Health Services: Motion [Private Members]

I move:

That Dáil Éireann:

agrees that:

— the health services are underfunded;

— the 2015 Health Service Executive National Service Plan is not sufficient to fully address the increasing demands and demographic pressures being placed on our hospital system; and

— key targets in the Plan are regarded as unrealistic by its authors; and

calls on the Government to fund the health services appropriately and sufficiently in 2015.

I am sharing time with Deputies Calleary and Ó Cuív.

Is that agreed? Agreed.

At this time of the year, we tend to discuss the annual service plan of the Health Service Executive. I am not filled with a great deal of confidence with what I saw in the overall plan for next year which was published recently. I do not believe that will be changed with the soon-to-be published divisional and sectoral plans. We could have a philosophical and ideological debate on how we construct society and our priorities in this regard. It is very evident, however, from the HSE’s recently published overall service plan that the Government’s priorities are elsewhere other than in the area of health.

I am concerned the ability of front-line health service providers and staff to provide care in a meaningful manner will be further eroded by this service plan. I am not saying that for the sake of it. This has been stated by many of the stakeholders in the health services, reiterated many times by front-line service providers, those at the coalface of health care delivery. It was also stated by Mr. O’Brien, director general of the HSE, at the launch of the 2015 service plan that there would not be sufficient funding in place next year to provide care in the key areas where there are significant pressures because of demographics. He cited pressures on the whole area of caring for the elderly through the fair deal programme and the nursing home support scheme. The other key area, inpatient and outpatient day cases, has an inordinate number of people waiting extraordinary lengths of time to see a consultant or be treated.

The figures and statistics are quite alarming. The Minister for Health, Deputy Varadkar, went to great pains when he was appointed to explain that, first and foremost, he wanted a sustainable budget built on sound foundations, one that was honest and upfront in how funding would be provided in the year ahead. However, he also admitted the Department of Health would need €200 million just to address demographic changes every year. When one drills down, examines the extra allocation of funding along with projected savings to be accrued and the other opaque measures for HSE funding, one questions whether its budget is sustainable at all. Whatever way one does the figures, the Minister will be down €85 million.

All of this stems from many factors but primarily from the Government’s priorities. It has decided, regardless of whether the Minister of State, Deputy Kathleen Lynch, likes it, to go after other key areas concerning the electorate. When we debate our priorities in society, it is evident the Government’s are not in keeping with what is needed in our society. Up to 2,100 people are waiting a minimum of 15 weeks to be approved for the nursing home support scheme. These are people who are vulnerable, old and sick and who are now looking to the State for support. Several weeks ago I pointed out how not just the waiting time for approval had increased but also the numbers waiting for approval. We went from four weeks with 500 people waiting in January to 2,100 waiting for 15 weeks this month.

Today, a woman from Blarney, County Cork, informed me she had to take her husband out of a nursing home because she could not afford the costs she would incur between now and approval time for a fair deal nursing home support scheme bed. At the same time, we have the Taoiseach, whenever a microphone is put before him and he is willing to answer a question, talking consistently about one issue only: tax cuts. Every Member accepts there are significant pressures on working families and any alleviation of the burden on them is welcome. The priorities must also focus, however, on reducing the level of tax back to people earning substantial sums of money and reorienting it towards those who need the support of the State.

Up to €35 million was to be ring-fenced every year for the funding of mental health services, the Minister of State’s responsibility. On numerous occasions, Members on all sides of the House have described mental health services as the Cinderella of the health services in that it does not get its fair share of funding and is consistently neglected. Commitments were made in the programme for Government to improve mental health services. Every year, the HSE’s service plan has provided for the rolling out of improved funding for mental health services. From the funding allocated for mental health services in the HSE’s 2015 service plan, it is quite evident that much work still has to be done to ensure adequate resources are put in place for the area. I know the Minister of State has answered numerous questions on this issue in the House and that she has made the clarion call for progress to be made in this area. While I accept there has been an element of progress, judging it against the commitments the Government said it would honour, however, it is still very shy in increased recruitment and the adequate provision of funding for next year due to the shortfall this year. Year on year, the mental health services budget is in deficit, which creates significant pressure on community services to deliver care for those with mental illnesses. This is not just said on the Opposition side of the House. Issues have been raised by advocates and stakeholders involved in the provision of care in mental health services, yet the Government consistently ignores the pleas from those who see overloaded, overburdened and inadequate services to deal with the mental health crisis in our communities.

Free GP care is another central plank of the Government’s health policy. The programme for Government stated there would be free GP care available to everyone by the end of 2016. We are 16 months shy of the Government’s full term but no nearer to that commitment being honoured, other than the fact that the Minister for Health said he is in negotiations with the Irish Medical Organisation and hopes to have agreement some time on the framework for the roll-out of free GP care for those under six and the over-70s. However, there is the continued culling of medical cards for the over-70s. I remember the Taoiseach, when leader of Fine Gael in opposition, and the former Tánaiste, when leader of the Labour Party in opposition, on Kildare Street shouting shame on the then Fianna Fáil Government for attempting to reduce the number of medical cards for older people, exploiting anger and concerns among those affected. What has happened consistently since is that more medical cards have been taken off people. Not only that, the terms for qualification have been made so strenuous and onerous that the cut-off income point for a retired couple is now €900 gross a week.

It comes back to priorities. The fuel allowance, telephone allowance and other home packages, which were seen as de facto entitlements for older people, have been stripped away slowly but surely. I know Government party Deputies will tread carefully in their criticisms during these kinds of debates.

Reading between the lines, they can see the Government has reneged on commitments it made to the electorate prior to the last election to ensure adequate services for older people. In this regard I highlight the nursing homes support scheme, medical cards, household packages, fuel allowance, bereavement grants and so on. All of these things have been taken away slowly and by stealth so that people do not notice for some time. The Government uses spin and PR to cover its tracks on a U-turn of mammoth proportions on commitments for older people.

The details of the plan highlight many other deficiencies. More than 50,000 people are now waiting as inpatient day cases and over 200 consultant posts are vacant. Some 380,000 people are waiting to see a consultant through an outpatient appointment, and all of this means there has been an increasing backlog in the system in the past number of months. Mr. O'Brien, the director general of the HSE, stated this on the day of the launch.

The contents of this motion are simple and cannot be refuted, though the Government will obviously table an amendment and vote down the stated fact that the health service is under-funded. The 2015 Health Service Executive national plan is not sufficient to fully address increasing demands and demographic pressures that are being placed on the hospital system. The key targets in the plan are regarded as unrealistic by its authors, the Minister, the Department of Health and the HSE. Those who drafted the plan have stated that it will not achieve its targets as some of them are unrealistic. This motion is intended to highlight hypocrisy and, more important, the pain the HSE service plan will cause to ordinary people throughout the country due to the lack of priorities. The plan fails to emphasise key areas.

There has been a U-turn on discretionary medical cards, but issues persist every day. A recent blog post by a parent highlighted the disgraceful way his son was treated when it came to a discretionary medical card. The card was granted to the child and then taken away. I raised this matter with the Minister, Deputy Varadkar, in an interview last week. There is a pretence that all is now well with the primary care reimbursement scheme and the manner in which people are assessed and their concerns addressed. Spin and PR were used the other day to blame doctors for failing to issue cards. All of this is an effort to camouflage the obvious: the policies pursued by this Government on discretionary medical cards were disgraceful and distasteful, to say the least. For over two years, this side of the House has consistently highlighted the problem in a non-alarmist, matter-of-fact way through Private Members' motions and on Leaders' Questions. A perusal of parliamentary questions will show that this is a major problem in society. We will have to wait and see whether it has been addressed, but the signs are not encouraging. As late as last week we saw cases in which people with major challenges and illnesses had discretionary medical cards withdrawn. As I said, the problem was recently publicised by the parent of a child.

I have addressed waiting lists and the HSE service plan as it relates to the nursing homes support scheme. I will now address the broad issues in Government health policy. Universal health insurance was a key point in the five-point plan. At the moment a Minister is being applauded and feted as honest for performing a U-turn on one of the central planks of Government policy, as stated in the programme for Government. I am referring to the abolition of the HSE and the establishment of trusts, followed by a move towards a money-follows-the-patient model that leads, ultimately, to universal health insurance. The Taoiseach launched the White Paper on universal health insurance but, at the same time, the Department of Health advised anyone who would listen at a political level that universal health insurance was unworkable. The Department said it would involve the setting up of too many organisations and quangos and would not provide the level of care we were led to believe it would. Universal health care was not costed at that stage and it still has not been costed - we are still waiting to know what the universal health insurance model will cost taxpayers.

The former Minister for Health, Deputy Reilly, was fixated on the Dutch model of health care, but this was on a wing and a prayer because costings were not done. If one reads reports published by eminent authors on the cost of the Dutch model, one learns that the universal health insurance model pursued by Deputy Reilly would cost the average family €12,000 per year. The Government is still stated to be pursuing this policy, though the Minister, Deputy Varadkar, says he has abandoned it. The figure of €12,000 is reached by combining what a family would pay in general taxation with the fee for compulsory health insurance. The reports are widely available. According to one of the authors, Michael van den Berg, the figure of €12,000 figure relates to gross income and includes premiums and taxes but not out-of-pocket expenses and payments. If the latter costs - for dental care, over-the-counter medicines and so on - are included, the total figure is higher, including €6,000 for health insurance premiums and more than €5,000 for exceptional medical expenses.

It is clear that no thought went into this proposal for universal health care, which was proffered as a panacea and a utopian model to address all health service concerns. One thing is for sure in December 2014: we are pretending our health budget will address the huge challenges facing people in need of services in 2015. This pretence goes on year in, year out. There is a potential budget deficit of over €500 million in 2014, and this will be carried into 2015, so the Minister of State will start off at minus €85 million. Regardless of spin, palaver and pronouncements, I have little hope that the health service will deliver in the key areas that we know face major problems. We know this already because of demographic changes and the fact that the number of people over 80 years of age is growing at 4% per annum. These statistics are available for all to see, but the Government continues to prioritise other areas rather than putting money where it is most needed. Any fair and rational assessment would show that older people deserve the support of the State after all the years they have served it. People with profound physical and intellectual disabilities should be supported and so should those who are dependent on mental health services. People who should be entitled to access health care with a discretionary medical card are being denied this facility as we speak. The aim of this motion is to highlight all of these issues.

I hope that in the context of this debate people will have the honesty to say what they are experiencing with regard to the difficulties facing people, including front-line staff, representatives of front-line staff and those who are at the coalface on a daily basis. I ask that the Government listen to their pleadings and the pleadings of people who are dependent on the health service but get insufficient support.

For all these reasons I commend the motion to the House. I hope we have a robust and honest debate on the matter in which we can at least point to a different and fairer way of ensuring people have access to services when they most need them.

I thank my colleague, Deputy Kelleher, for allowing us the opportunity to discuss volume four in the Harry Potter collection that has been the HSE service plan since this Government came to office. The author may have changed for this volume but the trend, storyline and conclusion will remain the same.

Deputy Kelleher is wearing the cloak of invisibility well.

A report is due next week, I gather, on "Prime Time" relating to Áras Attracta, an institution in my constituency which I know well. What we are led to believe is in that report is disgraceful and appalling. As public representatives, none of us can be comfortable with it. Why, ten years after the Leas Cross scandal, are we depending on RTE once again to shine a light on this issue? Someone in HIQA or the HSE has dropped the ball. Yesterday, we saw representatives from the HSE wringing their hands and saying that it was awful, but that does not excuse the HSE from responsibility. This has happened under either their watch or the watch of HIQA.

All of the constituency Deputies - I mean all of them - knew there had been resource pressures in Áras Attracta for some time. They are directly linked. The majority of the staff there do a very good job in difficult circumstances. It has served our community well. Since it is in her area of responsibility I call on the Minister of State to make the resource allocation necessary to bring Áras Attracta up to standard and to take the decisions necessary to restore its reputation. Once again we are depending on RTE to shine the light. Someone in the HSE or HIQA should have done that job. We cannot depend on RTE to give coverage or attention to every health care facility in the country.

I welcome today's report on the ambulance service. However what we need to see in the service plan but what is not evident is a detailed month by month implementation plan on where the allocations will be spent. In respect of the service plan for ambulances I welcome the staffing commitment to the bases at Mulranny and Loughglynn but when will the notice for staff be advertised? In what month will staff be in place at Mulranny and Loughglynn?

The ambulance personnel on the road are doing a phenomenal job. Tonight, God knows how many of them are facing unbelievable circumstances in trying to bring people to safety. However, those in management are disconnected from the reality. The difficulties we have in getting information from the National Ambulance Service makes North Korea look like a functioning democracy.

Last year the Minister of State intervened - I thank her for her intervention - to get information on an incident that happened in 2013 in which an ambulance took two hours to come to a case in Ballina. It took me three months to get that information. There have been two further incidents this year. The first took place in Castlebar in October, around the corner from Mayo General Hospital. Gardaí decided to bring the patient to the hospital because it was quicker than waiting for an ambulance to come around the corner. I have sought information on that case but I cannot get it because the service has moved its base to Ballyshannon. We are in a digital computer age but that is this year's excuse. Another incident occurred in Ballina town. Someone took ill in the middle of the summer and it took an hour to get an ambulance to the person in question. We cannot get information on that case either.

As well as investment in resources a change of culture is needed. The organisation should be more giving and sharing in respect of information. It is incredible that the organisation does not have basic management information, such as where vehicles are and the nature of incidents that have happened. That information should be available at the touch of a button. The notion of making public representatives beg for it and having to seek the intervention of a Minister are ridiculous. It amounts to those in the service telling this House that they have no respect for our role. It is time they copped on to themselves. It is time the management in the National Ambulance Service stood up and took responsibility for the service they are running rather than leaving the people who deliver the service to take the brunt of people's frustration.

Deputy Kelleher referred to the medical card situation. We all welcome last week's announcement but the reality is, as Deputy Kelleher has said, that it is still going on. Somewhere in Government Buildings a press conference was held. I do not doubt the intention of the Minister for Health, Deputy Varadkar, to change the system but somebody has forgotten to tell the people in the office in Finglas that this system has changed.

I will outline a case. The Minister, Deputy Varadkar, has the details. I will not name names. It involves an elderly couple. Both are retired, one is on a private pension and the other is on a social welfare pension. The man had a quadruple bypass earlier this year and is suffering from serious chronic obstructive pulmonary disease. He has an oxygen tank beside him everywhere he goes. The lady is suffering from a form of cancer which has claimed a number of members of her immediate family and she is currently undergoing treatment. The gentleman finds it difficult to leave his house.

They lost a discretionary medical card on 1 April this year. Since then we have been over and back with the service, like many Deputies. On 1 July the discretionary cards were re-approved and granted, valid from 26 June to July 2015. On the 12th of this month the lady went to register for chemotherapy and was told while having chemotherapy that her card was no longer valid. On the same day, while she was in Galway, the gentleman was at home. He received a telephone call from his general practitioner to say the card was no longer valid. Then he received a letter to say the cards, which were due to be valid to July 2015, had been withdrawn. They have not won the lotto in the meantime; there has been no change in their circumstances or income. We contacted the primary care reimbursement service. We received an e-mail from the PCRS on 17 November stating that those medical cards were valid and there was no problem with them. Then we got a letter on 18 November stating they were no longer valid because they had been reviewed.

One hand does not know what the other hand is doing. We challenged and queried this. New GP cards were sent out in the post. Now there are two valid GP visit cards and two full medical cards that are valid as well. There are four cards in the house.

A telephone call was received on 19 November stating that the GP card was no longer valid. We have been over and back to the PCRS. On 21 November someone from the PCRS rang the house to say it was all a mistake, that they were genuinely very sorry and two full medical cards were issued again on the basis of that telephone call. Then, last week we got an e-mail stating that the cards were being withdrawn and that a full review was under way. Last Friday I received an e-mail advising me that having queried the Department the PCRS could confirm that no further information could be added to the application in question and that since it has been previously reassessed, the application had closed. The e-mail stated that the letter dated 11 November referred. This was the letter that took away the card previously but which was subsequently replaced by e-mail stating the cards were still valid. This is what is going on.

All of this was in the case of a patient with COPD who cannot walk around his house without having an oxygen tank beside him and whose wife is in Galway having chemotherapy. One arm of the HSE will not talk to the other and as a result people are being put through trauma and stress. They should not have to ring my office. They should not have to endure the pressure of ringing my office and worrying about where the medical card is and whether they can afford the can of oxygen next week, but that is the reality. They have a small private pension and an invalidity pension but this is what they are being forced to do.

The e-mail of last Friday got a zinger of a response, which I copied to the Minister, Deputy Varadkar, because it seems the only way to get anything done is to get a Minister involved to talk sense. That is the new regime of medical cards.

Will the Minister of State clarify when the new regime actually kicks in? When will the local input actually kick in? When will there be some sort of justice or human touch rather than the "computer says no" approach, which is what governs how a medical card is issued in this country at the moment? It is time that humans said "Yes" in cases like this and in cases of parents with children with a disability or Down's syndrome.

It goes back to priorities. We will cut the tax rate for those on the highest rates but we will not give a child with Down's syndrome a medical card and we will force two old people to be put through the ringer like this. The priorities are so wrong. I am only one of 166 Deputies. Every Government Deputy will come to the House tonight with a script. The cheerleaders will say the Minister of State is the best thing since sliced bread, but they know the reality when it comes to medical cards and the ambulance service and so much else outlined in the service plan, as does the Minister of State, because they are dealing with it themselves.

Tá áthas orm deis a bheith agam labhairt ar an rún tábhachtach seo. Tá go leor le plé.

The first decision we must make collectively is whether we want a proper health service and then we must decide if we are willing to fund it. Choices are made and sometimes the choice is to reduce taxes. At other times, the choice is made to improve services. We must be conscious as money inevitably becomes available that rather than promise next year's tax cuts, as is already happening, we should have a rational, adult debate as to what we need to do. I am not talking about people on €38,000 to €40,000. If one reduces the top tax rate by 1%, it helps a person on €1 million a year a lot more.

Before we start doing top-of-the-head budgets, we must decide if we require more money to provide a health service. I am sure that the Minister of State and her Department are convinced in their hearts and souls that they can require efficiencies in services. Given that there are human being running the health service, however, it will never be fully efficient. We must recognise that while we must make things as efficient as humans can make them, a flawless service where everyone turns up every day and is motivated will never exist. Therefore, the Department must plan how to get the best service given the real human beings who run it with all their differences and the issues that arise and then ask if it has enough money on that basis to run it.

It is becoming clear that we have not put enough money into health. There is no cheap way of doing health. Every country in the world is facing a challenge in regard to people's expectations of health services versus the budgetary requirements. I am not saying there should be an infinite budget, but we must have a rational and reasonable debate about this as a society. I believe we can make different choices to those we are making. I remember saying many times when we were in government that no matter how much money one had, one would find a good way to spend it. No matter how much one is given, one's budget is finite. As every budget is finite, one must make choices no matter what state one lives in.

One issue that is a question of choice involves the nursing home subvention scheme. Currently, there is a 16-week waiting list from the time one gets approval to the time one goes into payment. One can take it that there will have been a lapse of eight weeks from the time a person went into the nursing home to the time he or she obtained the approval. Very few people get the approval to go into a nursing home before they go there. In many cases, something happens which means a person must enter a nursing home suddenly. That can mean a total wait of 24 weeks as I saw in a recent case. Every few weeks, one is notified of a case involving the wait for nursing home subvention. Nursing home care can cost up to €1,000 per week. Even if a person has a pension of €200, €700 must be found in cash. Over a 20-week period, that amounts to €14,000. Over a 24-week period, it is €16,800, which is a great deal of money. It is serious money to pay while waiting. This scheme is unique in a particular respect. Social welfare payments are backdated to the date of application but nursing home subvention is not even backdated to the date of approval.

The Minister of State might ask where I would get the money to do away with the waiting list. If there was a finite waiting list of a couple of weeks, while people would not be happy, at least it would be controllable. I would get the money by suspending the provision of GP cards to every person aged over 70 years. I would leave the limits which have been set in place. How much can GP services cost a person who has a €100,000 pension in one year? Even if one went once a week, which would be a lot of visits to make, it would only amount to approximately €3,600 at €50 to €60 a visit. That is not a great deal of money by comparison with the kind of bill I am talking about, which can run to €24,000 or €25,000 gross. Even if one set one's whole pension against the nursing home fee, it would still run to €16,000 to €18,000. Very few people visit the doctor every week. If one were that ill, one would probably get a medical card on health grounds.

The other scheme I would suspend is the proposal to give GP cards without means testing to everybody under six years old. I have grandchildren in that age group and am aware of what children need. A normal healthy child who does not have a disability or underlying health issue may visit a GP five or six times a year. If he or she has a disability or health issue, he or she should be given a card on medical grounds, but we are talking about a universal giving away irrespective of income. If a child visited the doctor four or five times a year, it would amount to €240. While parents are currently feeling pressure, it is nothing like the €16,000 to €25,000 pressure we are currently imposing on older people. By definition, all of these older people are means tested in respect of the nursing home subvention scheme and, as such, have been determined to need the support. Therefore, they are digging into something to try to come up with the money.

It would take a little courage to do one of the things that can be done. I note that according to the Department's own projections, there will be a little extra funding due to the diversion of €25 million from getting people out of hospitals earlier. That will have a €10 million effect and will cut the list in the short but not the long term. I share the Minister of State's concern about the following and acknowledge that it is unlikely she will be allowed to stand up and give her real thoughts on the issue. Whereas I welcome the €20 million for disability, I note the effect of demographic pressures and cumulative cutbacks. There was a point at the beginning where savings were being made and services were being slimlined that needed to be. I accept that. However, there comes a point where there is no more flesh and the cut is being made right into the bone.

I note that €20 million is not enough. I have always felt that we have not recognised the challenges people face where a member of a family has a disability. Families make huge sacrifices and need very good support services. People with disabilities are not ill but rather require continuous support. They have a lifetime to live and it is very mean to impose cuts on their sector. It will be very important to determine how much money we need to provide adequate services taking demographics into account. I would like to know the true figure. We know we have more people with disabilities and, thanks be to God, that they live a lot longer due to medical improvements. Extra money is not in fact extra money. It is the cost of standing still. The provision of €20 million will not ensure that services remain at the same level. I would be very interested to hear the Minister of State's thoughts about that.

While it is not a matter directly under the remit of the Minister of State's Department, I note a proposal I have made previously which I would still like to see being implemented. I proposed at one stage the restructuring of domiciliary care allowance and disability allowance.

The savings achieved from this restructuring should be moved to the domiciliary care scheme. An allowance should be provided until the age of 18 years but no 16 year old should receive payments of the magnitude of disability benefit. I would use the savings to provide a top-up to the domiciliary care allowance in the two years before children commence school. This would allow parents to purchase additional services.

We refer repeatedly to early intervention. The savings to which I refer could be recycled to deliver early intervention. This creative and constructive change could be implemented over a period without having a budgetary effect. It would, however, put to better use the overall funding available for this type of care.

I move amendment No. 1:

To delete all words after “Dáil Éireann” and substitute the following:

"welcomes the Health Service Executive’s national service plan for 2015;

recognises that the Government, in next year’s budget, has made provision for a welcome increase in the total financial resources available to the Health Service Executive, HSE, in 2015, and that this is reflected in the plan;

notes that this increase in funding, which is comprised of additional Exchequer funding of €305 million, increased projected once-off revenues of €330 million, and minimum savings of €130 million in areas such as procurement and drug and agency costs, is part of a two year programme to stabilise and improve health funding after seven years of significant retrenchment as a direct consequence of the emergency financial situation the Irish State has had to address;

further notes the fact that the Health Service Executive's 2015 national service plan provides generally for the delivery of existing levels of service while additionally targeting service enhancement in a number of priority areas through increased funding provision and further progress in the health service reform programme;

further recognises that:

— these enhancements include programme for Government commitments to extend the BreastCheck programme, the introduction of free general practitioner, GP, care without fees for those over 70 years of age and under six years of age, an expansion of mental health services, and further investment in suicide prevention; and there is also provision for 20,000 additional day surgery cases, additional funding of €2 million to improve maternity services, improved pilot ultrasound access for GPs in priority care sites and additional spending on community orthodontic and ophthalmic services; and

— an additional €25 million is being provided to help address delayed discharges from acute settings which will fund a range of community and non-acute supports, including an additional 300 places under the nursing homes support scheme, the provision of 115 short-stay beds, including the opening of Mount Carmel as a community hospital for Dublin, 600 additional home care packages and the extension of community intervention teams; and

supports the fact that the plan includes a considerably enhanced governance and accountability framework for 2015 which describes in detail the means by which the HSE and, within this, hospital groups, community health care organisations and other units will be held to account in 2015 for their efficiency and control in relation to service provision, patient safety, finance and human resources."

While those of us who live outside Dublin are used to community hospitals, the opening of short-say beds in Mount Carmel marks the first time such a hospital has opened in the capital. I will not address the suggestions made by Deputy Ó Cuív as I propose to stick to the prepared script for a change because it provides a detailed statement on the service plan. Private Members' business is structured in a way that does not allow for the type of informal debate that would be well worth having. Perhaps we should seek to arrange an informal and respectful debate on the issues raised by the Deputies opposite. All of us agree that the difficulty lies in the cost of change and how we would allow people to live a different life. A serious examination of this cost of change is needed.

I very much welcome this opportunity to address the House on the Health Service Executive's national service plan for 2015. It is important to recognise that the funding provisions set out in the 2015 plan constitute a very welcome turn of the tide after an unprecedented seven years of significant and continuing reductions in funding for health and social care services. In the period between 2008 and 2014, funding in excess of €1.5 billion was taken out of the health budget as a direct consequence of the financial emergency the State had to address. During this period of unprecedented budgetary constraint, the number of health sector staff was also reduced by more than 11% or almost 12,000 employees at a time when demand for health services continues to increase owing to the welcome growth in and ageing of the population. It is important in this context to acknowledge the resilience demonstrated by workers across the health service during these most difficult of times and the significant efficiencies and improvements in productivity that were achieved during this period. It is also important to acknowledge the improvements across a range of services, including stroke, cardiac and cancer services. Improvements in cancer services had their origins in measures which were introduced and driven by the previous Government. These achievements were made despite ever reducing budgetary ceilings and staffing resources.

Against this backdrop, it is most welcome to be able to report to the House that in 2015 the Health Service Executive will have an improved rather than sharply reduced level of resources to work with in delivering health and social care services to members of the public. The health allocation provided for in the 2015 budget constitutes a first step in reversing the prolonged cycle of budget cuts and is part of a two year process to stabilise and improve health funding. With this in mind, the spending ceiling for health in 2016 has been also already increased upwards by a further €174 million. For the first time since 2008, health funding is moving in the right direction. The net result is a very welcome increase in the financial resources available to the HSE in 2015.

The HSE will have €635 million more to spend next year than it did this time last year. This figure is made up of additional Exchequer funding of €305 million and projected one-off revenues of €330 million. The HSE has also identified a minimum savings target of €130 million in areas such as procurement and drugs and agency costs. In a welcome new development, any further savings that can be achieved over and above this target will go back into the delivery of health and social care services and will not be used to reduce the Exchequer provision, as occurred in previous years. Given overall expenditure constraints and other pressures on the public purse, it is important that full use is made of this incentive as a dynamic contributor to the delivery and reform of services within the expenditure level determined by government.

The more realistic budget parameters for 2015 have allowed the HSE to prepare a service plan which further progresses key elements of the health service reform programme and targets certain priority health and social care service enhancements in a number of areas, while providing generally for the delivery of existing levels of health and social care services. Deputy Kelleher should note that this was the point made by the director general of the HSE, Mr. Tony O'Brien.

Next year will be an important year for demonstrating the benefits of key reforms in the health service. We must all work collectively to improve safety, quality and the patient experience for those who depend on our services. It is also vital that qualitative aspects, such as the personal care and attention that patients receive, are the subject of focused efforts in order that people's experience of the health service is not only safe but also caring and pleasant.

I particularly welcome the integrated approach across acute, community and residential care settings to which the HSE has committed in its service plan to ensure patients are supported at all stages in the care setting that is most appropriate to their needs. This is most important in the context of the establishment and further development of the hospital groups and community health care organisations. The reorganisation of public hospitals into hospital groups is designed to deliver improved outcomes for patients. The hospitals in each group will work together to provide acute care for patients in their area, integrating with community and primary care.

The objective is to maximise the amount of care delivered locally while ensuring that complex care is safely provided in larger hospitals. The next phase of implementation of the hospital groups to implement fully the seven hospital group constructs is provided for in the service plan. Hospital groups will also develop and deliver strategic plans in 2015, setting out how each group will provide high-quality, safe, integrated patient care in a cost-efficient manner during next year.

The Government is also committed to the introduction of activity-based funding, formerly known as money follows the patient, whereby hospitals are paid for the quality care they deliver. This funding model will drive efficiencies and increase transparency in the provision of high-quality hospital services. The HSE intends to implement this new funding model further on a phased basis during 2015. In addition, 2015 will see the establishment of national community health care organisations and their management structures by the HSE. This represents an important step in improving how primary care in the community is delivered. The new structures will improve services for the public by providing better and easier access to services, closer to where people live and in which people can have confidence.

I also want to highlight the work of the national clinical programmes as an example of clinical leadership. They have already greatly improved services in many specialised areas, such as stroke and cardiac services. The HSE service plan will see the development of these national clinical programmes into five integrated care programmes, dealing with patient flow, older persons, chronic disease prevention and management, children's health and maternal health, and will improve the integration of services, access, and outcomes for patients generally. These developments will ensure that the new integrated clinical programmes are very much at the centre of operational delivery and reform, and I warmly welcome this development.

There are many positive service developments provided for in next year's HSE service plan. Key commitments in the programme for Government that will be delivered next year include the extension of the BreastCheck programme, the introduction of free GP care to the youngest and oldest in our society, an expansion in the level of investment in our mental health services, and further investment in suicide prevention. There is also provision for 20,000 additional day surgery cases, additional funding of €2 million to improve maternity services, improved pilot ultrasound access for GPs in priority care sites and additional spending on community orthodontic and ophthalmic services.

An additional €25 million is being provided to help address delayed discharges from acute settings which will fund a range of community and non-acute supports, including an additional 300 beds under the fair deal scheme, the provision of 115 short-stay beds, including the opening of Mount Carmel as a community hospital for Dublin, 600 more home care packages and the extension of community intervention teams. As Deputy Ó Cuív correctly said, this is an issue into which we need to put more resources and plan well for into the future.

I will provide further detail on a number of the priority health and social care service enhancements set out in the 2015 service plan. Breast cancer survival rates in Ireland have improved significantly in recent years through a combined approach of screening, symptomatic detection and improved treatment. Additional funding is being provided in the HSE service plan to commence the extension of the BreastCheck screening programme next year to women aged 65 to 69 years of age. Screening of the extended cohort will commence towards the end of 2015 and will be expanded incrementally. The additional eligible population is approximately 10,000, and when fully implemented, 540,000 women will be included.

The 2015 service plan provides for the implementation of the first two phases of a universal GP service, making available a GP service without fees to all children under six years of age and all persons over 70 years of age . The aim is to have universal GP care without fees for children under six years of age implemented early next year, subject to the conclusion of discussions with the Irish Medical Organisation and the completion of a fee-setting process. The measures for those over 70 years of age will be facilitated under the existing general medical card contract after the relevant legislation has been passed by the Oireachtas. By the end of next year, almost half of the population will have access to GP services without charges. That is a major step on the way to universal health care.

In response to Deputy Calleary, there are many medical cards in the system. What happened in the case he cited should not have happened, but when there are many cards in the system, one will always have hard cases because of the human element. We need to ensure what he described happens to as few people as possible.

The service plan also provides an additional €30 million to fund access to new hepatitis C drugs in 2015. This has the potential to bring major benefits for patients with serious illness as a result of hepatitis C. As with other countries, Ireland must ensure that access to high-cost treatments such as these is managed so as to prioritise access for patients who can benefit most, while also ensuring that the financing model is sustainable and affordable. The aim is to provide access for as many patients as possible with the resources provided by taxpayers. An early access programme for more than 100 patients with the greatest clinical need for these new direct acting anti-viral drugs is already in place.

Budget 2015 provides an additional €35 million in ring-fenced funding for mental health. This will bring to €125 million the total investment by the Government in mental health services since 2012. The additional funding will enable the HSE to continue to develop and modernise our mental health services in line with A Vision for Change. This includes the ongoing development and reconfiguration of general adult teams, including psychiatry of later life, and also child and adolescent community mental health teams, along with other specialist mental health services. This will be delivered through further recruitment and investment in agencies and services to achieve a consistent provision of quality services across all areas.

It will supplement the considerable investment since 2012 in the recruitment of up to 1,100 posts, which is due to be completed in 2015 when all the posts allocated for 2014 will be fully recruited. The funding will also permit urgent specialist needs to be addressed, including services for those with mental illness and an intellectual disability, psychiatric liaison services and addressing the gap for low secure acute care and rehabilitation services for service users with complex needs. Suicide prevention services will continue to be funded under the mental health heading, in line with the mental health promotion and stigma reduction objectives of A Vision for Change. A new suicide prevention strategy to replace Reach Out 2005-2014, the current national strategy, is in the final stages of development. Subject to Government approval, it is expected to be launched in early 2015.

Deputies will be aware that there has been a continuing upward trend in delayed discharges since the beginning of this year, with approximately 850 delayed discharges reported nationally. That is the equivalent of a large hospital. This is having a knock-on effect on hospital emergency departments, levels of elective admissions and on the health and welfare of the patients. I am very conscious of the upset this causes for patients and their families. Many of these patients are elderly and have been medically assessed as being well enough to leave hospital. Their health needs would be better met at home, in step-down facilities or in long-term residential care.

In response to these concerns, the 2015 service plan includes an additional €25 million to help address the issue of delayed discharges. This includes €10 million to support an additional 300 long-stay care places under the nursing home support scheme and to reduce waiting times for funding under the scheme to 11 weeks; €8 million to provide 115 short-stay beds, including the opening of Mount Carmel as a community hospital for Dublin; €5 million in extra funding to support an additional 400 home care packages; and €2 million to expand community intervention teams to deal with 2,000 referrals each year.

This additional funding in the service plan will allow the HSE to continue to progress the realignment of services towards home care and other community-based support services, where appropriate, to maximise the potential for older people to be cared for in their homes, close to their families and within their own local communities. Services will continue to be provided to avoid hospital admission and support early discharge through step-down, transitional care and rehabilitation beds, while maximising access to appropriate, quality, long-term residential care when this becomes necessary. It is also recognised that the matter of delayed discharges is not a matter that can wait until the new year to be addressed further and, in this regard, measures are under way to deal with this area of concern throughout the closing weeks of this year.

Other developments for 2015 include provision for 20,000 additional day surgery cases, additional funding of €2 million to improve maternity services and further development of primary care services, with an additional allocation of €14 million to fund measures to allow people to receive a wide range of high-quality services in their communities without having to present at hospital accident and emergency departments. This, in turn, will ease pressure on our hospital system. An example of developments that will be initiated in this area in 2015 include the extension of the pilot ultrasound access project to additional primary care sites on a prioritised basis next year and the provision of additional minor surgery services in agreed primary care settings and sites. There will also be an extension of GP out-of-hours services, within existing resources, to areas currently not covered, and additional spending on community orthodontic and ophthalmic services.

It is of utmost importance that patient safety remains an overriding priority across the health service in 2015, and this is reflected throughout the HSE's service plan. All health service staff, individually and collectively, will continue to have responsibility for the quality of services they deliver to the patients and service users in their care. It is important that they integrate a commitment to quality and safety into their core work and practice. Priority areas that were identified in this year's service plan will continue to be the focus of attention. These include medication safety, health-care-associated infections and the implementation of the national early warning score system.

The HSE will also have more autonomy with regard to staffing and human resources in 2015 and will be in a position to take on more temporary or permanent staff in order to achieve savings on agency costs, subject to compliance with its overall pay allocation. The HSE will be in a position to more readily contain and control the frequency and cost of agency staffing across both the HSE and HSE-funded services in 2015. The plan includes measures to bring this into effect, including the replacement of agency staff by fixed-purpose employment contracts and a focus on the retention of graduate nurses.

Management of health spending within available resources next year will require an exceptional management focus, with strict adherence by all services and budget holders to their allocations. However, with greater autonomy and greater capacity to utilise any further savings achieved within the health service comes an even greater responsibility for cost containment and cost avoidance. With this in mind, the HSE's 2015 service plan will continue to develop and strengthen its governance and accountability framework. The service plan provides for a considerably enhanced governance and accountability framework for 2015. This framework describes in detail the means by which the HSE, hospital groups, community health organisations and other units will be held to account throughout 2015 for their efficiency and control across the balanced scorecard of access to services, patient safety, finance and human resources.

A key feature of the new accountability framework will be the introduction of formal performance agreements between the director general and each national director for services and between each hospital group and community health care organisation head and the relevant national director. The framework is primarily focused on supporting improved performance. However, a feature of the framework is an arrangement for escalating areas of underperformance and specifying the range of interventions to be taken in the event of such underperformance.

Notwithstanding the positive and welcome developments that are provided for in the 2015 service plan, HSE management, the Minister, Deputy Varadkar, and I have been honest and up-front about the limited nature of what can be achieved with the additional funding available next year. It is also apparent that we do not have sufficient funds to address all areas of concern across the health sector immediately. For example, on the matter of the increasing demands and demographic pressures being placed on our hospital system, health care demand continues to rise due to our growing and aging population, the increasing incidence of chronic conditions and advances in medical technologies and treatments.

While the service plan provides for an increase in combined inpatient and day case activity in 2015 as against 2014 projected outturn, the Minister and I have acknowledged that there are too many people waiting far too long for operations and outpatient appointments. The service plan includes a number of measures that the HSE is putting in place to address waiting lists more efficiently, including flexible usage of theatre capacity within and between specialties and prioritisation of day surgery admissions where appropriate. Other initiatives set out in the service plan, such as action on delayed discharges and developments in the primary care area, will also help to reduce the pressure on the acute system.

Against this background, the increase in health funding secured for next year cannot address all of the challenges the health service undoubtedly faces. What the additional funding can do is to make a very welcome start, after seven years of reduced resources, in the restoration of stability to the health service budget. The increase in funding will not solve every problem, but it does make the funding situation more manageable and the targets set out in the service plan more realistic and achievable. For the first time in seven years, the HSE service plan has not been prepared against a background of further retrenchment and reductions in both funding and staffing resources. As a result, the HSE has been able to prepare its service plan in the knowledge that the increase in funding available next year is the first part of a two-year process to restore stability and certainty to the health system and the funding of health services. This, in turn, has allowed the HSE, in its plan, to continue to provide existing levels of service while maintaining an overriding focus on quality and patient safety, and to deliver certain new service enhancements in line with programme for Government commitments.

The early completion and approval of the 2015 service plan also means that the HSE can complete its detailed operational planning within the next two to three weeks. This will ensure that the executive is in a position to monitor its spending and performance from the outset of the year, which is of central importance from a governance and accountability perspective. I strongly commend the Government's amendment supporting the HSE's 2015 service plan to the House.

Listening to the contributions of Deputy Kelleher et al., I felt it was a bit like the parishioner who at the beginning of Holy Week went to the sacrament of reconciliation but, not having the courage to go in private to the confessional, went for the open absolution instead to purge himself of his sins.

I am sorry Deputy Martin is not present tonight, because he was the architect of much of our health policy. I am curious as to why we are debating the motion outlined by the Fianna Fáil Party, because we now have a health system on the brink of reform and have a better health budget than in the past seven years. I accept we have a difficulty in regard to the reconfiguration of the service, particularly in the south. I appeal to the Minister of State to consider this, particularly in regard to ophthalmology and the reconfiguration of these services in Cork, because the deficits in that area need to be addressed.

I am amazed that we are discussing a Private Members' motion on health put forward by a party that has no plan or policy.

Fine Gael has no plan either.

The sum total of the Fianna Fáil health policy amounts to just 244 words tonight criticising a budget and service plan that delivers more for health than Fianna Fáil ever dared consider. I accept the motion is not down to Deputy Kelleher, but it is the continuation of the Punch and Judy theme Deputy Martin promised to get rid of. However, he constantly resorts to that tactic to make himself and his party relevant to the public. Tonight's motion is a continuation of this. It proposes nothing, seeks to achieve nothing and lacks any kind of ambition. At the same time, Fianna Fáil is against the Government, which has-----

Universal health insurance-----

Which is part of a two-term policy.

Abolishing the HSE.

We have committed to abolishing the HSE.

We have begun the process of reform but we have always said that reform will take time. It has not been abandoned, as Deputy Kelleher knows, and the Future Health strategy framework is the blueprint for that. Let us look at what the Government has done in its time in office in terms of the clinical programmes and in terms of capital. Today, we were at the national children's hospital, which is going to be built and which is a commendable sign of this Government's commitment.

It is important that we have a constitutional convention-type approach in health. I believe we might look at having 100 people from all the different parts of the health system come together, devoid of their personal and professional interest, to have a detailed national conversation around our health system and how we can deliver it in a way that has the patient at the centre, at the coal face, and where vested interest is left outside.

The Minister of State alluded in her speech to the recruitment of front-line staff. The Fianna Fáil motion had a simple proposal that it would only recruit occupational and physical therapists. As Deputy Kelleher knows, while that is laudable, it fails to take account of the needs across the health system. I have always said in the House that the moratorium in health is not a one-size-fits-all approach and there are certain specialties which require a different approach. For example, the Minister of State has driven and achieved much in the area of mental health.

Following this speech, I will give the Minister of State a letter dealing with the issue of recruitment. I would like to bring to her attention the need for a child and adolescent psychiatrist with CAMHS serving the areas of Ballyphehane, Togher and Ballincollig in the city and county of Cork. That post has been advertised but it has not been possible to fill it, which is part of our difficulty. I commend the Government amendment.

The HSE national service plan for 2015 was published on 27 November following approval by the Minister for Health, Deputy Leo Varadkar. The service plan lays out the type and level of services that the HSE is to provide both directly and through agencies funded by it. The Fianna Fáil motion before the House focuses on this plan. In doing so, it focuses on one of the most important roles of government - providing appropriate, accessible health services. These are the services that we, as citizens, need right from our birth and throughout all our lives. Citizens are entitled to health services of a high quality and that respond to their needs. Good health is something we only fully appreciate when we no longer have it. Those who are sick and those with sick children and other family members are all too aware of the many difficulties facing this health system. Any parent would do anything within their power to ensure their child has the best care that will give them the best possible chance in life. Under our current system, there are so many examples of chronically under-funded and under-provided services. There are, sadly, so many areas in which sick children and adults are not given a chance at a healthy future. This must change but it appears, unfortunately, this is not a short-term priority for the current Government.

Dar le rún Fhianna Fáil rinneadh maoiniú ró-íseal ar an gcóras sláinte. Is rud é seo gur féidir linn aontú air. Tar éis gur thosaigh Fianna Fáil na ciorruithe, choinnigh Fine Gael agus Páirtí an Lucht Oibre orthu ag ciorrú caiteachais atá riachtanach don tsláinte. D’fhág sin muid sa riocht ina bhfuilimid anois.

The motion states, “the 2015 Health Service Executive National Service Plan is not sufficient to fully address the increasing demands and demographic pressures being placed on our hospital system”. This is a point I have made on several occasions over recent years, including when Fianna Fáil was in power. I feel that this oft-repeated fact will once again fall on deaf ears. There appears, again sadly, to be little recognition from the current Minister and the Government team that population demands on the service are increasing and need to be met.

The motion then reads: “key targets in the Plan are regarded as unrealistic by its authors.” This is true. Authors of the plan itself recognise that some of its key targets are unrealistic. This is an indictment of the Health Service Executive and of the Government, in particular, regarding the manner in which plans are drawn up and promises are made when they know full well they will be unable to deliver on many of them. This recognition by the authors can be seen in the following passage from the service plan: “After many years of significant financial reductions, this additional resource will assist in the allocation of more realistic budgets enabling the health services to maintain the current levels of services.” Some hope in 2015, I fear. Fianna Fáil calls “on the Government to fund the health services appropriately and sufficiently in 2015”, something, of course, it failed to do during its later years of opportunity.

I have previously described the HSE national service plan as wholly inadequate. There are now 50,000 outpatients on waiting lists for more than a year. There is nothing in this so-called national service plan that reassures me that these numbers can be significantly reduced in the short term. The fair deal continues to be under-provided for, leading to families stretched to breaking point and delayed discharges, yet this plan only offers the already announced €25 million. An extra 300 nursing home places will be provided for next year but there are currently 2,000 people who have been medically assessed as needing nursing home care and who are awaiting fair deal payment.

The minor increase in numbers of doctors and nurses is undoubtedly necessary but the numbers mentioned only go a very small way towards addressing some of the most savage cuts in staff numbers in recent years. I note there are many unfilled GP places at present, including in my own constituency, with our qualified doctors opting to work abroad in many instances. This exodus, apart from the tragedy of it, is extremely expensive as it means we lose graduates who have received heavy State investment throughout their education.

Many of the positive measures in the plan were already announced before the plan was presented. I have welcomed the additional €20 million funding for disability services but this is only a drop in the ocean. In Sinn Féin’s alternative budget, we would have provided an additional €31 million for these services, openly acknowledging, as I did, that even that would not be enough due to years of severe under-funding. Some €25 million is allocated for free GP care for children under six years of age, yet we still are not sure whether there will be a so-called "nominal" charge by GPs for this care. Will the Minister of State, Deputy Lynch, update us on this point?

It was never a runner.

It has not been ruled out - the Minister has not done so. The plan projects savings of €95 million next year in further medicine price reductions and reforms in the medicines procurement process. The plan does not, however, provide comprehensive detail of exactly how these savings would be realised. By the end of 2014, the top 20 medicines, by cost to the State, will be fully interchangeable, generic-for-branded medicines. When this occurs, further savings will become more difficult. I ask the Government to outline what specific medications will be targeted and in what way they will be targeted to ensure that further savings can be made. The Minister for Health has suggested that revised drug pricing agreements will be concluded with the representatives of the pharmaceutical industry - branded and generic - in Ireland at the start to the middle of 2015. In the past, these discussions have taken extended periods so I ask the Government to ensure these negotiations take place as a matter of urgency so savings can be made in 2015. In concluding, the Minister of State might advise when she expects them to conclude? We are told there can be savings from reform of the procurement of medicines. How exactly is this to happen?

There are some additional measures that could also be looked at. The medications known as biosimilars, designed to replace some high-tech biologic medicines, are accepted as having the same safety and efficacy as biologics.

This should be investigated as it could offer a significant saving.

Changing from a branded medication to a generic medication is not recommended for someone with certain conditions such as epilepsy who is stable or transplant patients. I have vocally supported this time and again. However, could those who are newly diagnosed with such conditions start their treatment on generic medicines and then be maintained on them in the longer term? This approach could also reduce the spend on drugs and, very importantly, offer the same level of efficacy.

The service plan fails to give much succour to those families dealing with mental health challenges. Budget 2015 laid out as a Government priority the development of community mental health services. While I welcome this aim, I note that little of substance has been provided to further it. It has been suggested more than 50% of the population suffer from some degree of mental ill health before the age of 25 years, which is a shocking statistic. This affects not only the individuals themselves but also the structures surrounding them. As in many other areas of the health system, mental health services have been grossly underfunded for many years.

Budget 2015 told us nothing that would reassure us that major change was on the way. While funding increases might be hard to attain, there are many measures the HSE could introduce that would not rely solely on increased budgets. A Vision for Change was published in 2006 and so much has changed since. If it is not to be implemented in full soon, we will need a new road map for how we progress the further development of mental health services. We certainly need an urgent assessment of mental health services, including the NGO sector, and to examine how best to integrate it. I am contacted regularly by citizens from all across the State who have difficulty in seeking the appropriate care. I suggest there is an element of a postcode lottery in this respect. Citizens should be able to rely on quality services no matter where they live.

I have said before the plan is being sold as adding an extra €625 million to the health spend next year, but of this €510 million represents the 2014 so-called overspend to be carried forward, leaving only an additional €115 million. Knowing the HSE's history, the likelihood is that much of this and more will be used to cover the cost of increased usage of the services that comes naturally with population demographics. Tacaím leis an rún. I will be supporting the motion.

There is an effort by the Government to pretend that the appointment of Deputy Leo Varadkar as Minister for Health will somehow wipe the slate clean of the damage already done by it to the health service. This plan is part of that spin, but, in fact, we can see that some of the measures announced as part of the new national service plan were already announced and that the plan for 2015 is not enough to deal with increasing demands and a growing population who depend on hospitals. My constituency is a prime example of how the service has been run down in some cases and directly and savagely damaged in others. It is hard to even call it a health service when the HSE's own management data service report for September shows that there were 7,800 on Kerry County Hospital's waiting list, of whom an incredible 2,216 had been waiting for over six months, a further 654 had been waiting between one and two years and a further six had been waiting for longer than two years. When it gets to the stage where nearly 8,000 people are waiting to see a consultant, it shows that the system is dysfunctional.

There is nothing in the plan that will reduce numbers significantly in the short term. Of course, I welcome the small increases in the numbers of doctors and nurses, but what has been announced will go only a very small way towards reversing some of the serious cuts in staff numbers in the past few years. The underfunding of Dingle and Kenmare community hospitals is an issue which is having a serious effect on the communities which depend on them. There are six hospital beds with no funding available to use them. Six beds are lying idle. That equates to six people who need a hospital bed, but who cannot get one because there is no funding available to service them.

Lip service is being paid to the need for early intervention for children with special needs. Everyone involved in the care of these children will testify to this, especially the parents. Children with special needs are being allocated SNAs for only half of their preschool hours, which means that parents have to take them out of school for the remaining period. An additional €20 million in funding for disability services has been announced, but this is very inadequate and will not fix the problems caused by successive cuts since 2008. Meanwhile, the Kerry Parents and Friends Association has had its funding cut by €44,000.

There has been a lot of publicity given to the new system for the issuing of medical cards, but meanwhile I have a constituent with terminal cancer who has to make do without one. I see this man every week walking the road and my daughter and I have contacted the Minister's office. The man had a discretionary medical card, but it was taken from him. He is terminally ill, but he is still denied a medical card. It is an absolute disgrace when somebody coming towards the end of his days has to do without a medical card because of the attitude taken by the Government. What is absolutely disgusting is that no reply has been received from the Minister's office. I have another constituent who has visited the accident and emergency department with severe headaches but who has been told he or she must wait 18 months to be seen by a consultant. These are real people who are being denied a basic right to a proper health service.

It does not matter how much the Government spins the figures. It is particularly misleading to suggest the so-called "extra" spend of €625 million is happening when €510 million of it will be used to cover the overspend this year. It is hard to watch while money is being spent on agency workers and basic services are suffering. Again, I go back to the practical experiences other Deputies and I have had with people who deserve a service. Will the Minister of State explain to me why somebody who is terminally ill and had a discretionary medical card until a number of months ago had it withdrawn? There is no explanation for it. The Minister's office did not even have the decency to issue a reply to explain why that was the case. I will send the facts to the Minister of State to see whether she will do something about it as the Minister has done absolutely nothing about it. I am looking at the man in question walking the road every week, knowing that his time is short and that he needs a medical card.

I welcome this very important motion which I will be strongly supporting it as it focuses on what is really going on in the health service. I also commend my colleague, Deputy Billy Kelleher, for bringing forward this excellent motion which hits the nail on the head in respect of three very important issues with which I will deal.

The Government needs to wake up, listen and look at the real reform agenda needed in the health service and the urgent need to place patients at the top of the agenda. Let us look at the context and details of the motion. The health service is underfunded. The 2015 HSE national service plan is not sufficient to address fully the increasing demands and demographic pressures placed on the hospital system. The key targets set in the plan are regarded as unrealistic by its authors. We call on the Government to fund the health service appropriately and sufficiently in 2015. This will take leadership and tough decisions. Tax cuts while children are ill, senior citizens are lying on trolleys or people with disabilities are without a proper service should never be an option.

That is the tough decision we must make on behalf of these people. We have to put our citizens first and the well-off further down the list. Of course, no Government will accept this or take the tough decisions in the interest of the patients. The reform agenda can be knocked down to a number of key issues. First, the Minister should allocate any extra money to accident and emergency departments to get senior citizens and sick patients off trolleys and into proper beds. The issue is a shortage of beds. Second, the Minister should focus on respite and residential care and providing adequate services for people with disabilities. I welcome that €20 million will be spent in this area but, as Deputy Ó Caoláin noted, we need between €30 million and €40 million. I welcome this debate and urge all Deputies to support Deputy Kelleher's motion.

The health service has suffered serious damage over the last six years. Budget cuts have amounted to some €3.5 billion and almost 12,000 staff have been lost to the service. The situation would be much worse than is currently the case but for the health service's dedicated and committed staff. We should pay tribute to staff across all categories who go beyond the call of duty every hour of every day. Together with underfunding and lack of resources, demographic changes are exacerbating an already difficult situation for the health service. The population of those aged over 65 years is growing at double the EU rate and will increase by 20,000 people per year until 2021. The population of those aged between 80 and 84 years will have increased by 20,300 or 29% by 2021 and the population of those aged over 85 will increase by 26,800 or 46% in the same period.

These demographic changes and the underfunding of the health service give rise to a number of issues. The number of patients being forced to wait on trolleys and in chairs in accident and emergency departments is increasing. This is an unacceptable practice which is reminiscent of Third World conditions, with a lack of privacy, inadequate facilities and, often, non-existent bathroom and toilet facilities. We need to set up community intervention teams who can carry out procedures on people in their homes so they do not require admission to hospital. The fair deal scheme needs to be properly funded. The waiting time of 15 weeks is simply too long and even the proposed 11 weeks is unacceptable. We also need community services, such as additional home care assistance and home help, as well as additional appliances. Elderly people are waiting significant lengths of time for chairs, walkers, beds and wheelchairs. The hospital I know best is South Tipperary General Hospital, which is a progressive facility that is almost regional in its scope. Despite cuts of almost one quarter of its budget and up to 200 staff, its activity levels have increased significantly and it is working at 120% capacity. The number of trolleys has increased from 750 in 2011 to 3,100 in 2013. We need additional beds, including step down beds. Twelve beds were promised at Our Lady's hospital in Cashel. We also need additional nursing and support staff in accident and emergency departments.

Debate adjourned.
The Dáil adjourned at 9.05 p.m. until 9.30 a.m. on Wednesday, 3 December 2014.