Dáil Éireann debate -
Thursday, 9 Feb 2017

Vol. 938 No. 2

Hospital Waiting Lists: Statements

Minister for Health (Deputy Simon Harris)

I welcome the opportunity to address the issues raised in the harrowing "RTÉ Investigates" programme, "Living on the List". People all over Ireland watching the programme found it hard to bear the pain and anxiety etched on the faces of the men, women and especially children who very bravely told their stories, and the shattering impact on those who love and care for them. I was genuine and truthful about my feelings on watching the programme. I will not defend the indefensible or excuse the inexcusable. Offering my honest response should not, however, be portrayed as being the only response I have offered. Today, I want to outline to the House the actions that were and are being taken, both before and after the programme, to address the long waiting lists that so traumatically affect patients.

When I became Minister for Health I was aware that I would receive increased funding for waiting list initiatives in the budget. However, I did not want to wait until then as the numbers were growing and the trajectory being forecast by my Department and the Health Service Executive was frightening. Something had to be done, even with limited additional resources and a short timeframe, to try to make a difference and I knew where I wanted to start. I unapologetically targeted resources at specialties with particularly long waiting lists, such as scoliosis and orthopaedics, through the winter initiative, and treating those patients waiting the longest by requesting the HSE to put in place an action plan to halve the number of patients waiting for 18 months or more for inpatient or day case procedures. Through this action plan, more than 11,500 patients came off the inpatient day case waiting list between August and December 2016, reducing the number of patients waiting more than 18 months for treatment by more than 50%.

While there are obviously still too many people waiting, the priority in 2016 was to reduce the number of long-waiting patients and the HSE, through its efforts, made considerable strides in this regard. Public hospitals showed they could deliver on sharing capacity and working together across hospital groups and the country. For example, 24 orthopaedic cases from Tullamore hospital were undertaken in Kilkenny hospital, 150 orthopaedic cases received treatment in Cappagh hospital on behalf of St. James's, Tullamore, Beaumont, Tallaght and Crumlin hospitals, and 34 adolescent scoliosis cases took place in the Mater hospital on behalf of Tallaght hospital.

Also in 2016, the National Treatment Purchase Fund, NTPF, undertook an endoscopy waiting list initiative to arrange for the provision of endoscopy procedures to patients waiting for longer than 12 months. By the end of December, more than 5,500 people had come off the waiting list and the NTPF had managed to clear more than 99% of those waiting longest on the list.

I want to do more in 2017 and we will do more. This is a priority for me, the Government and the people of this country. The NTPF allocation for 2017 will utilise capacity in the private acute hospital sector to provide treatment for our longest waiting patients on the inpatient-day case waiting list. The HSE will also submit an action plan to improve waiting lists in the public acute hospital sector for inpatients and day cases, as well as outpatients. Starting with the National Treatment Purchase Fund, in budget 2017 an allocation of €20 million was made to the fund and an additional allocation of €55 million has been made for 2018. In December 2016, I granted approval to the NTPF to dedicate €5 million to a day case waiting list initiative, with the aim of ensuring that no patient will be waiting more than 18 months for a day case procedure by 30 June 2017. It is expected that in excess of 2,000 patients will receive treatment through this process, commencing in March. The main areas of focus will be on lists with large numbers of long-waiting patients, namely, ear, nose and throat or ENT, ophthalmology, general surgery, dental, urology and vascular surgery.

The HSE will also submit a waiting list action plan for 2017 by the end of this month. The plan will concentrate on reducing the length of time patients wait for an inpatient, day case or outpatient appointment, with the aim of having no patient waiting longer than 15 months by the end of October. While I consider this is still much too long, it would mark a significant reduction in waiting times, with the aim of reducing waiting lists further. To ensure the best outcome for patients who are waiting, the HSE and NTPF will and must work together to utilise capacity in the public and private sectors. The plan will also be supported by the NTPF's proposal for a further €10 million of funding for patient treatment in 2017. In addition, I have requested that the HSE produce an action plan for scoliosis, which will be a targeted initiative prioritising scoliosis patients, and to focus on gynaecology, an issue discussed in the House many times, and cardiology.

Before I address other issues raised by the documentary broadcast on Monday night, I am sure we all agree that it was particularly difficult to watch the plight of Megan, Kira and Darragh who are waiting for scoliosis treatment. I was humbled by their courage and that of their parents. I am keenly aware of their burden and I stress my commitment to addressing the service problems they face.

Additional funding has been provided in recent years to develop paediatric orthopaedic services, including scoliosis services. I made available €2 million under the winter initiative in 2016 and more than 50 additional patients - children and teenagers - have been treated under this initiative to date. As a result, while we have made some progress, there is much more to do to provide the level of service needed.

On Tuesday, I met the chief executive officers of the children’s hospital group and Our Lady’s Children’s Hospital in Crumlin to discuss immediate action they can take to reduce wailing lists for children and adolescents with scoliosis. Although the new theatre in Crumlin was commissioned in 2016, it is only now being opened due to challenges with recruiting nurses. The hospital has undertaken an aggressive recruitment drive to attract new theatre nurses and I commend it on doing so. As a result of this drive, four new nurses will be in place by April and a further 16 international nurses have been offered posts and have commenced the registration process in Ireland.

The recruitment of these nurses means that the new theatre will provide the additional capacity for scoliosis procedures from April, as the nurses take up post. In addition, an orthopaedic surgeon post in Crumlin hospital will be filled in June, which will provide further capacity in that hospital and theatre this summer. As a result, Crumlin hospital expects to undertake 194 spinal procedures by the end of 2017, which is considerably more than last year, and this is expected to achieve significant reductions in waiting lists for scoliosis procedures and, most importantly, waiting times. Furthermore, bearing in mind the serious long-term health consequences for children with scoliosis, a specific action plan on scoliosis will be submitted to me by the end of the month. This plan will take on board the concerns of the advocacy groups in respect of scoliosis. My absolute commitment to families with children with scoliosis and to those with scoliosis is that this will be an absolute priority in 2017.

As Deputies will know, I have asked the NTPF to audit the practices in the hospitals highlighted by the individual cases featured in the programme on RTE. This means going in and auditing how waiting lists were addressed in each of the hospitals referred to in the programme. I wish to clarify an issue about NTPF data and waiting lists that was raised in the documentary. Since its establishment and in line with international protocols, NTPF published waiting list data has consistently excluded patients classified as pre-admit and planned procedure. Contrary to some political charges, this was not a decision made by me but one that has been in place since 2002. However, the NTPF is undertaking a project in conjunction with Trinity College Dublin to examine updated international best practice around waiting list data publication models. I will adopt its findings in full. Deputy Louise O'Reilly has made a good suggestion on integrated waiting lists and I will meet her next week about it. There is a lot of merit in what she says. She has been pursuing this with me for some time, which I acknowledge.

Before I conclude, I acknowledge that waiting list figures for January were published yesterday and, obviously, I am disappointed to see the figures go up, but I cannot be surprised. I knew the figures would increase because they tend to increase every January with the pressures on our emergency departments and as the action plan for the last year comes to an end. Due to the ongoing demands on our emergency departments and in order for the measures in train and those planned for the coming months to start having an impact, I am aware that it will take some time this year for our waiting list figures to start to go down. However, we will ensure that every patient in the country is waiting a shorter time for a hospital procedure or appointment by the end of this year.

I believe that we can do better for our patients. I do not believe that the challenges facing our health service will be solved purely by resources alone. Yes, resources are an issue, but if it was all about resources we would not have had any problems in the health service during Celtic Tiger Ireland. This is not just about resources. It is about how money is spent, how budgets are implemented and how hospitals are managed. These are all factors. We are reinvesting in our health service after some extremely difficult years but we have to be careful and must underpin this increased funding with new and tougher accountability rules. I want to see the performance and accountability framework deliver for patients and taxpayers. It is designed to do both. I want to be clear: we have some really excellent managers in our health service. I meet them and I know them as do other Deputies. However, there is definitely room to do more. I reject any assertion that we are already doing all that we can and that there is no room for improvement in terms of how the health service is managed.

I think we all recognise as well that we face a complex and multidimensional challenge. We are living longer and healthier than ever before, which is something to be celebrated. However, it also means that there are more demands on our health service. Every year, our acute health system delivers more than 3.2 million outpatient attendances in our hospitals, 94,000 patients have elective inpatient procedures and 1 million have a planned day case procedure, and the demand continues to rise. This is down to the hard work of front-line staff throughout our health service. We all know that, if we want to break the vicious cycle, we need to take the fundamental reforms, to have our ten-year plan, to address bed capacity and recruitment and to not play party politics with our health service.

An Leas-Cheann Comhairle

I call Deputy Billy Kelleher. I remind Members that they should indicate in advance if they wish to share time.

Deputy Billy Kelleher

I am sharing with Deputies Marc MacSharry and Michael Moynihan.

I welcome the opportunity to debate this issue because the "Living On The List" programme by RTÉ's "Prime Time Investigates" was a devastating critique of what is happening daily in people's lives throughout the country. The sad reality is that it is nothing new. In that context, in the area of scoliosis, on 16 November last, using pseudonyms, I read into the record of the House during a Topical Issue debate that was taken by the Minister of State, Deputy Marcella Corcoran Kennedy, an outline of the cases of some of the people who appeared in the programme, which was devastating to watch last Monday night. However, we should not be surprised because what has been happening over the past six years was always going to result in waiting lists escalating, people waiting inordinate periods of time, and more and more people depending on a public hospital system that had a shrinking capacity. Not only did it have a shrinking capacity but there was increased demand on it. The only safety valve that was available was the National Treatment Purchase Fund, NTPF, which was scrapped in 2011. Therefore, we were always going to arrive at this position.

We on this side of the House have consistently highlighted that capacity was a major problem, but nothing was done. The Fine Gael Minister for Health, James Reilly, who is the deputy leader of Fine Gael, stated at the time that it was not all about beds and capacity. He is right, but we subsequently found out that our hospitals are running at 100% on a continual basis. There is no room to deal with winter flu and bug problems or infectious disease problems, etc. There is no room in our hospital systems. The Minister for Health knows that as did his predecessor and his predecessor before him. The only avenue available to address the issues of scoliosis and many other elective surgeries that are urgently needed was through the NTPF, which was shelved. By the Minister's own admission, that was a mistake and he reintroduced it.

We now have a situation where the management in the HSE has been blamed consistently over recent weeks. I have no difficulty with HSE management being held to account. It should be held to account.

Deputy Fergus O'Dowd

Hear, hear.

Deputy Billy Kelleher

We also proposed that, but let us be under no illusion. The Minister is a bit like a nasty jockey on a very tired horse that is trying to get him up to the line and using the whip too much. The bottom line is that the HSE simply has not got adequate resources in certain areas to deal with these waiting lists and there is consistent spin in the past week that it is all the HSE's fault. The bottom line is that the previous two Ministers for Health were from the Minister's own party. They were James Reilly, who was removed and sent to the Department of Children and Youth Affairs, and Deputy Varadkar, who was removed and slipped off into the Department of Social Protection.

The bottom line is that Fine Gael's policies have absolutely failed and for a number of reasons. First, Fine Gael said that it would commit to universal health insurance. For the first three of the last six years, Fine Gael spoke about universal health insurance and tearing up the HSE and getting rid of it. The only thing that happened was the then Minister, James Reilly, sacked the HSE board. The reason I am saying this is that we are shattered from talking about reform. We are talking about it endlessly but we are not talking about delivery of services to patients. Patients are consistently waiting inordinate periods for outpatient and inpatient appointments, procedures and diagnostics. We now find that 633,000 people are waiting, which is a shameful indictment. The bottom line is that the vast majority rests with the policies that the Government has not been pursuing over the past number of years, that is, trying to expand capacity in the key areas where there was an inordinate waiting list as opposed to flexing the muscles and threatening the HSE with abolition and not doing it and threatening that managers would be sacked but not doing so.

Does the Minister have confidence in the management? The first thing I have to ask is if the Minister has confidence in Mr. O'Brien because he is the top manager. If he is to be honest with himself, the Minister will have to start by looking at the top if he does not have confidence in management. Let us get real, let us focus on patients and let us stop this undermining of the organisation that is charged with the responsibility of delivering health care.

Deputy Marc MacSharry

At this stage, the stones on the road know that we have many problems in our health service but what is needed is action. We are beyond the periodic outrage that we show in the House following an RTÉ programme or whatever local case some Deputy raises and we need to focus on tangible solutions. As far as I am concerned, our health service is focused exclusively on budgets by non-clinical personnel. That is wrong. As Deputy Kelleher noted, it is not focused on patients but on budgets. There are layers of management. I do not want to be critical of individuals who are setting out to do their jobs as best they can but the reality is that the level of autonomy and management that needs to be given to clinicians has not being given so far. Yes, we have decimated the numbers of personnel through the recruitment ban during the years of the crash.

We have taken thousands of beds out of the system and we need to focus on this. The €20 million allocated to the National Treatment Purchase Fund for this year is insufficient. I appeal to the Minister to contact the Minister for Public Expenditure and Reform before the day is out. There should be an emergency Cabinet meeting if necessary because many hundreds of millions must be allocated to the fund if we are to truly begin to deal with the problem.

We also need to focus heavily on capacity. How many times do we need to hear Fergal Hickey on the national airwaves saying, in his expert opinion, that extra acute beds are needed? Many Deputies have pointed out ad nauseam that we need to relax the means test on the carer's allowance so that we can capitalise on the goodwill of people to care for elderly people at home and give them the dignity to remain at home. This needs to be backed with a freer availability of medical cards, housing adaptation grants and other supports. There needs to be more clinical autonomy in order that GPs can deal with things like mild trauma by having instantaneous access to diagnostics, meaning acute beds are not taken up by people waiting for CT scans, MRIs and so on. We need to focus on retaining and attracting staff.

Despite the individual best intentions of those involved in management and administration in the health service, it is dysfunctional and does not work to the extent we need. We need to strip out layers of management. I spoke to a group of nurses this morning and they told me conditions are worse than 25 years ago. That is unacceptable. We need less debate, less outrage and less manufactured shock and horror from RTE programmes and the stories we hear in our clinics. Tangible action needs to be taken.

The message I give to the Government today is that €20 million for the NTPF will not cut the mustard. It will need €100 million, and maybe more, to eat into the problem while stripping out layers of management and retaining and attracting more staff. I have no difficulty with managers who do their best but we cannot run our health service like a business. It is not a business but a service that costs money to run. It should be non-profitable but this is difficult to achieve. When there was a matron and a county surgeon the janitor, the consultant, the nurse, the GP and the patient shivered in their boots when they walked along the corridor. The buck stopped with them but nobody knows where the buck stops any more.

Deputy Michael Moynihan

This debate is taking place on foot of the RTE's exposure of the health service in its "RTE Investigates" programme but many Deputies have been raising the issue of health service waiting lists for the past number of years. RTE could do a follow-on series on therapies for children and the elderly, relating to which there is a raft of issues but there does not seem to be any urgency to tackle these problems. There has been constant news of people waiting on trolleys in accident and emergency units. I have been in accident and emergency units with relatives on three occasions in recent months and a series of "Prime Time" programmes is coming down the tracks on this issue too. What is happening there is totally unacceptable. I hope the Minister is being fully briefed about the crisis because it is going to be highlighted in many television programmes. Deputies have been inundated with complaints from constituents about the chronic waiting lists, and about staff in accident and emergency units being run off their feet trying to cope. On one occasion people were taken from beds and put in chairs. I have heard of people on stretchers in ambulances not being allowed out of the ambulance because there was nowhere to put them. This was in the past four or five weeks and not 50 or 60 years ago or in wartime Vietnam. There is a massive crisis in the health service. Waiting lists are one issue but there is a crisis across the whole spectrum.

Deputy Gerry Adams

Táim buíoch as an deis labhartha ar an ábhar tábhachtach seo. On Tuesday I raised with the Taoiseach the scandal of tens of thousands of patients being omitted from official waiting list numbers, as published by the National Treatment Purchase Fund and highlighted by the "RTE Investigates" programme on Monday night. The bravery of families in these situations is heroic and their anguish is millteanach dona.

I want to raise the case of Jade Doran from Letterkenny. She is a 19-year old student studying law. She has had ENT problems for years and is going deaf in both ears. She has been seen by a consultant and been advised that she needs hearing aids. She is now on a waiting list but has received no indication of a timeframe and no follow-up appointment. Jade also has a problem with her knee and has Osgood-Schlatter disease. She has been on a waiting list for orthopaedics for four years. She is studying and all of this is affecting her studies, with the uncertainty making the situation even worse.

It is patients like Jade and her family who are affected by the scandal of the waiting list crisis and it is for people like Jade that solutions must be found. That is why I put Sinn Féin's proposals directly to the Taoiseach for a single, integrated hospital waiting management scheme. Teachta O'Reilly sent this to the Minister last September but he did not even bother meeting her. I commend the proposition to the Minister again. I ask him to consider, as he said he would, introducing a system that serves patients like Jade.

Deputy Louise O'Reilly

I would like to refresh the Minister's memory by going back to August 2016 and another Fine Gael five-point plan, a five-point plan to tackle waiting lists. One might have thought the Minister would have learned his lesson as regards five-point plans but apparently not. One of the points in the plan was to make sure waiting lists were accurate and that there would be a clinical validation of waiting lists. After this week's revelations, nothing could be clearer than the fact that the waiting lists, as presented to us, are far from accurate. Was hiding these 49,000 people on waiting lists part of the Minister's clinical validation? Was the change in the classification used by the NTPF early this year part of this clinical validation? Can the Minister share with us the reason the protocol used by the NTPF from 2014 to 2017 was abruptly changed earlier this year, with no fanfare and no launch but a radical departure in how the to-come-in, TCI, patients are defined? I sincerely hope this change was not prompted by panic at the realisation that the waiting list figures reflected very badly on this Minister and his plans, five-point or whatever, to reduce waiting times.

The NTPF issued a statement after the "RTE Investigates" programme to the effect that, "in line with international best practices published waiting list data excludes patients classified as pre-admit and preplanned procedures". The preplanned procedures in this case are the TCIs. What is disturbing about this statement is that the protocol used by the NTPF, dated 2014 and in use up until a few weeks ago, provided for the publication of the TCI figures. International best practice does not change overnight and it certainly does not change to suit the agenda of a Government running scared from its own abysmal failures.

I am deeply disturbed about this. As the protocol dated 2014 has disappeared from the NTPF website, was it discredited? What international best practice caused the change? I sincerely hope this change in protocol was not decided on simply to put off awkward questions. It seems to me that this protocol, and the reference to international best practice, magically appeared just as the figures waiting for treatment magically disappeared. This is not good enough and the Minister has to explain this fundamental shift in policy. Was it directed by his office? Was it directed by the HSE? Did the NTPF take it upon themselves? That is some classy validation process the Minister has going on there and we saw its effects on Monday night.

Rather than focusing on taking people off the lists who the Minister thinks should not be on them, he should ensure that the body into which he is pumping millions is transparent in its data collection and conforms to international best practice. Indeed, the Taoiseach made an important point on Tuesday during Leaders' Questions, when he said:

The list system is nothing new. It has been in place since 2002 and the counting of the list has always been the same. It is nothing new under this or any previous Minister in the 15 years since it was established.

What he did not say is that there has been a fundamental change in what is published. This makes the scandal worse. The Government is still recording the figures. It is just being very creative with those it publishes so as to make its five-point plan look like it is working. Let us look at the reality behind the smokescreen. When we strip away the smoke and mirrors, we see that the numbers waiting longer than 18 months for inpatient day cases trebled from 459 on 31 December 2015 to 1,738 on 30 December 2016. Every one of these figures is a real person.

The Minister has said he is ashamed they have been left waiting, and he should be. However, he should be more ashamed at his public congratulations of the HSE, which he was very quick to throw under a bus when it suited him. He should be ashamed at the manner in which the figures were manipulated. Yet Fianna Fáil retains its enthusiasm to pump vital public funds into this body, which has proven itself incapable of being honest with the data. Are we really back to a situation like that of the banks, investing public funds into something that is so out of touch with international best practice?

Deputy Billy Kelleher said the advent of new politics means things have to be done differently. However, it does not mean we pretend we have forgotten what Fianna Fáil did in government. We cannot forget that Fianna Fáil is very much a major part of the NTPF's past. It does not stop there. There have been initiatives before the Government's five-point plan. In 1993, under Deputy Brendan Howlin, the coalition Government established the waiting list initiative. In 2002, the NTPF was established. In 2011, then Deputy James Reilly oversaw the establishment of the special delivery unit, supposedly to reduce waiting times. What do all these have in common? Each one failed, as the Government's five-point plan has failed.

We need to get to the nub of the issue that perpetuates the waiting list and trolley crisis, namely, capacity, or the lack thereof, in our public system. Over a decade of pouring hundreds of millions of euro into the NTPF is proof that it does not address the underlying causes of the long waits for public patients in the first place. This week's revelations show that the waiting time for public patients, as articulated by the NTPF, have not been accurate. The Minister would be better off investing public funds in a new system, the digital solutions that are required to modernise our health service, than relying on the NTPF which has demonstrated that it cannot count or publish the figures accurately. Investment in developing capacity in the public health system would be much more beneficial in the long run.

Sinn Féin has proposed a new system of integrated hospital waiting list management, whereby people can move from one hospital to another to reduce waiting times. I very much look forward to meeting the Minister and considering our Comhliosta plan. However, I have to say it is regrettable that I have written to the Minister three times since August to ask for a meeting to discuss it. Now, following all the hoopla, we will have the meeting and it is to be welcomed. The Minister does not seem to be very interested in solutions. He seems to be very interested in spin, which is very regrettable.

Deputy Simon Harris

That is unfair.

Deputy Louise O'Reilly

The Minister needs to stop trying to cod me, the House and the people. He is fooling nobody. In real life, what lies behind those figures are the people who come into our advice clinics day in, day out, people such as Oliver, a young lad in Lusk, who has been waiting for an appointment with a gastrointestinal specialist in Crumlin. He has missed 50 days of school. He will never get those days back. It is not just what we saw on RTE. Every person on the programme represents another 10, 20, 30, 40 or 1,000 people who wait every day in pain and parents who watch their children in agony, slipping behind because they are in too much pain to go to school.

I have heard the Minister's promises and I am not convinced. Most important, the children, their families and the people we saw on Monday night need more than tea and sympathy. They need more than promises and fine words. They need action. As I have said many times, it is counterintuitive to imagine pumping money into the private sector will, somehow, magically improve the public sector. It will not. Our nurses will go on strike during the coming weeks. They work in the public sector. However, their colleagues are transferring into the private sector. They are following the Minister's money into the private sector. It is wrong. We need to invest in the public sector and support our nurses.

Deputy Jan O'Sullivan

We in the Labour Party are extremely concerned that the public has been misled about the true extent of those waiting for procedures in hospitals throughout the country. Having seen the programme on RTE, we saw the real-life situation for so many people who are on waiting lists. There is a need for an independent review to determine whether any deception in the compilation of waiting lists has taken place, or if there has been a deliberate attempt to mislead people regarding the official figures. The Minister must commission an independent review of how waiting lists are being compiled and audit the accuracy of the data being presented. An internal NTPF process is not good enough. For 14 years, the public and successive Governments, it appears, have had the wrong figures. People have lost faith in the accuracy of the figures and whether they can trust the health system when it reports how many people are awaiting procedures.

The practices the "RTE Investigates" programme uncovered, with people being placed on waiting lists at the wrong date and written to to confirm their ongoing need for a procedure shows how confidence in the waiting list system is at rock bottom for patients and the public. The "Living on the List" programme is a watershed moment for our health system and we must restore confidence in how figures are compiled. The only way to do it is with an independent review. This is separate from the actions needed to expand capacity in our health service and permanently reduce waiting lists. New hospitals are part of it.

On Tuesday evening, the Minister announced that the NTPF will audit practices in individual hospitals and that it will carry out a review of international best practice on waiting list data publication models. The Minister specifically said the NTPF, at the Minister's request, will audit the practices in each of the hospitals highlighted by the individual cases featured in the programme and will report to the Minister. The NTPF has informed the Minister that the way it classifies its waiting list has been the same since its inception in 2002 and follows international best practice. However, it has already commenced a review of international best practice on waiting list data publication models. It would be better if the Minister brought in an international expert to examine how the NTPF, the HSE and individual hospitals are compiling their figures and the systems in place for managing waiting lists. People are concerned that there is a lack of accountability in our health system and an independent review that would probe all aspects of the system is needed.

What "Living on the List" uncovered on Monday was traumatic and very upsetting. Anyone who saw the programme would have found it very upsetting for the individuals whom we saw struggling with pain every day, particularly the children. I was especially affected by the children who were curled up in pain on the couch at home unable to go to school. We should not tolerate it. In a country as well-off as ours, nobody should have to live with the uncertainty of knowing when they will be treated, and everything should be done to address the distress caused to families across Ireland.

The revelation of secret pre-admit and preplanned waiting lists have added further to the uncertainty as to what is happening in our hospitals and how many people are waiting to be treated. That is why we reiterate the need for an independent review of how waiting lists are compiled. It is about confidence, independence and ensuring the people can trust the information that will come from the independent review. Continually outsourcing problems to the private health service through the NTPF should not be used to let the HSE, the Department and the Minister off the hook. Increased funding for the NTPF alone may provide some short-term reduction in waiting lists, but it will not address the capacity problems in our hospitals nor will it improve the processes. While the extra €20 million extra allocated this year, rising to €55 million in 2018, will provide some relief, it is not a proper solution to the capacity issues in our health service.

Figures I have seen regarding the NTPF suggest that it is not cost-effective because, effectively, one is paying for treatment that should be done in a public hospital. We would be in favour of a single-tier public hospital system which treats people fairly. The fact that a person can get a cataract procedure done privately in several weeks but would be obliged to wait months if he or she goes public needs to be addressed. I accept that the Committee on the Future of Healthcare is getting on with its work but there is a need for a long-term strategy where people will be treated on the basis of need, not on the basis of the money in their pockets and where they will not have to wait months - even years - for treatment simply because they do not have the money to avail of private health care. That is a situation over which none of us can stand. We need to get to the bottom of this and implement a long-term financial plan. I wish the Committee on the Future of Healthcare well and hope it will give us solid proposals to which we can all sign up. That is the only way we are going to get a long-term solution to the kind of problems to which we are continually returning with the health service.

I welcome the fact that the HSE will present an action plan for scoliosis to the Minister by the end of February. I also welcome his announcement that the new theatre in Crumlin hospital will open in April and that an orthopaedic post there will be filled by June. The cases that got to me on the recent "RTE Investigates" programme were of the young girls waiting for operations. The young girl from Limerick, particularly after seeing the X-ray of the curvature of her spine, should have had her operation, as should the other young girl with a pin in her back. We must ensure this does not happen to the many other children who are on that list. The delay until June in respect of filling the orthopaedic post is long, particularly when one considers that this extra facility was provided a year ago. If one concrete action comes out of the RTE programme, it is that we should set a six-month deadline and fast-track treatment for the 200 and more children on the scoliosis waiting list. If we could do that, it would at least give the public some confidence we can solve these problems.

Alongside this, the emerging news of the €1 billion extra cost in respect of the national children's hospital must be explained. This adds further to the mounting financial crisis emerging in the health service. This is an issue which the Labour Party has highlighted in the past week. I am concerned that the costs coming down the line in the health service will distract from the need to help sick people. Resources must be better targeted. The contract for the children's hospital has been awarded at a cost of over 50% of the expected bill and an extra €200 million is going to be required to kit out the facility. It was reported on Tuesday that the €750 million of expected savings over the next several years from generic biological drugs will not materialise because brand name drugs continue to be prescribed. The HSE faces a bill for over €350 million in respect of the issue relating to consultants' contracts. On Sunday, it was revealed that transport could not be guaranteed for children awaiting liver and heart transplants. As Deputy O'Reilly said earlier, pay talks are set to get under way soon, not just for nurses but also for GPs and consultants.

Adding up all these figures shows that there are serious financial storms ahead for our health service which the Minister must address. He needs to explain why, in the space of two years, the projected cost of the children's hospital has increased by almost €350 million to €1 billion. This will have serious effects on other capital projects, including the national maternity hospital and new emergency departments.

The new emergency department in Limerick is due to open in May. However, we have been told that recruitment, kitting out and deep cleaning may cause delays. From the reply to a parliamentary question I submitted, I understand that an additional €1.4 million was allocated to facilitate the opening of the new emergency department this year. I tabled a further question regarding how much it would actually cost to open the emergency department in Limerick in May. However, that question was referred to the HSE and I have not yet received a reply to it. My concern is that the €1.4 million may not be enough to open the new emergency department in May. That department most certainly needs to be opened.

There is no funding for the national maternity strategy, which involves maternity hospitals in Dublin, Limerick and Cork. Answers are needed in respect of when the Minister knew about the increased costs for the children's hospital and what planning has been done to address that matter. It is incredible that the Department and the HSE are accepting cost increases of over 50% when the rate of inflation is practically zero. I hope the Committee on the Future of Healthcare will offer real solutions because we certainly need them.

Acting Chairman (Deputy Bernard J. Durkan)

I call Deputy Gino Kenny who is sharing time with Deputy Barry.

Deputy Gino Kenny

Last week, I raised the crisis regarding hospital trolleys and the health service with the Minister. I want to differentiate between the personal and political. Sometimes we have to do that in this game. This is not a perennial problem. Rather, it is a systematic problem with our health service. Unfortunately, our health service is quite sick. The reason for this is neglect. The reason the health service has been neglected is because, in the past eight years, the Fine Gael and Fianna Fáil parties have made political choices that have resulted in the health service being in a state of constant crisis. It does not have to be like this. The "RTE Investigates" programme broadcast on Monday night was horrendous. It was an embarrassment to be a Member of this Parliament watching people suffer needlessly. While the programme is imprinted on our minds, it will be largely forgotten. What will not be forgotten is the reality of what people have to face.

Statistics relating to the health service make for difficult reading for the Minister and for any Member who wants a decent society. In January, at the height of the problem, 612 people were on hospital trolleys. Yesterday, over 500 people were on hospital trolleys. According to the European health consumer index, Ireland has the longest waiting times for CT scans and minor operations and is the worst of 36 countries for ease of access to health care. Since 2008, due to Fine Gael and Fianna Fáil, 1,600 beds were lost in the health service. Health staff are overworked, underpaid and constantly battling with staff shortages, while morale has hit rock bottom. Patients wait years for surgery, as was seen on the recent RTE programme. This is absolutely unacceptable in 21st century Ireland. It is the same for waiting times for speech and language therapy, occupational therapy and physical therapy. The list goes on.

This is because of the two-tier health system. The NTPF just sells public patients to the private sector. It does not go any way in trying to address the fundamental issues in our health service. There is obviously something wrong. The Minister stated €14.5 billion is spent annually on the health service, a significant amount of money. According to the OECD, Ireland spends the third most on health services in the OECD. Why can we not get it right? The onus is on the Minister's party to address these issues. I am not blaming the Minister but it is up to him to address these issues.

Ultimately, what we want to see is a universal health care system that is not a two-tier system in which a person with money can jump the queue. In a civilised society, which we all live in, it should not be the case. It should be universal, funded through central taxation, where people on the point of care should get access to health care not because of the depth of their pockets. Waiting times are an absolute scandal in this country. I am asking the Minister to put his reputation on the line and say, like previous Ministers, the trolley crisis and waiting times are absolutely unacceptable and to give a commitment that if the same thing happens this time next year, he will resign.

Deputy Mick Barry

Yesterday we saw new information released on the latest position regarding hospital waiting lists in this country. If the figures from the three lists are added up, there are currently 623,442 persons on waiting lists in our health service, which is one in eight of the population. On the Government's target of having everybody on those lists seen to within 18 months, the European health consumer index said, "Even if and when that target is reached, it will still be the worst waiting time situation in Europe." It surveyed 35 countries and Ireland is in 35th position and bottom of the league table for waiting times in Europe. What is to be done?

The National Association of General Practitioners said that in recent years, under both Fine Gael and Fianna Fáil-led Governments, €980 million has been taken out of primary health care. That is almost €1 billion taken out by Fianna Fáil and Fine Gael-led Governments. Those cuts must be reversed. It is common sense that if there is a good strong primary health care system, there will be fewer waiting lists for the hospitals. One of the consultants interviewed on the "Prime Time" programme made very sharp points about the strict, fixed budgets hospitals are operating under. Apart from the human side of it, it is a completely false economy because if someone cannot be seen when they are in need of some surgery, they will be seen down the line when they are in need of more serious and more expensive surgery. That is leaving aside all the check-ups, appointments and administration that has to be done with longer lists. We need more front-line staff and better wages and working conditions. Who is fighting for that? The nurses are fighting for it. That is why their industrial action will begin on 7 March. Anyone who is seriously concerned about improving the health service and sorting out the issues of recruitment and retention will give their full support to our nurses as they enter that dispute.

John McManus of The Irish Times said recently, "Irish health spending is very close to the European average but, unlike most of our peers, one-third of it is channelled through the private healthcare system." Referring to perverse incentives within the system he said, "The worse the public system, the more profitable the private system." That is the scandal of the two-tier health system in this country. One third of all acute hospitals and one sixth of all acute hospital beds are now fully private. How many of these beds are empty? We do not know because the private hospitals will not give the information. They say it is commercially sensitive. We know a significant number of those beds lie empty at most times. What does the National Treatment Purchase Fund do? It penalises the public health service by diverting funds away from our public system. It subsidises and bails out the private hospital for having excess capacity and beds within its structures. This is a nonsense and it needs to change.

The private hospitals in this country should be taken into public ownership with compensation only on the basis of proven need and integrated into a fully fledged Irish national health service. There have been 1,600 beds taken out of the public system, as Deputy Gino Kenny explained. That would bring 2,100 beds back in by compensating for the beds that have been cut out of the system by both Fine Gael and Fianna Fáil-led Governments since 2007. My key messages are that we need better recruitment, better retention and to support the nurses in their industrial action in March. We need the nationalisation of the private hospitals, to integrate them into the public health system and finance and resource a proper Irish national health service. The time is long gone. That is what we need.

Acting Chairman (Deputy Bernard J. Durkan)

We now move to Independents 4 Change, Deputies Joan Collins, Catherine Connolly and Mick Wallace. Will the Deputies share time equally?

Deputy Joan Collins

There will be three and a half minutes for Deputy Connolly and me and Deputy Wallace will take three minutes.

It was not necessary to view the RTE programme last week to be aware that we have an ongoing critical crisis in our health service. Every single public representative in the Dáil knows there is a crisis but the nation was shocked by the sheer, naked pain of the people and children on the lists. It really shocked the nation. The people who rely on our public services are paying the price for decades of underfunding, mismanagement, the role of vested interests and Government inaction.

I am a member of the Committee on the Future of Healthcare and sitting on that committee and reading the reports is an eye-opener. The dysfunctional nature of our health service is beyond belief. We do not have anything we can even remotely refer to as our health services. What we have is a jumble of public and private health care alongside a plethora of NGOs, charities, religious institutions and voluntary groups providing services that should be part of a national health service. Health services of the sort developed in Ireland, as in other countries, as charitable institutions serving the poor. In the 18th and 19th centuries, unlike other countries in Europe, we never fully replaced these with a State health service. We just grafted on some State services. We did not have a Minister for Health until 1947, 25 years after the foundation of the State. A White Paper in the 1940s outlined plans for an NHS and a social welfare system following on from the Beveridge report in the UK. It was abandoned due to opposition from the Catholic Church, medical professions and the Department of Finance.

Until we face up to this legacy and confront the vested interests, whether they are religious bodies, elements of the medical profession, big pharma or others who provide health care for profit, we will continue with a dysfunctional health care system that is unfit for purpose. Patching up a broken system is very much a waste of time and money. We have seen that over the last period when we responded to crises by trying to put more money in and trying to deal with the issue. I find it very difficult politically to support the National Treatment Purchase Fund. We have a situation where private patients are using public beds and public patients are going into private hospitals either here or in England and Europe. It is just crazy and cannot go on.

As a Deputy in Dublin South-Central, I am often approached by parents from around the country regarding problems with the orthopaedic surgery at Crumlin children's hospital and especially waiting lists for scoliosis surgery. The longer children wait for treatment, the more serious the problem becomes, the more extensive is the surgery required and the higher the cost. It is quite incredible that a new and much-needed orthopaedic theatre was built in Crumlin in 2015 as a result of a massive campaign in the area. The former Minister, former Deputy James Reilly, was like a bee around honey on this campaign in 2009 and 2010. It was built in 2015 but has still not been opened due to a lack of necessary staff. It is absolutely crazy. I have submitted loads of parliamentary questions about this in recent years. I have been in contact with a young woman in Galway who has been on the orthopaedic list for scoliosis since June 2014. I contacted her yesterday again and asked if she was still on it and she is. I despair when I hear Fianna Fáil's mea culpa about all this, saying it is terrible and they are all at fault.

We heard then that Crumlin hospital was to clear the backlog of children awaiting scoliosis surgery by February, which involved 70 operations. We had major problems then in 2009 and also in the more recent period.

Deputy Catherine Connolly

It is shocking that it takes an "RTE Investigates" programme with post-truth waiting list figures and vivid images of suffering children and adults with deteriorating conditions directly related to their time on waiting lists for the Government to move to allow statements, not solutions, and for the Minister to say that he is broken-hearted and ashamed.

Deputy Simon Harris

I am.

Deputy Catherine Connolly

However, an emotional response is not what is necessary. The stories behind those who bravely participated in the programme put a human face on the obscene figures that we all know about and that I and like-minded representatives have raised in this Chamber since the day we were elected here. In fairness to the Minister, it has not only been an issue with this Government but with successive Governments, and what we have had from each of them is reaction after reaction, a blaming and a distancing, and failed initiative after initiative. We had the special delivery unit, the National Treatment Purchase Fund, NTPF, co-location and so on. The stark reality is that Government policy after Government policy has made the health service a sick service. The reason the NTPF was introduced in 2004 was because of the massive waiting list. It was to be a short-term measure and in the meantime we were to recruit and put back in the staff that were taken out. That did not happen. All of the initiatives the Minister has introduced and all of the reactions have the common theme of putting funds into the private system. The end result is what was so graphically described in the programme the other night.

I have repeatedly mentioned University Hospital Galway, which the Minister could not find the time to visit. To use the words of its clinical director, the hospital, and not just its accident and emergency department, is not fit for purpose. He has specifically given the Minister a submission stating that not only the accident and emergency department but the hospital is not fit for purpose. We had the tragic death of Savita Halappanavar in October 2012. We still do not know if the recommendations of the report into her death have been implemented. Many courageous doctors and consultants have spoken out, among them Dr. Fergal Hickey, Dr. O'Rourke, Dr. McCabe and many other doctors in Galway, pointing out, number one, the crisis and, number two, the solutions. This and previous Governments have not listened. There are now three ongoing investigations in the hospital in Galway. An operation was carried out on a ward, another review is being carried out following the death of a person in their 80s on a trolley, and another one relates to inappropriate surgery that was carried out. At the very least three, and possibly four, investigations are taking place in that hospital that is creaking at the seams and serving 1 million people - this is not a parochial issue - from Donegal to Clare. That is the crisis that the "RTE Investigates" programme put images on the other night.

The Minister said in June 2016 that universal health care is a direction and journey, but we have come to the end of the journey. This is the end of the journey. Let us today recognise that universal health care is a basic human right. We should all be ashamed if that does not happen in the lifetime of this Government.

Deputy Mick Wallace

I have submitted 12 written parliamentary questions since 11 October regarding issues such as assessment of needs, respite care, residential care etc. On each occasion the Minister concerned has informed me that, "The Government is committed to providing services and supports for people with disabilities which will empower them to live independent lives, provide greater independence in accessing the services they choose and enhance their ability to tailor the supports required to meet their needs and plan their lives." I have read that statement from the Minister of State, Deputy Finian McGrath, and I suppose when one repeats that mantra over and over, the words become sentiments and the sentiments must be true.

When a Wexford mother of two autistic boys wonders why her 12 year old son can get an assessment of need but his 16 year old brother cannot because he was born before a certain date, I am sure she would be delighted that the Government is committed to providing services and supports to people with disabilities. After the Minister kicks the question on to the HSE and it informs me that 1,035 out the 3,318 assessments of needs reported completed in 2015 were completed within the timeframes set out in the Disability Act 2005, I wonder whether the 69% of children who did not have their assessments carried out on time view this abject failure as the Government being committed to providing services and supports to people with disabilities. As for the 31% of children who had their assessments carried out on time, and after the State and the HSE recognised that there is a requirement for them, I wonder whether they are disappointed when they realise the HSE, in most cases, is not equipped to provide any or most of the recommendations arising from the assessment, or whether they think the Government is committed to providing these services and supports for people with disabilities. I do not think the parents of 60 service users in Wexford on the disability services residential care waiting list are happy.

Last Saturday a woman came up to me in a supermarket as she wanted to alert me to something. She had brought her son who has suicidal ideation to the child and adolescent mental health services in Wexford, in Slaney House. She was told that the clinical nurse phoned the mental health services to ask if they could be allowed to help the child. They were told "No" because they are not allowed deal with emergencies and the child psychiatrist was away. They had no choice but to send the child to the general hospital. This was on the Monday and the child was there until Friday, screaming for help. The mother said the staff were brilliant but dealing with an incredibly difficult situation. The child was having an episode. Eventually a child psychiatrist came down from Dublin on the Friday. Come Friday week in the south of Wexford, no child or adolescent who presents with a mental health emergency will receive any health care services for the next two weeks because the child psychiatrist is going on holidays. The HSE has known about it for a long time and it still has not provided for putting anyone in place. This woman was not crying about her child. She said this is going to happen to others. The service is not in place.

An Leas-Cheann Comhairle

The Rural Independent Group has ten minutes. I call Deputy Danny Healy-Rae.

Deputy Danny Healy-Rae

If what is happening in Ireland today was happening in Third World countries, there would be uproar. The Deputy is a young Minister and I understand he is trying to do his best but the fact is the system we have is not working. The HSE, as a body, is supposed to be helping our sick and vulnerable people who are in trouble, but it is not working out for many people. As I have stated here many times, as has my brother, Michael, it is not acceptable that people have to wait two years to have a cataract operation. The Sligo model is working in other parts of the country but why can it not be applied to Cork and Kerry? I dealt with one poor man could not bear to go blind and he had to sell his car to get the operation done privately. That is the truth. It is not good enough that young teenagers have to wait four to five years for orthodontic treatment.

The hospital in Kenmare which is relatively new is only half open. It has only one respite bed for all of its catchment area. Wards are closed in Tralee general hospital. That is why we have waiting lists, queues and people on trolleys. I told the Minister about a recent case involving Cork University Hospital. As of today, there are people waiting three, four and five weeks to have open heart surgery in that hospital because there is not bed available for them after they have their operation. That is not acceptable.

Deer Lodge in Killarney, which is a mental health facility, was built and opened in June 2015 but it is still not fully open. People are going private to get treatment. It is not good enough for people with medical problems who need attention to have to wait two or three years to meet a consultant. That is widespread and it must be sorted out.

We have heard of ambulance reconfiguration, which means there will be fewer ambulances. A would-be patient in Rathmore on New Year's day had to wait 50 minutes for an ambulance to come from Kenmare when it should have come from Millstreet. Many facilities are being closed, including the Mary of the Angels facility. Also, the Lantern Lodge was closed because it was considered to be too costly to give the people attending it a meal That is what is happening. We have a shortage of nurses and those who are in our hospitals are overworked. We cannot pay our rural GPs to ensure they stay in rural areas. A total of €900 million has been allocated to the HSE this year and we are almost two months into the year and I do not see any improvement anywhere. Most working class people are paying 48% and 52% tax to pay for the cost of these services but the services are not being delivered.

I have attended many HSE South/South West hospital group meetings but I have not got a straight answer to my questions from the officials. They have always been evasive when I have asked them a question.

I am very sorry; my time is up. I have no faith in the current system. It must be broken up and something new put in place.

Deputy Michael Collins

The "RTE Investigates" programme on Monday night was heartbreaking to watch but, unfortunately, the stories told sounded all too familiar to me. Countless constituents have come to me in similar situations: elderly people waiting up to two years to have cataracts removed, children suffering from increasing pain as a result of not having scoliosis treatment and cancer patients being given appointments that are later cancelled at short notice.

The 2016 Euro Health Consumer Index, EHCI, has ranked Ireland as the country with the worst waiting times in a comprehensive study of 35 countries. This is totally unacceptable. I agree that our health service is not underfunded but badly managed. We have been told that €900 million more has gone into the health system this year compared with last year, yet we do not see any results. This view was confirmed by the EHCI study, which found that Ireland was also the fifth worst country for efficiency, or "bang for the buck". Accountability at all levels is required. The Irish health system has been late to introduce technology, which has inhibited the ability to properly track an individual's interaction with the health service. The top place in the EHCI study is held by the Netherlands, ahead of Switzerland and then Norway. Uniform procedures for data gathering are needed. The improved management of waiting lists requires an understanding of the relationship between the demand for a service and the rate of supply. This understanding requires the development of information systems which can not only record the numbers of patients waiting for admission, but also enable demand and supply for particular services to be monitored.

We fail to take care of the little things, such as paying highly-prized nursing staff a fair salary and providing even simple things such as parking. Too many nurses spend their days performing routine tasks such as form-filling rather than clinical activity involving patients. Following changes to consultants' contracts, the only way many medical posts can be filled is by allowing doctors to work privately. This gives us doctors who work part-time in the public system and do not have any great commitment to it. We have too few beds and too many rolling closures of operating theatres. Operating lists do not start on time, they are inefficient and they finish at 4 p.m. or 5 p.m. In the private sector, they continue until the work is done. We need a tough Minister to effect change and one or two people in charge of the health system at the top. I do not buy the constant call for more resources; we need to make the present system work better.

We need accountability from management, which faces no real sanctions for underperformance. The system has been badly hurt by the cutbacks of the 1980s, 1990s and from 2009 to 2014 and has not fully recovered. We have fewer hospital beds than in 1980, while the population has grown by one third and the older population by twice that. We have too few hospital beds; we need more. We do not need capacity reviews to tell us this, though they might tell us where the extra beds should be. We also need more doctors, particularly specialists – perhaps up to 2,800 extra. There are new layers of management and there is less engagement with general practitioners than before. The system is not listening to GPs enough. There is unstable employment for nurses. There have been up to three nursing pay cuts since 2009, coupled with an increase in their working hours of six hours each month.

I have no doubt but that the Minister has an incredibly difficult task but I truly believe the system is not working. Action is required immediately, not down the road. We should consider the state of our hospitals. Many hospitals, such as Bantry General Hospital, are well able to carry out brilliant procedures but their accident and emergency services were closed overnight. People such as me, community people, were told at the time that we were scaremongering. We were not scaremongering. We now have the evidence of all these cutbacks.

Deputy Mattie McGrath

I am delighted to be able to speak on this matter. I compliment those who produced it but I did not need the "RTE Investigates" programme - none of us did - to know what is going on. The Minister has been in the job for long enough now to know what is going on. We have just celebrated the centenary of the 1916 Rising in 2016 and all that has happened in Ireland but what do we have? We have 632,185 people on waiting lists at the end of January. That is some legacy. That is some commemoration of the men who set up this country.

The HSE was set up by my colleagues to my right, the Fianna Fáil Party, of which I was a member at the time. I was told by the former Taoisigh Brian Cowen and Bertie Ahern, Senator James Reilly and others that it would be disbanded. It must be disbanded. It must be tackled and dispersed and go back to some sense of normality. It is cannibalising itself. There are many good people in the HSE - nurses, front-line staff, doctors and other people - doing great work but it is dysfunctional in the extreme. It must be got rid of. The Minister should not let HSE officials and their speak capture him.

The Minister has in his pocket a letter I gave him yesterday about a 51-month waiting list for urology. It relates to a blind man who does huge charity work and who is concerned for his life. It is scandalous and the list goes on. We have such cases all over the country. There is a €7 million overrun in an empty hospital in Tipperary. It renders the television programme "Yes Minister" insignificant. There will not be a single bed in this empty hospital. The Minister has visited it. He saw it and was shocked by the condition of it and how good a hospital it was. The system is dysfunctional. The children's hospital is going ahead in spite of the pleas from the sick children, some of whom we saw the other night on television, who cannot get to the hospital because of traffic. Helicopters cannot be landed there. We found out this week that its cost will overrun by €400 million or €500 million. Mr. Tony O'Brien has stated he has no money to build it but yet the Government continues with the fallacy and the scandal of going ahead with the site. The lunatics are running the asylum. Will the Minister please cancel the project first of all, build the hospital where it can be accessed, build it where patients can be treated and co-locate it with an adult hospital? It is a scandal he can stop. We will talk about this here in ten years' time. It will not be finished, it will be half built and it will not be accessible. We cannot get staff to go into it because they cannot get parking spaces. It is madness.

I have a contract, which the Minister has in his pocket too, with a private GP service that wishes to and can offer services. The Minister visited the place, for which I thank him. They got it after 12 months of negotiations. They were handed it last Friday evening. It is a two-week contract, that is, for 14 days. The people who drew up and issued that contract should be sacked on the spot. To put that much time into it - the Minister's time as well - and zero officials. The ink would not be dry on the contract papers before they had to close it again. This is what is going on.

I heard people here criticise the church. When the church ran the hospitals, when we had the matrons, the hospitals were clean and run properly. Now what do we have? We have a legacy of strikes, demands and more money and we have utter chaos, so I will not listen to anyone lecture the people who ran it. The hospitals were run-----

An Leas-Cheann Comhairle

Go raibh maith agat.

Deputy Mattie McGrath

-----right, cleanly and honestly-----

An Leas-Cheann Comhairle

Go raibh maith agat, a Theachta.

Deputy Mattie McGrath

-----and with integrity. Now they have been captured by senior officials who promote themselves. Then, when they retire, they go off setting up agencies to supply services by the agency-----

An Leas-Cheann Comhairle

Deputy-----

Deputy Mattie McGrath

-----weeks after they retire.

An Leas-Cheann Comhairle

Deputy-----

Deputy Mattie McGrath

Scandalous.

Deputy Catherine Martin

Maidir leis na fíricí a nochtadh ar RTE ar an Luan, caithfear a rá go bhfuil córas sláinte na tíre seo ina chíor thuathail amach is amach. Ba chóir go mbeadh bainisteoirí an chórais ag deimhniú nach bhfuil aon othar ag fulaingt, ach a mhalairt atá fíor mar go bhfuil an córas beag beann ar fhualaingt an othair.

Monday's "RTE Investigates" served as a harsh reminder of what we have known for so long: our health system is broken and remains broken. The problem is that not only the present Government but consecutive Governments continue to be reactive to problems by responding in a short-term way to the latest serious inadequacy, acting like a fire-fighting service endeavouring and struggling at times to put out the latest fire. What we need and what the people are crying out for is a more strategic approach that tackles effectively and permanently, for once and for all, huge inadequacies, gross managerial inefficiencies and glaring inequalities in access to services. The Government must work to strengthen the public health system to ensure it is sustainable into the future. This requires a radical new approach. Funding for primary and community care must be increased in order that acute hospital beds are kept for those with the most serious clinical needs. We need to increase rapidly the number of general practitioners, public health nurses and advanced nurse practitioners. I acknowledge this will require incentivisation as otherwise, many gifted nurses and doctors will continue to vote with their feet and turn to other counties for better job opportunities that incorporate a much better quality of work life. For too long they have been told they are doing a heroic job but at this stage, medical practitioners practising on the daily front line want more than our words. They want and deserve a managerial solution and the greatest tribute and meaningful gratitude one can pay the stakeholders is to deliver for them and for the patients real, competent, visionary management and to overhaul the system.

All the best international evidence tells us that a universal health care system is the most cost-effective model and it is that which we should move towards. Yes, delivering a proper, fair and efficient service may mean less or no tax reductions, at least in the short term, but that honest conversation must take place. If done fairly, taxpayers will recognise the need to prioritise improving such essential services over gimmicky tax breaks which are often born as meaningless pre-election promises. The public has a role in this regard, and one such role is to recognise cynical pre-election auction politics for what it is. It is the enemy of effectively overhauling and delivering a wide range of public services desperately needed in this country.

We need absolute transparency and accountability in our health system.

To begin with, fundamentally, the people deserve to know the truth. We need to be provided with an honest and accurate picture of the state of our public health services. There must be detailed analysis and breakdowns of current and future expenditure and information, justifying how funding decisions are made. Individuals who fail to deliver must be held accountable. That is what happens in a normal business but I challenge the Minister to name one person who has ever been held truly accountable for this ongoing saga, which tragically has real victims. Only in the past week Dr. Fergal Hickey warned us that up to 350 patients will die as a result of capacity constraints in intensive care units in our hospitals. Is é bun agus barr an scéil na nach féidir linn brath ar an gcóras seo againne chun freastal orainn. Access to health care should not be a paid extra for some. Health is not an entitlement. It is a basic and fundamental right.

Deputy Róisín Shortall

I pay tribute to Paul Maguire and his team on the "RTE Investigates" programme for an excellent programme last Monday night. It was a shocking and shaming programme but it was excellently done and represents the best in public sector broadcasting in exposing the major shortcomings in a public service that is so fundamental to people's lives.

The fact that as a society we are prepared to stand by while children in particular but adults also in significant numbers are left in agonising pain on waiting lists is a shocking reflection on our value system which needs to change urgently in respect of a commitment to public services. Of course, the point that Deputy Catherine Martin made is central to this. The Government cannot have good quality public services and tax cuts. The idea of undertaking to abolish the universal social charge and give back €5 billion of tax funding at a time when our health service is in tatters, when we have a major housing crisis, utterly inadequate child care and so many of our public services are bereft of funding is nonsense. People cannot have it both ways. We need to be honest with the public and tell it that it is not possible to have tax cuts in the context of the shortcomings in our public services. That was very clear in last year's election. For the first time that I can remember in an election people on the doorsteps were saying sort out the health service, deal with the housing crisis and do not talk about tax cuts or €10 or €20 back a week when we have such glaring problems in our society. Government needs to take that message on board. We need to stop, as a Parliament, talking about the prospect of tax cuts because we cannot afford them for the foreseeable future until we get our services right. As long as our services are starved of funding we do not have a proper society. It inevitably leads to people living in the kind of shocking conditions that we saw last Monday night on that programme.

There are several areas where urgent action needs to be taken in respect of health. How come waiting lists cannot be managed competently? We saw examples of several of the people referred to in the programme whose names had slipped off the list. We come across this constantly in our constituencies when people who thought they were on a nine-month waiting list were not called for treatment and discovered they were not on the list. There is significant incompetence in the management of the waiting lists. Heads have to roll for that. If we cannot get basic administration of waiting lists that must be dealt with then somebody must be held accountable for that failure.

There are many other areas that need to be dealt with. The budget allocation is going into a black hole, it is not tied to clear deliverable outputs and there is no measurement of activity. The fact that the HSE has a totally dysfunctional organisational structure did not happen by chance because if something cannot be measured it does not matter. We cannot measure activity, performance or output from the HSE because of the totally erratic and dysfunctional manner in which it is organised. We need to move away from the utterly dysfunctional two-tier system and introduce fundamental reform and a universal health system. I hope that when the all-party committee makes its recommendations, the entire Dáil will support them.

Deputy Seamus Healy

The recent "RTE Investigates" programme told us what we have all known for many years. The nation was rightly shocked. It put the human face of pain and suffering on the figures. The public have been misled. The term "alternative facts" comes to mind. The public is entitled to, must be told and know the truth. The long waiting lists are the result of cuts to services by successive governments. For example, 2,000 beds have been taken out of the system, there is overcrowding in accident and emergency departments, posts are not filled and there is a moratorium on posts. I have been raising these issues for some time.

I recently raised the issue of the urology waiting list at University Hospital Waterford. A letter received by one of my constituents puts the case very plainly:

We are writing to inform you that you have been placed on ... waiting list. We will forward you an appointment in due course.

You have been prioritised as: URGENT.

You should expect to be seen within 48+ months.

If you have any queries please do not hesitate to contact us.

The constituent must wait more than four years. The reply from the HSE and the Minister, which I received only yesterday, confirms that there is a major problem at University Hospital Waterford. It states, "The clinical risk for the Urology Services is on the Corporate Risk Register and is rated high risk." The management at the hospital has applied for additional resources, two consultant urologists, support staff and funding to provide a proper service to the hospital. Those resources have not been provided. Will the Minister provide those resources not just for University Hospital Waterford but for all those from the south east, including Tipperary, using the services at the hospital?

Deputy Fergus O'Dowd

A man dies in a Dublin hospital. He arrives in an ambulance totally dishevelled and in serious pain. His family accompany him. When they go into the accident and emergency department, the doctor in despair asks why they let this man fall into this condition, why he has arrived like this and why they did not look after him in their home. The doctor did not realise that the patient was coming from a HSE hospital where he had been abused. He died in appalling circumstances.

The family brought it to the attention of the HSE. An inquiry was set up. The inquiry does not include any doctor, medical information or specialist. The family rejects that. I get involved and a second inquiry into the man's death is set up. The doctor walks away from the inquiry which collapses. There is now a third inquiry into the death of this man which is held up for legal reasons.

The HSE is hiding and not facing its accountability in this Oireachtas, through the Minister or the public. It is a shame what is happening in this country. The waiting lists are a shame. It is a shame that a year ago Our Lady of Lourdes Hospital was short 55 nurses and three anaesthetists. There were six people in the intensive care units and another six lined up outside, waiting to get in there. Only one made it inside that door. I am trying to find out what happened to the rest of those patients. There is a crisis in intensive care beds in this country. I only know these things because of the Freedom of Information Act 2014. The HSE is not accountable to me as a Member of the Oireachtas, to anybody in this House or to the public and is hiding its accountability from the Minister. I welcome the Minister's commitment that heads will roll.

It is not accountable to the public and it is hiding its accountability from the Minister. I welcome the Minister's commitment that heads will roll. Heads must roll in this dysfunctional and appalling organisation, which from top to bottom is full of bureaucracy and lacking in accountability. I am ashamed that I have to stand up and say these things here. I support the Government, the budgets and the Minister. I believe he is the person to deal with the terminal crisis in the health service. The head of the HSE must roll and should roll now. Each of the three separate waiting lists is populated by people who are in pain and are suffering because they have been waiting for longer than they should be waiting for. What the hell are we going to do about it? The HSE claims that having multiple lists is standard international practice, but it is not the practice in England or in other countries. We should have one short list that is dealt with. We should not have the longest list in Europe. We should ensure we have the shortest list. I support the Minister in his intention to do that.

Deputy Peter Fitzpatrick

Along with thousands of other people, I watched the "RTÉ Investigates: Living on the List" programme during the week. Like my colleague, the Minister, Deputy Harris, I felt ashamed. It is simply not acceptable that so many people are going through such an ordeal. The revelations exposed in the programme with regard to waiting lists are extraordinary. It is time for those who are supposed to be accountable to answer for the shortcomings in our health system for once and for all. Time and again, I have come up against a brick wall in my dealings with the HSE as I have tried to get someone to be accountable and to explain the reasons for the decisions that are made. This has got to stop. The HSE must be held accountable for its decisions. It must operate in an open and transparent manner. I do not believe the operations of the HSE are accountable, open or transparent.

Deputy Peadar Tóibín

What about the Minister? He is accountable.

Deputy Peter Fitzpatrick

I come from a business background. If I had run my previous business in this manner, I would have had no customers and the business would ultimately have failed. As public representatives, we are fully accountable to our constituents. It is time for the HSE to be made fully accountable for its actions. We have been told by the HSE time and again that more funds are needed. Even though there has never before been a time when so much taxpayers' money has been invested in the health service, we are told on an almost weekly basis that more funding is needed. It is certainly not the case that more reports are needed. We have had report after report. Action must be taken on the ground. Better work practices are also needed. Most importantly, the HSE must realise that health care is a 24/7 issue and is not confined to the days from Monday to Friday.

I reiterate that we do not need more reports. Everybody knows what are the issues. Action is needed to resolve those issues. We are constantly told that there were 3,500 more nurses in the system ten years ago. We have never had a higher budget for the health services than we have today. I will put this in context. In the budget for this year, we allocated over €14 billion in taxpayers' money to the health service. This is the highest amount ever budgeted. Why, in that context, do we have 3,500 fewer nurses than we had ten years ago? Can the HSE provide a clear and concise explanation for that? I believe we must have a open and transparent health service that is accountable for the decisions it makes and operates at its most efficient. We do not need more reports. We need action to be taken on the ground.

Deputy Michael D'Arcy

I compliment the vast majority of the staff who work in the HSE. They do a good job and many people get a good service from this country's health sector. This is something that goes unsaid too often. To be honest, I am not surprised that issues and problems have developed. The country was bankrupt. There is always a lag or a delay in such circumstances. This is what happens after a country has had no money for a decade. The constant reductions in services caused lists to build up in the way that was depicted on Monday night. We are spending enough money on this country's public and private health sector. Over €14 billion is provided from the State Exchequer each year. A further €9 billion comes from private resources. This is more than most other countries in Europe spend on their health sectors. However, we are not getting the value for money or the throughput that is required to prevent long waiting lists.

The real issue here is lethargy. Nobody is prepared to change. Nobody in the health services, particularly in the public sector, is prepared to give an inch. We have had debates about the drug orkambi. Drug companies do not give an inch. I cannot explain why they charge this country a multiple of what they charge in other jurisdictions, but I can say that this eats into budgets in areas of the health service where this money would be better spent. Similarly, the staff and the unions do not give an inch. If there is a bad practice in an institution or a hospital, it is not given up. A reforming structure is not put in place to ensure staff are prepared to work better hours and show better flexibility. Nobody gives an inch in the Irish health sector.

The continuation of the hospital groups is vital for the future of the health sector, particularly the public health services. The hospital groups should be removed from the HSE and placed on a proper statutory footing. There should be full accountability within the hospital groups. Deputies and county councillors should be on the boards of the hospital groups because elected representatives can be held accountable by their constituents. We cannot establish the hospital groups without correctly integrating the other community services that are administered by the HSE. That is the future. Everybody has to give. People in this House have to give. The services that are required cannot be in every hospital. I compliment Wexford General Hospital on giving up services so that they could be reconstituted in the appropriate way with a proper throughput of patients, thereby allowing administrators, doctors and nurses to use their specialist expertise in the relevant areas. That is the future. We all have to give. If we do not give, we should stop coming in here and complaining.

Deputy Brendan Griffin

I welcome this debate. Unfortunately, what we saw on Monday night was nothing new to many of us here. Those of us who work on the front line in our constituencies are familiar with the unacceptable waiting times that have been endured by ordinary men, women and children throughout the country for many years. When we bring our concerns about the suffering of real people to this House, unfortunately we are reverted back to the HSE that gives us copy-and-paste answers. That practice has to stop.

Deputy Fergus O'Dowd

Yes.

Deputy Brendan Griffin

The people of this country send us to the national Parliament to raise concerns and highlight the issues that affect them in their daily lives. I ask the Minister to end the practice of referring health questions to the HSE for response. While I accept that the HSE might need to be consulted, I emphasise that parliamentary accountability in respect of the health service needs to be returned to this Parliament. I do not think it has been here since Mary Harney was Minister, or perhaps before that. The Department of Health needs to act like a Government Department by giving Members of this Parliament answers on health issues that affect the people who elected us to represent them. It is not good enough that this is not happening at present. There needs to be a change in this regard.

I would like to make a point about elected members of local authorities. I was a member of the regional health forum in the southern area, which is, in effect, a body that provides expensive responses to written Dáil questions. The answers we ultimately get from the forum are the same as the answers we get to parliamentary questions, except that it costs a great deal of money to hold meetings of the forum. We do not get an opportunity to scrutinise or ask questions at the forum. Anyone who attempts to do so is seen as some sort of pariah or pain in the arse. That is just not good enough. The people deserve far better than that. It needs to change.

There are certain things that can be done now and other things that will take a longer period of time. I welcome the move towards an all-party approach to the future of health care. Some people laughed at me when I said on the public record in advance of last year's general election that this was needed. Some people said it would never happen, but thanks be to God it is happening. It is long overdue. We should put aside party differences, where possible. We need to focus on the national interest when lives are at stake. Even though we have all known for a long time that what we saw on the television on Monday night has been happening, it is simply not good enough that it is continuing to happen in this day and age.

This is not about expenditure. Thankfully, we are now in a position to spend more money. That is a good sign. It is a sign that the Government and the people have got things right in recent years. We have not got things right in health. We need to admit that we have got things terribly wrong in health. If we want to move forward with the confidence of the people, we need to acknowledge where we have made mistakes. We have got things right on the economy, but we have got things horribly wrong with regard to hospital waiting lists. There is too much duplication of services. We do not have economies of scale throughout the health service. That is not a popular thing to say in here. Most people will never say it in here because they are afraid they will lose X, Y or Z from their own neck of the woods.

We need to be realistic and put in place a system that is responsive. Anything would be better than the system that is there now, which is simply not working. We need to go through the rank and file of people in the Health Service Executive, HSE, and the Department of Health to see who is surplus to requirements as I fear many of them are. I am not talking about those on the front lines but further up in the management positions, as far too many people are surplus to requirements, delivering very little but being paid a lot.

Deputy James Browne

I am sharing my time with Deputies Butler, Brassil and Rabbitte.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Deputy James Browne

It is clear our health system is broken, dysfunctional and, in parts, unethical. In an "RTE Investigates" programme this week, we saw children crying, women in undescribable pain and men talking about taking their own lives. People were and are angry, frustrated and upset and rightly so. Nobody who saw the programme would not have been deeply affected by what could be seen and heard.

We saw very real and visible examples of the physical and emotional pain being suffered by people and we also saw the effects on their families and friends who had to watch as this happened. We learned about the dishonesty in the waiting list process but the HSE is owned and funded by the same people on those waiting lists who are not getting the simple truth. They are being lied to about the lists; it is a lie of omission and a fear about telling the truth when there is a duty to do so. We learned there are two secret waiting lists that the public is not to know about and it took the "RTE Investigates" programme to discover them. How do we ever hope to resolve the dysfunctional health care system if we cannot get basic truths about numbers?

Confidence in the system has gone because time and again, our health system has proven to be dysfunctional and dishonest. There are a record 545,000 patients on the waiting lists for the end of the month and that does not include the planned procedure list of 60,930. Adding the published to the unpublished list, there are more than 630,000 people on the list or one in seven of the population is on a waiting list somewhere in the health care system. There are almost 100,000 people waiting for over a year for basic care. We have record waiting lists, secret waiting lists and record numbers on trolleys. We were told this week that insufficient funds are available to "fully proceed", as the HSE has stated, with the children's hospital. We have the worst record of 36 countries for access to health care. We have theatres ready for operations that cannot perform them because the HSE will not hire a theatre nurse or pay for implements. We are losing millions of euro to save pennies.

There is more to this. As Senator Joan Freeman ably pointed out in the Seanad on Tuesday, there has not even been mention of those children on the mental health waiting lists. In a two-tier health system, mental health is in the basement. Children often wait over a year or sometimes two years just to be assessed at the most formative time of their lives. In one case in Wexford, a three-year-old waited 18 months to be seen by a psychologist, only to be told after that time that the HSE does not cover mental distress arising from bereavement involving a family member as, effectively, there is no box to tick. The long waiting lists in mental health for children are just as critical as those for physical health and should not be forgotten. The people are relying on the Minister to intervene and take steps. I urge him to do so.

Deputy Mary Butler

The "RTE Investigates" programme revealed deep suffering among men, women and children as people struggle with daily life while waiting on never-ending waiting lists. Each Deputy in the House, from all parties and none, deals week in and week out with constituents on waiting lists for treatment of hips, knees, eyes and endless other routine operations. The difference a new knee or hip can make to people in their older years is life-changing; when the pain is gone, people can start to live their lives again. Being on a waiting list that seems never-ending is both frustrating and soul destroying and the new revelations that thousands of patients waiting for procedures were not included in the official list by the HSE adds insult to injury.

The latest figures I have for University Hospital Waterford are shocking. Currently, there are more than 6,000 people waiting for orthopaedic procedures involving either knee or hip treatment. These operations are normally extremely successful, as the Minister knows, and they can change a person's life from living with pain to being pain-free again. The list with the next highest number of people concerns ophthalmology, with in excess of 6,000 people also on that list. We know those operations are also very successful and improve greatly an older person's quality of life. We need and deserve a clear and complete picture of the real state of waiting lists. It is easy to look at figures but it is the real-life pain and suffering of patients on which we must focus.

The National Treatment Purchase Fund, NTPF, was sidelined in 2012 by the then health Minister, Senator James Reilly. It was not the solution for everything but while it was in operation between 2002 and 2011, it dramatically reduced waiting lists to between three and six months for the vast majority of people on the list. Contrary to the comments of the Sinn Féin spokesperson on health, Deputy Louise O'Reilly, 33,000 public patients were facilitated in 2010, and from 2002 to 2011, 200,000 public patients were treated. It is a myth that only private patients were treated with that fund.

It has come to my attention in the past couple of months that there are delays in processing nursing registrations, which is exacerbating the crisis in our hospitals. I have been contacted by nurses coming home from England, with one getting a job in University Hospital Waterford's accident and emergency department last December. It is taking up to 90 days for the registration to come through, which makes an existing problem worse. In reply to a parliamentary question I have determined there are still 1,300 people in that system. There are issues with paperwork but if the process could be speeded up, it would bring nurses in much more quickly.

Deputy John Brassil

I welcome the opportunity to contribute to the debate and rather than rehashing everything that has been said in the past hour, I will sum up the issue in two words. They are "resources" and "accountability".

Deputy Simon Harris

Yes.

Deputy John Brassil

If we do not put in place the required resources in terms of staff and infrastructure, those who should be responsible for dealing with the issues will blame a lack of resources. We must certainly examine why some hospitals perform much better than others with the same resources. The second and key solution to the matter is accountability. It is always somebody else's fault. As politicians we blame the Minister, the HSE blames a lack of resources, commitments will be given, targets will be set and yet nobody is held to account when the targets are not met. Next week there will be another "RTE Investigates" issue, with another emergency debate and shifting of resources. Around we go in circles. Until we get to the stage where the people responsible for delivering services are held to account, we are at nothing.

The Minister knows I sit on the committee examining the future of health care and we are doing much good work. If we are to solve the problem, we must start at the bottom rung of the ladder, which is primary health care. If we do not invest in primary health care, we will not keep those who do not need to be in hospital out of hospital. We must treat as many people as possible in the community as that will automatically free resources in the hospital services. It is quite simple if we think about it and we invest in it. As was alluded to earlier by many speakers, the treatment purchase fund is being reinstated but the Minister should seek further funding for it in order to deal immediately with the 500,000 people and get the waiting list down to a manageable level. The Minister would have the full support of this House in seeking to at least double that fund this year.

Deputy Anne Rabbitte

I also welcome the opportunity to speak today. To say last Monday night's programme was heartbreaking is to put it incredibly mildly. As a mother with three kids, I could not imagine what it would be like to be one of those parents having a child in a similar position. Sometimes in our consideration of the issues we must also examine where the HSE might have got things right. Professor Colette Cowan in University Hospital Limerick was one director of nursing who achieved her waiting list targets but I regret that this was not acknowledged in the programme the other night. Sometimes when we see problems we should also speak to the people who are delivering on the ground to see how they achieved it. I spoke to Professor Cowan over the past few days and asked her how she achieved the targets. She did it by in-sourcing, that is, with various surgeries done in the different hospitals within her grouping. She also outsourced to Cappagh hospital to get some orthopaedic procedures done.

Regrettably, the hospital could not deliver what she had outsourced because it did not have the equipment necessary to perform hip and knee replacements. These are the positives. She also made suggestions relating to theatre assistants. We all know there is a shortage of theatre nurses. If theatre assistants were available, it could help matters. Staff need not be theatre nurses to do the work. People can be trained up to support the surgeons.

Another suggestion related to recruitment of staff when they finish their studies and qualify. We could go to the young newly-qualified people and offer them contracts for three years and then agree to give them a break in the contract to allow them to travel, see the world and gain more experience.

These are valuable suggestions that come from simply talking and listening. It has to be a mix and match involving the NTPF. Between using the fund and in-sourcing, we could have a really good combination.

The most important thing is not to have another conversation about this. The lists have grown again during the month of January. We need to be able to say in 2018 that we have delivered and that the waiting lists have gone down due to a combination involving the NTPF. If the Government has to front-load funding to begin the work immediately, it should do so. Earlier, Deputy Kelleher said that if the Government needs to go back and seek extra funding and front-load it to get people off the lists and bring the latter down to a manageable level, then that is what the Government should do. No one should be in pain. No mother should have to see her child cry in pain. No mother should have to see her child denied the opportunity to attend education because the child is in pain. We cannot expect the teaching staff to be supporting the child in pain.

All the while, we have to look at resources. When people are going on annual leave, maternity leave, force majure leave or whatever, their positions should be covered in the HSE. Responsibility and accountability for the managing of rosters is necessary. When someone steps out, someone else should be in a position to step in to ensure a free flowing service is available at all times to the patient, who expects the service. An appointment should not be cancelled - or a place on the list lost - simply because there is no one available to deliver the service. If someone is on annual leave, he or she should have the leave booked and it needs to be noted. Patients' needs should be catered for at all times.

Deputy Caoimhghín Ó Caoláin

Monday night's "RTÉ Investigates: Living On The List" made for harrowing viewing, as many Deputies have acknowledged. The problems pertaining to the waiting times experienced by those seeking medical or surgical attention are issues we have all been aware of for a long number of years. However, no matter how bad we had thought the situation was before, we now know that the figures presented to us were grossly understated in an attempt to conceal the true scale of the crisis within the system. The NTPF is the body responsible for collecting, collating and validating information on persons waiting for public hospital treatment. The fund has deliberately excluded tens of thousands of people languishing on waiting lists. "RTÉ Investigates: Living On The List" uncovered evidence of at least two other significant waiting lists which are not published by the NTPF. This was a scandalous revelation. The deliberate concealment of figures is testament to a health service in perpetual crisis. It is time for the Government to realise that its so-called strategy to deal with this crisis is not working. What more will it take for the step-change that is so desperately needed to come about within our health service? I dread to think.

Sinn Féin has consistently raised concerns regarding waiting times. We have offered an alternative to the current failed system. The proposed Comhliosta system would constitute a new single integrated hospital waiting list management system whereby people can move from one hospital to another to reduce waiting times. It would involve the introduction of a new information technology system based on the one in use in the Portuguese national health service. The system would generate new maximum waiting times by transferring those on the list from hospitals that are struggling to meet demand to those in a better position to perform the procedure in a more timely fashion. The NTPF lacks transparency and is not accountable. The Comhliosta system would offer a practical solution to address the current mess.

The crux of all the serious issues within our health system is the lack of capacity within the health system to meet demand. Lack of capacity means those in our society who need urgent medical care and attention are left to suffer needlessly while Governments dither and facilitate tax breaks for the better off. An unnecessary tax break is of no use to anyone languishing in pain who has to wait day in and day out for medical or surgical attention. I concur absolutely with the arguments presented in that regard by Deputy Shortall earlier. It is time the Government realised what really matters.

Deputy John Brady

I take this opportunity to raise the case of a little girl from Wicklow, a constituency that I share with the Minister. Pearl Tamara O'Neill is a two-year old child who is seriously ill. Pearl has had acute breathing problems since birth. She is still waiting to have a windpipe tube removed. Last month, Pearl's parents were delighted to receive an appointment for the procedure, which was to take place in Children's University Hospital, Temple Street. The appointment was cancelled. Pearl was given another date and that was followed by a further cancellation. In other words, two cancellations were made within the space of two weeks. The hospital staff did not ring Pearl's parents to inform them of the cancellations on both occasions, despite having told them that they would ring in advance of the appointment to confirm bed availability. Instead, Pearl's parents were told of the cancellations when they made the telephone calls. The cancellation was due to there being no beds available.

This is the case of a two-year-old child, a helpless little girl who is vitally in need of what I understand to be a simple procedure. In her condition, infections are highly likely since it is easy for something to get into her airway. She is under constant supervision by her parents in case of an emergency blockage. She is only recently out of hospital, having contracted pneumonia some weeks ago. Yet, like many children throughout the State, she has been left to wait and suffer. Of course, we know from the Minister's statement that Pearl is not even on a waiting list because she has an appointment. According to the Minister, if a patient has an appointment date, whether it is one week away or three months away, the patient is not waiting. I am not sure how he can come to that conclusion. Perhaps it is a case of alternative facts.

Meanwhile, Pearl is left struggling to breathe, eat and vocalise. Following her appearance on the "Six One News" programme, she has received a new appointment for next Sunday. I hope that will materialise, but it is appalling that a patient has to go on national television or the national news to try to get an appointment. The Minister said there should be no sugar-coating of these issues. The pain being endured by many thousands of children like Pearl amounts to an absolute disgrace. Parents are languishing while they wait on appointment dates, only to be told at the last minute that the appointments are cancelled because of a lack of beds. This is a shame. We cannot endure any sugar-coating of the facts. We need this pain and misery to end for thousands of children and their families throughout the State.

An Leas-Cheann Comhairle

That concludes this part of the debate. We will now move to questions and answers. I appeal to Deputies to bear with me for a moment. I will make a suggestion. With the agreement of the House, we will group three or four questions and then allow the Minister to answer. I have a list of names. I think there will be an opportunity for everyone. The following are on my list: Deputies Fitzmaurice, Martin Kenny, McDonald, Eugene Murphy, Tóibín, Moynihan, Buckley, Scanlon, Stanley, Neville, Cowen, Boyd Barrett and Connolly.

Deputy John Brady

I asked a particular question.

An Leas-Cheann Comhairle

The Deputy has spoken already.

If Deputies are in agreement with that, then there will be enough time.

Deputy John Brady

I wanted to raise a specific issue-----

An Leas-Cheann Comhairle

The Deputy is not the only one.

Deputy John Brady

I know, but-----

An Leas-Cheann Comhairle

The Deputy's name is here. He is on the reserve list.

Deputy John Brady

The reserve list.

An Leas-Cheann Comhairle

Yes, and I think we will reach that list. Is it agreed that we should take three or four questions together?

Deputy Peadar Tóibín

Three.

An Leas-Cheann Comhairle

Okay, three. The first three questions will be from Deputies Fitzmaurice, Martin Kenny and McDonald. I ask the Deputies to put questions.

Deputy Michael Fitzmaurice

I ask the Minister to gather enough money together - be it €100 million or €150 million, as suggested by Fianna Fáil - for the NTPF so that we can start hitting the problem straight away. I ask him to do that for the Dáil. I also ask him to give an undertaking that from now on we will have the overall figure. If the Minister gives those two commitments today, that will represent progress.

Deputy Martin Kenny

My question centres on capacity. A lack of capacity is what we are talking about here all of the time. We saw the power of the media the other night, which has brought us all to this place today and we need to get this situation sorted out. Last year at Sligo University Hospital, 220 operations were cancelled on more than one occasion. There were multiple cancellations and this is happening all over the country, with people who are waiting on procedures being pushed back again and again. There are empty beds in Sligo hospital. There is a ward available with the beds already in it. What we need is the staff to run that ward. Will the Minister commit to providing staff for Sligo University Hospital? Yesterday, there were 18 people on trolleys in the accident and emergency department and seven people on trolleys in wards awaiting admission. We have a crisis and that is just one hospital. Sligo University Hospital is providing an excellent service. The staff are doing a tremendous job but there are simply not enough front-line staff there. Will the Minister commit to ensuring that before the end of the year additional staff will be employed to open that empty ward?

Deputy Mary Lou McDonald

Listening to this debate, there has been a lot of focus, rightly, on the issue of accountability but one would never imagine that within this House there are parties and individuals who have overseen the mismanagement and the scandal that now unfolds before our very eyes. Deputies Micheál Martin, Howlin, Varadkar, Noonan and former Deputy James Reilly, who is now in the Upper House-----

Deputy Billy Kelleher

What about Michelle O'Neill?

Deputy Mary Lou McDonald

-----all held the position currently occupied by Deputy Harris and all must be held to account for the chaotic and inadequate two-tier system that we endure. It is not a service for lots of people; it is actually an endurance test. People do not know whether they can get an appointment or get on a waiting list, how long they will be waiting on that list and whether they should go on national television to plead their case and to-----

Acting Chairman (Deputy Jim Daly)

Deputy, a question please.

Deputy Mary Lou McDonald

-----hope that they might get some service.

I have one very specific question for the Minister. This time last year I raised with the then Tánaiste and Minister for Social Protection, Deputy Burton, the plight of children and young adults with scoliosis awaiting surgery. I was informed at the time that the new orthopaedic theatre at Crumlin hospital would open in April of last year. The current Minister is presiding over the same scenario and the same suffering for those who endure scoliosis. He is now saying that this theatre will open in April of this year. I want a concrete assurance from the Minister today that the theatre will be open and functional in April. I also want him to give an assurance to all of those children and young people, including Pearl, who suffer in this way that they will have their surgery soon and without any further delay. I want him to assure them that they will not be left suffering on a list. Living on the list is a misnomer - existing on the list is the experience for so many children and their families.

Acting Chairman (Deputy Jim Daly)

I thank the Deputy. I have to move on to be fair to other Members. I must limit Members to questions so that we can get as many as possible answered.

Deputy Simon Harris

I will try to be succinct with my answers. In response to Deputy Fitzmaurice, I reserve the right to try to put more funding into the NTPF. I am currently considering that but am waiting to see the HSE's proposals in its action plan for waiting lists for 2017. As the Deputy knows, we have already put €20 million into the NTPF for this year. This is the first year in a long number of years that we have had a dedicated waiting list initiative through the NTPF. I will revert to the House and keep Deputies up to date on that. However, I am not going to allow everybody in positions of responsibility around the system to reduce this to an issue of funding because we have seen the health budget increase by almost €900 million in the past 12 months. Funding is part of it but what we do with that funding and how we deliver the results on the ground, in the hospitals and the health service is another aspect.

The figures were published yesterday by the NTPF. I will give the House an assurance that they will be published until such time as the important work that the NTPF is doing with Trinity College Dublin to work out the best way of ensuring that we publish clear, transparent and validated waiting lists is complete. I expect that body of work to be completed this year.

In response to Deputy Martin Kenny, I agree that there is an issue with capacity. A bed review is under way. We have not built a new hospital in this country since 1998 and we should not be surprised that we have a situation where people cannot access hospital beds. If we had not built a new school since 1998, we would not be surprised that there were not enough school places. We need to build more hospitals and to increase the bed capacity in our existing hospitals. I will have a clear, crystallised ask in terms of additional bed capacity in time for the Government's mid-term capital review, which will take place this year.

Deputy Martin Kenny also made the very important point that we cannot have extra beds without extra staff. The most recent figures, which I saw last week, show that we have 104 beds closed within our hospitals because of inadequate staffing levels. I have put proposals in place to hire an additional 1,000 nurses this year. I am sensitive to the fact that the Lansdowne Road oversight group will be meeting the Irish Nurses and Midwives Organisation, INMO, this afternoon. We have put forward a range of proposals to try to address nurse recruitment and retention issues. We are committed to holding further talks with the INMO and SIPTU on this matter in the coming days in order to avert industrial action. I would be happy to brief the House on those proposals once the talks have concluded.

In response to Deputy McDonald, I am very clear regarding my accountability. I have seen past Ministers for Health shrug their shoulders and say that they are not responsible. I am very clear on what I am responsible for in terms of this House, my Cabinet duties and the law of the land under the legislation relating to health. I am responsible for health policy and for funding the health service. I am also very clear on what the HSE is responsible and accountable for and that is the operational piece. So, my asking the HSE to be accountable and to live up to its obligations is not in any way to take away from my responsibilities or accountability. I want to be very clear on that.

The theatre in Crumlin will be operational in April of this year. We will see 194 scoliosis procedures carried out for children at Crumlin hospital this year, a significant increase on last year. I will come back to the House on this when I publish the action plan for scoliosis and I would welcome a debate at that stage. I expect to receive the plan by the end of the month. I am also looking at the outsourcing of some of the teenagers who are awaiting scoliosis procedures. I think there are 45 such patients in Crumlin at present. That is under way.

Acting Chairman (Deputy Jim Daly)

Deputies Eugene Murphy, Tóibín and Moynihan are next.

Deputy Eugene Murphy

The inpatient and day case list for Galway stands at 11,604. Regardless of whether they are from Limerick, Cork, Waterford or anywhere else, I hope people were listening carefully - the figure is 11,604. Recently Deputy Noel Grealish made a suggestion in this House, because of the absolute emergency in Galway, that the Minister would look at the possibility of opening an accident and emergency unit for more minor cases that might be turning up at University Hospital Galway. That is very important. While I do not blame the Minister for Health for this, the Taoiseach closed down the accident and emergency department in Roscommon which was handling thousands of patients each year.

Acting Chairman (Deputy Jim Daly)

I am going to cut the Deputy off shortly so I advise him to ask a question.

Deputy Eugene Murphy

There is no doubt that this is part of the problem. The Minister needs to do something. I ask him to open up a minor accident and emergency unit at Merlin Park. Second, will the Minister examine the possibility of doing what is done in the smaller hospitals in England? The authorities there have taken away accident and emergency units at such hospitals and replaced them with small stabilisation units.

Deputy Peadar Tóibín

The Minister said that he is ashamed of the waiting lists and that it is inexcusable that children and people would be left in limbo on those lists. With all due respect to the Minister, that is horse manure. Waiting lists are not a shock to the Minister. Waiting lists are the policy of the Minister. Consider Our Lady's Hospital, Navan, for example. It is the Minister's policy that the endoscopy theatre at the hospital is closed every Friday. It is the Minister's policy that the general surgery theatre at Our Lady's Hospital, Navan, is closed every Monday. It is the Minister's policy that there is a critical cap on orthopaedic surgery in Our Lady's Hospital, Navan on an annual basis. It is the Minister's policy that certain surgeons can only carry out five days of surgery over the five winter months-----

Acting Chairman (Deputy Jim Daly)

The Deputy has 15 seconds left.

Deputy Peadar Tóibín

-----at Our Lady's Hospital, Navan. It is the Minister's policy that this hospital surgery is only operating at between 70% and 80% of capacity.

Acting Chairman (Deputy Jim Daly)

Does the Deputy have a question?

Deputy Peadar Tóibín

How can the Minister say that the waiting list situation is a shock, is shameful and is something new, when in actual fact it is the Minister's decision-----

Acting Chairman (Deputy Jim Daly)

Does the Deputy have a question for the Minister?

Deputy Peadar Tóibín

-----that this could happen? My question to the Minister is, in his newfound desire to see hospital beds opened-----

Acting Chairman (Deputy Jim Daly)

Will the Deputy get to his question or we will move on to the next speaker?

Deputy Peadar Tóibín

-----will he then rescind the policy, determined by the small hospital framework document, that the accident and emergency department in Our Lady's Hospital, Navan, is to be closed down?

Acting Chairman (Deputy Jim Daly)

The Deputy has gone way over time. I am moving on to the next speaker.

Deputy Aindrias Moynihan

I have a range of questions for the Minister. It was difficult to watch the "RTE Investigates" programme this week seeing the distress and anguish for people on the waiting lists. It might have been a shock for many people but it was no surprise to many of us who have been raising these issues time and again. I have repeatedly raised with the Minister the issue in Cork University Maternity Hospital, CUMH. In fairness, he visited the hospital in response and in the programme in question he indicated that there are some changes in CUMH management for which he is aiming. I pointed out to the Minister the fact that there is an empty theatre at CUMH that has never been used.

Acting Chairman (Deputy Jim Daly)

The Deputy has 15 seconds left.

Deputy Aindrias Moynihan

Is the Minister going to open that theatre? Will he establish the one-stop shop that is needed? With regard to consultants, 28 were hired right across the country but there was none for CUMH, which has the longest waiting list. Is the Minister going to hire additional consultants for that position?

Acting Chairman (Deputy Jim Daly)

The Deputy's time is up.

Deputy Aindrias Moynihan

The situation regarding cataracts is seriously impacting on the quality of life of so many older people-----

Acting Chairman (Deputy Jim Daly)

The Deputy has used his minute. The Minister is to respond.

Deputy Aindrias Moynihan

I have one very brief question, with the indulgence of the Acting Chair. We hear, time and again, of situations that work better in other hospitals. For example, the Sligo University Hospital model assists people in getting through cataract operations.

Acting Chairman (Deputy Jim Daly)

The Deputy should allow the Minister to respond.

Deputy Aindrias Moynihan

Will the Minister indicate if such a situation can be put in place to ease the levels of distress and to allow people in Cork to have their operations faster?

Deputy Simon Harris

I thank Deputy Moynihan. He has been a passionate advocate for a greater role for our level 2 and level 3 hospitals to take the pressure off our level 4 hospitals and the point he made is very good. It is policy and we need to look at what more we could do. As the Deputy knows, I visited Roscommon. There is huge potential, and not just in terms of the endoscopy unit which we opened there, to take scope procedures from some of the larger hospitals and drive the traffic of patient flow into that hospital. We also have a stroke rehabilitation unit underway and plans for the hospice there. I agree that the future for our smaller hospitals is extraordinarily important. We are going to look at the opening hours of local injury units and the minor assessment units. If they can be open for longer to alleviate the pressure on our accident and emergency departments, that would seem to me to be a sensible idea. Merlin Park University Hospital-----

Deputy Richard Boyd Barrett

Ministers have been saying that for years.

Acting Chairman (Deputy Jim Daly)

The Minister, without interruption.

Deputy Simon Harris

I have not been saying that. There are already some proposals to see what we can do with Merlin Park University Hospital. I agree there is a need to look at some non-acute services that could perhaps be provided on the Merlin Park University Hospital site.

In the context of Deputy Tóibín's comments about horse manure, he can use any phrase he wants. Quite frankly, however, he does not know how I feel or how I felt while watching the programme. The Deputy can decide to impugn my name or my integrity - good luck to him with that - but as long as I am the Minister for Health, I am not going to be a spokesperson for the HSE and I am not going to be a bureaucratic spokesperson. I will call what I see and when I find something that is indefensible-----

Deputy Peadar Tóibín

Those theatres are closed-----

Deputy Simon Harris

Excuse me-----

Acting Chairman (Deputy Jim Daly)

Deputy Tóibín, please.

Deputy Simon Harris

I will answer the Deputy's question.

Acting Chairman (Deputy Jim Daly)

Deputy Tóibín was not interrupted and he had a good run so he must not interrupt the Minister.

Deputy Peadar Tóibín

Those theatres are closed as result of the Minister's policies.

Acting Chairman (Deputy Jim Daly)

I ask the Deputy not to interrupt the Minister.

Deputy Peadar Tóibín

The Minister cannot separate himself from it.

Acting Chairman (Deputy Jim Daly)

I will suspend the sitting if the Deputy is going to continue with this. He must be fair to every other Member who wants to contribute. Deputy Tóibín had his time.

Deputy Simon Harris

The Deputy asked me about three points and I am answering the three points. I am not going to defend the indefensible. When I see something that is appalling and unacceptable, I will call it out as such. I will tell Deputies what I, as Minister, will do to mitigate it and I will also tell Deputies what I expect from the people who receive €14.1 billion of taxpayers' money to fix the situation.

Reference was made to policy. I do not run Our Lady's Hospital, Navan. My policy is not in respect of endoscopies and theatres, but I will get the Deputy a full response from management with regard to Our Lady's Hospital, Navan. If the Deputy is saying that he believes more can be done in Navan to tackle waiting lists and carry out additional procedures, I will examine the position. On the emergency department in Navan, in the nine months I have been the Minister for Health I have had no contact from the HSE on proposals to change any services at that hospital.

I am extraordinarily concerned about what has happened at CUMH. Deputy Moynihan and other Deputies from Cork brought the matter to my attention. I visited CUMH and met the consultants, clinicians and management there. I cannot understand how we have a situation where women in Cork face waiting lists that are almost double the length of those that obtain in Dublin hospitals. We had a financial crisis across all of the health service in all of the country, yet we have a situation in Cork where women are expected to face much longer waiting lists. That can only come back to how we are actually managing the resources in that hospital. The Deputy has correctly said that in recent weeks we have seen a new group clinical director for maternity services, an appointment that has been very much welcomed by many clinicians there. In my letter to the director general of the HSE, I have made it very clear that I expect to see the gynaecological services in CUMH prioritised as part of the HSE waiting list action plan for 2017. I expect to have a follow-up meeting with clinicians and with Cork Oireachtas Members in the coming weeks.

Deputy Moynihan also raised the issue of cataract services. Under the NTPF, €5 million will be targeted at day-case procedures with a priority on operations and procedures such as the cataract procedures. I hope a number of the Deputy's constituents and people right around the country should start to be called for those appointments from March 2017. I agree absolutely with Deputy Moynihan who asked if we can learn from other parts of the country. This is the point about accountability - it is not that heads must roll or that everybody is appalling, it is about saying that we must find really good examples and demand that good practice everywhere. There are very good examples and the Deputy mentioned what is being done in Sligo. I would like to see a pooling of waiting lists and resources so that if a person needs to see a consultant today the entire hospital group works to try and get that person to see whichever consultant is appropriate, as quickly as possible. We are going to look at rolling out the pooling of waiting lists in 2017.

Deputy Pat Buckley

I want to ask the Minister about symphysiotomy. Last Tuesday, a woman in her 80s rang me in tears. She spoke about wanting to end it all. She was under pressure because her medical card had been rescinded. I definitely want to know why it was rescinded. It was very hard to listen to an 80-year old woman crying because she wanted to end her life. The Minister is aware of my background in the area of mental health and so on. It is bad enough having our hometown known as the suicide capital of the world and having a suicide row in the graveyard. I need answers on that.

My second point is around the Midleton ambulance in east Cork. It has been rumoured that the HSE is going to pull that service. The service is extremely vital to us. When it was removed two years ago, we had two high-profile deaths involving young people. We do not want to see this service removed, regardless of what the cutbacks are. I would like answers on both of these points.

Deputy Eamon Scanlon

I want to convey to the Minister what happened in Sligo two and half weeks ago. A young girl - a healthy young woman - was out for a meal with her friends. She collapsed with excruciating pain in her head and was admitted to Sligo University Hospital at 8 p.m. Nothing happened until 8 o'clock the following morning. I do not know what happened there, quite honestly, but I ask that the Minister would investigate on behalf of her father, mother and sister as to what took place there. The young girl had to be transferred to Beaumont Hospital in Dublin, but sadly, not in time. On behalf of the parents, I ask the Minister please to investigate this situation so they can at least get some peace of mind as to what happened.

Deputy Tom Neville

Since the PPARS debacle some years ago, there seems to have been a shying away from any attempt to upgrade IT systems within the health service. Delay is no longer acceptable, however, and the challenge must be met head on. We live in an IT age, with cloud computing and so on. Ten or 12 years after PPARS, however, we still have a paper-based system. Any large organisation in the private sector has an enterprise resource planning, ERP, system, usually running on a SAP or Oracle platform, with data accessible from user iPads and integrated such that a person in one office can access information from another office. Introducing something similar in our hospitals would free up a lot of resources, which is vital given that the crisis we are facing is largely to do with the management of resources. Are there plans to put an integrated IT system in place across the health service? We need to examine the logistical models.

In regard to waiting list times, will short-term targets, of three, six, nine and 12 months, be set? Will the Minister also give an update on the emergency department and the 93-bed unit at University Hospital Limerick?

Deputy Simon Harris

I acknowledge Deputy Buckley's track record in pursuing mental health issues and being a strong advocate in this area. If he sends me details of the first matter he raised, I will have it examined. I am not aware of the issue he raised in regard to the ambulance service but will have it checked out by my officials and revert back to the Deputy. We need to expand our ambulance fleet significantly, both the number of vehicles and the number of staff. Additional funding has been allocated to the National Ambulance Service this year to advance that objective. I will get back to the Deputy on both those issues.

I am not familiar with the case Deputy Scanlon outlined but I join him in extending my sympathy to the family concerned on what seems to have been a very tragic incident. The investigative function in such matters does not lie with me but if the Deputy wishes to write to me on the matter, I will make sure it is looked into and that somebody reverts to him with an outline of the situation.

Deputy Neville highlighted a very important issue which I expect, from following the work of the Oireachtas Committee on the Future of Healthcare, is likely to be very much at the core of our priorities. The need to invest in ICT within the health service is undeniable. The Deputy is right that in the past, as a result of projects that went wrong, many people shied away from taking the necessary steps. We cannot run a health service with large paper files filling room after room. There is an ambitious programme of work already under way by the e-health section of the HSE. The staff are a very dynamic and innovative group of people with whom I have had a lot of contact. The new e-referral system allows GPs to refer patients for hospital appointments electronically. The GP can see while the patient is in the room that the appointment is in the system and there is no need for the collection of letters of referral. We also have introduced an e-prescribing system in some hospitals. This year, every citizen will be assigned an individual health identifier which will be recognised by the HSE's computer system. These are the building blocks. Since December, Cork University Maternity Hospital is the first hospital in the country to have electronic records for every baby born there, which will stay with them throughout their lives. It seems appropriate that this initiative should commence in the maternity service, the plan being to roll it out to Kerry, the Rotunda and Holles Street this year.

Deputy Neville also asked about targets. I have outlined the targets we are setting, namely, that by the end of June, nobody will wait longer than 18 months for a day case procedure and, by the end of October, no person will wait longer than 15 months for an outpatient appointment, impatient procedure or day case procedure. I realise these are still lengthy waiting times, but we have to start somewhere. Given the appalling situation facing children with scoliosis, I have asked the HSE to produce an action plan on scoliosis, which I will have by the end of this month. In addition, the director general has committed that by the end of this year, no child will wait longer than four months for a paediatric scoliosis procedure. It is an ambitious and bold target considering where we are, but it sends a strong message that we will ensure the provision of scoliosis procedures and treatments for children in this country is in line with what is done in other jurisdictions, including in the NHS.

On the issues relating to University Hospital Limerick, I will arrange for an update to be sent to the Deputy.

Deputy Barry Cowen

This time last year, during the course of the election campaign, it was obvious people wanted to improve their lot and that of their families from an income and taxation perspective but not at the expense of the provision of health services, especially for children. It was against this backdrop that we negotiated an agreement with the Government and insisted on the restoration of the National Treatment Purchase Fund to the levels it was at in the past, which helped to address major logjams that had arisen previously. I implore the Minister to pour whatever resources he can into that sector to deal with the crisis we are facing.

The Minister mentioned that no hospital has been built since 1998. In fact, the Midland Regional Hospital, Tullamore, was opened in 2007 at a cost of €150 million. We are very proud of that facility which represented the realisation of the process that was put in place many years earlier to share services among the Midland Regional Hospitals at Mullingar, Tullamore and Portlaoise. However, like many other hospitals throughout the country, theatres in Mullingar sit vacant during the months of January and February because of the pressures on emergency beds and, ultimately, because of the failure to meet capacity that has arisen out of the problems in attracting specialist nurses and other nursing staff.

Acting Chairman (Deputy Jim Daly)

Does the Deputy have a question?

Deputy Barry Cowen

The situation will be made worse in the coming weeks when nurses go on strike. We must address the urgency and need in this instance. Gardaí have a special relationship with the public, and their concerns were addressed recently. Nurses' concerns must be addressed in the same light.

Acting Chairman (Deputy Jim Daly)

We must move on.

Deputy Barry Cowen

Will the Minister assure us there is a new urgency to address the issue of pay and conditions for nurses in order that they can carry out their vocation and assist society in dealing with the crisis in the health service? Has the Government moved any closer to allowing nurses to contribute as they are trained to do and as they wish to do?

Deputy Richard Boyd Barrett

One of the heart-rending and appalling cases that shocked the nation when it featured on the "RTE Investigates" programme last Monday concerned one of my constituency cases. Sarah-Ann Mitchell, who is 11 years old, was diagnosed with scoliosis in July and still does not have an appointment. I submitted a parliamentary question to the Minister on 20 December on behalf of her mother, Karen, which was batted off to the HSE on 17 January. There has been no reply. Sarah-Ann's consultant says her spinal curvature has increased by 10% to 60% since July because of the delay. She is suffering greatly.

Acting Chairman (Deputy Jim Daly)

Will the Deputy put a question to the Minister?

Deputy Richard Boyd Barrett

The consultant also said that part of the problem is the lack of nursing staff. Will the Minister agree to meet Karen in order that she can find out what is going on and when Sarah-Ann will receive treatment?

The orthodontic clinic at Loughlinstown hospital is no longer making referrals to St. James's Hospital because the list at the latter is so long. What does the Minister propose to do about this? It is bad enough for patients to be on a long list but even worse if one cannot get on the list.

Deputy John Brady

Deputy Boyd Barrett referred to the case of scoliosis sufferer Sarah-Ann Mitchell. There are many children enduring the same suffering, including my daughter who has a curve in her spine of 45°. As is too often the case, my daughter's problem was not identified early enough, until she was 16. At that stage, a back brace was not an option because her growth was coming to an end. When I was a child, the public health nurses who went into every school in the State, as they still do to carry out vaccinations, also checked for scoliosis. That no longer happens even though it is a simple procedure which takes less than two minutes. Early identification of scoliosis would alleviate the suffering children are having to endure and, in some cases, prevent the need for surgery later on. Will the Minister ensure that process is rolled out across the State? We do not need an action plan or to wait until the end of the month. It can be done in the morning.

Deputy Simon Harris

In response to Deputy Cowen, I am not partisan or petty on this, in that the NTPF was set up by the Fianna Fáil Party in government and the Fianna Fáil Party sought the reinstatement of it. While there have been differing views in my party, I am of the view that it is a useful and effective vehicle, at least in the short term. While people want to have ideological discussions about public versus private, we are increasing significantly the budget in the public health service. However, the capacity is not there in the morning and those waiting at home, including those on the "RTE Investigates" programme, want procedures done as soon as possible. We want them done as soon as possible. The NTPF is a useful and important vehicle in that regard.

The point about investment also was not a partisan one about the Governments in which Deputy Cowen's party participated. Collectively, we have failed to plan for demographics in the way in which we have done good work on school places. The Department of Education and Skills now knows the number of children next year needing a school place and the number of teachers and classrooms that will be needed. We have not undertaken that level of demographic analysis of the health service and that is what needs to be done. That is why the ten-year plan is important.

On nursing, I reiterate what I have said in this House, which is the issue of recruitment and retention of nurses is a key building block if we want to break what I have described as the vicious cycle of overcrowding on hospital waiting lists, bed capacity, recruitment and retention and a GP contract. We have engaged with the INMO and SIPTU on proposals to address recruitment and retention. That includes a fully-funded workforce plan for 2017, giving directors of nursing more power to fill vacancies and trying to improve some of the recruitment campaigns. I do not want to get into all of the detail because the INMO and SIPTU are still, I hope, willing to engage in further discussions with health service management.

Deputy Richard Boyd Barrett

The Government should just accept their proposals.

Deputy Simon Harris

We cannot usurp the Public Service Pay Commission process. That process is due to report in a matter of weeks and the Minister for Public Expenditure and Reform has set out the process for addressing issues of pay and allowances.

I believe issues of allowances and pay will need to be looked at if we are serious about recruitment and retention in the future and I believe the public sector pay commission is the vehicle to do it. The INMO was at the public sector pay commission on Tuesday. My Department was at the public sector pay commission making these points. We are willing to do everything and anything we can to assist with the recruitment and retention issue in nursing. We cannot get into the pay and allowances space because there is a process in that regard and, as the House will be aware, there are public servants right across both the public service and the health service where there could be a contagion effect in respect of some allowances.

In response to Deputy Boyd Barrett, I would be happy to arrange to meet Karen and Sarah-Ann with him. That would be no problem at all. I accept the issue of theatre nurses has been the reason. I told Deputy McDonald it has been the reason the theatre in Crumlin, which was meant to be the principal vehicle for getting more of these operations done, has been closed. When I met the CEO of Crumlin and the director of nursing this week, they confirmed four nurses will start in April, which will enable the additional capacity. A further 16 nurses from an international campaign are going through the recruitment process and another orthopaedic consultant is due to come on stream by June. That will provide the additional capacity.

As for the orthodontic services in Loughlinstown, I will have a look at them and revert directly to the Deputy. At present, we have the HSE's operational plans for each of the hospitals giving the hospitals their budget for the coming year. I will check it and revert to the Deputy.

Deputy Brady told us of his own experience, which I appreciate him sharing with the House. The issue of school screening has been raised with me by a number of the advocacy groups. It is one of the issues I have asked be considered by the health service in the context of the action plan. I am not asking anyone to wait forever for an action plan. By the end of this month of February, we will have a plan to deal with scoliosis that will see a dramatic reduction in waiting lists and waiting times this year. It seems a logical suggestion but I believe it was changed on clinical grounds. It sounds like there is merit in it. It is being considered in the context of the action plan. I will engage with the advocacy groups on that too.

Acting Chairman (Deputy Jim Daly)

I thank the Minister. Next are Deputies Connolly, Louise O'Reilly and McGuinness.

Deputy Catherine Connolly

I have a specific question in the form of a trinity. On 12 December 2016, management and the clinical director gave the Minister a submission on the hospital in Galway. They pointed out two specific matters, the first of which was that the hospital itself is not fit for purpose. They asked the Minister for the approval to proceed urgently with an options appraisal on infrastructure, in plain English, a new hospital. Second, they asked for immediate investment in the current emergency department because that is not fit for purpose. It is dangerous, according to an independent report. The final part of my question relates to the ambulance service in Galway, which is in Merlin Park in appalling temporary accommodation that I say is not safe. It is one question with three parts - a new hospital, accident and emergency and the ambulance service.

Acting Chairman (Deputy Jim Daly)

I thank the Deputy for being so succinct and timely.

Deputy Louise O'Reilly

I will ask the Minister some fairly simple questions. The first relates to the bed capacity review. Can the Minister share the terms of reference with the House?

Second, since there has been much talk here today about capacity, whatever the Minister proposed to the INMO was rejected by its executive. That was made fairly clear and put in stark terms. Since we all are agreed, as we rarely can be, that capacity is the key and nurses are the key to being able to generate that capacity along with their colleagues and allied health professionals and other workers, what new proposal can the Minister present to the INMO executive that it has not rejected already?

With regard to the points I raised on the NTPF protocol that was written in 2014, it had been available on the website and then was withdrawn fairly hastily, on the basis of what clinical evidence was that done and why? Clearly, what happened led directly to the programme we all saw on Monday. The Minister might explain that.

Deputy John McGuinness

The bucks stops with the Minister. That is the way it stands. The Minister is here to answer various questions, not about his role in terms of the Department but for the HSE. The House passed €14 billion worth of a budget and yet the body or agency getting that funding is totally chaotic. It is dysfunctional. I want to know whether the Minister has scrutinised the management of the HSE and how he will make it answerable to this House. Are there too many managers and not enough staff on the front line? Is the Minister funding a top-heavy organisation and should it be reformed?

As for the waiting lists and that question, how can anyone stand over a child in that bracket, with autism as well, having the operation cancelled on two occasions?

Acting Chairman (Deputy Jim Daly)

I thank the Deputy.

Deputy John McGuinness

If these managers are worth their salt, why do we have a waiting list? Why are we poorly managed? Unless we continue to focus on the management of the HSE with the Minister accountable, we will continue to have this debate year in, year out.

Acting Chairman (Deputy Jim Daly)

The Minister to respond.

Deputy John McGuinness

I have two questions that support this. St. Luke's General Hospital is held up as one of the best examples in the country and yet there is not enough funding for either the medical assessment unit or the step-down and discharge unit.

Acting Chairman (Deputy Jim Daly)

I must move on.

Deputy John McGuinness

That is the fault of managers not spending the funding properly. It is the same in Galway. Why is it that a proposition given to the Minister and talked about-----

Acting Chairman (Deputy Jim Daly)

I must treat Deputy McGuinness the same as everybody else.

Deputy John McGuinness

-----cannot be acted upon when patients are suffering on the corridors and cannot get into care?

I support my colleague who raised the issue of mental illness. It is simply shocking that patients have to pay before they get in.

Acting Chairman (Deputy Jim Daly)

I ask the Deputy to be fair to his colleagues.

Deputy Simon Harris

I thank Deputy Connolly for the specific questions. I will try to be as specific as I can. I presume the meeting on 12 December last that the Deputy referenced is where I met the clinical director while I was in Letterkenny.

Deputy Catherine Connolly

I am specifically referring to the written submission that was made.

Deputy Simon Harris

I had a conversation. Let me be clear, I believe there is a need to do more in Merlin Park. I want to see the Saolta Hospital Group and the clinical director in the Saolta Hospital Group------

Deputy Catherine Connolly

I asked the Minister a specific question. I did not take up time. There are three parts to it. The Minister got a submission for a new hospital and immediate investment in accident and emergency and I asked about the ambulance service. The Minister should address the question on the submission.

Deputy Simon Harris

If the Deputy will bear with me a moment, I will address the three parts.

The hospital group has made a submission on Merlin Park. There is merit in the suggestion that more can be done in Merlin Park. We are about to have a mid-term capital review this year and I have asked that the HSE consider it in that context. That is the situation in that regard.

In respect of University Hospital Galway, the second piece on the emergency department, ED, as the Deputy will be aware, the design phase has been approved for the emergency department and funding has been made available for that piece.

Once the design phase is approved, that then moves forward in the context of the capital plan. In regard to third piece, which is the ambulance service, I do not have the information for the Deputy but I will come back to her directly.

In response to Deputy Louise O'Reilly, I would be happy to share with her the information I have on the bed capacity review. The review will assess the following: first, current capacity and levels of unmet demand; second, trends in better utilisation of existing capacity and scope for further gains; third, drivers of future demand, including demographics, which is a big part of this, and epidemiological trends, innovations and technological advances; and, fourth, further capacity requirements based on a preferred model of care. As the Deputy knows, the committee of which she is a member and which aims to produce the ten-year plan on the future of the health service, is a very important part of that. If we are making a shift to primary care, we need to examine what impact that will have on bed capacity. I know the committee is making an input in that regard.

This will be a substantial body of work. This idea that we can just pluck a figure, say it is the number of beds we need and not be cognisant of the model of care or of primary care would not be a sound way to do this. However, we will have a crystallised ask for the mid-term capital review in terms of how many additional beds we believe we need in the Irish health service.

With regard to nursing, I am very reluctant to say anything that is unhelpful to the process that is ongoing.

Deputy Louise O'Reilly

The Minister has not said much that is helpful.

Deputy Simon Harris

I try my best.

Deputy Louise O'Reilly

The INMO executive are the professionals. Its members considered what he said and they did not think it helpful.

Acting Chairman (Deputy Jim Daly)

The Deputy should allow the Minister to speak without interruption.

Deputy Simon Harris

The INMO executive council met yesterday. I am deeply disappointed that it rejected the proposals, although I respect the right of its members to do as they wish. What is really important is they have now provided three weeks and six days before a work-to-rule takes place across the Irish health service, a work-to-rule that I believe, and the INMO has conceded, would be detrimental to Irish patients. We need to use those three weeks and six days to try to resolve this dispute. As was prearranged, the INMO is today attending the Lansdowne Road oversight group and I await the input and instruction from that group. We know the structure of that group in terms of unions and management. I hope it will suggest further discussion and dialogue, which is essential. I understand significant progress was made on a number of elements and I know there were one or two elements in particular on which the INMO did not feel adequate progress was made. I want to use this time. We will only resolve any dispute by sitting around a table and trying to sort it out. What nobody needs in the Irish health service is industrial action.

In regard to the NTPF, to be clear, no matter how many times it is asserted, I did not ask the NTPF to change anything in regard to protocols, its website or anything else. The NTPF has confirmed to me again, as recently as during this debate, that there has been no change in the way the preplanned and pre-admit lists are reported in the new protocol and the NTPF has not, since its establishment, under six Ministers for Health and five Governments since 2002, published the pre-admit lists. They were published yesterday and I have given a commitment in the House today that they will now be published each and every month until that body of work with Trinity is finished.

Deputy Louise O'Reilly

I have to say that-----

Acting Chairman (Deputy Jim Daly)

Sorry, the Deputy is not allowed to come in under any circumstances. Please respect the Chair. Will the Minister move on to Deputy John McGuinness's questions?

Deputy Simon Harris

I will. With regard to accountability, I appreciate the point Deputy McGuinness makes. I am clear on what I am accountable for but there are other people accountable for other elements of the health service. When I ask for them to be held to account and for them to redouble their efforts, I do not mean it to excuse me of my responsibilities. When I talk about accountability, I am talking about trying to identify the fact there is good practice and really good stuff happening in parts of the health service. However, if we do not look at the system and who is doing well, we cannot replicate that good practice. We have seen it in Beaumont Hospital and in the RCSI group, and Deputy Rabbitte pointed out the good practice in regard to some midwifery services in Limerick.

We have a performance and accountability framework. It is a document that every manager in the health services signs, and it is agreed by the Department of Public Expenditure and Reform, the HSE and the Department of Health. It states that managers must be held to account on four scores, one of which is financial. Deputy McGuinness and I would have talked about this a lot at the Committee of Public Accounts and the system is getting quite good at holding people to account on the financial side. However, the other three pieces are what matter to the people in the "RTE Investigates" programmes, and involve things like timely access, quality and the safety of the service. I have written to the director general of the service to say I want to know how each manager measures up against that balanced scorecard in regard to those four things, not just the financial piece.

Yes, I believe the HSE needs to be reformed. What I do not think needs to happen, and I hope the House would agree on this, is that another Minister for Health would just tweak the structures. In due course, hopefully in quite a while, we will have another election and perhaps a different Government. Deputy Billy Kelleher might one day be Minister for Health and might decide to change the system, and Deputy Louise O'Reilly might then be Minister, and she might decide to change it again. We need to have a cross-party plan for ten years in order that the structure does not keep changing no matter who else changes. I hope and expect that the Committee on the Future of Healthcare will give us that structure and I am committing to the House that we will then implement that structure. Let us then try to legislate for accountability and for governance, and let us try to address the piece that has been brought up time and again about the accountability of health service managers and executives to public representatives on behalf of their constituents and communities.

I will look into the points raised by the Deputy in regard to St. Luke's and the correspondence he has given me in regard to Galway.

Deputy Fergus O'Dowd

The Minister spoke of holding the HSE and its director general to account. Who will audit those standards the Minister rightly talks about? Will he have external auditors or will the HSE be auditing itself? The buck ultimately stops with the head of the HSE. What is the term of office of the HSE director general? Does the Minister have the power to fire him or her? If he does not, will he put in place standards to which he or she, and his or her senior executives, will be held accountable in a transparent public way?

Deputy Brian Stanley

I want to ask about the Midland Regional Hospital, Portlaoise. The extra resources provided for maternity services have proved beneficial and the results are there to be seen. A letter was circulated to hospital staff and the local media recently highlighting the fact that when the hospital gets resources, services can be improved. However, I want to highlight the fact there were 433 cancellations of surgery last year at Portlaoise hospital. I am told by staff that the bed capacity is supposed to be at 80% to 85%, as is good international practice, but it is at 110% in Portlaoise because 10% to 15% of patients are on trolleys and chairs. According to a reply I received from the Minister, one quarter of staff wages are going to agency staff and temporary locums despite the fact they make up less than 15% of staff, which shows they are more expensive. There are huge problems with recruitment because there is no certainty and there is no plan for the future of the hospital. Working conditions are bad due to the pressure caused by shortage of staff.

Will the Minister commit to quickly publishing the plan on the future of the hospital? Will he increase bed capacity? Will he employ the permanent staff who are needed to remove the bottlenecks in Portlaoise hospital?

Deputy Brendan Griffin

This is the way the Dáil should work. I welcome that we have had these statements. This open, honest and frank question-and-answer session is the way we should do business a lot more often in the House. It is a very good way to do business and I commend the Minister on facilitating this.

I would say to those who took the opportunity this morning to take cheap political shots at the Minister that at least Deputy Harris had the courage to be a Minister when the people elected him to the House in the same way everybody else in this Chamber was elected. He stood up and was counted when it mattered, which should be borne in mind by those who are very quick to criticise and throw this around like a political football.

On the matter of the written responses we seek, and in light of my contribution during the statements, will the Minister try to deliver change in this area for the purposes of accountability?

An issue raised on numerous occasions by my colleague in Kerry, Councillor Bobby O'Connell, is that of the "do not attends". This is costing the health service millions of euro every year and there is also the issue of keeping other people further down the waiting lists. What initiative is being taken to try to address this?

Is there an optimum amount the Minister could additionally spend in the context of the overall capacity that is available in 2017? How short of that amount is the Minister? Is he making efforts with the Department of Public Expenditure and Reform to try to bridge the gap?

Deputy Simon Harris

On Deputy O'Dowd's point, I want to be very clear that I have confidence in the director general of the HSE to do his job. However, I do not have blind confidence in anybody and I am not going to start writing blank cheques for anybody. Everybody in every role in the health service, from the person working on the front line to the person managing a hospital, big or small, needs to be responsible and accountable and we all need to redouble our efforts in this regard. I have confidence in the director general and the work he is doing but I am not offering a statement of blind confidence in anybody in any management position within the health service.

What I have done is to invoke the performance and accountability framework, a new framework brought in by this new Government to put in place a firmer and clearer system of accountability.

I have outlined the four criteria and I will not outline them again. The managers sign up to be measured against them. It says where managers do not deliver on them, and they can be examined first by their group CEO and then by a national director, improvement plans must be put in place. Where improvement plans are not acted on, the person can be removed from the post. I do not want to reach the point where we are removing people from their posts. I want to reach the point where we are improving the health service. The director general will come back to me as a result of my letter to him on 5 January, in which I asked that the performance and accountability framework be analysed against each manager. I would be happy to brief Deputies on the outcome of the process.

I was pleased to visit Portlaoise hospital recently and meet Oireachtas Members and members of Laois County Council. No decision has been made to withdraw services from Portlaoise hospital. I was also very clear when I visited Portlaoise, and I hope it was heard across party lines, that the HSE has a view on a plan for Portlaoise. While it is an important view, it is not the full picture.

Deputy Brian Stanley

When?

Deputy Simon Harris

The full picture must take on board the submission the GPs and the community made to me. I want to meet the GPs from Portlaoise in the coming weeks.

Deputy Brian Stanley

They are anxious to meet the Minister.

Deputy Simon Harris

While I want to provide certainty to Portlaoise hospital, I want to ensure we have all the pieces of the jigsaw before I do so. We hope to increase the number of nurses working in the health service by more than 1,000 this year and I expect Portlaoise will benefit from it. Regarding where we need to invest in more beds, I will be led by the bed capacity review.

I thank Deputy Griffin for his comments. This is the way the Dáil should work. It is much more interactive, when we get a chance. I do not try to be partisan in this role. It would be a futile exercise. Over the years, as we have seen on every RTE programme or news clip, while the Minister, Government and party may change, the problems remain. This has been a tough week for me trying to ensure we put a comprehensive response in place, and it has been a tough week for the people waiting on these lists. Those are the people we all care about. I have no intention of giving up on my responsibilities. I intend to redouble my efforts, and I need everybody else to redouble theirs. The Deputy's point on written responses is something I will look up.

Regarding Councillor Bobby O'Connell's request regarding "did not attends", from memory there were approximately 450,000 "did not attends" for outpatient appointments in the health service last year. It is a significant cost to the health service. To try to improve it, we are bringing in an SMS reminder system. We have it in place at a number of our hospitals, whereby patients are receiving a text message a couple of days before and on the day before their appointments. I want to examine modifying the text to inform patients of the cost of missing the appointment to drive home the point that if a person misses a hospital appointment, it has a knock-on effect on so many others.

On the question of whether we require more funding, I did not want to do what past Ministers for Health have done the first time a crisis arose, namely, ask for more money. The Government has provided €14.1 billion to the health service. It is the largest ever health budget. We may require more funding from within the budget to be allocated to the waiting list issue or the NTPF. However, sometimes too many more important issues are let off the hook if I immediately run to try to find the chequebook in the Department of Public Expenditure and Reform.

Deputy Billy Kelleher

Will the Minister outline the Government's policy on health? Is it still talking about disbanding the HSE? Is it talking about establishing hospital trusts? While we criticise the HSE, we, and everybody else, are unsure as to the Government's stated policy on the HSE, whether it is to be reformed or abolished, and how we underpin our health services. While we criticise management, there is an obligation on the Minister to outline the strategy clearly. Will the Minister wait for the ten-year plan or what is his view? We do not know, and everybody in the HSE does not know.

Deputy Mary Butler

I refer to two specific waiting lists in University Hospital Waterford. As the Minister knows, 6,000 people are awaiting orthopaedic operations, be it hip or knee. These are very successful operations and greatly improve people's quality of life. Most of the operations are done in Kilcreene Orthopaedic Hospital. Patients go into hospital on a Monday and are discharged on Thursday. They are very effective. The ophthalmology waiting list is also in excess of 6,000. Under the NTPF, can we specifically target extremely long waiting lists, given that 4,000 of these 12,000 people have been on the waiting list longer than 18 months? Specific targeting of these two extremely long waiting lists would be very much appreciated.

Deputy Mattie McGrath

Earlier, the Minister said more hospitals and capacity needed to be built. The Minister has visited Cashel hospital, where €22.5 million was spent, after which it closed. There was an overrun of €7 million and I have referred the matter to the Committee of Public Accounts. Will the Minister insist that step-down patients be allowed into the hospital and that beds will be put in? It is state-of-the-art. If we are going to waste this kind of money on a building that is being used just for a very few minor injuries, as the Minister saw, and offices for management, it is unacceptable. The Minister said he had spoken to them a week ago. We need it to be opened and we need beds and services for step-down patients to relieve the chronic conditions in South Tipperary General Hospital, which is one of the worst hospitals in the country, according to the nurses, for trolleys, people on chairs and ambulances backed up. It is breaking point for the front-line staff there and the management. We need to make the HSE managers agree to it.

Deputy Tony McLoughlin

I am led to believe that there are very few child neurologists in the country. What are the plans for employing additional child neurologists? Could the Minister take this opportunity to confirm that he will visit Sligo University Hospital and other establishments in Sligo in the near future, if it is possible?

Deputy Simon Harris

I am confused that Deputy Billy Kelleher is confused as to what the Government's policy is. It has been the same since the Government came to office. We are going to try to do what we have never done before regarding the health service, namely, agree on a cross-party basis what the structure of the health service should be. We all agree it should not be exactly as the HSE is. We all agree it has dysfunctional elements and we all agree it must be improved.

Putting the hospital groups on a statutory footing and giving them autonomy makes a lot of sense. This is what I would like to see underpinned in legislation. However, this is a minority Government, and to pass any legislation on HSE structures will require support. This is why it is over to this Oireachtas, including my party, to refuse to play party politics with the structures. I am not suggesting the Deputy is. When the report is published in April, I hope to see the structures every party wants. Then let us put them into law in the House as quickly as possible.

Deputy Mary Butler was right to highlight the two issues of orthopaedics and ophthalmology in University Hospital Waterford. She has, on a number of occasions, made me aware of the length of these waiting lists. We will have a target that no patient will wait longer than 15 months for any procedure, including those, by the end of October. Let me see if any more can be done about it in the context of the HSE waiting plan.

I agree with Deputy Mattie McGrath on Cashel. We do not need fiefdoms in our health service. The idea that Clonmel is under pressure while Cashel is not doing enough is unacceptable. The Deputy mentioned money being spent. None of that happened on my watch. On my watch, additional services will be provided in Cashel.

Deputy Mattie McGrath

Step-down beds.

Deputy Simon Harris

We need to see exactly what we can do. More services will be provided in Cashel to help alleviate the pressure on Clonmel, in addition to the works the Deputy knows I intend to carry out in Clonmel. I would be delighted to visit Sligo hospital and talk about the health service issues there with Deputy McLoughlin in the coming weeks. I will revert to the Deputy on paediatric neurology.

Deputy Aindrias Moynihan

The NTPF was much discussed last year and funding was put in place in the budget. January and part of February are gone. Have people received treatment through the NTPF yet this year? If not, why not? There were several months of lead-in and preparation. Is the NTPF the type of funding that could be used to open the unused theatre in Cork University Maternity Hospital?

Deputy Simon Harris

The funding provided to the NTPF in the budget became available to it on 1 January, when it started its tendering process. Patients will receive their procedures through the NTPF starting in March and 2,000 people will benefit from it. The NTPF did not have a ring-fenced budget until the first day of 2017. However, it has moved ahead on it.

Deputy Aindrias Moynihan

It would have had a number of months of a lead-in when it knew the money was coming and would have had the opportunity to prepare for it.

Deputy Simon Harris

The Deputy is correct.

Deputy Aindrias Moynihan

It would release those people on to theatre and not have them sitting on waiting lists.

Deputy Simon Harris

That is why we have already made sure the National Treatment Purchase Fund, NTPF, knows its allocation, not just for this year, but for 2018 of €55 million to ensure it can immediately start processing that to ensure there are no gaps.