Dáil Éireann debate -
Tuesday, 8 May 2018

Vol. 968 No. 6

Health Service Reform: Motion [Private Members]

Deputy Michael Harty

I move:

That Dáil Éireann:

recognises:

— that it has been 12 months since the publication of the cross-party consensus report by the Committee on the Future of Healthcare entitled 'Sláintecare Report', regarding reform of the health service over a ten-year period into an effective and efficient health service;

— the failure of Government to deliver a response to the 'Sláintecare Report' in spite of committing to do so by December 2017;

— the failure of Government to develop a new funding model for the health service including multi-annual budgets to deliver universal healthcare;

— the failure to fulfil commitments in the Programme for a Partnership Government to:

— reduce waiting lists and overcrowding in our hospitals;

— provide new contracts for consultants and general practitioners;

— recruit additional nursing staff to support increased bed capacity;

— reduce delayed discharges; and

— introduce hospital avoidance measures;

— the failure of Government to develop the Emergency Aeromedical Service (air ambulance) and its extension to a night-time service;

— the failure of Government to develop a humane approach to the provision of discretionary medical cards to those who are undergoing treatment for cancer and end-of-life care;

— the failure of Government to fully implement the strategy document 'A Vision for Change', including building capacity into Child and Adolescent Mental Health Services (CAMHS), the provision of counselling and psychological services in primary care, and fully populating community psychiatric teams;

— the lack of equal opportunity and quality of life for people with disabilities by the failure to implement personalised budgets together with a comprehensive employment strategy to aid independent living and social integration;

— the failure of Government to legislate for a statutory scheme for home care, to enable our elderly population to live within their community;

— the important role that carers play in maintaining family members at home, supporting their needs by providing respite services, financial support and disability services;

— that acute hospital bed numbers, hospital consultant numbers and general practitioner numbers per head of population are below the Organisation for Economic Cooperation and Development (OECD) average and need to be increased to meet that average;

— that Emergency Department services are struggling to meet the increased demands for acute and complex care, particularly given our increasing population and ageing profile, and waiting times for out-patient assessments continue to grow and waiting times for elective and planned surgery are unacceptably prolonged; and

— the lack of coherent comprehensive planning to address these issues, lack of governance and accountability to underpin meaningful reform and lack of statutory requirements to meet acceptable targets, for waiting times and annual performance targets as committed to in the Programme for a Partnership Government; and

calls on the Government to:

— work towards the 'Sláintecare Report' proposal for a universal single-tier public health service based on need, not on the ability to pay;

— ensure a coherent implementation plan is immediately actioned to address the increasing lack of capacity and unmet need in our health service;

— immediately introduce legislation to ensure the delivery of entitlements to services on a phased, income-based criteria until universal public access is achieved;

— deliver expanded entitlements on income grounds only when capacity is available to deliver services;

— ensure immediate actions are taken to address recruitment and retention of front-line staff by improving working conditions, career progression and job satisfaction;

— work towards expanding diagnostic service availability to seven-day access, for both in-patients and out-patients, to speed patient diagnosis and treatment in a timely manner;

— immediately provide resources and recruit staff in order to open beds in hospitals which have been closed during austerity years;

— immediately commence a building programme to expand bed capacity to reach the OECD average per head of population in order to eliminate overcrowding and deal with unmet need;

— immediately complete negotiations on a new modern contract with general practitioners which recognises their central role in delivering prevention, health promotion and continuing care in the community;

— immediately enter negotiations on a new consultant contract, to recognise their value and role in delivering public care in our public hospitals;

— recognise the value of fostering and encouraging our nursing staff by improving working conditions, promoting career progression and further education;

— commit to meaningful and continuing health reform to take into account the continuing changes that are developing in modern medical practice;

— review the de-congregation model of care as it is clear that a one-size-fits-all model of care is not adequate; and

— establish that all service users who have been transferred from congregated settings to independent living are progressing positively.

The purpose of the motion is to examine progress to date on health reform. It is two years since the formation of the Government on 6 May 2016 yet here we are on 8 May 2018 with no meaningful reform in our health service. The establishment of the Committee on the Future of Healthcare was viewed as a positive expression of the Government's interest in reforming our health service. One year after the committee published its report on 30 May 2017, however, the Government has yet to respond to it, never mind implement any of its fundamental recommendations. The report recommended: the development of a single-tier health service, delivered on the basis of need rather than ability to pay; the initiation of a fundamental shift of emphasis towards primary care; commencement of the integration of primary, secondary and tertiary care services; and legislation to ensure accountability and answerability in the management of our health service. The need to guard against implementation deficit was recognised by the committee, which committed a full chapter of its report to the subject of implementation. We recognised that an extremely important component of Sláintecare was that it should not languish, as so many health reports have, without implementation.

Health reform is not optional; it is essential. Sláintecare is a once-in-a-lifetime opportunity to tackle the disjointed and fragmented nature of our health service. Sláintecare talks about fundamental cultural change, not only in our health service but within the Department of Health, the HSE and all of its layers of management. The Minister, however, has failed to act to implement any meaningful health reform. He will be remembered as the Minister who had a plan but did nothing about it. So many of his predecessors had no plan. They did not have the luxury of a cross-party committee report produced following 11 months of sittings to deliver a blueprint for healthcare reform. He is the only Minister who has had that luxury but he has not acted on it in any meaningful way. I accept that Sláintecare is challenging to the health institutions of the State, the Department of Health and the HSE. They cannot cope with the challenge Sláintecare presents.

I am afraid that, rather than implement Sláintecare, the Government has spent the past year moulding it to suit its own policy. Sláintecare, however, recommended that Government policy should change. Sláintecare's recommendations on reform are far broader and wide-ranging than existing Government policy. The Minister must accept that we need fundamental change in how we run our health services. That is something which goes way beyond Government policy. The Government is taking over the implementation process to suit its own objectives rather than setting up an independent implementation body to develop the implementation plan Sláintecare recommends. This is contrary to the vision of Sláintecare. The Government is deconstructing Sláintecare to suit its own policies. That was never the intention.

We accept that many areas of the health service work well. However, those excellent areas work in isolation and there is no uniformity across the health service. Many areas of the health service struggle to prosper and deliver quality care. This is because management structures in the HSE are disjointed and dysfunctional. The most fundamental legislative provisions required include provisions to reinstate the HSE's board. A slimmed-down board would provide proper governance. One year after the publication of Sláintecare and seven months since the Taoiseach announced in the Dáil that he would reconstitute the board, the legislation has yet to come forward. It is one of the most fundamental underpinnings of Sláintecare.

The health service should not be about process, it should be about the patient. The difficulty we have is that our health service is all about process while the patient gets lost in the bureaucratic procrastination of that service's decision-making. The HSE has too many managers and too few leaders. The Minister has heard this on many occasions I am sure. One of the prospective candidates for the position of HSE CEO looked at it and declared it to be overmanaged and under-led. That is a fundamental issue. To make an analogy, our health service is like a Swiss watch in that it has many moving parts. All of those parts must be interlocked so that they move in unison, otherwise one does not get the correct time. We have a disjointed and dysfunctional health service which is not delivering to its full potential. The lack of integration is the problem and inhibits the delivery of quality services.

Taking the CervicalCheck scandal as an example, one sees how a lack of open disclosure, governance and leadership have led to the problem. This is at the core of so many of our health service's problems. We do not have proper governance and leadership. Too many layers of management get in the way of correct and logical decisions. Tied up in endless bureaucracy, the process trumps the patient who gets left behind. In addition to mandatory disclosure legislation, we need mandatory accountability legislation to guarantee accountability regarding decisions in the health service. People must be answerable for the decisions they make. We must create a proper management infrastructure to underpin a new and reformed health service. Legislative changes creating statutory powers, statutory targets and statutorily underpinned quality assurance will not cost money. They will not be a charge on the State. Rather, they will be the fundamental framework on which our health service is built. That legislation is outlined in the Sláintecare report but it has not been discussed or introduced in the House.

The development of a GP-led primary care service is critical to the development of Sláintecare. The countries with the strongest primary care services have the least pressure on their secondary services, shorter waiting lists and better outcomes for patients. This is critical and one of the fundamental recommendations of Sláintecare. We talk here about GP-led primary care teams. If we had those, we could keep people out of hospital and treat their chronic disease conditions within the community. The benefit would be the release of pressure on secondary care. Failing to invest in primary care makes no economic sense. We must concentrate on those who need the most care.

People spend less than a fraction of 1% of their time in hospital, yet the hospital service consumes most of the budget. I am not proposing that we take money away from the hospital service, but we must develop our primary care services. They attract 4% of the budget. It should be at least 10%, as is the case in other European countries. In the committee we often spoke about the inverse care law - the people who need the care most get it least. The Minister must take a fundamental look at how our health services are structured in that regard.

Austerity was universally applied across the health service and the public service, but the unwinding of austerity and of the Financial Emergency Measures in the Public Interest Act, FEMPI, has been uneven and unfair, particularly with regard to general practice and primary care. It was applied to other services, of course, but it was disproportionately applied to general practice. If the Minister allows general practice to wither on the vine he will reap as a reward a huge cost in secondary and tertiary care by not supporting primary care.

We must speak about recruitment of doctors and nurses, the retention of those staff and look at the reasons for the issues there. They have very poor working conditions. They are educated in a system that is very poor and which does not offer them career opportunities and career progression. They are the reasons staff are leaving the country. It is not because of pay, although pay is important. The average trolley count in 2013 was 247. It increased to 310 and last year it was 396. All the measures the Minister has instituted have not affected the trolley crisis. It is a crude measurement of the quality of our health service but it is a real-time measurement.

The Minister must address health reform. I hope to hear in his response to the motion how he will address it, how quickly he will do so and how urgently he is undertaking it.

Deputy Noel Grealish

I am delighted to have the opportunity to speak on this motion on healthcare. I thank Deputy Harty and Mairéad in Deputy Mattie McGrath's office for drafting the motion. I will take this opportunity to once again put forward an effective solution to address a major problem in Galway. I firmly believe that a minor injuries unit in the grounds of Merlin Park University Hospital would significantly reduce congestion and overcrowding at the accident and emergency department in the hospital. One can hear most mornings on the local radio station, Galway Bay FM, of how chronic the situation there is at times due to overcrowding at the emergency department in University Hospital Galway, UHG, particularly with people on trolleys. It has passed its worst record ever. A minor injuries unit would help to alleviate the pressure on the emergency department in Galway.

Last month, when I raised the possibility of a minor injuries unit at Merlin Park in Galway, the Taoiseach said it was a good idea and that he would appraise it further and discuss it with the Minister for Health, Deputy Harris, and the HSE. This should be done as a priority. Since I raised this on Leaders' Questions I have been informed by reply to a parliamentary question that people with minor injuries now face an average wait of five and a half hours from the time they are first registered to when they are discharged from the emergency department at University Hospital Galway. This compares with less than one hour at the minor injuries unit attached to Roscommon University Hospital. I compliment the staff in that unit in Roscommon. It is working exceptionally well, despite all the bad publicity when the emergency department was closed, which is why I believe there should be a similar unit in Galway. The fact that it takes six times longer to be seen, treated and discharged for a minor injury in an emergency department shows the need for a unit at Merlin Park to handle the minor injuries that currently take so much time to deal with in the emergency department.

Chronic parking congestion at the hospital is also a major problem. It frequently causes people to miss appointments. I have called for a designated parking spot to be established for people who have appointments in UHG, particularly cancer patients, but it has not happened. People have to leave the car outside, bring an elderly loved one to the unit where he or she is to be treated and run back out again and try to park the car. These people might have come from as far as Mayo, Sligo and Donegal. That issue must be addressed.

The number of people seeking treatment at the emergency department in UHG increased last year to a total of 62,355. At present, only one in four people coming to the emergency department in Galway end up being admitted to hospital, so the majority of cases could easily be handled in a minor injuries unit at Merlin Park. Consider how that would transform the picture at the overcrowded emergency department in UHG, where staff are working under enormous pressure in a unit that is universally accepted as unfit for purpose. A minor injuries unit for Galway is a no-brainer, regardless of what plans there are for new facilities. There are 11 minor injuries units operating successfully throughout the country that can handle everything from broken bones, lacerations, strains and sprains to minor scalds and burns. They are open seven days per week from 8 a.m. to 8 p.m. Last year the unit in Roscommon treated more than 6,000 patients. That unit is staffed by a small number of competent staff overseen by a consultant physician and an advanced nurse practitioner.

I acknowledge there are plans for a new emergency department at University Hospital Galway, but this project is still at design stage. A new facility is still many years away. The Minister recently informed me that an elective hospital plan for Merlin Park is a long-term plan and that with a ten-year plan many proposals, including an elective only hospital, are at a very early stage. It could be ten, 15 or 20 years away while the minor injuries unit could be up and running by the end of the year. If we could bring the people with scalds, burns, strains, lacerations and broken bones to a minor injuries unit in Merlin Park it could reduce the number attending UHG emergency department by tens of thousands. It would free up parking and take the pressure off the staff, allowing them to deal with emergencies and more serious cases. The Taoiseach admitted that this could be put in place relatively quickly and that the minor injuries units that work in other parts of the country should also work in Galway.

I call for support for this motion and I call on the Minister to work with the HSE to try to provide a minor injuries unit in Merlin Park University Hospital without delay.

Deputy Michael Healy-Rae

I thank Mairéad, David and Deputy Harty for preparing this Private Members' motion, which is both important and timely. I wish to discuss a number of the problems but I also wish to discuss solutions. First, I will concentrate on County Kerry. I have had meetings with the Minister in the past regarding University Hospital Kerry working in conjunction with the Bon Secours Hospital in Tralee. It is a unique situation where two hospitals are located within a stone's throw of each other. I compliment the management and staff in both hospitals because there have been improvements and there is more working together. However, we must enhance and grow that.

We must change the way people are admitted to our hospitals. It is absolutely insane that the emergency department is the only way a person can be admitted today to University Hospital Kerry. Take the example of a doctor attending a person and telling that person he or she must go to the hospital because it is a hospital case. That person has been assessed by the GP and the GP, in his or her expertise, has diagnosed what is wrong and what care is required. However, the person must then go and queue in the accident and emergency department.

The Minister knows as well as I do that it is not unknown to have to wait for 70 hours in an emergency department. That is in no way the responsibility of the people working in the hospital. I have visited emergency departments at odd times during the night and I have been told by the people working there that they are under unreal pressure. They are working flat out. They continually say, "For God's sake, talk to the Minister and use influence with the HSE to try to get them to see common sense."

An admissions department is where many people should be admitted. That is why it says "Admissions" over the door. Emergency departments are for accidents and emergencies, people who arrive in a bad way or are brought by ambulance and need urgent assessment, triage, X-rays and other procedures. This has been pointed out to the Minister previously. What has he asked the HSE to do about it or what has been done? Nothing has been done. A great deal was promised in the programme for Government. The Minister was a diligent participant in that negotiation. He genuinely put his shoulder to the wheel for 70 days and I have no problem complimenting him for that. However, what has happened since? Our health service and the delivery of that service have worsened and become a shambles.

I wish to speak about our community hospitals in County Kerry. We have community hospitals in Kenmare, Dingle and Cahersiveen. We definitely need a new community hospital in the great town of Killarney. I want to see this progressed. I want to see a shovel put into the ground. Killarney is a growing town in that the population doubles or trebles in the summertime. It is definitely deserving of a new community hospital. The existing hospital is great in that the staff and management are doing their very best, but they need a modern hospital and extra beds, just as we need extra beds opened in Kenmare and Dingle. There is a strong case to be made for Kenmare and Dingle because of our ageing population. If the HSE is to be serious, proactive and forward-thinking, it should consider extensions to those hospitals, even though they are new hospitals, to allow for future growth of the ageing population.

HIQA has an awful lot to answer for. The Minister was not the creator of HIQA; others were. At this stage HIQA is definitely an out-of-control monster. We must have regulations and standards, but there is such a thing as standards gone crazy and people running away with themselves. People involved in the management of hospitals have highlighted to me that what HIQA is engaged in at present is neither right nor proper.

Regarding the management of the HSE, we have layer upon layer of bureaucracy and it is failing us. We see psychiatric nurses who are fully qualified and who want to work in County Kerry. I highlighted this to the Minister today and he said he was delighted to be in a position to offer full-time employment to nurses. We have qualified psychiatric nurses who want to come-----

An Leas-Cheann Comhairle

I ask the Deputy to finish up.

Deputy Michael Healy-Rae

-----to County Kerry but who are being told they cannot. At the same time, we need them.

An Leas-Cheann Comhairle

I ask the Deputy to finish up.

Deputy Michael Healy-Rae

The spaces and the work are there for them but they are being told they cannot.

Finally, just one word-----

An Leas-Cheann Comhairle

The Deputy is infringing on others' time.

Deputy Michael Healy-Rae

I would like just one word on the cross-Border initiative. It is crazy to think we can pay for procedures in the North-----

An Leas-Cheann Comhairle

The Deputy is infringing on someone else's time.

Deputy Michael Healy-Rae

-----and we cannot carry them out ourselves here.

Minister for Health (Deputy Simon Harris)

I move amendment No. 1:

To delete all words after “Dáil Éireann” and substitute the following:

“acknowledges:

— the historic cross-party consensus that has been achieved by the Committee on the Future of Healthcare and that the ‘Sláintecare Report’ now provides an agreed vision and framework for achieving healthcare reform over a ten-year period;

— that the demand for nearly all health and social care services is growing as a result of overall population growth and an ageing of our population (60 per cent growth projected in the 65 plus population over the period 2016 – 2031) as demonstrated by analysis from the Economic and Social Research Institute (ESRI) last year and the Department of Health’s, Health Service Capacity Review 2018;

— the challenges that many patients, service users and their families are experiencing in accessing timely care, and the difficulties being faced by healthcare professionals who are doing their utmost to provide safe, quality care to as many people as possible;

— that the Health Service Capacity Review 2018, recognised the need for both investment in additional capacity and healthcare staff, and a programme of whole-system reform over the next decade to modernise and improve our health services to meet current and future healthcare needs;

— that the Government has committed a record level of €10.9 billion in the National Development Plan 2018-2027 to the health sector over the coming decade;

— that the Government has increased funding for health services each year since 2013, totalling a 19 per cent increase over the period, and that the Programme for a Partnership Government commits to sustain these increases;

— that robust performance management and accountability arrangements are an essential component of any healthcare system; and

— that delivering real and sustained improvement in our health services continues to be a priority for the Government; and

supports continued cross-party cooperation and consensus on the vision and direction of travel for health policy outlined in the ‘Sláintecare Report’, including the following commitments:

— put in place a programme of reform arising from the ‘Sláintecare Report’, this follows actions already taken to advance recommendations in the report:

— a Sláintecare Programme Office will be established and the recruitment of an Executive Director is almost complete;

— an independent expert group is undertaking an impact assessment of separating private practice from the public hospital system; and

— draft legislation will be brought forward this year to establish a governing board for the Health Service Executive (HSE);

— publish the Sláintecare implementation plan in the coming weeks which will set out a clear roadmap for delivering on the Sláintecare vision of a universal single-tier public health service based on need, not on the ability to pay;

— invest in additional capacity in line with the National Development Plan 2018-2027, which includes provision for 2,600 acute hospital beds including three new elective facilities, 4,500 community care beds, diagnostic hubs in the community and the rollout out of eHealth infrastructure across the health system, and work is underway to identify the number and location of additional beds that can be opened and staffed in 2018 and into 2019;

— continue to develop comprehensive primary and community care services with a number of investments and initiatives being pursued including:

— continued roll-out of primary care centres, with 114 now fully operational across the country, six of which opened in the first quarter of this year with a further fourteen scheduled to open this year;

— additional funding of €25 million for primary care services, including an expansion of Community Intervention Teams which will help to prevent unnecessary hospital admissions and facilitate early discharge of patients;

— the engagement process to develop a new, modernised contract for general practice has commenced which will have a population health focus, providing in particular for health promotion and disease prevention and for the structured care of chronic disease;

— the number of General Practitioner (GP) training places has been increased from 120 in 2009, to the current 194 places available in 2018; and

— the commitment of Government to develop a new statutory scheme for the financing and regulation of homecare services, to enable our elderly population to live within their community;

— provide improved care and services to our most vulnerable in society as a central component of overall health policy and delivery, and initiatives include:

— legislation will be brought forward this year to provide GP Visit cards to those in receipt of Carer’s Allowance or Carer’s Benefit, benefitting approximately 14,000 persons;

— increase in the number of discretionary medical cards in circulation, from 52,000 in mid-2014 to 135,728 on 1st April, 2018;

— over 182,000 respite nights and over 42,500 respite day sessions will be provided this year, with an additional €10 million provided by Government to establish twelve extra new respite houses;

— in line with national policy and international best practice, there are now less than 2,400 people living in a congregated setting, with 170 more people expected to move to community living in 2018;

— a taskforce has identified how personalised budgets can be introduced in disability services and its recommendations are under consideration; and

— in light of significant additional funding provided, the Government is committed to continuing to fully implement and refresh ‘A Vision for Change’, including building capacity into Child and Adolescent Mental Health Services, the provision of counselling and psychological services in primary care, including the recruitment of 114 assistant psychologists, and fully populating community psychiatric teams;

— prioritise a range of initiatives during 2018, aimed at reducing waiting times in emergency departments and elective waiting lists, including:

— as part of Budget 2018, an additional €70 million was provided to respond to winter pressures, this included €3.5 million for additional transitional care beds and €18 million for additional homecare packages;

— over 200 new beds have been opened this winter to help alleviate the pressure our hospitals faced this winter;

— €55 million has been allocated to the National Treatment Purchase Fund targeted at reducing waiting times for the longest waiting patients, the Inpatient/Day Case Action Plan 2018 published in April, provides for treatment of 20,000 patients, and an Outpatient Department Action Plan will be published later this year;

— an additional €9 million has been provided to paediatric orthopaedics, including scoliosis, to deliver on the commitment of a four-month waiting list target for surgery for clinically suitable patients, following an increase in the total number of surgeries delivered in 2017 to 321 from 220 in 2016; and

— continuing to manage an increasing volume of emergency department attendances, with an increase in overall attendances in the first three months of this year of 3.7 per cent as compared with the same period in 2017, including a 5.9 per cent rise in attendances of people over 75;

— continue a series of focused campaigns to attract frontline staff in order to meet patient care requirements, including:

— an additional 942 nurses and midwives were recruited in 2017, including student nurses, and all nurse graduates have been offered permanent contracts to work in the Irish Public Health Service in 2018;

— the Framework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Care Settings in Ireland was launched in April 2018, which sets out for the first time a methodology for calculating the staffing requirement and skill mix needed in our specialist medical and surgical wards in adult hospitals;

— the number of Non-Consultant Hospital Doctors has increased by 289 in the twelve months to the end of March 2018, and the number of consultants has increased by 110 in the same period; and

— the Public Service Pay Commission is currently examining issues relating to the recruitment and retention of staff in the health sector, and their report is expected in June; and

— to continue to develop and expand our aeromedical services and implement the recently published trauma policy.”

I thank the Deputies in the Rural Independent Group for tabling this motion, which raises a number of very important matters and provides us with the opportunity to discuss them on the floor of Dáil Éireann. The events of the last week demonstrate how important and how personal healthcare is to every individual in this country. The issues we have been grappling with on cervical screening and maternity services in Portiuncula show just how devastating the effects can be when there are failures within our health services. It is incumbent on all of us, as elected public representatives, to work together to bring about real change in our health services and real improvements in healthcare for everyone in this country.

Since taking up the role of Minister, I have been appreciative of the willingness of Deputies across the House to work together on health issues. This is one of the potential achievements of new politics and minority government. I refer to the fact that Government and Opposition Deputies sat on a cross-party basis to try to put together a plan for our health service. It is often forgotten in the narrative that Government Deputies also sat on the Sláintecare committee and that my party supports the Sláintecare recommendations as well. This really came to the fore in the workings of the Committee on the Future of Healthcare, where all parties stepped up to the plate and worked together to develop a roadmap for change in our health services, and I pay tribute to all involved.

It was evident again last week as we considered the serious failings in CervicalCheck. We have been united as an Oireachtas in our shock and dismay at what has happened to Vicky Phelan and her family, to other women across this country and to Mr. Stephen Teap and his late wife, Irene. I thank the Deputies who met me last week to discuss the establishment of an inquiry and who made submissions, which I sought to address in the proposals I brought to Government this morning. Today, the Government agreed to the establishment of a scoping inquiry to examine the facts and get answers quickly for Irish women, while also identifying the issues that will require a full statutory investigation. Dr. Gabriel Scally, who has been appointed to carry out the scoping inquiry, has widespread experience in undertaking reviews of this kind. He has had a distinguished career as a senior public health doctor and adviser with the UK Department of Health as well as the NHS, and is president of the epidemiology and public health section of the Royal Society of Medicine and a professor of public health at both the University of the West of England and the University of Bristol. He has also worked to unearth very many significant service and clinical failures in parts of the UK and Northern Ireland. I have no doubt that he brings huge experience to the issue, and he has really hit the ground running, starting his inquiry today. He will be joined by Dr. Karin Denton, a consultant cytopathologist who has huge expertise in cervical screening within the NHS. I thank Dr. Scally for arriving in Ireland today, for immediately beginning his work and for committing to report back through setting out his findings by the end of next month and providing a progress update at the start of next month.

For many, CervicalCheck is just one in a long list of failings in our health services, and I understand that point of view. Too often we are here talking about lack of services, poor performance or, in the worst cases, breaches of trust and duty. In the face of these failings, it can be difficult to talk about any positives. However, we must remember that, in the vast majority of cases, staff across our health service are doing their utmost to provide high-quality care. They are treating more patients than ever before, they are providing much-needed care, support and compassion to people when they need it most and they are doing this in an ever-increasingly busier environment.

We all know the pressures and challenges that face the health service. We all know people who are not getting the care they need as quickly as they should get it. We all know healthcare professionals who are frustrated and burnt out from working in a system that is not working all that well. Our system is already challenged, and the changes in demography, technology and the nature of illness that will happen in the coming years will place ever-increasing strains on it. Funding alone will not be enough to address this. There is no silver bullet or magic wand we can wave to get us the kind of health service we all want. The scale of the challenges we face means that fundamental change is needed, and this can only be delivered by an ambitious, coherent and sustained programme of reform that has broad support.

I am on record here and elsewhere in expressing my belief that the Sláintecare report and the cross-party support it enjoys present us with a unique opportunity to embed long-lasting reform. Sláintecare has the potential to fundamentally change the way we deliver healthcare in this country, to allow us to provide high-quality, safe and fair healthcare for all our citizens. I have listened to health service users, patients, staff of the health service at all levels and Members of this House and I know the challenges that lie ahead in driving through large-scale reform. We will only succeed with this ambitious programme if everyone - and that includes all of us here - are united on the overall goal and pulling in the same direction.

In the 12 months since the publication of the Sláintecare report, the Government has already taken significant steps to commence the programme of reform that it envisaged. We have already committed to the establishment of a Sláintecare programme office, and the recruitment process for the executive director of that office is in its final stages. This has been a very thorough and comprehensive process, led independently by the Public Appointments Service and involving a national and international executive search. I hope to be able to make an announcement on the new director for this programme office very soon, a key priority of Sláintecare. We have also prioritised the Committee on the Future of Healthcare's recommendation to remove private practice from public acute hospitals. Let me say on the record of this House again that I believe this must happen. We are an outlier among other countries in this regard. This is a far-reaching, complex reform but absolutely fundamental if we want to achieve a fairer, more equitable health service. I have established, in line with the Sláintecare report, an independent review group, chaired by Dr. Donal de Buitléir, to examine the impact of this measure. The group will conclude its work later this year, which will provide a valuable roadmap on how this can be achieved. That is another key recommendation of Sláintecare implemented.

The Sláintecare report made a series of important recommendations in respect of accountability, clinical governance and patient safety, which resonate even more strongly now. I have already signalled my intention to bring forward a Bill to legislate for the establishment of a governing board for the HSE. I am pleased to confirm to the House that I will bring a memorandum to Government next week with the general scheme of a Bill, which will then be published next week. I ask for the co-operation of all parties and groupings in this House - and I know it exists - in getting this legislation through the Oireachtas as quickly as possible this year so a new board of the HSE can take up office, effective January 2019. I know we all agree that we need more robust and transparent structures of accountability across our health service, and the appointment of a strong board with the appropriate skills set is essential to achieving this. I ask that we work in a bipartisan fashion to work out how best to populate this board. It is really important we have the right skills set. If ever we were in any doubt about the need to improve accountability structures, recent weeks have shown the importance of that need.

My Department has also commenced work on the committee's recommendations in respect of changes to the HSE structure itself. An important component of this will be the development of regional structures to support the delivery of integrated care, a key Sláintecare recommendation. This is an issue I raised with the committee myself during deliberations and it is something I fully support. Let me be very clear: my view on this is that the HSE as currently constructed is overly centralised, far too bureaucratic and does not have sufficiently devolved systems of governance and accountability.

We need to create a leaner central body complemented by regional organisations which will provide the framework within which much clearer, transparent and more robust accountability and performance arrangements can be developed. The structure has become far too complex and far too bureaucratic. It was set up in an inappropriate fashion but we are going to fix it and do so in line with Sláintecare roadmap.

On accountability, I spoke to Róisín and Mark Molloy, who have been incredible patient advocates arising from the terrible tragedy they experienced with baby Mark in Portlaoise hospital, about accountability legislation. They asked me to examine what other jurisdictions have done and I am undertaking that work now.

The first step in reforming structures is to better align our current regional structures, that is, hospital groups and community healthcare organisations. A public consultation on this is under way, I welcome the submissions of all and my Department will bring forward proposals later in the year. I have previously pointed out that I do not think that reform alone can solve all our problems. Given the scale of population change that is expected over the next decade, additional funding will also be necessary. This will build on the significant increases already delivered in recent years, with public funding on health increasing by 19% since 2013. In particular, the Government is committed to advancing a €10.9 billion capital programme over the next decade to improve our healthcare facilities and increase capacity across services. This is 165% higher than it was for the last ten years and will support major priority projects as well as enabling the roll-out of new additional capacity. The bizarre failed policies of the past of reducing hospital beds is over. We are now going to deliver in full the provisions in the capacity review, 2,600 acute hospitals beds, three new elective facilities - one each in Dublin, Galway and Cork, and 4,500 community care beds, and diagnostic hubs in the community. This is all funded. It takes several years to build hospital wings and new elective facilities and to put diagnostics into the community but we are beginning to plan for that.

Crucially, we are also delivering on a key Sláintecare recommendation in committing €1.6 billion to delivering enhanced eHealth and ICT capability, which the Sláintecare report identified as an important enabler of reform. I fully appreciate that extra staff will be required and I very much welcome the Framework for Safe Nurse Staffing and Skill Mix in hospitals. I made an announcement on that at the Irish Nurses and Midwives Organisation, INMO, conference last Friday in Cork, while the pay commission is also looking at issues on recruitment to and retention in the health service. It is due to report next month, and the Government will be guided by that.

I have secured Government approval to move forward with contract negotiations with general practitioners. I am pleased to inform the House that that engagement has commenced. It is clearly under way and meetings have taken place. We have many millions more that we want to spend in general practice but it takes two sides to negotiate and I also have requests on behalf of the Irish people and of patients.

We are developing a new homecare scheme for older citizens and people with disabilities. It is under development and in the meantime we are committed to providing an additional 754,000 home support hours this year.

I am running out of time but we will have an opportunity at tomorrow's joint committee on health to further tease through some of these issues.

Deputy Stephen S. Donnelly

I thank Deputy Harty and his colleagues for tabling tonight's motion on healthcare. Fianna Fáil is in agreement with much of tonight's motion, particularly the calls for immediate action for implementation for increased capacity in hospitals, in general practitioners' surgeries and in community care. I am pleased to say that Fianna Fáil will support this motion and has a very short amendment to the motion which we hope that Deputy Harty and his colleagues will support. It reads that the Government "in pursuing these healthcare goals, stay within the fiscal parameters required to maintain a prudent budgetary approach over the entire lifetime of implementation", which will be at least a decade.

Given Ireland's young population by international standards, we should not need to spend as much as other countries on healthcare. However, not only do we spend as much as other countries, we spend more per person than almost any country worldwide. Given that, and that we have really well trained doctors, nurses and other healthcare professionals, one would expect that we would have a Rolls Royce healthcare system but let us compare what we should have with what we have today.

We have the longest trolley lists in history. We have the longest waiting lists in history. There is a crisis across general practitioner practices that is so deep that seven in ten practices are no longer taking on new patients, whether private or public. We have a massive shortage of hospital beds, step-down beds, or rehab beds and a plethora of other different facilities. We have a chronic shortage of hospital consultants and people working as hospital consultants who are not even qualified as hospital consultants, and this has been the case for many years with the knowledge of the HSE. These are people working as specialists who are not on the specialist register. We do not have enough nurses and the job has become so difficult in recent years that over 70% of those who are about to graduate this year say they will leave the country and not work in this system. We have non-consultant hospital doctors who tell me that their training hours are being falsified by their employers and that they are still working 36 hour shifts. Many of them are also leaving the country. I am told that we are the biggest importers and exporters of doctors in the developed world. That is a shocking indictment on our duty of care to our healthcare professionals.

Then there is our culture of secrecy. The Portiuncula report which came out last week would make one's blood run cold. There needs to be time given for this House to debate it. The cover-up which was uncovered in the Portiuncula report and what families whose babies died in that hospital is horrific. If it was not for CervicalCheck, the Portiuncula report would be on the front page of every paper, but we have another scandal that is so big that Portiuncula has barely been mentioned. The CervicalCheck scandal affects every woman and every family in this country. Every woman I have spoke to or who has contacted my office is furious. They are not a little annoyed, irritated or let down, they are furious that they could have been Vicky Phelan or that they could have been one of the 208 women where the HSE and State found out that their diagnosis had been missed but they were not going to tell them, rather just file it away, and that their doctors would be told that he or she did not need to tell the women affected either.

It is very clear that what has happened to Vicky Phelan is not an isolated case. It is only because of her bravery that we understand just how deep this conspiracy of silence has run. We now have correspondence that shows that the clinical director of CervicalCheck, who has now resigned, wrote to Vicky Phelan's doctor and said that they thought all the women in question should be told, but that they did not think they should do it themselves but rather the doctor should. They debated back and forth over whose responsibility it was and escalated it to the hospital group, but nobody made it public. Then they escalated it to the clinical director of the HSE who did not make it public and was assured that the matter had been sorted out. We have correspondence from the ex-clinical director of CervicalCheck saying that in her opinion, Dr. Hickey, Vicky Phelan's consultant, need only tell three of his ten patients. That is not an isolated event. It is a deliberate culture of non-disclosure.

The background to this is that in 2013 the HSE brought in an unambiguous open disclosure policy. In 2014 CervicalCheck decided it would do an audit. In 2015, two years after the policy of open disclosure, it decided it would tell the doctors. In 2016, three years after the policy of open disclosure, it actually got around to telling the doctors. In 2017, four years after the policy of open disclosure, Vicky Phelan actually found out about it. In 2018, five years after the policy of open disclosure was introduced, the other women affected and their families are now being told. This is a deep and sinister conspiracy of silence. The women of Ireland are furious and they are absolutely right to be.

I put it to the Minister that there is also a great deal of political accountability for this too.

The HSE board was disbanded by a previous Minister, Deputy James Reilly. It is now going to be re-established. That action clearly led to a lack of oversight and governance. Another Minister, Deputy Leo Varadkar, pulled away from legislating for open disclosure when there was an opportunity to do so. While I respect that the Minister, Deputy Harris, acted when he found out about the scale of this, I put it to him that there was sufficient information and there were warning signs in that memo to lead him to act sooner. I am sure the Minister would dearly love to have acted sooner and I believe he should have. It was clearly a political error to let Tony O'Brien take on a position on the board of a company on the west coast of America. I also put it to the Minister that it is an ongoing political error to allow the director general of the HSE to remain in situ.

The director general of the HSE needs to resign immediately, without prejudice, for three reasons. He was in charge throughout this entire thing, he is clearly a distraction from supporting the women involved, and the response to date in terms of the helpline has been shambolic. There are many other things that need to be done, but I put it to the Minister that as a first step and as a message to the women, and indeed men, of Ireland he should ask Mr. O'Brien to resign with immediate effect as the person who was in charge and who has, to date, essentially had ultimate governance for the helpline, which has been a shambles.

Deputy John Brassil

I welcome the opportunity to speak on this very important motion. I want to concentrate my contribution on one issue, that of recruitment. Under questioning today the Taoiseach admitted that the advertisement seeking a replacement for the CEO of the HSE has not yet entered the public domain. It is less that eight weeks until the time when Mr. O'Brien will be leaving, if he does not leave before then. Regardless of when he leaves, the organisation that employs 110,000 people and is responsible for the well-being of our people will not have a permanent CEO for a period that will probably last at least six months. This is not acceptable. What organisation would survive with that recruitment policy? What organisation would let its head retire or move on without a replacement? The replacement should be there a month before the incumbent steps down to allow for a handover period.

It is not only the position of Tony O'Brien that operates in this manner. It is the same for consultants, doctors, nurses and healthcare professionals at all levels. When somebody retires, there is never a replacement there on the day that person steps down. If a person walks into a hospital or phones up looking to speak to a consultant and that person is told that the consultant has retired, if the person looks for his or her replacement, he or she will be told that no one has been appointed yet. It is simply not acceptable. It is in the Sláintecare report, but we do not need the Sláintecare report to have a functional recruitment office within the HSE. We need that to be put in place right now. It is symbolic of the organisation.

The Minister has responsibility for this. He has known of Tony O'Brien's imminent departure for the past 12 months, as has the whole country since the start of January. In today's response the Taoiseach said that the job description is changing and evolving. That is just not a strong enough excuse. There must be a CEO of the organisation in place at all times. It is very important not only that the lesson be learnt from this debacle but that, in respect of future recruitment, there is a root-and-branch overhaul of whatever recruitment policies are in place in the HSE so that not only the CEO but also doctors, nurses and healthcare professionals get recruited in a timely manner to allow the organisation to function properly.

Deputy Fiona O'Loughlin

As Gandhi said, "It is health that is real wealth and not pieces of gold and silver." It has also been said that without health, life is not life, that it is only a state of languor and suffering. In this motion we are dealing with patients who are trying to maintain good health or eradicate bad health, both physical and mental. In many ways we are dealing with very vulnerable people at every age on the spectrum. Two years into this Government we are still seeing inadequate delivery of services and, I have to say, a lack of urgency on the part of those in charge. Outpatient waiting lists have hit record highs. More than 10% of our population are waiting, many for more than a year. Emergency department overcrowding reached its highest level on record, which is 30% higher than last year. There are major delays in accessing community health services, especially services for children. Some 6,181 children are waiting for a primary care psychology appointment and, of these, 25% have been waiting for more than a year. This is happening at a time when we are saying that we care more about mental health than we ever have before. There has been a 10% increase in the number of children waiting for a child and adolescent mental health services, CAMHS, appointment. There is a GP crisis. There are 4,312 children with disabilities awaiting the assessments which are their right under the Disability Act 2005. Almost 10,000 children are waiting for an appointment in our children's hospitals. Many of these have been waiting for more than 18 months.

That is before I even touch on or get into the cervical screening scandal. It is a scandal but, apart from that, the management of the issue since it was uncovered has been shambolic. The women of Ireland are enraged. Their families are disappointed, frustrated and angry. Every day questions remain unanswered and more questions arise. The call centre system put in place has been disgraceful. A friend of mine who had had an abnormal showing rang the first day, the fourth day and the fifth day. She was told twice that somebody was looking at her case and that somebody would get back to her. To this day, no one has. Women are very worried and cannot sleep at night. We have to do better, make no mistake about that. We need reform and we need it straight away. We need it for patients and for the wonderful people at the coalface of our medical and health system.

Deputy Brendan Smith

I fully endorse the comments of our party spokesperson, Deputy Donnelly, tonight and over the past week in respect of the CervicalCheck scandal. The way so many women were treated in respect of this important screening programme is scandalous. The withholding of information from those women is inexcusable and those responsible must be held to account.

I refer to the Disability Act 2005 in regard to the assessment of needs. It is laid down in law that a person is entitled to an assessment which is to begin within three months and to be completed within a further three months. That provision is not being met. In my constituency of Cavan-Monaghan there are huge delays for hundreds of children. I appeal to the Minister and to the HSE to ensure that the necessary therapists, physiotherapists, occupational therapists, and speech and language therapists are put in place to ensure that those children get an assessment and the follow-up support that is needed.

I recently spoke to the Minister again with regard to the emergency department in Cavan General Hospital. Some years ago we were promised an investment programme. It is not happening. I appeal to the Minister again to ensure that department, which is working well but which is under extreme pressure, is given the additional resources, physical infrastructure and upgraded and additional facilities to ensure that it can meet the demands of a growing population and annually increasing attendance.

With regard to Sláintecare, I took the opportunity in this House before to compliment those who contributed to that committee. There is one thing with which I was disappointed. There is no emphasis on the all-Ireland dimension to the provision of healthcare on our island. That is one item which is unfortunately missing from the Sláintecare report.

Deputy Marc MacSharry

I would like to raise the issue of the Legal Services Regulation Act 2015. It was signed into law by the President on 20 December 2015. The new section 32B which the Act introduced into the Civil Liability and Courts Act 2004 provided that there shall be pre-action protocols relating to clinical negligence actions.

The inserted section specifically states, "The Minister shall by regulations make provision specifying the terms of the pre-action protocol" which will involve full disclosure of medical and other records. It was described by the then Minister for Justice and Equality as an historic day. Why has that section of that Act not been commenced by the Government, specifically by the Minister for Justice and Equality, Deputy Charlie Flanagan? Had it been, the Government would not be in the mess it is in today in terms of the provision of information to patients, and it would not have the head of the State Claims Agency saying at a meeting of the finance committee today that things would have been completely different had pre-action protocols been in place. The former Minister for Justice and Equality, Deputy Frances Fitzgerald, was correct that it was an historic day but it was an historic day in what epitomises the Government, namely, saying it is doing it but really doing nothing. I ask that the Minister for Health ask the Taoiseach to clarify on Questions on Promised Legislation tomorrow specifically why the Government has sat on its hands in commencing legislation passed by this House that would have prevented the tragedy of the cervical screening disaster.

Deputy Jackie Cahill

If ever there were proof needed that our health service needed reform, it would be the fallout from the cervical screening crisis. If trust is to be restored, we need full disclosure from CervicalCheck, the HSE and the Minister. We need it quickly.

One of the great barometers of the effectiveness of our service is emergency department overcrowding. INMO figures show a record number of patients on trolleys in 2018 by comparison with a similar period in 2017. There was a rise of 19%. This is a key performance indicator for our health service, yet the figures continue to spiral out of control. In March 2018, the total number of people waiting for an outpatient appointment was the highest ever recorded. Almost 150,000 were waiting for over a year, with 75,547 of them left waiting for longer than 18 months.

Ireland's three children's hospitals have 9,246 people waiting for over a year and a half. These figures are simply scandalous. With regard to child and adolescent waiting lists, recent figures show there were 6,181 children waiting for a primary care psychology appointment at the end of January 2018. Of young people waiting, 1,635 had been waiting for over a year to be seen. This effectively means that the children spent all of 2017 waiting for an appointment. The figures demonstrate the ongoing crisis in the provision of mental health services for our children.

There are other points I wanted to make but we have one more speaker who wishes to contribute.

Deputy Niamh Smyth

I would like to take this opportunity to put on the Dáil record my absolute admiration for Ms Vicky Phelan for her courage and conviction in not signing the gagging order that would undoubtedly have left the women of Ireland in darkness for perhaps another decade, with women unnecessarily going without treatment and, worse, dying. The cervical screening scandal is a national disgrace in which, yet again, the women of the country have been failed on their most fundamental right, namely, the right to proper health care.

I welcome the appointment of Dr. Scally to head up the scoping inquiry. It is critical that the women affected by the scandal receive answers quickly as to what happened and why it happened, and that we see accountability.

Our national CervicalCheck programme is very important. One of the most important jobs of the Government is to begin to restore confidence. Consideration should be given to the examination of our other national screening programmes to allay the fears of people who have been deeply disturbed by the revelations of the past 14 days.

In the Minister's programme for Government, there is a commitment to providing better healthcare but in Cavan General Hospital, particularly in the emergency department, there is an absolute need for investment. My colleague, Deputy Brendan Smith, just mentioned that need. The unit needs to be expanded to deal with the overcrowding. There are ten examination cubicles that are not adequate to deal with the approximately 32,000 patients who attend each year.

An issue arises over waiting times for young people and adolescents. The assessment of need is one of the critical issues. Parents are being told they have three years for the initial step in dealing with what they may need in terms of occupational therapy, physiotherapy and speech and language therapy. The Minister has to make the officials accountable. I ask him to do so.

Deputy Louise O'Reilly

I thank the members of the Rural Independent Group for bringing forward the motion. I commend them on the concise nature of the motion, which has captured many of the difficulties in our health service. It is very timely that we are debating this matter this evening in the face of yet another scandal. The Government may go down in history as one that was dogged by scandals. It is my estimation that it definitely will. It is not lost on the women of Ireland. Never have they been mentioned so many times. We are so grateful for all the mentions we get. Time after time, the scandals that emerge affect women, including the scandals associated with sodium valproate, breast cancer misdiagnosis in St. James's Hospital and the scandals in Portlaoise and Portiuncula hospitals. These are just a few. Now we have to add to them another scandal, that of CervicalCheck.

Anyone who watched the performance of the HSE officials at the meeting of the Oireachtas Joint Committee on Health last Wednesday could not fail to have been struck by the arrogance and complete abdication of responsibility for the service in the charge of Mr. Tony O'Brien. His utter refusal to take responsibility for the organisation he heads has angered not only me — it did anger me — because is has made the women of Ireland very angry. Mr. O'Brien, in response to the question on whether he is doing a good job, shrugged his shoulders and simply said "Yes". This was absolutely outrageous. Why does he do it? It is because he gets away with it. It is because the Government circles the wagons.

There is not a person in this Chamber or this complex who has expressed confidence in that particular individual's ability to do his job, yet he is still in his position. We will not see him tomorrow because, apparently, he is on holiday. Good luck to him with that. He will not appear before the health committee for the quarterly meeting, apparently. He had planned on taking annual leave and that is why he will not be there. It is because of the attitude of the Government that he behaves in the way he does. The wagons were circled; the protection was there for him. He had no need to answer any questions. He had no need even to pretend to take responsibility for the organisation that he heads because he knew he was going to get the protection of this Government. Contrast that with the position of a nurse starting her shift in an emergency department tonight. Does the Minister believe she feels protected to that level? She does not. She absolutely does not because she knows that, with the failings in the health service, her head would be on the block. She sees that those who are at the top, or those who refuse to take responsibility time and again, will be protected. They are obviously very valued. The nurse working in an emergency department does not feel valued.

I sat here and listened to the Deputies from Fianna Fáil bemoaning the state of the health service. Members will know, because I have said it before, that before I became a Deputy I represented workers under a Fianna Fáil Government and a Fine Gael Government. I was not impressed by either, and I do not believe the workers were either. Let us not forget that many of the issues we face in the health service today have their root in the recruitment embargo, which was brought in by Fianna Fáil two years ahead of the one for every other Department. When we say we have a recruitment and retention crisis, we need to go right back to where the recruitment and retention crisis started. It started with the recruitment embargo. It was a crude tool and it was resisted by the unions at the time. There was no reason for it but the Government ploughed ahead with it regardless. When we consider the crisis in recruitment and retention, we can see the health service has become a very cold place for those who work hard. Those people are voting with their feet and they are leaving.

Once again, I thank the Rural Independent Group for this motion and putting it on the record that there will be no change in our health service unless and until those at the top of it are accountable.

Deputy Pearse Doherty

Gabhaim buíochas leis na Teachtaí Neamhspleácha ón tuath fá choinne an rún seo a chur os comhair na Dála.

The wide range of issues covered by this Private Members' motion points to a system that is suffering from chronic under-investment by this and the previous Government. As my party's spokesperson on finance, I have said for the past few years, as we have had budget after budget, supported by Fianna Fáil, that it would result in a crisis in hospitals because we were under-investing in health services. It is clear to me that the policies of the Government will continue to keep them at crisis level. Is ceart a rá nach bhfuil acmhainní amháin taobh thiar de na fadhbanna seo. Tá fadhbanna ó thaobh cúrsaí rialachais i gceist anseo feasta. Feicimid é sin go soiléir i gcás Vicky Phelan agus na mná ar lig an Feidhmeannacht na Seirbhíse Sláinte síos go dona iad.

We see once again that the State does not do accountability, not only on the issue of health but on all issues - the bankers, those in high places and the politicians. If we consider the different tribunals, there is no accountability. We, in Sinn Féin, say this needs to stop. We need to see accountability and action. The refusal of this House to discuss the future of Mr. Tony O'Brien and of the Government and the Minister to call on him to resign show that nothing has changed. The parcel of accountability is passed around and around. We will see Mr. O'Brien sailing into the sunset with his pension in retirement and the health service that he will leave behind him is in a dire position, with many people left in a terrible position as a result of the latest scandal of misdiagnosis.

I point to some cases in my constituency which show where the health system is at. People are waiting two years for a diabetes recall appointment. Letterkenny University Hospital requires an allocation of €1.8 million. It asked the Minister for that allocation last year to enable it to open its short-stay ward, which would accommodate 19 beds, instead of having patients on trolleys. It has a maternity theatre that was built in 2000, but the Minister and Mr. O'Brien have refused to commission it. It lies idle and empty, just like the short-stay ward. We have 12 beds in the community hospital that are closed. Why? The answer is because there are no staff to cover them. Since 2015, 41 beds have been closed. To add to the nightmare and scandal that is unfolding, we found out today that the HSE completely misinformed the State Claims Agency when it stated during the Vicky Phelan case that all the women had been informed of their misdiagnosis. We found out two weeks ago that 162 women had not been. Therefore, somebody is lying; somebody is covering up and the person who must be held accountable is the person at the top. Therefore, the Minister should do his job and tell Mr. O'Brien it is time to go.

Deputy Brian Stanley

I welcome the motion tabled by the Rural Independent Group. We all know that the health service is in need of radical reform. The HSE is more or less dysfunctional as it is organised. There are long waiting lists; there is a two-tier system and there has been a range of scandals, the most recent being the cervical screening scandal. The HSE's response has been nothing short of outrageous.

All parts of the health system are important, but the emergency department strand is the vital front line. Dealing with emergencies, as the Minister and I both know, cannot be delayed, as we can see right across the hospital system. We saw it during the winter period with the trolley crisis. I saw it at first hand in Portlaoise hospital where its emergency department is part of the emergency department network. The numbers attending it have increased year on year and there are now almost 40,000 attendances every year. Capacity within emergency departments across the State must be increased. Everyone is saying this, including patients, people working in the hospital system and anyone who has observed what is happening. What we have in Portlaoise is a service that has been threatened and much promised consultation with local medics and the community. That consultation process needs to start. The time for decisions on Portlaoise hospital is now. We need to get the ball rolling to put in place the plan that is badly needed for the hospital, to provide the necessary resources and to secure staff. Staff will come once there is certainty about the hospital. I urge the Minister to do this.

I want to touch briefly on another strand of the health service - the home help service, which needs to be expanded. People are waiting for months for essential services. Some have been on a waiting list since 2017 to be allocated home help hours. Home helps are one of the success stories of the HSE. It is one of the good services it provides. However, we need more home helps because there is an ageing population which will only increase as the years pass by. If we had them, it would ensure people could be kept in their homes and communities where they want to be. It would also mean patients could be discharged in good time, thereby freeing up critical hospital beds. It would save money because providing a few home help hours is much cheaper than providing private or public nursing homes place or critical care hospital beds.

I plead with the Government to act now and begin to implement the Sláintecare plan, on which there is broad agreement and on which the Rural Independent Group has brought forward this motion in order that we can build a proper national health system. The HSE has been shot through. Organisationally, it is totally dysfunctional, as I have suspected for years. The past seven years during which I have been trying to deal with it have proved that to me. There are some very good people working in it, but they are frustrated because the system, as it is organised, cannot deliver.

Deputy Alan Kelly

I will be supporting the motion and thank the Members of the Rural Independent Group for tabling it. I will confine my comments to the CervicalCheck issue.

It has been said the chief executive of the HSE will not be turning up at the Joint Committee on Health at 9 a.m. I might be breaking some protocol, but, as the Acting Chairman of the Committee of Public Accounts on Thursday, he has informed us that he will not be turning up at it either. That is a disgrace. I ask the Minister, at whatever time he wants to do so, to take out his mobile phone and ring Mr. Tony O'Brien to tell him that he has to turn up. I believe nobody in this House would disagree with the Minister on that issue. Mr. O'Brien is not willing to turn up at the Joint Committee on Health, chaired by Deputy Michael Harty, at at time of national crisis when accountability is the real issue, as well as making sure the women concerned are protected. Furthermore, he will not turn up at the Committee of Public Accounts, the only constitutional committee in the State, at which we will be asking questions related to the HSE, the Department of Health and the National Cancer Registry. I will not blame the Minister and we will not find fault with him if the Minister of State, Deputy Jim Daly, has to stay in the Chamber while he has to leave to make a phone call because it is deeply unacceptable in the extreme and for the public watching these proceedings, it is a bloody disgrace. Mr. O'Brien has to be accountable. He is the chief executive officer of the HSE.

I want to confine my comments to a few issues and raise some concerns. First, obviously, we know the issues with the helpline. Let me make some suggestions. There are real issues about the volume of women with deep concerns. Will the Minister consider taking a random sample of smear tests undertaken in the past three years, given that is the cycle of smear tests involved and doing it quickly to give an initial stimulus of public confidence to the women concerned? We cannot get through all of them in that space of time. Therefore, we need something that will give confidence. Second, will the Minister, please, try to bring forward or fast-forward the introduction of the human papilloma virus, HPV, test because, ultimately, it will deal with many of the issues involved? It would be far more successful. It is something that has been proved in other jurisdictions. There will be issues with IT and laboratory space, but they can be dealt with. Third, will the Minister, please, go to the Health Information and Quality Authority to ask for an early health technology assessment of the HPV vaccine for boys? These three measures would absolutely help in giving confidence in dealing with this issue.

I am pleased about the scoping inquiry. At times during the past week or so I felt more like an adviser to the Minister than a political opponent. Is it new politics? I do not know, but the Minister has taken our views on board. In particular, there were many here who felt a HIQA-led inquiry was the right solution. It was not, as I said from the beginning. Now we are going down the route I expected we would have to go down and I thank the Minister for listening. However, I do have other issues. We know what the position is on open disclosure. We heard it at the Joint Committee on Finance, Public Expenditure and Reform, and Taoiseach today when Mr. Ciarán Breen, head of the State Claims Agency, essentially said if they were not indemnified, they would have no choice but to continue the process on the claims taken by the women concerned. That means that they are locked into the process. This has to change and if it needs legislative change, we should do it quickly. We would support the Minister in that regard.

We also found out that all ten legal cases being taken involve US laboratories. Was the Minister aware of this? When was he and his Department made aware of this? There has been a systemic and systematic failure of management across the health service, multiple organisations and the Department. I met the representatives from the Department last Tuesday at 3.30 p.m. Deputy Howlin, other colleagues and I were with them for an hour and 15 minutes. During that time, they were not aware of how many legal cases were being taken. I had to ask them to ask the State Claims Agency how many legal cases were being taken so that they would know for the meeting of the Joint Committee on Health the following morning. I asked them the same question again. If I had not asked them the question, I doubt they would have known. They were also unaware of any issues relating to the other cases the Minister had to bring to the attention of the Dáil, which he told us he was only made aware of beforehand. We now know there are 1,600 of those. We know they are categorised differently from the first batch of cases because of the circumstances in which these women got cancer or were tested. However, it is deeply worrying that the Minister was only told this at the last minute. It was the biggest debate in which the Minister has participated to date in his political life and he was just given this information beforehand. It does not add up for me. I do not believe the Minister is being told everything. I do not believe his Department even knows everything. If it does, it is certainly not telling the Minister. A cursory glance at the National Cancer Registry figures would have shown that only half of the women had been audited. How in the name of God is it possible that not one single individual within cervical screening, the overall screening programme, the HSE or the Department realised the differential between the two figures? The Minister has told me how he was told. I need him to find out who told the safety incident management team and who told Mr. Lynch about the differential and how they brought that information to him.

I had a discussion over the weekend with someone who was involved in CervicalCheck who spoke to me again before I came in here. They believe that the National Cancer Registry, and I want the Minister to find this out immediately, actually wrote to the Department and told it that there was an issue with regard to the volume of cases compared to CervicalCheck. CervicalCheck would pass on the cases to the National Cancer Registry but the National Cancer Registry could not pass them back. I was told that the National Cancer Registry notified the Department in writing so could the Minister please check it out? I was told it initially took place in 2011 but has happened on numerous occasions since and that CervicalCheck would have orally notified the Department as well regarding this issue. If that is the case and if either of those bodies, particularly the National Cancer Registry, actually notified the Department about this issue, that means that half of the women in Ireland were not audited but the Department knew this beforehand, possibly for years. I said previously in the Dáil that this was either a monumental level of incompetence or a cover up and I went with the first. If it is what I have just described - if the Minister asks those questions and any aspect of that is true - then the latter is true. The Minister should find out whether his Department had any communication with the National Cancer Registry with regard to these cases, which he had to reveal to us as a bombshell last Tuesday, because for me that would be very dangerous territory. I have invited the National Cancer Registry to appear before the Committee of Public Accounts on Thursday along with the Department and the HSE. We have to get to the bottom of what is happening here. We must get to the bottom of the following issues. Why were these women not told in the first place - the 162 and the process by which that happened? Was there knowledge within the Department relating to that one or those two? This is the issue I really need the Minister to check out. Was there information in the Department for some time that the figures in the National Cancer Registry, which were very public, were not being passed on to the CervicalCheck process because of data protection issues and that in reality, people in the Department knew this for years and did not reveal it?

An Ceann Comhairle

Before I call the next Deputy, this House is not just entitled but obliged to discuss issues of important national and public concern but I am concerned about a situation in which we might be perceived to be involved in the demonisation of anyone - public servant or otherwise. The courts have found that we have absolute privilege but we must show responsibility in how we use that privilege. I put it to the House that the precepts of natural justice should prevail. Tony O'Brien has obviously won very few friends in the body politic but he is entitled to the same - do not get excited Deputy - natural justice as anybody else. He is not in a position to come in here and defend himself so let us just-----

Deputy Alan Kelly

Absolutely.

An Ceann Comhairle

Excuse me. Let us be conscious of that and moderate what we have to say.

Deputy Simon Harris

My understanding is that Mr. O'Brien will be at the meeting of the Joint Committee on Health.

An Ceann Comhairle

The Minister should not say anything until his time has come.

Deputy Simon Harris

It is just that a lot of people are saying he will not come in; he will.

Deputy Richard Boyd Barrett

Is my time reduced because I am giving two minutes-----

An Ceann Comhairle

I think we will have extra time on the basis that we have had extra time all day so we might as well keep at it. Do not lose the run of yourselves. The Deputy has five and a half minutes.

Deputy Richard Boyd Barrett

I thought I had seven.

An Ceann Comhairle

No, the Deputy does not because he is surrendering to other Members.

Deputy Mattie McGrath

He never surrenders.

Deputy Richard Boyd Barrett

Drip, drip, drip go the revelations adding to the scandal around the cervical smear issue, which gives us a glimpse into the dysfunction in the HSE that needs to be radically addressed. This motion deals with all aspects of this problem and proposes Sláintecare and moving towards a single-tier universal health service as the answer. I agree with that and support the motion but I really want to focus, as have others, on the CervicalCheck scandal and what that tells us about the problems we face in delivering a health service that is actually adequate for the needs of the people who depend on it. The way in which these revelations are drip dripping out is beyond outrageous at this point. It makes this scandal worse. It is extraordinary that the Minister gave Tony O'Brien permission to take up a job when the health service is in the state it is in. It is beyond comprehension. I do not care whether it was five hours or five minutes per month, although it is a bit to hard to credit when he was going to get €65,000 and €180,000 of stock options in a private US company for it. He is doing this while the health service is falling apart and the Minister gave him permission to do it last summer. I find that extraordinary. The Minister should explain how he thought this was appropriate when everybody in the country has known for several years that the health service is in meltdown. How could the Minister think that the head of the health service could do a nixer on the side? It is beyond belief. Mr. O'Brien then adds insult to injury by saying he will not turn up for a meeting of the Joint Committee on Health or the Committee of Public Accounts this week to explain himself.

Deputy Simon Harris

He is.

Deputy Richard Boyd Barrett

He is now because people are screaming for him to turn up but we were informed earlier today that he was not going to turn up.

As a result of a question I asked today in the exchange with the State Claims Agency we finally revealed something that we could not drag out of the Minister, the Taoiseach or the HSE for the past week. I asked if there was a difference between the accuracy and the quality of the screening that we got because of the outsourcing to US companies. We could not get the information or the detail. Then I asked a question today and it only occurred to me today. Nobody else had asked the question, which is a simple question to a representative of the State Claims Agency. Were the ten outstanding legal cases only taken against the US companies? He revealed that it was only against US labs. No cases were taken against the Coombe. Cases were taken only against outsourced, privatised US labs. That tells us something. That tells us that the outsourcing was the problem.

Why is it only them? We certainly know that the outsourcing cost us in terms of public health and transparency because the State Claims Agency stated that under no circumstances would it try to gag anybody. It was CPL that tried to gag people because profit came first for CPL. That meant trying to shut Vicky Phelan up. If it had succeeded in shutting Vicky Phelan up - thankfully for her bravery it did not - what would the consequences have been? This would not have come out and we would not have forced the crisis which now means we might address the issue and get to the bottom of what the hell was going on.

The representatives of the State Claims Agency told us today that if it had been in-house, it would never have been an issue; it would never have tried to gag anybody. However, a private for-profit company wants to gag people because it might impact on its profits. While I am not saying we should not have a scoping exercise, I am saying we do not need it to draw a simple conclusion: we should stop outsourcing to US labs which try to gag people and are the only ones against which claims are now being made. Why are no claims being made against the Coombe? It is because the Coombe had a better detection rate than these private companies. The outsourcing was the problem.

Deputy Joan Collins

I thank the Rural Independent Group for moving this Private Members' motion. It was obvious from the start that Deputy Harty was the main driver behind the medical aspect of it given his role in the Oireachtas Joint Committee on Health.

We have a dysfunctional crisis-ridden health service which is simply not fit for purpose. We are an exception in Europe in that we never moved to a modern NHS-type model of public healthcare. In 1942 the Beveridge report recommended the introduction of the National Health Service in the UK as part of a welfare state. The NHS was seen as a stand-alone measure to improve people's health. It was part of the concept of the welfare state with social welfare payments, child support, better state pension provision and a major programme of public housing. This was because of an understanding that when it comes to health and life expectancy, inequality and poverty are key factors.

Those from a lower income group or who are working class or unskilled are three times more likely to die younger than someone from the top end of society. Some 47% of the consistently poor have chronic health problems and we have completely unacceptable levels of poverty. Poor diet, poor housing, low educational achievement and stress are key factors affecting general health. We live in a very unequal society and this is compounded by the inequality of a two-tier health system.

After the Beveridge report, a Government White Paper was produced here, outlining an Irish NHS and social welfare system. It was met by fierce opposition from the medical professions, the Catholic Church and the Department of Finance. The proposals were quietly dropped. We have continued since then with what is essentially a poor service for poor people and a better service for those who can pay. We have a hotchpotch of charities, NGOs, religious bodies and State agencies providing an expensive service, but as the current scandal over cervical smear testing shows, no one is really in charge. There is a huge democratic deficit and a huge accountability deficit.

Someone has to be held responsible for the wilful deliberate withholding of medical information from women. Calling for the dismissal of people, who will leave the service in about 12 weeks and have about six weeks' holiday due which they will take in the meantime, is not good enough. We should be calling people to account. When someone in that position is on a board for five hours every month getting money for it and then he withdraws from that, it is obvious that is where he is going and that is his path for the future or some pharmaceutical company. Mary Harney did the same when she got her gold-plated pension. She is on the board of pharmaceutical companies as well.

That is the problem here; no one is held accountable. Following the blood-transfusion scandal, the CEO of the Blood Transfusion Board got a gold-plated pension. He was not touched or held accountable for any of those women's deaths, including people I knew who had to campaign to try to get recognition and get money from the State over the period of time they would have to face huge medical costs.

When the same blood-transfusion problem happened in France, the CEO there was brought to trial and jailed for what happened in France's service. Women died and the situation there nearly mirrored what happened here in Ireland. We had a huge problem with holding people accountable for situations happening here in institutions like the HSE and Government.

The question of outsourcing is crucial from the point of view of Government policy. In 2008 it was outsourced on the basis of, "We don't know really what it is". I asked questions to be put forward for the scoping report. Were the minutes discussed with Tony O'Brien who was then CEO of the cancer screening programme? Were there minutes of doctors explaining to him, "We have a problem on this"? They noticed differences in the method of the screening. We must have accountability somewhere. I will be dogged in ensuring that will happen. I am sure other Deputies will do the same thing.

Sláintecare is the way forward and we really have to push it. It is the essence of the Private Members' motion and I agree fully with the thrust of the motion. Despite the Minister's declaration of support for Sláintecare, the Government is certainly dragging its feet. Sláintecare will not be implemented by the Department of Health and certainly not by the HSE. That is why a fundamental element of the report was a recommendation for an implementation body, not in the Department of Health, but independent and located in the Department of the Taoiseach. The Government has sidestepped this key element of the report by planning to place the implementation office in the Department of Health.

The implementation of Sláintecare will require increased funding over and above the annual health budget. The report calls for a €3 billion investment over six years. Will the October budget make provision for this funding? If not, the Minister's commitment is useless. In addition we also need a major increase in funding for capital development, as the Minister mentioned in his speech, and also day-to-day spending.

In the 1980s the Fianna Fáil Government cut hospital beds by 3,000. The service is still struggling and reeling from those cuts. I hope to see the 2,600 acute hospital beds the Minister mentioned and the health service capacity review. I want to see them coming through. I want dates for when they will be brought into the system along with the staff needed to facilitate these beds.

From 2009 to 2014 we had five years of cuts to services and staff numbers, including pay cuts and an embargo on recruitment.

The service is now faced with the consequences of an inability to recruit staff due to extremely stressful working conditions and low pay, including a two-tier pay scale for nursing staff. We need a health budget of at least €20 billion a year plus the multi-annual fund advocated in the Sláintecare report. We also need the political commitment and the determination to face down the vested interests who will no doubt oppose this report. A first step would be the establishment of the independent implementation office as recommended in the report. We are 80 years behind the European norm. We cannot afford to wait any longer.

An Ceann Comhairle

I call Deputy Róisín Shortall, who is sharing time with Deputy Seamus Healy.

Deputy Róisín Shortall

I commend Deputy Harty for tabling the motion. It is a matter of deep regret that almost 12 months after the publication of the Sláintecare report, so little progress has been made. There have certainly been plenty of positive noises from the Minister but actions speak louder than words and, unfortunately, the level of action from the Minister in this regard has been very disappointing.

Sláintecare is a fully costed, cross-party, ten-year plan for the reform of the health service. It represents a once-in-a-lifetime opportunity to do something of real significance in regard to our health service and to ensure that Irish people, no matter how much they have in their pockets, should once and for all have a legal entitlement to a proper public health service. We are on our own in Europe in terms of not having a universal, single-tier health service and it is not before time that we start to implement one.

The priority in the Sláintecare plan is for prevention, early intervention and a strong emphasis on primary care. We need to improve access to end the shocking current situation where we have an inverse care law, whereby those most in need of health care are least likely to get it. We also have an extremely hospital-centric health service and, for that reason, Sláintecare calls for a reorientation of the health service away from hospital care, with a strong emphasis on primary and community care. In that way, of course, we would get much better health outcomes, as well as much better value for money, and it is also what patients want.

The committee was very strong on the question of implementation. We did not want this report to be yet another report left to gather dust and, for that reason, we were very specific in regard to the implementation plan and devoted an entire chapter to that. There was a very tight timescale set out but, unfortunately, there has been enormous slippage since the publication of that report. At least six months has been wasted by the Government dithering in this regard and not committing fully to the cross-party report. The intention was that there would be a Cabinet response immediately. Unfortunately, we still have not seen that Cabinet response. The Minister promised it before Christmas, then before Easter, then by May and he is now saying "shortly", but we still have not seen that response. The implementation plan, as others have said, was supposed to be drawn up by the lead executive, not by the Department of Health. If the Department of Health was capable of a reform programme, it would have happened long ago. It is important that the implementation office is entirely separate from either the HSE or the Department of Health if it has to have the strength and the power to drive through the much-needed reforms.

When we look at what is most important in the health service, it is a fact that we seem incapable of providing good quality services to our people. That is because the health service has traditionally been dogged by vested interests, which need to be tackled. Equally, there is no accountability within the health service and the HSE does not have an independent oversight board. Some 88 Members of this House voted to abolish the board of the HSE in 2014 so it is empty words from many people now, thumping their breast about the fact the HSE has no independent board. Some 88 Members of this House voted to abolish that so how did they expect there to be accountability? Accountability is also required in other areas - from the Minister, from consultants and from senior managers. All of that legislation should be put in place before a new CEO is recruited.

I want to make the point that what happened in regard to Tony O'Brien looking to take on a very well-remunerated position in a US pharmaceutical company was outrageous. It was even more outrageous that the Minister for Health approved that position and he showed very poor judgment in approving it. It is entirely inappropriate that the director general of the HSE should be serving on a board whose chairperson is supposed to be answerable to him as the chair of the board of the biggest hospital group in the country. That is an entirely inappropriate appointment as well and Mr. Thomas Lynch should be removed from that position if we are to have any accountability whatsoever in our health service.

Deputy Seamus Healy

There will be no real reform in the health service until the HSE is abolished. It is accountable to nobody. It was set up precisely to allow Ministers and Government to evade responsibility for problems such as the CervicalCheck scandal. We have to remember the HSE was established by the extreme capitalist free marketeer, the former Minister, Mary Harney, and supported by former Taoiseach, Bertie Ahern, and former Minister for Finance, Charlie McCreevy. The agency was set up to deliver a service to customers, not patients, and to divest Government responsibility from the health service.

It went on to establish extreme right-wing managerialist models of public governance and delivery of services. The head of the HSE is not required to report operational matters to the Minister. His staff do not report failures to him. When a scandal breaks, of course, the Minister can say he did not know, he is shocked, in fact, he is furious. The head of the HSE can say he did not know, he is shocked, he is furious. The Minister and the head of the HSE cannot be expected to resign because they did not know. Now, they are required to clean up the mess. Both of them will set up investigations and inquiries, as they have done. They are both "bloody raging and mad as hell". Then, of course, the Minister and the head of the HSE will ride to the rescue of victims on a white horse. Of course, it will happen again on another issue in another few years, and the merry go round starts all over again.

The Minister should do the right thing and abolish the HSE. We need a health service which is democratically accountable at local, regional and national level, and where the Government and the Minister are ultimately responsible for the health service.

An Ceann Comhairle

I call Deputy Michael Collins, who is sharing with Deputy Danny Healy-Rae.

Deputy Michael Collins

I want to thank Máirín McGrath in Deputy Mattie McGrath's office and Deputy Michael Harty for their work on the motion. I stand to talk on health service reform but, in fact, I could be standing here a year from now and will we have a reformed health service?

The programme for Government promised the most fundamental reform of our health service in the history of the State. The need for change in the health service is unquestioned but where is this change? In November 2012 the Government approved Future Health - A Strategic Framework for Reform of the Health Service 2012-2015. Some of the measures it introduced were a health reform board, a programme management office in the Department and a system reform group in the HSE to drive the implementation of the health reform programme. It compiled two reports on the hospital groups, one on the establishment of hospital groups as a transition to an independent hospital trust and the other on securing the future of smaller hospitals. What actions have been taken on these reports? It is one thing to commission these reports but another to deliver action on them.

Healthy Ireland, under the heading Building Capacity for Self-care and Self-management of Chronic Diseases in the health service national implementation plan 2015-17, stated there would be implementation of a national framework for self-care for the major cardiovascular, respiratory diseases and diabetes. The HSE national service plan for 2018 states that its mission is to ensure people in Ireland are supported by the health and social care service to achieve their full potential.

It states that people in Ireland can access safe, compassionate and quality care when they need it and that people in Ireland can be confident that the HSE will deliver the best health outcomes and values by optimising its resources. This sounds like a wonderful plan but is there a realistic, achievable plan? Only last week I asked questions in the Dáil about the sad and shocking case of Vicky Phelan. When will there be justice for Vicky Phelan? Under the reformed health service, can the Government guarantee that this will never happen again to any person in the State? Why was there no accountability?

The current health system is unfair to patients and it often fails to meet people's needs. It is not fast enough but the long waiting lists and overcrowding are but some of the problems in the health service. Deputy Danny Healy-Rae and I will take two buses to Belfast again this month to facilitate people to have a cataract procedure. It only takes 15 minutes but people have been on waiting lists for up to four years in the Republic. Under the reformed health service, will we see waiting lists reduced, not just for cataracts but all procedures?

In December last year, my colleagues in the Rural Independent Group and I raised a motion on home care packages in which we called for the home care packages scheme to be established in law to allow everyone an automatic right to the service. Census 2016 recorded a 35% increase in the number of carers aged 85 and over. Carers provide over 6.5 billion hours of care per week in Ireland and, on average, they care for their loved ones for almost the equivalent of a full 40-hour working week. Almost 9% of them provide full, 24-hour unpaid care with no break at all. Last Friday, a constituent of mine from the Clonakilty-Timoleague area told me he cares for a loved one and gets carers allowance but he ends up being paid just €1.59 per hour for all he does. Many carers have to wait for over six months, which is an outrageous attack on our elderly and nothing short of abuse towards the person who cares for them. The first day it is proven by medical evidence that a loved one requires care, a social welfare payment should be made to the carer. This would cut out the shambolic carry-on of leaving a carer for five or six months without any payment, which is also outrageous.

The increased privatisation of community care is a clear indication that the public system is not working for some people. The fair deal scheme is the most unfair scheme that has existed in this health service, with people who have worked tirelessly all their lives being robbed of all they have saved by the system. Ireland has an ageing population and 30% of the population will be aged over 65 by 2030, which creates significant challenges and opportunities for Irish society, in particular the Irish health service which is in crisis and looks to be worsening. I cannot imagine how it might be in ten years if we do not begin to change it. In west Cork we have the largest population of elderly people in Ireland and we need extra beds for respite care and more supports for families which provide care for loved ones with dementia and Alzheimer's disease. We need to support and recognise the wonderful work the home help service provides, not only in west Cork but across the country. In most cases, only 30 minutes per day, five days per week is given by the home help service, which is utterly unfair. According to the Healthy Ireland survey 2015, 9% of the Irish population over the age of 15 have probable mental health problems.

Deputy Danny Healy-Rae

I thank Deputy Michael Harty and Mairead and David in Deputy Mattie McGrath's office for putting the motion together for us. It gives me the opportunity to speak on a few very important matters.

Waiting times for beds in Tralee General Hospital are unacceptable, with people waiting for two or three days. It is ridiculous. Front-line staff are an issue and we do not have enough nurses. The hospital is overcrowded and Dingle Community Hospital is only half-opened, as is the new hospital in Kenmare. We need a new facility in Killarney because the population doubles and triples at certain times of the year. We are waiting for it and have been told we are getting it but it cannot come soon enough.

In the case of St. Mary of the Angels, decongregated settings have to be reviewed. One size does not fit all. Two patients were moved out in the past three years and in June last year one of them was so agitated they kept giving him anti-psychotic drugs. He cannot talk but can lip read and they gave him 28 doses in June last year, with the result that he is now blind. He cannot talk, hear or see now and that is what the decongregated model has done to him. His family has no problem with me naming him but I will not do that. His life has effectively been ended by this.

St. Mary of the Angels is being closed by stealth. St. John of God will not take in any more patients and it will close because the patients will die off. The group is trying to do its best but HIQA is changing the goalposts and saying there is not enough room for the patients, so that they now have to fundraise and need to collect €180,000 to build three chalets so that they can keep the patients they have. Parents and friends are doing this work and they are hoping they will get money out of the Ring of Kerry charity cycle. While that is happening, €750,000 is being spent on a house in Cromane to take one patient out of St. Mary of the Angels but no one is fit to go there at the moment, so grass is growing around the house. Someone is being paid to maintain it but nobody is inside. There is another patient in another town in Kerry and no one knows what it is costing. It is costing an unreal amount of money to pay all the nurses and everyone else to mind one patient when they were getting on fine in St. Mary of the Angels.

We have five Ministers in the Department of Health and a Government but I know of one poor lady who has an adult son with autism and when she goes to bed every night she locks her door because she is afraid of him. Two or three years ago a son killed his mother and it will happen again if the Minister does not wake up. There was another Minister in Kerry spouting about what money he had got from the Government to deal with these things but on the eastern side of Kerry there is no place to deal with an adult autistic child, who is still a child despite the fact they may be aged 23 or 24 and very strong. This poor woman is afraid and I ask the Minister to address these issues. He should get on his bicycle and go around to listen to the people. When I highlighted the young fella who went blind at St. Mary of the Angels, the only thing St. John of God wanted to know was who told me the story. In other words, it should not have been raised at all. These people want to keep these things in the dark but we are talking about real people, human beings who are not being looked after. They are the most vulnerable people and I appeal to the five Ministers in the Department of Health to do something about it. They know about these things and it is time to act.

Minister of State at the Department of Health (Deputy Jim Daly)

I thank Deputies for their contributions to this debate on health service reform. We are all aware of the pressures facing our health service on a daily basis and it is important that we, as elected representatives, make the reform of our health service a priority in the months and years ahead.

The Minister, Deputy Simon Harris, has spoken about our commitment to health service reform. This Government has committed to increasing and improving the capacity and infrastructure of our health service. However, it is clear to everyone that expansion must go hand in hand with reform. The Sláintecare report gives us the platform for a coherent and ambitious reform programme. We are committed to working with all parties across this House and with the health service itself to make the vision outlined in the Sláintecare report a reality.

It is clear from the contributions from everyone today that health service reform is and will remain a top priority for this and future Governments. The last couple of weeks have revealed the trauma and agony that can face patients and their families when our health service does not work as it should. We can all agree we are united in our desire to deliver significant improvements, not just in the case of cervical screening but across the health service more generally.

The Minister set out clearly this evening the actions he and the Government are taking in respect of the issues that have arisen with the CervicalCheck screening programme in the last couple of weeks. The Minister has acted quickly and decisively. The announcement today of a scoping inquiry, to be led by Dr. Gabriel Scally, is an important step in getting answers to the many questions we all have. The Minister also announced today that the Government had approved the drafting of a patient safety Bill which will provide for the progression of a number of key initiatives including requirements in respect of mandatory open disclosure.

The issues that have been revealed in respect of CervicalCheck have happened against the backdrop of growing momentum for fundamental and wholesale reform of our health services. This culminated in the establishment of the cross-party Oireachtas Joint Committee on the Future of Healthcare and the publication of its Sláintecare report last year. Again, we are all united in the view that this provides a unique opportunity to bring about real improvements in our health and social care services. Earlier this evening the Minister, Deputy Harris, outlined the actions that have already been taken in response to the Sláintecare report. Claims that the Government has failed to take forward the committee's recommendations are simply not true. An implementation office is being established and a recruitment process for the person to lead that office is almost complete.

Legislation to introduce a governing board for the HSE will be brought forward this year and an independent group is undertaking an impact assessment of removing private practice from public hospitals - one of the key recommendations in the Sláintecare report. The group will report later this year and will provide essential guidance on how this can best be achieved. We know this will not be easy but it will be a fundamental step forward in bringing about a fairer public health service for our citizens. Finally, the Minister is committed to bringing his proposals for a Sláintecare implementation plan to Government in the coming weeks. This will set out a concrete programme of reform for the next decade arising from the report's recommendations and will include a more detailed programme for the immediate years ahead.

As the Minister of State with responsibility for mental health services, I am glad to say that mental health continues to be a priority area for this Government. It committed an additional €57.5 million for mental health services in the budget this year. The mental health budget now totals over €900 million, an increase of 28% since 2012. The Government has recognised the need to further develop early intervention mental health services for those under 18. That is particularly the case in light of the 26% increase in demand for CAMHS service between 2012 and 2016. A sum of €3.4 million has been provided for the recruitment of 114 assistant psychologists in primary care. Of these posts, 111 are filled. This will enhance the primary care response and help to reduce waiting lists for child and adolescent mental health services.

The Government remains strongly committed to modernising all aspects of our mental health services in line with the framework for Ireland's mental health service laid out in a Vision for Change. The implementation of a Vision for Change was undoubtedly affected by a number of factors since 2006. These include the changed economic context, public spending constraints and a moratorium on recruitment. I am pleased, however, that in recent years we have been able to increase investment in this area and significant advances have been made in the reconfiguration and delivery of mental health services.

Our focus continues to be on building the capacity of community mental health teams across all areas to facilitate the move from the traditional institutional-based model of care to a more patient-centred, flexible and community-based service. While much of a Vision for Change remains relevant, it is important to ensure we are addressing the current mental health needs of Ireland. As many Deputies will be aware, a process is ongoing to review and update the current policy framework. Developing and improving services for older people - a growing cohort of our population - is also a significant priority for the Government.

My experience of speaking to older people around the country, and of meeting with organisations which represent them, is that they want to live in their own homes for as long as possible. For that reason I am strongly committed to ensuring that older people can continue to live in their own homes surrounded by their family and friends for as long as possible. The Government is fully committed to the development of a new statutory scheme for the financing and regulation of home care in order to support the shift towards community services and help people live with confidence, security and dignity in their own homes for as long as possible.

Developing a new statutory scheme for the financing and regulation of home care will be an important step in supporting people to live with confidence, security and dignity in their own homes. This scheme will ensure that the system operates in a consistent and fair manner for all those who need home care services. An important milestone in this process was the public consultation which concluded in October last year. The response rate was very high, with about 2,600 submissions received. A report of the findings is currently being finalised and will be published later this month. Further consultation with stakeholders, including service users, will take place later this year.

However, we are not standing still in this area. While the new home care scheme is under development, the Department of Health and the HSE are continuing efforts to improve existing home care services. This includes the provision of an additional 754,000 home support hours in 2018. I would also like it to be noted that this Government recognises the outstanding work done every day by carers throughout the country and the need for further supports for those caring for the most vulnerable in our society. That is why we are committed to delivering new legislation in 2018 to enable people in receipt of full or half rate carer's allowance or carer's benefit to qualify automatically for GP care without fees.

Before I finish, I would like to re-emphasise a number of points made by the Minister, Deputy Simon Harris, this evening in respect of additional resources and capacity. As we have seen over the winter months this year, capacity across our system is constrained. While reform is absolutely essential, so too is continuing investment in our services. We know the additional pressures that will arise in the years to come as a result of an aging and growing population. I see this day in and day out in my role as Minister of State with special responsibility for older people. This Government has increased investment year on year for health services. It has committed to a substantial €10.9 billion capital programme to upgrade, modernise and expand capacity across all aspects of the health system.

The health service capacity review showed how much demand on our health services will increase over the next 15 years and made a clear case for the expansion of capacity in the system to meet this. However, I doubt that anyone thinks we should expand capacity around the current design of the health system. It is important therefore that increases in capacity go hand in hand with system reform in order to achieve the health system the people of this country deserve. The Minister, Deputy Harris, and I are committed to working with colleagues across Government and the political spectrum to bring about meaningful reform in our health services. As the Minister previously noted, development of the Sláintecare report, and the cross-party support it enjoys, is unprecedented in the history of the State.

As demonstrated by our debates here today, we all recognise how unique an opportunity we have to make sustained reforms to our system and therefore we must ensure the chance does not pass us by.

An Ceann Comhairle

I call Deputy Michael Harty, who is sharing time with Deputy Mattie McGrath.

Deputy Michael Harty

Yes, we are sharing four and six minutes. I thank all the parties that pledged their support to this motion - Fianna Fáil, Sinn Féin, Labour, Independents 4 Change and Solidarity - People before Profit. I welcome that. The fundamental issue is loss of trust. There has been loss of trust in our health service not only by patients who are seeking care but also loss of trust in those who supply the care, our doctors, our nurses, our home help providers and our care assistants. They have all lost trust in the capacity of this health service to supply efficient and effective care to our patients. That is a deplorable state of affairs. Looking across at the UK, the National Health Service, NHS, even having many problems as it has, is still held up as an icon of social and professional care in the UK.

Here, however, the HSE is viewed with derision unfortunately. Many people in the health service are trying to do their best. I know that myself. However, the system is letting them down. The lack of health reform is underpinning this lack of trust. The Minister, Deputy Harris, spoke of personal care. Who delivers personal care? Doctors and nurses deliver personal care. However, they have lost trust in the service. The Minister talked about working together. We worked together on the Oireachtas Joint Committee on Health on the Sláintecare report. I believe it is a blueprint for reforming our health service.

There is no resistance to health reform on this side of the House. The resistance to health reform is coming from the Government. The slowness in responding to Sláintecare underpins that. The Minister of State said that he could not engage in health reform until Sláintecare reported, and yet one year after it reported nothing has happened. There are prolonged appointment systems. There are prolonged review groups. This is a ten-year vision for our health service, and if we continue at the rate we are going it will be ten years before we start reforming the health service. There is no resistance to health reform from this side of the House. We have lost trust in the Minister because of his tardiness in delivering health reform.

Demographic changes are going to overwhelm our health service. We are facing huge difficulties down the line due to our ageing population. If we do not reform the health service and expand capacity, we are going to be in very serious trouble. We are in very serious trouble as it is, but it will get worse as years go on.

I was taken by Deputy Donnelly's reference to the fact that not only are we the biggest exporter of doctors and nurses but also the biggest importer. That is an extraordinary situation to be in. I fail to understand the Government's lack of curiosity about that position. How can we educate our brightest and best and allow them to go abroad only to trawl the world trying to replace them? It is ludicrous. We have to set timelines on how we address the recruitment and retention issue. We must have timelines for expanding our hospital bed capacity. Intensive care unit, ICU, beds are at a premium now, which is preventing people from having very urgent surgery. We need transitional funding to get over the hump and to meet the unmet need in our service.

Deputy Mattie McGrath

I thank Deputy Harty and his staff, Lorraine, in his office, and indeed Mairead and David in the Bills Office for their co-operation on this issue. It is a pity the Government could not see fit to accept it, but it knows that it will be beaten tomorrow anyway. It will also be bitten by the people when it goes to them to ask for a reaffirmation of support. Why would they not bite? The Government is presiding over a failed system which is rotting at the top. The Minister for Health, Deputy Harris, should resign. In Britain, Prime Minister May has lost four ministers and no one died. Here, 19 people are dead and many more are seriously injured and let down by a dysfunctional and unaccountable health service. The Minister of State, Deputy Jim Daly, is present, and I do not dispute his bone fides. I am sorry too that Deputy Neville has left, because his father was so passionate about mental health. The Minister of State knows the system is not working.

Today I pointed out that the HSE spends about €400 million every year on medication for the treatment of mental health. A mere €10 million a year, however, is spent on psychological and counselling services. How can that be right? A kindergarten child would know that there should be some kind of balance and that conditions should be treated with therapists and counselling services. I am not being critical of Deputy Harty, but the system seems to function on a prescribing basis. It creates more problems.

We need huge accountability. The Minister of State might say that we spend €917 million on mental health, but that is a mere 6.3% of the total health budget. It is dysfunctional. We raised the issue in the House this evening, but the Minister of State was not here. The Minister of State, Deputy Finian McGrath, was here instead. It is an awful habit of the Minister of State, Deputy Jim Daly. Is rud an-salach é. Different Ministers are sent in to take different debates.

I thank the Ceann Comhairle for allowing us to discuss the Topical Issue matter again about a meeting we attended in Clonmel last week. There were harrowing, heartbreaking stories. The Minister of State himself met one of those people some months ago, Ms Caroline Lonergan, who told the story of her brother. He pleaded for help. He cried out for it. He was clinging on by his fingernails but was rejected by every service. He eventually took his own life. There are countless other cases of people in the same situation. There were 400 pairs of shoes at the top of the stairs in memory of all the loved ones in Tipperary who have lost their lives in recent years. It is shocking. There is an epidemic and we have a dysfunctional, uncaring system that is unable to account for itself. Why would it, when there is no political accountability?

I am not going to dwell on Mr. O'Brien. He should be gone, and good riddance to bad rubbish as far as I am concerned. He has a chequered history of breaking and flouting the law. He did it with the Irish Family Planning Association a few years ago, and despite it all got a promotion from the Minister of Health, Deputy Harris. He is now mixed up in another gold-linked chain of board memberships. He was allowed to go and get other jobs when he had a job here that he could not do. The Minister of Health does not know the system. He does not have the experience and he is inept and unable. He should run away somewhere else and not deny the people what he promised.

There are excellent people working in the health service, including the Home Carers Association. Richie Molloy is the manager of that organisation in south Tipperary. There are so many people who give front-line service, and they are jaded. GPs are voting with their feet to leave. They have contracts that are almost half a century old that the Government will not renegotiate. They are constantly threatened. They are then told by the Minister that they are going to be the front line in delivering abortion care. Some 70% have said that they will not have anything to do with it, yet the Government believes it will force them into it. If the eighth amendment is passed, we will see Marie Stopes-type enterprises popping up. Many of the Government's cosy friends are involved in this. Fundraisers have been held for the Taoiseach. The whole thing is a stinking, rotten, murky cesspit, and the Government has no respect for the people.

People are going blind, and Deputies Danny and Michael Healy-Rae and Deputy Michael Collins are helping busloads of people to get to Belfast because their cataract operations cannot be performed in the Republic. They can be done in Belfast, however, and paid for here. What kind of dysfunction is the Government presiding over? Each Member of the Government has been through the political process. They should know that if they went back to their constituencies and said they were as dysfunctional as they are, they would never be seen again. To allow this malaise to grow is incredible. There is a hospital in Cashel that is empty. Some €22.5 million was spent on it. It is a patient-free and bed-free zone. They even took out the lift. There are managers galore. They were hired right through the recession. It is dysfunctional and it is giving the electorate and the Opposition the two fingers. It did it when it had a massive majority, but it is worse now that the Government is being supported, aided and abetted by the confidence and supply agreement.

The great leader of Fianna Fáil, Deputy Micheál Martin, set up the HSE. What will he say about it? There cannot be a vote of no confidence in Minister Harris now because of the referendum, where a cosy cabal will bring a gross, desperate industry into this country to perish our people again and to banish our young people and our future generations. To hell with the Government. It is a disgrace to humanity and it does not deserve to be sitting in this House. We are going out tomorrow morning to apprehend the Taoiseach. I am not going next to nor near the place. He should be ashamed of himself, going out there in the name of our dead generations and what they did for us. To hell with the people. Stand on them every way possible. Lock them out. Post office masters are being made to sign contracts saying that they cannot speak out. Is the Gestapo operating in Ireland? A man in Germany once carried on in this way and told the people that they could not think or do anything for themselves. We are going in a very dangerous direction in this country. Democracy is being subverted. We have spoken about terrorists. The Government is the real terrorist. Mr. Tony O'Brien is an emotional terrorist, with the bullying and intimidation of the parents of sick children. This Government will go down in history for terrorising the people of the country from whom it got a mandate, and a seal of office from the President so that it would help them. This Government is not helping the people and it does not care about them, but the people are waiting in the long grass with their pinn luaidhe in the ballot box and many egos will fall. This Government deserves no better.

Amendment put.

An Ceann Comhairle

In accordance with Standing Order 70(2), the division is postponed until the weekly division time on Thursday, 10 May 2018.

The Dáil adjourned at 10.10 p.m. until 2 p.m. on Wednesday, 9 May 2018.