. It seems the Health Act 2007 does not empower HIQA to set comparable standards as it does in other areas for the provision of health care in a home setting.

Most older people would rather stay at home if at all possible. If I were 80 years of age I would rather be in my home then go into an institution. Having said that, it would be inappropriate for the State not to be able to guarantee the quality of home care provided for older people. The general philosophy behind how we care for our older people needs improvement. Many other countries would put us to shame in terms of how they look after their older people.

In countries in the east and even as close as Italy older people are revered for having done so much throughout their lives and given so much. They are treasured, hugely respected and far better taken care of. We need to examine how we approach the care of the elderly and how we feel about them in society. We need to value them a lot more.

Deputy Jerry Buttimer

I am happy to speak in this debate on the Health Service Executive's national plan. We spend in excess of €13 billion per annum on health. If the transition year students in the Visitors Gallery were to listen to some of the Members opposite, they would say we spend nothing on it. We spend in excess of €13 billion on the public health service per annum. Can we put that in the context of our current position? There is an economic downturn, called a recession, which means there is a reduction in the public and private money available to the nation. Undoubtedly, the budgetary adjustment and legacy deficit make it inevitable that there will be a major challenge for the HSE this year.

It is necessary that all stakeholders involved in the delivery of public health services, including the HSE and the Department of Health, work together to ensure budgets are met, that reform is delivered and, most important, that the service is not compromised. It is undoubtedly a challenge but I heard not a single alternative proposed this morning and yesterday. If one had listened to Deputy Pringle, one would have believed the world was ending in Donegal, but that it is not going to happen.

We must prioritise patients and patient care. The health service is not an administrative system or an accountancy practice. It is not just a question of balancing books and having a cold computer printout; the service is about patients, the delivery of services and the women and babies in maternity units about which Deputy Wallace spoke. None of our debates should be about political point-scoring, ranting and raving or whipping up hysteria. We must be honest about the delivery of a health service that is accountable and manageable and which delivers for the patients.

I compliment the Minister of State, Deputy Shortall, and the Minister, Deputy Reilly, because they are both empathetic and sincere and have a vision. Their actions are to be seen on the ground, they do not simply engage in rhetoric. They operate under budgetary constraints. The special delivery unit has worked. Last Friday in Cork, I attended the HSE's launch of a retinopathy initiative. Dr. Diarmuid Quinlan has screened 3,500 people suffering from diabetes to bring about change regarding availability and how the system operates. The Minister of State, Deputy Shortall, pioneered primary care. This will have a profound and lasting impact on society. Mental health has been designated a priority.

Let us examine the trends set by the Government in just 11 months. We have seen the Minister unfurl a plan for seven new directorates in respect of which accountability will be the key. We have changed the management structure regarding the grouping of hospitals.

There are a number of trends about which we ought to be worried as a nation. These include the obesity level, including the childhood obesity level, and the level of alcohol misuse. I was very pleased that the Joint Committee on Health and Children published its report last week on the misuse of alcohol. I very much look forward to the report of the independent steering group and to working with the Minister of State, Deputy Shortall, in bringing about a new culture and attitude to the misuse of alcohol and tobacco.

Deputy Wallace referred to staffing. How is it that there has been a 45% increase in the number of consultants employed between 2002 and 2011 in the health service? Consultants create traffic; they have patients, theatre lists and outpatients. I look forward to seeing this year a complete realignment of the Health Service Executive. The Minister of State stressed the need to mitigate the impact of budgetary changes on front line services. We all accept that. I call on the HSE to ensure that the allocation of staff across front line services does not mitigate against the patient or compromise patient safety. This is the duty of the HSE because it is the accountable body in this case.

Deputy Wallace stated front line staff have been hit more than others in essential services. He may well be right but the reality is also that the Health Service Executive did not have all the relevant figures until some days ago. When I hear eminent people stating otherwise on the public airwaves, I wonder about megaphone diplomacy and advocacy in that regard. The last thing we need to do is create hysteria and panic, compromise safety and increase uncertainty.

There is a commitment in the programme for Government to reduce public service numbers. As we move towards the fulfilment of the criteria in the programme and those set by the troika, having due care in respect of the patient on the part of the Health Service Executive should be deemed essential.

Just last week, I met representatives of the INMO, front line staff, a group of consultants and some non-consultant hospital doctors. All of them understand the economic restraints and none is going public. Each expressed concern over staff reductions, which they fear will have an impact on the delivery of services, particularly front line services. It is critical that the HSE understands the genuine concerns of many regarding front line staff and puts plans in place to cope with the impending changes. I look forward to the HSE representatives appearing before the Oireachtas Joint Committee on Health and Children to deal with this issue in a couple of weeks.

The Minister of State, Deputy Shortall, and the Minister, Deputy Reilly, have asked the HSE to brief them on the staffing allocations in respect of each budget. I heard the Taoiseach's remarks on this topic in the Dáil yesterday. I urge the Minister of State to impress on the HSE the need to preserve the front line positions and ensure the safe delivery of services. It is important that the HSE spell out the tax savings and efficiencies achieved in the administration of the health service.

While the national service plan does not deal specifically with the budgets for specific hospitals, it indicates the overall budgetary reductions that hospitals face. The absence of this detail has caused concern for some of us in government. Those engaged with front-line staff are also concerned. However, the purpose of the national service plan is to provide an overview, and I hope the direct communications between the HSE and hospitals will provide clarification in this regard. I call on the HSE to be sincere in its negotiations with hospitals, particularly acute hospitals.

Over the past six months, hospitals have worked closely with the special delivery unit, which is one of the key reforming initiatives of the Government that has succeeded and delivered results. I very much welcome the targets being set by the Minister, which I hope will deliver further improvements in the delivery of service. We need to manage and review the operation of the special delivery unit and ensure that achieving the target is not at the expense of other areas.

The health system delivers integrated services. Each element of it needs to function if we are to review the level of care. The Minister has suggested another efficiency, the grouping of hospitals, which I welcome. This has the potential to achieve tangible results and can facilitate the pooling of resources and a sharing of facilities to deliver for patients. In Cork city, it can be used to deliver integrated surgical services and co-ordinated services across all the city's hospitals. If this model returns some local control to the system and gives those who deliver the service a greater input, it can achieve the results the Minister wants.

Deputy John Paul Phelan spoke about fair care. It is important we consider this in the totality of the way we treat the elderly. I will conclude by addressing the area of reform. As the Minister, Deputy Reilly, and the Minister of State, Deputy Shortall, have said, this is a year of reform. There are challenges facing the health service and these are recognised by all of us in Government. I challenge the Members of the Opposition to live in the real world and face up to the challenges and responsibilities which being a Member of the Oireachtas brings. It is not about megaphone diplomacy and shouting and roaring. They should be real about this.

In facing the challenges, it is important to ensure quality services are delivered where they are needed. I hope the Minister and the HSE will work together throughout that reform agenda because our country is spending in excess of €13 billion. This requires accountability and putting patients at the heart of the system. I am confident in this regard. We have a reforming Minister of State, Deputy Shortall, with us in the House and she has two reforming colleagues. It is about the patients. I am happy the Government will bring about that reform, which will deliver real change in our health system.

Deputy Mattie McGrath

I am pleased to speak on the health service plan for 2012. I have the summary of the plan, I would not like to have to read the full document as I do not know how many pages it would contain.

Having listened to the last speaker, I accept the Minister, Deputy Reilly, and the Minister of State, Deputy Shortall, and her colleagues are genuine about this issue, as is everybody in the House. The problem I have with the Minister is that he is caught on the hook again. He told us all he was going to disband the HSE and that it would be no more. Speaking for myself, I was here for four years putting down questions to the former Minister for Health and Children, Ms Harney. I wrote to the Taoiseach of the time when Ms Harney disbanded her party to have her replaced with a Minister from the Fianna Fáil parliamentary party in order to get answers on different issues. We were putting down questions to the Minister for Health and Children and they were all being fudged. The only response was, "Thank you for your question. This is not a matter for the Minister. It is for the HSE".

I believed the Minister, Deputy Reilly, when he said it was going to stop, but it has not stopped. He tried to stop it for a short time but it is back again now. I can put down a question to the Minister for Health about serious issues, whether it be medical cards or many other issues of local or national importance, yet it is the HSE to which I am directed. The HSE has to be dismantled or fundamentally changed.

There are too many people in the HSE. There are many good people who do a lot of hard, honest work, particularly in front line services. However, the front line services are being attacked and eroded. What has happened? We have the pen pushers making these reports. They are growing and growing - it is their careers they are growing in many cases. We have layers upon layers. We saw what happened when the health boards were disbanded. All the staff were taken in, with no loss of jobs except in the front line. It is top heavy with officials.

Deputy Róisín Shortall

It was the Deputy's party in Government.

Deputy Mattie McGrath

I accept that. I am talking about my party in Government, and about what I saw with my two eyes open in the past four years. I accept that we attacked the front line services and I am ashamed that was not addressed. The Minister, Deputy Reilly, promised to tackle it but he has not.

I could raise issue after issue but the fundamental problem is that the HSE is a big, monolithic organisation that is not fit for purpose. It should be on the scrap-heap. It should be totally disbanded because it has grown lazy, lethargic, inept and, above all, it does not answer to any public representative or this House. That is the shameful aspect.

The Acting Chairman, Deputy Tom Hayes, knows what I am talking about. We have been dealing with different managers in hospitals in south Tipperary. We are told one thing today and a different thing tomorrow. They move off to different careers. They move off to a reconfiguration service. They are no longer working for the hospital. They are there and getting paid out of the budget but they are now working for the reconfiguration part of the service.

Reconfiguration - it is a wonderful word. They create new words every couple of years to justify their jobs and their positions while pillorying the ordinary people of this country and deny them the basic services they are entitled to and had ten years ago. Take the mental health aspect, on which there is a spend of €55 million. Mental health services have been the poor relation for decades. We all voted for A Vision for Change, as the Minister of State, Deputy Kathleen Lynch, reminded me. Of course we did. We welcomed it because the draconian institutions must be closed and services moved on. However, part of the draconian institution that was closed in my town is now plush offices, more lavish than the Minister's office in this building. The walls are adorned with big paintings and pictures of previous officials.

This was hijacked and plundered by people who wanted to enhance their careers and to hell with the service. These people arrived in from a different land two years ago and told the board of South Tipperary General Hospital at a Tuesday night meeting that they were closing St. Michael's psychiatric unit - off the agenda - without any discussion, consultation or otherwise. The consultants and board present were shocked and contacted the local Deputies. Nonetheless, the director came on the radio on the Thursday and announced it publicly because the consultants had leaked it. Is that respect for consultants, staff or elected representatives, including county councillors who had served on the Southern Health Board? It is not.

This issue is still continuing in our town and, more importantly, in our county. They hived off all the north Tipperary patients and told them they had to go to Limerick. The north Tipperary representatives fell for that, which surprises me, but that is their business. Now, it is found they have not gone to Limerick but instead have gone to Ennis, although the people of Ennis have enough to put up with. I recently spoke to the Labour Deputy from Ennis and he complained about beds being inaccessible for his own constituents in Ennis because there is no space. It is playing with figures but, more importantly, it is neglecting and failing to treat people as human beings and as honest people who have worked and, for whatever reason, ended up in this situation.

What is going on in south Tipperary at present is an outrage. I thank the Minister of State, Deputy Kathleen Lynch, for at least yesterday acknowledging the facts in regard to closing acute psychiatric beds in St. Michael's unit. There is no comparison with St. Luke's Hospital, which we agree should be closed and, for that matter, should be bulldozed. However, they will not bulldoze it because they have big offices inside for their own people - some of the offices are as big as half a ward. It is madness. That is where the money was spent, not on the beds, not on patient services, not on outpatients and not on more psychiatric consultants, where it was needed. It was spent furthering their own careers in fine, plush surroundings. It is an abomination, a disgrace, a travesty and an injustice to the public of this country. That is what has happened.

Then we have reports like this one. They would not fit in the Custom House, all the reports that have been done on different hospitals - this report and that report, and paying experts and consultants to come in to prepare them. I do not mean medical consultants but outside consultants, enough to keep an industry going. That is what happened. They took the eye off the ball and left people waiting for medical cards.

Whoever made a decision to move the medical card system to Dublin should be sacked. It has been a disgrace of a system. While I will not say they are losing more files than they are dealing with, they are losing files by the hour. It is another disastrous move. Ordinary people, including cancer patients who are very sick, have had files go missing and they must telephone and wait, which causes great trauma. Patients have always received medical cards when terminally ill. The whole situation has become top-heavy with officials and there are not enough front line services.

I see from the figures the mental health budget is 5.3% of the total health budget. That is a scandalously low priority. I am not blaming this Government alone as I blame the last Government also. I pay tribute to the services at St. Teresa's Hospital, Clogheen, as well as those at Carrick-on-Suir, St. Patrick's at Cashel and St. Anthony's at Clonmel. I pay tribute to Sr. Áine at Clogheen and Ms Mary Prendergast at Cashel as well as to their excellent staffs.

There were rumours St. Anthony's was to be closed and the next thing beds were gone from St. Patrick's and then services at Carrick-on-Suir had been cut. An official came out from the health board to tell the management of a hospital of the finest quality at Clogheen that five beds must be cut because there was an overspend in Clonmel, in spite of the fact Clogheen was under budget. I know the answer they got from Sr. Áine, rightly so. Some of these officials need to get more answers of that kind because they are playing with people's lives. They are playing on the fears and worries of elderly people who have served this country well and need a bit of comfort in their last days.

These people should not have to be worried by the statement issued by the Minister and his people to the effect that so many nursing home beds are being taken out of the system. We must be careful. The last Deputy mentioned careless words and hysteria but these come mainly as leaks from the Department which is playing an old game, claiming it needs to make another report. Another team will arrive in Clonmel, Wexford, or wherever, and there will be another report. They are all reports about nothing. Much ado about nothing is the situation.

However, crucial services are needed and must be allowed. The attack now is on front-line services. The name of Dr. Brook has been mentioned in this Chamber every day this week. I do not believe that an eminent man in his position, who claims to be, or to have been, a member of the Minister of State's party, which is his own business, would make such serious statements without there being some credence to them. If there were not, and he were to do something of that kind, he would not be in his job.

What is happening in south Tipperary in respect of St. Michael's unit is a travesty. In Wexford people have psychotic attacks, as they do in Tipperary and every place else, but the ambulances are now flat out on the road ferrying the patients to Waterford and there are none to pick up patients who are sick. That is a fact. We went to Wexford to see a situation and we saw it. I thank the Minister for that opportunity. However, it is only a fledgling situation, newly built and not proven. We will not have the ambulances and gardaí will not have the time to bring people to hospital when they need to go. This will not work. We had solid commitments there would be no removal of services from St. Michael's until all aspects of community care were in place. They are not yet there on the ground.

This is a situation of confidence. A budget which has only 5.3% dedicated to mental health is inadequate. This plan will not happen. We cannot trust - this is not personally meant for the Minister of State - the statements that come from the HSE through the Minister because, unfortunately, that organisation does not respect the Minister and his people. Its members think they are bigger than Ministers and the elected Government. That is the problem and has been the problem for a long time. Unless it is tackled we are going nowhere. These people must be put back in their boxes and made to earn the money they are paid. They must provide value and quality for money and, above all, respect for the people.

Deputy John O’Mahony

I am glad to contribute to this debate on the health plan for 2012. I wish the Minister, Deputy Reilly, and the Ministers of State, Deputies Shortall and Lynch, well in the mammoth task they have been given, to reform a health service in the middle of the greatest economic recession this State has known. The Minister is trying to reform a system - some would call it a monster - where there are thousands of good and dedicated people working in front line and management who, on many occasions, are just as frustrated with the service they deliver as are politicians and the public at large.

Deputy McGrath referred to the number of reports and the medical card situation. All, or at least 99.9%, of the reports were produced by the Government of which he was part. I agree with him on the medical card situation. It is difficult because of the overwhelming number of applications from people who qualify for cards. It was not a good idea to centralise the system but that decision was also taken by the previous Government.

The Minister, therefore, has inherited a system which was set up at a time when there was plenty. When problems arose money was thrown at them without anybody examining what the problem really was. Layers of bureaucracy were added that complicated delivery of service rather than reorganising and improving it. In addition, in this year's plan the Minister must factor in the reduction of staff by some 3,700 at the end of this month. According to some stories I hear, the difficulty is that in many cases the wrong people are retiring. Perhaps I should say the people who are crucial to the ongoing delivery of the services are retiring. This is why the 2012 plan will be particularly difficult and challenging but it is the most important plan that has ever been delivered by a health service in this State.

It is only natural that most of the time it is the problems and bad stories that make the headlines. There are also many good stories and good things happening in the health service in recent weeks and months. In my constituency, Mayo, our general hospital has come in closer to budget than most hospitals throughout the country have, even as it improves services. For example, the number of patients on trolleys in 2006, at the height of the Celtic tiger era, was 2,285. The number on trolleys in 2011 was 599. That is still too many but it is a 400% improvement on what it was. This has come about because of greater flexibility, better use of resources, better organisation and changes in work practices. I compliment the chief executive officer in Mayo General Hospital, Mr. Frank Murphy, and the hospital manager, Mr. Charlie Meehan, who have improved services in many areas. An example is renal dialysis where all patients in County Mayo will get their treatment in the Mayo General Hospital rather than having to travel to Galway. A new MRI scanner has been added, with the help of massive local fund-raising. It is crucial, however, that good and efficient management is rewarded rather than punished. In other words, the line should not be taken that since such great savings were made last year the same can be done again next year.

For the overall delivery of an efficient health service the role of the district hospital is crucial. In County Mayo we have three: Swinford, where a magnificent new extension was officially opened in July by the Taoiseach; St. Joseph's Hospital, Ballina; and Belmullet District Hospital. In order to allow the acute hospitals to run efficiently it is vital that beds are maintained at the district hospitals so that patients can be transferred or stepped down from the acute hospital, in our case Mayo General Hospital. I compliment the Minister for the allocation of a special fund to allow front-line critical services to continue in a safe manner. This is happening in Swinford where there had been a threat to 12 beds. This has now been removed. It is crucial that the same should happen in St. Joseph's in Ballina which has similar difficulties.

I turn to the Minister's proposals to organise every acute hospital into a set of hospital groups so they can be managed efficiently and as co-ordinated units. The Minister stated that for far too long some hospitals have tended to work in isolation, not working with others or taking a team approach. Mayo General Hospital has always had a close relationship with University College Hospital Galway and it is critical that this relationship is allowed to continue in the new groupings. Ideally, any hospital network should provide a full range of services up to three-quarter level, with the exception of the super-regional or national specialties. Mayo General Hospital has been fortunate to have been part of such a network with UCHG as the regional centre. An increasing level of its services are provided on a outreach basis in Castlebar. Systems have been developed around that relationship, for example, in ICT and laboratory work. There are established and developing clinical relationships, most recently in the case of breast cancer services. It would be difficult and costly to dismantle such arrangements and provide equally good substitutes.

The linkage of Mayo, Sligo and Letterkenny hospitals would be a combination of relatively equal-sized hospitals, with roughly similar numbers of beds in general specialties. It is not clear that a network or regional arrangement has actually worked in that north-western region as the experience appears to be that where additional specialties were provided at Sligo General Hospital the tendency has been to seek to have similar services in Letterkenny. It is also unclear whether patients from mid to north Donegal have seen Sligo General as their hospital of choice.

The organisation of hospital services should take account of geographical relationships and the natural flow of populations. Apart from the border areas, County Mayo people travel to Galway as a regional centre when a service is not available locally. It is also interesting to note that regional bodies in tourism and other such areas tend to link counties Mayo and Galway. It is unclear why it would be in the interests of the Galway-based regional hospital services to lose County Mayo from its immediate catchment area. The presence of the university and related medical academy in Galway is also a strong reason why Mayo General Hospital should work closely with UCHG.

There are many other points I would like to address but I do not have the time to do so. I refer, for example, to the €35 million which has been allocated to mental health services. This is most welcome because more than any other service it has suffered the most in funding in recent years. I urge the proposed directorate for mental health services is appointed immediately to ensure the €35 million funding can be rolled out where it is most needed.

The difficulties with medical card applications was raised by other Deputies and it is one which I have raised many times too. I accept these are largely due to overwhelming demand and commend the Minister of State, Deputy Shortall, for her efforts in recent weeks to streamline the application process. Bottlenecks in systems such as those at the Passport Office previously were replicated in the medical card unit. It is important these are sorted out. People go through enough trauma with a medical condition without having to send their medical information to the unit three times in respect of an application.

The most fundamental job of the Department of Health is the reform of the health services. From the greatest challenges come the greatest opportunities. With people working together, a good health service can be delivered. This year will be crucial to that.

Deputy John McGuinness

I welcome the opportunity to contribute to this debate which is important for the health services, its reform and funding. When Mary Harney was Minister, I suggested when I was on the Government side of the House that we should put the broad thrust of reform of the health services beyond politics — not political debate — to allow the Minister to get as much traction as she or he needed to bring about the large reforms required then. Even on this side of the House now, I still suggest that is the sensible way to approach health service reform. One cannot expect Ministers to firefight the system every single day and complicate their job while expecting them to get the best value for money and reform. All Members should strive to ensure some leeway in how we deal with the health services to allow Ministers the scope to follow a particular line of reform or policy.

Those on the other side of the House can blame us for creating the Health Service Executive, which we accept. It was, however, never completed, is poor in its administration and information on health services must be extracted and dragged kicking and screaming from it. The manner in which it responds to parliamentary questions gives a clear indication of its total disregard and disrespect for politicians and our job of representing people. Responses can take up to months. When one eventually gets one, it is usually out of date and inaccurate.

Will the Minister of State insist HSE replies to parliamentary questions are answered correctly, comprehensively, accurately and in a timely fashion? Otherwise, Members representing the public cannot complete their parliamentary duties as we would like. Such a move would be a fundamental shift in focusing on the importance of this Parliament versus what is happening in the HSE.

The HSE's governance and control of human resources in administration leaves much to be desired. Until recently it was claimed over 2,000 HSE managers were not even sure of their own job descriptions. I understand from the last meeting of the Committee of Public Accounts that some of these managers have retired or been given a different job. Why was the administrative system, which costs so much to run, allowed to carry staff that were surplus to requirement when cuts mean those barely over the medical card limits do not qualify for them or others cannot get into hospital? Why was this allowed to drag on for over ten years?

Deputy Róisín Shortall

The Deputy knows why. Does he need a history lesson in the role played by Bertie Ahern in all of this?

Deputy John McGuinness

That does not mean a Government cannot and should not take a deliberate decision on it. It is about good governance and respect for taxpayers' money.

If one wants an example of a total collapse of how a system is administered, one only need look at how the medical card system is administered at national level. Deputy O'Mahony claimed the last Government was responsible for this. This and the last Government should not be directly blamed for the administrative errors that occur in the medical card system. It lies with those who administer it. It should be part of the standard of good practice that one would apply in any system, yet the HSE has failed in ensuring those who need medical cards get them in a timely fashion.

We can all give examples of the difficulties experienced. I know of one applicant who was approved for a medical card last week which was followed days later with a GP card. Both of them are in date but the individual does not know to which one he is entitled. I know of other cases where medical card applications have been lost or the applicant has been asked to apply on three different occasions for the same card. It is not correct that such a system should be allowed continue. The administrative errors in the system need to be corrected and the Minister must ensure some humanity and compassion in its operation.

It is unfortunate that whistleblowers who speak out to ensure improvements in the system for service users often if not always become the victims themselves, broken and out of a job. Recently in the House, I raised the matter of an incident in Kilkenny with the Minister of State, Deputy Shortall, in which a psychiatric patient was locked out of a facility and was forced to sleep out in the rain. The nurse who complained about this treatment now no longer works in the facility. The first investigation into the incident was in-house and all subsequent investigations continued to uphold its findings. Instead, someone from outside the HSE should have investigated the incident to ensure it never happens again and that the whistleblower's rights were protected and he or she did not suffer any consequences for his or her actions.

Senior nurses have come forward to tell me their fears that the psychiatric and community services in which they work are going to collapse and will not be able to continue beyond a particular time and date. They have made their views known within the service and have asked for the necessary changes to be made in the interest of patients. Those changes have not been implemented, however, and one of the nurses in question is now on sick leave. That is a terrible indictment of the organisation. I urge the Minister of State, Deputy Shortall, to respond to those who want to improve the services for the sake of patients.

I ask that a review be carried out of expenditure on home help packages. By supporting people in their own homes, we can prevent them from occupying hospital beds that might be put to other uses. That is worth doing.

We must review Graignamanagh in County Kilkenny in terms of providing a primary care unit for an urban centre with a large population and rural hinterland.

Anyone who looks for services in Graiguecullen in County Laois, which borders County Carlow, is told to go to a different county. I have repeatedly urged the local administrators to put in place a package to facilitate those who need services at that location. They should not be penalised just because they fall between two stools. I appeal to the Minister of State to work with the local HSE office or general administration to ensure services are improved and extended in that area, as in most other parts of counties Carlow and Kilkenny.

Deputy Eamonn Maloney

I concur with other speakers on the need for a broad review of medical services in Ireland. I commend the Minister of State, Deputy Shortall, and her colleagues and wish them well in bringing about at least some of the changes outlined in this review.

The health service is more often than not the subject of criticism by the media and others. In defence of the vast majority of hard working public servants in the health sector, they should be complimented for the work they do in often difficult circumstances. Those who work in the health service will seldom receive a compliment from our newspapers but this Parliament should praise rather than criticise them.

As regards reform, other speakers have referred to the umpteen reports that have been produced on health in Ireland. We are good at producing reports but we are not as good at reform. There are individuals in the health sector who are as conservative as some politicians and who do not want change but politicians also have to take some blame for the lack of reform. Every politician who spoke about this review expressed support for reform provided it is not in his or her constituency. That has also been the experience historically and there has been very little reform of the Irish health system for that reason.

I remind those who speak about funding hospitals that a former Taoiseach told us in 1986 that we were the richest country in the world. Of course, we went out and celebrated that night, or all two of us. It is nonsense to argue that money is the solution to the problems in the health service. As a Labour Party Deputy, it is difficult to defend a former Progressive Democrats Minister for Health and Children but, for all that was said about Mary Harney, she certainly put money into the health system. It did not work, however, as this review proves. We cannot blame her for that because people stood in the way of reform.

I am fortunate to represent a constituency which has Tallaght hospital, the busiest hospital in the country, on its doorstep. Tallaght hospital has a dedicated staff but it received the lowest level of funding during the heyday of the Celtic tiger. We could be here all night debating that issue but I am only stating a fact. Further towards Brittas, a very good and long-standing service is provided at St. Brigid's nursing home in Crooksling. However, even though the nursing home recently received a glowing report from HIQA, the HSE is proceeding with a review of its future. I am in favour of keeping the facility in place and I hope the Minister of State takes note of my views.

Deputy Bernard J. Durkan

I welcome the opportunity to speak on the important issue of health services, which affect every family in this country. Our current circumstances encourage us to focus on reality. I commend the Minister for Health and his colleagues on identifying the need for reform in the health service.

I am long enough in this House to remember when we were members of health boards. As part of visiting committees, our visits to institutions gave us the great advantage of becoming familiar with health services on the ground. This familiarity disappeared when the health boards were abolished and replaced with a free standing self-supporting system that was supposed to be the Rolls Royce of health service provision. As an Opposition Deputy I opposed the transformation on the basis that it would become an unaccountable entity with its own policy making department and no regard for supervision. It was claimed at the time that political supervision was bad and that politics had to be taken out of the health service. I am afraid that did not work.

The review now taking place has to identify the issues and, more importantly, introduce a system that is accountable to national Parliament, budget providers and the people who vote for the Department's budget. To endorse a system whereby the national Exchequer funds a devolved department is without question wrong - it can only lose. We, the people elected by the public, are the ones who will pay for it because none of these people will so do.

I emphasise the points made by Deputy Maloney about St. Brigid's nursing home in Crooksling, which is on the border of my constituency and his. The existing services provided to the very deserving patients in that women-only nursing home are second to none. The facility is state of the art and over the years it has been proven that institution is well capable of delivering the highest quality of service for the people for whom it was intended. Some, in the course of revisionism, will say we need to find new ways. We used to hear insulting remarks about bed-blockers. It was appalling to suggest that a patient was blocking a bed from somebody who was more deserving. All the people who require in-hospital health services or other institutional care are entitled to them. We have an obligation to ensure that the people, who worked all their lives in this country and who may need recuperative, supportive or ongoing full-time nursing care, get those services. I am sorry to say that over the years that has become very vague.

Some things in the HSE's pipeline have been proposed without having full regard for the extent of the requirement in terms of primary care or institutional care. It is wrong to suggest that primary care is less expensive than institutional care in all cases because it takes three times the staffing levels in community care if the patient requires continuous 24-hour nursing care.

The five minutes both of us had were simply not sufficient to cover the health services in any kind of detail and I hope we will have another opportunity to do so in the not too distant future.

Minister of State at the Department of Health (Deputy Róisín Shortall)

I thank all the Members who contributed to this useful debate, with many important issues raised. We all share an interest and concern in the health service, which is one of the most fundamental services in terms of the impact on our constituents.

The Government is committed to introducing a better and more efficient health system, which will have improved services for the people of this country. With this in mind, we are committed to introducing a single-tier health service that will deliver equal access to care based on need, not income, albeit at a time when extremely challenging economic and fiscal conditions prevail. The Minister for Health, Deputy Reilly, has already outlined to the House the financial challenge facing the health sector and the difficulties anticipated owing to impending staff retirements. He has also described the various actions and reforms being taken across the broader health system to mitigate the effects of budget and staff reductions on front-line services and to ensure that there will not be a straight-line reduction in services.

I wish to outline for the House the detailed reforms proposed within the primary care area. As recently announced by the Minister, Deputy Reilly, new administrative structures will be put in place within the HSE to reflect the need for greater operational management focus on the delivery of key services and greater transparency in funding, service delivery and accountability. These are essential if we are to provide a responsive health service.

This will involve appointing a number of directors at national level, one of whom will have responsibility for primary care. We are all agreed that 90% to 95% of a person's health needs should be catered for in primary care and yet it is the poor relation of the health service and incredibly there is no national director with his of his own budget for primary care. The director of primary care, who will be appointed shortly, will be tasked with establishing clearer service delivery structures and clear funding arrangements.

It is important at any time, but particularly in these challenging times, that money is spent wisely and services are delivered in the most cost effective way. The HSE's national service plan for 2012 includes a challenging cost saving target of €124 million in the area of drug costs. Legislation will be introduced this year to provide for a system of reference pricing and generic substitution for drugs prescribed under the GMS and community drugs schemes. These measures will reduce costs for both the HSE and patients. Discussions with pharmaceutical manufacturers are also under way to ensure these savings will be achieved.

It is clear that reform is needed and the development of primary care services is an essential component of the health service reform process. In a developed primary care system, up to 95% of people's day-to-day health and social care needs can be met in the primary care setting, which is what we want to do. Primary care teams are being developed. Even though we are talking about a 2001 primary care strategy, progress on delivering that strategy during times of plenty in this country was pathetically slow and we are paying a serious price for that now. If we can make progress at this late stage in developing the primary care teams, they will give people direct access to integrated multidisciplinary teams of GPs, nurses, physiotherapists, occupational therapists, public health nurses and all other critical health-care personnel required to provide that multidisciplinary care. Additional services such as speech and language therapy should also be provided on a sessional basis.

Each primary care team will serve a defined population. There are currently 425 primary care teams in place, but they are not all fully developed yet. It is regrettable that progress on this matter in the past decade has been so terribly slow. The HSE's service plan commits to having 489 operational teams in place by the end of this year and I, as Minister of State with responsibility for primary care, will be in constant discussion with the HSE to ensure we have fully operational teams by the end of the year.

Each primary care team will be supported by a wider range of professionals, including pharmacists, dieticians, psychologists and chiropodists, who will form a health and social care network. Each network will support approximately three to six primary care teams. The vast majority of specialist-based services will be organised at this level, including mental health community teams, child protection etc. Primary care teams will also create an environment which enables structured approaches to chronic disease management, enhanced multidisciplinary team working, improved diagnostic capabilities in primary care, and the integration of services between primary and secondary care.

The service plan states the HSE intends to commence a national roll-out of chronic disease management for diabetes during 2012. I am very glad that €2 million has been provided in the current service plan for this very important new development in our health service. The HSE will also progress preparations for the roll-out of similar initiatives for other chronic diseases, including stroke, asthma and heart failure. The delivery of these chronic disease management programmes at community level is key to moving to a new, much more responsive and cost effective model of care in the health service. The provision of integrated services whereby the patient has access to an extensive range of services in their own community, ideally all in the same building, is undoubtedly the way forward and this will help to reduce considerably the reliance on hospital-based services.

The service plan also demonstrates the continued success of the general practitioner out-of-hours service. In addition, a key commitment in the programme for Government and a fundamental element in the health reform process involves significant strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients. This commitment will be achieved on a phased basis. As it stands, the system cannot deal with the demands that will come in future. Therefore, we must gear up on a phased basis to ensure we have the additional GPs, nurses and other professionals to provide universal access to free GP care. The introduction of this programme will begin this year with the first phase in which all those currently claiming under the long-term illness scheme will come under the free GP care initiative. Legislation is being developed in this regard at the moment and we hope to have it in place by mid-year.

Funding of €20 million has been provided to fill as many vacancies as possible arising from retirements in the HSE within the primary care area. There is no doubt these retirements will pose significant challenges for us in terms of continuing to provide an acceptable level of care. However, within the primary care area a figure of €20 million is ring-fenced to back-fill as many of these places as possible. Naturally, we will be unable to fill all these vacancies but we will fill as many as possible and we will concentrate the resources on front-line resources. There is also the prospect of an additional €5 million being available if we can make additional savings in the drugs area.

The Department has also commissioned a study to examine the question of workforce planning in primary care in order that we can be assured that there will be a sufficient number of GPs and practice nurses to cater for the demand that will arise as we roll out free GP care. The provision of GP care without fees during this Government's term of office is an absolute priority for me. The implementation of this commitment will be delivered upon beginning this year. We hope to continue this development during the coming four years in order that we get to a point where the whole population will be covered by the initiative.

The strengthening of primary care planned in the programme for Government reflects the need to move to new models of care throughout all service areas that will treat patients at the lowest level of complexity in their community and provide quality services at the least possible cost. This approach makes sense from the patient's point of view, from a health point of view and from a cost point of view. We are determined to deliver on this as soon as possible and work is well underway on these commitments as we speak.

I refer to the issue of medical cards and the difficulties that have arisen in recent times. I realise this is a matter of concern to many Members. There is no question but that the level of service provided to patients has been unacceptable. There are several reasons why this has been the case and the issue has come to a head in recent months. There was a changeover from the system of community welfare officers, CWOs, processing medical card renewals and applications. A considerable backlog was passed over to the HSE primary care reimbursement service, PCRS, to deal with, to the point where at one stage those involved were overwhelmed by the sheer numbers involved. There was also an issue in terms of their gearing up for the centralisation. I took the view that they undertook this too quickly and I expressed that view at the time. In addition, there were difficulties with the processing systems. I was not satisfied with the type of service being provided or the systems in place in the PCRS in Finglas. Progress has been made in recent weeks and I intend to circulate all Members with the details.

From this month we will have moved to a situation whereby there will be self-assessment for the renewal of medical cards and this will assist the process greatly. This will be matched by a spot-checking system to ensure there is proper accountability. I assure Members that anyone whose medical card has come up for renewal and who has engaged with the HSE in a meaningful way will not lose an entitlement until a final decision is made on that entitlement. Members can put at rest constituents' minds in this regard. The backlog is being worked through the system and we are moving towards the new self-assessment system. I hope to see significant improvements in the coming weeks in this regard and I will inform Members of the details of the new system without delay.