Ceisteanna ó Cheannairí - Leaders' Questions

I thank the Ceann Comhairle for his statement, with which I agree.

On Leaders Questions on 1 October I raised with the Taoiseach concerns about the escalating costs at the national children's hospital. He undertook to reply to me. Last week, I received his written response, which again clearly points to escalating costs at the national children's hospital. It is all a far cry from April 2016, when the Taoiseach, then Minister for Health, announced that the hospital would cost €650 million all-in. Those costs increased year by year and the current Minister for Health had to apologise to Deputy Barry Cowen in the Dáil for misleading information about those costs. As the Taoiseach said in his reply to me, the guaranteed maximum price established through the two-stage tender process does not provide a contractual ceiling on cost and significant residual risks remain of additional further costs. These include the risk of construction inflation in excess of 4% which are allowed by the contract to be recovered.

We also learned from the Taoiseach's response and from the August minutes that the main contractor has submitted claims to the board, which I understand to be quite significant as well. For some reason, ICT is not covered in these costs, neither are the costs associated with the children's hospital integration programme. I suggest that is designed to reduce the overall cost for appearances and so on. I ask the Taoiseach to give me specifics on the costs of the ICT programme and the integration initiative.

The Taoiseach will recall that PwC's report on the construction of the new children's hospital was a shocking indictment of a badly-managed project. Critical phrases leap off the pages of that report, such as "Significant failures" and the "lack of sufficiently comprehensive or robust planning". The report said the understanding of the risk profile was "poor at all levels of the governance structure" and that "red flags ... were missed." The report said the business case: "contained material errors and did not adhere to the Public Spending Code." It also described the execution as: "poorly coordinated and controlled."

We have learned from the August minutes, as revealed in the Irish Examiner yesterday, that the State's chief procurement officer, Mr. Paul Quinn, who appears not to have alerted the Government to the original spiralling costs of the hospital, has resigned from the hospital board. This follows the resignations of Mr. Tom Costello and the project director, Mr. John Pollack. The minutes state that all we have at the moment is "a best estimate" on the overall cost of this project and that a significant increase in financial claims is being made by the contractors at the Dublin site, about which the board is very concerned. Can the Taoiseach indicate to me why Mr. Quinn has resigned? Does he know something the rest of us do not? How robust are the procedures, given the resignation of the chairman, director and the State procurement officer? Would the Government agree to an oversight mechanism from the Oireachtas to rigorously monitor the costs of this project, given its capacity to devour the health capital budget and delay and perhaps prevent other badly-needed projects from developing?

At the outset, I want to welcome the Ceann Comhairle's earlier statement. The integrity of the voting process is at the centre of our democracy. Whether it is people going to the polling station to cast their vote on election day or referendum day or whether it is Deputies or Senators voting in these Houses, people need to know the system is robust and valid. I welcome the fact you have acted swiftly, that an investigation is being carried out, that there will be a report this week and I welcome the fact the Deputies concerned will be invited to make statements to the House on Thursday to explain their roles in all of this.

On the Deputy's question, the cost of the capital element of the national children's hospital project, as agreed by Government in December 2018, is €1.433 billion. There has been no change in the Government decision since then, and that includes VAT. The €1.433 billion is the cost of the capital build in the project. That is the main hospital at the St. James' Hospital campus, as well as the urgent care centres at Connolly Hospital Blanchardstown and at Tallaght University Hospital. There have been references to figures such as €1.7 billion or even €2 billion but those figures can only be approached when lots of other elements of the project are included such as ICT equipment, the electronic health record and the entire cost of the children's hospital integration programme - which is decommissioning Crumlin and Temple Street hospitals and is moving those hospitals to the new site. Those figures also include pre-2013 expenditure on the failed attempt to build the national children's hospital at the Mater Hospital, which I know the Deputy will be familiar with, having been involved in same. They also include the children's research and innovation centre, as well as contingency provision. There is also a clause in the contract to allow for an uplift if the rate of construction inflation exceeds 4%.

These figures we often hear used such as €1.72 billion, are much more than the cost of the project at St. James' Hospital. People are including Connolly, Tallaght and the Mater project that never happened, as well as the moves out of Crumlin and Temple Street, the cost of ICT equipment, the electronic health record, the entire integration programme and the research and innovation centre.

On claims, as was stated last June at the joint committee, it is possible, as is the case in any construction contract, for a contractor to make claims for additional expenditure that was not covered in the contract.

Where those occur they are independently assessed before any decision is made on whether they should be granted.

With regard to the resignation of Mr. Paul Quinn from the National Paediatric Hospital Development Board, it happened in July 2019 and is not news and certainly not new news. He has not resigned from his day job working as a civil servant but he has resigned from his position on the board. His decision on this is a matter for himself. I do not know the reasons for it nor do I have any reason to believe there is a conspiracy theory behind it.

We have this kind of detached "It's none of my business". The Minister for Health says it is none of his business. The State procurement officer resigned from the board of the most expensive capital project in the history of the State and it is nobody's business, the Government is not a bit worried about it and it is his decision and a personal decision.

It is a conspiracy theory. I have deliberately reiterated for the Taoiseach the criticism of the PwC report on how badly managed the project was until quite recently. We have had the resignation of the director. Has the Minister for Health met the State procurement officer? Has the Minister for Public Expenditure and Reform met the State procurement officer? The project is a matter of genuine and reasonable concern to the Oireachtas. The minutes do not give room for any confidence. Surely the Minister for Health should meet the board, given the alarming levels and high volume of safety issues. It is in the minutes.

You should visit the site.

You should visit the site and meet the health and safety officers.

You have never visited the site.

Through the Chair, it is a high volume and there twice have been alerts in the minutes.

He was an engineer.

I call for a full, transparent presentation on what the concerns are about health and safety on the site.

The Deputy's time is up.

Relative to other sites, what is going on there? More importantly, why is the State procurement officer getting off the bus early?

Deputy please, the time is up.

Does he know something we do not know? I ask the Taoiseach whether the Government will now agree, given the history of the project, to an Oireachtas oversight mechanism, perhaps through the finance and expenditure committee, to monitor the project very closely?

Deputy, you are way over time.

There have to be serious question marks about how robust the process is in terms of coming in within some reasonable budget.

Mr. Quinn was appointed to the board in his individual capacity and he resigned in his individual capacity. It is up to him to say whether he had a particular reason. I am not aware of a particular reason for his decision to resign from the board last July. The Oireachtas Joint Committee on Health has oversight over the project.

As recently as June, the chairman of the hospital development board, Mr. Fred Barry, came before the committee and was asked a lot of questions. I am sure the committee can do so again. I do not think anyone in the House would have any objection to the Oireachtas taking an interest in the project.

The Taoiseach will be well able to open it.

I believe the committee has been invited to visit the site. I believe that, unfortunately, only a small number of Deputies have taken up the invitation to take a look at the site with their own eyes.

Any high-vis jackets left?

Put on your hard hats and get your photographs taken. We will have to queue up behind you.

What I can say is that I had the privilege and honour of visiting the urgent care centre at Connolly Hospital, which is now up and running. It is not fully commissioned but is now up and running. It is the first element of the hospital and children are being seen in the urgent care centre.

There are a lot of design faults.

The outpatient element is fully open and already the number of children waiting to see a general paediatrician has decreased by 30% as a consequence of the fact the facility has been opened and there is now more outpatient capacity for children who need to see a paediatrician.

Health and safety.

Tallaght is under construction and will be finished next year. Construction of the main hospital on the St. James's site has reached the point where the scaffolding is at roof level.


This was promised by successive Governments for decades.

Health and safety.

Fianna Fáil even spent a lot of money not delivering it and now it is being done.

Health and safety.


Deputies, please.

Will the Taoiseach undertake to send me the details on the health and safety aspect of the site?

Deputy Martin has gone over his time already.

I cannot. I do not know.

I do not know; I do not know.

Can we hear Deputy McDonald please?

I want to raise the controversy that has struck at the integrity of the voting system of the Dáil. Over the weekend, as we know, it emerged that Deputy Niall Collins voted on behalf of Deputy Dooley on six separate occasions. Subsequently, questions have been asked of other Dáil Deputies as to whether they cast votes for absent colleagues.

This has been portrayed by some as a controversy over who sits in what seat - a game of political musical chairs, Deputies sit in the wrong seats and press the wrong buttons. We must acknowledge that the real world outside looks on gobsmacked at the fact that highly-paid officials cannot manage to sit in the right seats or hit the right buttons. I suggest that we collectively decide that, from hereon in, we will sit in our designated seats and endeavour to press the right buttons. That would resolve the concerns over musical chairs.

The real story here is much more serious and alarming because Deputies have cast votes on behalf of colleagues who are not present before also casting their own vote and, thereby, voting twice on a given question. Article 15 of Bunreacht na hÉireann states that the decisions of this House are determined by a majority of the votes of Members who are present and voting. Our own Standing Orders echo that position. Standing Order 77 explicitly sets out that Members must be present to vote. We are elected to make laws, amend laws, pass budgets and make decisions that impact society and the lives of real people. Measures have been voted on in this House that have denied respite care, taken away home help hours, prevented meaningful action on runaway rents and I could go on. It is because of the gravity and reach of our decisions that we must be present and vote. That is why it is spelled out so explicitly in the Constitution and Standing Orders.

The behaviour of Fianna Fáil Deputies has discredited the Dáil. It conveys a complete lack of regard for the Oireachtas and institutions of governance. It demonstrates, above all, an absolute disrespect for those who have elected those Deputies and who they represent but it is even more serious than that because if the behaviour of the Fianna Fáil Deputies represents a pattern of behaviour in that party, it calls into question the validity of decisions and votes taken here. That is how serious it is to vote on behalf of a colleague who is not present or to vote twice on any given issue.

I ask the Taoiseach for his response to this. Beyond the investigation that has been ably taken up by the Ceann Comhairle, how are we to establish whether this practice is, and has been, widespread? How will we deal with the consequences of that?

I want to say once again that I believe the integrity of the voting process is absolutely central to our democracy. When people go out to vote and cast their ballots on election day or on referendum day, they expect the procedures to be followed properly. It would be a crime if an ordinary citizen cast a vote on their own behalf and that of someone else. To vote on behalf of somebody else is impersonation and to vote twice is a crime. It would be no defence to say that it did not matter because the person who won the election did so by a wide margin anyway. We must apply the same standards to the Members in this House as apply to ordinary citizens going out to vote on an election day or referendum day.

Deputy McDonald rightly quoted the Constitution. Bunreacht na hÉireann states that any votes that occur in this House must be decided by majority vote cast by Members who are present and voting. There is a world of difference between someone being present in the Chamber, although not in one's seat, and not being present in the Chamber or the building at all. To allay any future concerns or confusion, all Members should be in their seats for all votes from now on.

I welcome the Ceann Comhairle's comment earlier that there will be an investigation and report this week and I very much welcome that. I understand that, separate to that, a complaint is going to be assessed under the ethics Acts. I believe that is done by the Committee on Procedure and that will allow for a hearing. I also welcome the fact that there will be statements on this issue on Thursday and those Deputies who admitted to voting on behalf of others, or allowing votes to be cast on their behalf when they are not in the Chamber, will have an opportunity to make a personal statement at that time and will perhaps also agree to take questions.

Over the course of the weekend I was asked by somebody in my constituency whether it would be okay if they showed up at a polling station and voted for their friend because their friend could not make it. Of course, the answer was, "No, absolutely not." There cannot be one law or standard for citizens and the electorate and a different one for Deputies. The real concern is beyond the antics of Deputies Niall Collins and Dooley and others in Fianna Fáil. Is this a pattern of behaviour? Was it an isolated incident, or is there some unwritten, implicit or explicit agreement between some Deputies that it is all right to cast a vote for colleagues who are not present? That needs to be established. I absolutely accept, a Cheann Comhairle, that you will do your work diligently in respect of last Thursday's turn of events, but the big question for the people is whether it is how we do our business here. That is what citizens are asking. Aside from not sitting in the correct seats and the almost farcical comedy it was, is something else at play? How will we establish if that is the case? Beyond the inquiry and investigation that will be carried out by the Ceann Comhairle, how will we establish whether this is a pattern of behaviour engaged in by Fianna Fáil in the House and how will we deal with the matter? What is the Taoiseach's view, as Head of Government?

The Deputy asked some very pertinent and relevant questions that deserve answers. Unfortunately, I cannot give them because I cannot speak on behalf of Fianna Fáil Deputies or any individual Deputy. It is agreed by all of us that an investigation is required. The Ceann Comhairle has announced that it will be carried out by the Clerk of Dáil and that there will be a report this week. Separately, I understand some members of the public have made complaints under the ethics Acts which will result in a statutory investigation to be held by the Committee on Procedure. We should allow those investigations to take place and I hope they will be thorough and robust. It is welcome that there will be an opportunity to make statements and have a debate on the matter on Thursday.

I also welcome the Ceann Comhairle's statement on the voting controversy in the House last Thursday. I, too, regard it as a most serious matter that deserves to be addressed urgently and resolved.

The Government recently announced plans to extend free GP care to children aged seven and eight years. As the Taoiseach will know, the previous Government provided GP care for all children up to the age of six years and for those over the age of 70. The move to provide it for the under-eights is a slow realisation of the pledge made by the previous Government to provide free GP care for all. It suggests the current Fine Gael-led Government is not convinced by the arguments made in the Sláintecare report for a single tier public healthcare system, rather than the current two tier one. It is also another example of the poor use of public finances. The Government will have to negotiate with the GPs again to agree a new contract to cover the under-eights. What then? If free GP care is expanded further to the under-tens or the under-12s, it will require new contracts. How many contracts will it take before the Government reaches the objective of providing free GP care for all? How much more time and money will it take to go through the various rounds of negotiations? Every time there is a new contract, the public finances lose leverage over the whole project and the next phase becomes more expensive. It would be much better value for the money to move directly to providing free GP care for all those above the age of 18 years, which is what we had envisaged, rather than take a series of incremental steps. We know from medical statistics that older people and the under-sixes use GP care services more than most and they already have access to free GP care. By and large, people with major medical needs have a medical card.

There is simply less medical need among the population of older children, teenagers and working adults. It does not require an incremental approach. It should be done as one negotiation. It is inefficient to drag this process out and it represents a failure of Government to deliver. We were able to negotiate care for children under the age of six in the worst of times but no progress has been made on this critical issue over the past three years. I have two questions. Will the Government agree to extend free GP care to everyone or at least to those under 18, rather than the policy announced by the Taoiseach of simply adding another two years to include those under eight? If not, will the Government at least produce a cost-benefit analysis of both courses of action?

I thank the Deputy. I am very committed, as is this Government, to moving towards universal healthcare in this country, but I also know the steps that have to be taken and how difficult it is to achieve that. Part of universal healthcare and the Sláintecare vision is ensuring that everyone in the State has access to healthcare that is either free at the point of use or provided at a very low and highly subsidised cost. My party, in coalition with Deputy Howlin's party, made a very positive step in that direction even before Sláintecare by extending free GP care to all children under six and all adults over 70. I worked closely with the Deputy and the then Minister of State, Deputy Kathleen Lynch, to deliver that during the last Government.

This Government, comprising Fine Gael, the Independent Alliance and Independents, has built on that still further. We extended the medical card without any means test to all children with profound disabilities, 40,000 of them. We also extended free GP care to anyone in receipt of the carer's allowance and carer's benefit.

Last year, we increased the income limit for low-income working families by 10% so that more of them would qualify for free GP care. The budget announced a few weeks ago included changes to income limits to extend the full medical card to approximately another 50,000 people aged over 70.

This Government has very much built on the progress Fine Gael and the Labour Party made together. We intend to build on it still further. The next step, which will be taken later next year, is to extend free GP care to children aged seven and eight. The year after that, it will be extended to children aged nine and ten, and the year after that to those aged 11 and 12. That does not preclude us from also doing other things by changing income limits, but that is our current plan.

The incremental approach is right. When I was introducing free GP care for children aged under six, I remember seeing the research from health experts and all of the people who go on the radio and tell us about health expertise. They said there would not be a big increase in attendance of GP services by those under six. They were wrong because there was. We know that now. When free GP care for children aged under six was introduced there was a big increase in attendance at GP surgeries, particularly at out-of-hours services. I do not want to do this too quickly and overwhelm the capacity of general practice to deliver. The NHS is a pretty good health system, but people using it have to go on waiting lists to see their GPs. A two-week or three-week wait to see a GP is normal in the NHS. I know that happens in Ireland, but it is pretty uncommon. I do not want us to overwhelm the capacity of primary care and general practice to deliver. That is why I think it is better to do this in an incremental manner, and that is what we have decided to do.

Legislation is required to deliver on the commitments. It is relatively straightforward. The Minister for Health is working on it. We think we can have that through the Houses before Christmas, or if not, in the early part of next year. It requires consultation with GPs on fees. However, because we have agreed with the GPs that this will not be compulsory and they do not have to provide the service, it does not require negotiation to be concluded. We just need to consult GPs on fees. They can then decide whether they want to opt in to providing care to children aged seven and eight.

There will be another budget now and we will try to get it all sorted.

If the Minister of State reflected on what the Taoiseach has just said, he would be shocked. He basically said that he does not want GPs' surgeries to be overwhelmed so he will put a brake on them, namely, cost. The Government will continue to charge and that will be the brake. If people can afford to go, off they will go. The Government will monitor and reduce the numbers by keeping a charging mechanism in place. That is not the universalism approach we have been advocating and which we advocated in government.

The changes the Taoiseach has outlined move against the principles of universalism - a universal health system available on the basis of the need, not ability to pay. Having been in the Department of Public Expenditure and Reform for five years, it makes no sense to me to negotiate incremental contracts. The closer we get to getting the final tranche done, the more it will cost. That has been the experience of any incremental contract system. It is much better to do it in one fell swoop and agree a contract for all the under 18s and then the next tranche up to full universal coverage. That is the approach we worked on together in government but it has been abandoned since the Labour Party left government. It is not acceptable to propose reducing pressure on GP surgeries by continuing with a charging mechanism that allows those with the money to have access to have their children treated, but those without the money to have to wait.

I do not think that is quite the case. We agreed in government that we would first provide free GP care to those aged under six and over 70 regardless of their incomes. The next step we had agreed - money was provided in the Deputy's final budget - was to go from age six to 12. We were, therefore, pursuing an incremental approach.

This Government has done something slightly different. We decided to increase the income limits by 10% for low-income families. Some 40,000 children with profound disabilities now get full medical cards as of right regardless of their parents' income. We have decided to increase the income limits for the over 70s in the budget just introduced. We also decided to give people on carer's allowance and carer's benefit access to free GP care because carers also need to have their health looked after. It is still an incremental approach by the previous Government and by this Government, but perhaps a different approach to that incrementalism.

I will answer the Deputy's question very frankly and I say this as a former GP, former Minister for Health and Taoiseach. If we provided free GP care for everyone tomorrow, next year, the following year or even the year after that, we would overwhelm primary care and general practice in Ireland.

People cannot see their doctor if they cannot afford to.

We know from the experience with those aged under six that there is a big increase in attendances. I do not want us to have primary care systems such as those in the NHS-----

Sick people have to stay away because they cannot afford to pay.

-----where people have to wait for weeks and weeks to see a GP. That is not the norm in Ireland at the moment and I do not want to see general practice and primary care overwhelmed. I do not want a situation where people cannot get a GP - I know that is an issue for some people-----

It is for a lot of people.

-----but most people still can - and where people have to wait for two or three weeks as the norm to see the GP, as is the case in England. We do not want that to happen here. It is better done incrementally in co-operation with the GPs and the IMO representatives.

I welcome the speedy inquiry into the voting debacle.

I might direct the Taoiseach's attention to what is the norm in our hospital in Galway. However, it highlights in the most acute way the utter failure of the Taoiseach and the Government to focus on public health and the hospital in Galway. As recently as 25 September in the Taoiseach's absence, the Minister, Deputy Humphreys, answered questions and I raised the hospital in Galway. I specifically raised it in the context of the INMO statement that warned that Saolta management should be gravely concerned due to the high levels of missed care, delayed care and poor patient outcomes arising from the number of nursing and midwifery vacancies.

I went on to highlight the 200 vacancies. The Taoiseach has referred to primary care, which is an illusion. I mentioned the de facto embargo in primary care and I mentioned 11 posts. I spoke of the continued closure of a theatre at Merlin Park and a consultant telling us that the situation was unbearable and that management could not cope with it. Since then I have discovered that there have been 13 external reviews into the situation at the hospital over a ten-year period, which is more than one a year. It looks like we are heading for another external review.

A family contacted me about what happened to their 74 year old mother. I ask the Taoiseach to listen and put himself in the shoes of that woman or, indeed, on the trolley on which she spent 72 hours even though the policy and ethos in the hospital require that it be no more than 24 hours. That woman was admitted from another hospital with a suspected infection, which I might add was hospital acquired. Subsequently, during her three days on the trolley she was found on the floor screaming in pain.

Nobody knows how it happened. She was taken back to a bed or trolley and left for five solid hours without having an X-ray or pain relief. The family who have no medical training diagnosed that she had a broken hip. As the Taoiseach can imagine, it must have been very obvious. Subsequently, when they had a little energy, almost two and a half weeks later they made a formal complaint, but they heard nothing from the hospital until the formal complaint was made. Once it was made, they received a telephone call and learned that some investigation was in being. We do not know what type of investigation is being carried out, who is behind it, when it started or when it will be completed. I want the Taoiseach to take a hands-on approach. I also want the Minister for Health to come into the Dáil with a written statement and convey to us verbally what happened to this patient in Galway, how it happened, why the family were not contacted and explain to us exactly what happened because, unfortunately, it is not unusual or uncommon.

I am very sorry to hear about what happened to that lady and, of course, my thoughts are with her family. As is often the way when an individual case is raised in the Dáil, I am loath to speak about it because I do not have all or any of the facts of some of individual cases. However, I have been informed that there is an investigation under way into this case. There is a Garda investigation and one by the hospital authorities. I do not think it would be appropriate for me or the Minister for Health to comment on an ongoing Garda investigation or one by the hospital authorities that is ongoing, but I absolutely agree that whatever happened in this case, the incident needs to be investigated thoroughly by the Garda if there is a criminal aspect to it - I understand there may be - and by the hospital authorities in respect of her medical care. The Minister for Health and I will follow up on the case and make sure any investigation that should be carried out is carried out, but for very good reasons mentioned, we will not be commenting on any investigation while it is ongoing.

As the Taoiseach has not used the three minutes available to him, I might take some of the time for my answer because this case is really serious. I am not asking the Taoiseach to comment on the individual facts. That is not possible and it is not my way. I am asking him to acknowledge that both he and the Government have been put on notice repeatedly about the state of the hospital in Galway. It is not fit for purpose. It is No.1 on the risk register in terms of capacity. We have put the Taoiseach on notice about this. I have pointed out that in a period of ten years there have been 13 external reviews, or more than one per year, carried out. I am not talking about an internal or other type of review which, presumably, includes those carried out by the Health Information and Quality Authority, HIQA. In this case the woman was allegedly assaulted by somebody who was drunk and roaming about with a carer but not being properly cared for. There was no porter to take the woman to a hospital between 6 a.m. and 9 a.m. There were no security staff. One cleaner appeared to clean up the mess when the person who was allegedly drunk also went to another patient. The family were told, "Let's go forward." Can the Taoiseach imagine from his previous life a diagnosis of a hip fracture being made by a patient's daughter who has no medical experience? I want him to consider this in the context of what other Deputies and I have continually said to show him that the hospital in Galway is not fit for purpose. The Irish Nurses and Midwives Organisation put him on notice that it was "gravely concerned", that there would be "delayed care", "missed care", "poor care" and so on. I really want an answer to the question about the absence of staff, the overburdened health system and the collateral damage of people suffering, not just from their illnesses but also from mismanagement in a health system that is not fit for purpose.

I absolutely acknowledge that the Deputy is putting us on notice about this issue, issues in the hospital in Galway and the health care system in general. There has been considerable investment in University Hospital Galway in recent years.

The budget has been increased year on year for the last three, four or, perhaps, five years and there are more staff. The new 75-bed block, all individual rooms, which was opened in the last 18 months is a good addition to the hospital too. We have never had a bigger health budget than we have now and we have never had more staff working in the health service than we have now, but I appreciate that it is not enough. We need to increase the number of staff and budgets for health care further. All of this is provided for in the budget to which we agreed only a week or two ago. We need to add more beds to the hospital system, as well as investing in primary care services. When it comes to the hospital in Galway specifically, there is another new block in planning - a new emergency department - which I accept is long overdue. As part of the new block, there will be maternity and paediatric services also. We need to get it through planning and start building it.