Health Care Committee Establishment: Motion

I move:

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.

This motion is real evidence of the new Dáil responding to the message the people delivered at the recent general election. The message I heard loudly and clearly in my role is to put the benefits of economic success to work for people to deliver the services that matter to them. However, the people also gave us the challenge of finding a new way of working together and responding to this challenge presents an historic opportunity.

The new Dáil is diverse but need not be divided. Together we can achieve one thing that has never happened in health policy, namely, a long-term consensus on its fundamental principles. I am excited about this and grateful to everyone who has agreed to this motion. I acknowledge, in particular, the role of Deputy Róisín Shortall in liaising with me on the motion on behalf of the Opposition. Opposition Members presented a motion on this issue and we worked together to arrive at this hybrid motion, if one likes.

While members of the public and the people who work so hard in our health service have no lack of appetite for reform, they are certainly fatigued by piecemeal reforms that do not really change anything and the shifting priorities that often come with political change. The work of the new committee will mean members of the public and those working in the service can have a sense of certainty that there is a long-term strategy agreed by political consensus and, I hope, societal consensus that will not change no matter what the make-up of the next Dáil.

We all know the health service faces many challenges. Moreover, the programme for partnership Government acknowledges that we have an ageing population who are living longer and whose needs will become greater and more diverse. We also have the highest birth rate in Europe. As citizens, all of us at some point in our lives will need to access health services. Therefore, we have a common interest in finding a common way forward for improving and developing our health services.

The Government comes to this motion with a clear objective in sight. As set out in the programme for partnership Government, the Government is committed to the goal of universal health care, a concept endorsed by the World Health Organization, United Nations, OECD and European Union. As an overall goal to improve our health services, universal health care involves four main objectives, as set out by the WHO, namely, reducing unmet health needs; reducing inequalities in access to health goods and services; improving service quality; and improving financial protection, which means patients must not face catastrophic or impoverishing levels of health spending as a result of seeking health care.

The World Health Organization notes that no country fully achieves all the universal health coverage objectives for 100% of the population, 100% of the services available and 100% of the cost, without waiting lists. However, it believes that every country can improve efficiency, reduce waste and increase value from its health spend. By doing so, we can advance the cause of universal health care.

In striving for the optimal single tier health service for Ireland, there are inevitable policy trade-offs to be confronted. These trade-offs often involve tensions between efficiency and equity or between comprehensiveness and cost control. In all countries, not only Ireland, the trade-offs centre on three basic dimensions of the health service which must be confronted when designing a health service. These are the proportion of the population to be covered, the range of services to be covered and the proportion of the total costs to be met.

We also know there are factors outside of the health service which affect universal health care, including housing, employment and education. This requires a whole-of-Govemment, health in all policies approach and this is echoed in the Healthy Ireland framework. There are, therefore, tough policy choices, trade-offs and decisions to be made, especially in terms of managing resources, addressing performance and ensuring accountability.

The previous programme for Government, 2011-16, committed to a major programme of health reform, the aim of which was to deliver universal health care, with access to quality services based on need and not ability to pay. In April 2014, the White Paper on Universal Health Insurance, UHI, was published. It proposed a competitive, multi-payer model of universal health insurance as the means to achieve universal health care.

Having reviewed the results from the UHI costing project, it was concluded that the high costs associated with the White Paper model of UHI were not acceptable and further research and cost modelling were needed before definitive conclusions could be drawn on the best means to achieve universal health care. This is the current position and whatever approach we adopt, there is a need for consensus on the direction of health policy. The new committee offers a great opportunity to try to achieve this consensus.

One of most important features of any country's health service is how it is funded, both in terms of the amount of money required and the manner in which it is financed. These are difficult questions to answer and will clearly be central to the deliberations of the all-party committee. Making changes to funding levels and financing methods takes time and requires careful management, not least to avoid disruption to what are vital existing services. That is one reason it is important to take a long-term view of how the health service can be developed.

The 2016 health budget is €13.1 billion and increases in the health budget have been possible in the previous two budgets.

It is the Government's intention to work with the Oireachtas to sustain these annual increases going forward, basing health expenditure on multi-year budgeting supported by a five year health service plan.

One aspect of the motion we can all support is the need for a decisive shift within the health service towards primary care and the effective delivery of primary care in every community. The more intervention we can have for patients at the earliest possible stage and as close to home as possible, the more likely there will be a better outcome for patients. To do this, it will be necessary to build up GP capacity to respond to patient's needs and the expansion of chronic disease management in general practice. We will continue to support the provision of mental health and disability services within the community where appropriate. Developing primary care services and integrating primary and secondary care services is a vital component in any strategy to address the issues facing our hospitals, in particular emergency departments. In developing models of person centred, co-ordinated care, we can draw on the work of the national clinical programmes, in particular the piloted integrated care programmes.

While the new committee will have many health service challenges and difficulties to examine, which should not be underestimated, we should also acknowledge that the health service has been changing and it would be wrong not to acknowledge where success has happened. For example, we have seen life expectancy in Ireland increase by two and a half years since 2004 to where it is now above the EU average. We have seen mortality rates for circulatory system and respiratory diseases fall, an improvement in cancer care, a reduction in the in-hospital mortality rate following admission with a heart attack, a decrease in the average length of stay in hospitals and significant progress in reducing tobacco consumption. Progress has been made in many health areas and it is important to recognise that progress along with recognising those who work so hard at the front line.

There is much more to do, particularly in regard to prevention and integrated care. However, there are important changes already under way on which we can build. Universal health care is not just something to implement but is a direction and a journey. Ultimately, how far and how fast we proceed in the direction of universal health care is a question of choices and how we make them. I pledge my full support as Minister, and that of the Government, to assisting the committee in any way we can. I passionately believe that if we can arrive at a political and societal consensus about our direction of travel for a universal public health service, we can provide a degree of certainty to citizens, patients and those who work on the front line. I look forward to working with people on this.

I congratulate the Minister and the Minister of State, Deputy Finian McGrath, and wish them success with their portfolios.

Fianna Fáil supports this motion because we believe we need a discussion at both parliamentary and societal level about how we should fund health care in the years ahead. We talk about universality and access to health care as a right and entitlement but we must acknowledge that the State's capacity to fund that creates difficulties in regard to achieving that goal and ambition.

Previously, rather than talk about the delivery of health care, we have talked about structural reforms. Our constant obsession with structural reforms, without knowing clearly and definitively what direction we intend to go, has undermined confidence and morale among those who provide health care services across the country and has sapped the ability of the organisation meant to deliver health care. If we are committed to a public health service, we need a public service that can deliver health care. Fianna Fáil is committed to a national public health system. Currently, the HSE has responsibility for delivering health care and while there have been many challenges in regard to its ability to manage and deliver health care, we must acknowledge that even if we change the name or structure, we will still require a national organisation to deliver health care. I hope that following the discussions and deliberations of this committee, we will be able to come to a political arrangement as to what direction we intend to go in terms of delivery of health care. I hope that once we have reached that consensus, regardless of political outcomes after general elections, there will be a single pathway towards our goal.

We must acknowledge the huge demographic pressures beginning to build in this country. I do not believe we are adequately prepared for these. The demographics show there will be a major increase in the number of people over 65, 75 and 85 in the next ten to 15 years. We must put clear strategies in place now to ensure we have the capacity, both in terms of physical infrastructure and clinical delivery, to cope with this in the years ahead. To date, we have been unable to consider how to put these structures in place. We talk about the issues but we have been unable to deliver. Take for example our deliberations on primary care. We have had a primary care strategy for more than ten years but as far back as 1988, when then Minister, Rory O'Hanlon, took on the health portfolio, he spoke about five key principles in the delivery of health care. The overriding import of what he said then was the importance of primary care. We have travelled a long way since then in terms of time but our primary and community care structures are not fit for purpose in terms of the delivery of modern, 21st century health care, medical and clinical outcomes. We must accept that is the case.

I welcome the fact the committee will discuss a ten-year strategy and blueprint for how we will deliver health care. This is an ambitious undertaking as we have provided just a six month timeframe to meet all the stakeholders and come up with an interim report on the direction. The issue of how we will fund our health care service in the future will certainly arise. Currently, half of our population has private health care. Private health care and people who take out private health insurance make a significant contribution in the sense that they lighten the obligation of the State in regard to providing health care. Without private health insurance, if those now willing to pay for health care were all dependent on the public health system as it stands, the system would collapse. We must be honest and acknowledge that the public health system as it stands does not have the capacity to deliver health care for all 4.6 million citizens.

We need to talk about a sustainable health service. We should remove ourselves from ideological debate on the type of health service the various political parties and individuals want and focus on developing a clear pathway to universal health access and ensuring funding is put in place to provide that. Currently, the State does not have the financial wherewithal to deliver on this immediately, so we need a stepping stone process. Take for example the roll-out of free GP care. We debated this issue on many occasions in the previous Dáil. I am not opposed to the concept of universal, free access to GPs. However, we are going about it the wrong way if we prioritise one cohort over another and disadvantage those who most need health care in the stepping stone process towards that. The rolling-out of free GP access should be based first on those in greatest need and means tested to the point where by some stage in the future, everybody will have free access to GP services.

In talking about the capacity of primary care, we cannot expect a service to provide the best clinical outcomes when it is completely overwhelmed and incapable of delivering the care we wish to ensure. We have talked about moving the focus from the acute hospital setting to primary and community care but at the same time, we have not bolstered the capacity of personnel and infrastructure in these areas to ensure we have proper primary and community care services that will lighten the burden on acute hospitals. Day in, day out people are referred by GPs to acute hospitals throughout the State because they cannot access diagnostics in the normal course of events. People are consistently referred to emergency departments for X-rays, radiography services and other diagnostics. There must be another way to access diagnostics rather than through the acute hospital setting.

We have talked about the grand plans of hospital groups and this Government has focused on hospital trusts, something we have major concerns about. However, the practical changes we could make over the next number of months, which should not be too costly, could make a huge difference in regard to the capacity of the acute hospitals to deal with the issues they should be dealing with and the capacity of the primary and community care units to deal with issues they should be dealing with.

I hope the committee will not get caught up on addressing a strategy that has a ten-year outlook without first acknowledging that, in the meantime, we could make key structural changes, such as access to GP services for diagnostics without referral through the emergency departments. We should enhance the services as this is the best way to deliver health care in the years ahead.

I have been thinking about the fiscal rules for some time. A focus on preventative care will require front-loaded investment but there are fiscal rules relating to budget deficits and I believe there should be some discussion with the European Union with a view to showing that by front-loading investment in preventative medicine we will produce cost savings in the years thereafter. Within the strict budgetary parameters it will be difficult for any state to invest in preventative care without running huge surpluses. With investment in education programmes about lifestyle changes to address areas such as diabetes, obesity, cardiac problems, COPD and many others, we can create huge savings, both financially and in human terms, in the coming years. We have to look at this if we want to strategically invest in a preventative health care programme. We have spoken about health and well-being as constituting the new emphasis of how we deliver health care. In this context preventative medicine, while it comes with a front-loaded cost, does create potential savings.

Mental health has been described as the "Cinderella" of our health services for many years. We have to be honest with ourselves and question how much of A Vision for Change has been achieved. We have to admit that we have not grasped the issue of mental health and well-being in society in any serious or meaningful way. There are significant challenges in the area and the committee should also focus on them.

The other key area where society and policy makers have failed in the past few years is disability, especially in the case of getting people with disabilities into the workplace. Even during the Celtic tiger era, when we had 4% unemployment, we failed to move these people into the workplace.

I look forward to embracing the spirit of this motion but we should focus on a few areas in the short term in order to encourage the Government to change its policy direction on access to health care, as well as develop a vision for the delivery of health care in the years ahead.

I congratulate Deputy Finian McGrath on his appointment, and Deputy Simon Harris, who is temporarily out of the House. I also thank Deputy Shortall for her initiative in this area, which has been somewhat overlooked in some of the press statements, particularly those coming from the Government. I acknowledge her efforts to bring all parties together.

Everyone wants an efficient, fair and humane health service. Politicians from every political party and none have called for this in every single election since the inception of this State. However, what we have is a two-tier system in which individuals and families face years, if not months, of waiting for treatment or diagnosis. Trolley numbers have spiked and it is only a few years since Senator James Reilly, the former Minister for Health, told us we would never again see 569 patients on trolleys. The words were only just out of his mouth when the target was breached. Waiting lists stretch into years and medical staff, nurses and health professionals trained at home are leaving in droves due to poor working conditions.

Deputy Billy Kelleher referred to mental health services as the "Cinderella" of the health system but this is not a pantomime, it is very real. The people who depend on the mental health services and the men and women who deliver them have reached breaking point. Our health system is in a state of perpetual crisis. We all know people who have been let down and failed by the two-tier health system. We know people who cannot afford health insurance but have borrowed money to avail of private health care because they cannot bear to wait for as long as they are expected to. We know people who can neither afford insurance nor borrow for health care and who have to wait in pain and in fear. We have seen public patients with late diagnosis die where private patients survive. The tragic part of this is we know that this is now the rule in the Irish health system and not the exception.

This crisis can be boiled down to two key failings on the part of successive Governments. First, is a fundamental inequality in how patients are treated, differentiated on ability to pay and geography. Second, is the sheer incapacity of the system to deal with demographic pressures, evidenced particularly in our emergency departments and in maternity care. No two patients are identical. However, some pay more than others for the same care. Families in one part of the country get access to necessary services denied to those in a different HSE region. The less well off die younger and live less healthy lives. This is not acceptable. Inability to pay should not deny anyone the opportunity to lead a full, long, healthy life. We need to increase investment in the health system, not simply to provide more resources and capacity but to directly challenge and eliminate these structural inequalities. Building adequate capacity across our health system and eliminating the unequal barriers to access will require significant and sustained public investment. Sinn Féin is 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.

The task we face in the coming period will not be an easy one. The clock counts down from the moment of our first meeting and we only have six months to present a report, which is to be discussed in this House. Politicians have never been able to agree on health across the decades. If the members of the committee can agree a strategy in six months it will be a miracle but we in Sinn Féin will work hard to ensure that the committee does its work efficiently and in a spirit of co-operation. The internal dynamics of the committee and the work it does are only one part of the puzzle. What happens after we discuss the report? What happens to the report, its recommendations, the stakeholder input, the expert opinions and evidence, and the possible funding models?

It was said that many Ministers for Health commissioned so many reports that one could paper the inside and outside of Leinster House with them and we do not need another report. We do not need another photo opportunity, another trip to the plinth to talk to journalists. My concern with this process is that the report, the recommendations, the expert opinion, potential models and stakeholder engagement will all be discarded if they are seen to run contrary to the Government's policy. Can the Minister assure us that this will not be a futile exercise in that regard? Are we tying up members, stakeholders, academics and others into a process that will just consign the report to a library afterwards?

There are very large parts of the programme for Government to which Sinn Féin cannot sign up. I will not sign up to an agenda for privatisation, whether it be outright or through the back door. This is completely at odds with the realisation of a universal health care system. If the Minister is serious about this committee coming together to work collectively on a vision for the health service, we must be clear that any moves to privatise the health service in the form suggested by the programme for Government need to be shelved. The committee cannot gain legitimacy and respect, or develop a comprehensive programme of work, if it is precluded from its work by contrary plans pursued by the Minister at the outset. It is important the Minister make a full statement on this matter.

This issue will not be easily addressed within the six-month timeframe. Many factors need to be considered, including the demographic profile of the population and its geographical spread, demand and what constitutes health spending. When we talk about prevention and early intervention, we must be cognisant that this will impinge upon other Departments, and that there needs to be a whole-of-Government approach.

It is not clear how the ten year plan will work with other Departments. There are broader social issues at play. Will the Minister of State convene a ministerial committee to reflect on the work being done by the health committee? Will other Departments be involved? We will propose that the Minister for Health in the North, Ms Michelle O'Neill, be invited to discuss adopting an all-island approach to health care delivery. I strongly suggest this be done.

That is good to hear. I have met many stakeholders since my appointment as health spokesperson and there is one common thread - people talk consistently about the need for prevention. It is welcome that the motion mentions prevention, early intervention, self-management and primary care. It seems that across the service this is where we are falling down. Too often we allow situations to reach crisis point, leaving personnel fire-fighting and doing nothing more. We take our eyes off the bigger picture in terms of policy-making and budgetary processes. In the race to reach fiscal targets or as the HSE struggles to stay within budget, we long-finger important interventions and initiatives that could prevent crises from occurring in the future. It is easy to leave the health problems of the future to the politicians and decision makers of the future, but the committee should transcend that thinking. We need to spend mention on preventive care services and it is not just a case of throwing money at initiatives. How does one prevent children from needing multiple extractions under a general anaesthetic, given that they cannot access dental services while at school? How does one ensure timely discharge from hospital in the absence of proper community rehabilitation services, sufficient home care supports or access to therapies? In that context, it is welcome that we are discussing this motion. I welcome the establishment of the committee.

As a package of reforms, including the establishment of a committee on the budgetary process, there is the potential to frame a new dialogue, but there needs to be a blueprint and a plan. I hope, therefore, that the committee will not be just an exercise in electoral platitudes or photo opportunities. I will play my part on it and will be advocating strongly for access to health care as a right. The model of universal health care Sinn Féin is working to achieve includes general practitioner and other primary care services. Quality of care is essential and must be at the heart of the service. Such a new comprehensive system will not be achieved overnight, but a start must be made. That requires political will and a fundamental change in the direction of policy, away from the piecemeal, inequitable, semi-privatised and crisis management approach that has perpetuated the many problems in the health service. How this debate will be framed, how we move beyond the dominant political ideology of recent years which has seen public services starved of funding, how we report, present and act will be the litmus test of the success of this parliamentary exercise. We need to be honest with ourselves. When agency staff cost more than the staff directly employed, regardless of whether we have an ideological bent towards the market and market forces, we need to be able to say the use of direct labour is right, more efficient, cheaper and represents better value for money for the taxpayer. It is not good enough to say a hospital can recruit if it has the money. If it does not have the money, a moratorium is effectively in place in the health service. That is happening and needs to be addressed.

Six months from now the real work will begin. The committee will deliver a vision for the health service. Delivering on it will be the biggest task facing the Department, the Minister and future Governments. Many people are depending on us. We cannot let them down and should not sell them short.

We welcome the motion to develop a single long-term vision or plan for the provision of health care. I add my congratulations to those of others to the two Ministers and acknowledge Deputy Róisín Shortall's singular vision in creating the motion. We are in positive mode in relation to the potential of the committee and will engage productively with it. I welcome the tone of the Minister's speech in that there appears to be a genuine willingness to engage with all parties and all Members in this Dáil in seeking a meeting of minds on how we can figure out and instigate a proper vision for the provision of health care into the future. If we are honest, we can reasonably assume that there is much common ground between us on the needs of citizens. There has to be a particular focus on the continuum of care as between primary, secondary and tertiary care.

The one question I have on the creation of the committee is how it will dovetail with the commitments in the programme for Government. Will it be a tool of Government policy into the future or what mandate will it have if it comes up with a set of recommendations that do not tally with the commitments in the programme for Government, of which there are many? Given that approximately €13 billion is to be spent this year alone in the health sector and considering the many commitments made in the programme for Government from primary care through to secondary and tertiary care, including mental health, the issue of resources will have to be addressed within the remit of the committee. If we are to aspire to having a comprehensive continuum of care between primary, secondary and tertiary care, including community care and mental health service provision, it will cost a good deal of money and clear choices will have to be made. To be fair to him, the Minister mentioned this in his contribution when he referred to the trade-offs between efficiency and equity and comprehensiveness and cost control. This is something that will merit further interrogation.

I welcome the document Better Health because it provides a good template and sets out the parameters within which we are operating. Some of the challenges in health care provision include the fact that the number of people aged over 85 years in Ireland is, according to CSO estimates, increasing by approximately 3.3% each year. This presents a major challenge for all of us in the management of demographics. Some 38% of Irish people over the age of 50 years suffer from one chronic disease. Chronic diseases account for 80% of all GP visits, 40% of hospital admissions and 75% of hospital bed days.

The Minister speaks strongly about focusing on primary care and trying to intervene as much as possible at that level. That is something on which we all agree. The aim of such a policy should seek to ensure people are kept out of tertiary care facilities for as long as possible and that interventions are made at community level. That would have a major impact in patient care and would also create the ability to reduce costs and be more efficient in the use of resources. On the flipside, it would require a massive injection of capital into the primary care system. If we are to manage the demographic challenges and the ongoing challenges in chronic care services, as I have outlined, in that paradigm primary care facilities will need resources.

Speaking as a former Minister of State with responsibility for research and innovation, the last Government created a health innovation hub. We created a demonstrator model whereby we sought to utilise the best research that exists from a geographical perspective in terms of medical devices and services. We sought to inculcate the thinking that exists based on the research that is ongoing within our academic institutions as a means of seeking to ensure those greater efficiencies. I am not sure where the health innovation hub stands at present now that there is a new Government formed. However, I believe that innovation and engagement with stakeholders in the academic space is going to be vital. We will need a proper analysis of population figures and a sense of inculcating some of the thinking that exists within academic institutions to determine how we are going to provide the vision that is necessary.

I believe that the primary care centres are one mechanism by which we could link up with academic institutions to try to drive innovation and to ensure, as Deputy Kelleher stated earlier, that more diagnostics take place within the primary care settings so as to prevent people from presenting to secondary and tertiary care facilities and to keep them at home for longer. The data that is used can then be analysed and partnered with medical device companies, innovators in the health care provision space or academics to try to analyse the data so that we can then produce policy outcomes that deliver the efficiencies that are necessary for the system. We need more of that within the system. It is a case of mainstreaming that into the system because currently it is peripheral.

We need to have a greater interrogation of the relationship between the HSE and the Department of Health. There is still some siloed thinking in how the HSE, this House, the Department of Health and the Minister interact. We need a greater interrogation of that relationship to ensure that there is more transparency around it. We also need to look at why there is a constant need for a Supplementary Estimate on an ongoing basis. I say that objectively. Taking this year for example, if there is provision made at the start of the year for €13 billion, will this committee have a remit to examine and interrogate the deployment of resources more closely? We need to look at it in terms of seeking efficiencies for the system in order that the citizen can have confidence that he or she will have access to the services that are necessary, whether he or she presents to a GP, a secondary care facility or a tertiary care facility.

We need to look at the whole issue of health insurance and we need to talk to the health insurance providers. We need to look at why there is spare capacity within secondary care facilities, such as Mallow or Ennis, where more elective surgery could be done. We could take much of the constraints that are in hospitals such as Cork University Hospital and radiate more services out to secondary care facilities. With regard to mental health, we need to have a proper discussion on how A Vision for Change is implemented and resourced.

Táim buíoch as ucht an deis seo a bheith agam ráiteas a dhéanamh faoin ábhar tábhachtach seo atá gar do mo chroí agus, níos tábhachtaí, gar do chroí mhuintir na Gaillimhe agus go háirithe na hothair atá ag fulaingt ar liostaí feithimh agus ar trolleys.

Ba mhaith liom comhghairdeas a dhéanamh leis an Aire Stáit nua. Guím gach rath air ina ról nua.

Go raibh maith agat.

This issue is something that is very close to my heart, but more importantly, to the people of Galway, the country and the patients who are on waiting lists, trolleys and who have not got a health service. I know Deputies have complimented the Minister for Health and I really would like to be positive, but I despair of such statements as "Universal health care is not just something to implement but is a direction and a journey". It is not a journey or a direction. It is a basic human right to have public health. It is a basic human right to walk into a hospital and be treated with dignity and respect and not be sitting on a trolley for three or four days. Even on an economic basis, it is nonsense to make elderly people sit on trolleys. The research clearly points out that somebody over the age of 70 who is on a trolley for two days will inevitably spend a longer period of time in hospital and will therefore cost more. Even on an economic level, we have no choice but to do something about our creaking health system.

I have had the privilege in a long career in local politics of sitting on the regional health forum along with 39 other dedicated councillors from Donegal down to Tipperary. I am more than familiar with the health service and its inadequacies. Deputies could come in here in every debate and point out the long waiting lists. I can tell the House that they are extraordinarily long in Galway. At any given time, we have up to 30,000 patients on an outpatient waiting list waiting for basic health services. On inpatient lists, the figure varies from 5,000 to 9,000. One has to ask why our health service is creaking at the seams. Why are we in the position of establishing a committee consequent on many reports up to now, yet we are still in trouble with our health system?

I wish to pay tribute to Deputy Shortall for her initiative. I have no difficulty in supporting the initiative with regard to the committee. However, I have some concerns with the direction that the committee might take in spending time looking at models of funding for a health service rather than making the health service accountable and available to all our people. In contrast to the Minister, I do not think funding is difficult at all. Funding for our health service comes from our taxes. When I knocked on doors, I did not meet a single person who wanted their taxes reduced. They wanted a health service. I do not know why we need to go down the route of looking at funding. I hope that the committee will look at how to make the health service available as quickly as possible. I hope it will listen to the people on the frontline, the nurses who have never been listened to, the cleaners, the porters and then the consultants on how to improve our health service.

If I analyse what has happened in my time as a councillor on the regional health forum, there were cutbacks in 2006 during the height of the Celtic tiger. Only the language was different. The Government of 2006 talked about bed refurbishment measures to justify bed and ward closures in Merlin Park University Hospital and the regional hospital. It talked about cost containment measures.

We had many failed initiatives. I despair when Fianna Fáil champions the National Treatment Purchase Fund. In my time, we have had at least four failed initiatives without any analysis of the fundamental problems. We had the co-location of private hospitals on public lands led by the former Minister for Health, Mary Harney. It took all of our effort in Galway to fight that appalling initiative to co-locate a private hospital on public lands. We then had the National Treatment Purchase Fund, which in effect channelled public money into private hospitals to keep the private for-profit hospitals making a profit while, at the same time, depleting our public health system. On top of that, we had a special man in Galway for three years on a special salary to deliver the special delivery unit. Again, that channelled public money into private hospitals, allowing waiting lists to build up and then paying public money to treat public patients in a private for-profit hospital.

I apologise if I am parochial in speaking about Galway, but it is the microcosm of what is happening in the country. Only last Friday, there was an announcement that two DEXA scanners were closed. These are vital pieces of diagnostic equipment in the diagnosis of osteoporosis. They were closed because there was no staff. We had professors speaking out against it and we had the embarrassment of hosting a conference in Galway on that very topic when we could not use the DEXA scanners.

I have heard indirectly that some effort was made and that one of the scanners has opened again. However, the fundamental problem in regard to lack of staff has gone unanswered. While the Minister tells us there is no embargo, and in any speech he appeals to the HSE to employ further staff, we have the HSE making a statement that it cannot employ any staff until three leave, when one can come in.

We go from crisis to crisis. Again last week I put down a question in regard to a new public hospital in Galway. I did not do this off my own bat but because the clinical director of the hospital in Galway, which serves the region, has said a new hospital is absolutely necessary and that we must begin planning for it. Under the new politics and in the new atmosphere prevailing in the Dáil, I tabled a question asking, in view of the clinical director's statement, what steps the Minister intended to take. What I got back was Civil Service-speak, although, again, I place no blame on the civil servants. The Minister is paid a very good salary to deal with the questions put. He neatly sidestepped that question and continued on with the old politics in the guise of the new politics. I find that unacceptable. I am sorry he is not present in the House. I thought he would have addressed the serious issue of the lack of capacity in Galway, which is the top risk factor. It was a very serious statement in that the clinical director said the congested site in Galway is simply fire-fighting with each additional building. I listed the buildings involved and he acknowledged the hospital is simply fire-fighting. It is past time to plan for a hospital at Merlin Park, where there is 150 acres of land.

There are very good consultants in the health service. As he did not ask for his name to remain confidential, I am going to quote one of them, Dr. Peter O'Rourke from Donegal. He took the trouble of writing a two-page letter to all Deputies and he then gave us a document highlighting how practical solutions can be used pending the decision of the committee. That has not been mentioned by the Minister, who received a copy of the letter, as did all Fine Gael Deputies. Dr. O'Rourke makes very practical suggestions in regard to medical day units, five-day wards, diagnostic services and access to simple X-rays. If these measures were implemented, it would reduce the situation pertaining in Galway and in every other hospital throughout the country.

I will speak later on the issue of mental health. In Galway, every month 300 patients, including patients suffering from mental health problems, simply leave accident and emergency because they will not be seen. They walk out, lacking the patience to wait. Nobody could have the patience to wait the length of time they have to wait in Galway, notwithstanding the best efforts of the staff. On a monthly basis, 300 people walk out of accident and emergency because no service is available.

On top of that, people with mental health problems are trying to access a congested site and an overworked department of psychiatry by going through accident and emergency. We need to ask ourselves a question. Which of us would like to do that? It is okay to make fine speeches in the Dáil but which Deputy would like it if they, or their wives or children, were suffering mental health problems and had to go through a packed accident and emergency department? Which Deputy here today has spent time on a trolley? I have not. That would guide the direction of the conversation and the urgency of recognising that universal health care is a right - not a journey, not a decision, but a right. I will happily work with the committee if it is considering implementing that right as a matter of urgency, dealing in a practical way with the problems and listening to the people who know best.

Deputies Mick Barry and Gino Kenny are sharing time. I call Deputy Barry.

In 1948 a leaflet was delivered to every home in the United Kingdom. It stated:

Your new National Health Service begins on 5th July. What is it? How do you get it? It will provide you with all medical, dental and nursing care. Everyone – rich or poor, man, woman or child - can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as tax payers, and it will relieve your money worries in time of illness.

The National Health Service was introduced in Britain by a Labour Government, very different to the Labour Party of today, responding to pressure from a working-class majority population, determined after the Second World War never to go back to the poverty of the 1930s. Today, nearly 70 years after the introduction of the British NHS, the Irish capitalist State has failed to introduce anything that might compare with it. Here, with a health service which prioritises treatment for those who can pay and which dumps thousands of patients on trolleys in overcrowded emergency departments each winter, the State struggles to even provide free GP care for all of its under-sixes.

In what direction does the Fine Gael Government now aim to take the nation's health services? The programme for Government tells a tale. First it will seek to progressively dismantle the HSE. Second, it will seek to establish hospital trusts with stand-alone finances and third, it will open the door to private finance for sections of hospitals and to outsourcing to private companies. In other words, it is a programme of creeping privatisation and the continuation of neoliberal policies in the Irish health services.

The Minister praises the idea of a ten-year plan but if it is to be a ten-year plan going down the Fine Gael road that would be a disaster. On the other hand, if it was a ten-year plan which started by breaking with the current health care model, quickly establishing an Irish national health service, and then strengthening it progressively through the years, that would be something very different. In concrete terms, what would that mean? It would mean the State becoming the provider of the health care needs of all. This would be funded from a pool provided by the taxpayer within the framework of a progressive taxation system. There would be free GP care for all, free dental care for all, free access to good mental health services for all, free operations and hospital care, and free prescriptions at the pharmacy. In other words, there would be genuine universal health care, free at the point of use.

The Minister charged with overseeing the introduction of the NHS in Britain, Nye Bevan, said:

The National Health Service had two main principles underlying it: one, that the medical arts of science and of healing should be made available to people ... irrespective of whether they could afford to pay for them or not [and] the second was that this should be done not at the expense of the poorer members of the community but the well-to-do.

That is the way it should be done here. The introduction of a 2% millionaire's tax would raise €2.7 billion, enough to reverse all of the health cuts of recent years; a 10% increase in the effective rate of income tax paid by the top 10% of earners would raise the same amount again; and to cut corporate welfare by just 10% would raise another €1.5 billion. That would provide nearly €7 billion with which to kick-start an Irish national health service.

The Institute of Obstetricians has recently expressed concern that the National Maternity Hospital will be governed by St. Vincent's Hospital when it transfers to the St. Vincent Hospital's campus. St. Vincent's is owned by the Religious Sisters of Charity, there are nuns of the board of directors and doctors must sign contracts promising to adhere to the religious ethos of the hospital. For example, St. Vincent's prohibits female sterilisation as it conflicts with that religious ethos. This is a disgrace in a modern health service in a modern state in the year 2016. Hospitals funded by the taxpayers must be owned, controlled and run by the people, in other words they must be State-owned and democratically controlled.

Hospitals funded by the taxpayer should not be run by religious orders. We are for a national health service in this country but this can only work in the context of a genuine separation of church and State.

It is good we are having this debate because this issue affects everybody, regardless of who they are and where in the country they live. The perpetual crisis of our health system mirrors the glaring inequalities of society in Ireland today. According to public health experts, health outcomes and our general well-being are deeply affected by inequality in income and inequality in access to health services. Access to health care when needed is a fundamental human right. From the moment we are born, in the course of life's challenges, somewhere along the way we will all need a health system that takes cares of us at our time of need. The Department of Health has been compared to Angola but even Angola managed to dig up its landmines and find a peace settlement to resolve the bitter civil conflict that ravaged that country.

The recent report by the Irish Cancer Society that waiting times for life-saving tests for cancer patients are up to 25 times longer for public patients than for those paying privately is distressing and shocking. The report highlighted striking differences between access for public patients and private patients, with GPs reporting that some public patients have to wait up to 480 days for an ultrasound. That means waiting for well over a year for a cancer investigation. The report also quoted an Irish College of General Practitioners report that delays in accessing diagnostics force many patients to pay for scans and tests privately to secure diagnosis and as a result, a patient's ability to pay is linked to his or her ability to access diagnostics used to detect cancer in a timely manner. The report gets to the heart of what is wrong with our health system.

I would go even further and state that this way of dealing with cancer patients amounts to negligence and a violation of a basic human right to health care. In its crudest form, those with the ability to pay can skip the queue and access early intervention for cancer and a better life outcome. Health care should not be about queueing for years. It should not be about how big a person's wallet is. It should be about the delivery of universal health care that is not based on someone's ability to pay or any discrimination based on income or social class. If it was any other form of discrimination, such as based on ethnicity or sexual orientation, this health system loophole would have been quite rightly closed down by now. It is no coincidence that successive right-wing Governments, led by Fianna Fáil or Fine Gael, have created a two-tier health system. Both parties have applied the logic of the market to water, housing, transport and health. For them profit always comes first even if, such as in the tragic death of Susie Long, patients die waiting.

Another example of Government failure in early intervention in our health service is waiting times for children with special needs. According to the reply to a parliamentary question I tabled a number of weeks ago, the average waiting time in Dublin Mid-West for a speech and language therapist is 12 to 18 months and for an occupational therapist it is 18 months to two years. These waiting times are only for assessment and do not include the further wait for treatment. This is clearly unacceptable. Children cannot be routinely expected to wait more than half their lives for intervention that needs to be made as early as possible.

Inclusion Ireland has stated that Ireland is in breach of the recommended number of children who should be assigned to each speech and language therapist. It commented that the recommended caseload size is 30 to 65 children per therapist but in Ireland the national average is an unbelievable 162 children per therapist. To meet international standards, the number of speech and language therapists working in children's disability services would have to be tripled from its current level of 283 speech and language therapists to 800. Inclusion Ireland and other agencies report that, increasingly, hard-pressed families are incurring financial hardship by having to pay for services they cannot access through the public system.

It is good that we are having this debate about the Irish health service. I hope that by adopting this motion we will make a start at abolishing the two-tier health service that is not fit for purpose. I have worked in the health service for the past 16 years. I know that the fault does not lie with the staff who are very dedicated and extremely professional in what they do. Most people will say that when they use the health service, their experience of front-line staff is incredibly positive. Having gone through numerous pay cuts and cutbacks in the past eight years, it is a testament to the dedication of health service staff that we have a functional health service. Ireland spends more on our two-tier health service than any other European country but we do not get as good a service as countries which spend more on public health services and less on private services. It is time to move away from profiteering and away from buying and selling health care for profit and follow the international evidence that one-tier publicly funded not-for-profit health care is best by far.

I commend the motion to the House. I thank Deputy Róisín Shortall for tabling the motion and the Minister, Deputy Simon Harris, for accepting it. I also thank the 150 Members of the Dáil who signed the motion.

The Irish health service needs a long-term vision. It needs a framework that can build an efficient, effective and functioning health service. At present, unfortunately, in many areas our health service does not function properly. Year on year planning is not delivering an effective acute service. Our service tends to fire fight and respond to crises rather than anticipate crises and problems. Every year, we have a trolley crisis with up to 500 or 600 people per day on trolleys. This should be anticipated. Unfortunately, our trolley numbers are not falling back to zero at present and we continue to have people on trolleys. Today, 250 people are on trolleys but we are in the middle of summer. Each year, this situation deteriorates and the number rises to 500 or 600 people. We should build a service that can anticipate these problems and deal with them.

The HSE delivers some very good services. We have excellent acute cardiovascular services. I know the Minister of State, Deputy Halligan, feels there is a deficit in Waterford but throughout the country, and certainly in the mid west, we have wonderful acute cardiac services. We have wonderful breast, prostate, skin and lung cancer services. Our laboratory services for haematology and biochemistry are excellent. Our medical and surgical assessment units work extremely well, provided they are not used as an overflow for casualty during very busy times. These are very positive aspects of the HSE and we should recognise this.

There is a huge deficit when it comes to communication and integration between community and primary care services on the one hand and casualty and hospital services on the other. There should be a seamless transition between primary and secondary care and one of the most important areas the committee should examine is how we integrate primary and secondary care. This is the view of major medical organisations, including the Irish Medical Organisation and the National Association of General Practitioners. We are looking for solutions and accountability on planning decisions. Quite often, decisions are made in the health service which are devoid of input from those who deliver the service on the front line. This makes no common sense.

We must think laterally and differently about how we deliver our health services. In Ireland, 3% of the health budget goes on general practice. This needs to increase to approximately 10% over the next ten years, in line with other European countries. General practice is the engine which will deliver health care reform but, at present, general practice has severe capacity issues. GPs have suffered severely as a result of the financial emergency measures in the public interest legislation. They were affected disproportionately because of the manner in which general practice is funded. GP incomes were hit but funding to support and develop general practices was reduced by 38%, which is unsustainable. Many areas have lost GPs and many areas which still have a GP will find it very difficult to replace that GP when he or she retires. New GP graduates are not going into general practice because our contract is out of date and not fit for purpose.

Debate adjourned.
Sitting suspended at 1.30 p.m. and resumed at 2.30 p.m.