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Dáil Éireann debate -
Tuesday, 30 Sep 2014

Vol. 852 No. 1

Priority Questions

HSE Expenditure

Billy Kelleher


69. Deputy Billy Kelleher asked the Minister for Health the position on the Health Service Executive’s financial position; the latest projection for the deficit in 2014; and if he will make a statement on the matter. [36796/14]

I congratulate the Minister on his appointment and wish him the best of luck. This is first opportunity I have had to extend my best wishes to him.

This time last year we were involved in a dishonest lead-up to the budget in the context of funding for the Department and the HSE to provide services in 2014. On 9 September the Minister said the HSE's budget would overrun by a huge amount. Will he at least set out what he intends to do regarding the budget deficit and overrun and, more importantly, how he intends to address in an honest and meaningful way the putting in place of a realistic budget for the HSE in 2015?

I thank the Deputy for his words of congratulations.

Vote 39 for the Health Service Executive, HSE, is showing a net current deficit of €260 million against profile at the end of September. However, receipts from the United Kingdom which were profiled for November were received in September and when they are excluded, a net current deficit of €432 million emerges.

In income and expenditure terms, the HSE is reporting a year to date net expenditure figure of €7.039 billion to the end of July against a budget of €6.754 billion, leading to a variance of €285 million. The acute hospital sector accounts for €160 million or 57% of the overall deficit. Employment agency costs were €194 million, up €63 million on the figure for last year, a significant element of which was incurred in acute hospital services. The primary care division had an overall deficit of €54 million, with local demand-led schemes a key area experiencing excess expenditure.

Undoubtedly, 2014 is proving to be a financially challenging year for the health service. While the budgetary targets this year are particularly constrained, it is important to recognise that demanding financial and resource constraints have applied in each of the past number of years as a direct consequence of the crisis in the public finances. The cumulative impact of this unprecedented period of financial and resource restraint has resulted in reductions in the health service budget of €1.5 billion since 2008, with numbers employed reduced by 14,000 over this period.

These challenges come at a time when the demand for health services is increasing each year which, in turn, is driving costs upwards. Despite these resource reductions, the HSE has managed to support increasing demand for its services arising from such factors as population growth, increased levels of chronic disease, an ageing population, increased demand for prescription drugs and new costly medical technologies and treatments.

Currently, it is anticipated that a Supplementary Estimate in excess of €500 million will be required to support services in 2014. This is based on costs to the end of July and takes account of the HSE’s best estimate of likely expenditure to year end, mitigated by ongoing cost containment plans and income generation. It is important to stress that, as with any forecast, there is some degree of uncertainty, particularly given the scale of the overall HSE cost base, the complexity of the services and the lack of a national financial system. This forecast deficit excludes any overrun on the State Claims Agency, which relates to medical negligence payouts.

The HSE continues to work closely with my Department to mitigate the projected deficit to the greatest degree possible.

The HSE is not being enabled to deliver the services it outlined in its service plan for 2014. Waiting lists have increased; for example, only recently in University Hospital Limerick 47 patients were waiting on trolleys. The notion that the HSE has managed to maintain services is simply not credible by any stretch of the imagination when one considers the difficulties health services face every day in front-line provision.

That is evident in emergency departments and outpatient waiting lists.

The key problem stems from last year when the previous Minister for Health, without support and possibly lacking all credibility at the Cabinet table, was unable to deliver a meaningful budget to fund the HSE service plan for 2014. No one inside or outside the House believed last year's budget was sustainable and it was in difficulty from the word "Go". Hopeful phrases such as "unspecified savings" and "probity" were included in a service plan that was meant to deliver services for those who needed them the most. Will the Minister have an honest and up-front appraisal of the funding required in 2014 and engage in a meaningful discussion aimed at ensuring the Department secures a sustainable budget that will provide the services required?

One should not make the mistake of believing serious problems in one area reflect the position throughout the health service. I look at the figures for the numbers of patients on trolleys every day and while there is an overcrowding problem in Limerick, the figures on a given day may show that half of perhaps 50 or 60 patients on trolleys are in three hospitals and another ten hospitals may not have anyone waiting on a trolley. The same applies to outpatient waiting lists, with three of 49 hospitals accounting for more than half of the waiting list. Let us, therefore, not make the mistake of believing a small number of services or areas are representative of the whole system.

As I am in discussions on the budget, I am precluded from discussing that matter. However, it is worth making a few points that are not often made in the debate. The health budget has declined from €16 billion in 2008 to an outturn of approximately €13.7 billion this year. Once the figure has been adjusted to take account of the funding transferred for children's services, the budget outturn increases to close to €14.1 billion. This indicates that the health budget has been cut by approximately €2 billion in cash terms since 2008. No other Department has made such a large cash contribution to reducing the budget deficit and in some Departments expenditure has increased since 2008.

According to figures bandied about in the press, I am seeking either €1.2 billion or €900 million in additional funding for next year. I can state categorically that is not the case. I am seeking to achieve a neutral health budget to enable the Department to spend more or less that what was spent this year. I will try to provide a better service next year within the existing budget.

While we all understand the public finances are under pressure, choices must be made every year as to where funding is to be targeted. The Government has proposed for some time that children aged under six years receive free general practitioner care. Last year, under the guise of probity, decisions were taken which resulted in medical cards being removed from the most vulnerable. I am a realist, but one must target scarce resources at areas where they are most needed.

The previous Minister for Health had a vision and outlined grand plans for universal health insurance and free general practitioner care for everyone. At the same time, however, the Department cut funding for services for the most vulnerable. The key task is to identify how to provide sustainable services in a fair, equitable and compassionate manner. The Minister should forget the idea of pursuing his predecessor's proposals on universal health insurance and free GP care for everybody when we cannot afford to provide basic services for the most vulnerable. His starting point must be to have an honest appraisal of what can be funded and how to do so in a fair and sustainable manner. The idea of making grand promises and subsequently trying to find budgets to fit into them by taking money from the most vulnerable is, to say the least, distasteful.

Two weeks from now, Ministers will know what their budgets will be. At that point, they will be able to determine how their allocations should be spent and will obviously have to identify priorities. The nature of health and all areas of public expenditure is that everyone believes his or her priorities should be the main ones, but the nature of politics is that decisions must be taken on what the priorities should be.

I emphasise that health expenditure has been reduced from €16 billion in 2008 to €14 billion this year and that, in cash terms, the Department makes the largest contribution of all Departments towards balancing the books.

My objective in next year's budget is not to look for loads of extra money. I am realistic about that. I am seeking to hold health spending next year at what it is this year.

Ebola Virus Outbreak

Caoimhghín Ó Caoláin


70. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will provide an update on the contingency plans for Ebola in view of the WHO’s statement that Ebola is a public health emergency of international concern; if education of medical staff has occurred; the status of the national isolation unit at Mater Misericordiae University Hospital, Dublin; the travel cautions and checks that have been employed; the likelihood of a case appearing here; the number of cases in which testing for Ebola has taken place here; and if he will make a statement on the matter. [36737/14]

I join Deputy Kelleher in welcoming the Minister, and I wish him well in the responsibilities of his new portfolio.

I am seeking to establish what steps have been taken by the Department of Health, the HSE and other Departments, including the Minister's former Department, to ensure that our population is not subjected to the risk of contracting Ebola, a merciless scourge that has already taken more than 3,000 lives along the west coast of Africa, as well as the lives of others exposed to this highly contagious disease.

On 8 August 2014, the World Health Organization declared the Ebola outbreak in west Africa to be a public health emergency of international concern. As of 24 September 2014, the cumulative number of cases attributed to Ebola in the five affected west African countries stood at 6,263, including 2,917 deaths. There have been no cases of Ebola in Ireland. The focus of public health planning is on dealing with any cases of viral haemorrhagic fever that may be imported from another country.

The HSE's Ebola scientific advisory group and emerging viral threats group have been meeting regularly to review the situation and approve national guidance for Ebola and other emerging viral threats to health, and to ensure implementation of this guidance.

The Health Protection Surveillance Centre, which is part of the HSE, has issued this guidance to hospitals and GPs, including an algorithm for the assessment of viral haemorrhagic fevers and clinical assessment forms. Health professionals have been advised that any individual presenting with particular symptoms must be urgently assessed using the viral haemorrhagic fever algorithm and clinical assessment forms, which are also available on the Health Protection Surveillance Centre website. There are also protocols in place for viral haemorrhagic fever risk assessment by ambulance personnel at airports and shipping ports. Paramedics will transport suspected victims either to the national isolation unit at the Mater hospital or to the nearest emergency department, depending on the risk assessment for each individual case. Posters giving information about Ebola are on display in ports and airports.

It is national policy that any case of Ebola should be treated at the national isolation unit, if the patient is medically fit for transfer. The guidance includes protocols for the safe ambulance transfer of such a patient. The National Ambulance Service has arrangements in place for a Garda escort for the ambulance transporting the patient to the national isolation unit.

In Ireland, all diagnostic testing for Ebola is carried out in the National Virus Reference Laboratory. Testing is carried out only with prior consultation with the laboratory, which provides advice on the packaging and transfer of specimens. As a precautionary measure, tests have been carried out on 18 samples from 12 patients with reported symptoms and a travel history consistent with the case definition for Ebola. The results of all tests have been negative for the Ebola virus.

There is ongoing contact between my Department and the Department of Foreign Affairs and Trade. Updated travel advice is available on the latter Department's website. The Department of Foreign Affairs and Trade strongly advises Irish citizens to avoid all non-essential travel to Liberia, Guinea and Sierra Leone.

Considerable public health planning is under way with a range of bodies and professionals in relation to the implications of the Ebola emergency in west Africa. The matter was discussed in Milan last week at the informal Council of Ministers meeting at which I was present.

I thank the Minister for his reply. The European Commission has donated some €180 million to help fight the epidemic. The death toll has now exceeded the 3,000 mark and that is just six months after the outbreak first occurred. It would appear from the statistics that there is an increasing incidence of deaths due to Ebola. Over the past fortnight the number of deaths has been much greater than in any previous fortnightly period since the outbreak began. On this morning's RTE radio programme, "Today with Sean O'Rourke," it was suggested that by January 2015 the figures could have risen to exceptional levels, even to 1.2 million. These are alarming indicators of a situation that is not under control, although I am not suggesting that it is out of control. I ask the Minister to consider what further steps can be taken. The Minister said no case of Ebola had been identified in Ireland, thank God.

However, what direction are we giving the population? This is a highly contagious disease, yet people are being encouraged to seek medical attention. This could be putting others at risk, not only general practitioners but also others in hospital sites. We must have a very clear indication as to what steps people should take if Ebola is suspected, because the disease can take hold very quickly, by which time there is a crisis.

Is the Minister in a position to tell me whether we have in this jurisdiction a stock of the drug ZMapp, which appears to have been effective in the treatment of two American aid workers who contracted Ebola? What further steps does the Minister believe the Government can take on travel? We heard this morning that a suspected case of Ebola was identified on a flight out of Africa. This is absolutely frightening for people. It is very important that representatives of the people, on both the Government and Opposition sides, ensure we have the very highest levels of protection in place for our population and face up to our international responsibilities by contributing the best we can offer to help curtail and, I hope, eradicate the disease, which presents such a terrible challenge.

I appreciate the Deputy's concerns about the Ebola outbreak. The outbreak in West Africa is very serious. Our main efforts are obviously to support the work taking place there through the Department of Foreign Affairs, the World Health Organization, the European Commission and various aid agencies on the ground. We must issue travel advice and have measures in place to identify a case quickly should it occur in Ireland, and ensure that any person affected is isolated at the isolation unit in the Mater, provided he or she is fit to be transferred there. Therefore, we have plans and contingency arrangements in place. General practitioners and other doctors have been advised of the diagnostic algorithm and what to do should a case be suspected in their offices or surgeries.

I do not know whether we have a stock of the particular drug the Deputy mentioned, but I will certainly check that out.

Is the Minister in a position to tell us the capacity of the national isolation unit at the Mater hospital? It is used for a variety of infectious diseases. Has there been any upgrading or preparation for Ebola? It would be an obvious location for the drug I mentioned, ZMapp, if there is to be any supply in this jurisdiction.

On Ebola itself, what steps have been taken to ensure there is adequate training and preparation for an outbreak, even a single case, in our population? Are steps being taken across the first line of engagement for people presenting, be it through hospitals, doctors' practices or nurses? What steps have been taken to prepare and train personnel to respond properly to circumstances that are unprecedented in our living experience, and can the Minister advise us on what help and assistance we are offering, in terms of personnel or financial support, in the effort to address the problem at its point of origin in west Africa?

There are many questions there and I do not believe I will be able to answer them all in the minute allowed, unfortunately. With regard to the national isolation unit in the Mater hospital, there is a self-contained unit with 12 beds. These include six lobbied en suite single rooms with negative pressure ventilation so the virus cannot spread through the air. Two of the isolation rooms are of high specification and are separate from the rest of the unit. They have a different air-handling system.

The Deputy also asked about our support for efforts in west Africa. To date, Ireland has provided direct funding of €350,000 to organisations working on the Ebola response in Sierra Leone and Liberia, which are partner countries for Ireland. The funding is in addition to that associated with Irish Aid's ongoing programmes in both countries. It provided €3.9 million in bilateral aid to Sierra Leone and over €2 million for health and nutrition programmes.

I can provide the Deputy with the remainder of the information.

Is training being provided here?

I will answer that question if the Deputy puts it to me with the others.

Abortion Legislation

Clare Daly


71. Deputy Clare Daly asked the Minister for Health in view of the comments of the UN Human Rights Committee and the Ms Y case, his views on the Protection of Life During Pregnancy Act not being fit for purpose; his plans to replace it and his further plans to address the constitutional impediments of the eighth amendment. [36747/14]

What is the Minister going to do about the comments at the UN Human Rights Committee which roundly condemned Ireland as contributing to the mental suffering of women by failing to address the abortion reality? These warnings tragically have been vindicated quickly in the horrific Miss X case which shows that the legislation the Government introduced last year does not give a woman whose life is in danger access to an abortion to which she is legally entitled. Is it time to repeal that legislation and the Eighth Amendment to the Constitution, as suggested by the United Nations?

As the Deputy is aware, Article 40.3.3o of the Irish Constitution states:

The State acknowledges the right to life of the unborn and, with due regard to the equal right to life of the mother, guarantees in its laws to respect, and, as far as practicable, by its laws to defend and vindicate that right.

The interpretation of Article 40.3.3o was considered by the Supreme Court in Attorney General v. X in 1992. Furthermore, in December 2009 the European Court of Human Rights heard a case brought by three women in respect of the alleged breach of their rights under the European Convention on Human Rights in regard to abortion in Ireland. This action was known as the A, B, and C v. Ireland case.

The Protection of Life During Pregnancy Bill 2013 was enacted in July 2013 and commenced in January 2014. The purpose of the Act is to restate the general prohibition on abortion in Ireland, while regulating access to a lawful termination of pregnancy in accordance with the X case and the judgment in the European Court of Human Rights in the A, B, and C v. Ireland case. The Act received careful consideration by the Houses of the Oireachtas and the Oireachtas Joint Committee on Health and Children, including three days of public hearings.

The guidance document on the Protection of Life During Pregnancy Act 2013 has now been published. The guidelines are designed to assist professionals in the practical operation of the Protection of Life During Pregnancy Act. The guidance document includes advice on identifying referral pathways to fulfil the requirement of the Act to ensure women whose life might be at risk can receive appropriate medical care. I do not intend to propose any amendment to the Act or the eighth amendment of the Constitution at present.

In regard to the case now known as the Ms Y case, I am awaiting the report by the Health Service Executive and hope to receive it as soon as possible. Once I have had an opportunity to review it, I will consider if any further action needs to be taken.

We do not need any further report, although the drip-feed in the media indicates that the information we will get will be illuminating. The guidelines reiterate that the purpose of the Act introduced last year was to confirm the general prohibition on abortion, but that was not the case. It was to legislate for the lawful circumstances in which a woman was entitled to have an abortion in this country, when her life was in danger. Tragically, the Y case proved that a woman who had met the criteria was unable to access her lawful right to have an abortion here because of the inadequacies of the legislation introduced by the Government. We have doctors and the medical profession operating on the basis of a criminal prohibition, which has a chilling effect. We have excessive scrutiny by the medical profession, which adds to the mental anguish experienced. Interestingly, the UN Human Rights Committee pinpointed the circumstances of Ms Y when it referred to the discriminatory impact of the legislation on people who did not have a right to travel. When we add this and the inefficiencies of the legislation to the fact that 160,000 Irish women have had to travel for abortions in recent decades, does the Minister believe that in the interests of decency, respect and the recognition of the abortion reality, they should be able to have that treatment at home rather than being forced to travel?

There are various accounts in the newspapers of the Y case. The reason I want to wait for the report is that there is information in the newspapers about which I know nothing. Therefore, I want to wait for the report, to see all of the facts and consider them. I do not want to jump to conclusions and I am concerned that people on both extremes of the issue, within a day or two of the case happening, had already decided that everything that had had happened confirmed their pre-existing views of the issues involved. That is not a good approach to adopt.

The UN Human Rights Committee recommended that Ireland's laws on abortion be liberalised, but it did not go as far as the Deputy seems to recommend - abortion on request or demand. The Deputy is being a little selective in using the UN committee to bolster her case.

It has not endorsed the Deputy's view of abortion.

The purpose of the Protection of Life During Pregnancy Act was, first, to confirm the general prohibition on abortion in the State and, second, to codify and provide in law for the legal termination of pregnancies where a life was at risk. A termination of pregnancy did occur in the case referred to by the Deputy, but it occurred by Caesarean section rather than being an abortion due to the gestation of the foetus.

I agree with the Minister that some of the media commentary has been very unhelpful. However, I do not believe his points about extremes in the debate. The reality has been, as successive opinion polls have shown, that the majority of Irish people believe a woman should have access to a termination in a wide range of circumstances where her health is in danger, where she is the victim of rape, in the case of fatal foetal abnormalities and so on. The recent opinion polls also indicate we should be repealing the eighth amendment, given that most of us were not around when that legislation was brought forward.

What the UN Human Rights Committee actually stated was that we should look at legislating for those circumstances, including looking at the difficulties being caused by the constitutional scenario, which ludicrously and appallingly equated the life of a grown woman with that of a foetus. That is what it asked us to look at; that is the truth and I am sorry if the Minister does not like it. I am asking him, as a young man, if he thinks it is a little ridiculous that we enacted legislation that would only ever deal with a tiny minority of women who needed to secure an abortion where their life was in danger, when, for each of these women, there are thousands of other Irish women every year whom we say have a constitutional right to travel to England or Holland for an abortion, but they cannot access that medical treatment here at home. Does the Minister, as a doctor and a young man, think that is an abomination in the modern era?

What the opinion polls show is that a clear majority of the Irish population still do not support abortion on demand or request. I understand that is the Deputy's position. It is one she is-----

I am not talking about my position.

It is a position she is entitled to hold, but it is not the majority view in the State, based on the opinion polls to which she refers. I will give my opinion as a doctor and a young man at a later stage. However, I am Minister for Health and the Government's position is clear - we have no plans to repeal the eighth amendment. It is important to bear in mind that if the eighth amendment were to be repealed, it would result in the removal from the Constitution of any protection afforded to the life of the mother and the unborn child.

The Deputy will recall, for example, that the first divorce referendum was unsuccessful and that it was successful the second time because people knew what they would be replacing it with. It was replaced with a different amendment and the legislation was published. That is not what the Deputy is proposing. It appears that what she is proposing is just the deletion of the amendment and allowing the Dáil to enact any legislation it likes. I believe people would have a difficulty in voting in a referendum in those circumstances.

Then regulate it like other medical procedures.

Health Services Staff Recruitment

Colm Keaveney


72. Deputy Colm Keaveney asked the Minister for Health if his attention has been drawn to issues in the recruitment of counselling psychologists by the Health Service Executive; and if he will make a statement on the matter. [36797/14]

The HSE service plan deliberately provides for a time delay in the recruitment of critically important mental health professionals. The object of this question is to establish from the Minister of State what her plans are to accelerate the recruitment of professionals within that sector. One can argue that this is the consequence of the breach of the programme for Government last year when funding that was to be ring-fenced was cut in a very crass manner. It has resulted in the HSE cynically designing a situation where it would leave the impression that it was recruiting in this calendar year when it intended to recruit them in December.

I will answer the question as submitted.

Psychologists employed by the health service play an integral role in the delivery of a wide range of psychological services. These include the following: working with children and their families who present with developmental, emotional or behavioural difficulties and others who have intellectual and physical disabilities; working with adolescents with a wide range of difficulties from adjustment problems to serious mental health issues; and working with adults who present with mental health problems, including anxiety, depression and mental disorders.

Psychologists deliver services in a number of ways: as part of a multidisciplinary team of health professionals, as part of a network of health professionals, or as sole health professionals providing services to individual clients. They deliver their services in a range of settings, including community-based health centres, residential centres, nursing homes and hospitals.

The HSE employs professionally trained psychologists, including counselling psychologists, clinical psychologists and educational psychologists, in a range of roles across the health service. Counselling psychologists are largely employed in primary care and national counselling services. Under section 22 of the Health Act 2004, the HSE has the authority to appoint persons to be its employees and may determine their duties. This includes the appointment of persons to posts within the psychology service. With regard to the recruitment of psychologists, in the context of significant organisational change and realignment, it is the executive's intention to review the selection criteria for posts within the psychology service. The review will commence in November, and as part of this process the views of stakeholders will be invited and consideration will be given to developments within the profession. This review is timely in order to ensure that the recruitment of professionally trained psychologists continues to meet the needs of our evolving health services. I welcome the review and look forward to receiving the results of the report once it is completed.

I thank the Minister of State for her response. As she is aware, up to 15,000 children are languishing on waiting lists for early intervention teams. The much-lauded concept of the early intervention team lacks the sort of supports that are required to ensure that the multidisciplinary expertise is there across the disciplines described by the Minister of State in order to give children at an early stage of life an opportunity to develop and have educational opportunities in the same way as any other child.

What plan does the Minister of State have to accelerate the specific recruitment of the psychologists? I am concerned that the advice the Minister of State has received from the national association representing that profession is being ignored in her approach. It is important that we both agree that the critical thing is to address the waiting lists. We have demonstrated in this Chamber that up to 15,000 children have been waiting over two years for assessment, which is unacceptable.

I agree with the Deputy and share his concerns about this area. I am having another meeting this evening with the officials who operate the national mental health services within the HSE. I agree with the Deputy that there is a difficulty. I have been doing a bit of research lately that may not be joy to the ears of those working within the service, but it is definite that some services are working extraordinarily well while other services simply are not. We must remember at all times that this is about the child. We are recruiting as best we can.

I am sure the Deputy also knows that there is a difficulty with recruitment processes. The new review will help that, but we must certainly take a serious look at whom we recruit, how we recruit them and the shortage that exists. The shortage deeply concerns me, but even more worrying is the fact that children are waiting longer than necessary for assessments.

The HSE service plan was deliberately designed to prevent recruitment. Last year there was a commitment to provide for €35 million in ring-fenced funding for mental health services. That broken promise has resulted in the Minister of State designing a time delay which deliberately prevents the recruitment of staff that would address the waiting lists we have described. In the forthcoming budget, does the Minister of State intend to address that situation and restore the moneys that were cut in last year's provision that was ring-fenced in the programme for Government - the figure of €35 million? Is it her intention to restore that €15 million, as was the rhetoric at the time, on top of the €35 million specifically designed for the recruitment of specialist staff?

I will not take that long. My clear intention is to ensure we have a plan relating to recruitment and the upcoming budget. The Minister and I have been involved in those negotiations for the past number of weeks.

Part of that planning will involve today's meeting. It is all about planning and ensuring we have timeframes. There was a timeframe last year, no matter what other opinions may be. It is my job to ensure the timetable is adhered to and that when we get the additional money this year, which I assume we will because I have no reason to believe otherwise, we will have a plan to use it. Things change and one should be flexible enough to ensure that when changes occur one is prepared for them in order to get the best possible results for the people one is charged with representing.

Hospital Groups

Caoimhghín Ó Caoláin


73. Deputy Caoimhghín Ó Caoláin asked the Minister for Health his views on the smaller hospital sites; the steps he will take to establish the real potential of smaller hospitals that have lost critical services over the past decade; in view of the impossible footfall presenting at many of the larger hospital sites, if he is providing serious consideration to the restoration of services to smaller hospitals, thereby alleviating overcrowding elsewhere; and if he will make a statement on the matter. [36738/14]

I ask the Minister, who has demonstrated some new thinking regarding his new portfolio of responsibilities, if he has had time to form a view or decide on an intent regarding the great and under-utilised resource that is our network of smaller hospital sites across the State. These hospitals are still in service, though their services have been significantly reduced over this past decade and more.

The Government’s decision to establish hospital groups, where small and larger hospitals work together, was informed by two reports, the hospital groups report and the smaller hospitals framework. The hospital groups will provide an optimal configuration of services, with benefits relating to safety, quality, access and cost. Every hospital, large and small, will play a vital role in their group.

The smaller hospitals framework defines the role of the smaller hospitals and outlines the need for smaller hospitals and larger hospitals to operate in partnership as a single hospital group. It also defines the need for the smaller hospital to be supported within the group in terms of education and training, continuous professional development, recruitment of high quality clinical staff and safe management of deteriorating and complex patients.

The framework outlines in detail the wide range of services that can be provided in smaller hospitals, the services that can be transferred from larger to smaller hospitals and commits to the expansion of less complex services in these hospitals, such as day surgery, ambulatory care, minor injury units, medical assessment units, screening, other medical services and diagnostics. It is envisaged that smaller hospitals will provide more, rather than fewer, services, with more flexibility so that patients are the ultimate beneficiary of the reforms.

The initial focus is on getting the hospital groups up and running as single cohesive entities. In 2015, each hospital group will be asked to develop a strategic plan to describe how they will provide more efficient and effective patient services, reorganise these services to provide optimal care to the populations they serve and how they will achieve maximum integration with other groups and all other health services, particularly primary care and community care services. Alongside the work done at hospital group level, work will be done at a national level on the best configuration for certain national specialties.

Small hospitals have a bright and busy future providing a wide range of existing and new services, but it will not be possible for every hospital to be a centre of excellence or specialist centre for everything. We need to be honest with people about that. Separately, I foresee many services moving out of hospitals and into primary care in line with clinical programmes strategy.

I thank the Minister for his reply. I support a policy of having more, rather than fewer, services. As in so many areas in this country we go overboard in following the lead of others in other jurisdictions in comparable matters, and that has been the experience of many people in many reconfigured arrangements currently in place. I could instance several such cases. We have heard today of the situation in Limerick regional hospital where overnight an exceptional number of patients were kept in wholly inappropriate settings. That cannot go on unchecked.

We have to recognise that there are other options. There are alternatives, in cases where certain ailments are present, to transporting such patients by ambulance to a so-called centre of excellence and bypassing existing facilities which have the capacity, trained staff and competency to deal with such situations. This has been acknowledged to me by hospital management and practitioners in critical hospital sites across the State.

I appeal to the Minister as a new mind with a fresh approach, as he has demonstrated in other areas, to look seriously at the potential of smaller hospitals to relieve the distress presenting at so many of the larger sites.

When it comes to reorganising services, we must always bear in mind that medicine, best practice and clinical science are always changing. There will never be an end point when it comes to reorganising services and we will always be adapting them. What we need in the health service is not disruptive reform but evolutionary reform, which means more things moving from hospitals to primary care, more specialist centres being centralised and more services moving from large central hospitals to smaller ones. I had the opportunity to visit Roscommon on Saturday where I spent a few hours in the hospital. I was impressed to see that there were services in the hospital which were not available in Blanchardstown, where I live, including, for example, a minor injuries unit where one can be seen in less than an hour with a laceration, broken bone or other injury of that nature. It also has a medical assessment unit to which a GP can send a patient during the day for assessment by a consultant. That is a good example of a smaller hospital providing the services those of us in Cork or Dublin would love to be able to offer our constituents.

To perhaps answer the Deputy's question a little better, when I look at trolley and overcrowding numbers across the hospital system, it is evident to me that one may have a great deal of overcrowding in three or four hospitals and none in ten or 11. It is not always down to resources, but is sometimes the result of management. It is clear that more beds are required in Limerick and a plan is in place to provide a new emergency department there. Between now and then, there will be difficulties; perhaps some work might be moved back out to Ennis or Nenagh in the interim to alleviate the pressure.

I welcome the Minister identifying both of the sites he has just mentioned. I had not intended to refer specifically to any of the hospital sites for fear of leaving one out. The Minister has identified immediately what might be done in relation to University Hospital Limerick. There are many other examples. There is international evidence of increasingly poor outcomes, including increased mortality, in relation to the closure of accident and emergency departments and their over-centralisation. A recent study in California has demonstrated as much and it is reflected across a whole range of studies conducted globally. We need to recognise that is the case. It is estimated by some of the Minister's colleague practitioners in front-line hospital employment that up to 90% of some of these emergencies, particularly in the older age group, do not require a transfer to larger hospital sites with a range of specialty supports. One could be dealing with pneumonia or a range of other things that could be provided for and dealt with clearly on the smaller hospital sites to which I have referred and which are still open, working and capable of dealing with these issues. It would also be hugely welcomed by the individuals concerned because they are closer to their homes and accessible by their families, with all of the better and speedier outcomes that come as a consequence.

I ask the Minister to look at all of these matters. I speak from experience; it is not something I am reading about. I live in a community that lost the greater number of its services at Monaghan hospital, a fine institution that is way under-utilised in terms of its potential. I urge strongly the Minister's review of the area.

There will be a job to be done in educating the public and, to a lesser extent, GPs about where patients should go and when. Ideally, an older patient with pneumonia should be referred by his or her GP to a medical admissions unit, if there is one available. He or she should not - at least not during the day - be calling an ambulance to take him or her to an emergency department. The same applies to minor injuries. Where there is a minor injuries unit available, a patient should go to it rather than the emergency department. Certainly, he or she should not be calling an ambulance. There is a significant job to be done to change mindsets around this issue.

In some countries ambulance crews can discharge patients from the ambulance and not take them anywhere if they do not need to go to a hospital. Similarly, ambulance crews have more autonomy in deciding where they take the patient, and there are many such systems that can change in time.

Any decision to reconfigure services among the hospitals in Limerick, Nenagh and Ennis is a matter for the hospital group to decide, not me. Unfortunately, that group is running very much over budget. It is the one running most over budget among all the hospital groups, and that is a matter of concern in itself.