Health Service Executive (Governance) Bill 2012 [Seanad]: Second Stage (Resumed)

Question again proposed: "That the Bill be now read a Second Time."

I am pleased to have an opportunity to contribute to the debate. The administration of health services has been a source of irritation to many of us over a long number of years. I am of the vintage who experienced the termination of the county health system and the beginning of the health board system, which was interesting. The late Erskine Childers is reputed to have said, "How can you unscramble an egg?" when asked whether he could go back to the original system. I am afraid the egg has been scrambled a few times since and the question of how the health services should be run has come into focus on numerous occasions in the past number of years. I served on the health board system and there was accountability, responsibility and action in response to the problems raised by elected public representatives regarding services. The major players, including GPs, nursing professions, psychiatric services, consultants and the chemists, were on board in the old health boards because it was felt necessary at the time in 1970 to ensure the major contributors would be in the same building at the same time with the same responsibility, answering the same questions, accountable to the same people and committed to the same vision. That was the case but, unfortunately, as time passed, it became awkward to administrate and questions were raised.

The leader of the Opposition was Minister when it was decided to abolish the health boards and to introduce a new system. I strongly opposed that at the time both within my party and anywhere else anybody would listen me. I am sure not many people wanted to listen to me still but I remained opposed to it for a good reason. One of the propositions advanced at the time as to why we should have a different system was a comparison made with the greater Manchester area, which has a similar population to this country. Management experts around this country and several from outside the country made contributions in which they opined that it should be possible to have a similar administrative structure to that which prevailed in Manchester. They were wrong because it was chalk and cheese as two entirely different geographical areas were involved. In one scenario, there was a compact urbanised population, which was easy to administer and in which it was possible to walk from one end of the area to the other in a few hours whereas in Ireland, if somebody attempted to walk from the south end of Kerry to the north end of Donegal in a few hours, he would find out after a short while that there is a difference and if he wanted to walk from there across to Carlingford, he would find another difference. If he then walked back down to Wexford and Waterford and around to Kerry again, he would find out there was a major difference.

My view at the time was the equation was wrong, the structures were not analogous and attempting to superimpose a similar structure in this jurisdiction would not work. The Acting Chairman, Deputy Wall, and I have discussed this many times in the past. I do not claim to the be only one right about this because many others had the same view. However, I was right and it did not work. I recall asking the first chief executive officer of the HSE whether he felt a single executive with the appropriate authority could administer the health service and he said, "I don't know". He knows now, as does everybody else. I emphasise we attempted to impose a structure that was seen to be in management circles as the ideal response to a situation but it was not because they did not know what was the situation.

Then Members experienced an issue which we anticipated on the Opposition benches where when we tabled questions to the Minister for Health and Children, we were told the Minister had no responsibility to the House. I recall refusal after refusal from the Ceann Comhairle's office. This was no reflection on the Ceann Comhairle because the prevailing advice at the time was that the Minister had no responsibility and eventually the Ceann Comhairle inquired as to whether any Minister had any responsibility. Earlier, Opposition Members complained about a lack of accountability and responsibility but I know all about that because I was here at the time, as was the Acting Chairman, and we learned a harsh lesson during that period.

I pay tribute to the Minister who knows me well enough to know that I do not pay tribute too readily. However, there has been a dramatic difference in the way questions to his Department are responded to as compared to the previous Administration. That is no reflection on the previous Administration because its members admitted they did know much of what was happening. I would like to acknowledge the major improvement in the ways questions are answered. However, it is not ideal nor will it ever be. Somebody can ask who do I think I am and what do I think should be done. I acknowledge I am not always right but, in this instance, it is beyond any shadow of doubt that those who held the same view as me all along were right but we did not wait until now to find out.

The second issue I would like to deal with is accountability and the composite bodies in the health boards at the time. Consultants, nurses, GPs, chemists and administrators, including three or four programme managers, were accountable to the entire board area. The Eastern Health Board was the largest in the State and it was possible to gain access at the highest level instantly. Those who opposed this concept said it was all wrong and it was too politician-oriented. What they meant was there was too much accountability and it was alleged that nothing could be done because politicians would not allow it. There are ways and means of dealing with that. I believe in responsible public representation as well as everybody else and it is important that when people are in opposition or government, they act responsibly. We learned during that period to try to act responsibly and that meant that the health board spent what it had and nothing more and stayed within budget. However, the budget was beginning to creep up and get out of hand. The same experience is repeated in the House every day. Opposition Members promote excessive expenditure we know the country cannot afford on a daily basis. This money would have to borrowed at high interest rates. We have to beg for this money on a regular basis from our colleagues in Europe yet Opposition Members want to spend it lavishly at every hand's turn and pretend to the people that it is possible to take actions that are impossible.

I also learned during that period about the need to respond to patients' requirements.

It is all very well to state we will provide a certain quality and level of service, including an after hours service. I compliment the outstanding cohort of people who provided these services over the years, including consultants, general practitioners, chemists and nurses, as well as many others in the health service structure. Many of them gave above and beyond what was required of them as they contributed to the sum total of the response of the health service at the time. They did very well and stand unheralded, unsung and largely unrecognised to this day.

General practitioners, who were represented on the health boards, worked extremely long hours providing clinics in the morning, afternoon and evening for six or seven days per week as they sought to respond to need. They showed the vocational calling that is found in education, politics, the health service and across the public service. Unfortunately, this calling is disappearing at an alarming rate. I hope it will be rediscovered in the not too distant future because it is essential and central to the delivery of health services. I acknowledge the quality and commitment of the general practitioners and consultants who worked in the period following the 1970 Act. They did very well in providing what was needed in response to the needs of people.

Time moves on, however, and we must proceed to a different scene. The entire Health Service Executive structure must be abolished and the Minister for Health held directly responsible to the House for the functioning of the health service. The Minister of the day should answer questions in the House, as the current Minister does to a large extent, although many questions are referred to the HSE for direct reply for understandable reasons. For many years, while the Acting Chairman, Deputy Jack Wall, sat alongside me and many others on the Opposition benches, we had to put up with appalling nonsense in this regard. To discover now that the current system has its critics on the Opposition benches is equally alarming.

In any event, the system should be transformed and the old health board structure reconstituted, albeit with fewer health boards. Given the different requirements and demands in urban areas, such as the greater Dublin area, and large rural areas, it is not sufficient to concentrate services in more densely populated areas. Every citizen is entitled to a fair degree of service under the Constitution and to provide for anything else would be wrong. The current HSE structure should be abolished and replaced with a new structure. The new system should be centralised with a budget that is determined on the basis of submissions received from the various constituent health boards. These boards should be given responsibility for running the health services in their respective areas. The public and private sectors must not trip over each other and become involved in turf wars or financial wars. They should focus solely on delivering services to members of the public.

Public representation should be part and parcel of the new system. Local authority members should be represented on the new boards, as should Deputies and Senators for as long as the Seanad remains in place, which is a matter for the people to decide. General practitioners, consultants and the nursing and pharmacy professions should also be represented. All the professions involved in the delivery of health services should have a role in the health boards, which should be charged with the responsibility of delivering services. The boards must be accountable and do their business in a responsible manner. This would present a serious challenge for politics, citizens and our European partners. Those of us who examine what is taking place in other EU member states will note a tendency to resile from reality and pretend that things will go away if one ignores them. Nothing goes away, which means we must accept responsibility, even if it means telling citizens that we do not have enough funds to do the job they expect of us or that we must do the job in a way they do not expect.

Major economies can be secured in the health services, especially in the area of procurement. During my time as a member of a health board, we did an exercise on generic prescribing which resulted in substantial savings. Some of the opponents of moves towards generic prescribing were Members of this House, with certain Deputies voicing in a highly loquacious manner their opposition to the proposal. While they must have had reason to be so impressed with the argument for continuing to use branded products, the basis for their position was not made clear. We proved our point and our solution was workable.

We also set about determining in which European countries prescriptions were most economical. We decided to use Spain as a template for achieving the best solution available to us for Irish citizens and it proved highly effective. Subsequently, a certain Minister, whom I will not name in the House, decided that the health services were costing too much, were too democratic and were subject to too much intervention from the various constituent bodies. As a result, it was decided to abolish the health boards and establish the Health Service Executive. What a disaster. Not alone did this decision not save money, as originally intended, and not alone was the Secretary General of the Department moved sideways during the machinations that took place at the time, but the cost of the health service subsequently increased to an unprecedented extent. I will hold the view that abolishing the health boards and replacing them with the HSE structure was an appalling disaster until the day I die. In doing so I do not mean any disrespect to those who were given responsibility for the HSE structure and the many thousands of health professionals who were condemned to work within it. It is, however, a serious condemnation of those who determined that the HSE structure was an appropriate way to run the health service.

Having exchanged views with me on the matter many times, the Acting Chairman will be aware of my strong views on the health service. The Minister is aware that some Deputies have serious concerns about the governance of the health service. I hope the current proposal will be reviewed and revised and a structure will be established similar to that which I have suggested. While I do not claim to be the only authority in this business, I spent 20 years on a health board for my sins - I must have been very sinful - during which time I learned a great deal and met many of the great people who forged the structures for the delivery of health services. They were trailblazers in medicine who did a tremendous job in addressing people's concerns.

The health board structure may have required some refinement but it was an excellent structure. The Government of the day, in an extraordinary intervention, decided to increase the number of health boards to eight and, subsequently, to 11.

The Deputy has one minute remaining.

I wish I had more, but I will conclude. It would take much longer to go through this matter in great detail. I emphasise that my comments are not a personal reflection on the staff of the HSE, countless people who have done a great job for years. Rather, it is a reflection on the structure, which is inappropriate in terms of accountability and dealing with the services required by the country. It is also inappropriate for recognising the changing times and the necessity to respond to people's needs in a meaningful and democratic way.

As Deputy Durkan suggested and, I suspect, most people would agree, few institutions need a fundamental re-organisation of how they operate as badly as the HSE. It has no credibility in the eyes of the wider public or the health service's users. However, it is important to qualify this statement. There is an almost universal phenomenon in which everyone who engages with the health service believes its nurses, doctors and other front-line staff are wonderful, yet the way in which the system is organised is a nightmare. As I am sure other Deputies have pointed out, anything I say is not a criticism of the heroic front-line staff in the health service, be they ambulance drivers, nurses, medical practitioners or so on. They all do a wonderful job under difficult circumstances and in a dysfunctional structure.


I apologise, as I do not know how to turn off mobile telephones. Mine is dysfunctional as well.

Re-organising the structure is a positive move if, as the Bill suggests, that re-organisation is a transition towards a better structure that is more responsive to the needs of the service's users, for example, patients, delivers services better and ends the unacceptable scenario of some politicians asking about the executive's dysfunctional nature and being told it is an operational matter for the HSE while other politicians take no responsibility for what goes wrong in the health service.

The aspirations are good, as is the rhetoric. However, the rhetoric was also good when the HSE was being established in 2004. The digest supplies a telling quote from the then Minister for Health and Children, Ms Mary Harney. Her rhetoric was electrifying. One would really have believed we were on the brink of a wonderful revolution in the way health services were being delivered. She stated, "This is an historic piece of legislation." How often have we heard that? She continued:

It provides for the most comprehensive reorganisation of our health services since 1970 which is long overdue and vital. It is a once-in-a-generation event. It is our generation’s chance to put patients first in the design of the management of health services. It is our chance to put in place modern, effective management to make the best use of these tremendous resources we are applying to health and to get clear value and clear results for that money.

To be honest, there is not much difference between the 2004 rhetoric and the rhetoric now. The main question is whether the new re-organisation of the dysfunctional health service into what it needs to be - modern, efficient and a provider of the services that people desperately need - will transpire in reality. I am sure Ms Harney sounded convincing when she made that speech, but the reality did not match.

I will put my cards on the table. The Minister is trying to square a circle that cannot be squared. It comes down to resources. I am not claiming there are not structural issues of management, mismanagement and organisation, elements on which the Government places much emphasis. Historically, Fine Gael has put a great deal of emphasis on them. The Government's main assertion is that we need better management, but this argument does not stack up for me. I am not saying we do not need better management, but focusing on it is to gloss over the fundamental problem, that being, from where does bureaucracy come. Does it just arise because we do not devise the right structures?

I am sure the HSE's current structures probably sounded reasonably convincing following the rhetoric of Ms Harney's speech. I am sure there were many arguments about how health boards were not terribly functional, were somewhat corrupted by political influence and cronyism, etc. Directorates based on particular areas of service provision or care also sound like a good idea. However, is this element the problem? I do not know whether the word "Directorates" is a reference to the French revolution and Robespierre, but it sounds good and revolutionary. I put it to the Minister that the HSE's structure is not the main problem, although it may be a problem and probably could be redesigned.

Someone whose name one probably cannot mention in polite company without being laughed at by certain sides of this House, but who I will simply call a revolutionary from the turn of the century, explained that bureaucracy and corruption developed because of shortages. He used the example of a bread shop. If the shop is packed with enough bread for everyone who enters the shop, there will be no queue and people can get the bread as they need it. However, if there is a shortage, a queue forms and people start jostling with one another over who will be at the front. Once a queue develops, it becomes necessary to have someone to keep it in order. That person often seems to use an arbitrary and coercive power to keep in line the people who are queuing for bread that they desperately need. As the person whose job it is to order the queue has power over people's access to scarce resources, he or she is vulnerable to corruption even if he or she does not start as a corrupt person. This allegory of how bureaucracy and corruption develop is at the heart of the problems with the health service.

I do not know how one can resolve the problem of great layers of bureaucracy that are dysfunctional and where there is mismanagement of the health service when the problem is that we do not have the resources. We are cutting the elements in the health service that work. We are cutting the number of nurses. Everyone says the nurses are wonderful. The front-line staff are wonderful but what have we done to the number of front-line staff but slashed them? We are cutting the one part of the system that works, and we are demoralising such staff with pay cuts. Even if they were wonderful up until now they certainly do not feel wonderful anymore. One wonders how long their goodwill can last under the hammer of the cuts. Front-line staff are the one part of the health service that work. Ambulance drivers and others are withdrawing their goodwill for the same reasons. They say they are working their backs off trying to provide the service and everybody acknowledges that they do it well but what do they get for it? They have their wages cut. They get attacked and are asked to work longer and harder for less. One could ask how that can work. I put it to the Minister that it cannot.

Perhaps the lack of detail on the directorates and what will follow what the Minister describes as the transition provided for in the legislation tells its own story in that regard. It may be a dawning awareness of that fact. As I understand it, it is Government policy that we are in transition towards a model of universal health insurance. We need to know what the model will look like. I am not sure whether the Dutch model, about which the Minister initially spoke a lot, is still the model we are following. The evidence is piling up in the Netherlands that what the Dutch model produces is ever-higher health insurance costs. More and more of the resources that go into the health service there are being taken up with the bureaucracy of the private health insurance system. The most dramatic and developed example of such a system is the United States, which is the ultimate example of where universal health insurance as delivered by private health insurance companies is the main model, in contrast to, for example, the national health service model in Britain that was set up at the end of the Second World War where everyone gets free health care and it is paid for out of general taxation. What is happening in this country seems to be a transition towards that failed model in the United States and the failing model, in so far as it has been developed, in the Netherlands where the public are becoming increasingly angered and outraged over the increased costs.

The facts about the American model are shocking. They spend more on health than any other country but 40% of it is wasted on administration. The reason that is the case is to do with money, because companies are billing people. There is a massive administration for billing people. That is what it is about. The money is not going into the front-line services. That is not its primary purpose. It exits to make money so one has a huge bureaucracy whose job it is to capture the money instead of financing health care through revenue and a system of taxation that already exists and which is progressive and can capture the funding necessary for public services without creating a new privatised bureaucracy whose main job is to make money and who will push up insurance premiums as it needs. I ask the question in that context because there is so little detail in the Bill. Is the main concrete proposal in the Bill the separation of service provision from procurement? Is that what is going on, that the Bill is setting up the system for the move towards privatisation where services will be purchased by the private health insurance companies and provision will come from the public system? I suspect that is the case. I urge the Minister not to go in that direction because it is a failed model. The alternative is more in the direction of the British health service model.

I see it as a positive step that the Minister is seeking to take more personal responsibility for what goes on in the health service, but there is a need for checks and balances at local level. I agree with Deputy Penrose’s point about the former health boards. It was a localised form of governance of health services. It would be necessary to reform them. The boards should not be as they were, made up of cronies but of patient representatives, health professional and other stakeholders such as representatives of the workforce and perhaps elected representatives to represent the wider public to see how policy translates at the other end. My concern is that we are preparing for the outsourcing of much of the health service to private insurance companies and the directorates, which will possibly compete for resources among themselves, will still represent a top-down structure.

I stress the importance of localised oversight and management of health services. I wish to bring to the Minister’s attention what on the face of it the evidence suggests is an absolutely shocking example of the mismanagement of HSE funds in the home help sector. I am reluctant to go into too much detail because the charges that are made are serious against home help companies in the Fingal and Wicklow areas. There is substantial evidence, and allegations have been put forward by employees in both areas, of rampant misappropriation of HSE funds. Significant amounts of funding were invested by the HSE in home help services in Wicklow and Fingal. The allegations suggest the misappropriation of hundreds of thousands, perhaps millions of euro in funding. One company was getting €250,000 a month from the HSE. Allegations have been made of company credit cards being used to finance holidays and to buy cars. There was no oversight of the expenditure of funds. No regard was taken of proper regulation and how the service was being run although it was dealing with vulnerable people. Rules were flouted and people who blew the whistle were sacked, among other actions. I will not go into much more detail in that regard. Snippets of information appeared in the newspapers before Christmas but some of the people directly involved have told me they met a brick wall in trying to get proper investigations into these matters which they describe as rampant corruption and misappropriation of scarce resources supposed to be directed towards a vulnerable sector of society from the public purse via the HSE but where the HSE did not provide proper oversight in the matter.

It is not clear to me at all, from what the Minister is proposing in this Bill and from the lack of detail about where this is going, that the new structures will deal with this problem. We need a level of local oversight to determine what is happening with moneys that are being allocated centrally. What is being done with the funds? Are the local units delivering health services to vulnerable citizens being managed properly? Are the resources actually going to patients, staff and so on? That is a role that any reformed health board system operating at a local level and made up of stakeholders would be far better at performing. Most of all, though, I am concerned that this is really just facilitating a move towards a Dutch or American model, which is based on making money out of scarce resources and out of health care, which I do not think is the way to deliver the reformed health service that everybody desperately wants.

I welcome the opportunity to contribute to this debate on the Health Service Executive (Governance) Bill. I am not surprised that this has been introduced because when I was involved in the debate about setting up the HSE, I expressed my extreme concern about the development of such a monolithic organisation. I appreciate that the objective was to ensure co-ordination between the old health boards and consistency in terms of service delivery. However, this could have been achieved while maintaining and reforming the local health boards themselves.

Admittedly, there were some difficulties with the old health board system but I believe we threw the baby out with the bath water at that time. We now have a situation where there is very little input from service users, interested parties, public representatives and professionals. I was a member of the Mid-Western Health Board for seven years and was also involved in the Association of Health Boards in Ireland and a lot of good work was done by individual boards and by that association. Issues were brought to the attention of Ministers and the Houses of the Oireachtas, in terms of difficulties experienced by people. Such issues were also brought to the attention, at a local level, to the managers of the health boards. Monthly meetings were held, which were attended by public representatives, consultants, dentists, nurses and so on, who would raise, in public and in the presence of the media, their concerns regarding the delivery of health services. The health boards were made aware of the concerns and needs that existed as well as the changes in the requirements of the general public with regard to the delivery of the health services. Furthermore, the Minister was responsible for what was happening in the delivery of health services throughout the country.

The setting up of the HSE changed all of that. The potential for external input all but disappeared and the opportunities for those at the coalface to have an input into the delivery of services were lost. Also, the removal of the responsibility for the delivery of the health services from the Minister created a situation whereby there was a complete lack of accountability to these Houses in terms of service delivery. Others have raised the issue of replies to parliamentary questions about the delivery of health services and the fact that, in certain circumstances, the HSE is quite tardy in issuing responses. It can be extremely frustrating for those of us who want to respond to the concerns of our constituents. In that context, I welcome the fact that the Bill will abolish the structure of the HSE and provide for a directorate to be the governing body of the executive, in place of the board, which will be headed by a director general. The Bill also provides for accountability arrangements for the HSE, which is very important.

I wish to draw attention to the important decision which has been made to appoint a director of mental health services and that the recruitment process is under way. I welcome the fact that the director will have full control of the delivery of mental health services. I also welcome the appointment of Mr. Gerry Raleigh as director of the National Office for Suicide Prevention, which has had a lot of difficulties in the last 12 months, not least the fact that moneys allocated by the Minister to the work of suicide prevention, suicide postvention and research were not spent last year. It is important that the €35 million allocated in the budget for the delivery of mental health services is spent in the most appropriate way to deliver A Vision for Change. There has been much debate about the non-spending of some of the resources last year. However, I understand the complications that arose because of the delay in the formulation of the service plan and the recruitment of the 411 consultants and professional staff for community-based mental health services. I ask the Minister in his response to inform us of the plan for the delivery and improvement of the services, based on this year's allocation of €35 million. We need to know what will happen with that money this year.

I welcome the opportunity to speak on this Bill. The Government is committed to the eventual dissolution of the HSE. However, this is a complex process which will take time and this Bill is a transitional measure along that path. The Bill is all about accountability and its aim is to make the HSE more directly accountable to the Minister for Health. The provisions of this Bill will see the abolition of the board structure of the HSE and a directorate created as a new governing body, headed by a director general. The directorate does not have a fixed number of members - the Bill provides for a maximum of seven and a minimum of three. This should allow flexibility for the directorate to deal with circumstances as they arise. It is important to stress here that the HSE will continue to have operational responsibility for running the health service. The director general will account, on behalf of the directorate, to the Minister. As with any large corporate structure, one needs to have good governance practices and structures in place in order to implement the changes that are necessary.

This Bill will aim to make sure that Government policies and objectives relating to the HSE functions are implemented and this is no mean task. The Minister will specify his priorities for the HSE and the HSE must have regard for these in preparing its service plans. Like any good plans, they must have performance targets and metrics for measuring performance. The HSE must pay particular regard to these targets as they are set out for it. These operational changes will ensure that the HSE, which is a very large organisation, will have greater flexibility and will be able to react more quickly, as change is required.

I wish to stress that while this Bill is about making sure the HSE reacts faster and in the direction that the Minister wants, my experience of the HSE in the south has been very positive. Everybody likes to criticise the HSE but it certainly has a lot of good points. It would be wrong of anyone to suggest that all areas of the HSE are not performing. Only last week, the reconfiguration plan involving Cork University Hospital and Mallow General Hospital reached the point of implementation. The HSE and its staff played a pivotal role in this, liaising with all of the consultants and everyone else involved, in drawing up a very detailed strategy and everybody is on board, I am glad to say. I am delighted to say that this will probably form the template for how small hospitals work in the future and will allow for a future for them.

Until now we have been worrying about the future of all our small hospitals. Most importantly, this will see better service delivery to the patient, with shorter waiting times and the freeing of emergency surgery wards for emergencies requiring specialist care. I particularly thank the regional director of operations in HSE south for his tireless work in ensuring that the Minister's aims are being delivered on the ground.

We must move forward toward greater accountability and transparency in health care delivery. The Minister, Deputy Reilly, has succeeded in reducing waiting times and time spent on trolleys, with individual performances across the HSE to be monitored and accessible for all. If three surgeons can perform the same procedure, the waiting times for each surgeon should be available online so a patient can decide which surgeon to go to. With prescription drugs, there should be a list of those who give prescriptions, particularly general practitioners, taking into account those who prescribe cost-effective generic medicine in preference to high-cost brands. That would generate best value for the patient. We must also move to a system where prices of drugs can be published online so that patients who pay for drugs with minimum subvention can have access to the information that will allow best value for money.

I congratulate the Minister on the establishment of the medicines management programme, which is concerned with the spend on medicines. The Minister is tackling the issue with the programme, which will evaluate medicines under the headings of safety, efficacy, access, and savings for the State and patient. It is an holistic process as part of a broader remit, with co-ordination between the National Centre for Pharmacoeconomics and the National Medicines Information Centre, coming together with collaboration of the HSE under the primary care reimbursement services.

In private business, getting policies delivered is important; it is done quite quickly in small business but doing it in a large organisation is very difficult. Delivering such change can take time. I congratulate the Minister on the establishment of the national early warning score. All these initiatives may sound like they are more jargon but they are well thought through and will deliver for the patient and, in time, bring cost savings.

I am delighted to welcome the Bill to the House. In doing so, there is a statement of an ongoing need for reform, reorganisation and refinement of services for the patient, although this in no way reflects on the professionalism, commitment and wonderful work done by individual HSE employees at all levels in recent years. There is no implicit criticism of their professionalism in the legislation or its objectives, which is concerned with structure, future direction and ambition to deliver a single-tier health services.

Today marks the Government's second anniversary in office. In that context I salute and compliment the achievements of the Minister for Health, Deputy Reilly, and his Department in those two years which have led to the Department being overhauled. Since 2011, the Minister, Deputy Reilly, and his Department have cut the cost of medicine by €400 million, which is a very significant achievement. They have allocated a further €35 million to mental health services and filled 246 new mental health posts, which is another great achievement. They have also established a special delivery unit to work with hospitals to reduce the number of patients on trolleys and waiting times. In 2012, the number of people waiting on trolleys decreased by 23.6% and although this is not where we wish to be, it is a true reflection of the work done and tangible evidence that we are going in the right direction. It means much to those who are affected and it is a great achievement in the context of very stringent economic times. The Minister has achieved much with significant budgetary constraints.

There has been a 98% decrease in the number of adults who must wait more than nine months for inpatient and day surgery, with a 95% decrease for children. I am pleased to report that in Cavan General Hospital, the number of patients waiting on procedures has fallen by 48%, which is a very significant development. A new 34-bed cystic fibrosis unit was opened in St. Vincent's Hospital and we have established a site for the new children's hospital. The Bill is being brought forward against that backdrop of real reform and achievement, with tangible differences for people. The ambition of the Bill is to continue the reform and build on it.

There are two essential objectives of the Bill. The first is to make the HSE more accountable to the Minister for Health and the second is to restructure the HSE in line with the programme for Government commitments, specifically the move towards universal health insurance. The Bill is a transitional measure with the intent to implement the proposals as set out in the programme for Government. It aims to ensure there is more accountability between the Department and the HSE and, more importantly, it will ensure that there is greater accountability and involvement by the Department of Health and the Minister, who is answerable to the electorate. It is an important component of the legislation.

The Minister has already started a process of change in this way. In 2011, he made changes to the composition of the HSE board, ensuring greater co-ordination and a higher level of dialogue between senior officials in the Department and the HSE. The fundamental flaw of the HSE as introduced in 2004 and 2005 was that a structure was imposed on an existing health board process, meaning there was not a sufficient link to the greater resource that is the Department of Health. It is a fundamental difficulty that became more of an issue in a number of ways over the years.

The Minister, Deputy Reilly, has referred to this as a unity of purpose, with the changes made guaranteeing a higher level of integration between the Department and the HSE. The Bill will seek to eventually dissolve the current board structure and establish a new arrangement of governance. The HSE will have operational responsibility in the interim but accountability will be strengthened.

The second objective is to begin dissolving the HSE board and move towards universal health insurance. The new HSE structure will have directorates and a director general, with a flexibility about the number of directors in that the minimum will be three and the maximum will be seven. That will allow adaptability and a response to certain circumstances. The directorate will be fully accountable to the Minister, which is important. The Minister may issue directions to the HSE and the directors regarding the implementation of Government policies relating to specific priority areas, which is important.

Section 10 refers to levelling the balance of power between the Minister's Government policy and the HSE's operational responsibility. The Minister has indicated that the HSE has a responsibility under the Health Act 2004 for the provision of health and personal social services. However, the HSE also has a statutory obligation to have regard to ministerial and Government policies and objectives when performing functions. The new structures are intended to strengthen that process inherently. The Bill is only an element in a reform process that is moving toward a single-tier health system in which access to and quality of health care will be available to everyone, irrespective of means. That should be the objective.

I will refer to one or two specific areas within health policies as we are given such scope on Second Stage of a Bill.

I am delighted with the developments in primary care. My colleague, Deputy Ó Caoláin, who will be speaking later, and I are aware of recent openings of new health care centres in our area, namely, in Bailieborough, Cootehill and Cavan town. Another, in Kingscourt, is already functioning but the opening is pending. It is entering the full development stage. The primary health care centres have enormous potential to allow for the effective treatment of people in the home, which is where they want to be. They allow people to remain in their community and have treatment brought to them.

The home help service is a great resource with enormous potential to augment the primary care service and keep people in their own homes. Dovetailed with this is the carer's allowance, which I know is the direct responsibility of the Minister for Social Protection. The allowance has great potential to facilitate people being looked after at home. It should be made more attractive and easier to access, and it should be advertised and recommended more. This could make it very attractive for people in lower-paid occupations who have sick relatives to become full-time carers. It has inherent advantages already but could be improved further. The Department of Health and the Department of Social Protection should consider the carer's allowance as a vehicle to achieve more with a view to keeping people at home, reducing institutional care and, ultimately, reducing costs. It will allow for people to be cared for at home, which is where they prefer to be.

We should be very careful not to reduce home help hours where possible. It is reasonable to redistribute them and examine their allocation. It is reasonable to ensure they are targeted according to need but it is not a good proposition to reduce the number of home help hours in absolute terms. We should be increasing the number. It is through the provision of home help, the use of the carer and home care packages that we will reduce institutional costs, make patients happier and allow patients to remain in their own homes. This is why I salute this measure.

The €35 million extra for mental health services represents wonderful news. I ask the Minister to elaborate on the plans to spend this immediately to implement the recommendations of A Vision for Change and to have community services developed. That is very important. I look forward to the Minister's response.

Gabhaim buíochas leis na Teachtaí as ucht a gcuid ranníocaíochtaí sa díospóireacht seo. I thank the Deputies for their contributions to the debate. Mar is eol do Theachtaí, tá an Bille mar chuid de chomhthéacs níos leithne. Tá an Rialtas ag tabhairt faoi chlár athchóirithe mór ar an gcóras sláinte, agus é mar aidhm aige córas sláinte sraith amháin a chur ar fáil le tacaíocht ón árachas sláinte uilíoch, áit a bhfuil rochtain bunaithe ar riachtanas seachas ioncam. Creidim go bhfuil an Bille seo ina chéim ar an mbóthar athchóirithe sin. Tá dhá chuspóir aige. As Deputies are aware, this Bill is part of a wider context. The Government is embarking on a major reform programme for the health service, the aim of which is to deliver a single-tier health system supported by universal health insurance in respect of which access is based on need, not income.

The Bill is a step on the health reform road and its purpose is twofold. Ar an gcéad dul síos, forálann sé do dheireadh struchtúr bhoird an HSE agus le haghaidh stiurthóireacht a bheith ar an gcomhlacht nua rialaithe don HSE in ionad ag an mbord, faoi cheannas ard-stiurthóir. Ar an dara dul síos, forálann sé do shocruithe freagrachta breise don HSE. Baineann siad seo le athchóiriú a dhéanamh chun deireadh a chur leis an gcóras dhá shraith, chun é a dhéanamh othar-Iárnach. Beidh mar thoradh ar seo ná coinníollacha d'othair a bheith mar thosaíocht i ngach a dhéanfaimid. First, it provides for the abolition of the board structure of the HSE and for a directorate to be the new governing body for the HSE in place of the board, headed by a director general. Second, it provides for further accountability arrangements for the HSE. It is about reform to end the two-tier system to make it patient centred, and it will keep outcomes for patients as its priority in all it does.

Tá dul chun cinn suntasach feicthe againn cheana féin. Bunaíodh an t-aonad seachadadh speisialta i mí lúil 2011. Ag an am sin, bhí 2,732 othar ag fanacht níos mó ná bliain agus 6,277 othar ag fanacht níos mó ná naoi mhí ar chóireáil cónaitheach nó ar chóireáil lae. We have already seen significant progress. The special delivery unit was formed in July 2011. At that time, 2,732 patients were waiting more than a year and 6,277 patients were waiting more than nine months for inpatient or day case treatment. Faoi Nollaig 2011, bhí titim tagtha ar líon na ndaoine fásta ag fanacht níos mó ná naoi mhí le haghaidh cóireáil cónaitheach nó cóireáil lae go dtí 3,706. Faoi dheireadh mí na Nollag 2012, bhí an líon sin tite go dtí 86. Léiríonn sé sin laghdú de 98%. By December 2011, the number of adults waiting more than nine months for inpatient or day case treatment had fallen to 3,706, and by the end of December 2012 the number was just 86. This represents a decrease of 98%.

I gcás páistí, is é an sprioc gur cóir nach mbeadh aon pháiste ag fanacht níos mó na 20 seachtain mar othar cónaitheach nó ar obráid máinliachta mar othar lae. Faoi mhí na Nollag 2012, bhí an líon ag fanacht nios faide ná 20 seachtain síos go dti 89, le titim de 95% ar an 1,759 páiste a bhí ag feitheamh níos faide ná an sprioc i mí na Nollag 2011. For children, the target is that no child should be waiting for more than 20 weeks for inpatient or day case surgery. By December 2012, the number waiting longer than 20 weeks was down to 89, representing a decrease of 95% on the 1,759 children waiting longer than the target in December 2011.

In the area of emergency departments, despite the winter pressures, including increases in the incidence of influenza and respiratory illnesses, the year-on-year improvements continue nationally. The number recorded on trolleys at the end of 2012 showed a marked improvement, namely, 23.6% fewer than in 2011, which equates to 20,342 fewer people lying on trolleys. Progress continues to be maintained in 2013. On Friday, 1 March 2013, the number on trolleys for the year to that date totalled 12,283, representing a reduction of 2,116 patients, or 14.7%, on the improvements already made in 2012. We have much more to do and we will continue to make progress.

Let me turn again to the Bill. The Bill is about a new governance structure for the HSE and increasing the HSE's accountability to the Minister for Health and, ultimately, the Oireachtas and the people. Contrary to what has been suggested during the debate on the Bill, it is not about the Minister for Health taking over the HSE's functions, nor does it give sweeping powers to the Minister. The HSE has responsibility for managing and delivering health services, and that does not change under this Bill. The Government has responsibility for policy. Any State agency must have regard to the policies and objectives of the Government to the extent that those policies and objectives may affect or relate to its functions. A State agency must be accountable to the Minister concerned and, therefore, must explain its actions and decisions.

The Health Act 2004 and this Bill provide for this accountability.

The board of the HSE is the current governing body for the HSE. The abolition of the board structure and the increased accountability measures are intended to help prepare the service delivery and funding systems for the next phase of the reform programme. As the HSE board structure is to be abolished, it is necessary to replace the board with an alternative governing entity. The proposal in the Bill is to have a directorate as the governing body, comprising the director general and senior employees. The directorate will have collective responsibility as the governing authority for the HSE.

Issues were raised in the debate about the detailed governance mechanisms and inter­relationships for the directorate members under the Bill. In practice, the directorate model will involve a combination of a senior management team working together on major corporate issues but with the usual operational line of reporting for the specific service functions.

Deputies asked why members of the directorate must be appointed from HSE employees. The establishment of the directorate is about more direct accountability, whereby the governing body of the HSE is drawn from people in senior positions within the organisation itself. I should clarify that this means that appointed directors are not limited to current employees but may be drawn from HSE employees irrespective of when the employee was appointed.

There will be new administrative structures in the HSE which, while in support of the Bill, are separate from it. The HSE has begun the process of putting in place the new administrative management team. The recruitment process for five new national directors has now commenced through a competitive process to be run by the Public Appointments Service. One of the new posts is director of mental health. Deputies asked if there could be specific reference in the Bill to a director of mental health with specific functions. While I am very glad to say that the director of mental health post is one of the posts included in the competitive recruitment process I mentioned, I do not believe that the legislation should specify the functions of particular grades within the HSE.

The appointment provision for the first director general was raised. There are legislative precedents providing that the first person appointed to a new office be appointed as envisaged under the Bill, and this is the most practical way to advance the new governance arrangements.

The Bill is a transitional measure and is part of a much larger plan. I said at the beginning that the Government is committed to fundamental reform of the health care system with the objective of delivering a single-tier health system, supported by universal health insurance, where access is based on need, not income.

Deputies have asked me to state clearly my plans for the changes that are coming for the health system. In November 2012, I and the Ministers of State, Deputies Kathleen Lynch and Alex White, published Future Health: A Strategic Framework for Reform of the Health Service 2012-2015. This document sets out the major health care reforms that will be introduced in the coming years as key building blocks towards the introduction of universal health insurance, UHI. I intend that further detailed actions will be built on the foundations of the document as the reform process proceeds.

I have identified an overall governance structure for the programme of reform. The new structure includes a strong programme management office in the Department of Health to drive and oversee implementation of the health service reform programme in line with the public service agenda, and a systems reform unit in the HSE. The Government recognises that effective consultation and collaboration with stakeholders will be crucial for the successful implementation of the reform programme. In the two weeks following the launch of the framework, I met some 1,500 local clinical and administrative staff and management, as well as regional health forums at 14 different events across the four HSE regions. Consultation will continue throughout the reform process. The progress to date underlines this Government's commitment to health service reform and the implementation of universal health insurance. We are confident that with the involvement and support of all the main stakeholders in the health system, we can deliver on our objectives in the best interest of patients.

Deputies asked about universal health insurance. Preparation is key to UHI and the new governance arrangements for the HSE under the Bill are intended to play a part in preparing the system. Under UHI, every individual will have equal access to a standard package of primary and acute hospital services, including acute mental health services. A new insurance fund will subsidise or pay insurance premiums for those who qualify for a subsidy.

There are a number of important stepping stones that are necessary to pave the way for the introduction of UHI. Work is under way to advance these initiatives which will bring benefits and drive efficiencies in advance of implementing universal health insurance. They include the strengthening of primary care services to deliver universal primary care with the removal of cost as a barrier to access for patients, the work of the special delivery unit in tackling waiting times and establishing hospital groups, and the introduction of a more transparent and efficient money-follows-the-patient funding mechanism for hospitals.

In February 2012, I established an implementation group on universal health insurance to assist in developing detailed and costed implementation proposals for universal health insurance and in driving the implementation of various elements of the reform programme. We must learn from other countries and build on best international experience. This is reflected in the membership of the UHI implementation group. The UHI implementation group comprises a mix of those with executive responsibilities within our health services and external expertise, including international experts working with the World Health Organization and the European Observatory on Health Systems and Policies.

In addition, my officials have been examining the experience of health reforms in a range of countries, including the Netherlands and Germany. This analysis is vital to enhancing our knowledge and informing policy. A prerequisite for designing the UHI model for Ireland, however, is that it meets the needs of individuals in Ireland and that it achieves the best outcomes for patients. This requires that we have regard to our starting point, 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. Ultimately, the Government is committed to introducing an Irish model of universal health insurance that best fits the Irish system.

The Department is advancing work on drafting the White Paper on universal health insurance which will outline details of the UHI model in addition to the estimated costs and financing mechanisms associated with the introduction of universal health insurance. Preparation of the White Paper is a complex and technical process requiring significant research and financial modelling to support analysis and costing of different design options. My Department is engaged in a process to ensure availability of the necessary expertise to support work on preparing the White Paper in 2013.

In the meantime and in advance of the White Paper, my Department published a preliminary paper on UHI. That paper provides a succinct update on work on universal health insurance as well as providing further details on the path ahead. The reform programme is a major undertaking that requires careful planning and sequencing over a number of years. The implementation group will assist, advise on and oversee different elements of the reforms as they are being put in place. It is also my intention to consult widely as part of the reform implementation process.

Several Deputies referred to medical cards and, in particular, individuals with very serious health conditions. More than 1.8 million medical cards have been issued to individuals, the highest percentage of the population covered in the history of the State. Medical cards are provided to persons who, under the provisions of the Health Act 1970 are, in the opinion of the HSE, unable, without undue hardship, to arrange GP services for themselves and their dependants. Under the legislation, determination of eligibility for a medical card is the responsibility of the Health Service Executive. The assessment for a medical card is determined primarily by reference to the means, including the income and expenditure of the applicant and his or her partner and dependants.

Under the legislation, there is no automatic entitlement to a medical card for persons with a specific illness such as cancer. There is, however, a provision for discretion by the HSE to grant a card in cases of undue hardship where the income guidelines are exceeded. The HSE set up a clinical panel to assist in the processing of applications for discretionary medical cards where there are difficult personal circumstances.

Most importantly, the HSE has an effective system in place in relation to the provision of emergency medical cards for patients who are terminally ill, or who are seriously ill and in urgent need of medical care that they cannot afford. Emergency medical cards are issued within 24 hours of receipt of the required patient details and the letter of confirmation of the condition from a doctor or a medical consultant. This can be initiated through the local health office by the office manager who has access to a dedicated fax and e-mail contact within the primary care reimbursement service.

While it can take a day to produce the plastic card physically and a further day to allow for its arrival in the post, the medical card number can be provided to the local office or social worker within 24 hours, if requested. Once approved, any primary care contractor can validate the entitlement of a client through the online system.

With the exception of terminally ill patients, the HSE issues all emergency cards on the basis that the patient is eligible for a medical card on the basis of means or undue hardship, and that the applicant will follow up with a full application within a number of weeks of receiving the emergency card. As a result, emergency medical cards are issued to a named individual, with a limited eligibility period of six months.

The arrangement is slightly different for persons with a terminal illness. No means test applies to an application by a terminally ill patient. Once the terminal illness is verified, the patient is given an emergency medical card for six months. Given the nature and urgency of the issue, the HSE has appropriate escalation routes to ensure that the person gets the card as quickly as possible.

Some Members mentioned the backlog of medical card applications. The major backlog of last year has been cleared. Furthermore, in the case of discretionary medical cards, there was the backlog towards the end of last year and that has been reduced, from 3,500 to only nine cases today. Contrary to some of the contributions and common belief, the centralisation of medical cards has resulted in an €8 million saving to date. The PCRS can be commended on the work it has done to address the issue of backlogs and in bringing in a more efficient system.

The issue of free GP care was also raised. The Bill to allow for the extension of free GP care to persons with prescribed illnesses will be published in the next couple of weeks. Progress also continues to be made in building primary care capacity and in chronic disease management, particularly for the management of diabetes which will commence in the coming months.

Some Members asked what I was doing to address the costs of health insurance. I can assure the House that the Government is committed to keeping down the cost of health insurance so that it is affordable for as many people as possible. We remain committed to protecting community rating, whereby everyone pays the same price for the same health insurance product, irrespective of age or health status.

The programme for Government contains a commitment to put a permanent scheme of risk equalisation in place, which is a key requirement for the existing private health insurance market and is designed to keep health insurance affordable for older persons and to maintain the stability of the market. The Health Insurance (Amendment) Act 2012 gave effect to a new risk equalisation scheme with effect from 1 January 2013. This will contribute to the protection of affordability for those who need it most. It is important to note that the measures contained in the new risk equalisation scheme are designed to result in no overall increase of premiums paid in the market. Rather it is intended to spread the risk more evenly between the healthy and the less healthy, as well as the old and the young.

I have repeatedly raised the issue of costs with health insurers as a whole and I am determined to address costs in the sector in the interests of consumers. Last year, I established the health insurance consultative forum which comprises representatives from the country's main health insurance companies, the Health Insurance Authority and the Department of Health. The forum was established to generate ideas which would help address health insurance costs, while always respecting the requirements of competition law. Given the VHI's significant share of overall costs in the market at 80%, I will continue to focus strongly on the need for the VHI to address its costs and to address aggressively the base cost of procedures, including professional fees. I will also continue to focus on the need for more robust auditing and the need for clinical auditing to be introduced, which would be for the first time. In other words, the treatments that some clinicians are delivering would be challenged as to their necessity.

The issue of delays in replies to parliamentary questions was commented on by many Members and I am happy to provide some detailed information. My Department received over 7,500 parliamentary questions in 2012. Some 4,045 of these concerned operational issues and were referred to the HSE for direct reply to the Members. In its service plan, the executive has a commitment to answer within 15 working days 75% of parliamentary questions referred to it. Of the 4,045 referred to it for direct reply, 74% were answered within 15 working days and 83% within 20 working days. This represented a significant improvement on 2011 when the percentage answered within 15 days was 56%. Of the total amount of parliamentary questions referred to it in 2012, only 64 remained open at the year end. We want to improve further on this by examining IT solutions that would help Deputies and Senators to track the progress of parliamentary questions.

Procurement issues were also raised in the debate. The HSE is fully committed to the Government's procurement objectives and initiatives and will continue to support the Government programme to reform public sector procurement. Adherence to the Government's public service reform objectives regarding the use of shared services will be a requirement for the newly created structures, in procurement and other matters. The director general designate of the HSE has acknowledged that the new governance and management arrangements for the future health service will require us to change radically the way we approach the provision of shared or common services to meet the needs of all parts of the health system. In addition, the financial challenges we face mean we must take advantage of any opportunity for increased value in the way we provide such services.

As this day marks two years in Government, I have mentioned some of the progress that has been made but I might just mention some other areas. On outpatients, there are clear and comprehensive data now being reported for the first time which will allow the special delivery unity and the National Treatment Purchase Fund to target resources at the longest waiting lists. There are new cystic fibrosis services in the Nutley wing of St Vincent's Hospital which opened in the summer of 2012 at a cost of almost €30 million. There is the decision to co-locate the new national children's hospital at St James's, made in November 2012. Thirty-five locations for primary care centres have been identified, of which 20 will be commissioned subject to the agreement between the local GPs and the HSE on active local GP involvement and subject to site suitability and availability.

In October 2012, a new drug pricing agreement was reached with the Irish Pharmaceutical Healthcare Association, IPHA, which will deliver savings in excess of €400 million over a three year period. Approximately half its value - €210 million - will be used to cover the cost of new drugs from 2013 to 2015. The balance will go towards reducing expenditure on drugs supplied through the General Medical Services scheme and community drugs schemes. The Department and the HSE have also reached an agreement with the Association of Pharmaceutical Manufacturers in Ireland, APMI, which will deliver further savings in the cost of generic drugs. Total gross savings, between the IPHA and APMI agreements, for 2013 will be in the region of €120 million. There is also a drug reference pricing Bill, which is going to committee this week or early next week, that will allow us, after consultation, to set the price for generic drugs. We have a new medicine management initiative, as outlined by Deputy Barry.

The HSE's health care capital allocation for the period 2012 to 2016 is €1.87 billion, of which €1.67 billion is allocated for construction of health care facilities and the remaining €200 million is allocated to ICT infrastructure. In addition, the Government announced in November 2011, that up to €200 million from the proceeds of the sale of the national lottery would be allocated for the construction of the new national children's hospital. We have also appointed the chair to the new national children's hospital group.

We will be opening new facilities. There will be a new wing at Ennis hospital. The new emergency department at Letterkenny is finished and will be opened officially later this year. The outpatient and emergency department at the Mater hospital are completed and we are making progress with the new central mental hospital.

Value for Money and Policy Review of Disability Services in Ireland was published on 20 July 2012, the National Housing Strategy for People with Disability 2011-2016 was approved by Government in October 2011, and the implementation framework was jointly published with the Department of the Environment, Community and Local Government in July 2012.

The children, adolescents and young people with complex disabilities unit, led by a principal officer, has been established in the Department of Health. On 1 January of this year a permanent scheme of risk equalisation put in place in the private health insurance market.

In December the Government approved the implementation of the judgment of the European Court of Human Rights in the A, B and C v. Ireland case by way of legislation with regulations, within the parameters of Article 43.3.3° of the Constitution as interpreted by the Supreme Court in the X case and progress has been made towards producing the heads of a Bill.

There many other areas relating to older people, health and well-being, and health protection. Deputies asked about the €35 million earmarked for mental health and the increase in the number of beds for child and adolescent psychiatry. There were also issues around the drugs task forces, HR and health reform as I have outlined. So there has been considerable improvement.

I also wish to mention the long-running problem with Tallaght hospital board has been resolved. Hospital groups have been set up in Galway and Limerick, with a phenomenal effect in Galway in particular. Clinical programmes are moving ahead - we have developed them in emergency medicine, acute medicine, fragile older patients, stroke care and heart failure. For the first time anywhere in the world that we are aware of, we have introduced a new early-warning scorecard so that doctors and nurses in Tralee will react in the same way as they would in Letterkenny, the Mater Hospital or St. James's Hospital in the face of a patient who may be deteriorating. The screening for bowel cancer has commenced.

The reforms will continue unabated. I will not be deflected from the course we have set. I remain determined, as does the Government, to see this through. I am as committed to it as ever. I am more certain and convinced than ever that we will succeed because of the new leadership emerging in the HSE, the Department of Health and indeed the VHI, but most importantly among the clinicians, medical nursing and allied professionals - the men and women on the front line who have already delivered so much for us in terms of the improvements I set out earlier.

Molaim an Bille don Teach.

Question put:
The Dáil divided: Tá, 89; Níl, 43.

  • Bannon, James.
  • Barry, Tom.
  • Breen, Pat.
  • Burton, Joan.
  • Butler, Ray.
  • Buttimer, Jerry.
  • Byrne, Catherine.
  • Byrne, Eric.
  • Cannon, Ciarán.
  • Carey, Joe.
  • Coffey, Paudie.
  • Collins, Áine.
  • Conaghan, Michael.
  • Conlan, Seán.
  • Connaughton, Paul J.
  • Coonan, Noel.
  • Corcoran Kennedy, Marcella.
  • Coveney, Simon.
  • Creed, Michael.
  • Deasy, John.
  • Deering, Pat.
  • Doherty, Regina.
  • Donnelly, Stephen S.
  • Dowds, Robert.
  • Doyle, Andrew.
  • Durkan, Bernard J.
  • English, Damien.
  • Farrell, Alan.
  • Feighan, Frank.
  • Fitzgerald, Frances.
  • Fitzpatrick, Peter.
  • Flanagan, Charles.
  • Flanagan, Terence.
  • Hannigan, Dominic.
  • Harrington, Noel.
  • Harris, Simon.
  • Hayes, Brian.
  • Hayes, Tom.
  • Heydon, Martin.
  • Hogan, Phil.
  • Howlin, Brendan.
  • Humphreys, Heather.
  • Humphreys, Kevin.
  • Keating, Derek.
  • Kehoe, Paul.
  • Kelly, Alan.
  • Kenny, Enda.
  • Kenny, Seán.
  • Kyne, Seán.
  • Lynch, Ciarán.
  • Lyons, John.
  • McCarthy, Michael.
  • McGinley, Dinny.
  • McGrath, Finian.
  • McHugh, Joe.
  • McLoughlin, Tony.
  • Maloney, Eamonn.
  • Mathews, Peter.
  • Mitchell, Olivia.
  • Mitchell O'Connor, Mary.
  • Mulherin, Michelle.
  • Murphy, Dara.
  • Murphy, Eoghan.
  • Nash, Gerald.
  • Naughten, Denis.
  • Neville, Dan.
  • Nolan, Derek.
  • Ó Ríordáin, Aodhán.
  • O'Donnell, Kieran.
  • O'Donovan, Patrick.
  • O'Dowd, Fergus.
  • O'Mahony, John.
  • O'Reilly, Joe.
  • O'Sullivan, Maureen.
  • Penrose, Willie.
  • Phelan, Ann.
  • Phelan, John Paul.
  • Rabbitte, Pat.
  • Reilly, James.
  • Ring, Michael.
  • Ryan, Brendan.
  • Sherlock, Sean.
  • Spring, Arthur.
  • Stagg, Emmet.
  • Timmins, Billy.
  • Tuffy, Joanna.
  • Wall, Jack.
  • Walsh, Brian.
  • White, Alex.


  • Adams, Gerry.
  • Boyd Barrett, Richard.
  • Broughan, Thomas P.
  • Browne, John.
  • Calleary, Dara.
  • Collins, Joan.
  • Collins, Niall.
  • Colreavy, Michael.
  • Cowen, Barry.
  • Crowe, Seán.
  • Daly, Clare.
  • Doherty, Pearse.
  • Ellis, Dessie.
  • Ferris, Martin.
  • Flanagan, Luke 'Ming'.
  • Fleming, Tom.
  • Healy, Seamus.
  • Healy-Rae, Michael.
  • Higgins, Joe.
  • Kelleher, Billy.
  • Kitt, Michael P.
  • Mac Lochlainn, Pádraig.
  • McConalogue, Charlie.
  • McDonald, Mary Lou.
  • McGrath, Mattie.
  • McGrath, Michael.
  • McGuinness, John.
  • McLellan, Sandra.
  • Moynihan, Michael.
  • Murphy, Catherine.
  • Nulty, Patrick.
  • Ó Caoláin, Caoimhghín.
  • Ó Cuív, Éamon.
  • Ó Fearghaíl, Seán.
  • Ó Snodaigh, Aengus.
  • O'Brien, Jonathan.
  • O'Dea, Willie.
  • Pringle, Thomas.
  • Ross, Shane.
  • Shortall, Róisín.
  • Smith, Brendan.
  • Stanley, Brian.
  • Wallace, Mick.
Tellers: Tá, Deputies Paul Kehoe and Emmet Stagg; Níl, Deputies Seán Ó Fearghaíl and Jonathan O'Brien.
Question declared carried.