Priority Questions

I call the Minister of State at the Department of Health, Deputy Róisín Shortall, to respond to Question No. 3 in the name of Deputy Billy Kelleher.

Has Fianna Fáil disbanded?

We cannot take Question No. 3 now; we will take it later. Deputy Ó Caoláin's question, No. 4, is next. I call the Minister for Health, Deputy James Reilly.

Health Service Staff

Caoimhghín Ó Caoláin

Question:

4Deputy Caoimhghín Ó Caoláin asked the Minister for Health the way he is monitoring the effects on front-line services of the departure of some 4,200 staff from the health services up to the end of February 2012; the additional numbers expected to leave the health services during the remainder of 2012; the criteria for the lifting of the recruitment embargo in certain circumstances; and if he will make a statement on the matter. [16564/12]

My Department continues to work closely with the Health Service Executive, HSE, to ensure the contingency plans put in place for both hospital and community services are operating satisfactorily and that all critical front line services continue to be delivered. It is necessary to be as innovative and flexible as possible to mitigate the impact of reduced budgets and staffing. The Government's priority is to reform how health services are delivered to ensure a more productive and cost-effective health system.

Between September 2011 and February 2012, approximately 4,500 members of staff retired from the health service. This figure includes some 800 staff who were not in active service when they retired, for example, staff who had retired on preserved benefits or staff retiring because of permanent infirmity. Since the precise date of retirement is a matter for personal decision by each staff member, it is not possible to indicate the number of staff who will retire during the remainder of 2012. The HSE will be monitoring the level of retirements as part of ongoing management of its resources.

Health sector employment numbers must be reduced to approximately 102,100 whole-time equivalents, WTEs, by the end of this year. Based on the end-2011 outturn of 104,400 WTEs, this requires a net reduction of 2,300 staff. Subject to the achievement of this target and to budgetary constraints, the service may make appointments which are necessary to ensure critical services are maintained and in line with the developmental priorities set out in the national service plan.

I want to take this opportunity to thank all those who work in the health service for ensuring a continuing safe service in our hospitals and elsewhere despite the serious challenges they face.

Since I tabled this question we have become aware that the number who left by 29 February had increased to 4,515. That is the figure provided by the chief executive officer of the HSE last week at the health committee meeting. It must not be forgotten that this is on top of the estimate by the Irish Nurses and Midwives Organisation, INMO, that 8,700 personnel have left the health services since 2007 and have not been replaced. Of this figure, 3,500 were nurses and midwives. Of the figure that left up to 29 February on the early retirement scheme, over 2,000 were nurses. That compares with the order of some 400 management and administration personnel. It is significantly kinked towards front line service deliverers.

When the Minister stated in his reply that he is not in a position to indicate or speculate what number may leave the service over the course of the remainder of 2012, I must remind him that one of the service area plans for 2012 actually states a number and uses the language "required to leave the service by the end of this year". This is for the service plans for my area - the north east - and the Minister's as well, Dublin.

Could the Deputy frame a question, please?

Is the Minister aware that a further 561 departures have been signalled as required in the service plans for the area in which both and I and the Minister live?

While the Minister was very bullish at the health committee meeting last week regarding this, stating everything is fine and everyone has coped wonderfully, there are clear signs that this is not sustainable. Despite the indications of the numbers that will be recruited by special arrangement, the fact remains that we are looking at a serious situation with front line health services.

This is a very long question, Deputy.

This is my final point which I believe is the core issue. Will the Minister set a date for the lifting of the recruitment embargo? Will he make a clear statement on the floor of the House today that he will lift the recruitment embargo and allow for normal personnel replacements to recommence in the health services?

Not for the first time Deputy Ó Caoláin attempts to confuse the issue. The service plan was written before all the retirements had actually taken place. For him to state now that another 550 odd people will leave Dublin and north-east health services is utterly inaccurate. We have to see how many have already left from that number. As we know, 4,500 - 4,515 to be absolutely precise and the figure I used at the committee – have already left. I am not in a position to say how many of the 550 count among the 4,515, but many do. To suggest that 550 are still required to leave would be misleading.

I have no intention of setting a date for the lifting of the embargo. When considering how many people have left the health service since 2007, one must bear in mind how many joined in the preceding five years, some 25,000 plus or perhaps even more. I do not have the figures before me. At a time when we quadrupled our spend on health and increased the number of personnel working in the sector, we did not reform the service in the manner necessary to deliver care to our citizens.

January 2011 saw the highest number of people, some 569, lying on trolleys since counts began by the Irish Nurses and Midwives Organisation, INMO. I gave an undertaking at the time that the situation would not recur. Thanks to the hard work of front line staff, the special delivery unit, SDU, and the clinical programmes, this has been achieved right through March and in the teeth of extraordinary challenges, for example, the €2.5 billion removed from the health budget in the past three years, the moratorium and the 4,515 personnel who left last month. This situation has not been helped by Deputy Ó Caoláin in this Chamber talking about doom and gloom and the catastrophe and disaster about to befall people, and upsetting those awaiting cancer treatment or the birth of their children. Childbirth should be a joyous event. A certain degree of anxiety is always associated with it but additional anxieties should never be added to it by scaremongering, something that the Deputy has engaged in more than once in the House.

The Minister is also engaged in scaremongering.

It is quite appropriate to say that I am sick of the Minister's balderdash. That is all that he ever employs. He is a big bombast.

Could we have a question, please?

He was a big bombast on this side of the House and he is no different over there.

Does that make the Deputy a little bombast?

The fact of the matter is that the Minister concluded his contribution at last week's meeting of the health committee by stating that he would always be accountable and was quite open to accepting Opposition voices.

That is right.

The one thing that he is not able to take is what he was quite prepared to give during his years in opposition. He is a double-sided individual.

What does that make Sinn Féin? It has double standards.

The Minister can take any interpretation he likes but the figures I cited came from the HSE's service plan. They clearly indicate what will be further required this year. The Minister is indicating that he is not in a position to project what might happen in terms of a further staff exodus before the end of this year. That is a statement of acceptance of his failure to oversee the health services.

Does the Deputy have a question?

I will close with this. At times, trying to get any straight answer from the Minister is futile. What methodology is he employing to monitor the impact of the departure of 4,515 personnel? Is it being done on a day-by-day or week-by-week basis? Is the Minister receiving reports? Almost one month later, does he know the impact on the health services of the departure of 4,515 people?

The question has been asked. I call on the Minister to reply.

Will the Minister give the House a clear indication and explain why he will not set a date for the lifting of the recruitment embargo?

Deputy Ó Caoláin, please. The Minister to reply.

Answer the question.

Unlike the bombast opposite, I take responsibility. I made it my business to travel around the majority of hospitals during the latter weeks of February to ensure that contingency plans were in place and that a safe service could be continued. I am happy to report that during the course of my tour, front line personnel engaged in a major way with the clinical programmes and the SDU in changing their practices. I commend them in this regard. When I met 120 personnel last Friday, I told them that were they to be called anything, it would be "the Impossibles". They make the impossible possible despite all of the challenges they face. More work needs to be done because additional reforms are necessary to fix our health service. It was dysfunctional and grossly unfair and must be turned into a fair and equitable system that delivers for patients on time. It must be somewhere that patients can feel safe and of which everyone working in it can feel proud. This is the Government's goal and it will be done.

Is the Minister receiving reports on the impact?

We are constantly monitoring what is occurring in hospitals. We have real-time information, which we never had before. We can now predict problems and take action, which we were previously unable to do.

We will now return to Question No. 3 in the name of Deputy Kelleher.

Primary Care Strategy

Billy Kelleher

Question:

3Deputy Billy Kelleher asked the Minister for Health his views that there are sufficient resources being directed to ensure the Primary Care Strategy is implemented in full; and if he will make a statement on the matter. [16567/12]

The key component of the primary care strategy is the development of services in the community to give people direct access to integrated multi-disciplinary primary care teams, PCTs, consisting of general practitioners, nurses, physiotherapists, occupational therapists and others. Following changes to team boundaries across the country to integrate with the HSE's new integrated service areas, a number of PCTs have been merged. The total number of teams targeted by the HSE for establishment by the end of 2012 now stands at 486. At the end of February 2012, 400 PCTs were operating, that is, holding clinical team meetings. Funding of €20 million has been provided for in the HSE's national service plan for 2012 to fill as many vacancies as possible that have arisen as a result of the recent public service retirements and to expand existing arrangements where sessional services are provided by allied health professionals. 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. At this time of scarce national resources, it is essential that such posts will be allocated according to an objective assessment of needs. The HSE is accordingly analysing the current provision of posts in proportion to population and population health needs to identify which areas are least well served.

The allocation of the extra posts will be subject to approval by the universal primary care project team, which has been tasked with working through the issues relating to the programme for Government commitments on primary care.

The primary care strategy is a primary objective in the programme for Government. However, questions arise for the role of primary care as a front line service in the context of the moratorium and the early retirement of highly skilled professionals. Is it possible that the moratorium will delay the roll-out of the primary care strategy because insufficient human resources will be available for deployment in the areas where they are most needed?

The Government has patted itself on the back for the progress made on the strategy to date but when one drills into the figures many of the primary care teams are barely up and running. They may be holding meetings but whether they are delivering primary health care is another question. Does the Minister of State accept that while a considerable number of meetings are being held they have not reached the point of delivering care?

Is the Minister of State seeking private funding for the strategy and has an approach been made to her Department by people who are willing to provide private investment for primary health centres?

I accept there has been much talk but little action on primary care over the past 11 years. More decisions have been taken on developing primary care over the past year than during the previous decade. I am pleased to say that the budget includes a special allocation of €20 million for primary care, which will enable us to recruit the equivalent of 300 posts over the coming weeks. That money will be prioritised for the filling of key front line primary care posts, including public health and community nurses, occupational therapists and physiotherapists. I have also put in place a system which will allow us to identify gaps in front-line services. There are considerable gaps in primary care posts across the country. I look forward to the recruitment of these posts over the coming weeks and months. That will greatly strengthen primary care, which is what should have been done a long time ago.

The Minister of State said she would need approximately €50 million a year so her budget is considerably less than that for which she hoped.

The Deputy is mixing up staff and centres here.

Let us be clear that she still does not have sufficient funding to implement the proposals outlined in the programme for Government. On the broader issue of the provision of primary care, at last week's committee meeting the Minister spoke about a smaller hospital strategy. Will the small hospital strategy and urgent care units be part and parcel of primary care - in other words to keep people out of acute hospitals - or will we have another strategy with regard to the smaller hospitals on top of the primary care strategy? That does not seem to fit into the overall measures proposed in the reconfiguration, some of which we support and many of which we do not.

It is a framework for smaller hospitals and not a strategy. However, we have a primary care strategy and I remind the Deputy that is an 11-year old strategy. We are taking that seriously now. That is why I am very pleased we can now proceed to recruit an additional 300 people in the health service. I am glad to say that this week the HSE is engaged in drawing up the job specifications and putting together the panels to recruit those 300 people. It is a really good news story about what is happening in the health service. We will be recruiting 300 new front line people in the health service to deliver primary care. I point out that this is Revenue money - it is €20 million for 300 additional posts. The Minister, Deputy Reilly, will speak later about the capital funding. I repeat that 11 years down the road it is disgraceful that there are so few primary care centres. We will address that as a matter of urgency in the coming months.

Primary Care Centres

Stephen S. Donnelly

Question:

5Deputy Stephen S. Donnelly asked the Minister for Health the steps he will take to ensure that the proposed Wicklow Primary Care Centre, which was due to go into construction in April, is built and opened as scheduled, and that any shortfall in funding will be provided or guaranteed by the Health Service Executive [16865/12]

I thank the Deputy for his question. The development of primary care, as the Minister of State, Deputy Shortall, has said, is central to the Government's objective to deliver a high quality, integrated and cost-effective health system. The programme for Government states that primary care will be an immediate priority area. The development of primary care centres, through a combination of public and private investment, will facilitate the delivery of multidisciplinary primary care and represents a tangible refocusing of the health service to deliver care in the most appropriate and lowest cost setting.

The HSE's draft plan for 2012 to 2016 is under consideration by my Department. It includes some provision for primary care, but further work is required to ensure that the provisions in the plan for a mix of private and Exchequer-funded primary care centres are in line with the programme for Government commitments.

Wicklow town is one of the locations where the Health Service Executive proposes to deliver a primary care centre through a leasing arrangement with the private sector. The executive has signed an agreement with a developer to lease part of this development once it is completed. I acknowledge the work that all parties, including GPs, have contributed to the progress on this centre to date. As the Deputy is aware, under public financial procedures the Health Service Executive is precluded from guaranteeing third parties as this may be interpreted as imposing a contingent liability on the Exchequer. However, the HSE has agreed to allow the developers a three-month extension to the agreement to lease, which was due to expire shortly. Extensions of this nature are granted only where progress and commitment have been demonstrated, which, thankfully, is the case here. I urge the parties to continue with their negotiations to expedite the completion of this centre.

I warmly welcome the extension from the HSE, which is greatly appreciated and will buy some much needed breathing space. The centre in Wicklow town seems to represent best practice. It is a public-private partnership. It brings in multidisciplinary teams and high-end diagnostics, and in time there may be a nursing home there. It will create an additional 50 to 60 jobs. I believe some 50 or 60 existing jobs will be moved. The health care benefit for the region is enormous. As the Minister and two Ministers of State will know, Wicklow is one of the most poorly served counties across a wide range of services, including mental health services, acute coverage and palliative care. The issue is that if the extension is not fixed in the next 12 weeks this development will be lost because of an amount of €271,000. I accept that it is speculation on my part but this appears to be the case. I met the Wicklow Town and District Chamber and I spoke to the developer yesterday. It seems the bank is trying to get out of lending the money. The gap was €700,000. The developer has said the general practitioners have agreed to purchase their areas. That brings the amount to €300,000. The bank indicated that it did not count that amount as part of the €700,000 and that it intended to lend the project less money. Indications that the bank is trying to find any excuse to exit are written all over this project. It must not be allowed to fail for €231,000. The planning levy from Wicklow County Council is €543,000. Potentially, we will lose a remarkably important centre from a health care and an economic perspective over an amount only half of what the county council seeks for permission to build.

I accept the Minister's point about the HSE not being able to extend it. However, will the Minister and his officials explore with the council any and all options, including equity in property or whatever it takes, to ensure that an amount of €271,000 does not stop this critical facility from proceeding?

This centre or a centre for Wicklow town is critical indeed. We have no wish for a centre that is at an advanced stage to fail. I accept what the Deputy across the Chamber is saying in terms of banks not lending and the difficulties therein. We are looking outside the box at various methods of how we might fund the primary care centres we require throughout the State. We need a large number of them. However, I am of the same mind as my colleague, the Minister of State, Deputy Shortall. She is equally concerned about not only buildings but about services being available. This is why the emphasis on the previous question related to revenue for the employment of staff to provide services and care. That is in no way to suggest that we are resiling from investing in a capital programme or from making capital available to GPs to invest or from the State investing in primary care centres where they are clearly not commercially viable. However, where they are commercially viable we seek partners and interests from outside in respect of funds we can make available or joint partnerships to develop the range of primary care centres we need.

Deputy Donnelly's point is well made. Aside from the excellent new services and care they will bring and aside from the fact that they will take considerable pressure off hospitals, they will provide real employment in their areas. That is a factor as well.

Are you happy enough Deputy?

I accept the Minister's point that he will seek alternative funding options for the roll-out of the primary care strategies in principle. However, my question is specific to Wicklow town. Given the Minister's extension, only three months or 12 or 13 weeks remain. Will the Minister and his officials undertake to explore alternative options to bridge the €271,000 shortfall specifically for the Wicklow town primary care centre as a matter of urgency?

We will always explore all options. That is part of the job of the HSE estates management. Its job is to examine all options. I have no problem giving an undertaking that all options will be examined. Obviously, until they are examined we will not give an undertaking that they will be agreed to.

I have a request from Deputy Kelleher to put back his Question No. 6 until after Deputy Ó Caoláin's question if the Minister, Deputy Ó Caoláin and the House are satisfied. Is that agreed to? Agreed.

Hospital Services

Caoimhghín Ó Caoláin

Question:

7Deputy Caoimhghín Ó Caoláin asked the Minister for Health if his attention has been drawn to a statement by a member of the working group on the proposed Medical Assessment Unit at Monaghan General Hospital that the working group has not met its terms of reference and that its recommendations cannot be accepted; if he will ensure that the development of the MAU will proceed; and if he will make a statement on the matter. [16565/12]

I am unaware of the comments referred to by the Deputy. I am aware that the HSE established a representative group to undertake a feasibility study on the development of a medical assessment unit in Monaghan and that this report was submitted to the Cavan and Monaghan hospital group manager in February 2012. As I stated at a committee meeting last week, I have seen the report prepared by the group and I have asked Dr. Barry White, national director for clinical strategy and programmes, to review it. Naturally, my concern is to ensure that patients in the Monaghan area have a safe, high quality and effective service. In order to meet these criteria, the review of the national director of clinical strategy and programmes requirements and the determination of the resources which may be required are key considerations which will determine what additional services may be introduced to the Monaghan hospital site.

As incredulous as I was with the Minister's reply to me on 13 March, which opened with the words, "I am not aware of the comments referred to by the Deputy", I am doubly incredulous that the Minister would repeat the same line in his response to the question today, particularly given that I outlined all this to him at last week's meeting of the Oireachtas Joint Committee on Health and Children and pointed out the deficiencies in the report's position. I pointed out also that it was a majority report and that there was a clear dissenting voice among the eight, that of Dr. Illona Duffy, a general practitioner representative from my community. I find it incredible that the Minister would repeat the assertion that he is not aware of the comments to which I referred. These comments have been sent to him directly and for him to repeat today that he is unaware of them is beyond belief.

I outlined last week and I repeat again now that the terms of reference were clearly not met by the eight-person group established to carry out the feasibility study. The report states that costs "could not be clearly defined", yet the terms of reference require that it "provide a detailed analysis of the pay and non-pay costs". That is confirmation, in the words of the report, signed off on by Dr. Doherty, that Dr. Duffy's claim that the terms of reference had not been met is indeed the case. The time period was inadequate - six weeks within which to carry out a study on an important proposal regarding the future of services at Monaghan General Hospital. Last week, when I put the question to the Minister, he indicated, and he has repeated it again, that he agreed with me the matter could not end on that and that the issue was being referred to the acute medicine programme. I presume that means it is being referred to Dr. Barry White who has oversight of this as national director of clinical strategy and programmes.

Will the Minister elaborate on the purpose and intent of that referral? Is he asking for a further opinion on the potential of the siting of a medical assessment unit, MAU, at Monaghan General Hospital? Is Dr. White likely, working alone or with others, to come back with a different opinion from that of seven of the eight members of the group? Will the Minister accept that the terms of reference could not have been met and were not met? The words of the authors demonstrate they found the project impossible within the constraints of the six-week period.

I reiterate that my Department trawled through its files today to see whether we were sent that statement, but we were not sent it or informed that its recommendations cannot be accepted or that it did not meet its terms of reference. I have not received that. The key point is we have not received the minority report we are supposed to have received.

I said last week, and I reiterate today, that the acute medicine programme would review the position through the clinical programmes, under the auspices of Dr. Barry White. I have no problem in ensuring that is done. For the Deputy to ask me to answer the question as to what his likely opinion will be is unfair. That would be to prejudge and pre-empt his considerations and I do not intend to do that. I will give him and the acute medicine programme a free hand to review the position and see whether they come to the same or a different conclusion. That is the only fair thing to do in this situation.

I emphasise again that we want to extend as many more services as we can to Monaghan General Hospital and to ensure that it becomes busier and that jobs there are secure. I cannot guarantee each individual job or where the jobs will be, but I want to see a greater footfall in that hospital. A 10% increase in activity is planned for this year.

I agree with the last remarks made by the Minister. Not only is that our hope for the future of Monaghan General Hospital, but I hope the Minister will do everything he can to ensure there will be enhanced service provision at the hospital into the future. It clearly has the capacity to cater to a much greater provision of services for the significant catchment, not only of County Monaghan but further afield and cross-Border, which the site presents.

It was not a question of whether the Minister had received Dr. Duffy's minority report; I have not had sight of it either. In the Minister's own words, he was not aware of the comments referred to but most certainly he was aware before he gave his reply here this afternoon because I made him fully aware of it at last week's meeting of the Joint Committee on Health and Children. I again conclude by asking for an assurance that Dr. Barry White's further consideration of the proposals in regard to the medical assessment unit siting at Monaghan is not constrained by the opinion presented in what is, finally, a flawed report. It is flawed because of the time constraints and the inability of the group to perform its task in line with the terms of reference as set out and with all the circumstances with which it had to contend.

Will Dr. White give the matter further consideration, taking the views into account, but wider than that, in the understanding that this will be a significant advance in terms of service provision at a key hospital site within the north east, something to which the Minister has indicated as having a warm disposition not that many months ago?

Absolutely. The Deputy opposite is well aware of the financial situation in the country and well aware of the consequences of such for the health budget. He is also well aware of the need for cost-based analysis for our actions. The volume of business in a facility must justify a medical assessment unit. The reply and the report from the initial group indicates this is not the case. The clinical programmes and the acute medicine programme in particular will review this decision and give their opinion free from any influence from me or anybody else. This remains the case and it is the only way it can be. Of course I would like very much to see a medical assessment unit in Monaghan if one were justified but I cannot justify it if the volume of patients would not be such as to make it financially viable when we are so constrained in budgets and there are implications across our health service for every euro we have.

The Deputy opposite belongs to a party that is in another jurisdiction on this island where it is presiding over cuts right, left and centre but when that party is down here, they do not want to see anything being cut. That may be the politics of opposition-----

-----but the fact is that we have to take responsible decisions and I have to maintain a service which is safe and this is what I am attempting to do, with tremendous co-operation from the many people who work in the health service. I take this opportunity to commend the staff for the job they are doing.

Doing everything to protect and defend services, North and South of the Border.

We will now deal with Question No. 6 from Deputy Kelleher.

Health Insurance

Billy Kelleher

Question:

6Deputy Billy Kelleher asked the Minister for Health if he will provide an update on the progress of the Implementation Group for Universal Health Insurance; the model of care on which UHI will be based; and if he will make a statement on the matter. [16566/12]

I recently established an implementation group on universal health insurance. This group will play a central role in assisting the Government to deliver on its commitment to introduce a single tier health system, supported by universal health insurance. For too long there has been a two tier system operating in our hospitals and which has been very detrimental to those who cannot afford insurance. They are forced to wait a long time for their health care. I refer to the tragic case of the late Susie Long and unfortunately there are many others who have also suffered consequences. I want to see this end, as does this Government. This group will assist in developing detailed and costed implementation proposals for universal health insurance and will actively help drive the implementation of various elements of the reform programme. It will, therefore, have a dynamic role with a strong practical focus on implementation. It will report to me on an ongoing basis. The first meeting of the group was held on 1 March 2012 and it will meet again before Easter.

In designing the model of care on which universal health insurance will be based, I want to ensure that it meets the needs of the Irish system and that it achieves the best outcomes for patients. This requires that we carefully plan and sequence the reform programme and that we give detailed consideration to the most appropriate structures for delivery of different services. We also need to look at the relationships between services and at best practice in health care reform.

Officials in my Department have been examining the experience of health reforms in a range of countries, including in the Netherlands and in Germany. This analysis is vital to enhancing our knowledge and informing policy. I want to implement a model of care which best meets Irish needs but which also builds on best international experience. This is reflected in the membership of the universal health insurance implementation group. The membership comprises a mix of those with executive responsibilities within our health services and external expertise, including international experts working with the World Health Organisation and the European Observatory on Health Systems and Policies. In line with the pragmatic focus of the group, its membership will be flexible and subject to periodic review as different stages of the implementation process are reached. It is my intention that the group will also consult widely as part of the reform implementation process.

I welcome the Minister's reply. The provision of universal health insurance is a key Government commitment and the established implementation body is wide-ranging, drawing on a cross-section of expertise. Is it charged with implementing universal health insurance of some form or other or might it state its belief to be that universal health insurance based on the criteria laid down in the programme of Government would not work? The Minister commented on the Dutch model and the group is looking also at the German model and elsewhere. Are there overall instructions to bring forward a universal health insurance policy, or has the group the authority to state it does not believe a universal health insurance system, as proposed by the Minister, as has evolved in Holland, is suitable or practical for the Irish health system as traditionally established and funded?

I can make my answer very short. This group has been put together to advise how to implement universal health insurance as per the mandate given this Government by the people. Its mandate is to come back in October with a White Paper that will give a steer on how we should proceed onwards from that point. In answer to the Deputy's question, therefore, it is not open to the group to start looking at all sorts of different systems other than a universal health insurance system.

There is a reason for my question. The Minister spoke about a mandate; he is very strong in his view that he has a mandate for universal health insurance. Equally, however, he has a mandate not to hike insurance premia, as he stated prior to the election. He was not given a mandate to bring forward proposals and policies that would hike up private health insurance. The conduct of policies in the budget of last year has been the exact opposite.

The Dutch model, for example, is clearly under huge stress and will have enormous difficulties in the years ahead in funding itself. It is now curtailing supports and services to people, in particular those at the latter stages of life. There should be a strong debate on that subject in this House. The Minister claims he has this mandate and I do not deny this. Equally, however, this House should have a role with a strong debate on how we will go about funding health services. The change the Minister proposes may not be suitable or applicable to the Irish system that has evolved over many years. The Minister stated, and all the reports show, that the Irish health services have moved forward and have increased quality of life for patients on a broader basis. What is happening here is not all wrong.

In the interests of clarity, the Deputy is right. All is not wrong, there is much that is very good about the Irish health service. What is particularly good about it are the excellent people we have working in it. It was the system within which they were working that was preventing them from delivering the sort of care at the speed and access people require. That is why we are changing the system. I put it to the Deputy we made it very clear that we would first maximise what we have. That means fixing the inefficiencies in the system, bringing in a money-follows-the-patient system so that there will be a very clear tracking of patients as well as a focus on the patient. Heretofore we had a system that was self-serving rather than one where patients were the focus. They will now be the focus of the system because, simply put, if there is no patient there will be no payment. Only when that is sorted would we bring in universal health insurance.

We have many parallels working at the same time, moving towards the single end point, the universal health insurance system.

Parallel lines never meet.

They are moving towards the same point across another line which is perpendicular and they will arrive at the point we require. If we wish to continue with this kind of mathematics we can put them through a prism that will ensure they will all join at the end point we so desire - the one the people of this country voted for and which they deserve, a system where the medical needs of people are met and is not dependent on what is in their pocket but on how acute is their medical condition and the urgency with which it should be treated. I never want a parent to look into the cot at night, wonder whether the baby has meningitis and wonder whether she should take the baby to the doctor or pay the ESB bill at the end of the week. It is not right, moral or ethical and is not reflective of a society that cherishes all its citizens equally.