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Dáil Éireann debate -
Wednesday, 8 Mar 2017

Vol. 942 No. 1

Priority Questions

Legislative Reviews

Billy Kelleher


14. Deputy Billy Kelleher asked the Minister for Health his plans to review the Health (Amendment) Act 2013, specifically in respect of its impact on the hospital sector. [12346/17]

Deputy Billy Kelleher has 30 seconds to introduce his question if he so wishes - or does he wish to catch his breath?

I am in training so my oxygen levels are not too bad.

Does the Minister have any plans regarding the Health (Amendment) Act 2013, specifically in respect of its impact on the hospital sector and the concerns about the treatment of private patients in public hospitals? I know he has made an announcement since I tabled the question.

I thank Deputy Kelleher for this question. I acknowledge the Deputy has raised the issue with me previously in the Oireachtas Committee on Health and when we were considering the Health Insurance (Amendment) Act. I acknowledge his interest in the issue and wish to put a little information on the record of the House on the policy rationale behind this when it was originally put in place.

As the Deputy knows, although a proportion of activity in public hospitals involves the provision of care to private patients, the core purpose of our public health system is obviously to provide services for public patients. Government policy is to ensure that there is equitable access for public patients, that the proportion of private activity is appropriately controlled and that the costs of provision of services to private patients are recouped by public hospitals. It is important to note that when patients are admitted to hospital, they can choose whether to be treated as private or public patients.

The Health (Amendment) Act 2013 provided for the charging of all private inpatients. The Act addressed a situation identified by the Comptroller and Auditor General in his 2008 report whereby when a private inpatient was accommodated in a public or non-designated bed, no private inpatient charge applied. The report of the Comptroller and Auditor General noted that in 2008, 45% of all private inpatient throughput was not the subject of a maintenance charge because the patient was accommodated in a designated public bed. A further 5% was not charged for because the patient was accommodated in a non-designated bed, with the result that only 50% of private inpatient throughput gave rise to any maintenance charge at all. This was despite the fact that due to treatment costs, the type of room in which a patient is accommodated is by no means the major contributor to the overall costs of a hospital stay.

The absence of a maintenance charge in such instances represented a significant loss of income to the public hospital system and to taxpayers - I think this was generally accepted by many parties at the time - and was an indirect subsidy to private insurance companies, which cover most private patients. The additional income generated as a result of the enactment of the 2013 legislation is a key element of the funding to the public hospital system and any curtailment of this funding stream would put pressure on the taxpayer to maintain services.

I intend to review this, as the Deputy knows, and I will outline in my next response what I intend to do in this regard.

I welcome the fact that there will be a review, which we requested. There are concerns about this. It has been brought to my attention by some health care providers in the private sector that there is now competition in certain areas in trying to attract private patients and treating them on public beds. The concept of the 20% designation in public hospitals with treatment of private patients was originally a historical hangover from the time when it was a sweetener given to retain consultants we were unable to pay to keep them in service. However, subsequently, this has been breached continually, and it is not just me saying this. The bottom line is that Mr. O'Brien, the director general of the HSE, said that the 2013 Act has made a farce of the application of the rules restricting the level of private practice senior doctors can carry out in public hospitals. In an e-mail to the Minister's predecessor, the director general said large voluntary teaching hospitals were in some instances breaking the rules in how they went about recruiting consultants in the context of attracting and being able to guarantee that more than the 20% of private patients would be treated in public beds. Overall, we could now have private patients receiving preferential treatment, and more of them receiving preferential treatment ahead of public patients, to bolster hospital budgets.

That is absolutely not the policy intention, and Deputy Kelleher's assertion in this regard is one of the reasons I have instructed my Department to carry out a review. I have asked the Department of Health to conduct an analysis of trends in private activity in public hospitals since the Health (Amendment) Act commenced in 2013 and I intend then to review policy changes at that stage as well. As the Deputy was already aware when he raised this important matter with me at the Oireachtas health committee, I have undertaken to share this analysis and policy review with him when it is completed. My concern is not for the health insurance company but for the impact on premiums, which I know is the Deputy's concern as well. However, health insurers have expressed some important and legitimate concerns about the use of the private insurance patient form at a hospital level, in particular the manner in which patients are being requested to waive their right to be treated as public patients. It is accepted that there is a need for a consistent and clear approach at hospital level as to how the private insurance patient forum is presented to patients. In this regard, the HSE and the insurance industry will now meet. They have started an engagement, a series of meetings about this, to consider how the forum may need to be reviewed and in what circumstances it should be used. If a vulnerable sick patient is on a hospital bed or waiting in an emergency department, merely waving a form at him or her is not appropriate; there needs to be a clear and consistent protocol in place.

One should never ask the fox to carry out an inspection of the fence around the hen house, but that is what the Minister is doing in respect of the Department of Health on this occasion. It is a policy decision of the Department of Health to bring forward the 2013 Act, which allows for a designation of all beds in public hospitals for private patients. There is no doubt, even in the context of budgets being forced on hospitals, that there are now stretched budgets, which have effectively been put in place to force hospitals to maximise the number of private patients going through their hospitals for billing purposes and to bolster budgets. Stretched budgets are in their stated policy. We have asked all the hospitals about this but they all deny that this is what a stretched budget is. However, we know for a fact that the stretched budget primarily entails private patients being treated in public hospitals, and there is concern about this. I do not have any truck with the private health care providers; my representation here is on behalf of public patients who are potentially waiting longer to access treatment because beds are full of private patients in public hospitals.

I accept the Deputy's bona fides on this but he must also accept that the 2013 legislation came from the Comptroller and Auditor General’s report of 2008, which pointed out that there was a significant lacuna in the law, which was making it effectively impossible for up to 50% of any potential charge to be collected by the public health service. We would all share the view that the priority must be to invest in the public health service. If there was a possibility that private health insurance companies were not picking up their portion of the tab, that needed to be addressed legislatively and that was the decision of these Houses at the time.

The question that now arises is whether the policy is being correctly implemented, whether the way forms are administered in hospitals regarding waiving a patient’s right to be treated as a public patient is consistent and co-ordinated across the hospital system. From talking to the insurance industry I do not believe it is. That is why I have asked the HSE to meet the insurance companies, hear their concerns and come back with a set of proposals on that. It is why I have asked the Department to carry out an analysis and review and why, very much to protect the Deputy from the fox, I intend to share that review with him.

Crisis Pregnancy Services

Louise O'Reilly


15. Deputy Louise O'Reilly asked the Minister for Health the progress that has been made by his Department, following his comments on 17 November 2016, to give consideration to ways of better protecting the public from certain crisis pregnancy agencies or counsellors that are providing information (details supplied); the resources that have been made available by his Department to do this; the status of legislation to tackle the issue of rogue crisis pregnancy agencies; the status of his Department's review of the Regulation of Information (Services Outside the State for Termination of Pregnancies) Act 1995; and if he will make a statement on the matter. [12348/17]

Last November, the Minister said he had asked his officials to give timely consideration to ways of better protecting the public from certain crisis pregnancy agencies or counsellors providing information that is neither truthful nor objective. I seek an update on that commitment.

I thank the Deputy for this question about an important issue which we debated in this House when Deputy Howlin tabled a Bill on this matter that received almost unanimous support. He wanted to make sure that women with crisis pregnancies received accurate and truthful information. We were all appalled by the reporting of Ellen Coyne at the time showing that was not the case and that there were rogue agencies in operation. The regulation of a new profession under the Health and Social Care Professionals Act 2005, involves a consultation process and the making of a number of statutory instruments by the Minister for Health and by the relevant registration board.

In September of last year, the Department engaged, at my instruction, in a formal consultation process in which interested persons and organisations were invited to formally submit their views on how the statutory regulation of counsellors and psychotherapists should proceed. A total of 84 submissions were received by the closing date of 30 November 2016.

I am undertaking an examination of these submissions which will inform the approach to be adopted in progressing the statutory regulation of psychotherapists and counsellors. I envisage that the next steps in the statutory regulation of the profession or professions under the Act will commence in the coming months with the submission of draft designation regulations to the Houses of the Oireachtas.

As the Deputy is aware, the Regulation of Information (Services Outside the State for Termination of Pregnancies) Act 1995 prescribes the conditions for making available information to pregnant women and the public about services lawfully available outside the State for the termination of pregnancies. During the Second Stage debate on the Health and Social Care Professionals (Amendment) Bill 2016, I undertook to have this Act reviewed by my Department to establish if its provisions need to be strengthened. This review is ongoing. For example, subject to the views of the Attorney General, it may be possible to amend this Act, and this is my gut feeling on the issue, to ensure that only registered professionals provide services under the Act. This might be feasible, as expected, if it is decided to proceed with the statutory regulation of counsellors. One goes hand in hand with the other.

Finally, the HSE has developed a quality framework for State-funded crisis pregnancy services. Under the crisis pregnancy programme, 16 such services are funded by the HSE and each is requested to comply with this framework under the terms of its service level agreement. Specifically on that Bill, engagement continues today between Deputy Howlin's advisers and departmental officials on how best to progress it.

In the glare of the media spotlight the Minister was very quick to say that the women of Ireland deserved better. Today is International Women's Day and as has happened on many of the issues relating to women I have raised today, the Minister says the women of Ireland might deserve better but they can wait. It is four months since the commitment was made to conduct the review. With the greatest of respect to the Minister's officials, all of whom I know are busy, this is a very serious issue. There are counselling agencies that offer good and appropriate advice to pregnant women but others do not. These agencies strategically target vulnerable women and need to be stopped. I agree with the Minister that the women of Ireland deserve better but they do not deserve to wait. They deserve better and they deserve it quickly.

Of course they do and that is why I am progressing this and why I accepted Deputy Howlin's Bill on Second Stage and why I have initiated the public consultation on regulation of counsellors or psychotherapists. I am very clear that we absolutely should. As a result of that consultation I have received 84 submissions which are being reviewed in the Department as we speak and I have already told the Deputy that I expect to be in a position to bring draft designation regulations to the Houses of the Oireachtas within the next couple of months to move on in respect of this.

One would imagine that, subject to the advice of the Attorney General, the most appropriate way to amend the Regulation of Information (Services Outside the State for Termination of Pregnancies) Act 1995 to make sure women have the protections the Deputy and I want them to have would be to make sure the information could be provided only by registered professionals. The registration has to be set up and that is what I am doing with the regulations and then the Act has to be amended.

Deputy Howlin's Bill is on Committee Stage. It is a matter for the Select Committee on Health and Deputy Howlin to decide when to move on that. I appreciate the fact that Deputy Howlin is doing that cognisant of the work going on in my Department and is engaging with the Department on the matter today.

Four months ago the Minister said he would ask his officials to give timely consideration to ways of better protecting the public from certain crisis pregnancy agencies or counsellors that are providing information that is neither truthful nor objective.

Maybe the Minister and I have different definitions of what we might consider timely. These agencies operate less than 1 km from where we stand and are offering terrified women incorrect, inaccurate and sometimes dangerous advice. I would have thought that timely consideration of a serious issue such as this would have come to some class of a conclusion before now, yet the Minister says it will be done in a couple of months. I put that in the same category as "timely". It is not a definitive framework.

At the time, in the glare of the media publicity and on the back of the good work done by Ellen Coyne everybody expressed outrage yet here we are four months on from this revelation, ten years on from the revelation in Hot Press and these agencies are operating, preying on vulnerable women and girls and we need to take serious action on this, not timely consideration or in a couple of months, in a while or women have to wait yet again, we need it now.

The Deputy's remark about the glare of media publicity is unfortunate. It attempts to divide and be partisan about an issue on which I do not think anyone in this House is partisan. No human being could but have been appalled-----

That was the context of the Minister's remarks.

I would appreciate if the Deputy did not conflate the time taken to formulate regulations and pass legislation through these Houses, in which the Deputy and her party have a role to play, with people's genuine responses to sickening behaviour. That is quite an important point.

The Deputy is making it sound like nothing has happened, for whatever reasons she wishes. If she actually listened to my answer, which I am sure she did-----

-----the HSE now funds 16 crisis pregnancy agencies and has put in place a framework to protect women and it is a condition of that funding that the framework is adhered to. The Deputy refers to ten years since the Hot Press revelation. I have been in office for ten months and the consultation is done. I will bring regulation to the House within months. We are going to move on this. The Deputy knows the process very well in respect of regulations, the Attorney General's advice and the legislative process. We will get this done and after decades or more of women waiting, they will not wait much longer.

Health Services Provision

Margaret Murphy O'Mahony


16. Deputy Margaret Murphy O'Mahony asked the Minister for Health his plans to address the absence of a dedicated specialist medical rehabilitation unit for persons with neurological disabilities in the south. [12347/17]

What are the Minister for Health's plans to address the absence of a dedicated specialist medical rehabilitation unit for persons with neurological disabilities in the south of the country?

I thank Deputy Murphy O'Mahony for raising this very important issue of neurological disabilities in the south.

The Health Service Executive's national service plan for 2017 contains a priority to finalise and progress implementation of the framework for the neuro-rehabilitation strategy.

Full implementation of the strategy will, of necessity, be a long-term project. The Department of Health has agreed with the HSE that the focus initially will be on implementation in the community, which is in keeping with the programme for Government commitment.

The HSE has committed to undertake a mapping and gap identification exercise for the country as a whole in order to establish a clear picture of where specialist rehabilitation services are being delivered and where demands for such services exist. The HSE's social care division and the rehabilitation medicine clinical programme will work together to form an action plan under the HSE's clinical strategy and programme division. A national steering group, which, importantly, will comprise stakeholders who represent all interested parties, will be responsible for the governance and implementation of the action plan.

The priority capital development at present is the delivery of replacement accommodation at the National Rehabilitation Hospital. The procurement of a contractor has commenced. It is projected that a contractor will be appointed in the second quarter of 2017.

It is acknowledged that further investment in rehabilitation services at acute hospital and post-acute and community levels is required to meet the ongoing needs of clients across the country, including in the south.

I understand the HSE's South/South West hospital group is considering the scope for developing regional specialist rehabilitation services in the south in line with the national model of care for the provision of rehabilitative medicine and the neuro-rehabilitation strategy. A group led by a UK-based consultant in rehabilitation medicine has been established by the hospital group to consider this issue. A report is expected to be completed later in 2017.

As the Minister of State is aware, there is a severe shortage of rehabilitation services in the Irish health care system for people living with neurological conditions such as stroke, acquired brain injury, multiple sclerosis and Parkinson's disease. It has been estimated that Ireland should have 270 inpatient beds to meet the needs of its population in this regard, but it has less than half of that number. There are no such beds outside Dublin.

Numerous reports have highlighted the critical need to provide a dedicated specialist rehabilitation unit to serve the needs of people in the south of our country. Patients from the south represent one in four referrals to the National Rehabilitation Hospital. Individual reports in 2000, 2003, 2007, 2008 and 2011 pointed to the need for a special medical rehabilitation service to meet the needs of people with neurological conditions in Cork and Kerry. One of the many recommendations made in the report on the configuration of acute hospital services in Cork and Kerry, which was published by the HSE in 2011, was that a consultant in rehabilitation medicine, shared between the HSE south and the National Rehabilitation Hospital, should be appointed. The report also recommended that there should be a new regional rehabilitation medicine service with formal links to the National Rehabilitation Hospital and a named clinical lead. I ask the Minister of State to comment on what I have said.

I accept the Deputy's point about the importance of investing in these services. I also take her point about the objective of having 270 beds. This is a priority for me because we have to meet the needs of the people. One of the priority actions in the HSE national service plan for 2017 is the establishment of an innovative pilot day service aimed at supporting people with severe acquired brain injuries. The inclusion of this action was informed by the meetings between the Minister for Health, the Department of Health and the HSE and the representatives of the An Saol project, for example. The head of operations in the HSE disability service wrote recently to a representative of the project to confirm that approval has been given for the progression in 2017 of a pilot initiative that will focus on the provision of therapies for people with severe acquired brain injuries. It is important to note that the HSE funds a large range of services across the country, including acute hospital services, the National Rehabilitation Hospital, a range of multidisciplinary services, a range of assisted living supports and rehabilitation training services. Of course, we must accept that this issue needs to be dealt with. The Minister, Deputy Harris, and I have made this a major priority for 2017.

The programme for Government includes a commitment to publish an implementation plan for the development of neuro-rehabilitation services in the community. Will the Minister of State give the House a commitment that the plan will provide what has been recommended for the south? In his initial response, he used the word "considering", which is really not strong enough. A firm commitment is needed. The 2011 report clearly highlighted that Cork and Kerry need an acute rehabilitation medicine service that can provide a post-acute specialist rehabilitation service for acquired brain injury and neurological diagnosis to people between the ages of 18 and 65. The report argued that this service should be led by a consultant in rehabilitation medicine linked to the National Rehabilitation Hospital in Dublin and supported by a regional rehabilitation co-ordinator and a multidisciplinary professional team, including a clinical neuropsychologist. The report specifically highlighted that the presence of specialists in rehabilitation medicine would be of considerable benefit to the health service in Cork and Kerry.

We have to ensure that services are not just focused in one or two regions. We need to have a national service. I take the Deputy's point about the implementation of the plan for Cork and Kerry. It is important to note that although Acquired Brain Injury Ireland works mainly with adults between the ages of 18 and 65 whose main disability is an acquired brain injury, it is also involved in the development of pilot projects providing services for children and runs parenting programmes in Dublin for the parents of children with acquired brain injuries. Headway Ireland provides a range of services to people with acquired injury between the ages of 16 and 65, including day services, psychology and social work services, community integration programmes, employment and family supports and rehabilitation training places.

It is important for further investment in rehabilitation services to be considered in the context of the overall acute hospital rehabilitation medicine infrastructure programme. The needs of the hospital group will be prioritised within the overall capital envelope available to the health service. Such issues are important. The Department of Health will work with the HSE and the Department of Public Expenditure and Reform during 2017 to conduct a mid-term review of the capital programme.

Abortion Services Provision

Ruth Coppinger


17. Deputy Ruth Coppinger asked the Minister for Health his views on allowing access to abortion in circumstances in which a woman's physical or mental health is at risk; and if he will make a statement on the matter. [12199/17]

On International Women's Day, I want to ask the Minister whether he thinks women's health matters as much as men's health in this country. If so, he must have been shocked by a recent report drawn up by a professor of psychiatry at Trinity College showing that women's mental and physical health is being affected by the ban on abortion in this country. Does the Minister intend to hasten the process of enabling women to access abortion in this country on health grounds?

I think we have significant specific women's mental health issues in this country. As the Deputy probably knows, the National Women's Council of Ireland and Trinity College made a successful bid to host the World Congress on Women's Mental Health, which is taking place in the RDS this week. The Deputy is familiar with my position and that of the Government on how to deal with the eighth amendment. This position has been adopted by the House.

The Protection of Life During Pregnancy Act 2013 regulates access to a termination of pregnancy if a pregnant woman’s life, as distinct from her health, is at risk from a threat to her physical or mental health.

The principal constitutional issue dealt with in the Act is the right to life of the unborn with due regard to the right to life of the mother as set out in Article 40.3.3° of the Constitution.

The effect of this article is to prohibit abortion in Ireland subject to exemption where the life of a pregnant woman is at risk. The 2013 Act does not confer new rights to termination of pregnancy, but clarifies existing rights. As the Deputy knows, a referendum would be required to broaden the scope of the 2013 Act.

Any proposed change to Article 40.3.3° of the Constitution requires careful consideration of the policy and legal issues involved. The removal of the current constitutional protection of the life of the unborn would have significant implications for the law. This would require questions to be answered about our existing laws and, most importantly, the future legislative framework which would apply.

Accordingly, the Government established a Citizens' Assembly in line with the programme for Government. The assembly, which is chaired by Ms Justice Mary Laffoy, is discussing the issue of the eighth amendment over a period of five weekends. I followed its very intensive engagement last weekend. A report setting out the assembly's recommendations on this matter is expected to be presented to the House in the first half of 2017.

I look forward to the outcome of the Citizens' Assembly's detailed examination of this issue and to participating in the arrangements by the Oireachtas for consideration of the assembly's proposals.

The Deputy knows I believe we need a referendum on the eighth amendment but I also know we need a majority to get any constitutional referendum passed. The Citizens' Assembly is playing an important role in this regard.

The Deputy is the Minister for Health.

Is he concerned the Citizens' Assembly has not even got around to discussing abortion on the grounds of health after four meetings? Has he done anything about that? When does he believe it will get around to discussing it? It will be five years since the death of Ms Savita Halappanavar in October and we still do not have abortion for what led to Savita's death. Abortion does not exist in this country where a woman's health is at risk. Doctors gambled that her life was not at risk and it was only her health. This differentiation between a woman's health and her life is exceptionally dangerous. Why does abortion exist for health reasons in Burkina Faso, the poorest country on the planet, but it does not exist in a European Union state with same-sex marriage? There is only one reason, and it is because of cowardly politicians failing to legislate to protect women's lives and their health in this country, kowtowing to the Catholic Church for the past number of years. They have not challenged the amendment they pushed.

The Deputy may call politicians or previous Members of these Houses cowardly if she wishes but she would hardly call the Irish people cowardly. Whether I agree or disagree with their decision, it was the people of Ireland who inserted the eighth amendment into the Constitution.

That was over 30 years ago.

Quite frankly, I do not agree with it and we need a referendum on the issue. This was not just dreamed up on the floor of the Dáil but it was passed by the people of this country. It is not for me to discuss the legislative constitutional realities of any other country but the Deputy knows full well that if we want to change the Constitution of this country, we need 50% plus one to accept the proposal. I see the Deputy is wearing the "repeal the eighth" jumper, and the challenge for anyone who believes in repealing the eighth amendment will be to engage with the electorate and the citizens of this country on what would replace it. I know the Deputy has views and, in fairness to her, she put forward legislative ideas in this regard. We have seen there are significant different views in this country and they are different from mine and the Deputy's. I hope we have a referendum and I expect we will ultimately have a referendum. The Citizens' Assembly is doing good work and it is not for me to dictate what the Citizens' Assembly discusses. It is for all of us to expect it to report quite quickly to this House. That will happen and it is then for us to act on it.

I am wearing a "repeal" shirt and I hope the censorship that is ongoing with the camera work avoiding showing it will end. A side angle shot is being used. We should not censor the word "repeal" in the Dáil and people should be able to state it. I am wearing it because I have just been on O'Connell Bridge, where thousands of young people in particular and mainly young women are saying they will not wait. They are impatient because it mainly affects them. It is their generation of women of child-bearing age that is affected.

Does the Minister at least agree that banning abortion does not lessen it? In Holland, for example, with the most liberal abortion regime in the world, they have the lowest rate of abortion in the world bar none. The abortion pills mifepristone and misoprostol are used all over the world. They are used for 80% of abortions in Finland but a woman in Ireland will get 14 years in jail for accessing them online. Why is the Government intercepting them and preventing women from taking their chances online when it is not willing to legislate? It is just adding expense, stress, stigma, secrecy and shame. I see the censorship is ongoing. I do not know where the order is coming from but it is outrageous. When will the Minister speak to the Citizens' Assembly about discussing the issue of health as a ground for abortion in this country?

If I started dictating or directing the work of the Citizens' Assembly in any way, the Deputy would rightly be asking what I was doing interfering with the Citizens' Assembly, bringing my own views or those of the Government or anybody else to bear on it. The Citizens' Assembly is chaired by the very eminent Ms Justice Mary Laffoy and I trust it will do its work well. It has heard from an array of speakers and received a huge number of submissions, showing how emotive this issue is and the strong views that many people have in this regard.

I believe I agree with the Deputy's assertion that banning abortion does not lessen abortion. We must have a referendum on the issue. We must have a serious discussion, as I indicated in my reply, about what the legal framework will look like should the people of this country decide they wish to repeal the eighth amendment.

In the ten months I have been Minister for Health, we have had three debates in this House on the issue of abortion, the eighth amendment or matters linked to the Protection of Life During Pregnancy Act, including one last night. No matter how many more debates we have in this House, in the clear legal views made available to me by the Attorney General, the only way of changing this further would be constitutional change. We must wait for the Citizens' Assembly to report.

Health Services Expenditure

Joan Collins


18. Deputy Joan Collins asked the Minister for Health if his Department estimated that the health budget would need to be increased by 25% in 2017 to compensate fully for the austerity cuts made from 2009 to 2014 and to take account of demographic change; and if he will make a statement on the matter. [12341/17]

There have been two periods of cuts in health spending by the State from which the service has yet to recover. In the 1980s, the Fianna Fáil Haughey Government cut public hospital beds by 3,000, and this is still a key factor in the accident and emergency room trolley crisis. From 2009 to 2014, there were five years of cuts in the health budget and staffing numbers. This is against a background of a growing and ageing population with greater needs. According to the Department of Health, the budget in 2017 would have needed an extra 25% to compensate fully for the austerity cuts and demographic change, amounting to an extra €3 billion this year alone without any increase in eligibility criteria. Will the Minister make a statement on what will be done in this regard?

I always appreciate Deputies seeking additional resources for my Department and the health service. This Government is committed to prioritising the needs of those requiring health services in determining the annual budget and it will continue to prioritise those needs. This is evidenced by the provision of an additional €977 million in this year's allocation to the Health Service Executive, HSE, in comparison with the original allocation for 2016. The provision for 2017 represents a 3.5% increase on the final projected 2016 outturn and a 9.4% increase over the 2015 outturn position. That the funding provided for health is the highest ever clearly demonstrates the Government’s commitment to investing the gains from a recovering economy in a better health service.

The additional funding secured will continue to ease the pressure on the health service to provide the optimum level of safe services for patients within the budgetary limits. There will always be a need for effective management of overall resources, particularly as health care demands continue to rise due to our growing and ageing population, the increasing incidence of chronic conditions and advances in medical technologies, drugs and treatments.

The Deputy may be better informed than I am but having checked with my officials, I am not quite sure to what she is referring with a 25% budget increase. A 25% increase in the health budget would require additional funding of €3.5 billion in a single year, as the Deputy correctly notes. Such an increase in a single year would likely lead to a breach of EU fiscal rules and would also raise questions about the capacity of the health services to plan and recruit staff in the time available so as to manage this level of increased resources effectively. We are now back in an era of reinvestment in health and the Deputy is correct that there were a number of extraordinarily difficult years for the health service. The issue cannot just be about the level of investment and we must consider what we are doing. It must be about moving services to primary care, doing more in the community, the new GP contract we are currently negotiating with GP organisations, and bed capacity. The bed capacity review is under way and that will lead to a clear figure for the capital review. Crucially, this is about recruitment and retention of staff, as we currently do not have enough nurses in the health service.

The 25% figure came from a reply to a question put to the Department. Budget cuts were achieved through a variety of means over the austerity years. Staff numbers in the HSE were reduced from 111,000 to 99,000 from 2008 to 2015 and we are still reeling from that. Having listened to public health nurses last week on potential industrial action, I know they are absolutely crippled with work and cannot keep going. There were also cuts to pay. In the same period, home help hours for the elderly, disabled and sick went from 12.2 million to 8.3 million. Along with this, the cost of health care was shifted from the public purse to individuals, with increased charges introduced for accident and emergency visits and hospital stays and prescription charges introduced for medical card holders. A higher threshold was introduced for drugs for those who did not hold that card. All of this means that in 2013, citizens paid €450 million more for health in 2008. I am not asking the Minister to say he will produce €3 billion in a year but how will we bring ourselves back to the level we saw in 2008 and eliminate those out-of-pocket payments?

The Deputy is asking a reasonable question. We need to continue to invest and reinvest in the health service. We have made progress in that regard and I outlined that with the €977 million increase this year in comparison with the original projected budget from a year before. I am glad the Deputy raised the now deferred industrial action by the Irish Nurses and Midwives Organisation.

The Deputy is right. Our nurses believe there is a recruitment and retention challenge. So do I. That is why we had a very good engagement with the INMO and SIPTU at the WRC.

We have put in place a set of very good and innovative proposals that will help fill the 1,200 new nursing posts we want to deliver this year, including more than 120 advanced nurse practitioners, more midwives and staff to cover maternity leave - and today is International Women's Day - in what is a nearly all-female workforce. We have put in place a pre-retirement scheme to allow nurses aged 55 to 65 to choose to work part time rather than retiring. We have doubled the amount for the "bring them home" campaign. It was €1,500 for a nurse who returned from the UK. It will now be €3,000, €1,500 in the first 12 months followed by another €1,500, and we have extended it beyond the UK. We have much work to do after a lost decade for our public services. These are some of the areas in which we are trying to get progress.

I raised points around the cuts that have taken place during recent years. The Minister's Department states it needs €3 billion per year to bring us back to the previous level. The Minister knows we are in crisis regarding staff and staff retention. Before Christmas, the Minister tried a recruitment drive. It did not get the numbers he was hoping for. We have a crisis regarding people accessing surgery and lists being cut. I could name several issues, such as problems with access to the St. John of God Menni services. Basic surgeries and appointments are being cut, outpatient appointments are being put off and lists are being changed. The list goes on and on and people have completely lost faith in our service. I know people from Tallaght hospital, Cappagh National Orthopaedic Hospital and St. James's Hospital who have been waiting months for basic requirements. If we do not reinvest money in our health services where it is needed, this will continue and there will be no fruits from the cuts nurses endured during the past five years.

The era of cuts to the health service and public service pay is over.

We are in a worse situation.

Will it take us time to get to where we need to be? Absolutely, but the era of Ministers for Health being obliged to stand in this position and cut health services due to the financial situation is over. We are increasing the health budget and staffing levels and are putting money into waiting list initiatives. In the House later tonight we will pass legislation to provide domiciliary care allowance medical cards for approximately 10,000 children with disabilities. We are recruiting again. During the three days at Christmas which the Deputy spoke about, we hired 115 new nurses. This year, we have a target of 1,200. Because of the talks we had with the INMO, we have a much better set of proposals to try to attract those nurses.

We are reducing prescription charges for people over the age of 70 with a medical card and their dependants, which means 390,000 people will see a real difference when they go to the pharmacy each month. We must do more about it. As we all know, it is not just an issue of funding. If it were an issue of funding, some of the issues the Deputy is raising would not have existed during the Celtic tiger era. It must be about how we deliver the service, the work of the Oireachtas Committee on the Future of Healthcare and moving to primary care. I do not deny that there is a major challenge and a huge amount of work but these are the steps we want to take.