Priority Questions

General Practitioner Contracts

Billy Kelleher


1. Deputy Billy Kelleher asked the Minister for Health if he will provide an update on the implementation of free general practitioner, GP, care for the under sixes; the number of GPs who have signed up to the new contract; and if he will make a statement on the matter. [21016/15]

Will the Minister of State elaborate on this matter? My question arises on the back of the extension of the deadline, which I assume arises because there has not been a large uptake. There are genuine concerns that a large number of GPs do not find this contract as attractive as it might be.

The introduction of universal GP care for all children aged under six years represents the first step in the phased introduction of a universal GP service without fees. The new enhanced service will involve age-based preventative checks focused on health and well-being and the prevention of disease. The contract will also cover an agreed cycle of care for children with asthma under which GPs will carry out an annual review of each child diagnosed.

The contract for the under sixes was issued to GPs by the HSE at the end of April following the conclusion of contractual discussions and the approval of fee rates by Ministers. GPs are self-employed contractors and it will be up to each individual GP to decide whether he or she wants to sign up and provide this new enhanced service. A substantial number of GPs have signed the contract to date. As of 27 May, some 830 doctors had returned signed contracts to the HSE. The executive anticipates the receipt of further signed contracts in the coming days. I am confident that there will be sufficient numbers of GPs participating to introduce the new service as planned.

The HSE plans to begin patient registration for the under sixes service on schedule in early June so that the service can commence in early July. In order for a doctor's details to be included in the HSE's online database when patient registration begins, signed contracts must be returned by 5 June at the latest. The HSE will continue to accept signed contracts after that date and will add the details of the doctors concerned to its database on an ongoing basis.

This service will be of great benefit to young children and their families. It involves significant new elements that support the Government's policy of keeping people well. It is tangible evidence of our commitment to the goals and objectives of the Healthy Ireland framework. I welcome the fact that this important new service will commence in July.

I thank the Minister of State for outlining what has happened. We tabled our question because this is a key platform in the delivery of health care and the roll-out of universal access to GPs. It is also a stated policy of Government that feeds into the move towards primary care. The contract is important. The negotiation of the broader General Medical Services, GMS, contract is, conveniently, to conclude next April.

Let us be honest - free GP care for the under sixes does not appear to be getting off to a great start. Why has there not been a large uptake? Why are GPs not clamouring at the Minister of State's door to sign contracts?

Will the Minister of State clarify whether contracts are being offered to GPs who have not undergone the vetting process? This issue was reported at the weekend.

Neither I nor Deputy Kelleher would want to give a signal that, somehow or other, there are GPs practising who are not on the specialist register. They are all on it. The contract is not available unless a GP is on the specialist register. This reassurance needs to be made.

There has been a significant uptake. In the coming days, there will be more. It is not as if we will have a cut-off point on 5 June. Rather, that is the point at which we will start putting details online so as that young families can see who is available in their areas.

Delays resulted from the court case that was taken by an individual. The courts determined to give the HSE two weeks. However, there is no delay in registration or access. That process is going ahead. As we speak, more contracts are arriving. Deputy Kelleher will agree that GPs, by their nature, are cautious people, and so they should be, as they are dealing with the health of the nation. They want to consider what is available to them. In the main, though, they are signing up and we are receiving new contracts every day.

What would the Minister of State consider a successful rate? The register will be published on 6 June and families will be able to see which GPs are partaking in the scheme. Geographical access will be important. The rate of uptake is one matter, but if large geographical areas see no uptake by GPs, has the Government a plan B?

There is no plan B. Plan B is not an option.

The Minister of State does not contemplate defeat.

I never do, as the Deputy knows. He has known me for long enough. Even before this process began, we experienced difficulties with GP coverage in certain areas. Workforce planning in terms of what needs to be delivered in a primary care service in the community will always be a challenge for us.

As to what number I would consider a success, I would prefer 100%, but we will never get that. Certain practices do not have a large cohort of under sixes. Therefore, it will not be an issue for them. Whether the rate of uptake is 80% or 60%, as long as there is coverage in the country and options for young families, it will be a success. However, the real success was getting the commitment of a Government to introduce this scheme. I do not doubt that Fianna Fáil will support it as well.

Patient Safety Agency Establishment

Caoimhghín Ó Caoláin


2. Deputy Caoimhghín Ó Caoláin asked the Minister for Health the reason the Government decided to drop plans by the former Minister for Health, Deputy Reilly, to establish a patient safety authority and who described the proposal as a critical part of any new health service, stating that it must be underpinned by legislation; his views that a patient advocacy agency, as is now suggested, would operate to complement a patient safety authority that would be equipped to ensure enforcement of the Health Information and Quality Authority, HIQA, standards and recommendations; and if he will make a statement on the matter. [20886/15]

Despite the fact that the former Minister, Deputy Reilly, described the commitment in the coalition programme for Government to establish a patient safety authority as a critical part of any new health service, why did An Taoiseach announce in October 2014 that the Government was not proceeding to establish a patient safety authority on a statutory basis, opting instead for a patient advocacy agency?

I am strongly of the view that any new patient advocacy service should be set up independently of the HSE from the outset. For this reason, the HSE removed reference to the establishment of an interim patient advocacy agency from its service plan for 2015. My view has been supported by the recent recommendation made in the HIQA investigation report on services at Portlaoise hospital on the need to establish an independent patient advocacy service. HIQA's recommendation is that an independent patient advocacy service should be in place by May 2016. I fully agree with the recommendation and intend to see it implemented in advance of the timeline provided by HIQA.

The scope, role and functions of the independent advocacy service will be considered, with the appropriate structural, governance and funding arrangements that need to be put in place. My Department will be consulting widely on the best way to get the service up and running in the shortest possible timeframe. The role of the independent patient advocacy service will be to support and advocate for patients in their dealings with the health service. Regrettably, the health service has not been as responsive to patients who have had bad experiences as is required. A patient advocacy service can assist in redressing the balance in the relationship between patients and service providers.

Enforcement and implementation of HIQA recommendations are also essential. Creation of a further body, with a potentially overlapping role with existing statutory bodies such as HIQA, is not my preferred solution. In many ways, HIQA is already a patient advocacy agency and has very strong powers to monitor service providers' compliance with national standards, conduct targeted inspections and make recommendations. As part of my 2015 priorities, I committed to developing a new mechanism for demonstrating that HIQA's recommendations were being implemented by the HSE. Discussions are under way between my Department, HIQA and the HSE to finalise this mechanism which will see action plans to implement HIQA's recommendations transparently reported on and monitored. In the meantime, I have put in place a specific oversight mechanism for the implementation of the recommendations made in the Portlaoise hospital report. This process will be chaired by the Chief Medical Officer and will submit monthly reports to me which I will publish on a quarterly basis.

The Minister did not address my question at all. I understand he is not the author of what he has just read, but, not only in the question I posed to him but also in the brief introduction I delivered orally, I asked why a key component of the plan announced by the former Minister in respect of the Government's policy on health, namely, the patient safety authority, had been dropped. It was announced by the Taoiseach in October 2014 that there were no plans to proceed to introduce a patient safety authority. Surely it should not be a case of either-or between a patient safety authority and a patient advocacy agency. When the matter of patient health and safety is involved, one should complement the other. It is interesting that within two months of Deputy James Reilly's removal as Minister of Health this was the position articulated. I note this followed a statement from the Department of Public Expenditure and Reform on new structures, including the patient safety authority, describing them as being part of the proliferation of quangos. The Department of Public Expenditure and Reform is not known for its caring nature, let alone its knowledge and appreciation of the reforms necessary in the health service. Did the Minister, Deputy Brendan Howlin, play a role in influencing the decision not to proceed with the establishment of a patient safety authority?

No. The Minister, Deputy Brendan Howlin, and the Department of Public Expenditure and Reform had no role to play in the decision, rather it was a policy decision taken by me. The plan before I took office was to establish a patient safety agency as a sub-agency of the HSE and the post of CEO of that sub-agency was advertised. The CEO would have been an employee of the HSE. I decided, however, that the original plan was wrong on two counts. First, a patient advocacy function should be independent of the HSE from day one. Staff should not be employed by the HSE; its budget should not be controlled by the HSE and it should be a separate entity, funded by my Department, for obvious reasons to avoid conflicts of interest. Second, the previous plan was to establish a patient safety agency that would, in fact, duplicate the functions of HIQA. HIQA has extensive patient safety agency functions. It is a patient safety agency which will have additional functions, including licensing, to enforce its recommendations in the future. Therefore, something different was needed. We did not need a duplicate HIQA as a sub-agency of the HSE but a totally independent patient advocacy service. That was my thinking, which has now been confirmed by the recommendations made by HIQA. My understanding is that the Deputy accepts HIQA's recommendations and supports the establishment of a patient advocacy service. Therefore, we agree on that point. Perhaps the Deputy might tell me what a separate and additional patient advocacy agency would add that is not already provided for.

The Minister is a very confused holder of his portfolio this morning. He should play back what he has just said. I fully accept that a patient advocacy agency is a requirement and the subject of one of the recommendations made in the Portlaoise hospital report. I also agree that it should be independent of the HSE. The current position where Patient Focus has performed this role and performed it well for many years is that it is directly funded by the HSE, which is inappropriate. We are ad idem in that respect. However, a patient safety authority is an entirely separate proposition.

If the Minister allows me to answer, perhaps he might learn a little. The point is - the Minister knows it as well as any other voice in this House - that HIQA's reports, findings and recommendations are continuously ignored by the HSE. The Minister's Department is not playing the role it should have been in insisting on recommendations being acted on and implemented. We have report after report from HIQA with recommendations that have been ignored. We need a patient safety authority, acting not only on HIQA's recommendations but also the findings of reviews commissioned by the HSE, many of which have been completely ignored. We need a body with the power to act and ensure health and safety are always the critical factors, rather than budgetary considerations at the expense of people's lives.

I am very glad that we agree that a patient advocacy service is needed and that it should be independent. It is not the case that HIQA's recommendations are ignored, as significant numbers are implemented. That has been the case, particularly in matters around hospital hygiene. The reports show that we now have the lowest MRSA rates in years. For example the rates for Clostridium difficile are falling. We have put an extra €5 million or €6 million into the ambulance service this year in response to HIQA's recommendations. However, not all of HIQA's recommendations can be implemented immediately. Some require spending, for which we do not have the capacity, while others are unlawful. For example, HIQA made a recommendation regarding the ambulance service, the implementation of which would have been unlawful. We would have had to change European law to implement it. It is not the case that HIQA is right about everything. If the Deputy talks to people who run nursing homes or nurses who work on a ward, they will give him chapter and verse. I agree with him, however, that we need to make HIQA's recommendations more enforceable. The way to do that is to give it the power to license hospitals. It would then have an added licensing function, to license hospitals to do X, Y and Z and if hospitals did not implement its recommendations, they would lose their licences. There is already that power in the case of nursing homes and care facilities, where HIQA can go to court to have them deregistered. I want to give it that power in the case of hospitals also. We do not need an extra agency to do this.

Cancer Services Funding

John Halligan


3. Deputy John Halligan asked the Minister for Health if he will confirm for the people of County Waterford and the south east the reason access to prostate cancer services at University Hospital Waterford is significantly below the national average, with only 16.7% of attendees seen within the target of 20 working days in January 2015; if any man has been sent to a private hospital to cope with this backlog; if he is aware that 50% of new attendees at the hospital's prostate clinic had a subsequent diagnosis of prostate cancer in February 2015; if the promised additional consultant urologist appointments for the hospital have been filled to address capacity issues in the hospital; if not, when they will be filled; and if he will make a statement on the matter. [20884/15]

Why is the level of access to prostate cancer services at University Hospital Waterford significantly below the national average, with only 16.7% of attendees seen within the target of 20 working days in January 2015? Has any man been sent to a private hospital to cope with the backlog? I draw the Minister's attention to the fact that 50% of new attendees at the prostate clinic in University Hospital Waterford received a subsequent diagnosis of prostate cancer in February.

University Hospital Waterford has experienced problems in recent months in achieving the target set by the National Cancer Control Programme for rapid access to prostate clinics. The target is that 90% of patients be seen within 20 days of receipt of a referral.

A number of actions have been taken by the hospital to improve the timelines of access for patients to prostate cancer services. These have included the referral of 37 new patients to St. Vincent's University Hospital in Dublin in February and the referral of 47 new patients to the Mater Private Hospital in November 2014.

Additional consultant urologists are required in University Hospital Waterford and the hospital has prioritised these appointments. One new consultant urologist commenced work in April and a second is due to commence work next month. When both consultants are in place, University Hospital Waterford will be better positioned to achieve the national access standards for prostate cancer services.

In February 2015 there were 24 new attendances at Waterford’s prostate clinic and, of these, four patients or 17% not 50%, have had a diagnosis of primary prostate cancer. In total in February, 12 patients received a prostate cancer diagnosis but it is important to say that some of these were not new attendances and they were not seen for the first time in February.

In conclusion, the development of prostate cancer services in Waterford has been identified as a priority and because of that significant service enhancements are now under way and the private sector is being used in the interim.

In the first few months of this year only one in every six men with potential symptoms of prostate cancer were referred to the prostate clinic in Waterford. Only one in eight men nationally were seen within the recommended deadline of 20 days of referral. The clinic is supposed to provide rapid access yet delays in filling staffing shortages in Waterford University Hospital have resulted in the longest delays. That is very worrying because according to the HSE's own figures, half of the men referred to the Waterford clinic were subsequently diagnosed with prostate cancer. I do not need to remind the Minister that early diagnosis is key to the survival rate of patients with prostate cancer.

We were promised additional consultant urologists. Could the Minister confirm whether he said a urologist who was appointed in April is now working in Waterford and that ancillary staff are in place?

It is a side point but it is important to get the facts right, in particular if some of this is going to be covered in local media. Approximately one in six new patients are diagnosed with cancer on referral, not half. What Deputy Halligan is including there are people who were already diagnosed previously and are returning to clinics.

I wish to be clear on that. It is not that half of people referred have prostate cancer. That would never be the case for a cancer clinic.

What has happened is University Hospital Waterford needed more staff and it was hard to get the staff. The private sector has had to be used in the interim and will be used if needs be. I do not like doing that but I have no qualms doing it if it is necessary for patients to get timely treatment. Recruitment for consultants is difficult. Deputy Halligan will know that the socialist high tax, low pay policies he supports would make it much harder to recruit the necessary staff. If he honestly believes that it would be easier to recruit consultants to Waterford by increasing income tax on those who are well paid, he does not have the interests of his constituents at heart.

I wish to make two interesting points. First, internationally, Ireland ranks among the lowest in Europe for urologists per capita. A recent European survey stated that there were only 23 urologists in Ireland representing a rate of 3.2 specialists per 100,000 males aged 40 and over. In Spain, the rate is 19 specialists per 100,000 of similarly aged males.

Hospital workers told me during the week that we could double the amount of urologists in Waterford and we would still not have enough to address the referrals. Does the Minister acknowledge that? I also understand that many patients who were on elective urology waiting lists had appointments cancelled because we simply did not have additional beds or theatre space. That has nothing to do with the cost of appointing a urologist. I am telling the Minister what staff in the hospital told me. Anytime I am in the hospital I speak to consultants and others about the relevant issues. They told me that the prime concerns are space, beds and ancillary staff. Therefore, even if we were to appoint urologists we do not have the facilities in place.

I said we appointed one urologist already and another will start next month. In view of the growing population and the fact that there will be more older men every year for the next 20 years or 30 years - I will get there at some point - we will need to increase the number of urologists every year. It may well be the case that we need to double the number of urologists in the next five to ten years. It is not an easy thing to do. It costs money. We need to be competitive with other jurisdictions such as the United Kingdom, Canada and America, which is the reason it is important that people do not vote for candidates who would impose high taxes on people who we are trying to recruit back home. That is why it is very much in the interests of people in Waterford who may have a cancer diagnosis that they do not vote for Deputy Halligan's politics at the next election. That is very important. It is not just consultants who are hard to recruit, we are also having difficulty recruiting theatre nurses. There is theatre space in Waterford but it is difficult to recruit theatre nurses as well. We are embarking on a campaign overseas and in the UK over the summer to try to improve the situation.

All I can say to the Minister is that he is completely out of touch with how people feel about hospital services in Waterford.

Services for People with Disabilities

Colm Keaveney


4. Deputy Colm Keaveney asked the Minister for Health the measures he will put in place to reduce waiting lists for disability-specific services; and if he will make a statement on the matter. [21017/15]

People with disabilities continue to face harsh cuts. The objective of the question is to find out what plans the Minister of State has to invest in services where there are deficits across the country, in order to ensure that people with disabilities on waiting lists can have a fulfilled opportunity to play an active role in society.

I appreciate the question but before I read the formal reply I should say that the budget for services, which is the focus of the Deputy's question, has not been cut. As a matter of fact there has been an increase.

The Government currently provides funding of approximately €1.5 billion to the disability services programme through the Health Service Executive's national service plan for 2015. The HSE aims to ensure that the resources available are used to best effect, in order to provide assessment and ongoing therapy to children and adults in line with their prioritised needs. However, it is acknowledged that current waiting lists for some therapeutic supports are high. We are coming from a very low base.

In 2013, additional funding of €20 million was provided to strengthen primary care services. This comprised €18.5 million for the recruitment of more than 260 primary care team posts and more than €1.4 million to support community intervention team development. In 2014, the roll-out of the Progressing Disability Services for Children and Young People programme entailed targeted investment of €4 million and the provision of 80 additional therapy posts, to improve services for children with all disabilities. As of 30 April 2015, a total of 47 of the 2014 posts have been filled, a further 20 are at the stage of "post accepted" and the process is ongoing for the remaining posts. A further €4 million allocation was announced in 2015 to continue work on this programme. I am confident that the additional resources being invested in both primary care and disability services will have a positive impact on the provision of clinical services to all children with disabilities, including those who may currently be on waiting lists to access therapy inputs.

Deputy Keaveney probably knows better than I that we are coming from a low base. The difficulty is that we are building up a system in order to ensure that people do not have to wait more than 12 months.

My question relates to disability services as opposed to the cuts to mainstream services that are taking place. I thank the Minister for the response on the specific area of investment in waiting list reduction. Currently, more than 400 people with disabilities are on a waiting list for speech and language therapy. A total of 1,000 people are waiting for physiotherapy. In particular, I am concerned about the growing waiting list for personal assistants. More than 520 people with disabilities are waiting for personal assistants and 680 are waiting for home help hours.

I welcome the renewed focus to address those waiting lists, as opposed to the cuts that have taken place with respect to mainstream services such as cuts in disability allowances, fuel allowances, drug payment schemes and the increase in prescription costs, among others. I am separating the issues in the response. I am particularly interested in the focus of investment on tackling waiting times with a greater urgency. The issue is critically important. Waiting times are of concern, and I am particularly alarmed at the volume and number of people who are waiting.

We are agreed on the point that these waiting lists are unacceptable and they need a particular focus.

That is why in 2014 the HSE began a waiting lists initiative using innovative approaches, including public voluntary and private providers, in order to achieve targeted reductions in waiting lists. The initiatives will continue to be funded this year. Given that we have provided additional resources of €20 million, plus €4 million for those aged up to 18 years, it is unacceptable that waiting lists continue to be as they are. I agree with the Deputy that the focus needs to remain on waiting lists for speech therapy and physiotherapy, in particular.

I compliment the Minister of State on focusing on this issue and her acknowledgement that it is unacceptable that waiting lists are spiralling in the light of the fact that, in theory, there has been some investment, although it is insufficient. In the light of the slightly unedifying spectacle on the last Priority Question about taxation, we need to see greater urgency. I would be grateful, therefore, if the Minister of State spoke to the senior Minister in that Department to secure greater resources. This issue needs greater urgency and focus and there also has to be greater political will. I do not doubt that the Minister of State has that political will, but perhaps the Minister needs to reflect on the scale of investment required to tackle the spiralling waiting lists.

The one thing I have learned in this job is that to rush system reform is to do it badly. In fact, both the project and the system should be well thought out and managed. We are building a system that will respond, but the building of the system will take time because, as the Minister rightly said in his last reply, it is quite difficult to get people through the recruitment process. We are having the same difficulties in disability services as in acute hospitals. In fairness to my parliamentary colleagues, there has never been resistance to the budget for the delivery of services. While I do not have responsibility for the social protection element, as the Deputy knows, in the case of the element for I have responsibility, I have received nothing other than complete support.

Hospital Waiting Lists

Caoimhghín Ó Caoláin


5. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will provide the details of all public hospitals using private facilities to provide treatment for those on waiting lists; the number of cases that have been treated in this manner; the cost of same; the locations where it has taken place; if potential conflicts of interest have been identified or investigated; and if he will make a statement on the matter. [20887/15]

I seek details of all known public hospital referrals to private hospitals and so-called private addresses on the same or adjoining facilities and ask the Minister if he sees potential for abuse in such arrangements.

Reducing long waiting times for hospital treatment is a key priority for the Government. Last January, taking into account current pressures on acute hospital services, I directed the HSE to ensure maximum permissible waiting times for inpatient and day case treatment, or a first consultant-led outpatient appointment, of 18 months by mid-year and 15 months by year end. In February, shortly after the 18 month maximum waiting time was announced, the number of inpatient and day case patients requiring treatment by the end of June to achieve that requirement was 4,995. As of last Friday, 22 May, this number had reduced by about half to 2,693. The HSE, in conjunction with hospital groups, is focused on delivering treatment targets through maximising the use of existing capacity within and across hospital groups in the first instance. However, there are key limiting factors, primarily in terms of theatre nursing staff and consultant manpower in particular specialties. Consequently, it has been determined that up to 1,500 inpatient and day case procedures may need to be outsourced. A notice to tender for the provision of these services was issued on Friday, 15 May by the HSE, with a view to contracting with service providers this week. It is anticipated that the outsourcing of treatment to private facilities will commence shortly and conclude by the end of June. The HSE has advised that the number of inpatient and day case patients waiting over 18 months will have been reduced by 98% between the announcement of the maximum permissible waiting time in January and the end of June.

As regards outpatient appointments, the number at risk of breaching the 18 month maximum waiting time by the end of June has reduced by 7,773 within the past seven weeks. As well as initiatives similar to those for inpatient and day case treatment, regular intensive waiting list validation and additional clinics will be used to further reduce waiting times for outpatient appointments.

In the context of this question, have potential conflicts of interest been identified or investigated, to the Minister's knowledge? Does he agree that a system where such referrals are allowed is open to abuse and presents a potential conflict of interest, at the very least? Given that practitioners are being paid in these instances a second time for work they are already contracted to do and handsomely paid to carry it out, does the Minister not believe a very serious scrutiny of the practice is required, if he has not already embarked on such? In case he is not aware, I refer him to a parliamentary question for written reply which I submitted earlier this week which draws his attention to the fact - I repeat it is a fact - that this double jobbing, double pay abuse, is not confined to front-line practitioners within hospital services but applies also, apparently, to some managers and directors of services at hospitals and other settings within the HSE. Will he act to root out all such potential conflicts of interest across the health service?

I am not aware of any particular abuse that has been identified. If the Deputy wants to write to me with the details and evidence, I will certainly have the matter investigated, as is always the case. As this initiative has only started in the past couple of weeks, it is too soon, obviously, to have it audited. It is necessary. Having people waiting so long for outpatient appointments and treatment is a huge risk. Frankly, I do not think waiting periods of 15 months and 18 months are particularly ambitious targets, as the figure should be a lot less than that and closer to three or six months. However, we are doing what we can within available resources.

I accept that there is certainly potential for conflicts of interest. There is also potential for moral hazard because, when one pursues waiting list initiatives such as this, one sometimes ends up rewarding those who are not performing and those who are not keeping their waiting lists down and there are, of course, other risks. However, in this case, we really had to put patient safety and patient outcomes first, ahead of all those legitimate concerns about initiatives such as this.

One thing that is very different between what is being done and what was done by the NTPF is that it is not a case of people self-referring. What is happening is that somebody is going through the waiting lists, validating them, finding the people who are waiting for very long periods of time and offering them treatment. Where it is possible, we are using existing public facilities, but, sometimes, that is not possible. To give one simple example, there is just not enough theatre space in Crumlin hospital to undertake the number of scoliosis operations that need to be performed on young children. As a result, a number of cases have been dealt with in Blackrock, Temple Street and Cappagh hospitals, as well as in other public and private hospitals, and more will be dealt with because that is what is required.

My concerns have been sharpened in the recent past - not for the first time in my political experience - by actual cases that have been presented to me where people either do not have private health insurance or their plan is inadequate to cover the cost of the procedure they need and they are being told about inordinate waiting times. At the same time, however, they are being pushed into the private system, with the same consultant in the same hospital, if they furnish five figure sums - fact - and it is then a case of, "We can see you in the next two to three weeks." This puts those families in financial distress as they are not the people with ready cash to pay for it. They are already struggling in life and this is a hugely important moment, a challenge to either the man or the woman, in the case about which I speak, and his or her family. This is an absolute outrage and it has fed an ever-growing view in society that there is an abuse involved, whereby waiting lists are being created to put further pressure on those who are waiting to drive them towards "pay up and pay out" to line the pockets of those in this mode in front-line practice.

They bring only shame on their profession in my view.

Sorry, this is Question Time. Thank you.

It is time the Minister and the Department faced it head on.

Again, I must stress that the more time we spend on priority questions, the less time there is for the backbenchers to get their questions reached. Will Members adhere to the times allocated?

I do not believe people are deliberately creating waiting lists to pressurise people into paying out of pocket or to take up health insurance. Health insurance does not cover pre-existing conditions, so it would not cover it anyway in such cases. Quite frankly, waiting lists sometimes are badly managed. One has to drill down into them to really understand them. When I looked at some recently, I noted when it came to surgical procedures and day cases, people being seen within three months were being seen quicker. So, there were more people being seen quicker but then at the tail-end, there were people being put on the long finger for longer. That is a particular problem.

There are significant capacity constraints and it is for that reason the private sector is being employed.