Dáil Éireann debate -
Wednesday, 8 Jun 2016

Vol. 912 No. 1

Leaders' Questions

Deputy Micheál Martin

This morning, I believe, the Cabinet allocated an additional €500 million to the health service, which is extraordinary in itself in so far as it illustrates what we had all been saying at the time of the publication of the health service plan at the beginning of this year and prior to the election, which was that the budget for health was insufficient and represented a massaging of the figures before the general election. I pointed out that the figures were grossly inaccurate. The CEO of the HSE said that the health service was under a death sentence and that the level of money provided in the budget was wholly inadequate and had left a significant shortfall. The then Minister for Health, Deputy Varadkar, had indicated that there was a sufficiency of funding available to the health service.

If one goes back over the past three to four years, every year at budget time we essentially got false figures on health.

They could never have stood up and subsequently did not, including the infamous €680 million supplementary provision for 2014. We now know because it was stated by the former Minister for Health, Deputy Reilly, that he knew the game was up when he lost the battle on that particular budget. Last year, a €600 million supplementary provision was provided.

The head of the HSE said that the current budget would only meet existing levels of service, that is, the level of service provided in 2015. Will the Taoiseach indicate if the €500 million allocation announced today will result in additional home care packages and mental health services and address acute hospital waiting lists and the shortage of funding in acute tertiary hospitals? The Taoiseach will be aware that the figures for May show that there are 509,000 people on the outpatient waiting list and that there are approximately 75,000 people waiting for surgery, which is a 50% increase on the 50,000 figure for 2014. These are extraordinary figures by any yardstick. They illustrate a failure over recent years to provide any meaningful health service provision. Will the extra €500 million provide additional services or is it a sticking plaster to enable delivery of current levels of service across the board?

The Taoiseach

I thank Deputy Martin for his question. While we must work together in the interests of the country, Deputy Martin knows well the difficulties often encountered in health and that, as history has shown, throwing money at a problem is not the answer. The Government is being criticised for making an adjustment to the health budget of more than €400 million and a further adjustment to the justice budget. We are in a position to do this because of the strengthening of the economy and growth in the economy. One of the lessons we have learned in the recent past is that, where possible, we should spend money from that growth on areas of social need and, in this case, health need. The extra allocation in terms of the adjusted Estimates, in respect of health in particular, is to deal with inadequacies, over-expenditure and much-needed investment in particular sectors. The Minister's top priority is immediate address of some of these problems within 100 days. Today's announcement confirms provision of additional funding for a winter initiative, about which the Minister has spoken, to help address overcrowding in emergency departments, which is always a cause of stress for people. As an integral part of that particular initiative the Minister will increase resources for home care services, including home help packages and so on.

The Minister, in conjunction with the Minister of State, Deputy McEntee, will utilise the Revised Estimate to restore the full ring-fenced mental health budget and provide more training to school-leavers with disabilities, which are two important and sensitive areas raised occasionally by many people. Both Ministers will outline the detail of how that extra allocation will be spent to ensure delivery of services for people in those areas. Also, the Government made clear this morning that this is not a case of throwing money at the problem as demand and expenditure continues to rise and expecting to continue as before. The Government expects senior HSE personnel to be personally responsible for the management of their budgets and to ensure additional resources provided because of the strengthening economy are used to best effect in the interests of the patient they are supposed to serve. We have demanded a different range of governance and better accountability from the HSE and so health service management will be responsible for performance of their budgets, including any additional resources. It is in the acute hospitals that the Government sees the real possibility of greater returns. It is hoped that these additional allocations will benefit the people they are intended to benefit, namely, patients.

Deputy Micheál Martin

The reason for the allocation announced today is because the budget provision at the commencement of the year was inaccurate and false. This was pointed out before the election, including by the HSE chief executive officer when he said very explicitly that there was an under-provision for the health service, which has been under a death sentence for a number of years in terms of a lack of planning or vision. They are the words of the CEO of the HSE, not mine, as stated in the context of the health service plan.

The winter initiative is a hardy annual which had been announced already. I am still not clear on whether the €500 million will cover the overruns about which we learned when we met the health officials during talks prior to the formation of Government. These officials were estimating dramatic increases in the first two months of the year above allocated levels and projecting a significant deficit by the end of the year. This all points to a fundamental lack of transparency around health budgeting. The last three budgets have not provided the Dáil with an honest portrayal of health service requirements and needs.

An Ceann Comhairle

Does the Deputy have a question?

Deputy Micheál Martin

Given the under-provision of €680 million in 2014, the under-provision of €600 million last year and the current additional €500 million now being allocated despite that we have not yet reached the halfway point of this year, there is no conclusion a person can come to other than that this is the result of bad planning and is resulting in extraordinary pressure on many services. I get no sense that there is the added value emanating from this that the Taoiseach mentioned.

An Ceann Comhairle

The Deputy must ask a supplementary question now as his time has expired.

Deputy Micheál Martin

Is it the Taoiseach's view that the €500 million is to cover existing pressures on hospitals, or are there, line by line for each €10 million, additional services to be recognised over and above what was provided for in the health service plan?

The Taoiseach

When we were spending almost €15 billion in the health system, we had serious overruns, a lack of accountability, a lack of transparency and a lack of effective management. The programme for Government commits to the establishment of a performance management unit which will require managers of individual hospitals to work with the Health Service Executive and the Department of Health to achieve an effective return on the moneys they receive. The extra allocation of more than €400 million is for the maintenance of existing services, to address overruns that have occurred, particularly in acute hospitals, to deal with what the Deputy called a hardy annual, namely, the winter initiative, which is an important element of health care, and to provide for school-leavers with disabilities, home care packages and full restoration of the intended allocation for mental health services, which money was not allocated in the manner it should have been.

I expect that following organisation next week by the Whips of Dáil business, there will be ample opportunity for Members of this House to tease out the details of these issues in plenary session and in committee. As I indicated, the Minister for Health, Deputy Harris, and the Minister of State, Deputy McEntee, will spell out the details of what is involved in terms of additional services for mental health and in respect of school-leavers with disabilities who need these extra funds.

Deputy Gerry Adams

Last week, I raised with the Taoiseach the need for a full investigation into the sale and purchase of NAMA's Northern loan book, Project Eagle. As the Taoiseach avoided my question, I propose to put it to him again. Some of the allegations are shocking. Between May 2010 and November 2013, a member of NAMA's advisory board is alleged to have been charging a fee for advice about NAMA. It is further alleged that the same individual had an unethical working relationship with a senior NAMA officer who gave him access to additional and sensitive commercial information. It is also alleged that he was lobbying on behalf of clients to reduce loan repayment demands and in return he would secure cash payments, so-called fixer fees which were shared with the senior NAMA officer. When NAMA decided to sell its Northern loan book to the US vulture fund Cerberus, this individual was offering to disclose information relating to the value of the loans to a bidder called PIMCO.

It is alleged that PIMCO discovered that payment of a fixer fee of £15 million was requested, to be paid if PIMCO was successful. PIMCO reported this to NAMA and withdrew from the process. According to the response to a Sinn Féin freedom of information request, the Minister for Finance, Deputy Noonan, was updated by the NAMA chairman regarding these transactions. It is still unclear why the Minister did not intervene to exercise his general powers of direction over NAMA to suspend the sale’s process until these matters were fully investigated. If found to be accurate, these are serious allegations of financial corruption and insider trading from which the taxpayer has suffered a huge loss. Since 2005, this State has had a market abuse regime and regulations which provide for the prohibition of insider dealing and market manipulation. These are criminal offences. Will the Taoiseach explain why he will not establish a full investigation into these matters? He has refused to do so thus far. I and others have been asking for a very long time that he would at least do us the courtesy of explaining to us why he will not set up such an investigation.

The Taoiseach

Commissions of investigation in this jurisdiction operate in this jurisdiction. If the Deputy wants to give me evidence as to why there should be a commission of investigation in this jurisdiction, I would be quite prepared to listen to it.

Deputy Gerry Adams

I have just given it.

The Taoiseach

I hear allegations, rumours and speculation, but that is not the basis for setting up a commission of investigation on any particular matter. The Minister for Finance dealt with the question of a company that was in a tender position here which was not proceeded with when the question of a fixer’s fee arose. If the Deputy has other information beyond that, he knows to bring it to the fraud squad and the Garda Síochána. He should produce evidence to me here in the House as to why a commission of investigation should take place in this jurisdiction when there are legal cases being pursued in Northern Ireland where a commission of investigation set up here would not have jurisdiction. The principal personnel with NAMA were in front of the relevant committees here. They gave long and detailed explanations. Nobody has presented me with evidence of wrongdoing by NAMA in this jurisdiction. The allegations the Deputy makes-----

Deputy Mick Wallace

They did not say anything.

The Taoiseach

-----relate to other areas. I am quite prepared to receive from the Deputy, or anybody else, evidence as to why the Government should consider something else.

In so far as these are serious matters, and they are serious matters, there is no allegation or evidence of wrongdoing by NAMA in this jurisdiction. If that is not correct and somebody has evidence to the contrary, I would be happy and would like to see it.

Deputy Clare Daly

It has been given already.

Deputy Gerry Adams

All accusations are allegations until proven. That is a distraction. These are allegations and I have been very careful to couch them in that way. The Taoiseach speaks of rumours. I have not put any rumours to him. It is very precise. A member of NAMA’s advisory board is alleged to have been guilty of malpractice and possible criminal offences, aided and abetted by a senior officer with NAMA. Why will the Taoiseach not set up such an investigation when called upon to do so? NAMA is an arm of the State. It is not the Taoiseach’s money and it is not my money; it is the people’s money. NAMA should be accountable and the Government should be transparent, open and accountable as well.

We have never been given an explanation for the failure by the Minister for Finance, Deputy Noonan, to intervene to suspend the sales process when he was informed that a fixer’s fee of £15 million was requested. That is very straight and direct. I am giving the Taoiseach the substance of these allegations. We are concerned that taxpayers are not getting full value. This includes the tens of thousands of families struggling to pay mortgages. The money the Government is not putting into health services could have gone into these other people’s pockets and bank accounts. The homeless and the citizens lying on hospital trolleys are the victims of this type of behaviour. Will the Taoiseach commit to the establishment of a commission of investigation into the sale of Project Eagle? The Taoiseach should not fob me off by saying it is happening in another jurisdiction. This is a national issue. NAMA’s Northern portfolio is a national asset belonging to the people of this State.

The Taoiseach

The Deputy can believe me that I have no intention of fobbing off anything that is happening here or in any other jurisdiction, unlike some of the stuff that I hear. I believe, and my understanding is, that this loan was executed in a proper manner and that despite all the confusion and conflation, there has been no allegation of wrongdoing made against NAMA down here.

Deputy Clare Daly

The Taoiseach should read the Official Report of the Dáil.

The Taoiseach

The loan portfolio was sold following an open process to the highest bidder for what it was worth. NAMA paid no money to and had no relationship with any party on this loan sale against whom allegations of wrongdoing are now being made.

Deputy Mick Wallace

Not true.

The Taoiseach

Deputy Adams did raise the point here-----

Deputy Clare Daly

Was it only people who worked for it?

The Taoiseach

-----that there were two individuals arrested on 31 May in respect of the UK’s National Crime Agency’s investigation into the sale of Northern Ireland assets owned by NAMA. I understand that several investigations are going on, as Deputy Adams is probably aware, including those with the UK National Crime Agency, NCA, the Department of Justice and the Law Society of Northern Ireland. We welcome those investigations.

Deputy Gerry Adams

Not here.

The Taoiseach

The allegations are being pursued by the authorities of the jurisdiction in which they are being followed through. NAMA continues to co-operate with-----

Deputy Mary Lou McDonald

The Government has jurisdiction over NAMA.

The Taoiseach

-----the NCA and other relevant authorities in respect of those investigations.

Deputy Mary Lou McDonald

The Government is responsible for NAMA.

The Taoiseach

The Department of Finance has not had any direct contact with the National Crime Agency but it is willing and available if required. The Department of Finance has made all relevant information in respect of Project Eagle publicly available on its website and, separately, the Comptroller and Auditor General is examining the disposal of the loans of Northern Ireland debtors. The Comptroller and Auditor General is independently positioned to comment on this if necessary. The officials at the Office of the Comptroller and Auditor General have confirmed that given their independent role, any queries related to the timing, content or any other specific aspects of their reports have to be directed to their office.

Deputy Bríd Smith

Will the Taoiseach please respond to the news that the Psychiatric Nurses Association, PNA, has voted by a staggering 87% to take strike action over staff shortages in the mental health services, particularly among psychiatric nurses? The famous report, A Vision for Change, dates back to 2006 and recommended an increase of 1,800 staff in mental health services. By 2012, we were 23% below that recommendation. In 2014, the suicide rate was 475. That figure does not include the numbers who attempted to take their own lives or did themselves harm because of the continuing deprivation in mental health services.

The reason the PNA gives for this serious ballot on strike action is that there is no clear plan from the Health Service Executive, HSE, on how to address this staffing crisis. Staffing levels in child mental health services are down 50% and the staffing level in adult mental health services is only 75% filled. The PNA says that there are 600 vacancies for psychiatric nurses and there will be another 400 within the next year because of retirements. To stay at the current level would require an extra 1,000 nurses in the mental health services. That does not include child psychiatrists and other therapists required.

The Taoiseach will be asked many questions later about the programme for Government, but I want to use this opportunity to ask what the programme intends doing in this regard because in the mental health section it states it will implement A Vision for Change.

Given the level of crisis in terms of staff shortages and funding for mental health services alone, can the Taoiseach outline for the House what answer he will give to the Psychiatric Nurses' Association, PNA, the mental health services generally and those who require mental health services to address the chronic shortage in the service? It seems to me that the programme for Government and HSE are failing to address this urgent crisis.

The Taoiseach

Deputy Smith has raised an important question. That is why the Government made clear this morning that the extra allocation to the Estimate for the Department of Health and the HSE will restore in full the ring-fenced moneys for mental health services. The details of how they are to be located and spent will be outlined by the Minister of State, Deputy McEntee, and the Minister, Deputy Harris, over the course of the discussions on the Estimates next week and the week after.

It is fair to say that there are some serious recruitment issues in respect of the problem to which the Deputy referred. The Minister and Department are examining that question. I can stand here and say that because of the increased strength in the economy, an adjustment will be made to deal with what was set out in the programme in terms of the allocation for the mental health area.

I spoke to people the other day with regard to the Department of Children and Youth Affairs. I find there is always a complication between psychologists and psychiatrists working for the HSE and Tusla when children might need services and things are to be contracted again. The legal costs arising in areas surrounding children are always significant.

Suicide and self-harm are very traumatic and sensitive issues that exist not just in any particular location in the country, but across every area. The clinical programme for the assessment and management of self-harm in emergency departments provides a skilled response to people presenting with self-harm issues or suicidal ideation, as it is called, in emergency departments through a network of self-harm psychiatric nurses. Some 24 of the 35 additional nurses available have been recruited to this programme and trained for the role, and are doing a very important job, as the Deputy is aware.

The HSE is committed to further developing early intervention and prevention services. I hope the extra allocation being made to the health area and the restoration of funding for the mental health area will benefit these persons greatly. The details will be outlined by Ministers over the next week or so.

Deputy Bríd Smith

The period I outlined, in which there was an ever-increasing shortage of staff in mental health services, was also a period of austerity, when economic hardship and worries such as where to live, job losses, putting a roof over one's head, sending children to college, etc., put a major stress and strain on people, which led to further loss of mental health in families, the self-employed and unemployed workers.

The period to which I referred, when there was a reduction in psychiatric nurses in particular, is the one on which the PNA is focusing. The Taoiseach has failed to address my question. If the PNA takes strike action on the issue of nurse shortages and the need to recruit at least 375 extra psychiatric nurses per year for the next few years, where will the money and determination come from?

The Taoiseach answered Deputy Martin's question about the extra funding that has been allocated to health, and said it would be allocated to existing services, overruns in acute hospitals, disability, home help services and mental health. Many areas require funding before one even begins to examine the need to engage an extra 1,000 psychiatric nurses, according to the PNA, which is taking strike action because of that fact.

The Taoiseach

I apologise to Deputy Smith for not addressing her question. Obviously, I hope industrial action will not take place. The Minister for Health met the association last Friday and is engaging with it. Some of the issues that are being considered are the possibility of more training places for psychiatric nurses, bringing back a number of recently retired psychiatric nurses and continued efforts to attract nurses who have been working abroad back to Ireland This is a genuinely serious problem and one that the Minister is working hard to grapple with.

In 2015, almost 30,000 people were offered a first appointment and seen under A Vision for Change, the mental health strategy. As Deputy Smith is aware, every emergency department has 24-7 access to mental health services. Consultant psychiatrist and non-consultant hospital doctors in psychiatry working in general adult and old age psychiatric services, together with liaison psychiatry medical staff, provide an on-call service outside normal working hours. It is largely focused on people presenting with urgent mental health problems.

The Government made a decision to adjust the Estimate in respect of the health Vote. Funding for the mental health area is being fully restored. Details will be outlined by Ministers and I am quite sure that the Deputy's input will be valuable to what is a serious argument.

Deputy Michael Collins

As of 2015, more than 500,000 people aged over 65 are living in Ireland. In the next 30 years this figure will double. It is vital that the current Government prepare for our ageing population. It has been Government policy since 1960 to support older people to stay at home for as long as possible. However, a recent report carried out by Age Action, the Alzheimer's Society of Ireland and UCD, Meeting Older People's Preference for Care, found that acute hospitals and nursing homes are being prioritised over the kinds of community services that enable older people to remain in their homes.

The report estimates that half of the older people spoken to in long-term residential care could live at home. The number of people in nursing homes in Ireland is 35% greater than the EU average. The report also states that community supports are disorganised, fragmented and underfunded. It found that across all areas, the home help service available was minimal and ranged from less than an hour to a maximum of five hours a week, usually between 9 a.m. and 5 p.m. The current programme for a partnership Government promises increased State support for the elderly and aims to keep older people independent and active while living in their communities. It promises to improve supports and services for older people to enable them to live independently in their homes. It aims to increase home care packages and home help hours every year. In sharp contrast to these promises, the HSE said on 24 May 2016 that funds are now being rationed and more people will wait longer for home supports. This is due to overspending on home help and home care packages in the first quarter of the year in order to free up beds and ease the pressure on hospital emergency departments.

There is an added fear that home help will be privatised. I ask the Taoiseach to confirm whether this is the case. I strongly disagree with privatisation on the grounds that it is a business, rather than a care, model. In other countries, such as Sweden, the privatisation of home help was found to have a negative impact on the standard of care provided, as the need for profit prevailed.

The current programme promises additional funding for the nursing home support scheme in order to keep the waiting period for the fair deal scheme at approximately four weeks. However, new figures from Nursing Homes Ireland revealed that waiting times for nursing home funding have doubled over the past three months. Long waiting times can leave families struggling with a bill of €15,000 before any funding is received. This is completely unacceptable. If waiting lists are not dealt with, I urge the Taoiseach to backdate payments for care from when an application was received until when it was approved.

The Taoiseach

The general principle outlined by Deputy Collins is important. It is the wish of the vast majority of people that they will be able to stay in their homes until such time as they have to become institutionalised. That is why there has been a move from institutional and hospital care to community care. That is why home care packages are so important and why the waiting list initiative and the fair deal scheme received substantial moneys in 2015, which resulted in a reduction in waiting list times from 18 to four or five weeks.

Deputy Michael Collins is correct in pointing out that the demographic pressures will increase in the future. In fact, the population is projected to increase by 4% between 2016 and 2021, with the number of people in the 85 plus age group expected to rise by 4% between 2015 and 2016 alone. As Deputy Collins is well aware, that cohort, or those much younger, can require extensive and expensive care. That is the reason it is important for us to focus on primary care centres, community facilities and home-care packages that allow people to stay in their own homes as long as possible.

Some time ago, Deputy Michael Healy-Rae made a point to me about the availability of Sunday care under home help and home care packages. That is an issue the Minister will consider in the context of the extra adjustment made to the health budget. I do not think anybody in the House would disagree with the concept of people being able to stay in their own place in their senior years for as long as is possible. Why would that not be the case? That is where the continued effort of Government will be. The approach must take into account the pragmatic understanding that the population of the country is ageing and that every year brings a new cohort of those aged over 70 - as I pointed out in the context of those aged over 80, the consequences of that can be expensive - but it is very important that the State provides the very best level of support to people in their homes for as long as that is possible. Advances in the treatment of chronic disease and expensive medical technologies can ease the discomfort of people and make it somewhat easier for them to stay at home for longer periods. That is where the focus of the Government must be for that cohort.

Deputy Michael Collins

Could the Taoiseach again clarify whether it is the intention of the Department of Health to privatise the home help service in the future? I urge the Taoiseach to support the home help service as we know it. The workers involved have tirelessly cared for the elderly. Many of them only get 30 minutes to deal with an elderly person on a daily basis, to carry out numerous tasks and take many phone calls during the day in order to look after those in their care. They are fighting a major battle against banked hours. They have no work payment for the time spent going from client to client, even though a recent European ruling stated they should be paid for that time. The home help service is willing to work days, nights and weekends but staff are refused hours and those hours are being given to private companies instead. I and many others believe there should be a review of the management of the home help service in this country. I call on the Taoiseach to start the process and by doing so to protect the future of the home help service and its delivery.

The Taoiseach

There is no question of there being any intention of privatising the health service at all. In some cases it can be very difficult to get personnel to manage the home care packages, depending on the nature of the complication or circumstances of individuals in need of home care. The intention is to increase the extent of home care packages so that more people can stay out of hospital and be in their own place - kitchen, sitting room and bedroom - while they do not have to be institutionalised. Everybody can agree with that approach.

If it is of interest to Deputy Michael Collins, I am sure the Minister can arrange a briefing for him in respect of the area he represents and the particular issues to which he referred from first-hand knowledge. The Minister will make that arrangement for the Deputy if he wishes to take him up on the offer.