Dáil Éireann debate -
Thursday, 19 Oct 2023

Vol. 1044 No. 3

Investment in Healthcare: Statements

Minister of State at the Department of Health (Deputy Hildegarde Naughton)

As Deputies are aware, ensuring people are healthy and active and that they get the healthcare they need when they need it is a priority for this Government. These are not just empty words. Let the facts speak to the Government’s commitment to ensuring that our health services are well funded. Over the past three years, the Government has delivered record investment in healthcare. The Government’s €22.5 billion health budget for 2024 is the biggest ever and will facilitate the continued delivery and expansion of quality, affordable healthcare services. This funding equates to a spend of €4,000 for every man, woman and child in the State.

The emergency department action plan is fully funded, which means that anybody who arrives in an emergency department having suffered an accident or medical emergency will be seen and will get the treatment he or she needs. The waiting list action plan is also fully funded, which will reduce waiting times for life-altering treatment. Funding to maintain existing services has been provided to meet inflation and rising patient demand. Resources are in place to hire 2,000 staff additional to those already there. Provision has been made for the opening and staffing of six new surgical hubs across the country, including in my constituency in Galway.

We must be honest and say that, despite the great strides made in recent years, we need to do more in the coming years. We must also point to the fact we have an ageing population and pent-up demand for services has arisen as a result of Covid-19, so the demand for healthcare has increased and continues to rise. It is clear, too, that, the HSE must deliver services in a more efficient manner, achieving cost savings where it can and ensuring taxpayer’s money is spend as efficiently as possible. I have every confidence that the Department of Health and the HSE will ensure this happens in 2024 and future years.

I will turn to developments in the areas for which I am responsible as Minister with responsibility for public health, well-being and the national drugs strategy, outline some of the progress made in recent years and set out some exciting new initiatives under way. Among the best uses of public money in our health service is spending to avoid the onset of medical conditions through the promotion of healthy lifestyles. A key element of this preventative approach is our healthy Ireland framework, at the core of which is the healthy Ireland fund. Working with partners including Departments, agencies, NGOs, community organisations and the country’s 31 local authorities, this fund focuses on health and well-being with programmes designed to counteract and prevent negative health outcomes as a result of smoking, alcohol, poor diet and physical inactivity, as well as addressing the wider social and environmental factors which impact on health and well-being. Established in 2017 with an initial annual budget of €5 million, we have gradually increased investment in the fund in the years since. Our budget for the fund in 2023 was just over €14 million and I was delighted to secure an additional €2.3 million for 2024, bringing the total to some €16.5 million. That represents an increase of 16%. That is new money and new investment in this important initiative.

Knowing the importance of good nutrition and the development of good eating habits, I secured an additional €300,000 to facilitate the recruitment of four community food and nutrition workers, which will bring the national complement to 19. These workers are a vital support to local communities in developing responses to food poverty and insecurity.

I am pleased to highlight the further development of outdoor exercise facilities. In 2024 we will build on the success of the GAA walking trails initiative that I announced earlier this year. The Government will also provide funding to develop facilities to support outdoor swimming.

Some €1 million will be provided for these initiatives next year.

Our smoking rates continue to give cause for concern, given the huge impact they have not only on the individual in terms of poor health outcomes but also on the wider health system. Great strides have been made, with the percentage of the population who smoke falling from 23% in 2015 to 18% in 2022. Some 22,000 people are expected to engage with HSE anti-smoking services in 2024, of whom a quarter will require medical intervention and supports. A total of €1.82 million is being provided to assist these people in kicking the habit.

Moving to sexual health, the House will be aware that work continues on the development of a new national sexual health strategy and as part of this we will increase the budget for free home sexually transmitted infection, STI, testing by €700,000, allowing people to test in the privacy of their own homes. Some 91,000 testing kits were provided last year, and this valuable initiative will expand over the course of 2024. We will also increase funding for our national HIV pre-exposure prophylaxis programme, PrEP, to help fund additional staff and increase access to PrEP medication, helping to provide better access to HIV prevention for more people.

As part of our response to tackling gambling addiction, some €500,000 will be provided in 2024 to develop supports for the estimated 130,000 people with problems in this area. Since my appointment to the Department of Health almost ten months ago, I have met many people who use drugs, some of whom are living with addiction, medical experts and people delivering addiction services on the ground. One key message that I have received has been that we need to change how we think about and tackle drug misuse and addiction.

At the heart of this is ensuring that core services are funded and in 2023, I provided an increase in core funding for our drug and alcohol task forces and section 39 organisations. Knowing the importance of education, I also provided €1.5 million in funding for a drug and alcohol education and awareness programme, the first time such funding has been provided. For 2024, we are going to deliver new groundbreaking services never before provided. They include dual diagnosis hubs, which will support the recovery of young people with drug dependency and mental health issues, and dedicated funding for services after people embark on their road to recovery to support their integration into everyday life through housing, employment, education and other supports. It is important to note that in the last two years alone. funding for our drug and alcohol services has increased by almost €10 million. I am keen that we continue to build on this so as to ensure the fantastic care that is provided from within the community is supported.

In conclusion, I would like to pay tribute to all the workers and professionals working across our healthcare system for their hard work and dedication, and to thank them for the care they provide to people who are often at their most vulnerable. These people are often forgotten in a politically-charged debate but it would be remiss of me not to pay tribute to their enormous contribution in helping to keep people healthy for longer.

Minister for Health (Deputy Stephen Donnelly)

I am really pleased to have this opportunity to address the House on investment in healthcare. Before I do, I would like to add my voice to those condemning the bombing of the al-Ahli Baptist Hospital in Gaza. While there are claims and counter-claims about which side the bombs came from, the killing of hundreds of innocent patients, healthcare workers and families is outrageous. Our thoughts are with the families of all those who died and were injured.

At the same time, we must never take our eyes off the Russian murderers who have deliberately targeted healthcare workers, patients and health facilities in Ukraine. According to the Ukrainian health minister, Russian forces have destroyed around 180 hospitals and damaged more than 1,200 hospitals. They have shot up more than 350 ambulances. These deliberate attacks are utterly repugnant. They violate international law and the clear protections that should be in place for patients, healthcare workers and health facilities.

To turn to the debate in hand, for years we have invested in our health services at a lower rate than many other countries. Of the 15 western European countries, Ireland comes 11th in terms of the amount we invest in healthcare per person. Germany, the Netherlands, Austria, Belgium, France, Sweden, Norway, Switzerland, Luxembourg and Denmark spend more than we do per person on healthcare, when we adjust for local prices. Of the best comparator countries we have, we are in the bottom third. We need to bear that in mind when we have any discussion on future investment in healthcare.

The result of this was that when Covid arrived, and before that, we were not in a good place. We had fewer hospital and ICU beds and hospital consultants then many of these countries. We have not opened a new hospital in 25 years. Our digital health or ehealth service is rated as one of the poorest in the entire EU. We all know that this has led to higher waiting lists and too many overcrowded emergency departments in too many hospitals.

There has been a response to this. The response has been an unprecedented increase in funding for healthcare. The previous Government, in its last three budgets, increased core funding for healthcare by 40%. In the first three budgets of this Government, that was increased by a further 18% increase. That is a huge increase in capacity, but capacity alone is not the only solution. Our health services were not designed to treat the greatest number of people for the money that is available. Until recently, too many people were being treated in hospitals rather than in the community, which is a better and less costly place to provide that care.

Our goal is high quality, affordable healthcare for everyone when they need it, that is, universal healthcare. We are all signed up to that via Sláintecare. To achieve this in the lifetime of this Government, we have been following a clear plan, namely, increase the capacity of our health service and fundamentally reform how and where patients are treated. I fully accept that there is still a long way to go. This will take years to do. However, thanks to the efforts of our healthcare workers, substantial and important progress is being made. Our focus, as colleagues will be aware, has been on reducing costs, improving services and speeding up access for patients. Inpatient hospital charges have been abolished, saving people up to €800 a year. Free contraception has been rolled out to women up to the age of 30. Half a million more men, women and children have access to State-funded GP care. We have just rolled out State-funded IVF for the first time. The most a household now has to pay for medicines in any month has been reduced to €80.

We have allocated unprecedented funding to our national clinical strategies. Our healthcare workers are in the middle of delivering a revolution in women’s healthcare. This includes opening new menopause clinics, fertility hubs, perinatal mental health teams, specialist endometriosis centres, same day see-and-treat gynaecology clinics and lots more across the country. That is having a huge impact. New services are becoming available for the first time in areas like diabetes, stroke, dementia and obesity. Existing services are being expanded in cancer care, maternity, trauma, home care, cardiology, ambulance services and lots more. Last year, waiting lists fell for the first time since 2015. We all know there is a long way to go, but progress is being made. The total number of patients removed from waiting lists in the first eight months of this year is 150,000 more than was achieved last year. The number of patients being treated who have been on waiting lists is going up, thanks the work of our healthcare professionals and the unprecedented level of investment the Government is providing to them. We are absolutely determined to continue with that progress.

Waiting lists in the Republic are now half of what they are in Northern Ireland. For the most urgent cases, that is, people waiting more than a year for a hospital procedure, believe it or not waiting lists in Ireland are now one tenth what they are in Northern Ireland. Our healthcare workers deserve huge credit for bringing this about. Over the past three years, we have added 22,000 healthcare workers, comprising 6,700 extra nurses and midwives, 3,100 additional health and social care professionals and 2,500 doctors and dentists. We have increased our hospital bed capacity by over 1,000. We have significantly increased ICU capacity. We are going to keep going.

Critically, we are also improving productivity in our health services. A growing number of people are now getting the care they need when they need it and where they should be getting it, which is in their own community rather than having to go to hospital.

This is better for patients and better for our health service because such care can be provided at a fraction of the cost of someone having to go to hospital. This is not happening by accident. It is happening because over the past two and a half years we have rolled out a completely new community care service, called enhanced community care. We have 180 new healthcare teams around the country doing this. There are 96 primary care teams, 30 chronic disease management teams, 30 older persons' teams and 30 community intervention teams.

We are working with our clinicians to have them provide care to patients to the fullest extent of their qualifications, which they want to do. Our GPs are playing a more central role. The new public-only consultant contract is phasing out the deeply distorting effect of private income on public hospitals. The safe staffing framework for nursing is being rolled out in every hospital, making Ireland one of the leading countries globally in making sure we have the right level of nursing care for a given level of patient need on any given day, on any given ward.

We are training and hiring more advanced practitioners in nursing and midwifery and rolling this out for health and social care professionals. We are working with pharmacies to support them in providing a higher level of care in things like oral contraception, minor ailment clinics and more, which we are in discussions with them about.

The National Ambulance Service is going from strength to strength. It is providing more advanced care in the home or on scene, avoiding the need for patients to go to the emergency departments. We are investing in injury units and other initiatives to provide people with alternatives to emergency departments.

We are also rolling out a new productivity system in every public and voluntary hospital so that for the first time we will be able to see the extent of patient care being delivered by every hospital, every clinical speciality and every consultant. We have never had the ability to do this before. It is central to being able to ensure that patients are getting the best care possible, given the resources being provided to our healthcare professionals.

The budget for 2024 will continue a lot of this progress. The total budget allocation is €2 billion. Approximately half of that is recurring funding and the other half non-recurring funding. The waiting list action plan and urgent care plans are fully funded. Staffing is fully funded for 162 new acute beds, 22 new ICU beds, which is a very welcome increase, six new surgical hubs, which we are deploying around the country, and 70 new community beds. There is a lot more investment through HIQA in expanding the appropriateness and the quality of the existing community beds.

Full year costs for new measures such as 500,000 more GP cards and IVF are included. We are increasing the age for free contraception to age 31. I admit this is a modest increase. Colleagues will be aware that I wanted to go further but I was determined that we would not just stop at age 30. We have to keep the progress going. I am determined that we will see free contraception provided to all women. That is the policy objective we are committed to and that is why I made sure that we are make some progress. It is not the increase I would have liked but we will keep going with it.

Funding is also in place to continue with our Covid vaccine and testing and tracing programmes as well as supports for Ukrainians fleeing war who need access to our health services.

Between the budget and conversion of agency costs, we intend to hire 2,000 more healthcare workers. This includes the full completion of the roll-out of the safe staffing framework, phases 1 and 2, in all public and voluntary hospitals. It includes more advanced practitioners, more training posts and more expertise for ehealth, which we are laggards on. I am determined to make big strides in this regard.

Some areas are not getting the same investment next year as they have over the past three years. This is due primarily to an increase in inflation and patient demand being well in excess of what was forecast last year. This requires approximately €1.1 billion of the €2 billion allocated for this year. More than €700 million in recurring funding is allocated for current service levels next year and an additional €400 million in one-off funding for the non-pay pressures being seen in the hospitals is allocated for next year. This includes the necessary increased spending on medicine, catering, cleaning and all the things required in our hospitals to deal with the increase patient demand.

There has been much discussion on whether the budget is sufficient. I note the position of the chief executive officer of the HSE. Echoing the Tánaiste, the CEO is completely within his rights to give his view publicly on what he sees as the challenges faced in running our health services next year. He has my full support in having made the comments that he made.

Like many other countries in Europe, we are experiencing unprecedented demand for services. I want to give colleagues a flavour of what we are dealing with. Over the past 12 months, there have been 3.5 million outpatient appointments and 1.8 million inpatient and day case attendances. Our hospitals also treated 1.7 million patients in emergency care. The number of people, so far this year, referred to a hospital consultant is up 16% on last year. That was not forecast. It is not normal. I, along with others, believe that it is part of a post-Covid surge in patients, possibly due to deferred care during Covid.

The number of people aged 75 and older presenting at emergency departments is up by more than 20% versus pre-Covid levels. These are enormous increases in demand. I give huge credit to the HSE because these increases are being met. Not only are the increases being met, targets are being exceeded in the number of outpatient appointments being provided to get people off the waiting lists.

After the budget last week, I indicated that a supplementary budget for next year is entirely possible. We simply do not know at this point what demand will be seen, and what rate of healthcare inflation we will have to cope with. These two factors will be the main drivers of any potential supplementary budget. For example, this year's supplementary budget is estimated at approximately €1.5 billion. I believe that two thirds of that is due to higher than forecast inflation and the huge post-Covid demand, which was not expected.

While we address these challenges, we are going to continue our work on increasing productivity and treating more patients with the resources available. I am also commissioning an in-depth report into the future costs of healthcare. We are all united in our ambition for healthcare for everyone in Ireland. We are agreed on where we need to go on this. We need to understand better exactly how much that will cost in a much more volatile world than when the report was written in 2016 and 2017 in terms of medical inflation, post-pandemic patient demand and wars in Europe. This report needs to include some of the more modern innovations such as personalised medicine, artificial intelligence, remote sensors, breakthrough medicines for conditions such as dementia, genetics advances and much more. This can provide us with a baseline that everyone can work to in order to get to the place we all want to get to.

Minister of State at the Department of Health (Deputy Mary Butler)

I am very pleased to comment on the investment in health by the Government. I will focus on the areas of older persons and mental health services.

Ensuring adequate and appropriate supports for older persons' health and well-being has been a priority for me since I took office. There should be no doubt that investment in social care older persons' services has been a major priority for this Government. The budget has risen from €1.97 billion in 2020 to just over €2.6 billion next year. According to the World Health Organization, WHO, Ireland had the highest life expectancy in the EU. It is also the first country in the world to secure age-friendly status.

Next year will see the largest allocation ever for older person services, representing an overall increase of approximately 32% since 2020. Every day, a wide range of core services continue to be provided for older people across the country. This includes home support, day care, community supports in partnership with voluntary groups, intermediate care, as well as long-stay residential care when remaining at home is no longer feasible. The nursing homes support scheme, or fair deal, was designed to protect and support vulnerable older people to ensure equal access to nursing home care based on what they could afford. This gives important certainty to older people and their families.

In 2023, I secured a funding increase of €40 million for the scheme and for 2024, a further increase of €35.6 million. This funding will support nursing homes to maintain services and to manage inflationary increases.

I announced in budget 2024 the establishment of a dedicated new €10 million fund to support private and voluntary nursing homes with HIQA regulation and compliance measures. My officials are working on the details of the scheme which will be announced shortly. That is bringing investment to nursing homes to an additional €45.6 million for 2024.

This is in addition to the substantial support the Government has provided to the private and voluntary nursing home sector over the course of the pandemic. Over €151 million has been provided through the temporary assistance payment scheme. The Government continues to provide free PPE and oxygen to private nursing homes, costing approximately €77 million to date. A €10 million temporary inflation payment scheme was established last year. It was extended twice and a short-term extension to this scheme is currently under review.

Across the country, our HSE community nursing units play a vital role in the provision of long-term care. The Government is committed to continued investment in healthcare infrastructure which supports the highest quality care for our older population. This investment includes the community nursing unit programme, which was launched to ensure that up to 90 of our public community nursing units, CNUs, would be refurbished, rebuilt or replaced to ensure the best quality environments for our older people. On Monday, I was honoured to open the new Joe and Helen O'Toole CNU in Tuam along with the Tánaiste and the Minister of State, Deputy Rabbitte. It was fantastic to see such a state-of-the-art facility.

The delivery of home care continues to increase each year. In 2020 some 17.5 million hours were delivered. In 2024 we expect to deliver 22 million hours of home support. This is more than has ever been delivered before. The Government has prioritised home support and provided over €228 million in additional funding since 2020. The budget for home support today stands at €723 million. I know people will point to the waiting lists, with approximately 3,000 people funded for home care but only receiving a partial package and about 3,000 people funded for home care but we do not have the carers to provide it. It is important to point out that the budget is there to fund those 6,000 people. The HSE provides approximately 40% of home support hours directly. Of the posts funded in 2023 for home care, 55 are still outstanding and still being recruited. Recruitment also continues among private and voluntary providers who deliver approximately 60% of home support.

Dementia continues to be a priority for the Government. In budget 2024 I announced that a minimum of 18% of all new home support hours are now ring-fenced for people with dementia. I also announced €300,000 new funding for weekend activity clubs for people with young onset dementia - working with the Alzheimer Society of Ireland - which will provide social activity and peer support.

It is the Government’s stated policy to support older people to age in place for as long as possible. We know that our community services play a vital role in helping to keep older people well, out of hospital and living in their own homes and communities for longer. Over many years, both day care and the meals on wheels services have proven to be important components of the community services offered to older people, particularly in rural communities.

We are continuing to build on recent investment to support the 323 HSE-funded day centre services, a further 316 funded meals-on-wheels services - last year almost 2.7 million meals were provided through this service - and, in collaboration with the Alzheimer's Society of Ireland, 49 dementia-specific day centres.

I will move on to mental health because my time is short. I was pleased to announce funding in budget 2024 of €1.68 million for our supported care homes. These are unique to the south-east community region and play an incredibly important role in enabling people to live independently for longer. Budget 2024 brings funding to mental health services to nearly €1.3 billion for next year. This year’s budget focuses on further developing youth mental health. Specific funding has been provided for the recruitment of 68 posts associated with child and adolescent mental health services, CAMHS. The extra staff for CAMHS will support the implementation of the recommendations of key reports. I am delighted to have secured funding for an exciting new initiative, the youth mental health app. We know young people sometimes approach services differently and can be more likely to engage with digital or online supports. This app will help direct young people to the services they need.

Budget 2024 also provides funding for the development and provision of a new central referral mechanism for services for children, to be established on a pilot basis within the HSE. This referral mechanism will allow the HSE to appropriately triage referrals to specialist services, including CAMHS, to ensure that no child ends up on the wrong waiting list for the care that they need and deserve. This model, which is sometimes referred to as "No Wrong Door", is a key priority for me.

In line with this, I am pleased to confirm the continued roll-out of suicide bereavement liaison officers in budget 2024, as well as specific funding next year for the further national roll-out of the Traveller counselling service.

I look forward to delivering on the commitments of this budget and continuing to drive real and tangible improvements across our mental health and older person services.

Deputy David Cullinane

We were all hoping that we would hear more from the three Ministers today. Today, from my perspective, it is more about the Government trying to control the narrative, change the story and shift the blame but not fix the problem it created with the chronic and very deliberate underfunding of our health service. In reality, we are now being told that we should stand logic on its head, that previous statements from the HSE, from the Department and from the Minister for Health should be set aside, and that black is white. That is what we are being told here today and I will explain why.

In her contribution, the Minister of State, Deputy Naughton, said funding to maintain existing services has been provided to meet inflation and rising patient demand for next year. That is simply not true. Some funding has been made available but not all of what is necessary. That is what the head of the HSE said on RTÉ this week. It is what the head of the Department said at the Oireachtas Joint Committee on Health a number of weeks ago. They spelled out what was needed to maintain existing levels of services just to stand still. That does not even deal with whatever recurring expenditure from this year's deficit will carry over to next year; it is just to stand still. Ministers have stated we have provided the funding for the health service to stand still for next year, but we have not. That is why the head of the HSE has clearly and publicly said that the health services are not properly and adequately funded.

The Minister for Health said we simply do not know at this point what level of demand will be seen and what level of health inflation we will have to cope with next year. He is correct in saying that, but in recent months we have been told by him, by departmental officials and by the HSE that there are three drivers for the deficit for 2023, which we know will be €1.5 billion. They are health inflation running at between 17% and 20%; an increase in demand because of an ageing demographic, population changes and illness circulating in the community - Covid and all those things have obviously increased demand; and an inability to deal with cost controls. However, two thirds of it are essentially outside the control of the head of the HSE.

When those individuals appeared before the Oireachtas Joint Committee on Health, they told us that the vast majority of the deficit for this year will transfer into next year. The Minister has provided no additional funding for that. He has provided some one-off funding but has not provided for any of that. Health inflation will certainly will not be zero and we will certainly not see a collapse in demand for health services. I do not have to tell the Minister; he knows in his heart that the health service has not been properly funded.

The best of all is commissioning an in-depth report into the future cost of healthcare. I welcome that because it is necessary for all the reasons the Minister has set out. However, in the context of what we are dealing with today, it is a fudge. It is an attempt to shift the responsibility and change the narrative to something that is not the case.

In the days since the budget, I have listened to many Government representatives talk about the issue of health spending. They are trying to blame all this on wasteful spending in the HSE. They claim that if we could rein in the wasteful spending and if the HSE did better, we would not have this big black hole in HSE finances.

It plays well to a narrative - let us be honest - but it simply is not the case. As the Minister has conceded, the majority of the deficit is outside the control of the HSE. Even if we were to achieve savings in the areas where we can achieve them, it would not come within in ass's roar of dealing with the deficit for last year and next year.

I have argued for years with the Government and the Minister, as has my predecessor, Deputy Louise O'Reilly, and her predecessor, Caoimhghín Ó Caoláin, about way too much money being spent on outsourcing in healthcare, on agency and on management consultancy, and the lack of digital transformation, electronic patient records and a single integrated financial management system in the health service. We have long called for a single integrated waiting list management system. If all that were in place, and if corrective measures had been taken a long time ago, we would be in a better position. We therefore do not have to be told by any Government backbencher or Minister about reforms in healthcare. We have spelled out chapter and verse what can be done to fix the problems in healthcare, make the health service work better and deliver greater efficiencies.

All of that, however, has now been used as an excuse by a Government that made an intentional decision not to properly fund our health services, and there is a responsibility on me and others in opposition to spell out the consequences of that. We know we have a recruitment embargo now in place. That has now reached into the front line to non-training junior doctors, some healthcare assistants, some home help workers and many other areas. Clerical grades are also needed to provide a lot of the healthcare infrastructure which will be needed. We know that 7,000 posts which were approved but not funded are now gone. I still do not know about these 1,500 beds the Minister announced a number of times or when we will see an announcement on them. Certainly, there was no additional capital funding or a mention of them in the budget. All of that will concern people. There is concern about all the clinical programmes and national strategies and access to new medicines. All those will be really important. I am concerned about the impact all this will have on patient care.

I will give the Minister a local example. We can all talk about the abstract and big figures running into billions. The quantum of money can bamboozle all of us. The stark reality is that this budget will have an impact on patient care next year. I have absolutely no doubt about it. I contacted the manager of University Hospital Waterford. The Minister has rightly praised management, as I have and as the Minister of State, Deputy Butler, has done, for the work it has done to ensure we got to zero patients on trolleys in that hospital. One of the reasons the hospital achieved that is it was allowed to open a medical ward. It is medical ward 6, which has 35 beds. Almost all the staff who keep that ward open are from unfunded posts or agency staff, so the manager told me that, in reality, he should really be closing that ward. He certainly will not have the staff to keep it open. The consequence of that is 35 fewer beds, and in a hospital that achieved zero people on trolleys, it could now be back to people on trolleys again. However, the manager does not want to do that so he has been forced into an impossible position of having to take staff from elsewhere. One of the areas from which he can take staff is cardiac care and the operation of the two cath labs, including the second one that we worked so hard for, and there will be fewer planned procedures.

The Minister was in University Hospital Waterford some months ago opening the palliative care centre and he announced that the emergency cardiac services, which now run from 8 a.m. until 8 p.m., Monday to Friday, will become a seven-day-a-week service. I am sure he will know, because he would have been briefed, that that means we need more junior doctors, more doctors generally, support staff, administration staff, porters, nurses - a whole range of posts. Again, managers in the hospital have told me that some of the grades necessary to deliver that are now on the recruitment embargo list, so that can be forgot about until that is lifted. I have no doubt that if one goes through every single hospital in this State, there will be similar stories.

National strategies cannot be starved of funding. Cardiac, cancer care, diabetes and all those really important strategies need year-on-year, continuous funding. If we do not provide the additional funding, they simply stand still. I am on record as accepting the additional investment that has been put into healthcare in recent years. There are lots of things on which I have agreed with the Minister and the Government - public-only consulting contracts, the enhanced community care model and so on - which I know will serve the health services well. However, there has to come a time, when mistakes are made, that we are very clear, honest and forthright in our approach to what this Government has done as regards healthcare. There is no doubt that if it were a Sinn Féin Government sitting opposite and we made the decision this Government made to deliberately underfund the health service, with all the consequences - a recruitment embargo in place, beds which are needed and may now not be funded, no new medicines for new drugs - the current Minister would be making exactly the same speech I am making today because he knows that what I am saying is true.

It was really regrettable that some Government Members - not the Minister for Health - tried to throw the head of the HSE under the bus and made some misleading and inaccurate statements about briefings he has given me, which he has not given me. The only information I ever got from the head of the HSE was when I contacted him to seek clarity. I am sure the Minister will agree that it is important we have factual information and not misinformation. There lots of other things I have read over the past 24 hours which I do not believe are helpful. This person has come into the role, has been six months in the job and has a job to do. What has happened is part of this pushback and this shifting the narrative and trying to blame somebody else, rather than taking responsibility for the decisions that have been made.

Here is the point. There may well be a Revised Estimate - there has to be one before the end of the year - and we know now that the deficit for 2023 is €1.5 billion and that it will have to be paid for. If it is not all paid for in a Revised Estimate, some of it will carry over into next year. However, when the Minister says we do not know, that is not true. We may not know the full extent of it but we certainly know that the vast majority of it will be recurring. It has not been provided for, however. What the Government provided for in the budget was €707 million for existing levels of service, €100 million for new measures and then an expenditure line of non-core, one-off funding of €1.032 billion, which includes Ukraine money, waiting list money, money for Covid and then this resilience fund of €480 million. However, it is not core, does not go into the base and does not deal with the permanent funding the health service needs. If we had a big black hole in the health budget last year, we will have an even bigger black hole in the health budget next year. The Minister has left the head of the HSE, clinical leads across the healthcare system, hospital managers and those who are trying to deliver healthcare to the best of their ability, as well as all the front-line staff, in the lurch.

The final point I will make is this. The last message we needed to give out at this point in time, when we struggle to recruit staff, is the words "recruitment embargo" because that will resonate and will be felt and I think more people will leave. When I was in St. Luke's hospital in Kilkenny this week, hospital management told me it was fighting to hang on to non-training junior doctors. The HSE is trying to poach them. Now they have been given a green light to go to the NHS and elsewhere because they are on the recruitment embargo list. For all those who are in training colleges and whom we want to come and work in the public system - and the Minister talked about increasing training places - the message they have now heard from budget 2024 is "recruitment embargo". I know it is not across the system, but the very notion there is a recruitment embargo at a time of crisis in healthcare, with a million people on waiting lists and all the issues we have as regards emergency departments and so on, just beggars belief. I am very disappointed that no news or new information came from the Minister today. That is regrettable.

Deputy Mark Ward

The Government has thrown in the towel on health and disastrously chosen to underfund the health service in this year's budget. Unfortunately, this will have a profound negative effect on patients, their families, workers and wider service provision, no more so than for those looking to access vital mental health services. Access to mental health services was in crisis before this budget and it will be in crisis after this budget.

It was widely reported that the Minister was disappointed with the health allocation in budget 2024, but there was no mention of disappointment in his opening speech.

Disappointment will be cold comfort for people who are waiting for vital mental health services.

It is welcome to see more resources going into CAMHS. That is badly needed but it does not go far enough. The highlight seems to be an app and a pilot project in one community healthcare organisation, CHO, area. To me it is just spin and an attempt to make a silk purse out of a sow's ear. The Minister can disagree with me all he wants but the facts do not lie. Some 6,400 children have presented to accident and emergency departments with mental health difficulties since he took office, including almost 1,000 children this year. Over 2,500 of these children have been hospitalised. This is a direct consequence of successive Governments failing to invest in early intervention. Waiting lists for CAMHS reached a record of over 4,500 children this year. The figure has more than doubled in the three years since the Minister took office. Some 735 of these children have been waiting for more than a year for an initial appointment. That is a 209% increase under the Minister's watch. Primary care psychology services have over 16,000 young people waiting for appointments. Jigsaw services have wait times of up to 15 weeks in some areas and children in CAMHS who are at a high risk of suicidal ideation or deliberate self-harm are having to wait up to 190 days for an assessment.

The Minister can feel free to stop me if he feels these facts are wrong. If he does not believe me, he should believe the damning report into CAMHS by the Mental Health Commission and the Maskey report under this Government's reign. He should also believe the Ombudsman for Children, who joined calls from parents and Opposition parties in response to the State's dereliction of its duty to children. The letter he wrote was shocking. The Ombudsman for Children did not receive an urgent, credible and serious response outlining how these unsustainable situations will be resolved. These issues will still not be resolved after the recent budget. This has all happened on the Government's watch. The Government may have inherited some problems from the previous Fine Gael Government but nothing it has done has addressed these problems.

The Government is out of ideas and it is running out of time. We need solutions to this emergency but every waiting list is going in the wrong direction; all of them are going up. Sinn Féin has solutions to the crisis in youth mental health. We have prioritised CAMHS inpatient capacity to fully resource all CAMHS teams in our alternative budget. This would provide a much-needed service to young people with moderate to severe mental health needs. We have also prioritised early intervention, with a move towards universal counselling, GP referral and expanding Jigsaw. Sinn Féin has solutions and the longer this Government is in place, the worse this emergency will get.

I spent the recess meeting a vast range of mental health organisations. They do a really good job, despite working in difficult circumstances. They all stress the need for multi-annual funding and early intervention. This budget will simply not address these issues. It is unforgivable that the Government has failed to invest in the development of national clinical programmes for mental health for the second year running. This means there will be no funding for self-harm and suicidal ideation. In the past three years, 23,000 people have presented to 25 hospitals with suicidal ideation. That is an average of 15 presentations per day.

Specialist eating disorder teams are life-saving and to find out there is no additional funding again this year is concerning. Eating disorders have the highest mortality rate of any psychiatric diagnosis. The Government's failure to resource early intervention psychosis is a blatant disregard of its duty of care to those experiencing mental health difficulties. We also have no funding for adult ADHD, which means that more children will fall through the gaps when they transition from CAMHS into adult services. We need to fund these programmes. I am concerned about the year ahead and how people will access care.

Deputy Louise O'Reilly

I am grateful for the opportunity to speak in this debate. We are effectively having statements on the lack of investment in our healthcare service. Members are not discussing the investment in healthcare because, as we know, it is not even enough to stand still. We are discussing the lack of investment. Since the budget, we have had Ministers and others from the Department of Health expressing disappointment and frustration at the lack of additional funding for our health services. This is in conjunction with medical professionals, trade unions, service providers, pharmacists and primary, secondary and tertiary healthcare services expressing their extreme concern over the budget for health in 2024.

The health service is in a state of crisis but it will be made worse by this budget. One example is the doubt cast on the funding for the national stroke strategy. Failure to fund this strategy means that patients will spend longer in hospital due to insufficient funding for the supported discharge programme. Stroke units may have to close. The withdrawal of funding will cost lives but it will not save the Government a shilling. The fault for this crisis, and the others that will hit health because of what has been done, lies with the Government as a whole, in particular the Minister, Deputy Stephen Donnelly. The reports that the Minister arrived to negotiations with no clear plan do not surprise me in the slightest. Be under no illusions; the fault for this lies with the Government and the leaders of Fianna Fáil, Fine Gael and the Green Party. They have made a deliberate decision to dramatically underfund our health services. Their actions will have consequences which will be felt widely across all of the health services and in every area.

In my area of Fingal, the consequences will be acute. North County Dublin already suffers in several areas and this will get worse in 2024. There are no dentists being added to the dental treatment service scheme for those with a medical card. I have had people in my advice clinics and offices in Swords and Balbriggan who are in pain and cannot access a dentist. I spoke to a man last week who was on his way to the credit union to get a loan he could not afford so that he will no longer be in pain as a result of not being able to get a dentist or a referral to the dental hospital.

We also have an issue with general practice. People cannot source a GP. I have constituents who have gone to Dundalk, Portlaoise and Dublin city centre just to access a GP. The situation for children is even worse. The Government has provided free GP care for more children but there are no GPs to deliver it. It was a miserly stroke to tell people they are entitled to something and then to ensure they cannot access their entitlement. Where is the Sláintecare commitment of 2017 for salaried GPs in areas where it is hard to attract them? We sat on that committee for a year, working for hours, hearing from experts and putting together a comprehensive plan and document, yet there is no sign of many of the elements in the plan. What is the point in having the debates and accepting a roadmap and then completely ignoring it?

Then we have the state of the children's disability network teams, CDNTs. The budget may have been transferred to another Department but we should be under no illusions - when people cannot access the services under the CDNT they will end up in the general health service and in another queue. In Balbriggan, the CDNT is understaffed by 40%. The overpowering feeling of parents following budget 2024 is one of fear and anger. They feel as if they have been abandoned. They know their children are not getting seen now, they hear about underfunding and they know the possibility of getting the services their children need is moving further away from them.

The Minister of State, Deputy Butler, stated she is "delighted" with her "exciting new" app and said the "app will help direct young people to the services they need" when they need them. With the greatest of respect, I am sure the Minister of State is delighted and that it is very exciting, but if there are no services - and there are none in my area bar crisis intervention - what will the app direct them to? Will it direct them to another waiting list and tell them to wait until there is a crisis? What is the point of an app when there are no services to back it up? It is an exciting idea, and I am sure the Minister of State is delighted with it, but this app will only point people in the direction of services if they exist, and they do not. It is an insult and the Minister of State's delight is somewhat misplaced.

Deputy Duncan Smith

Deputy Cullinane made a point that is worth repeating. The statements by the Minister of State, Deputy Naughton, and the Minister, Deputy Stephen Donnelly, are fundamentally contradictory. The Minister of State indicated that funding "to maintain existing services has been provided to meet inflation and rising patient demand", whereas, according to the Minister, "Some areas are not getting the same level of investment ... as they have [done] ... due primarily to an increase in inflation and patient demand being well in excess of what was forecast last year." Those two fundamentally contradictory statements encapsulate just where we are with this health budget and why there has been so much rancour and righteous anger in the last nine days.

In summing up, the Minister of State, Deputy Naughton, also mentioned that the workers can sometimes be "forgotten in a politically-charged debate".

I mentioned the workers in the drugs sector earlier. Those workers were almost forgotten by this Government earlier this week in the section 39, section 10, and section 56, campaign, when it waited until the very last minute to go to the Workplace Relations Commission, WRC, at 3 a.m. on the day a near historic strike was due to take place in order to come to the table and reach an agreement. This provided much distress for those very workers and of course the service users and their family members who need those services. That is how the Government treats the workers and those who need the health service. The fact that we are here today talking about the damage this budget has done is indicative of just how tired and jaded this Government is and how mismanaged our health service has become. Yesterday again, the Minister, Deputy Donohoe, noted how every Government agency and every Department he engages with at budget time, always makes the case for more funding. That is understandable and we appreciate that. However, it also shows the blatant disregard this Government has to how unique our healthcare service is. It is not like any other Department. A delay in funding for another Department, such as in transport, education, or any other Department, may have a hard impact and may be difficult for communities and for people to take if we are not getting new rail infrastructure or an extra building to a school. They are hardships but nothing suffers as much when it is underfunded than our health service. Our health service is a demand-led service. Nobody turns up at an accident and emergency unit, or a GP service, or gets on a waiting list because they are well. They do it because they are unwell; they are sick. For the Minister, Deputy Donohoe, to lump health in with the other Departments and say that is what every Department does, is totally disingenuous of the needs of our health service.

We heard this week from HSE chief executive Bernard Gloster that harm would certainly be caused by the budget allocation to the HSE. It was a clear and concise message that this Government needs to make sure patients are properly protected. It is not good enough for the Tánaiste to say there is always a commentary on health budgets, as he said today. Has the Tánaiste stopped to think that may be because this commentary, as he calls it, or what we would call politically holding to account, is because of the chronic mishandling we have seen year after year in our health service? Where is the accountability from the heads of Government? The honesty in their approach to heath is absolutely missing. It seems that the Government has given up on health. There is not only a lack of vision in the health budget, but on a more basic level, there is an absence of proper planning. That may be because we have two Ministers, in Deputies Donnelly and Donohoe, who seem to be wrestling for control of the health portfolio. Over the last few days, I have heard from many constituents who have expressed their anger and sadness over the lack of funding for new medicines next year. One such email I received was from a lady who suffers from a chronic heart condition, whose hope of accessing a new drug for treatment has been dashed by this frankly irresponsible health budget. This lady spoke of how her doctor advised her that access to treatment may only be possible by going up to the North of Ireland. That is a complete and utter failing for this Government. We had hoped the days of sending our citizens out of the State to receive basic medical care were long and truly over. Alas, once again, due to the decisions made by this Government, we have managed to somehow see that remain firmly as a choice our patients have to make.

Up to 4,000 people will be affected by this Government's decision not to secure funding for new developments in any of the clinical programmes in the health service and this will create real consequences for patients across a wide variety of areas, including cancer care, diabetes, sepsis, and critical care. The Irish Pharmaceutical Healthcare Association estimates that 1,000 cancer patients will be impacted by the lack of funding. The Minister, Deputy Donohoe, stated this week that spending our budget surplus all at once would be immoral. Will the Minister explain the morality behind denying people suffering from chronic illnesses, who rely on our clinical programmes, the chance to have better health and a better life? The Irish Cancer Society has clearly outlined in recent days that there is a real risk that cancer outcomes could decline in years ahead due to the Government's health budget. The society asked for only €20 million for a cancer strategy. I doubt there is a person in this House who has not had cancer impact on them directly or on someone close to them. How this Government could not find €20 million to invest in a strategy for such an important area that touches everybody's lives is quite frankly beyond me.

Almost 15,000 people contract sepsis in Ireland every year resulting in almost 3,000 deaths. According to the Royal College of Surgeons in Ireland, one report states that sepsis kills more people than heart attacks, and lung, colon and breast cancers combined. In some reports, 60% of all hospital deaths can in some way be related to sepsis. I note the HSE's own sepsis report indicates that 20.3% of deaths in our hospitals are related to sepsis. That is the 2021 figure, up from 19% in 2020. It is a frightening number for what is a frightening illness. This number will not improve with underfunding.

We know from what Bernard Gloster said the other day that he will try to protect access through our accident and emergency departments and will try to continue to bring waiting lists down. It will be difficult to do but if that is where the area of focus is going to be with this constrained budget, it will be our clinical programmes that will be impacted due to underfunding. All the big killers in our country, such as heart disease, sepsis, diabetes, and cancer strategies, are the ones which will be impacted. We have to take a minute to think because we are all guilty - myself included - when we are having health debates of focusing on the day-to-day, week-to-week crises such as trolley numbers, waiting lists, the state of our accident and emergency departments. However, our national clinical programmes dealing with people with the most serious illnesses are the ones that will be impacted according to the chief executive of the HSE and these are the decisions this Government has made. If we take patients affected by diabetes, cystic fibrosis and stroke, a total of 316,000 people impacted by those and related illnesses, have instantly become more vulnerable in the last nine days since this budget was announced. I ask both Ministers, Deputies Donnelly and Donohoe, what they say to the people who have for the last week been panicking about the level of care on which they rely through our national clinical programmes; programmes which aim to improve quality, access and the value of healthcare. One thing we have all said is that the difficulty in our health service is access to the care but once you get in, the care is good if not very good. That is true for many of our national clinical programmes. However, if they are underfunded and a recruitment freeze is implemented on trained non-consultant hospital doctors, on healthcare assistants, and on the absolute bedrock of workers who are needed to require safe staffing, it will impact on these national clinical programmes and on these people who are so sick.

As Bernard Gloster has said, I acknowledge that funding issues have been driven by inflation and unforeseen demand but I have highlighted in the start of my contribution further confusion being laid by two of the three opening statements as regards how the Government is targeting both of those things. I acknowledge the Tánaiste stating today during Leader's Questions that we are now going to set up a forward-looking group to see what the future level of demand will be. This is so the demand will not be unforeseen and that we will be able to see it. However, we have reached 5.1 million people in this country, the highest population level since the 19th century. The fact that this has not been done up until this point, and that this is a knee-jerk emergency reaction to what is an abhorrent health budget, just goes to show again just how tired and jaded this Government is. I will say one more thing. The Minister spoke about community care. We are not seeing that in north County Dublin. We are still served by Beaumont Hospital. In 1986, one year before the founding of Beaumont Hospital, the population of Fingal was 138,000 people. It now stands at 330,000 people. We still do not have minor injury clinics or primary care centres in towns aside from Swords. We still rely on Beaumont Hospital for our acute needs. The community care system is not working there. It is not delivering in my constituency. I had a little bit more to say but I have run out of time and will leave it there.

Deputy Cormac Devlin

I welcome the opportunity to examine the Government’s investment in healthcare today. This debate needs to be framed in the context of the unprecedented increase in funding for the health service, going from €19 billion in 2019 to over €24 billion today. Inflation has caused massive challenges across society and this is no different for the health sector. The Minister, Deputy Donnelly, and the Ministers of State, Deputies Butler and Naughton, are all well aware of these challenges and they have made tremendous efforts to secure funding and to prioritise front-line healthcare. As chair of the all-party Oireachtas committee on diabetes, I would like to turn to the Government’s investment in diabetes services.

Under this Government, there has been a significant shift in both the quality and delivery of diabetes care throughout the country. More patients are being provided with care in the community and at an earlier stage, which is critical. Patients with diabetes who have a medical card or GP visit card have, under this Government, had access to the chronic disease management programme in GP settings. Under this programme, patients with diabetes have four planned appointments with their GP or GP nurse over the course of a year to monitor their condition on an ongoing basis. These appointments are critical to monitoring patients and identifying any changes needed to the management of their condition. This policy empowers patients to take the lead in the management of their diabetes.

With the expansion of eligibility for GP care to an additional 500,000 people under budget 2023, the number of people who can access this programme has increased significantly. Where necessary, GPs can refer patients with diabetes to the enhanced community care chronic disease teams. These teams provide specialist services, including podiatry, dietary advice and, if necessary, access to consultant-level care in the community. Combined, these programmes mean that patients can access the care they need close to where they live, without needing to attend a hospital setting in the majority of cases. Research into the chronic disease management programme has shown that more than 90% of patients with chronic diseases, including diabetes, are now successfully managing their conditions in community settings. This is a stark contrast to where we were a number of years ago.

The Minister launched the diabetic retinal screening programme in June. The programme is for people in Ireland with diabetes and who are at risk of retinopathy. Diabetic retinal screening is available free of charge once a year to all patients over the age of 12 with diabetes, regardless of eligibility status. Screenings are offered annually for the first two years, and then every two years if no retinopathy is found. Screening is a way of detecting any changes to the small blood vessels in the lining at the back of the eye. Diabetic retinal screening allows patients early diagnosis of diabetic eye disease, which can reduce or prevent damage to sight.

Budget 2023 provided resources for all women, whether or not they are General Medical Services patients, who have suffered gestational diabetes or pre-eclampsia to have access to ongoing diabetes screening through the course of their lives. Access to this service is commencing this month and it will be delivered as part of the national chronic disease programme in general practice. This service will give women who need it access to an annual screening for diabetes, as the risk of developing diabetes is increased in women who suffered gestational diabetes or pre-eclampsia. Women who develop diabetes will have access to the full GP chronic disease management programme, which involves four planned visits per year as I outlined a few moments ago. These women will also have access to the enhanced community care chronic disease programme teams when required.

As chair of the Oireachtas committee on diabetes, I have been working closely with diabetes practitioners and specialists, including Diabetes Ireland. A key ask is the establishment of a national diabetes register. I have put on record previously, and it is very appropriate to do so again today, my appreciation of the Minister, Deputy Donnelly, who has spearheaded this and has prioritised it over the past 12 months. He has been a very strong advocate and has taken a keen interest in supporting people with diabetes, while also championing preventive care. I was delighted he secured €500,000 in budget 2024 to fund the establishment of a new national diabetes register. This register is an important development in how we respond to and manage diabetes in Ireland. It will draw on quality real-life data to support the design and delivery of future services for diabetes. This will help to improve diabetes care for patients throughout the country and it is very welcome. I thank Ministers for their support.

I will turn to health service funding for a moment. It must be noted that healthcare funding is at record levels, with an increase of more than €5 billion since 2019. Just like any front-line demand-led service there will always be calls for increased funding, and it must keep up with inflation and demographic changes. This is understood. I know from experience that the local CHOs do their best in difficult circumstances in certain areas. It is critical that they are supported in the services they provide. However, as Dr. Theresa Reidy noted recently, we must also ensure the funds allocated are spent properly to ensure effective services are provided. For example, we have seen significant increases in clerical and management grades that were unapproved. While they may be necessary, it is critical that the CEO of the HSE and senior management exercise proper budgetary control, particularly with the additional challenges of inflation. The HSE recently came before the Committee Of Public Accounts and this scrutiny will continue. I thank the Minister, Deputy Donnelly, and the Ministers of State, Deputies Butler and Naughton, for their efforts to secure additional funding and additional services, including at community level, to provide front-line services. It is greatly appreciated and their work is noted.

Deputy Maurice Quinlivan

As we speak, 74 people are on trolleys in University Hospital Limerick, UHL. This is the lowest number there has been for the whole month of October. The average is 100 people a day on trolleys. It is an absolute disgrace. The budget gives no comfort that the issue will be addressed. In the round, the budget lacked ambition and neglected the core issues of health and housing. It was a budget focused on short-term one-off measures, and these highlights tried and failed to give the Government cover in its failings in health and housing. Those in opposition have known this for some time and it now appears that Government colleagues do too. It is clearly demonstrated by the failure of the recent budget to invest properly in healthcare. It is a case of not wanting to throw good money after bad. It seems the Government has thrown in the towel when it comes to health. It has definitely abandoned the people of Limerick and the mid-west who need to use the emergency department at UHL.

I will focus my comments on UHL. It needs investment in capacity and staffing. It is consistently the hospital with the highest number of people treated on trolleys and in hallways. Last week in an article by Bernie English the Limerick Post reported that it had been doing a survey and UHL had spent 100 days as the hospital with the highest number of trolleys in the State. Elective procedures are cancelled regularly in order that the numbers presenting at the emergency department can be managed. Patients in the hospital are stacked cheek by jowl in corridors and on trolleys.

Recently I had the misfortune to be in the emergency department with a relative. I witnessed at first hand the chaos that goes on. Trolleys were bashing off each other. I saw a patient being injured. I saw complete overcrowding, with trolleys everywhere and medicine supplies in hallways. I saw elderly people abandoned in trolleys and left to languish for hours on end because the medical staff were too busy to check on them. There are simply not enough staff there.

With each passing year, the numbers treated on trolleys at UHL increases. Last year 18,012 people were treated on trolleys. This exceeded the 2021 figure. As of today we have had 17,271 people on trolleys in 2023 and we are only halfway through October. We will surpass last year's figure and probably will hit a figure of 20,000 people, which will be a disgrace. In September 2,174 people were on trolleys and it was the worst month ever but it looks as though October will, unfortunately, surpass it.

We can get lost in these figures and statistics but behind each one of the 2,174 patients on trolleys in September is a person with friends, families and loved ones who are deeply worried about him or her when he or she attends a hospital. Attending hospital is daunting in its own right but to be placed on a trolley compounds the worry for the person and their family members. Being in a hallway offers no dignity or privacy to a patient. It is simply unfair and not safe for patients or staff. We know from figures that the longer someone is on a trolley and not in a bed, the higher the chance that person will pass away. Treating someone in such a space makes the job of our health professionals all the more difficult.

We know there is a need for investment in healthcare. There is a need to invest to ensure the delivery of new beds. It is also crucial to invest in the recruitment of additional staff as our nurses and other healthcare professionals are spread too thin. Yes, there is a commitment to deliver a 96-bed unit at UHL. As the Minister knows, in real terms this unit will deliver only 48 additional beds. It is welcome but it is far too little and will open far too late. Will we even be able to staff it, given the lack of staff we have at present?

The Government seems to have given up on health. We are in the unique position today that the Minister is here when I am speaking about UHL. He is not here when I raise it as a Topical Issue. The Government's approach to health has been haphazard and incomplete. The most recent budget made this abundantly clear. It is demonstrated by the reduction in moneys directed towards new measures. The 2024 budget committed €100 million to new measures, which is €150 million less than the previous year's budget. This year there was a surplus, some of which could and should have been used to invest properly in our health service. It is patients and healthcare professionals who will pay the price. The budget was an opportunity to make a difference to the lives of patients and healthcare professionals. It was an opportunity to announce new funding for the delivery of 1,500 promised hospital beds, of which we have seen nothing.

It was an opportunity to accept and address the challenges facing those with mental health illnesses, yet no new funding was provided in this area. It was an opportunity to provide funding for new medicines and to help patients who struggle with the cost of their medicines, yet there was very little funding for this purpose. Even rudimentary measures, such as reducing parking fees in hospitals, were not considered or provided for. It is the patients, their families and hospital staff who suffer the impacts of failures in the budget.

The Minister does not have to take my word for this. Let us consider the pronouncements from the professionals in the field. The Irish Hospital Consultants Association, IHCA, stated that the budget allocation is insufficient to address the decades-long public hospital capacity deficits that are the root cause of the unacceptable public hospital waiting lists. The Irish Medical Organisation described the budget as a missed opportunity to meet demand, while the IHCA said that not enough capital funding had been provided to open previously promised beds and theatre capacity. I would love to go on, but I have run out of time.

Deputy Róisín Shortall

I am not sure what the point is of having this session and these statements. There had not been a demand for statements. The Minister and the two Ministers of State have come in here with scripts to try to put the best gloss on things. They have Government, or rather Fianna Fáil, backbenchers coming in and trying to put the best spin on things. I would have thought that the least that could have been done if Government time was being made available for these statements would have been to agree to have questions and answers. I say this because coming in here and just reading out a script is not especially enlightening or helpful. What we, or certainly I, want to be able to do is to ask the Minister questions about the implications of what is a reduced health budget. I think that is also what the public wants to know.

Regarding cancer and stroke programmes, what are the implications of the budget for those? What are the implications then in respect of the existing waiting lists for children's mental health services, for example? We know these are fairly well threadbare. We have had representatives from the Mental Health Commission in with us at an Oireachtas committee. We wish to know what the implications are for the existing huge shortcomings in relation to the disability services, especially those for children. What are the implications for home care? In the middle of this year, the allocated hours were cut and this cut, I notice, goes into next year as well. What about the waiting lists and the demand that will arise towards the end of this year and into next year? What are those people who need home care going to do now if the allocation has been cut?

These are the kinds of questions that we want to hear answers to. The big concern, of course, is that the failure to secure adequate funding for our health service is going to result in a situation where patients will pay the price. This is inevitable. There will be major disappointment on the part of patients and staff because the momentum that had been achieved will, inevitably, slow down. The least we could have had, therefore, would have been questions and answers in a three-and-a-half-hour debate. I just do not know why the Minister did not agree to this and why there is this session. I asked yesterday-----

Deputy Stephen Donnelly

I was not asked.

Deputy Róisín Shortall

I asked yesterday.

Deputy Stephen Donnelly

I was not asked.

Deputy Róisín Shortall

Okay. The Taoiseach was asked and he completely ignored this request. If we are to have accountability to the Dáil, which Ministers are provided to provide, then we need to have questions and answers. As I said, I do not know what the purpose of this session is.

The whole issue of the underfunding of health, of course, actually started last year. The allocation made in budget 2023 was not sufficient to maintain the existing level of service and to provide for new services. The whole question of a budget campaign for any Department is a key aspect of the activity of that Department, in terms of the Minister and the Secretary General. Quite clearly, that campaign on the part of the Department of Health was not sufficiently successful last year. This was spelt out very clearly. We know there was a three-month delay in approving the service plan. We also know that a senior member of the HSE board resigned over this because he was not prepared to go along with the pretence that it was possible to deliver that service plan when there was a black hole of €2 billion in the allocation.

I must say this does raise questions about the ability of the Minister's Department, and senior people in it, to make the case sufficiently and to secure sufficient funding for the health service. Additionally, in the early months of last year, we saw the acting head of the HSE at that point being very clear about the shortcomings in what was allocated. An attempt was made by the Minister's Department to silence the person and to get that person to go along with the pretence that the money would be fine. Of course, we know it is not and we are facing a significant deficit this year.

I wish to talk for a few moments about the Department of Public Expenditure, National Development Plan Delivery and Reform. I think that Department is a disgrace. It is by far the most conservative Department in this country. It does not seem to have any appreciation at all of the fact that it has a role in relation to reform. I do not think it gets the reform programme that is under way, or that has been under way, within the Department of Health. When we look at the kind of spinning that the Department of Public Expenditure, National Development Plan Delivery and Reform engaged in this time in respect of other Departments, it was telling them that they could not get their allocation because of what the Department of Health had done. It claimed that we spend more in this country on health than in any other OECD country. Both those things were lies being spread around by the Department of Public Expenditure, National Development Plan Delivery and Reform.

Equally, some of the inherent and fundamental problems, the structural problems, in the HSE are largely down to the failure of the Department of Public Expenditure, National Development Plan Delivery and Reform to understand what providing a decent health service is about. I refer to those things that are critical to ensuring value for money and a properly functioning system. I refer to the individual health identifiers, which is a key element in this context, the digital health strategy and the need to ensure multi-annual funding is provided. The Department of Public Expenditure, National Development Plan Delivery and Reform just does not get that at all.

I am not sure where these people come from. Do any of them actually depend on the public health service? Is it a case that they are okay because they have health insurance with VHI, Laya Healthcare or whatever? Do they get what a public health service is about? The other aspect, of course, is the failure to fund an integrated financial management system. This is why we cannot get to the bottom of the black hole of the funding of the HSE. We do not know where the funding is going and we do not have the data to measure what is going on.

I cannot help but comment on the fact that the Secretary General of the Department of Health came directly from what was then the Department of Public Expenditure and Reform. Is there a mindset there that does not understand about what a public health service is and does not understand that we have an agreed, all-party strategy for health that is about creating a single-tier, universal health service, comparable to what is available in every other country in Europe and most other developed and advanced countries? Do those people not get that? What is wrong with that mindset there that it is so shortsighted and unappreciative of the shortcomings in our health service?

Deputy Stephen Donnelly

I am genuinely loath to interrupt. I am just asking for some advice, and I do not mean to criticise. The Deputy is referring to an identifiable person, who is my Secretary General.

Deputy Róisín Shortall

Excuse me, sorry, I did mention a person. I am talking about a mindset that has been in the Department of Public Expenditure, National Development Plan Delivery and Reform, and has continued to be there for some time.

Deputy Stephen Donnelly

I just wonder if the Deputy might withdraw those comments. It is very unfair and he cannot defend himself. They are not true.

Deputy Róisín Shortall

Okay. I will just say that a key element of the responsibility of a Secretary General is to secure adequate funding for what his or her Department requires. I am saying that there is a mindset in the Department of Public Expenditure, National Development Plan Delivery and Reform, which has been there and continues to be there, that does not understand the principle of fully-funded public services, especially a key service like that of health. Nor does that Department understand the political decisions that have been made in recent years in terms of everybody signing up to providing a public health service, as I said, like every other European or developed country has. That needs to be dealt with.

I also wonder about the commitment of some elements of government to the Sláintecare programme. We have a situation now where it is easy to point the finger at the Minister for Health. I understand the Minister's disappointment. It is quite obvious irrespective of the speech he read out. I share that disappointment but, more than anything, the public shares the disappointment in the Government's failure to adequately fund our health service. As a result of the decisions that were taken in the underfunding of the health service for this year and the underfunding that will be inevitable next year, patients all over the country will pay a price. There is an attitude that public services are just for the poor and people who cannot afford to go private. This is quite evident in some elements of this Government and at senior levels in some of our Government Departments. Until that mindset changes, until we understand that we will have a better country, a more inclusive country and a more successful country by having a universal single-tier health service, and until we are prepared to fully fund that and stop the galloping outsourcing and the galloping privatisation going on in our health service, we are not going to be a fully developed modern country. I have to wonder is that actually the agenda at play here. Is it a question of protecting those interests that are making a packet out of private healthcare?

Deputy John McGuinness

I am delighted we are having these statements because it gives us all the opportunity to put on record what we believe should be done in health or our views on the various aspects of the policies of health. I am sure there is nobody else in this House who will appreciate more than the Minister himself that what gets counted gets done. Is that what we are doing? I have been here at various budgets and I have seen the health budget increased year on year with substantial amounts of money. How is that money being managed? In her contribution to this debate, Deputy Shortall is correct that we have to go back to how reform is treated in this country by this Government and by successive Governments. When we examine it we will see there is little or no reform around the management of taxpayers' money in most Departments and particularly in health.

For years we have debated the integrated finance system and the integrated management system for patients and nothing has happened. We have seen very senior people from the commercial world resign from boards of the HSE or from activities within the HSE because they say they met with huge resistance to change. The status quo in the Department of Health and the HSE cannot continue. It cannot continue because regardless of how much money we put in we are not just funding the services in the HSE and the delivery it is responsible for, we are also funding the huge waste that went on the previous year, the year before, the year before that. If we do not correct that we will be in the same difficulties next year and the year after regardless of which Minister is in place.

I welcome the fact the CEO of the HSE is briefing people. It is a great idea. I do not see anything wrong with it. He does not work for the Government and he does not work for a political party. He works for the HSE and he should be telling it as it is just as Ministers should be brave enough to put their names to the statements we are reading in the papers about what they think of the Minister or the allocation. They are showing total irresponsibility. They are irresponsible in their statements. They do not have any regard for the impact of those statements on people who are working within the HSE or those receiving services from the HSE. They certainly do not have respect for the patients, absolutely not. They are showing an awful lot of weakness in their own characters. If we are to have budgets and if we are to have a well-run organisation to deliver on those budgets then we must start telling the truth. Somebody in the HSE or in the Department of Health has to tell the truth about what is happening. Did anyone hold an exit interview with those people who resigned from the organisation? Did anyone take up the recommendations of Dr. Eddie Molloy, for example, who in the AV room many years ago told us we can have as much reform as we like but if we do not have the change managers in place to implement the reforms - I am referring to the bureaucracy of the HSE - then we will never have real reform?

One of the ways we get information from the HSE is through parliamentary questions. A parliamentary question was sent to the HSE in relation to the section 44 report, which is all about money owed to people who are now retired or a cohort of people still working in the HSE. I asked if the €42 million was set aside to meet and cover that expenditure. I was told that the question could not be answered and yet the information was released to some other individual under a freedom of information request, not a Member of the House. There is a need for fundamental change in our attitude towards transparency and accountability within the HSE. We are not getting it. Until we get that then we will continue to preside over all sorts of misspending, inefficiency in spending and poor planning. Change and reform is not only about money and how we spend it: it is about planning for the loss of jobs and people leaving positions; it is about having the correct number of GPs; it is about having the correct number of consultants; and it is about ensuring that Government policy is put in place.

I have heard a lot about Sláintecare. We hear a lot about it and then we do not actually do anything about it and we ignore it. Either the HSE management is wrong or the Department of Health is wrong. It is, however, the responsibility of the Minister and Ministers of State to give leadership in the Department to make sure the reform happens and to make sure the services are delivered. There is a political obligation on all of them to take steps to make sure this happens. The people I represent will judge that reform on the delivery of services. For example, people who are on various medications that come through the medical card system and are collected from their pharmacy cannot now get that medication because of the lack of product on the shelves at the chemist. What do they do? They are paying for it now from their own pockets. The Minister needs to correct that immediately and ensure that they get paid for whatever replacement product is there and that it is covered by the HSE and covered by the medical card.

The Minister of State, Deputy Butler, was very good with regard to the spend for community homes but that money had to be dragged out of the Department if the truth were told. Why should that happen? A policy decision was made and the money was given but we all had to kick up a stink in this place in order to get it paid. Not only should that money be paid there should be a plan in place by a group within the HSE to ensure that whatever money is needed for this year and next year is paid in advance or at least on time. Commercial contractors are owed a considerable amount of money. These are contractors to hospitals doing various tasks and delivering services and they are not being paid on time. The HSE is actually putting at risk commercial entities throughout the country by simply blaggarding them by not paying. That is not good enough.

I want to mention CAMHS. Last weekend, a young child aged nine had an exceptional meltdown, according to her parents. I know the case quite well,. There were no services available for that child - none, zero. I was told to come back on Monday. The parents were not even contacted on Monday but they were told on Tuesday that they would be considered at some meeting this week. How in the name of God can we explain to the parents of that child that these are the services we are standing over? Money needs to go directly to where it is most needed. We need to employ the people there and we need to ensure that the staff are provided. We, therefore, need the planners to do their job. If they do not do it, let them get a job somewhere else. That is what needs to be done here. Drastic action needs to be taken because there are no services and there is no real effort that I can see to fill the vacancies and get people attended to.

I have raised SOS funding in Kilkenny umpteen times. The individuals are referred to now as business cases; they are not. They are individuals who need specialised care. They are families who are in distress. Managers within the system are in distress because they are being ignored, not just this year but going back over the past five years. Respite care is not being delivered. Somebody has to step in and give leadership in all of these areas. The mental health system is not just broken; it is in a shambles all over the country. It is no comparison to the private services being delivered. We should be delivering to that level. Telling a patient who is suicidal and in real difficulty to give us a shout back on Monday and we will try to fix it up is just farcical.

I appeal to the Minister of State, Deputy Butler, because she has visited the facility. Teac Tom is running into serious financial difficulties. We are meeting HSE officials on Friday. If they tell me they are going to do a report or that we will see about funding for the future, and it jeopardised the continued services being given by that voluntary organisation, I will be in this House demanding that the Minister of State meet with Teac Tom and the HSE to secure the funding. Likewise with the cancer services, voluntary organisations are filling the gap where the HSE should be, yet they are not being acknowledged by the HSE or the Department. They are having to fight for every cent to keep their services going. I am aware of them all over the country. We had them here yesterday in the Dáil lobbying. I am aware of the services in Kilkenny such as Cois Nore. I am giving the Minister that example. He should immediately set out a pathway to fund all these services. These services are filling in where the HSE has failed. Yvonne - not her name - went through the services in Waterford University Hospital. Her family fought for the services that were needed. They fought for respite care and asked that she be sent to Thomastown to be looked after. She died. She had not been washed for 16 days. She had the same clothes on her for 16 days. I cannot stand over that health service.

All the Ministers today would give the impression that everything was okay. They are all constituency operators. They are all elected and work in the same way as we do. They know damn well the system is not working. They know the money is not going directly to the different areas that I have just mentioned. There is an awful lot more. The other example is Covid recognition payments. The Ministers know from the letters they are getting that these payments have not been made to people who are on the front line or who left their jobs to go to the front line. They have not been paid. I am asking that the Ministers take not of what is being said in this House. They should not take it as a personal criticism but as constructive criticism. Going back to Deputy Shortall's point, maybe the Minister is not here to answer questions. That was the way it was arranged. There is nothing to stop officials from going back over the contributions that are made, writing back to the Deputies and giving them the answers. That would be a start as far as transparency goes.

Deputy Martin Kenny

The budget and the huge underfunding in the HSE affects us all in every constituency around the country. The previous speaker mentioned that all of us are constituency Deputies. We all work with communities that are struggling, trying to survive and trying to manage. The head of the HSE, Bernard Gloster, recently made it plain that they simply cannot be expected to deliver an effective and efficient service on the funding that is in place at present. Across the western seaboard, particularly in the north west and Sligo hospital, we have massive waiting times for people to get operations or to be seen. We also have continued overcrowding in the hospital services there. That is the same across the whole country.

The cap on staffing is one of the serious issues that is affecting people everywhere. My daughter is doing nursing at the moment and like many of her colleagues, they work with an agency at the weekends. Friends of hers do the same. A friend from Limerick who is in college with her in Sligo worked in a hospital in Limerick recently. She was there on a 12-hour shift and she was the only nurse. There was no senior nurse with her, and she was looking after 16 patients. That is the kind of situation she was in. She said to the others that she would not be able to take those people out of bed. They said, "That is fine; leave them in the bed." That is the kind of health service we are going to have if we do not put the resources in place and remove these ridiculous caps and ensure we have services in place for people.

There is a specific issue regarding ambulance services that I want to raise. I received an email in respect of my own area in County Leitrim, which stated:

I feel I must highlight to you the absolute abandonment of ambulance services in the area of Carrick-on-Shannon in recent times. Carrick-on-Shannon base is our closest resource and unfortunately for the entire of south Leitrim, one ambulance per shift is allocated to work. I must put this in context. This one ambulance is consistently being utilised by the Cavan-Monaghan and Longford-Mullingar area as well as our own south Leitrim area. Basically at any time during a 12-hour shift, this ambulance is certainly not in Carrick-on-Shannon or surrounds but unfortunately this has become the norm. This is a lack of resource and, to be honest, a lack of uptake in overtime for staff due to burnout and morale being at an all-time low.

He goes into detail in regard to a particular case, which I will not raise. He then states that Carrick-on-Shannon needs another ambulance per shift, if not two, and needs to have a proper, functioning ambulance base to accommodate ambulances to ensure that we have a proper service. There have been tragic road traffic accidents in recent times. An ambulance is called and it takes anything from half an hour to three quarters of an hour, and sometimes up to an hour, for that ambulance to arrive. It is because of this policy of dynamic deployment. The ambulance that is supposed to be in a particular area could be practically anywhere in the country. That is what happens. Then the crew is told they have to go over to Mayo or up to Donegal. When they are three quarters of the way there, they are told it is all right, someone else is covering that, and they are sent back again. This thing is going on all over the country in every constituency. Every Deputy or Senator the Minister talks to in here will tell him the same stories of staff who work in the ambulance services being absolutely at their wits' end because of what is going on.

I also want to raise home help services and resources. There are loads of people in my constituency trying to get home help services but who cannot get them. Hours are being cut and the staff are being pushed and squeezed all the time. They are told they can get a person up and give them a shower but not to dare bring them in a few sods of turf to put on the fire - do not dare organise anything for them, things that they need. It is called home help for a reason. They absolutely need.

Deputy Mary Butler

It is not----

Deputy Martin Kenny

If they do not have a family to do it, what are they going to do? Should they sit in the cold? That is what the Minister of State is telling people; to sit in the cold if they cannot light a fire because nobody going to do it for them. It is absolutely ridiculous. That is the reality for people I know. A man in his nineties was told that if he could not light the fire, that was too bad. The person who is going to help him get out of bed and get dressed in the morning cannot take an extra five minutes to come in and light the fire for him. That is not allowed. That is a ridiculous service and the Minister of State needs to recognise that.

I also want to raise disability services, which are in dire need throughout the country.

There are difficulties with CAMHS and difficulties with intellectual disability services. I dealt with a young person who was going through CAMHS until it was decided that was not the right service and there should be a transfer to the intellectual disability team. There is no intellectual disability team in the area but that is where the family was told to go. I understand there are only four intellectual disability teams in all the CHO areas in the country. When the family asked whether the child could be transferred to a team in one of the other areas, the answer was that this was not allowed. The answer to this ten-year-old, who recovered from cancer when still a baby, was, "Sorry, you cannot get a service." "Sorry" is not good enough. We have the head of the HSE telling us the resources are not in place because it does not have the money to provide them. There must be a recognition that the notion we have a functioning health service is simply not correct. It reminds me of when Maggie Thatcher was asked about bus services many years ago, to which she replied that successful people do not use buses.

An Leas-Cheann Comhairle

We are way over time, Deputy.

Deputy Martin Kenny

The attitude of the Government seems to be that successful people do not need a health service. It is simply not good enough.

Deputy Gino Kenny

I acknowledge the really good work all our healthcare workers do on the front line of the health service. We rely on them so much for our care and everybody else's care. I am very critical of the inequalities in our health system but, as I have said many times, once people get into the public system, it is a very good system. They are treated very well and their experience is the best it can be in that environment. That is something of which this country can be very proud. However, there are historical inequalities in accessing that care, with waiting lists and so on. The job of successive Governments has been to address that but there remain gross inequalities in access. The funding shortfalls in the budget will have consequences for those who rely on services. The embargo on the recruitment of certain professions will have consequences across the board.

I will focus on one issue in the budget. I spoke to the Minister informally about this serious matter, on which I hope he can throw some light. It relates to access to life-saving medicines. There is normally a budget for these medications and treatments but for next year, that budget has, in effect, been cancelled. Many patients rely on certain medications and treatments. There are 1,000 cancer patients who may not get access to 23 new medicines. Will the Minister provide clarification in this regard? Being able to get treatment is a life-and-death issue. Like all other Deputies, I received an email concerning one of these patients, who was told there would not be access to the new drug and it would require leaving the jurisdiction to access it. That is not good enough. People are reliant on these drugs as part of their medical intervention. Even Bernard Gloster has said there will be a significant slowdown as a result of the lack of additional funding for clinical programmes. This is quite serious, to say the least. I would be grateful if the Minister could offer some clarity on the funding shortfalls, particularly for new drugs and treatments. There are more than 1,000 people waiting for these new drugs and treatments; in fact, there are 4,000-plus. I hope he can provide clarity in this regard.

Deputy Colm Burke

I very much welcome the work the Minister has done over the past two to three years. There are challenges in healthcare provision and a supplementary budget will be needed to deal with the expenditure of an additional €1.5 billion this year. There are issues we need to look at in dealing with healthcare. It was interesting to hear the Sinn Féin spokesperson on health acknowledging that the health service in this country had contributed to the increase of 11 years in life expectancy, from 71 to 82, in the past 50 years. In the past 20 years, in particular, the way in which healthcare has been provided has had a major influence on life expectancy.

Part of the challenge in providing healthcare arises from the increase in population. CSO figures show there were 3.85 million people in the country in 2000. There are now more than 5.2 million, which is an increase of 1.5 million, or 40%. In real terms, there should have been a 40% increase in healthcare provision. There has been such an increase in a large number of areas but there are challenges in some areas, which we must work to resolve. Over the past seven years, the number of staff in the HSE has increased from 103,000 whole-time equivalents in December 2014 to more than 142,000 now. There are approximately 162,000 staff in real terms but when the number is converted into whole-time equivalents, it amounts to 142,000, which is an increase of 40% in that period. Every one of those staff is required, no matter what area they are in.

The question is whether more efficiencies can be created. An area of concern is that a huge number of organisations deliver healthcare services. The health budget is €22.5 billion for this year but more than €6 billion of that will go to 2,500 organisations that receive their funding from the HSE or the Department but are not under the remit of either. They provide really good services but there is a question as to whether we could do better in achieving efficiencies in some areas. Are different organisations providing the same service? We might be able to do more in looking at that issue. At the meeting of the Committee of Public Accounts this morning, I asked whether there are enough checks and balances in this area. Some of the organisations I am talking about are voluntary hospitals and others are organisations such as COPE that provide a superb service, including rehabilitation services, right across the country. Those services were developed because there was a gap in provision by the healthcare sector. The organisations have filled that gap very well for a number of years but we need to examine how more efficiencies can be created.

To give an example of a lack of efficiency, I was talking recently to a consultant who has worked in the United States where there was access to an operating theatre two days a week. This person is now back in Ireland and has access to an operating theatre for only half a day a week. The problem is that the half-day slot is after lunch but the consultant has been advised that no patient can be admitted into theatre after 4 p.m. I am not blaming staff, who want to leave at 5 p.m. because they have children to collect and look after or there are other demands such as caring for elderly parents. Surely, however, it should be possible to have an arrangement whereby one lot of staff work from 6 a.m. until 2 p.m., say, and another lot cover 2 p.m. to 8 p.m. This would make better use of the facilities. In the private hospitals, many of the theatres are operational until 8 p.m. because that is the way the rota is done. The question is whether a more efficient service can be created with what we have. A lot of people are calling for more consultants to be appointed, which I fully support.

It is fine to appoint consultants, but we also have to make sure they have access to what they require, whether that be theatre space or treatment rooms. When we have built the new children's hospital, that will not be a problem there, but not having access to facilities is a problem in an awful lot of other hospitals in the country. While we must employ more consultants and get the best people in here, it is important that when we do so, we use them effectively and efficiently. That is something we need to look at.

This goes back to the issue of management. There was a big call last year to get in consultants on Saturdays and Sundays to discharge patients from hospital. That is all fine if we want to discharge someone, but if it is the case the person being discharged cannot go home because they are not well enough to do so, even though they are well enough to be discharged, and if they need to go to a step-down facility, will enough administrators be in place to arrange that step-down facility, or what forward planning has been put in place? That is where we can create efficiencies.

I acknowledge the HSE will say something like 500 people who are in hospital on any one day are ready to be discharged but, unfortunately, cannot be discharged either because there is not adequate support at home or because there is no step-down facility arranged for them. We need to prioritise step-down facilities and the issue of contracted beds. For example, I was recently dealing with a patient in Cork University Hospital, CUH, who had Huntington's disease. One nursing home already had 12 contracted beds with the HSE and one of the people it had been looking after was a person with Huntington's disease. It was quite prepared to take the second person because it now had expertise for dealing with a patient with Huntington's disease, but the HSE would not engage with it because all 12 contracted beds were in use. We need to start thinking outside the box in regard to such issues in order that we can create more efficiencies.

I was recently in an emergency department, not, thank God, as a patient but to help the family of someone with an intellectual disability who was a patient there. It was at a weekend. Staff in emergency departments face significant challenges. First, they need to assess the patient, and if he or she then needs to be admitted, it is about getting a bed. In a lot of cases, people there did not need to be in an emergency department. If proper structures were in place at weekends, they would not have to go to emergency departments. We need to look at how we can put in place a proper GP system for weekends. A very successful unit in Cork, for instance, is the minor injuries unit. Rather than having to go to the emergency department of CUH in Cork city, people can go to the minor injuries unit at St. Mary's Health Campus. It deals with a huge number of people because it is just for minor injuries, and it has a team of nurses and doctors who can deal with minor injuries every day of the week. We need to develop that to get it in place more widely.

I acknowledge the Minister has been working on the issue whereby a nursing home gets concerned about a person and needs to have them admitted to hospital. A system was set up during Covid, which I think St. Vincent's University Hospital in Dublin spearheaded, to get a team to come out from the hospital to the nursing home to assess the patient and then to give guidance to the nursing home as regards how they were to be managed. The Minister has encouraged this to be developed but it is important we develop it in every part of the country in order that we can keep people where the same level of care can be provided for them in the nursing home as can be provided in a hospital. In that way, we will not have to look for a vacant bed in a hospital and people from nursing homes will not have to wait in emergency departments for a number of days before a bed becomes free when, in fact, they could have been looked after just as well in a nursing home. We need to look at these issues with a view to creating efficiencies while, at the same time, giving a good quality of care.

It is important to acknowledge the commitment and dedication of the staff in all our hospitals and care facilities, whether they are people who are dealing with disabilities or others. We should recognise the work they have done, not least during the very challenging time of Covid. One area that now presents a challenge relates to home care, and the Minister has done a great deal of work to try to develop that area and improve access to home care. The big challenge he faces, however, concerns the lack of availability of people who are prepared to take on that role. We need to see how we can further entice people who were previously involved in those roles back into them while also getting new people into them. The Cork-Kerry region had 1,800 really dedicated people providing a very good service of home care but, unfortunately, 400 of them decided to opt out of the system, and the HSE in the south and south-west area has found it challenging to recruit additional people.

There are now more than 805,000 people in this country over the age of 66 and there has been a huge increase in the number of people who are over the age of 80 and even over 90, and that trend is going to continue. The more home care we can provide, therefore, and the more people we can keep out of nursing homes and out of hospital, the better. We need to look at how we can advance the recruitment and make it attractive. If we spend some more money on that, given the service home care providers give, we will get a much better return on the money spent. It is a challenge, however, and I fully accept that, with full employment, it is going to be a challenge to get people into areas where both people with disabilities and elderly people who require care and support in their home have to be catered for.

Overall, we need to be positive about the healthcare system. While we need more money, we also need to create efficiencies, and I have no doubt the Minister will deliver comprehensively in all areas of healthcare over the next 12 months.

An Ceann Comhairle

I thank Deputy Burke and call Deputy Ó Snodaigh, who is sharing time with Deputy Paul Donnelly.

Deputy Aengus Ó Snodaigh

Gabhaim buíochas. Ar dtús báire, leanfaidh mé leis an téama a bhí á lua ag an Teachta Burke, is é sin ag gabháil buíochas leo siúd atá ag obair go dian dícheallach sa chóras sláinte, ag tabhairt cúram d'othair agus dóibh siúd a bhíonn go minic in ísle brí nuair a shroicheann siad an córas slainte, cibé in ospidéal, ag an dochtúir, nó ag freastal ar dhuine de ba daoine eile atá ag déileáil leo go gairmiúil lá i ndiaidh lae.

Ar ndóigh, tá aithne agamsa, cosúil le gach duine eile sa Seomra seo, ar a lán acu toisc ghnáthshaol na bpáistí atá againn nó baill na clainne a bhímid ag déanamh idirbheartaíochta ar a son nó ag bualadh isteach san ospidéal anois is arís. Tá aithne agam orthu agus, den chuid is mó, nó b'fhéidir iad ar fad, tá obair iontach á déanamh leo sin.

Chomh maith leis sin tá aithne agam orthu toisc go bhfuil mise, cosúil le gach uile Teachta Dála eile, ag déileáil leis an gcóras sláinte agus leo siúd atá ag obair ann lá i ndiaidh lae chun cuidiú a thabhairt dóibh a thagann chuig na hoifigí atá againn ag lorg cúnaimh nó faoisimh éigin nó ag lorg go mbeidís in ann teacht timpeall ar na scuainí feithimh atá ann. Is é sin an phríomhfhadhb atá againn nach bhfuil an infheistíocht ag déileáil leis na scuainí feithimh, nó na scuainí feithimh atá anuas ar na scuainí feithimh. Níl na leapacha, níl na lianna nó níl na haltraí ann sa chóras. Tá an córas ag obair ar bharr a chumais nó níos mó ná sin, áit nár chóir a bheith ann. Níor chóir go mbeadh aon eagraíocht sláinte ag obair 100% nó 120% sa chóras. Ba chóir go mbeadh sé in ann a bheith ag obair ar bhonn réasúnta.

Ag casadh ar rudaí áitiúla, tá fadhbanna bunúsacha ann. Ó thaobh pleanála de, tá an t-ospidéal nua leanaí sa cheantar agus níl aon phlean ann nuair a chríochnaíonn siadsan atá an tógáil, chun an tógáil a dhéanamh ar an ngá maidir le hOspidéal San Séamas nó chun Ospidéal Ollscoile an Choim do Mhná agus do Naíonáin a bhogadh go dtí an suíomh sin go fóill.

Níl cead pleanála ann so stopadh an tógáil agus ansin tosóidh sé arís ag am éigin eile. Cuirfidh sé sin as do gach duine a bheidh ag úsáid an tsuímh sin, an gnáthphobal sa cheantar ag an áit chéana.

I appeal to the Minister to please sort out the problems in the CDNTs. It is crazy that there are vacancies upon vacancies in some of them. CDNT 3 in particular has to be addressed, as otherwise people will move to other CDNTs and place an additional burden on those areas.

Deputy Paul Donnelly

Sometimes we get bogged down and lost in numbers, statistics and figures. We hear of millions and billions. I listened earlier to a report from Zara King on Virgin Media. It frightened me to my core and angered me. Many of us have elderly parents who could be in the position she described. Ms King wanted to illustrate that a particular lady was active and how healthy she was when she got a tummy bug and got sick. She was sick with her stomach. She went into the hospital on 3.30 p.m. on a Monday and was left sitting on a chair for two days. On Wednesday afternoon, she was finally allocated a bed. The lady died on Thursday morning at 6 a.m. after taking a turn overnight. The family do not know how she died. They do not know what happened to her and they are stunned. This lady died in the first week in October, only two weeks ago. The family are asking how their mum went from being a vibrant and healthy 78-year-old living her life, to be gone with no explanation. The only thing they know for sure is that she was sitting on a chair for two days in an emergency department. While she was there, her family were with her and witnessed multiple instances of older people on lines of trolleys through the hospital. They told the story of one man who needed help to go to the bathroom. He did not get the help he needed and because of bad health ended up in an undignified situation in front of a lot of other people. How can we stand over this? How can we stand over a health service that is in crisis?

I will raise another important issue. This week we met the hugely impressive Stuttering Awareness Mental Wellbeing group, which is supported by Deputy Mark Ward who was in the Chamber earlier. Members of the group spoke about the devastating effects of stuttering on children and young people until they received help and support. They said one thing that would make a massive difference to children who stutter and struggle is early intervention. Speech and language is the one thing that would transform their lives. Those are not my words. Those are words from a book, of which I am sure the Minister of State will receive a copy.

Deputy Mary Butler

I met the group.

Deputy Paul Donnelly

She has a copy. She should read that book. The stories are heartbreaking, but also inspiring.

Deputy Peter Fitzpatrick

The Department of Health is already facing an overspend of around €1.5 billion this year and €1 billion next year, which is an overrun that will require a Supplementary Estimate allocation. However, only €22.5 billion - current and capital - was allocated for the public health system as part of budget 2024. Despite this being an increase of €1.1 billion in current expenditure on last year’s budget, the budget 2024 allocation has been roundly criticised as insufficient to meet rising demands in the health sector. Notwithstanding this, the question of a bailout for the Department of Health will only be considered later in the year. This seems paradoxical considering the official policy of the Government is to expand access to healthcare under the Sláintecare programme.

When Sláintecare was published in 2017, demand projections were based on population projections to 2026 and carried out within the health service capacity review. However, the projected population for 2026 was surpassed last year. We are therefore working from out-of-date projections. As in all other sectors, medical inflation is resulting in price increases for contemporary, effective drugs and devices. Bernard Gloster, who runs the HSE, is in a difficult position. The HSE must either put forward a service plan that has an inbuilt deficit or make a series of cuts that are undoable.

The current recruitment freeze is an inevitable consequence of underfunding. Last Friday, Mr. Gloster extended the recruitment freeze beyond clerical and management grades to include patient and client care roles. Many plans in place to improve services were in the process of recruiting. Mr. Gloster also announced an immediate pause on 7,000 posts, previously approved in principle, which cannot now be funded.

Let us assume the cost of the existing level of health service, which means keeping the health service running with no expansion, is €2 billion for the current year. If it receives less than €1 billion investment, the health service is on track for a deficit that does not account for demographic expansion or medical inflation, let alone any increase in services. The Government is calling this deficit an overspend. Many in the healthcare field are calling it lack of funding. Regardless of opinion, when it comes to healthcare, we need to focus on meeting the needs of our growing and ageing population. According to a former director general of the HSE, Tony O’Brien, “dodgy maths and dark politics are putting Irish patients in danger.” The Government is putting surplus moneys into the creation of two new funds, which are needed. However, health services are demand led and will only increase in the coming year.

If the Government wants to avoid a healthcare disaster, especially considering the common winter crisis, the only way to do that is to properly fund the health service. If it does not invest now, this will have consequences, including a negative impact on patient safety. Services across healthcare, from disability and mental health services to hospital and primary and community care services will be affected. We need to invest in beds, personnel, innovation and medication. Not a single euro was invested in new medications in this budget. We are going to fall behind because of lack of funding.

There is also a growing sense of apprehension about the future of mental health funding. Mental Health Reform estimated that an additional €115 million to mental health funding in budget 2024 was essential to improve access to timely and effective mental health care. What percentage of the health budget will go to mental health?

Supplementary funding needs to be recurring in next year's budget, but also needs to address the problem that not enough funding has been allocated for this year. However, the details of Supplementary Estimates will not be considered until more financial information is available towards the end of the year. Reactive governing, a lack of foresight and funding and an absence of negotiation will affect every service going forward. We need to act now.

Deputy Matt Shanahan

I do not want to come into this Chamber and suggest that our health service provision is a mess, but clearly some things are not working and need to be changed. I acknowledge the many people in the service who are doing extraordinary work. I also commend the ongoing development of our community and primary health sectors. These are fundamental to relieving pressure on our acute hospital systems. On community sector developments, I congratulate all those in my local area, CHO 5, on the work they do. I acknowledge the work done by the Minister of State, Deputy Butler, in the area of mental health services and older people. I acknowledge the announcement made by the Minister this morning of a new neurology team for CHO 5. It is very welcome. It is also important to acknowledge the Government's engagement with section 39 health workers, and the Minister of State's work on children's referral, in particular to CAMHS, and the No Wrong Door strategy. These are all to be welcomed.

On the drug strategy the Minister of State, Deputy Naughton, spoke about, I point out the important work done in the area of addiction. I highlight Gerry Carroll and Aiséirí in Waterford who do terrific work. There are, however, significant funding problems for organisations like this. I ask the Minister of State, as part of her budget, to provide funding for therapy services, addiction therapy counselling in particular.

The health debate can be divided into a number of major areas but it boils down to a number of issues. Those are cost versus efficiency, service planning and recruitment, training and retention of staff, capital delivery and the future-proofing and embedding of technology in our service practices. What is not measured cannot be managed, as we have seen. Unfortunately, a large number of our problems in budgeting are because we are not properly monitoring or looking at the best in class and trying to get others to emulate what they are doing. That is what would be done in private business but that seems to be anathema to the public service. We have stellar exemplars and we let them do what they do. The Ministers know what work has been done in University Hospital Waterford on emergency department management, in particular when the Wexford emergency department was closed. How were all those patients managed? How were the acute beds managed? Why did we not have patients on trolleys during all that time in the model 4 hospital with the lowest level of funding in the country and the smallest number of healthcare staff? Nobody has looked at that case and asked why it happened.

I have written to the senior Minister on an issue I raised recently concerning the number of interns at Beaumont Hospital versus UHW. There are 92 in Beaumont and only 25 in UHW, despite UHW having a higher rate of outpatient procedures. The question was "Why?" When I wrote to the Minister what I got back was that it was basically the colleges who provide medical education and look after placement. This has to be sorted out. A budget has not yet been provided to open the second cath lab seven days per week. The commitment is there to do that by Christmas. I understand that, despite moneys being promised by the HSE to support the activities of UHW during the Wexford emergency department closure, nothing extra has been given to the budget of UHW.

The diabetes unit in Waterford has no insulin pump therapy or adult insulin pump programme. It is the only model 4 in the country without that. I ask the Ministers of State to look at that.

Deputy Verona Murphy

I would be the first person to say efficiencies can be made not just in health but in all Departments and county councils across the country. However, this discussion concerns investment in healthcare. The health budget has been cut and the Department of Public Expenditure, National Development Plan Delivery and Reform has given no indication as to where the savings can be made. I ask the line Minister and all Ministers to ask that Department to provide a line-by-line account of where the spending must be cut and to tell us where it wants the cuts and savings and which parts of the service it considers oversubscribed and undersubscribed.

Bernard Gloster appeared before the Committee of Public Accounts a number of weeks ago and was very upfront. Leaving cuts aside, he has a mammoth task ahead of him. He has to deal with the ineffectiveness and inept management of his predecessor and has to address why Martin Curley left the HSE. Martin Curley made a statement when he resigned from the HSE which resonated with me today. He blamed it on a lack of "will and skill" in HSE management and constant blockages of innovation. He said he no longer believed it was possible to fix the system from the inside. I and the public would like to know if there has been any investigation into that statement. Where have the lessons been learned from someone who was headhunted by the Department and left just one year later? That warrants a serious investigation. We need to know the answers.

By cutting a budget and bringing someone like Bernard Gloster in, he will be operating with one hand tied behind his back. It is fundamental to any business and, as my colleague, Deputy Shanahan, said, to how efficiencies are managed. If we do not have something that is digitally efficient in the times we live in, it will be difficult for anyone to obtain efficiencies anywhere. I ask the Ministers of State to address that in closing statements, please.

Unfortunately, I can outline where moneys have been set out in budgets for years. This is my third, if not fourth, budget and I can see moneys are not being spent because services are not being delivered. This is not to admonish any Minister but the reality is we are failing our children in the services we are providing; as a matter of fact, it is the service we are not providing that is failing the children.

I appreciate the Minister of State, Deputy Butler, will open a third CAMHS unit in Wexford. It is pointless. We need a fully staffed CAMHS unit among those that exist. We do not have it, either north or south. It is a bit like having a third car with no driver. We need to look after the first two. It would be better to provide transport for anyone to whom the third service would be available to bring them to a fully staffed unit. That would create efficiencies and remove the waiting list.

I also ask that a serious look be taken at why one CAMHS in Wexford has a referral rate that is half the other. It is not staffing levels. We have GPs who are tearing their hair out and failing families who tell me they are afraid they will lose their children if this continues. If the referral is not accepted they have nowhere to go. That is what I call investment. If we catch and treat mental illnesses at the appropriate time, we can save an adult and family from years of misery. Unfortunately, we are not doing that at this point.

I could go on about CDNTs. It is a similar statement. They are not fully resourced. We need to look at whether to disband them and move to a service we can resource with the staffing levels we have. There is no point in providing half a service. If this discussion is about investment in healthcare, they are primary to what we need to do and Bernard Gloster must be assisted in that.

Deputy Joe Flaherty

In discussing health and the health budget 2024, it is important we stand back from the media spin and the claims of the Opposition. Spin has never cured a patient and will not aid any recovery. The reality is we have seen unprecedented investment in health. The budget for 2024 will be €22 billion, up 80% on the €13.2 billion in 2015. It is an extraordinary increase by any reckoning and indicative of this Government’s determination to get to grips with the many challenges facing health. I hypothesise that if we had given the additional €2 billion to health, the same Opposition would clamour and claim we are simply throwing taxpayers’ money at the problem.

Throughout the Covid era we dedicated enormous resources and money to addressing the structural issues in our healthcare system. I have listened to the Tánaiste speak on the issue a number of times since the budget. He is a former Minister for Health and probably better understands the workings and failings of the system, and specifically the HSE, than anybody else in this House. He correctly pointed out we need a deeper analysis of how we spend money in health in the context of analysing demographics and taking account of fuel and food inflation. I have also heard several health economists in recent days speak on this issue. They see a balance in the argument. They see the Government’s position but also see the challenges facing the health sector.

Much has been made of claims the HSE will not be able to recruit in 2024 but the reality is throughout recent years, when the system was awash with money and record investment by the Government, the HSE still could not recruit to fill home care roles and disability sector posts because of inherent flaws in its processes. Giving it the money will not address those issues but will further line the pockets of agencies which are creaming the health service at the moment.

Every Member of this House has listened for hours to families struggling to get therapies for children and desperately trying to get home care for their parents. We feel for staff on the front line trying to deal with these beleaguered parents and families daily. These staff have pointed to the issues and shortcomings and have lamented the inability and unwillingness of senior management to address these glaring inadequacies. It is time to challenge the HSE. The Government should not and will not allow the health system to suffer. Equally, it should not fling money at a sector racked by shortcomings and inefficiencies. It is time for the HSE to step up, work with the Government and finally deliver a world-class healthcare system befitting a €22.5 billion budget.

We need to start seeing accountability. If we, as in the past, allocate €20 million for the treatment of scoliosis, it needs to be spent on just that and alleviating the pain and discomfort for so many young people. If we provide funding for an additional 200 therapists in the disability sector, we need to see those roles appointed. If we provide funding for additional home care staff, these people need to be appointed on HSE terms and conditions, not outsourced from agencies where profit is king and patients are ancillary.

What is not and has not been acceptable is the failure of the HSE to follow through on this Government's actions rather than appointing more administrators and outsourcing agency staff at enormous cost to the HSE, the State and, consequently, taxpayers.

If funding is the challenge in 2024 for the health service, this Government will not be found wanting. Equally, it is time for the HSE to embrace the concept of accountability and to play its part in delivering the service we expect and people would and should expect from a €22.5 billion allocation.

I want to acknowledge the role of Bernard Gloster. The Opposition has made much of him addressing the threat of an overrun in 2024 in a weekend interview. We need the head of our health service to be a strong voice for the service. We need to hear his views and concerns. The Government will work with him for the betterment of the service and the well-being of patients.

I want to address a couple of specific points. I commend the Minister of State, Deputy Rabbitte, in particular, and her colleagues in the Department of Health on the progress we made on section 39 pay in recent days. We still have a fundamental problem with section 39 organisations. They are out of kilter with their colleagues and contemporaries in the HSE and other sister organisations throughout the country. It is something I would like to see grappled with within the lifetime of the Government. Notwithstanding the recent pay increases that have been agreed in the order of 8%, they will still be some way off their colleagues in HSE posts. I refer specifically to the staff of St. Christopher's Services, Longford, who are still due back pay in terms of increments and the €1,000 pandemic bonus which was not paid to them even though they worked throughout pandemic. That is disappointing. It is a significant sum of money for a lot of people and something they had planned to use for children going to college or to do something around the house. It is important that this be addressed and I would like to see it addressed. It is embarrassing at this point as a Government Member that I have to come, three and a half years into the life cycle of the Government, and speak to something that I consider as minor. By the same token, however, something as important as that should have been resolved.

While I am on the pandemic bonus, I also want to address the issue of registry offices in CHO 8. It was the only CHO in the country where staff in the registry office did not get the pandemic bonus. It speaks to the folly of the HSE that those staff are taking a case to the WRC, which will result in additional expense for the HSE. I ask that the Minister contact CHO 8, and tell it to stop this folly and pay the €1,000 due to the handful of people there. It is quite ridiculous. If this happened in the private sector, someone would be answerable and held to account.

Last week I mentioned a nurse in St. Christopher's Special School, Longford. There is a bizarre situation whereby a school with 14 children with complex and advanced medical needs, many of whom are PEG fed and require hoists to be lifted in and out of school, only has a nurse on site for 14 hours a week. The school could not keep a nurse; the last one was appointed only in March and left in recent weeks. The school has made the business case for a nurse to be appointed for 32 hours per week and interviews for the post concluded yesterday. I understand the school will recommend an appointment to the HSE. I hope to see that appointment followed through on and that a nurse will be in situ in the school as soon as possible. It is a crisis situation and there is a real risk that children and parents have to be notified that the school cannot accept children.

In the time I have left I want to raise a case with the Minister of State, Deputy Butler, who has been very supportive of me. The case involves a young boy and family with whom I am familiar. The boy is currently in a general hospital and has complex care needs, including autism, mental health issues, bulimia and anorexia. He is at a crisis point at 13 years of age. His family are at their wits' end. In fairness, the team from Linn Dara visited the general hospital this day last week and assessed him. The hope and expectation was that we would get the young boy to Linn Dara as soon as possible. We have heard many people in the House address issues with CAMHS during this debate. Over the past week, I have lived that experience to some extent. The boy's aunts and older sister have phoned me. I am extremely fortunate to be in a position whereby I am not living this experience directly, but I feel their pain and empathise with them. It has to be frustrating for them to know there is a facility that can deliver care and give this young man a fighting chance. We all remember when we were 13 years of age and had the best of ambitions and the greatest of plans for life. To see a young boy in a general hospital with security guards on his door and the hospital having no recourse other than to try to force-feed him when 80 miles up the road, there is a facility that can deliver the state-of-the-art car he needs is difficult. The Minister of State is aware of the case and has engaged with me and been hugely supportive of the family. It is very much a plea from the heart. I am in a privileged position to be able to make this plea on behalf of the young boy and parents, aunts, siblings and extended family. I appeal to the Minister of State to ensure we get him to Linn Dara without delay.

Deputy Ruairí Ó Murchú

We have all been shocked by underfunding in the health service. We went straight from the budget into what seemed like a near disaster. We have all been very worried about the moratorium on recruitment because we are constantly talking about the number of positions left unfilled. The Government promised many more beds - 1,500 or so - but none were allocated in the budget.

We are worried about hospital waiting lists. We are also worried about the nurses we train and who work in the medical sphere. Everyone, including speech and language and occupational therapists, have to live in the real world and the problem is they are dealing with the cost-of-living and accommodation crises. Some of those who work directly for the HSE in hospitals are dealing with a crisis therein. We know the issues that pertain in respect of working conditions. If we are now saying there is insufficient money to deliver an existing level of service, I dread to think what will happen with the gaps we are not filling and which we have not dealt with to this point. That is something that needs to be dealt with as soon as possible.

As has been said by others, we are all very glad that, by the skin of our teeth, the strike that was threatened for Tuesday by section 39 and section 56 workers has not happened and we have seen some sort of resolution. There are outstanding issues regarding disparity of pay. We all found it very strange that something has to go to absolute calamity and disaster before it is resolved. I do not think that makes sense to everybody. We all know the vital work the Irish Wheelchair Association and others do and I am very glad the constituents who have contacted me and others were not put out. We welcome that the strike was averted, but we need to look at how we resolve issues. We should not need the plates to fall on the floor before we lift them and keep them spinning. I do not think that is good enough in any way, shape or form.

I refer to what Deputy Paul Donnelly said. I also met the Stuttering Awareness Mental Wellbeing Ireland organisation. This is an issue that crisscrosses into the remit of the Department of Children, Equality, Disability, Integration and Youth, but it is the same scenario whether we are talking about autism or disability services, CDNTs or primary care. We all know what should happen. We all talk about early intervention and multiagency approaches. I do not always see a lot of that. I accept that even if we set out today to do absolutely everything perfectly in regard to making sure we have enough occupational and speech and language therapists and psychologists, they are not necessarily in place. Workforce planning needs to happen. Beyond that, we need to ensure we get the best bang for buck. We are very good in this State at carrying out pilot schemes and we hear about the school inclusion model. A lot of people understand that we take the services to where the need is and the children are. That is absolutely necessary.

I would like to think there would be engagement with those organisations, and through the HSE and others, which represent occupational and speech and language therapists regarding what we can do until we can fill the spaces that need to be filled.

That is also using technology and whatever else can be done to facilitate and make this a much better process. We often talk about these types of solutions but they do not happen.

I brought up the issue of Dealgan House with the Minister for State, Deputy Naughton. It has been almost three years since the Minister met the families. I acknowledge there is an inquiry in relation to Covid but I still maintain they need to be provided with the mechanism the Minister had promised previously.

Finally, I want to bring up an issue from a constituent about Louth County Hospital. A large number of teenagers who are waiting for braces and other urgent treatments are categorised as 5A priority, which is the highest. Some in category 4 are getting the benefit of treatment in the Beacon Hospital, which is being paid for by the HSE. Why is this the case when the waiting time for 5As, who are clinically more urgent, we are being told is too long? This needs to be looked at and dealt with. It is quite strange that those who seem to be in a worse category are not being dealt with. I welcome the fact that we are dealing with the category 4s. This is not the first time I have brought up the wider issue of dental care for those with medical cards.

Deputy Bernard J. Durkan

I am glad to have an opportunity to contribute to this very important debate on the issue of investment in healthcare. There are many facets to it and many demands because it is demand-driven. I have raised this issue on numerous occasions. Every year after the budget, the question has always been to ask the Minister for Health to indicate whether the budget allocation for his Department is sufficient to meet the requirements for the next 12 months. It is a simple, straightforward question and the answer is always "Yes". However, as we come to the end of the year, the answer becomes a little bit faded and not as clear as it was before. Suddenly we hear condemnation of the Government, that it has not done things according to the plan, that it has fallen down on the job and is to blame and so on and so forth. This is despite the fact that a considerable investment is being made on annual basis here, comparable to that made in any other country in Europe. In fact it is considerably more than in many countries.

It now falls to us to ask the simple question. We need to put our ducks in a row. We need to find out exactly where the cost increases are coming from. That requires a certain person, when drawing up the Estimates, to be able to identify the potentials in every area and to be able to put that into a package that is readily available to the Minister when the allocations are being agreed upon. Without that we will always have the same problem of running after the cart, as it were, and all the time trying to catch up from a position of being behind the curve. This simply does not work. In private industry, if somebody is given the job of projecting the cost for the next 12 months or the next two years or more and they do not do it in accordance with the request they have to find a job elsewhere.

We have to admit that we need a correct assessment of the costs at the time of the budget. That includes everything. There are prime cost sums in every other sector of life that are provided for and priorities are determined. The sooner we get to that stage and rely on it, the better for everybody concerned. This would eliminate the continual harangue about how bad the services are and how everybody is under pressure as a result and how no one gets the level of care they need. We either cost it properly and effectively and we then deliver on that or we continue this same circuit on an annual basis. It does not work.

I remember, as will the Ceann Comhairle, when the old mental health facilities were closed down. Everybody said that it was a great idea, which it was. It was essential that it happened. There were people in some places who had spent up to 20 years in the same room upstairs and had never seen the light of day in all that time. However, the problem was that when the facilities were closed down, we did not make alternative provision. As a result of that, we have a greater number of people living on the streets and a greater number of people who are incapable of functioning in today's challenging society. That is in respect of child and adult mental health services and indeed general health services. The list goes on forever and we have all dealt with it on a daily and a monthly basis and it keeps coming back up again.

Some years ago we also discussed the need for more home care. This is an absolutely wonderful idea. Some of us had experience of the daycare services in County Kildare. They worked extremely well. Of course it meant that the patient had to go to daycare service, which they wanted to do, anyway. They wanted to mix with other people and be part and parcel of society and get the same care that they would get there as if they went to a hospital. It still works very well in County Kildare but it is limited.

The problem was that other people sold the story that care would be better in the home. Of course it would be but it cost an awful lot more and nobody ever said that. The Ceann Comhairle and I pointed this out on numerous occasions. It is logical that it would cost more. The most important element here is that it does not matter how many carers we have. With an increasing population and an increasing demand, it takes time to travel between point A and point B. With the increase in traffic on the roads and the increase in population, it takes longer to travel between point A and point B, so it is more expensive, as we anticipated it would be We need to address this issue. We either want it one way or the other way but we need to provide the service. We have to think about the most appropriate way to deliver the service and we have to do it soon.

There is an increasing demand for child mental health services for all the reasons we all have talked about. It is wrong that children who have mental health problems are put on the long finger in terms of attending to their needs. This has been going on for years. I am not blaming any Minister, it is just a fact of life. We need to get the show up and running and to deal with the issue. This applies to all counties. It requires an accurate costing at the outset and it requires putting the show on the road and into operation. I think that can be done but we have to first identify the costs. If we do not, we are going to be disappointed because there will be overruns.

I am tired and sick to my back teeth of hearing about cost overruns in the health service. It is a question of identifying what the real costs are in the first place and then delivering on them. It will be an improvement to the health service because the providers are under the cosh, as it were, all of the time. They are under the microscope and they face continuous criticism that despite more money and more staff the service is not as good as it should be. Whatever the other issues are, we need to deal with that as a matter of urgency. A couple of years ago, I read a report by an official who had the temerity to put on paper her observations of mental health issues and the number of cases referred to hospital over a two-year period. What shocked me at the time was that children as young as eight were being referred to hospital for self-harming and attempting to commit suicide. That is a sad situation that should not be allowed. In our constituency clinics we can observe the children who come in with their parents. Without being an expert at all, it is easy to notice the child who is in difficulty. If it is that obvious, the child should have been attended to long before it becomes obvious to a passer-by. We need to concentrate our efforts on this.

The children's hospital is notorious for being one of the largest cost overruns ever. Many people say that it is the greatest waste of money ever. I say that it is not. That is what is required in today's competitive society. For many years, we have been working with old fashioned systems that are no longer applicable in the present demanding world. If we can deal with this, we can silence the constant criticism and ease the pressure on the people who are trying to provide the service and are doing the best they can in the circumstances but we also have to commit ourselves to the actual identification of the spend.

The oldest trick in the book as we know - I used to do it when I was in opposition, strange as it may seem - is to predict an overspend by allegedly identifying an actual cost in the beginning. If that is pitched low enough, it can be adjusted as needed and as meets the demand in order to exaggerate what is needed to provide a reasonable service. I think we have sufficient funding in the system and it is consistently sufficient to be able to do the job to a far greater extent than we are doing it, but it needs considerable operational review.

I have spoken in the House before about the layout of accident and emergency departments. I spoke previously in the House about delivering a patient to an accident and emergency department. The accident and emergency department was crowded with people who had alcohol and drug addictions. They are correctly entitled to their treatment and should get it. That is the appropriate place in the whatever room is available in that particular institution. However, they should not have to sit on the seats that are around, two at a time with a blanket thrown over them waiting, and the people behind them who are in pain and obviously in need of attention, have to wait until these are all cleared. I can understand people having to wait for somebody ahead of them. However, they should be in the area where the specialty is available to deal with the situation; that is good organisation.

On this occasion, I was told I could not park in various locations. My obvious question was, "Where do you park, if you bring your person who is not ambulant into the reception area?" The answer was nothing - just blank silence and that should not be. We have to make the comparison with a private hospital because there should always be a certain amount of competition between the two. We need to have the two, one to take the overflow from the other as necessary. We need to have good solid reliable services. In the private system, people can go to the set-down area right outside the reception area, drop the patient off, go into the reception area, find a seat, come back out, take the vehicle away down into the car park directly underneath and go back up in the lift to reception again. The patient does not need to drag themselves or to be dragged by somebody else from one place to another and be told, "That's not really the place you're supposed to be." We need better organisation and delivery by a long shot.

I know the Ministers have made unannounced visits to hospitals, which is a good thing. As they will know, in the old days we were all on hospital visiting committees. We had a very difficult job to do; nobody liked to see us arriving on the scene. We did some things that needed to be done at the time without any fuss and without waiting for any report. It was never a question of asking for a report on something and then six or ten months later we might see some action on it. It was done the next day, within 24 hours. That is another lesson.

I could go on forever and I am sure the Ceann Comhairle could go on for at least as long, but I do not intend to so do. I ask the Ministers not to lose sight of the objectives and not to take criticism too seriously because there will always be criticism. However, one issue needs to be determined and that is the amount of money required to run the hospital services, the community care services and all the services for a year. Giving it a year at a time would make a huge improvement in the delivery of services.

An Ceann Comhairle

I thank Deputy Durkan for those words of wisdom.

Deputy Thomas Pringle

It was interesting listening to Government Members before I came into the House and hearing their take on what is happening with the health services. In the same breath we hear that they have got extra money - a record amount of money - and then we hear about all the problems. There should not be any problems because they have this record amount of money. The reality is that the record amount of money is not enough. If the Government and Government Members were to recognise that, we might get somewhere with solving the issue in the first place.

In 2000 there were 3.8 million people in the Twenty-six Counties and today there are over 5 million, which is 1.2 million extra people in need of healthcare and everything else. There are fewer beds in the system today than there were in 2000. How can the system work? It cannot. It is not possible for it to work. Regardless of what needs to be done and whether the system can get working, we will need to carry a lot of extra money at the initial stage to get a system that is working and then we can start to pare back. It is only by getting the system to work in the first place, that we can then start look to make savings.

We hear an awful lot about the need for huge savings because of maladministration. I would love somebody to point out where it is happening and how much could be saved by addressing that. Much as I would like to feel that it would be very easily solved - that getting rid of the administrators would solve the maladministration problem and we would have a load of extra money to deal with issues - unfortunately, I do not think that is there.

One of the Deputies said the Tánaiste said we need a full look at what the HSE is doing. If only he was in government and could actually do that. That would be really powerful. Imagine if we had a government that would do those things. These are coming from the fecking Government Members in the House. It is nonsensical.

Is anyone else listed to speak along with me? I do not think so, which means I have a bit more time than I thought I would have, the Ceann Comhairle will be glad to hear. I will go on a bit more about that.

Our healthcare system is on its knees, and one area that is suffering particularly badly is children's disability services and the CDNTs mentioned by one other Member. I could talk about many areas of the health service that are suffering at the moment. Earlier, I raised the issue of services in Letterkenny University Hospital, as well as elderly services in Donegal. A huge number of areas could be addressed and there would not be time to address them all in today's debate.

There are serious recruitment issues within children’s disability services in my constituency and throughout the country. Children's disability network teams are experiencing very high vacancy and turnover rates. At the beginning of September, the overall national vacancy rate was at 34%. In Donegal the vacancy rate was over 40% in the CDNT areas of Donegal north, Inishowen and Donegal east, and Sligo-south Donegal. There is no doubt that recruitment is a major issue, however, the newly founded special needs parents network in Donegal has stated that employee retention, staff morale, workload and job design are also critical issues that need to be addressed by the HSE.

Despite only being established last month, the new parents network in Donegal has carried out significant research into the experiences of parents of children with disabilities and their findings are very troubling. In a survey of over 300 parents in Inishowen and Donegal east, Donegal north, Donegal south west, Donegal south-Sligo, 87% of respondents stated that their children’s needs were not being met by CDNTs. That is a sad and shocking reflection. I know the CDNTs were supposed to represent the way forward, but like everything else in the health service, they are suffering and getting off to a bad start because they do not have the staff to function properly.

The special needs parents network in Donegal outlined the huge financial burden from the lack of service provision from the CDNTs, with parents, especially parents of children with complex disabilities, feeling they have no option but to access private treatment. It is absolutely essential that children get the therapy they need, as those who do not can experience significant regression and pain. No parent or child should be forced to experience this.

However, we are forcing them into this situation because the HSE will not allocate funding for children availing of private services. This means that services are only available to those who can afford it, which is very unfair on disabled people. The HSE, recognising that it cannot get the staff to get the CDNTs working, should support families in sourcing private solutions.

I know that is not, and should not be, the solution, given the replacement of public services by private services should never be the solution, but something has to happen in the meantime because children are being left behind and failed. If children are unable to avail of public services, they have to be facilitated in availing of private services. Services for children with disabilities, especially complex disabilities, are not optional. Some 86% of parents in Donegal feel that support to access private therapy would be helpful to them, and families in the region have reported paying up to €400 a month on private therapy. Such services should not be available only to those who can afford them. Even those families paying that amount cannot afford it because they lose out on other stuff, but they are forced into that situation because they have to help their children. That is completely unacceptable and raises serious questions of inequality. It is in direct contradiction to the United Nations Convention on the Rights of Persons with Disabilities, which was created to ensure the full and equal enjoyment of all human rights and fundamental freedoms by all disabled persons.

Addressing issues of recruitment will, as I mentioned earlier, require thinking outside the box. What we are doing clearly is not working, and a better way needs to be found. One of the ways these issues could be addressed is by ensuring that graduate doctors in the North of Ireland are facilitated in registering in the South. That is a massive obstacle for northern graduates and forces many overseas. The reality is that, because of a timing issue, graduates from the North cannot complete their training in the South. Basically, their results do not come out on time for registration in the South, which is shocking. It means that they all go over to England to complete their training and then are lost to us and the Irish system.

In addition, 83% of parents in Donegal felt that it would be helpful to extend the cross-Border health initiative to incorporate disability services. For counties such as Donegal and those along the Border, that would make a difference and would not require much thinking on behalf of the HSE. It would make the cross-Border initiative available to those parents in order that they could in many instances get services based in Derry, Enniskillen or somewhere like that and that their children could benefit from them. Again, that could be done as a temporary solution. It is a solution that would last only a short period, one would hope, in order that recruitment could take place.

The solutions are there but the Government is failing to implement them and, in turn, failing disabled people in this country. The HSE is trying to recruit locally rather than relying on national recruitment and is trying additional stuff all the time, including advertising on Facebook and so on, to ensure that this can go ahead. It should, however, be able to do that across the board. That might go some way towards alleviating some of the problems. It could ignore the national recruitment processes and work on local recruitment, trying to identify people who could come forward as healthcare services staff right across the board.

The families of children who have additional needs and who are working on the CDNTs were putting forward solutions and want solutions. They got the solutions from the health service and suggestions as to what could be done. Another meeting is coming up in six to eight weeks or so, when actual progress will be shown as to what is happening. I hope that progress will be made there because that will be vital. Perhaps that should be a model in showing how things could work across the country, whereby the people are working together with the families that need the services but they are also accountable in allowing themselves to come forward and come back to another meeting to show whether or not they are making progress and what is going on.

There is no doubt that we could talk in this debate about other services in the HSE that are also suffering from a lack of funding and service difficulties. One of the main issues is the recruitment and the retention of staff. That is the reality and that needs to be sorted out. That needs to be done across the board. If that could be resolved, we could go a long way towards looking after our health service. The reality, however, is that the budget that has been allocated for next year will not solve that problem because a recruitment embargo is ongoing in the HSE. How will the HSE recruit staff during a recruitment embargo? The Minister might address that in his summing up, but that is the reality and, therefore, Government Members need to come to terms with that. There may be a record budget allocated for the health services and the HSE but it is a record that will be broken because it has to be broken and because we need more money and more staff to make things happen and to make things work properly. The Government needs to come to terms with that and make things happen.

Minister for Health (Deputy Stephen Donnelly)

I thank colleagues for taking the time to contribute to the debate. I listened very carefully to the debate and there are some common themes. In spite of the fact that there are differences of views, there is actually an awful lot on which we are broadly in agreement, if not on all the detail then certainly on the main themes. One of the most important is what our collective ambition is for healthcare in our country. We are united on that. We are agreed that we are looking to provide universal healthcare in our country, a public health service whereby people get the care they need when they need it. It is very important and very useful that we are all united as to where we need to go.

The other theme we are united on, broadly, is how we need to get there. There was broad agreement that we need to continue to invest in community-based care, be it mental health services, disability services, primary care services, general practice or whatever else. There was broad agreement that we need to continue to invest in our hospital sector. Nobody questioned moving to a regional model. Nobody questioned our move to joined-up care for the patient from his or her home to his or her GP, to primary care services and to hospital services.

Critically, then, unlike in many other parts of our country and our society, we are pretty well in agreement on where we are trying to go and, broadly, how we get there. We all know we need to have much better digital services and e-health services. We are agreed that we need more hospital consultants. We are agreed on nursing levels based on safe staffing frameworks. That is a very positive thing, and that is what will bind us together from government to government in getting to this place that we are all fiercely determined to get to on behalf of everybody.

While there might be differences of opinion as to how much progress has been made, I have heard broad acknowledgment that, while there are very significant challenges in various areas that we must address - they might be in individual services, in an individual hospital or in a part of an individual hospital - a lot of progress is being made, not by me, not by the Ministers of State here, not by the Government and not by us in the Oireachtas, but by the doctors, nurses, health and social care professionals, hospital managers, porters, cleaners, care assistants and all our healthcare professionals. They are working so hard, and they really are making a difference for patients.

Let me take our cancer services. Our screening services are far more advanced than they were even ten years ago. We are identifying cancer earlier and earlier. The rapid access clinics are fantastic. They were not in that place ten years ago. We are consolidating services. Tomorrow I will launch a new state-of-the-art radiation oncology service in Galway University Hospital. We have psycho-oncology services. We have access to better treatments, be it radiation oncology, chemo or cancer medicines, than we have ever had before. For those who unfortunately do not make it through, we have palliative care services that we did not have. They did not look anything like they look like today even ten years ago. There is broad agreement that, in spite of the many challenges to come, our healthcare workers, not us, are making things better for patients. Services are getting better. The women's health services that are being rolled out, including see-and-treat gynaecology centres, menopause, endometriosis, perinatal mental health, maternity services, eating disorder teams and so much more, are getting better and better. We can emphasise different amounts but we are broadly agreed that that is the case.

We are also agreed that there are real challenges that we must still overcome in youth mental health services. We have huge opportunities that we need to seize as regards health and well-being. More needs to be done as regards addiction services, treatment and rehab. We know that our clinical services need to go further. We know we need more neurorehabilitation. We know we need to invest in new medicines and I am acutely aware that there is no new development funding for medicines.

I have explicitly told the HSE and the National Centre for Pharmacoeconomics that any savings that can be found next year can be reinvested into new medicines. To give colleagues a sense of that, our medicines budget is at about €3.2 billion. A 0.5% saving would give us €16 million next year for new drugs. The new drugs budget for this year was €18 million. Therefore, a 0.5% saving gets us to broadly what the new drugs budget was for this year. I am having conversations with the National Centre for Pharmacoeconomics about individual high-cost drugs that are coming off patent next year, for which we want to immediately move to generics and biosimilars where that is clinically appropriate, to accelerate savings. We can find that money, although it remains to be seen how much, and we will ring-fence it for new medicines. The biggest challenge is access. The budget funds the waiting list action plan, which is working, and it funds the emergency department plan as well. We will keep driving on with taking people off the waiting lists by getting them the treatment for which they have been waiting for too long, and important progress is being made.

I heard from a lot of Deputies, both in Opposition and Government, that we need to focus on productivity and I agree. Over the last three years we have put a lot of these measures in place and we have put a lot of structural productivity measures in place, including moving patients out of hospitals and into the community. That is better for the patient and it is also much cheaper to treat the patient. We are investing in advanced practice. For example, we have advance practice nurses seeing a lot of patients who would have previously had to wait to see a consultant. The patient is getting much quicker access and we are getting expert care to that patient at a fraction of the cost of them having to see a consultant.

I hear colleagues say that we have a long way to go and we do. We will never have a really productive health service until we have proper ehealth. We just will not have it. I hear colleagues say that we need to accelerate the financial management system and we do. I have put an additional €40 million into the budget this year to accelerate the roll-out of that so that we can get proper line of sight of spending right across the service. It is worth saying that when we talk about the service and a culture of cost control within it, I do not accept the view I have heard expressed in some quarters that there is no respect for money or a culture of cost containment in the HSE. That is not true. When we look at the HSE, community services, mental health services, older persons services and primary care services are on budget. A lot of parts of the HSE are on budget. The one part of the HSE that is spending beyond what it is funded to is our hospitals and that is because they are not going to turn away the patients who are coming in. There is more we can do in productivity and we will do that.

It is clear from listening to the contributions from Dáil Éireann this evening that we need an agreed baseline for how much money it will cost us to get where we all want to go. We all want to get to healthcare for everybody and we all broadly agree with the steps we have to take to get there. What we have not had so far is an agreed and independent assessment of how much that costs, including this existing levels of service, ELS, funding we all refer to, which is just the amount of money needed from year to year to keep the current services going. How much does that cost? This is a world where we have, as Deputy Pringle said, a level of population growth that was not forecast. It is beyond what the statisticians forecast. We have a large number of people coming into the country fleeing war who we must and will always help and provide health services to. We have huge healthcare inflation, driven partly by the war in Ukraine and partly by Covid. We have an unprecedented and unforecast wave of patient need because of Covid, driven partly from unmet need or deferred care during Covid.

I am setting up this study and report to give us that so that we can have an agreed baseline for how much money it will cost, and then we will have a simple conversation before us. We know where we want to go and if we can get an agreed view on how much money it will cost to get there then we can agree that we will fund that, and it is more expensive than is broadly understood by all of us. It is an expensive journey but a worthwhile one. Alternatively, we can decide that we do not have that funding and we can say we will do it more slowly, for example. I think we should move there as quickly as we possibly can. That is one of the things I will take away from the last few weeks and from the Dáil debate this evening, namely, the sense that we need to get that work under way so we can all have an independent assessment of how much it will cost us. If we achieve this, and we will do so together as we are all signed up to universal healthcare and Sláintecare, as a nation we will have achieved one of the cornerstones of a decent society and of our Republic, that is, to make sure that everyone can get access to great healthcare when they need it.