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Dáil Éireann debate -
Wednesday, 1 Jun 2016

Vol. 911 No. 2

Health Care Committee Establishment: Motion (Resumed)

The following motion was moved by the Minister for Health, Deputy Simon Harris, today, 1 June 2016:
That, notwithstanding anything in Standing Orders, Dáil Éireann:
— the severe pressures on the Irish health service, the unacceptable waiting times that arise for public patients, and the poor outcomes relative to cost;
— the need for consensus at political level on the health service funding model based on population health needs;
— the need to establish a universal single tier service where patients are treated on the basis of health need rather than on ability to pay;
— that to maintain health and well-being and build a better health service, we need to examine some of the operating assumptions on which health policy and health services are based;
— that the best health outcomes and value for money can be achieved by reorientating the model of care towards primary and community care where the majority of people’s health needs
can be met locally; and
— the Oireachtas intention to develop and adopt a 10 year plan for our health services, based on political consensus, that can deliver these changes,
orders that:
(a) a special all-party Committee, which shall be called the Committee on the Future of Healthcare, shall be established, to devise cross-party agreement on a single long-term vision for health care and direction of health policy in Ireland;
(b) the Committee shall be made up of fourteen members of the Dáil, of which four members shall be appointed by the Government, three members by Fianna Fáil, two members by Sinn Féin, one member by the Labour Party, one member by Independents4Change, one member by the Anti-Austerity Alliance-People Before Profit, one member by the Rural Alliance and one member by the Social Democrats-Green Party group, and four shall constitute a quorum; members may be substituted as provided under Standing Order 95(2);
(c) notwithstanding the provisions of Standing Order 93, the Committee shall elect one of its members to be Chairman, who shall have one vote;
(d) the Ceann Comhairle shall announce the names of the members appointed under paragraph (b) for the information of the Dáil on the first sitting day following their appointment;
(e) the Committee shall have the powers defined in Standing Order 85 (other than paragraphs (3), (4) and (6) thereof);
(f) the Committee shall examine existing and forecast demand on health services, including the changing demographics in the Irish population;
(g) the Committee shall examine and recommend how to progress a changed model of healthcare that advocates the principles of prevention and early intervention, self-management and primary care services as well as integrated care;
(h) the Committee shall examine different funding models for the health service and make recommendations on the funding models that are best suited to Ireland and have these models fully costed;
(i) the Committee shall examine and make recommendations on how best to reorientate the health service on a phased basis towards integrated, primary and community care, consistent with highest quality of patient safety, in as short a time-frame as possible;
(j) the Committee shall be mandated to hold hearings in public with expert witnesses; invite and accept written submissions; draw up a report(s); make findings; and-or suggest recommendations if the membership so agrees in unison or in majority/minority format;
(k) the Committee shall produce an interim report, containing also its proposed work schedule, to be debated at a meeting of the Dáil no less than one week, and no more than two months, after its establishment;
(l) the Committee shall, within six months of the initial meeting, present a final report to the Ceann Comhairle for earliest possible discussion in the House;
(m) the Committee shall meet as frequently as appropriate to fulfil its remit.

As I was saying before the debate adjourned, general practice is under severe pressure as a result of the cuts introduced under the Financial Emergency Measures in the Public Interest, FEMPI, Act, as well as the undermining of general practice and the failure to support it properly. If general practice is to be part of the solution to problems in the health service, and I believe it will be central to that solution, it needs to be supported. Many areas have lost their general practitioner and many general practitioners who will retire in the near future may not be replaced. Some 33% of general practitioners are aged over 55 years and 20% are aged over 60 years. New graduates are not taking up general practice because the current GP contract is not fit for purpose. A new contract must be urgently negotiated as part of any new framework for future health care and the cuts made under the FEMPI legislation must be reversed.

Patients spend 99% of their lives living in their communities where they are cared for by their general practitioner, public health nurse, community intervention teams and community therapists such as physiotherapists and occupational therapists, and supported by community pharmacy colleagues who supply essential services. If these services were to be fully developed, many patients could be looked after in the community and unnecessary hospital admissions avoided, thus taking pressure off overstretched accident and emergency departments. This could be achieved by managing chronic illnesses and old age in the community.

Ireland's demographic trends are frightening, with 20,000 people reaching the age of 65 years each year. Furthermore, patients aged over 85 years account for 14% of bed occupancy in hospitals but only 1.4% of the population. It is clear, therefore, that demographics are causing severe problems in hospital capacity.

It is essential that bed capacity in hospitals is increased. Hospital bed numbers are currently approximately 500 lower than what is required. Hospitals work most efficiently when operating at 85% capacity and yet many of our hospitals are operating at 100% capacity, which causes inefficiency.

We must also develop home care services and packages. Despite being highly cost effective, these services are the first item cut when the Health Service Executive seeks savings. This approach creates a false economy. Cutting home care hours and packages has a negative impact because people end up as patients on trolleys or occupying expensive hospital beds.

Services must be integrated.

We need ambulatory care and medical assessment units. We should be investigating patients to ensure they will not be admitted to hospitals, rather than admitting patients to hospital to be investigated. Many acute illnesses cannot be avoided and these are the ones that should be dealt with effectively and efficiently in our cluttered accident and emergency units.

In order to build a proper health service we need to reverse the measures introduced by the FEMPI legislation and to support general practices in rural, urban and deprived areas. A new flexible contract for general practice is essential. If we are to introduce free GP care for everybody, we will need to double the number of GPs we have in our service. If the service is to be efficient, we need to see an integration of primary and secondary care. Increased access to diagnostics is essential. Many of our diagnostic services operate between 9 a.m. and 5 p.m from Monday to Friday and close over the weekend. This is inefficient. Patients are staying in hospital over weekends waiting for scans which should be provided during that weekend period, thus allowing them to be discharged.

We need to properly fund chronic disease management - diabetes, heart failure and chronic respiratory illness - and increased community supports must be put in place to help elderly patients with multiple morbidity issues. Primary care needs to be the engine that drives major health care reform and I hope that will be part of the new committee's remit. The bed capacity issue is exacerbating the accident and emergency unit crisis, but the emphasis in the proposed health reform must be to keep people out of hospital, thus freeing up accident and emergency units for essential cases.

I commend the motion to the House. Reform should be solution driven and should produce recommendations that centre on patients, are transparent and provide accountability. Input from those who provide front line services is essential.

I wish to acknowledge the ready support for this motion from Fianna Fáil, Sinn Féin, Independents4Change, People Before Profit, the Green Party and a number of Independent Members. In total, 89 Members from the Opposition benches supported the motion and I thank them for doing so. I also welcome the fact that once the new Government was in place, the new Minister for Health, Deputy Simon Harris, was happy to come on board, with some minor amendments to the motion. He pledged the support of the Government, Fine Gael and the Independents who support the Government. Quite unusually therefore, we now have a motion before the House that is supported by almost 150 Members. This unprecedented circumstance is an indication of the willingness of everybody to work together in a collaborative manner to try to find solutions to the many problems that dog our health service.

I will not take up time speaking about the many problems in the health service, because we are all too familiar with them. Our wide-ranging health services cover a significant number of different areas, in most of which we find difficulties. There are many reasons for this. Historically, there have been funding issues, but the main problem is that we do not have any overall coherent plan for the health service, in contrast to what happened in the United Kingdom after the war when the Labour and Tory parties agreed on the National Health Service. While there have been ups and downs with that service over the years, by and large people in the United Kingdom are proud of the NHS and would not contemplate its abolition. This applies in the political arena also and although the Conservatives may have cut funding at times, there has always been agreement on the model of health service and nobody has suggested the NHS should be abolished. The problem here is that we have no agreement on the model for our health service. Down through the years, our health service has evolved in an ad hoc way, to the point where it is now quite dysfunctional. There is no political consensus on the kind of model we need for the service.

This has resulted in a situation where every time there is a change in government or a change of Minister, each new Minister introduces a new plan. However, that plan does not have political consensus and when the Minister begins to implement it, that causes an enormous churning within the health service. Over the past 20 years therefore, the health service has been in a constant state of flux. This is bad for the health service and for the patients who depend on it. However, it is also very bad for those charged with delivering the service, because there is huge uncertainty about what the future holds. By an large, people are not quite clear where they fit into our quite dysfunctional health service. This is a major factor in regard to the ability of the State to retain staff in the service and to attract staff who have emigrated to return. The service does not make Ireland an attractive place to live in and it is not a good model for the delivery of services.

We have an extraordinary situation where some 38% of the public are dependent on the public health service and they encounter long waiting lists for practically every service. On the other hand, some 46% of the public pay thousands of euro every year in health insurance. This health insurance amounts to significant additional taxation. This kind of two-tier health system is unheard of in any other European country and would not be tolerated elsewhere. It is unknown in any other European country that sick people would not get speedy access to proper health services. Health services function in other countries and people have a right to expect their governments to take responsibility for basic health services and for ensuring there is a good quality health service in place that is available to everybody, irrespective of whether people can pay for it. This is the standard in the rest of Europe and there is no reason we cannot have a similar high quality public health service here. Any talking down of the Department of Health or description of it as a ministry nobody wants or as an Angola is a political cop out. Irish people are entitled to a quality public health service that is available when they need it and there is no reason we cannot provide that kind of service.

It is important there is cross-party agreement on this kind of approach. If people sat down together to design a health service, they certainly would not design the kind of dysfunctional service we have here currently. That is the reason we now need to come together politically to identify the most important things we need to deliver in terms of our health service and decide how to go about achieving that. The most important section in our motion is the recognition of the need to establish a universal, single-tier health service which treats patients on the basis of health need rather than on the ability to pay.

In setting out to achieve this ambitious objective - one realised in most other European countries - I hope the new committee will work on the basis of considering the high level issues that come into play in this regard. Over the coming weeks, the normal Oireachtas committee on health will deal with day-to-day issues arising in the health area. However, we need to have a high level debate and to reach agreement on what our health service should deliver and how we can achieve the kind of health service that will provide a universal, single-tier health service.

We must also consider how we can transition from the current system to the new single-tier system over a period. How can we do that in a planned way so that, irrespective of whether there is a change in Government or of Minister, it will not all be thrown up in the air again? We must work towards an agreed consensus.

The other aspect of the motion deals with the need to reorientate the health service. Our health service is very hospital-centric and provides care predominantly at the most expensive level, that of acute hospitals. This puts an emphasis on preventative medicine and early intervention to ensure that, as far as possible, people can access the health service locally in their own community through their primary care services. There is no doubt that an approach where there is a front-loading of primary and community care delivers the best health outcomes and the best value for money.

In short, the second high-level objective is to introduce a single-tier health service, to agree on the most appropriate funding model and on how we reorientate the health service towards primary and community care and to model that and phase it in over a reasonable period. Everybody agrees there should be more emphasis on primary care as it will save money and there will be better health outcomes but we need to work out how we are going to go from the present system to the new system in a phased, ordered way. We need to work out how we can do it in a way that ensures services are not diminished in any way and that we move smoothly so that resources are switched from hospitals to primary care.

It is a tall order to come up with recommendations within a six-month period but it focuses people's minds. I would hope that all members of the new committee would approach this task on the basis of looking at the evidence, rather than listening to the many vested interests that have dogged our health services down through the years. We need to look at objective evidence to see what works, what our experience has told us and what is best practice in other countries, from which we can learn. We should do it in an open manner and in a way can keep the vested interests at the door. We should use the resources available to us in the shape of the ESRI, the department of public health in Trinity College Dublin and a number of other experts in the field and there is plenty of expertise around.

Finally, it is important the committee be resourced properly so that we have access to the best possible research and evidence to underpin the recommendations and so that we can move forward to achieve the single-tier health service that Irish people deserve.

This motion is perhaps one of the most important to come before this House in recent times. How we fund, govern and manage our health services over an extended period of time may be the most useful initiative that has been taken by any government in the past 30 years, and presents us with a unique opportunity to challenge forever the way we address our health needs as a society.

We have ten years to save a generation. Devising cross-party agreement on the direction of health policy in Ireland will hopefully give us long-term clarity on funding, staffing, contracts and the hospital network organisation. I hope it will also remove opportunities for political opportunism that prevent us from making good decisions about where to allocate resources. It is vital that there is recognition of the impact of socioeconomic deprivation on health. Now that we are finally entering a period of relative economic stability and growth, I believe that there is scope to address the inequality of access that exists for service users and that this committee will move to establish a universal, single-tier service where patients are treated on the basis of health need rather than on ability to pay.

We are moving towards being the most obese country in the world if we do not change course. We have an emergence of food poverty where there is an inability to afford or gain access to a healthy diet. Low income households, due to a combination of lack of money, education and access, often have diets made up of cheap, poor quality, calorie dense foods with little nutritional value. This is the root cause of the spiralling obesity epidemic. Obesity is a risk factor in four of the five biggest killers in this country and it affects all sectors of society, but disproportionately the poorest people. We have the lowest breastfeeding rates in Europe. We are witnessing a battery-fed population. A generation is coming on stream that will, for the first time, live shorter lives than their predecessors if we do not intervene. Cancer mortality is three times higher in disadvantaged areas and it is the second most common cause of death. Patients in disadvantaged areas often struggle to manage these conditions whilst facing other social and financial pressures. People who are the most likely to die have the least access to the health service. This is fundamentally wrong.

This happens when services are distributed according to number and not need. If you have the same number of services, for example, per 1000 people, regardless of where they live, those in the most disadvantaged areas get effectively half the service as they are twice as likely to get sick. In the case of primary care, there is not even the same number of doctors per head of population in disadvantaged areas. The average number of patients per GP in this country is 1:1,600. In the north west of Dublin, which has three times the cancer death rates of the most affluent area, the ratio is 1:3,600. Public patients from that region wait 11 months for vital tests diagnosing cancer, whereas in south east Dublin it is two months. I represent the south east of Dublin, and I consider two months an outrage, so what must the people and the Deputies of north west Dublin think?

As a student I worked as a hospital cleaner and ward aid in Tullamore Hospital in order to pay my way through college. Upon qualifying as a pharmacist I worked as part of a multi-disciplinary team in the NHS alongside hospital consultants, nurses, physiotherapists and others to enable a clear pathway to recovery for each patient on a case by case basis. Believe me, the NHS is by no means perfect, but we must look to it and learn from its successes and mistakes. We have an opportunity here to replicate all that is good in other countries' health services while tailoring it to the needs of our nation.

Everyone in the health system, from consultants to the cleaner, are working for the best outcomes and to deliver the service that patients require. We have gone to great lengths as a country to set up hospital networks, yet these networks are not functioning coherently, either for emergency or elective care. In a network where the primary care sector channels patients towards the major hospital in a region, that network as a whole should be responsible for the hospital-based care of its catchment population. Unless they have a clear idea of whom they have responsibility for, specialists in the major hospitals cannot plan and then deliver their service. Patients should not therefore have to cross network boundaries in order to access the care they need, other than in cases where the service they need is not available in their own network. We cannot remain in a situation where we do not know what we have, where it is, and who is in charge.

We have ended up with a situation where the quality of outcomes has been compromised because patients from all over the country are arriving at hospitals that have neither the clinical nor the financial resources to deal in a timely fashion with the volume of patients coming through their doors. In a recent conversation with a consultant surgeon, he described the dangerous deficit of theatre capacity to me in the major specialist centres, including in the Dublin children's hospitals. He told me how common it is that young, healthy patients suffer needless long-term disability as a result of delays in access to theatre. He described the service as irresponsibly inadequate. Apart from the lifelong harm that individual patients suffer as a result of all these challenges, there is the economic cost that runs in tandem with the human cost. As patients wait, occupying beds, waiting for delayed treatment, their conditions are deteriorating to a point where they then require extra operations to deal with the consequences of totally avoidable infection.

We need to accept that illness does not take the weekend or evening off. If we are to provide the best outcomes for people, we need to recruit skilled staff. A good outcome for a patient depends on the entire team being involved in his or her care in a routine, organised and regular manner. This simply does not happen in Ireland. There has been a noticeable loss of expertise in the system. This has been accompanied by poor resourcing of hospitals, worsening terms of employment for staff and improper administrative planning.

The cornerstone of any progressive health service should be the delivery of local and accessible health and social services in the community to a defined population. We cannot continue to depend on the goodwill of health care professionals in the primary care setting to advance this objective. Investment in primary care as a unique entity is required. Those of us who work in the community setting currently see it as an add-on to our roles. All evidence suggests every €10 spent in the primary care area saves the State €100 in the long run. The introduction of a functioning and universally employed information technology platform would greatly enhance efficiency and communication, decrease the current paperwork load and speed up the process from the point of access to the point of delivery and on to aftercare in the community.

Primary care remains under-utilised and under-valued. Morale is on the floor. When this new committee is formed, it will need to address the concern and confusion regarding the future of primary care. Now is the time to create a vision for that future, while the wider health care community still has the willingness and the energy for health care reform. In the past 15 years I do not think I have gone a day without speaking to multiple people involved in the provision of health care. Everyone engaged in active health care provision wants the system to be fixed. The passion among these professionals to deliver a world-class health service is driven by a fundamental desire to improve people’s lives. In the light of the recent tragic events in Cavan and Holles Street hospitals, it is imperative that the national maternity strategy be implemented as a matter of urgency. The patient is the central focus in the delivery of maternity services under the strategy, which is long overdue. If the patient is not the central focus of care, who is?

I could stand here all day listing the inadequacies of the health service. I could try to assign blame to those whom I believe contributed to getting us to this crisis. Such political opportunism would neither be constructive nor of any benefit to the thousands of citizens who require adequate care right now, as we sit here fit and healthy. I hope today we have a platform to a new dawn. We have a chance to be part of something constructive, rather than destructive. Collectively, we must face the challenges and save a generation. It is with great hope that I support the motion that the Minister, Deputy Simon Harris, and Deputy Róisín Shortall have commended to the House. I urge Deputies of all parties and none to unite in supporting it.

I congratulate the Minister on his appointment. I welcome the proposal to establish an all-party committee to devise a cross-party agreement on a long-term vision for health care and health policy. Fianna Fáil will support the motion which seeks to build a cross-party consensus on health. We believe in a publicly funded and delivered health care service that emphasises patient care above structures. We are also committed to making primary care the bedrock of the health system. For too long, the country's health care system has been based on fire-fighting. We welcome the intention to agree a strategic plan to address these issues. The current health system is neither fish nor fowl. It is neither public nor private. We often hear about the two-tier health system, but we know that there are many more tiers. There are separate tiers for medical card holders, GP-only card holders and the working poor who are not entitled to any kind of medical card or support, even though they cannot afford private health care. It is important that this new committee is not used as an excuse for inaction by the Department of Health. There are many obvious, acute and immediate failings in the system.

Discrimination in service provision based on one's address is particularly insidious. I will talk about the area I know. Wexford psychiatric services are tied in with the services in Waterford. A person in Wexford who has an acute psychiatric event is not allowed to go to the emergency department in Waterford, even though he or she is living in the Waterford-Wexford area. He or she has to go to the emergency department in Wexford. If this happens out-of-hours, the person in question will be seen by a triage nurse who will contact the service in Waterford by telephone. If a psychiatrist in Waterford can be contacted, an assessment will be made over the telephone. If the person is refused at this point, he or she will be sent home after spending three, four or five hours in the Wexford emergency department. If he or she is accepted, he or she will have to travel to the emergency department in Waterford and spend another three, four or five hours waiting to be seen by a psychiatrist. That psychiatrist will have to make a decision on the basis of whether the person's case deserves to be prioritised over those of others who need to be admitted, rather than on the basis of whether he or she needs to be admitted. If he or she is not admitted, he or she will be sent back home into the care of his or her family if he or she is lucky enough to have family to take care of him or her. Otherwise, he or she will just be cut loose.

The admission of children to adult psychiatric units needs to be dealt with immediately. The Mental Health Commission's reports on approved centres were released a few days ago. The commission reported that nine children had been admitted to an adult centre at St. Luke's Hospital in Kilkenny and were, therefore, placed at high risk. According to the report, "the approved centre was deemed non-compliant as there was no evidence of required Children First training or any other relevant training for all staff". This centre "was not suitable for the admission of children", but they were admitted nonetheless. As far as I know, this was not the first time the centre in question was deemed to be insufficient. We are continuing to admit children to high-risk facilities. I accept that the parents of these children signed consent forms, but I suggest they did so out of desperation and under duress.

I would like to speak about some other issues that have been highlighted in the reports on mental health approved centres. Some hospitals have no toilet rolls. Others have no shower facilities, or have facilities that are covered in mould. All of these issues could be addressed quickly and readily without the need for a committee to report. The lack of services for children with disabilities is another such issue. There is a shocking lack of the availability of services for children who need speech and language therapy. A significant part of mental health suffering is related to connectedness - people need to feel a connection to those who love them. If they feel isolated, it can develop into mental health problems.

Many young children cannot access the speech and language therapy they need to enable them to communicate. I am talking about children who might have other issues. If they could develop their speech and language facilities, at least they could communicate with their parents and families. The same parents have to fight for everything. People have to wait up to two years for needs assessments. They might have to wait another two years after that to access inadequate services. Bizarrely, they are the lucky ones. There are many conditions the HSE simply refuses to recognise. It seems to have a policy on health conditions that are treated with medicinal creams. Children with rare conditions such as ichthyosis need significant care and support from their parents. Many children and adults need to have medicinal creams applied to them three or four times a day. In some cases, they have to sleep in bandages. People in such circumstances have to go back to their GPs and the HSE every three months to beg for medical cards. It seems that they are deemed eligible for short-term medical cards only. DNA testing can be used to identify the conditions to which I refer. It is easy to prove that someone has one of these conditions which cannot be cured. Across the water in England, people with these conditions receive all the services they require as if they had any other medical condition. We are refusing to recognise them in the same way. Ultimately, any health system must be rights-based and have regard to availability and need while taking account of ability to pay.

I would like to speak about the role of the proposed committee in the area of mental health. Fianna Fáil believes any attempt to devise cross-party agreement on a single long-term vision for health care and the direction of health policy in Ireland must prioritise mental health and well-being. Our vision is built on five key principles. First, public policy ought to ensure people with mental health problems are included in society and enabled and assisted to play their part in it. Second, the recovery model of mental health care is the most appropriate in terms of the well-being of individuals and enhancing their ability to defend themselves as citizens of the country. Third, mental health should be taken as seriously as physical health in the deployment of resources and other areas such as health and safety and planning. Fourth, there should be an emphasis on early intervention and early action. Most mental health conditions are readily treatable if there is early intervention.

Even when they reach crisis point, as I have outlined earlier, the supports are not there.

Fifth, mental health policy must be mainstreamed across society in order to promote mental health well-being and to lessen the risks to mental health. There has already been a ten-year plan for mental health that had cross-party support but it has not been fully implemented. As we all know, that plan was A Vision for Change. Its time is nearly up but it needs to be fully implemented while a review is carried out as to what to do for the next ten years. It needs to be integrated into the overall health policy. Ultimately, we need to reach a point where mental health is not distinguished from health and is treated with the same respect.

Over the last number of years, community care teams have not delivered on the partnership approach and have instead moved the services that were provided in the hospital out into the community in a "ward in the community" approach, with treatments still being primarily limited to classic psychiatric-led treatments. Mental health policy is in need of a reboot in 2016. Fianna Fáil believes that Government should carry out a full review of what is still left to be achieved and commit to the reinstatement of a plan to achieve that in the period 2016-26, taking into account any deficiencies identified in A Vision for Change by a review group. The Government needs to ensure that the critical feature of that review will be the holding of a mental health summit of all key stakeholders and must direct the review group to consider placing particular attention on the need to stress non-medical approaches to dealing with mental health issues, including talk therapies such as cognitive behavioural therapy.

The Government must ensure that the recovery model's ethos is placed at the centre of mental health policy as expressed in the policy document that will follow and build on from A Vision for Change. It must re-establish the implementation review group to issue regular reports on the progress in delivering the 2016 to 2026 plan. A Vision for Change envisioned a partnership model between health professionals and service users that would have an equality of respect at the heart of its approach. This has not been followed through, with a regression from initial progress in that respect. Service users need to be put at the centre of any future programme. Access for 24-7 crisis supports for all ages needs to be delivered irrespective of geography.

My central point is that mental health must be a fundamental part of this new committee that is put together and not simply shunted to the side.

I welcome this motion to establish a special all-party committee to develop a single, long-term vision plan for health care. This is a positive step, albeit one that should have been taken a long time ago. For too long, our health system has been in crisis. This crisis can be boiled down to two key failings on the part of successive Governments: first, a fundamental inequality in how patients are treated and differentiated on their ability to pay and their location and second, the incapacity of the system to deal with even demographic pressures, as evidenced particularly in emergency departments and maternity care.

Universal health care, and not universal health insurance, is the solution. I welcome therefore the reference in this motion to "the need to establish a universal single tier service where patients are treated on the basis of health need rather than on ability to pay". Sinn Féin has long been committed to the realisation of a world-class system of universal health care accessed on the basis of need, free at the point of delivery and funded by progressive taxation.

As my party's health spokesperson over the past 14 years, I have consistently argued for such a system of health care delivery. I am encouraged by the growing number of voices adopting this position and by the albeit slow but hopefully real movement by Government away from the health insurance model, whether multi-payer or single payer. Welcome on board. Fáilte ar bord.

I hope that the new plan will have a particular focus on disability services and their prioritisation. It was very worrying to hear yesterday that there are proposals, once again, to raise the age of those entitled to disability allowance from 16 to 18 years. This, we will all recall, is the same proposal on which the former Minister for Social Protection, Deputy Joan Burton, was forced to make a U-turn in 2013. Once more, we see the most vulnerable in our society being used as easy targets. This must not be allowed to happen again.

Changes should be made immediately to ensure that a full medical card is granted to every child qualifying for the domiciliary care allowance. My party colleague, Deputy Louise O'Reilly, will be seeking the support of Members for the adoption of this proposal. Despite the findings of the Keane report, the horror stories continue of seriously ill children being refused medical cards and the lengths to which distressed parents are being forced to go to secure a medical card. The Government must urgently introduce and implement a schedule for the extension of full medical cards to people with serious illnesses and disabilities without a means test, working towards a universal entitlement year on year.

I note and welcome the reference to the focus that needs to be taken on the changing demographics and on how best to re-orientate the health service on a phased basis towards integrated, primary and community care. A greater emphasis on community-based care has the potential to reduce the number of older people requiring nursing home care. However, this has not been quantified because, as the Department of Health report on the nursing homes support scheme makes clear, the further development of community-based care is dependent on new approaches. I hope that is exactly what we are about here today.

Sinn Féin estimates that as many as 13% of nursing home residents, possibly as high as the 30% figure given by ALONE, would be able to stay at home if the appropriate services were put in place. We are committed to the provision of health care services and social care services as a right, with equal access for all based on need and to the greatest extent that resources allow. This right is especially relevant for older people and the provision of supports for older people is becoming increasingly important as our population ages.

We should see improved health and longevity as an opportunity as well as a challenge, with older people contributing more and more to our society. In the words of the democratic programme of the First Dáil Éireann, we are committed to the care and support of Ireland's older people "who shall not be regarded as a burden, but rather entitled to the Nation's gratitude and consideration".

I wish to thank and congratulate all Members of these Houses, both the Dáil and Seanad, who have openly demonstrated their support for the Green Ribbon campaign throughout the month of May. The wearing of the ribbon is no longer required since it is 1 June, but our collective efforts to address and support the mental health needs of our population is a daily and yearly need. I hope that the establishment of this committee will not simply provide a talking shop but rather a gathering of people with ideas, vision, and most importantly, solutions, to bring about the changes that are so desperately required in our health system today.

I join in commending Deputy Shortall on her proposal. It amused me today to see Deputy Seán Sherlock play political footsie with Deputy Shortall on the idea, given the fact that the Labour Party allowed Deputy Shortall to walk the plank in her battle with the former Minister for Health, James Reilly.

Access to health care has to be key to this new committee because it has ground to a halt over the last number of years under Fianna Fáil and Fine Gael. Let us take for example the ambulance service. Just this week, a 75 year old person in my county had to wait 35 minutes for an ambulance to arrive to be brought to a hospital because the ambulance was in Cavan when it was needed. That is not unusual because in the period of one year, 40 people contacted me in County Meath stating that it took over an hour for an ambulance to attend to their particular crises. In seven of those cases there was a fatality involved.

Access to health care can also be seen in the difficulties of getting a bed through accident and emergency departments. Last year in the hospitals of Navan and Drogheda, 9,000 people spent time on a trolley. That is the equivalent population of Trim, in our county, who were on a trolley in the last year. We know that if one is on a trolley, one receives substandard treatment. One receives delayed treatment, which is not as good. Therefore, one has a sub-optimum health outcome. That means that some people remain injured or ill for longer and, in some cases, lose their lives. The Irish Association for Emergency Medicine stated that roughly 350 people a year lose their lives due to accident and emergency department overcrowding.

That is roughly one person a day and a startling indictment of Government health policy.

There are 490,000 people on public hospital waiting lists. That is equivalent to the population of the cities of Cork, Galway, Limerick and Waterford being refused access to the health service and made to languish on waiting lists. In my constituency access to the doctor on-call service is becoming more difficult and sometimes it is not available during the night. We have heard there is the possibility of a Skype doctor replacing the doctor-on-call service, with a doctor, from a distance of 50 miles, remotely diagnosing and treating a patient in crisis during the night, which is quite shocking.

A common thread of all of these stories is that there is no capacity in the system to meet demand. One would expect the capacity we have had to be maintained, but, unfortunately, that is not the policy of the Government. I am cathaoirleach of the Save Navan Hospital campaign, probably one of the most successful campaigns in the State. We have brought some 40,000 people onto the streets of County Meath in the past six years, in which time we have battled hard to ensure the emergency department will remain open. However, it is stated Government policy, in its framework for small hospitals, that it will be made into a minor injuries unit. I would love if that was not the case. I ask the new Minister of State, Deputy Helen McEntee, who is from County Meath to publicly state it is not the case and that we will have a functioning emergency department in Navan hospital long into the future, as well as a full ICU, coronary care and anaesthesia service to back it up. I will wait for the Minister of State to make that statement.

Capacity is obviously dependent on a number of factors. It is dependent on efficiencies, better management and keener input costs, but it is also dependent on investment. This is the area which is going to be difficult for the new committee into the future. This is the ideological fault line between my party and the likes of Fine Gael which believes private funds have a part to play in this regard, but private funds need profit and profits in health care provision create inequalities. Sinn Féin wants to ensure health care is funded with public money to ensure there is equal provision in public health care services. That is why, at this stage, I am sceptical about the likelihood of success with this new committee into the future. Nonetheless, I wish it well. I hope the Government means business when it states it will adhere to the outcome of the committee's deliberations.

I wish to share time with Deputy Ruth Coppinger.

The state of the public health service is a scandal and a disgrace. In so far as this new committee can contribute anything, its contribution will be to moving away from a failed policy that has been pursued for the past decade at least and pursued consistently by the last Government in pursuit of the mirage of universal health insurance, a policy it has finally abandoned. If only it had listened to the criticisms we presented to that model right from the beginning, but finally, five years on, the previous Minister, Deputy Leo Varadkar, had to admit we were right and that it would cost more. We had said in 2011 that it would cost more, but the Government just did not listen. I hope, despite it having gone down that cul-de-sac, the new committee offers us some vehicle to look seriously at the problem and abandon failed policies.

The list of ills and crises and the catalogue of suffering and failure to provide services for those who need them are simply too long to list. I will just mention in passing some of the key areas that urgently need to be addressed. They include, for example, the disaster in emergency departments, the latest manifestation of which is the figure of 50,000 people who walk in and then walk out of emergency departments. Could there be a more severe indictment? One can add to that number the people who did not even go in because they were afraid to do so, given that they knew how bad the situation was.

There are chronic waiting lists of people in chronic pain or in chronic need of hip replacements and of children waiting to see ear, nose and throat specialists. There is a shameful situation in mental health services, where we do not have the 24/7 emergency services we need for persons who are suicidal. In particular, there is the absence of sufficient resources to provide for individuals who go into emergency departments and say they are suicidal, only to be told, "Sorry, we are not treating you because you have alcohol and drink problems," which is in itself disgraceful when we need dual diagnosis and the resources to deliver such a service. In contravention of European directives, children and young people are being placed in adult mental health wards. There are outrageously long waiting lists to see occupational and speech and language therapists. We hear about the deaths of mothers and babies in hospitals because of the lack of consultants and other staff. I could go through the list, but I do not have the time to do so.

Can we address all of these issues? The only way we can address them, as we have been saying for five years, is by taking profit out of the equation. When we talk about the need for a national health service from the cradle to the grave and funded through progressive central taxation, the other side often says it is a fantasy and asks from where we would get the money. Of course, we have had the answer to this question provided recently by the OECD, when it revealed the fact that we actually spent more on health services in this country than almost anywhere else in the world; we spend way above the average. Where is that money going? Some €13 billion comes directly from the Exchequer into the public health service which is in pieces, but another €5 billion is also being spent on health services. Where is that money going? The CSO helpfully tells us. Some €2.68 billion is going in household, out-of-pocket payments, mostly in private health insurance which is going into the pockets of the private health industry. Another €2.7 billion is spent on pharmaceuticals and drugs. Therefore, an extra €5 billion is being spent on unnecessary administration or going into the profits of for-profit health services, whether in the production of drugs or the private health care system.

In a way, one can see this happening. The two-tier system and the waste of money on private, for-profit health services are very obvious when, as I have said on a number of occasions in the House, patients go to St. Vincent's University Hospital or St. James's Hospital. They find a war zone and are told they will be waiting 12, 24 or 36 hours, but they then hear on the radio an advertisement for the Blackrock Clinic: "Come here; you will not have to wait, as long as you can pay". How many such private clinics are there? They are all over the place. We have the capacity, but, shamefully, only a tiny proportion of the population can access it, while we, the public, are subsidising it and lining their pockets. What we need to do is take that profit element out of the equation and redirect the money into the public health service in order that we would have a national health system available all on the basis of medical need. It is not difficult.

I refer to a case to which I have been alerted by a constituent. It sums up the problems people are experiencing in the health service which the new committee should examine and research. Obviously, the Minister and the HSE also need to provide answers. I have checked the details of the case with the constituent and they want to have this issue aired publicly. People want to have such details aired publicly in order to get answers but also to ensure these things will not happen again.

There was a catalogue of errors in the treatment of the woman in question, Mrs. Margaret Breen, who had a stroke in February. Her husband, Felix, has raised these issues with the hospital and the HSE. On Saturday, 20 February, Mrs. Breen suffered a stroke. Her husband rang for an ambulance from Huntstown, Mulhuddart at 1.48 p.m. The times have been confirmed by the National Ambulance Service. Despite there being an ambulance and a fire station located nearby, the ambulance came from Maynooth, County Kildare.

It arrived at the house an hour later at 2.44 p.m. According to reports on the ambulance service, it has eight minute and 19 minute response targets for ECHO and DELTA but this family had to wait an hour while the wife was clearly suffering a stroke. There must be answers to this.

To add insult to injury, the driver did not know the area, being from Kildare, and decided to go through Blanchardstown town centre on a Saturday afternoon, through the traffic and shoppers, adding to the journey time. It was en route to Connolly Hospital when it was discovered there is no stroke treatment there at weekends. The ambulance then had to make its way to the Mater hospital. Obviously, it arrived very late.

When Mrs. Breen was being treated at the Mater hospital, that was fine but in a specialist stroke unit, she suffered her second stroke on 23 February 2016 at approximately 6.15 a.m. The HSE needs to explain to all of us and to her family why somebody in a specialist stroke unit would be left unaccompanied to go to the bathroom and not checked when she failed to return. There was a 20 minute delay before anyone even noticed Mrs. Breen had suffered a second stroke in a specialised stroke unit. There was a further delay in her examination by the medical team, who did not review her until 6.55 a.m. These are all official times. A CT scan was ordered at 7.06 a.m. but did not take place until 7.57 a.m. Why does it take 51 minutes for a CT scan to be done on somebody who has suffered a second stroke in a specialist unit? We also need an answer as to why there was a delay in the ambulance transfer to Beaumont Hospital. Mr. Breen was telephoned at 8.10 a.m. to be told his wife had been transferred to Beaumont Hospital for an operation on her brain. He was told an ambulance had been called but no ambulance call went through until 8.41 a.m. A 999 call was made instead of a 2222 call and there were many other issues. Mrs. Breen did not arrive at Beaumont Hospital for the procedure to begin until 10.15 a.m. Four hours had elapsed between the woman having a stroke in a specialist stroke unit and being treated properly.

Mrs. Breen has had intensive rehabilitation but she has lost her short-term memory. We do not know what effect those delays have had on this woman's future quality of life and short-term memory recovery. Why put out ads telling people to respond within minutes to a stroke if an ambulance will not arrive for an hour? Why put out ads with taxpayers' money if ambulances cannot respond when people do notice a stroke? There is an increased prevalence of stroke in society among young people. This is a very serious issue and the committee, the Minister and the HSE must answer to this family with regard to why a woman waited four hours to get the treatment she needed. Eventually, she had to have a brain operation. There are real questions for the ambulance service. I am running out of time.

The Deputy is well over time now.

I know but I do not think there is a rush for time either.

Standing Orders are Standing Orders.

There are reports about ambulances, and response times can be dramatically improved when money and personnel are provided but the idea that people do not know where they are going or have to come from different counties is absolutely outrageous. The family needs and wants answers.

I very much welcome this debate and the proposal to establish this special all-party committee. It is past time some long-term structure was given to our health service. I will refrain from criticising the HSE and its predecessors for not putting in place such a plan. This is because for decades health authorities in this country have been chasing their tails fire fighting one problem after another rather than planning for the future. This fire fighting was the result of, in a circular but predictable way, a lack of any long-term plan for the health service in this country.

If a service is pared down to its most essential parts, as happened during the recent financial crisis, it becomes easier to see where the problems are. This is for another day, however, and the committee has ahead of it probably one of the most important jobs in recent generations. There is nothing more important where we stand now in 2016 than tackling our health problems. What is required now is political maturity and an ability to work together and not stick rigidly to fixed ideological positions. All that matters in any committee deliberations are patient outcomes and a process that leads to a modern, efficient and cost-effective service for everyone, notwithstanding their means.

I wish to make one point in this debate which will resonate with Deputies whose constituencies cover rural areas such as mine, or areas of the country outside Dublin. Yesterday, I saw a very interesting figure, that 41% of Irish people live outside urban areas. An urban area is defined as one with a population greater than 1,500. Dublin's population, city and county, is approximately 1.25 million. Dublin, therefore, has just more than a quarter of the entire population of approximately 4.65 million. I mention this because many Deputies in the House would feel the majority of the citizens of this country are playing second fiddle when it comes to infrastructural investment, particularly in health care. Dublin is bursting at the seams in terms of transport, a lack of housing and other areas. Billions can be invested in the cross-city Luas, an airport extension or new hospitals.

While I did not agree with much of what the former Secretary General of the Department of Finance, John Moran, stated in a recent article, some of it made sense. There is a huge lack of infrastructural investment outside Dublin. This is simply a fact. Health care is one of the most obvious areas. University Hospital Galway is shoehorned into the middle of a medieval city, with no room to park or to expand and no plan for the future except for necessary but short-term replacement building projects. It is supposed to be a centre of excellence but I would try persuading either the staff or the patients going through the accident and emergency department of this. Cancer patients have to queue for hours or even days to be admitted. I could go on and I am sure other Deputies have similar issues in their constituencies. In Galway, we have all of this and an underutilised hospital campus of 150 acres of State-owned land at Merlin Park, a few kilometres away from University Hospital Galway. This is an example of the issues the committee needs to examine. We badly need vision in our health service.

I do not for one minute advocate a one for everyone in the audience approach. I fully realise that expertise in a given field has the best outcome for patients if centralised in a specialist centre. I do not advocate a centre of excellence in every town and village in the country. What I advocate is that the committee takes a good hard look at the services offered, how and where they are delivered and imagine our health system in ten years' time. Imagine a system which does not have 90 year old patients endlessly waiting on trolleys, cancer patients endlessly waiting for admission or nurses and doctors at their wits' end trying to cope.

Earlier I stated the committee has a hugely challenging task ahead but it is one with huge rewards. This committee, and subsequently this House, have a generational opportunity to create a health service on which all our citizens can rely and of which they can be proud.

I welcome the opportunity to speak on this motion and the establishment of the special all-party committee to develop a single long-term plan for health care. As the Minister, Deputy Harris, has already said, now is the time to put the benefits of our economic success to work for the people so that we can help deliver the public services this country deserves.

Today, there are still too many people on hospital trolleys in accident and emergency departments waiting for a hospital appointment or a surgical procedure. With the make-up of the current Dáil, we now have an historic opportunity to work together, take a cross-party approach and develop a long-term plan for health services that will deliver the services we all want for this country. I firmly believe we should all work together on this and we can develop a plan with a vision of how health care can be delivered to the entire population.

Coming from County Louth, I am acutely aware of the challenges facing the health services. Our Lady of Lourdes Hospital in Drogheda is, unfortunately, regularly in the news for the wrong reasons. Hardly a week goes by when we do not hear the number of people on trolleys in its accident and emergency department is among the highest in the country.

While I agree that one person on a trolley is one too many, I do not agree with the regular commentary which seems to judge Our Lady of Lourdes Hospital based on the number of patients waiting on trolleys as opposed to the services they ultimately receive. Our Lady of Lourdes Hospital is one of the top hospitals in the country and its staff are excellent. I am basing this opinion on the views of people who have been treated in it. I have met many people during the course of my constituency work who have been treated or cared for in Our Lady of Lourdes Hospital and the overriding consensus is that once one gets past the initial admission procedure, the treatment received is second to none.

In my home town of Dundalk Louth County Hospital has never been busier. Last year alone more than 25,000 patients were treated. This is despite the fact that the hospital was downgraded by the previous Fianna Fáil Government and that at one stage it was feared that it would be closed completely. Far from being closed, it is growing the list of services available, including the number of acute services.

In line with A Programme for a Partnership Government, the minor injuries unit in Dundalk will see its opening hours increase and the age at which patients can be treated extended.

One of the most significant problems I see in Dundalk with health services is the fact that too many people are still not aware of the many services available in Louth County Hospital. Too many are still going to the emergency department in Drogheda when they could simply go to the minor injuries unit in Louth County Hospital. By using the minor injuries unit in Dundalk as opposed to the emergency department in Drogheda, substantial improvements could be achieved in both hospitals.

In the past few years I have worked closely with the previous Ministers for Health, Deputy Leo Varadkar and Dr. James Reilly, to ensure a primary care centre is opened in Dundalk. I now look forward to working with the new Minister, Deputy Simon Harris, and his Department to ensure this much-needed primary care centre will finally open in Dundalk.

Getting back to the motion, I firmly believe, as does the Fine Gael Party, that universal health care is the way forward. It should also be noted that this approach is supported by the World Health Organization, the United Nations, the OECD and the European Union. A successful universal health care programme, as described by the Minister, will have four main objectives: reducing unmet health needs, reducing inequality in access to health goods and services, improving service quality and improving financial protection.

I fully support the motion on establishing an all-party committee to develop a single long-term plan for health care. What I would not like to see happen is old-style party politics dominating the committee. We have a unique and an historic opportunity to work together across the House to develop a plan that will shape the future of health care in Ireland. We must not expect results to happen immediately; nor must we expect that simply throwing money at them will solve all of the issues. For this vision and plan to be successful, it must consider all aspects of health care systems from the ground up. We must consider work practices within the health service, what is working and what is not. We must not be afraid to make hard choices if the end result will be a world-class health service that will be fit for purpose and service all of the people.

I welcome the opportunity to contribute to this debate and wish to begin by congratulating the two Ministers of State and wishing them well in their new roles. It is a sign of the times that we are having this debate and that the Government, which is made up of Fine Gael Ministers supported by Independents, acknowledges that there is wisdom in all areas of policy formation other than that found on the Government benches. We have lived through a period of five years when whatever was said by anybody on this side of the House was usually rubbished, when Opposition Deputies were accused of scaremongering and saying things for political advantage. In fact, sometimes Members on this side of the House were merely raising awareness of some of the critical issues faced by men and women in the communities we represented. To strike a note of caution, perhaps if Members on the other side of the House had listened to Members on this side a little more often during those five years, they might not be relying on Members on this side to ensure the adoption of policies into the future. However, I welcome the new composition of the Dáil and look forward, as the previous speaker said, to engaging constructively with the Government on how we can make the necessary improvements that will ultimately benefit the people whom we are fortunate enough and honoured to represent.

To strike another note of caution, I hope the new committee is not being set up ultimately to deflect responsibility if the necessary improvements are not made in the lifetime of the Government. Unfortunately, when one looks back at what was promised in 2011 and what was delivered by 2016, many of the improvements in the health service were simply not delivered. Elderly people are now waiting possibly three times longer for standard hip or knee replacements than in 2011. Only last week an elderly person aged 81 years from County Longford contacted me about the severe pain he was in and looking to find out whether there might be any way his operation might be expedited. I wrote to a particular hospital about this patient and stated he was quite visibly in awful pain. To my surprise, on Monday the surgeon in that hospital rang me to tell me that he could not disagree with one thing I had written in my letter. He asked me to use my position as a Member of Dáil Éireann to say the hospital did not have the money to carry out operations and that he could be performing five operations a day but was currently only allowed to perform two. I asked him innocently how long it took him to perform the two operations. I remember that I asked him at about 11.45 a.m. by which time he said he had performed the operations to be performed that day. I asked what he would do for the rest of the day. He said he would have his lunch and probably read the Medical Times and then go home because he did not have any more work to do. Surely no one in this House can say that that is appropriate. Surely no one can stand over not giving highly qualified staff working in publicly funded hospitals and being paid from taxpayers' money the necessary funding to carry out the work that needs to be done, given that all the time people are suffering, in pain and on long waiting lists. The two Ministers of State will need to address this issue speedily.

I wish to take the opportunity to speak about the disability sector. It is yet another sector that needs radical attention. In my constituency two people have been evaluated separately and had personal assistant hours approved. One lady aged 43 years is practically confined to bed and totally reliant on her elderly parents to provide full-time care. The HSE acknowledges that she needs assistance and has awarded her a number of hours but - wait for it - it does not have the funding to actually give a personal assistant for these hours. It states, however, that if she wants to go into a nursing home, she can avail of the fair deal scheme.

In a similar case a 62 year old man had a stroke more than 15 years ago. His wife provided full-time care for him. Unfortunately, she passed away from cancer three months ago. Who is to look after him now? The HSE has been contacted and evaluated his case. Again, it has confirmed that for this man to continue living in his own community where he has been cared for the past 15 years, he needs a home care package. It has approved such a package, but, lo and behold, the patient has been told the necessary funding is not available for the package to commence.

If he wants to enter into a nursing home and apply under the fair deal scheme, he will be possibly looked upon favourably. That is ludicrous. There is no joined-up thinking. Each department is working in silos where every department is looking at its own individual budget with no thought of the consequences on other budgets. It makes sense to keep people in their home for as long as possible. It makes social sense, it makes moral sense and, if one wants to look at it in brass tacks, it makes economic sense to provide the certain supports to keep people in their own home rather than putting them into institutions. We must look at how the various elements within the department are working and how each section is utterly focused on its own budget and makes decisions on its own budget with no interaction with the various other sections within the HSE. That is something that needs to be looked at by the committee.

I take this opportunity to focus on the area of mental health. I listened to the Minister, Deputy Harris, this morning on the issue of the €35 million in funding transferred to other services. It annoys me when people talk about time-saving measures. The reason those people are not employed today is because somebody did not advertise in time. They talk about the period of time it takes to advertise and go through the recruitment and that as a result, they will not be hired by the end of the year. If they knew the funding would be there, why were the advertisements not issued in time, why did the process not start in time and why are the staff not recruited? There was a conscious decision taken somewhere - it might not have been in the Department and it may not be the Minister's fault - that they would not start this process so that they would be able to peel off a certain amount of this funding and put it into another section within the HSE. That is wrong. From what I understood from listening to "Morning Ireland" today, the Minister stated that the decision was not set in stone and is under review. I hope it is under review and I hope the Minister and the Minister of States use their positions of authority to ensure it is stopped and that, even if those necessary professionals cannot be employed by the end of the year, the money is spent where it should be, on the provision of mental health services.

This is a welcome and timely debate. I fully agree with the motion. If we can all sign up to changes and if we can sign up to a ten-year plan or a plan of whatever length in terms of the cycle of change, I do not have a problem but the changes I would like to see would not take ten years. They would not take ten days, if we attach the importance to them that we should.

The HSE is an unaccountable organisation. It is accountable only to the Oireachtas committees and to the Minister for Health. There is no accountability, to me and every other Deputy in the Louth-Meath Cavan-Monaghan area, other than by written request or by meeting an official. Given the significant controversies that are arising, as we see in Cavan hospital, and as we see regularly in Our Lady of Lourdes Hospital and in County Meath, etc., we ought to go back to the system of accountability of the HSE at regional fora of Members elected to the Oireachtas. That would be useful. Such meetings should be held quarterly, where one could receive reports into the care provided by hospitals in one's region and could also raise, directly and publicly, the issues that arise as a result of those concerns. That is something that is missing in the formula in terms of accountability. If one could bring in before the regional Oireachtas Members the officials of the health board in a transparent, accountable way and hold them to account for the issues that arise, it would be constructive for both sides. One needs that creative tension between the administrators of the health service and the public representatives. It would be a two-way process because the administrators would be able to clearly identify to us directly the changes that they believe are necessary as well.

Does it take somebody to be dying to get a medical card? That is the question I must ask today. In the past week I have had contact with two constituents who are terminally ill. One of them has serious cancer and most of their bowel and stomach has been removed. The other person has terminal heart disease and will be dead, the person tells me, probably within six months at the most. In both cases, their income is higher than the limit for medical cards. Both of them have been kindly turned down by the HSE medical card appeal system for a discretionary medical card. It is a shame and a disgrace that somebody who is terminally ill should be deprived of the comfort of the concern of the community. Such people should be given a medical card if they are terminally ill, regardless of their income. It would recognise their importance as a human being. It would recognise their battle to live as long as they can in the best way that they can. It is a shame and a disgrace that constituents are telephoning me with those concerns in the past week. I note, from listening to other Members in the Oireachtas, it is not unique to my good self. We need to look again at the discretionary medical card applications. The HSE needs to be much more empathetic towards families and the seriously ill. It is unforgivable and unacceptable that the current system prevails.

The other element missing in the health service is advocates for the elderly, for those who are terminally ill and for patients who are in hospital about whom families have concerns. One telephones the hospital and leaves a message and perhaps the call will be returned or perhaps not. One talks to the liaison staff and maybe they will or will not be sympathetic to the point one is making. What we need in the HSE are advocates whose full-time job is to deal with the bureaucracy for and on behalf of the patients who lie in those beds who are not getting the treatment that their families feel they need or who need to be in hospital and are not, and who will be accountable to the patient and families. I recognise and welcome the work that the patient liaison staff do but I am not convinced that they are on the side of the patient. What we need is a clear, absolutely committed and fully funded advocacy service that will reach out and meet the needs of those people.

Never is this more important than when people have dementia. I and every Member of this House are aware of people who suffer from dementia, the problems in the families and in the homes, and the fear that people outside of the immediate family have about getting involved. It is like the way cancer was treated many years ago. People do not know what to do or what to say. We need to reach out much more to people with dementia and to the families who support them. One should not forget the family gives day and night support, 24 hours a day seven days a week, to keep them in their home. If anything must change in society, it is the way we treat people with dementia and the way we interact and support the families who are caring for people who have that illness. In particular, I welcome the nomination of a representative from the Alzheimer Society of Ireland to the Seanad. I do not know whether it was Fianna Fáil. Whoever made the nomination, it is a welcome place where the person can articulate views on what should be done in this area. I would fully support such concerns and views.

It was Deputy Micheál Martin.

I do not mind. I am happy that it happened. I welcome it. It is a positive, constructive appointment to the Seanad and it is essential in terms of informing our thinking. We need to articulate their needs on a national level.

Returning to the wonderful HSE, it is more a hide and seek than a HSE.

For two years, I have been trying to get at the facts regarding a death in County Louth and find out what went wrong with the ambulance service that night. For some reason, no ambulance turned up and the poor, unfortunate patient died tragically. He was brought to hospital in a Garda car. It was New Year's Eve, and a critical member of the ambulance crew had not turned up for work, which meant the service was one ambulance down. The absent crew member went and worked in the private sector as a private ambulance worker on the night on which the man died. I do not know how it impacted on the events in the Louth, Meath and Cavan area.

I have been frustrated by the HSE and the system. The case is before the Information Commissioner for the second time in an attempt to get at the facts of the case. I am not seeking the name of the ambulance driver concerned. I want to know what happened, and why and how we can ensure it never happens again. It is unacceptable for somebody to leave the ambulance service and work in the private sector on the busiest night of the year. I do not know why the young man died. I do not know whether he could have been saved had an ambulance reached him in time. The fact that concerns me most is that no ambulance came within the required period of time. I want to get at the truth of it. It has taken two years to get this far, but I will find out.

It is a disgrace that we must go through this and that the transparency, knowledge and accountability of the ambulance service is the way it is. This is why I return to my point regarding accountability in the Louth, Meath, Cavan and Monaghan region. The old health board system was not bad in terms of accountability. We are not talking about interfering in the process but about asking the questions. At the health board meetings one could ask directly what was going on, which we cannot do now.

I am very concerned about the treatment of the elderly in nursing home care, both private and public. Shameful and disgraceful acts are still happening to our elderly in many institutions. I will return to it very soon in the public domain. We need more inspections. HIQA is doing far fewer inspections than it should. One is lucky if it visits a nursing home once a year. HIQA must be far more active and involved in what is happening and we need much more transparency and accountability. For whatever time is left to me in this House, I will push this.

I thank all the parties and Independent Deputies who have signed up to the motion before us. There is much concern about the fact that we have a minority Government, and those concerns may, in time, prove to be well-founded. While I hope they do not, they may. However, the minority situation also provides the Dáil with a voice it has not had before. It provides the Dáil with the opportunity to table motions and legislation and build cross-party coalitions for good ideas. While the Social Democrats initiated the motion before the House, it is a motion of the Dáil, supported by all parties and groups. Hopefully, through this cross-party approach, we can achieve some important breakthroughs in health care.

The motion calls for the establishment of a committee to examine four specific health care challenges, namely, the existing and forecast demand for health services; how to progress a model of health care that advocates the principles of prevention and early intervention, self-management and primary care services, and integrated care; the different funding models available, which I imagine the committee will spend much time on; and how best to reorient the health service from an acute-based system towards an integrated, primary and community care system.

The motion outlines “the need to establish a universal single tier service where patients are treated on the basis of health need rather than on ability to pay”. It is a very serious statement for the Dáil to make. It is a cross-party statement signed up to by all the Independent Deputies. It is a major departure from today's health care system and I very much welcome the fact that the statement has got such agreement in the House.

There is more that most, if not all, Members agree on. They agree that our health care system should provide a high quality, modern and timely service which should be provided as close to the patient as practicable. They agree our health care system should be cost-effective and should invest in prevention and early detection. They agree our health care system should protect people’s dignity, which our clinicians try to do every day but which, sadly, they are not always able to provide, for a variety of reasons. They agree that our health care system should be a rewarding and exciting place for clinicians and non-clinicians to work in and that it should be open to change, responsive to concerns and accountable for its work. I, and many Members of the House, would argue that this is not the case.

It is important to recognise some of the successes we have had in health care, including the great success and progress in paediatric leukaemia treatment during recent years. However, the system is struggling. International comparisons do not suggest Ireland does very well. For example, the European Health Consumer Index ranks us 21st out of 35 countries, which puts us close to the bottom of the middle group. The index also found that we have the longest waiting times for emergency care in Europe, which we must take very seriously. Today, nearly 300 people are on trolleys. In west Wicklow and Kildare, more than 1,800 people are awaiting speech and language assessments. The vast majority of these are children, and the waiting time is 18 months to two years. By the time some of those children receive care, much of the opportunity to provide help has been missed. Over the weekend, we heard the bone density scanners in Galway University Hospital have been shut down. We have two high-tech machines that had been running five days a week, and both have been mothballed due to lack of staff. We cannot allow this.

The Cappagh National Orthopaedic Hospital has seven operating theatres which used to operate every day and a surgeon in a given eight hour list could do approximately seven procedures. Two of the operating theatres have been closed indefinitely and another two have been closed for refurbishment with no understanding as to when they will re-open. Only three of the seven operating theatres of the Cappagh National Orthopaedic Hospital are being used. It is worse than that. A given orthopaedic surgeon takes one of the three operating theatres for a given day. The surgeons are being told they can have a theatre only every second or third Monday, for example, given that only three are available. They are also being told not to do as many procedures as they could. For example, rather than doing seven procedures, they are told to do only four, and then go home. The HSE will still pay the €22 million it costs to run the hospital, and will pay the surgeons, theatre teams and all the costs. The reason the surgeons must go home is that the only thing the HSE will not pay for is the implants.

We have a hospital, surgeons, technicians, operating theatres, wards, a car park and insurance. We are going to pay for all of these, but we will just not pay for implants. Therefore, rather than having seven operating theatres within which six or seven procedures could be carried out each day, we have three within which perhaps four procedures are performed each day at more or less the same cost. We paid €22 million for the hospital and some of the €1.5 million for implants. That is what is happening in the hospital system. Consequently, those who can afford it can avail of private care. The waiting time to see a surgeon to whom I spoke recently was 18 months in the case of his public list but only six months in the case of his private list. Therefore, there is a two-tier system. There is health care for those who can afford it but not for those who cannot.

What is frustrating is that it is not due to a lack of funding. It is not that there is not enough money going into the HSE. We have the second highest expenditure ratio on health care in the OECD. We spend money, but we do not get the service we should for it. The issue is not clinicians. We have some of the best trained clinicians on earth, as well as some of the best doctors, nurses and surgeons. We have the second highest expenditure ratio on health care, yet we are effectively telling the National Orthopaedic Hospital to close more than half of its operating theatres, and not to carry out as many procedures as possible on patients with deteriorating conditions which will result in their ending up in wheelchairs because we do not have the money for implants. That is what is happening on a daily basis.

There are many reasons for the low performance rate in the health system. There is a lack of local autonomy for hospitals and there is a poor level of accountability and transparency in the HSE. There is little econometric analysis to show where we need to provide health care. We do not have integrated ICT systems for the management of patient records. In many places we have silos rather than continuous and holistic care pathways. We have a deep culture of mistrust between clinicians and managerial staff across the health care system. It is corrosive. However, such a culture does not prevail in other countries in which I have worked. There is little access for patients to clinical quality data. Consequently, they do not know which hospitals are good and which are bad. Some are good and others not so good, but we are not allowed to know which is which. There are also poor working conditions for clinicians. The list goes on.

Each of these operational challenges is solvable, but they are not being solved. Why? It is because behind it all there is a lack of vision. We cannot achieve success in health care because we have not agreed what it is. We cannot give managers and clinicians the tools they need to succeed because we have not told them what we want them to do to succeed. We need a unified strategy for health care, but for that we need to know what it is to achieve and right now we do not know what that is. That is why the motion is important. It will bring together a cross-party group to which we can all bring political ideas, but I hope it will not be used as a political football. We can bring the group together to ask some of the following questions. What are the health care services we need and where are they needed? How do we support prevention and early detection programmes? How can we move to an integrated primary care system? How much money are we willing to spend on health care, as we can spend as much as we want to spend on it? How will we raise the money? If we can make progress on these questions, we can put a long-term system in place with agreement on what it is we are trying to achieve, how we are trying to achieve it and, critically, how we will pay for it.

We need to be honest about some uncomfortable political truths which the committee will have to examine. One is that a modern health care system requires an increasing amount of money because it is becoming more sophisticated and people are living longer. Another is that a modern health care system is of a scale which makes it impossible for all services to be delivered everywhere throughout the country. We will have to have a serious conversation about that issue. Another truth is that some hospitals are simply better than others and that people have a right to know which are doing well and which are doing badly.

We need a vision for health care for which we need cross-party support. We must also learn to start trusting clinicians and managers in primary care centres, hospitals and hospital groups.

I wish whoever will serve on the committee well. They will face some very difficult technical and political issues. If the committee can succeed in bringing back to the House a vision for health care and real options in terms of how much it will cost and how we can fund it, we can start to move on and accept that if we are to spend more on health care than almost any other country, let us have the best health care system in the world for that money.

The next two speakers are the Ministers of State, Deputies Marcella Corcoran Kenny and Deputy Finian McGrath. Am I to take it that one of these good Ministers of State will speak for ten minutes and that the other will wrap up the debate as they are the two final speakers?

I will speak first. I am delighted to speak to this all-party motion to establish a committee to devise a long-term strategy for health care. I hope it will be as successful as the Sub-committee on Dáil Reform on which I served since the first meeting of the Dáil and which was chaired most ably by the Ceann Comhairle. All members of the sub-committee represented the Members elected to the House. It was very constructive and positive and while its members held different views, they came to a consensus. If we can achieve the same with the new committee that is being established with the Members who will serve on it seeking to achieve something positive for the population that will ensure the delivery of health services will be much improved, that will be a very good outcome. I urge Members who have not thought of serving on it to put their names forward and to serve on the committee if they get the opportunity to do so. It will be an enriching experience for them and I hope the outcome will be one of which we can all be proud and that we can all look forward to implementing its recommendations.

Much of the focus of the health service is on the difficulties that arise within it. However, any of us who has had occasion to experience the health service has found that once one is in the system, one is looked after very well. The front-line staff are fantastic and patients receive exceptional care. The focus will be on whether there are delays in emergency departments and whether there are patients on trolleys to try to come up with strategies to reduce such delays.

The focus of the Government is on improving people's health and well-being to keep them out of the health system. This is a positive direction to take. We want to put strategies in place that will ensure people will take positive steps to improve their health and well-being and that of their children through schools and in communities and through taking responsibility for their own health helped by public information programmes, the HSE, Departments and cross-departmental efforts to ensure people will become more physically active and cut out or cut down their alcohol consumption and tobacco use. Some of the figures are stark. When we consider all of this, we note the importance of focusing on what we can do for ourselves, ably assisted by the agencies charged with responsibility of assisting us in that regard.

The level of obesity is of great concern. I am conscious of it as a parent who has reared children and I also see its high incidence among young people. Unfortunately, one in four children and around 60% of the population are obese. I will have to look into my own heart on this one. I always thought I was curvaceous, but I have been told I am obese; therefore, I had better do something about it. We are getting older and need to maintain our cardiovascular health to try to resist developing conditions that will leave us prone to having a stroke, a heart attack or developing cancer and to all of the other difficulties that we all know only too well having seen family members suffer from some of these conditions or bad health outcomes. Obesity levels are, unfortunately, also higher among those in the low income bracket in society.

That is something we need to be concerned about. We need to look at the type of food people are eating and to encourage them to eat better food and to avoid fast food. Actions will be put in place in the coming months in terms of our obesity strategy which we will, hopefully, launch very soon. There will be actions in terms of the public alcohol Bill which will address among other things preventing young children from being exposed to advertising and the marketing of alcohol. There is quite a lot of action taking place.

If we look at obesity again, "Operation Transformation" on RTE is partnered by the Department of Health. There are also partnerships with the GAA in terms of getting young people active and moving. All of these things are very beneficial because physical activity is good not only for one's physical well-being but also one's mental health. Reading into my brief recently, I came across a figure on alcohol consumption and its impact on people's mental health. As it is a depressive, people who are hoping for a lift might only get a temporary one. In the long-term, however, they will not get any benefit from it. In fact, the incidence of alcohol in relation to suicide shows that it is involved in more than 50% of cases. That is something we need to take care of because it is of great concern to me in my new role. The national physical activity plan, which I touched on earlier, is also of incredible importance. It is something I urge everybody to have a look at to see how they can use the ideas contained in it to encourage those within their communities to engage also.

There are many challenges but I am very optimistic. If we can focus on a practical level on keeping people out of the health system and have them take positive actions in terms of their own health, it will cost a lot less and we will all have longer and healthier lives. That is what all of us want for ourselves and our children. I hope sincerely that when the committee is established, there will be a very positive attitude to it and that people will adopt a very constructive approach. At the end of it, I hope we have something we can all stand over, be proud of and see delivered into the future.

I wish Deputy Simon Harris the very best in his new role as Minister for Health. I ask him to take charge of all aspects of health to ensure that there is accountability in our health service. I think back over the years and my time as a member of Kerry County Council and it seems to me that former Ministers for Health were not really accountable for health at all. They threw it back to the HSE. In reply to any question asked in the Dáil, a Minister would say he or she would refer it to the HSE. If one was at the HSE forum in the County Hall in Cork and asked the HSE to account for something, it would refer it back to the Department. The buck needs to stop with somebody. I ask the new Minister, who is a fit young man himself, to take charge of the Department of Health to ensure that the service is properly run and overseen.

Are there too many officials in the HSE rather than front-line staff? Front-line staff in the hospitals in Kerry, including nurses and those on the floor especially at night, are, and have been, under tremendous pressure. There are clearly not enough nurses. At University Hospital Kerry in Tralee and at Killarney Community Hospital, staff are visibly under pressure every day of the week. If a nurse goes off sick on a ward, which happens, the rest of the staff are under severe pressure for the duration of the shift. We need more nurses and that must be addressed.

There is a problem with recruiting GPs in rural areas. I highlight Rathmore in Kerry where it is a real issue now. Graduating GPs are not inclined to stay in our country. They cost a great deal to educate but in one year - 2014 - 89 of the 91 who graduated left the country. Something has to be done to rectify that and, as such, I call on the Minister to ensure it is.

Every morning an account is given on radio in Kerry of the number of patients on trolleys. It happens all over the country. Why is that so? Why can we not sort it out? In Kerry, it appears the reason is that so many of our wards are closed. At University Hospital Kerry, two or three wards were closed completely four or five years ago because they could not be staffed. Staffing is the issue. The new community hospital in Kenmare is only half open as is Dingle Community Hospital. The grounds for the hospital in Dingle were given over by the landowner for free to build a community hospital for the people of the area and yet a lot of its accommodation is being used as office space for the HSE. I deplore that because it is not why the hospital was built.

Turning to mental health, a new unit has been built at Deer Lodge on St. Margaret's Road in Killarney. It has been completely finished for almost 12 months but there are no staff available for it. Sadly, close to my home in Kerry, four people have committed suicide. I am not saying the opening of this unit would have prevented that but the unit has been built for a purpose and is not serving one as long as it remains unopened. I ask the new Minister to address that issue immediately because the unit in Killarney is needed by all of the people in Kerry.

We had what we were told was a reconfiguration of the ambulance service two or three years ago. "Reconfiguration" is a terrible word because I take it to mean a reduction in service rather than a reconfiguration of the service. In Kerry, and I suppose it is the case nationally, the rule is that an emergency hospital ambulance cannot take a patient to a district hospital. We had a case on the Muckross Road in Killarney where a patient could not be taken by the emergency ambulance to the district hospital in Killarney. The man took his last drive in the world in the back of a builder's van when the doctor involved secured a wheelchair to put him into it. We are supposed to have intermediate care vehicles to take care of that situation but in the south, sadly, there are no staff to operate them. I ask that the issue be addressed. There is no point having vehicles if there is no one to drive them.

What is happening with home help is a serious issue for me. Home help is vital to keep elderly and disabled people in their homes for the last years of their lives but it has been seriously cut. A great many people are in contact with my office each day to ask about hours or to say that the hours that they already had have been cut. In one case, an elderly woman of 88 years of age was getting five half hours over five mornings but that has been cut to two half hours. The woman was born in 1928 and has given her life to the country.

After spending her life rearing her family and doing her best for everyone she met, this is how she is being treated. Her home help has been cut from five half hours - a half hour each morning - to two half hours. A blind man in another part of the constituency has had his home help removed at the weekends. On Saturdays and Sundays, he gets up and tries to put on his clothes but because he cannot see, they are upside-down and inside-out. He burns himself with water whenever he tries to make himself a cup of tea. He lives alone and his neighbours are worried about him.

It is not fair, as people do not get better at weekends or on bank holidays. It is sad to think that on Christmas Day, St. Stephen's Day and New Year's Day, when all of the world is operating under the guise of peace and good, or on any other bank holiday, there is no home help for some people. This matter must be addressed. Surely doing so would be cheaper and easier than putting people into nursing homes. Some of them die after a few weeks of being in a nursing home. If they could be helped to stay in their own homes, it would mean so much to many and save the country a great deal of money.

Kerry has a separate issue and is under more pressure. People are as entitled to live in Kerry as in any other county. A few weeks ago, we had the case of a patient whose address was given as Ballydesmond, Mallow, County Cork. While that is her correct address, she is actually on the Kerry side. If she was on the Mallow side, she would get 20 hours of home help per week but because she is on the Kerry side, she only gets ten hours per week. We are in the same country, so everyone should be treated the same. All of the children of the country should be cherished equally. This matter must be addressed. There are no ifs or buts about it and I will not settle for anything less. People who need home help should get as much of it as possible and it should be distributed equally to everyone.

A very good point on which to end. I thank the Deputy. The Minister of State has five minutes to wrap up the debate.

I thank colleagues for their contributions to this debate. It has been a valuable experience, as I have heard many good and different ideas and positive contributions. A number of Deputies proposed solutions to a number of the problems in our health services. The committee has significant potential to develop further solutions to some of the issues that have been raised in this debate and it can bring a clear plan to the House. As many Deputies stated, however, any recommendation from the committee must be implemented. Health is an important issue and must be placed at the heart of Government and Government policy. I will do my best to ensure that this happens.

The funding, reform and management of our health services are important matters. As such, I confirm my support for the motion establishing the committee on the future of health care. One of the motion's key aims relates to achieving the best health outcomes and value for money by reorienting the model of care towards primary and community care where the majority of people's health needs can be met locally. This is of particular importance in supporting people with disabilities. According to the motion, the committee will examine how to progress a changed model of care that advocates principles such as early intervention, self-management, greater use of primary care services and integrated care. These are important principles for any health system.

A key Government aim is to provide services and supports for people with disabilities that empower them to live independent lives, provide them with greater independence in accessing services of their choosing and enhance their ability to tailor the supports required to meet their needs and plan their lives. This commitment is outlined in the programme for a partnership Government and is guided by two principles, namely, equality of opportunity and improving the quality of life for people with disabilities. As part of our commitment to equality of opportunity for all citizens, we will support people with disabilities in maximising their potential by removing barriers that impact on access to services, education, work and health care. Particular focus will be placed on supports at key transition points, namely, going to school; progressing to further training or education; commencing employment; and moving into new homes. These are key elements of our plans for the coming months.

This is a time of major change in the delivery of services and the Transforming Lives programme has already been embarked upon. I urge all Deputies to examine it. Meeting the needs of the individual is at the heart of our disability services and the aim of the Transforming Lives programme is to put people with disabilities at the centre of everything we do. Its implementation will mean a seismic shift in how disability services are funded and provided, moving choice and control from professional administrators to where it rightly belongs, that being, the individual with the disability and his or her family. Services and supports will be delivered with greater efficiency, transparency and accountability.

These issues are covered by the programme for a partnership Government but so is another important issue, namely, cystic fibrosis services. We will endeavour to ensure that everyone with cystic fibrosis will get a top-class service. Capital investment in emergency departments is also required.

To speak more broadly, I will discuss children with disabilities and people with serious illnesses. On page 56 of our programme for Government, we plan on extending medical cards to the approximately 10,000 children in respect of whom domiciliary care allowance is received. A number of Deputies rightly mentioned mental health services. We must bring further capacity to Child and Adolescent Mental Health Services, CAMHS. We need more 24-hour supports in primary and emergency care. We must consider those in our wider society who need our help. As such, the Government is examining the idea of increasing the disability benefit, allowances, carer's benefit and the blind person's pension. As Deputies probably know, the €1,700 respite care grant resumed this week after it was cut. Some 17,000 carers are on the register for this grant but there are many other carers who are not. My colleagues might highlight this fact. I am also considering the introduction of a new mobility scheme and since we are discussing reform, it is important that we ratify the UN Convention on the Rights of Persons with Disabilities. The programme for Government contains many other things that we all want to do.

The new committee has the potential to cause a seismic shift in the long-term vision for health care and health policy. I look forward to the committee's development of a political consensus on a long-term plan for health services and the health of citizens, especially the most vulnerable in society.

Question put and agreed to.