Health Services: Motion

I welcome the Minister for Health, Deputy Leo Varadkar.

I move:

That Seanad Éireann:


- the deplorable overcrowding being regularly experienced in hospital emergency departments;

- the record number of patients waiting on trolleys;

- the further delays in scheduled hospital treatments that will result from such overcrowding; and

- the failure of the Government and the Health Service Executive, HSE, to adequately prepare for a situation they fully expected to happen;

further noting:

- the sustained and consistent deterioration in the waiting lists for both outpatient appointments and scheduled treatments since the start of 2014;

- the failure to meet time related targets for waiting times over the past year; and

- the decision of the Minister for Health to extend the target for waiting times to inpatient and day case treatment from eight to 18 months;

agreeing that:

- the overcrowding crisis is causing an intolerable risk and danger to patients;

- patient dignity is being compromised;

- there are insufficient beds and frontline medical staff to treat the increased number of patients needing admission; and

- the crisis is being exacerbated by the number of patients clinically discharged who cannot leave hospital because the Government and the HSE are not providing sufficient nursing home beds or home care support;

agreeing further that:

- the health services are underfunded;

- the 2015 HSE national service plan is not sufficient to fully address the increasing demands and demographic pressures being placed on the hospital system; and

- key targets in the plan are regarded as unrealistic by its authors;

calls on the Government and the HSE to:

- immediately provide beds and increased front-line staff in order that the overcrowding can be eased;

- restore the number of beds funded under the nursing home support scheme to at least the level supported in 2013; and

- fund the health services appropriately and sufficiently in 2015.

I welcome the Minister. It is about time we got answers and solutions. In opposition we are often accused of not having a health policy. We are working on that but it is clear the Government does not have a health policy. That is the truth of it. I acknowledge that the Minister is very good at telling the truth but that is what we should all do. It is part of the job we all try to do. One needs to carry out those actions, it is not enough to sit back and comment. His comment today, that people will die, was appalling because his job, as Minister, is to keep people as well as possible within the available resources. It is not enough to accept death, suffering and outrageous waiting lists.

The overcrowding in the hospital emergency departments in recent months is deplorable. In one case we heard that a 103 year old woman was left on a trolley for 48 hours. In January there were record daily numbers of patients waiting on trolleys. The number of patients on trolleys is very high today. That week in January when there was a record number of patients waiting on trolleys saw a five-day weekly total of more than 2,500. There was no daily figure of 601 last week but the cumulative five-day total was even higher than the worst week in January, therefore the position is getting worse according to the statistics. On Tuesday there were 514 patients on trolleys. The overcrowding is leading to further delays which is the nub of the issue because it affects a vast number of people. In scheduled hospital treatments the waiting lists soared in 2014, partially because of the reversal of a trick the Minister's predecessor pulled in terms of putting people into one-off appointments to private consultants without any follow up but they have continued to increase in 2015.

It is right to record the changes to waiting list targets, the changes that have taken place and the announcements made in recent years but it is very difficult to get this information as one has to start looking around for what was said and when it was said. When the Government came into office, the National Treatment Purchase Fund was effectively abolished. However, it stayed as an organisation and monitored what was going on. It stated in July 2011 that the maximum inpatient waiting time would be eight months and for outpatients a year. In September 2012, the then Minister for Health, Deputy James Reilly, by way of newspaper interview said the waiting list for inpatients would be a year but would be reduced to nine months. That is how these things are usually announced, they are slipped into an interview as if they were already in place.

In 2013, a trick was played by sending a huge number of people off the waiting list to private consultants, not to get anything done but for a one-off appointment. They were taken off the list for a temporary period and the Minister was congratulated on what he had done to reduce the post-12 months waiting list to about 4,000. What actually happened was that he sent a number of people on the waiting list to private consultant appointments. In some cases these consultants were not of the specialty required and once the patients saw the consultants once they were put back on the waiting list and lo and behold the waiting list shot up again.

When the Minister became Minister for Health last summer he said there would be a maximum waiting time of 18 months; therefore, it has changed again. At the end of 2014 he promised the waiting list would be reduced to 15 months by the end of this year, as set out in the Government's amendment. It also states there will be an 18 month target by the middle of the year. The question is what is the target today? What is acceptable?

By my calculations, if the target is a maximum waiting time of 18 months, although I suspect it is higher, plus 12 months for an outpatient appointment, a person could wait 30 months for a hip replacement, for example, and that would be deemed acceptable and as meeting the targets set by the Department of Health. It is crazy. As far as I can see, waiting times and the targets have been changed eight times since the Government came to power. In other words, we have had eight variances in what are regarded as acceptable waiting times. There is also allegedly a maximum waiting time of 20 weeks for children. Will the Minister confirm whether it still applies? It seems doubtful in the context of a case brought to my attention recently, in which a three year old is waiting since last April for an ear, nose and throat outpatient appointment. That is absolutely extraordinary.

The crisis in the health system is being exacerbated by several things that are going wrong or have gone wrong in the management of the hospitals service. There are not enough beds and not enough front-line medical staff. Announcements on the appointment of new staff will not solve the problem today. There are record numbers of patients who have been clinically discharged but cannot leave hospital. Only in a very small number of cases can we attach blame to the patient in such instances; there have always been a few who do not want to move. Generally, however, the problem is arising because the Government and the Health Service Executive are not providing sufficient nursing home beds and home care supports.

One of the tricks pulled by the Minister's predecessor was installing a waiting period for the fair deal scheme. Prior to this, the Government would fund any waiting period retrospectively, either by reimbursing the nursing home or giving a refund to the patient where he or she had covered the cost of the waiting period through personal funds. The change is effectively a really stealthy cutback. The Government is now stating that for the 12, 14 or more weeks people are waiting for their application to be accepted, cover will not be provided. In the vast majority of cases people are in nursing homes because they have to be. The very definition of a requirement for such care is that the person cannot live at home. It is a last resort for families and, when it gets to that stage, elderly people cannot hang around waiting to be admitted. In many cases, the obligation to fund the waiting period is bankrupting families. It is utterly unfair.

It is essential that beds be opened immediately and staffing levels increased without further delay. It is not enough to tell our emigrants to come home and that they will find a great welcome. The problems I have detailed require immediate resolution, but the Minister is not doing what needs to be done. As I outlined, he has changed the maximum waiting time target a number of times since he came to office last summer. That is not acceptable. He has had plenty of warnings about what is going on. The former chairman of the HSE's emergency department task force and national director of acute hospitals, Dr. Tony O'Connell, warned last September that delayed discharges were putting lives at risk. Dr. O'Connell has since left the HSE. Instead of examining the issues he raised, the Minister took another opportunity to complain about pay levels in the health service without doing anything about them. Incidentally, the headline comment was that Dr. O'Connell had left for pay reasons.

The cancellation of elective surgery was a massive mistake. The involvement of the Irish Nurses and Midwives Organisation, INMO, in making representations supporting that move, as I understand it, was retrograde. I understand SIPTU did not support it. Trade unions should represent their members, which the INMO generally does very well. In this instance, however, its stance gave the Government cover for cancelling large numbers of operations for people who were in pain, particularly on the orthopaedic side. That is adding massively to the waiting lists. Will the Minister consider bringing back the National Treatment Purchase Fund in some form to have these operations carried out and help people who are in pain? It was not a perfect system, but it got the work done.

What exactly is the special delivery unit doing or does it even still exist? If it does, nobody seems to be clear on its role. The programme for Government promised that this initiative would be the be all and end all, the greatest thing since the sliced pan, as the phrase goes. However, we hear very little about it now. It was mired in controversy over expenses, consultancy payments and so on and it has not really shown anything in the way of progress. Will the Minister set out exactly what it has achieved?

It is time to get stuck into the nitty-gritty of the work that has to be done to resolve the health crisis and keep people well and alive. The Minister put it very starkly when he said people were dying, but it is not good enough to talk about it if he is not going to take the action needed. He is required not to be a commentator on health matters but an action man. He must show that he can get things done and is capable of doing what so many deemed him to be capable of doing. Instead of simply telling us what is wrong, he must right those wrongs.

I second the motion. On the first occasion on which the Minister came to the House in his new role I noted how much I admired his straight-talking approach and wished him well. I expressed confidence that if anybody could reform the health service, it would be him. He responded by saying I might not be saying this within a few months and, sure enough, here we are. My colleague, Deputy Billy Kelleher, issued a statement today in which he asked whether somebody would tell the Minister that he was the Minister for Health.

It makes a change for that Deputy to be saying something about health.

The Senator can check the Official Report to see what he has been saying.

Where is his policy? Where is the Senator's policy?

The reality is that the entire health service is underfunded. I am not saying it is perfectly well managed. Clearly, there are management challenges and changes that have to be made, but inadequate funding is the underlying problem. It has moved beyond the point of crisis and I do not envy the Minister his position.

I accept that it is difficult to come up with adequate solutions. The Minister is noted for his straight talking, but we also need action and, above all, funds to address the difficulties. The overcrowding we saw in the run-in to Christmas and again more recently had been predicted. At the beginning of the preparations for the service plan, the director general of the Health Service Executive, Mr. Tony O'Brien, outlined the risks to patient safety and the difficulty of delivering necessary services safely without an additional injection of funding in the region of €1.3 billion. We all accept that there is only so much pie to go around, but in response to the request for €1.3 billion, the Government allocated €100 million or thereabouts.

We all are aware of the situation in hospitals around the country, with patients being left on trolleys and elderly people left unattended. That is unacceptable. I have told people not to bring an elderly family member to hospital, unless they are able to wait with him or her. In fairness to nurses, orderlies and the various other hospital staff, they are pressed to the pin of their collar in trying to carry out their duties and cannot give the time required to patients. The reality is, as the figures outlined by my colleague clearly show, we have a health service that is at breaking point.

Dr. Tony O'Connell left the HSE less than one month ago after just eight months in one of that body's most senior roles. At one stage he wrote a three-page analysis in which he indicated that there were 703 delayed discharge patients taking up 30 wards of capacity. Why can these patients not go home? Are there no nursing home or convalescent beds available for them? Are we thinking outside the box at all to deal with this problem? Has the Minister sat down with the Tánaiste and Minister for Social Protection, Deputy Joan Burton, for instance, and considered whether we should look at abolishing means testing for carer's allowance? Should we explore the possibilities in that regard? Do elderly people have aunts, brothers, sisters or children who would be in a position to look after them in their own homes if they had sufficient support, including medical cards and other back-up supports? That might well be a more cost effective way of doing things, given that it costs €900,000 per week or something like it to keep people in nursing home beds.

Has it been examined? Has a costing been done because, if not, that is the kind of outside the box thinking we need. I do not know whether it will work but it is certainly worth considering the abolition of the means test which, with other supports, could provide a solution to the hold up on the fair deal waiting list of some 2,000 and free up some of the 30 wards of capacity. At one time 703 people were waiting to be placed. In other material I have read that is credited to Mr. O’Connell he states there are several patients in hospital waiting up to three years for a place. They are effectively living in hospitals. That is not the kind of management we need.

I do sympathise with the problem of resources faced by the Minister. He is sent with a statement laundered through some public relations industry, which is not I am sure how he likes it, in terms of calling it as it is, to say everything is rosy, the special delivery unit is doing its job, we are making progress, it is a difficult task. It is way beyond a difficult task. Dr. Fergal Hickey of the Irish Association for Emergency Medicine has warned about the risks but we do not seem to be any nearer a solution. The Minister needs to think outside the box and say this is what we will do rather than say this is challenging, this is unacceptable. We are all sick of that rhetoric. I am sick of saying it. That is one suggestion for the Minister. He can come back to me the next day and tell me why it is not workable to abolish the means test for the carer’s allowance on a trial period to free up some space in nursing homes and acute beds in hospitals and see if it is practical. Let it not be said that I am not trying to make some suggestions.

While it is slightly off the subject of today’s motion, I predicted when this Minister took office that it would not take long before he issued the parrot like responses his predecessor, and indeed Mary Harney when she was Minister, wheeled out regularly, to the effect that under the Health Act 2004 the chief executive officer of the HSE is now responsible for that area and the Minister has written to him and asked him to respond directly to the Deputy or Senator. That kind of behaviour is not acceptable and I am sure the Minister does not like doing it.

Following the debacle of recent years I want to bring up three medical card cases I have asked the Minister about: one concerns X and Y, twins, aged three, born prematurely, whose lives have revolved around medical appointments. X has had cerebral palsy since birth and has numerous other health issues as a result; Y has recently been diagnosed with asthma which will require increased doctor and specialist visits in the future. Both boys qualify for domiciliary care allowance from the Department of Social Protection and medical reports are provided to qualify for it. It is clear the Departments do not talk to each other because that case is under appeal through the Minister’s office. The second case involves an 18 month old who has Down’s syndrome with medical complications and is seeing a consultant in Crumlin hospital who cannot believe she does not have the medical card. Once again the response was that it is under appeal through the Minister’s office. These cases are all in south County Sligo. Another child, two years old with serious medical problems, awaiting a call to Crumlin hospital qualifies only for a general practitioner card.

The final case concerns a man who has cancer in two places and heart conditions. I have written to the Minister’s office about him. I will not name him here but he is from Cartron in Sligo. I am sure somebody in the Minister’s office can look him up. We cannot continue on the autopilot that I will quite openly say ran this country into the ground in so many ways. The Minister should not let autopilot rule his tenure in the Department of Health. We know how challenging it is. He does not need to tell us. We hear it every day. He should tell us the tangible things he is going to do to make it different this time.

I move amendment No. 2:

To delete all words after “That Seanad Éireann” and insert:


- the difficulties which overcrowding in emergency departments causes for patients, their families and the staff who are doing their utmost to provide safe, quality care in very challenging circumstances;

- that the Government regards the current emergency department overcrowding situation as a major problem and that optimum patient care and patient safety at all times remain a Government priority;

- the wide-ranging set of actions which have been put in place by the HSE to achieve improvements;

- the specific measures which have been put in place to address hospital waiting lists more efficiently and effectively, for example through initiatives on colonoscopies, special funding for scoliosis and ophthalmology, the appointment of additional consultants and the extension of ultrasound access to additional primary care sites; and

- the targeted, integrated approach being adopted by the HSE in relation to the needs of elderly patients who no longer require acute care;

notes in particular that:

- all hospitals have escalation plans to manage not only patient flow but also patient safety in a responsive, controlled and planned way that supports and ensures the delivery of optimum patient care;

- actions taken to date to address emergency department overcrowding include the opening of additional overflow areas, providing additional diagnostics and strengthening discharge planning with a range of measures including:

- 900 transitional care beds funded in private nursing homes (500 in January, and a further 400 in February), to assist in the discharge of patients from acute hospitals;

- 173 short stay public beds being opened across the country for a three month period;

- agreement on additional nursing posts: this year the number of nurses directly employed in the public health service will increase by at least 500 (excluding the increase in mental health nurse numbers);

- up to 300 overflow beds opened in acute hospitals; and

- additional community intervention teams introduced in Naas and Drogheda, with 11 such teams now in operation;

- the Minister for Health convened the emergency department task force last year to find long-term solutions to overcrowding by providing additional focus and momentum in dealing with the challenges presented by the current trolley waits;

- the HSE is finalising an action plan under the auspices of the task force to be implemented immediately to specifically address emergency department related issues across hospital, social care and broader community services with a view to a significant reduction in trolley waits over the course of 2015;

- actions being taken by the HSE to address waiting lists include observation of the national waiting list protocol, prioritising day of surgery admission where clinically appropriate; and provision of new patient care pathways such as medical assessment, minor and local injury units and urgent care centres and provision of care in non-hospital settings to support the efficient use of hospital resources;

- waiting list targets have not been changed and the HSE is finalising an action plan for waiting lists with a focus on very long waiters, such that by mid-year, nobody will wait longer than 18 months for inpatient and day case treatment or an outpatient appointment, with a further reduction thereafter to no greater than 15 months by year end;

- the HSE has committed in its national service plan 2015 to the publication of waiting lists on line at consultant and specialty level and aims to reduce waiting lists by way of process redesign, consolidating further the work of the special delivery unit to date;

- the Government has made provision for a welcome increase in the total financial resources available to the HSE in 2015, the first in seven years;

- the HSE is now in a position, where it knows there is an urgent service requirement, to recruit the necessary staff including additional nurses, doctors and therapists;

- the Government provided additional funding of €3 million last December and €25 million in 2015 to address delayed discharges: this funding is being targeted at hospital and community services which can enable initiatives to address specific needs of delayed discharge patients positively and thereby aims to improve timelines for admission from emergency departments and reduce waiting lists;

- the review of the nursing homes support scheme which is currently under way and due to be completed shortly will consider the future funding and sustainability of the scheme, as well as how community and residential services are balanced - following the review’s completion the Government will consider how best to meet the health, and related community and social care needs of older people;

- the failure of Fianna Fáil to make any proposal in its alternative budget for 2015 to address waiting lists and emergency department pressures, its leader’s broken promises when Minister for Health to eliminate waiting lists and the direct link between the constraints in recent years on the health budget and the economic crisis caused by Fianna Fáil’s reckless behaviour in government;

and supports:

- the Minister for Health in his continued determination to bring about improvements in urgent and emergency care services and hospital waiting lists.”

I welcome the Minister. It is good to have a debate on this matter but it is also good to talk about the real issues. It is important to recognise and give credit to the Minister, the Department and the HSE for their response in the past two months. A total of 900 transitional care beds have been opened, 500 in January, 400 in February, 173 short-stay public beds have been opened and 300 overflow beds have opened in acute hospitals but there remains a great deal of work to be done.

When dealing with this issue, however, it is important to consider what is happening in accident and emergency departments. For example, in 2014 there were 1,104,000 attendances in accident and emergency departments, that is over 3,000 each day. If there is even a 20% increase that means an additional 600 people attending each day. That is the challenge we face. There is a feeling the whole hospital service is collapsing but we need to realise that last year there were over 3,189,000 outpatient attendances. There were 451,000 emergency admissions and approximately 100,000 elective procedures. That is the work hospitals deal with outside the accident and emergency departments.

There are major challenges in the service which I will continue to highlight. Owing to the shortage of funds in recent years and the cutbacks, there was a reduction in staffing levels. One of the major challenges we face is consultant vacancies. There are many locums and agency consultants employed but according to my calculation, 325 positions require to be filled. When they are filled hospitals can start dealing with the waiting lists. We need decision makers. We need to give priority to this area.

I refer regularly to the Hanly report of 2003. There was a lack of action in the following ten years while we expected junior doctors to provide a high level of care in hospitals. The Hanly report set out a clear guideline. We should set out new targets over the next five years to implement that report. The target was to have 3,600 consultants by 2012 but now we have 2,500. We would then reduce the number of junior doctors. We have lost a huge opportunity to use nursing staff in the hospital service. Every nurse is competent but they have acquired additional skills which we are not using sufficiently. We need to consider their responsibilities to make sure they can make the contribution they want to make.

I note that Senator Marc MacSharry has left the Chamber but the 2005 report on accident and emergency departments described access and long-term planning. According to that report, the lack of consistent development of services outside hospitals is a primary cause of the volumes being experienced by the acute sector. International experience indicates improvements in primary care services as part of the health reforms reduce accident and emergency attendances, hospital admissions, occupied bed days and delayed discharges. Those commenting on the report said they experienced in many areas in the review an over-focus and emphasis on the acute sector as providers of all services to local populations from highly specialised interventions to very routine outpatient services such as phlebotomy, monitoring and dressing clinics, all of which should have been more appropriately happening within a community setting both as a first line service and a follow up.

There were several recommendations in that report but we have not made much progress on diverting work from accident and emergency departments to primary care, particularly when there was adequate funding between 2005 and 2008-9. I have spoken to several GPs in recent days who talked about their lack of access to diagnostic services.

They know what is wrong with the patient but they cannot get anything done unless the patient is admitted to hospital, although they are quite capable of delivering a service. We must prioritise this issue in order that GPs can access diagnostic services in the hospitals without having to refer patients to consultants or clinics. When GPs refer patients they are put on a waiting list and can be waiting to be seen for four to six weeks. The only way around that is to refer them to the accident and emergency department. This is something we could tackle immediately and it would help to deal with the overflow in our accident and emergency departments.

It would be worth the Minister's while to read that report from 2005 and to tick the boxes beside the recommendations that were followed through. He will find that there are a lot of boxes that cannot be ticked because we have not acted on them.

Cuirim fáilte roimh an Aire go dtí an Teach. Despite no longer being front page news, the trolley crisis is still rumbling in emergency departments across the country, with 514 people waiting on trolleys yesterday. Waiting lists are growing longer, with 385,781 people now waiting for outpatient care. The number of people having to wait for more than a year for an outpatient appointment also increased to 61,400 at the end of last year. We have heard the current and previous Ministers for Health tell us that they know it is bad and that they are working on it but when nothing is improving, that response is simply not good enough.

The Minister has decided to extend the target for waiting times for inpatient and day case treatment from eight to 18 months. Of course, this puts a better spin on the Government's failure to reduce waiting lists or even keep them at the same unacceptable level. The record high of 601 patients on trolleys in January has not yet been addressed. Dr. Tony O'Connell, the HSE's former head of acute hospitals and chairman of the task force on emergency departments, issued a warning months before the crisis. He referred to some 700 patients awaiting discharge, overcrowding and use of trolleys and said that from a quality and safety perspective, the situation was unacceptable. There are still hundreds of patients in hospital beds around Ireland who are waiting to be discharged but who cannot be because of a lack of step-down facilities, long-term care and nursing home beds. The number of such beds has been cut by 2,000 in the past few years.

The fair deal scheme delays have begun increasing again. The average wait time is almost three months and this could stretch to 18 to 20 weeks by the end of the year. Despite continued warnings in the past year about the need for additional resources for the nursing homes support scheme, the Minister has failed to provide adequate funding to relieve the situation and as a result, services right across the health system are being severely impacted. I am aware of many essential surgeries that have been delayed due, in part, to the failure to address emergency department overcrowding.

Despite all of these problems we still see the HSE making massive payouts to retiring staff, with four retiring consultants receiving lump-sum payments in excess of €300,000 last year. In Sinn Féin's alternative budget we would have provided for an additional 1,000 nursing and midwifery posts. This would have gone some way towards returning nursing levels in emergency departments and on wards to the levels seen before the massive contraction of staff numbers overseen by Fine Gael and the Labour Party. A total of 2,724 nursing posts have been lost since the Government took office and we must not forget that this followed similarly large cuts by Fianna Fáil in government.

We need additional funding for step-down beds and extra nursing home places. The Government has failed to solve the challenges facing the fair deal scheme despite ample time and opportunity. The Minister seems to forget that these are real people, real families and real heartbreaking situations. The €25 million extra provided for the scheme in the budget is likely to be now exhausted. The Government had no issue paying for private banking debt but not for a scheme that the HSE's own chief executive describes as an Achilles' heel.

My party has tabled the following amendment to the Private Members' motion:

After "the health services are under funded" to insert the following paragraph:

the HSE structure put in place under the Fianna Fáil party and maintained by the present Government was flawed from its inception and is not fit for purpose and the long promised fundamental reform of the organisation has not yet occurred;.

This is to reflect the fact that despite being recognised by virtually everyone as necessary, no one has yet grasped the nettle and undertaken a root and branch reform of the structure of the HSE. I hope the Government and the Minister will finally take the necessary steps to adequately fund staff for emergency departments and to ensure the fair deal budget relates to demand rather than being simply capped. Is gá don rialtas cinntiú go bhfuil maoiniú leordhóthanach ar fáil do na seomraí éigeandála agus don scéim fair deal agus bunleasú á dhéanamh ar Fheidhmeannacht na Seirbhíse Sláinte.

It is telling that a consultant from the Saolta hospital group was on local radio in Donegal this morning saying that he will have to resign if sufficient support resources are not put in place. This is on foot of another consultant leaving the service recently. It is obvious that we have a massive crisis in our health system and in our acute hospital system in particular which this Government has failed to address properly. Táimid ag súil go dtógfaidh an Rialtas na moltaí ar bord atá déanta againn le gur féidir an cheist seo a leigheas mar ar deireadh thiar, is daoine daonna atá ag fulaingt leis na gceisteanna seo ar fad agus ní leor caint, is leor gníomh ar an gceist seo.

I welcome the Minister. There is no doubt that accident and emergency departments are facing significant challenges but it is rather bizarre to be lectured by Fianna Fáil on the issue. It is telling that when Senator Marc MacSharry spoke, he made reference to the current Minister for Health and his predecessors but stopped just before he came to the architect of the HSE, the current leader of Fianna Fáil. Deputy Martin placed an un-reformed structure, the HSE, on top of an ailing system without making any provision for improvements in the service and that is probably the major cause of our current problems. In that context, it is unpleasant and unpalatable to me to be lectured by Fianna Fáil Members today, whose party was the architect of the problem.

Senator Thomas Byrne made several references to stealth and tricks in his contribution. If the Senator is correct in what he is saying, the Minister is some tricky devil who was motivated by something other than public service to take the job-----

I gave several examples of the tricks-----

-----and that it is only tricks and stealth in which he is involved.

I gave the examples.

However, any reasonable person would say that the current Minister is a straight-talking, dedicated public servant with no agenda other than fixing the problems that we have. It would be ungenerous of Fianna Fáil not to acknowledge this. It would be ungenerous of anyone not to acknowledge it. The problems within the health service cannot be solved immediately, contrary to the simplistic suggestion put forward by Senator Marc MacSharry and his colleagues that we only need to do one or two things and the whole problem will be solved. Anyone who knows anything about the health service knows that there is a chain of care from the moment someone presents to the service until he or she leaves it. A reorganisation of the HSE is what was needed.

The accident and emergency departments are the gateways to other services. The problems being presented at emergency departments are not, strictly speaking, problems of that department; they are problems of the entire chain of care. To solve the problems requires operational and political interventions at every level of the service, not just at accident and emergency level. If the Minister announced an additional 1,000 beds to solve the accident and emergency problem, in two months time those beds would be full and the problem would continue at the gateway.

Senator Trevor Ó Clochartaigh suggested that if we adopted the Sinn Féin alternative budget we would have a perfect health system. Of course, Sinn Féin's perfect budget builds castles in the sky. Perhaps we could build accident and emergency departments in the sky too-----

We are in a nightmare scenario.

We need to deal with reality.

The first point to make, which has not been mentioned yet, is that political responsibility rests with the Minister for Health. He will be judged on his performance and how he handles not just the accident and emergency crisis but the myriad of other challenges, rather than crises, in the health system. The term "crisis" can be overwhelming and can lead to an inability to act but the Minister is not overwhelmed to the point of inactivity. He is doing what is required to be done.

We must examine the culture of delivery within the health service.

To give an example, I train a couple of soccer teams and one Sunday morning just before Christmas, a young fellow went over on his knee. While driving him to the accident and emergency unit in the car, the symptoms with which he was presenting were quite obvious. He was in distress and it was clear that a cruciate ligament injury or something like that was what was wrong with him. While on the way there, he asked me what was going to happen when he went into the accident and emergency unit. I told him we would be obliged to wait at reception, would register and would go to the triage nurse. I told him we would then be called in, he would be taken for an X-ray and thereafter he would be given some sort of treatment after he had been diagnosed. This of course is exactly what came to pass except it took eight hours for it to happen on a Sunday morning. We queued at three different locations. What if an enhanced role was given to non-medical professionals in accident and emergency departments and throughout the services in order that, for instance, instead of seeing the triage nurse, the patient perhaps could have seen an advanced nurse practitioner who could have referred him directly to the X-ray department? Everyone knows that is what is required for minor injuries and limb injuries. In general, they are uncomplicated and advanced nurse practitioners are trained up to a point that is at a similar level to most of the medics one meets in accident and emergency units. They are different professionals and have different specialties but ultimately, they are competent to perform these roles.

Although non-medical professionals are being introduced into the health service, there is much opposition from other professionals. While I do not wish to name any professional, everyone knows who I am talking about and there is a territoriality associated with it. When one refers to vested interests within the health service, it is automatically assumed that the vested interests lie within the trade union movement. While there undoubtedly is a vested interest in that regard, there also is a vested interest in respect of the other top administrators and consultants. The Minister is aware of this and while one may not wish to acknowledge it too widely, I worked in the health service for 30 years and it is clear to me. There also are many cultural difficulties facing us.

In addition, were one to state the post-discharge solution of providing more step-down beds is the answer, the same problem would present as with the provision of more inpatient beds, which is that no matter how many nursing home beds one might provide, ultimately, they will be filled. My colleague, the Minister of State, Deputy Kathleen Lynch, did state she hopes this ultimately will be a demand-led scheme. While one can envisage the challenges in that regard, ultimately it probably is part of the package of solutions surrounding this issue. However, simply to lay the blame at the feet of our elderly population is both unfair and factually incorrect as there are several other issues at play. I refer to the possibility of giving a more enhanced role to the general practitioner, GP, service. I understand that the GP contract is causing much difficulty and perhaps more investment is also needed in this area. The GPs are the gatekeepers of the services and perhaps consideration should be given to how to better involve and integrate GP care into the accident and emergency and hospital services in order that the transition from one to the other is seamless. I could speak here for the rest of the evening about what I think is wrong with the Health Service Executive.

The Acting Chairman looked at me with despair on his face when he heard me say that. I understand the problem is complex and is not amenable to simple solutions. It is certainly not amenable to having money thrown at it, which is what Fianna Fáil did over the course of its tenure in government and Members have seen the results. It certainly did not cure the problem and probably made it even worse. I wish the Minister well in his job and in his determination to provide the country with a health service of which one can be proud.

Again, I welcome the Minister. He is a young man and about the same age as I was when I first became a consultant oncologist in Ireland's medical service. I was full of enthusiasm and optimism and thought a problem was what one was here to fix, not something that made one go away wringing one's hands, which is a common attitude in Ireland. I like to think I have managed to keep some of that enthusiasm although my youth has waned and I still look at problems that I try to fix and overcome. However, I must state I am a little weary now of one or two of them, and one about which I am most weary is the structure of the health system here, which is wholly irrational. Lincoln once famously stated, "A house divided against itself cannot stand" and I am afraid that our health service is a house that is divided against itself. It is one that I believe could be fixed and the only real impediment to fixing it is the will to do so.

I am in an awkward position because I agree with approximately 95% of the contents of the motion tabled by Fianna Fáil. In a number of terse bullet points, its Members here have pointed out eloquently and accurately many of the deficiencies within the system that must be fixed. As has been pointed out by others, I state this with no desire to be personally critical of anyone, the reality is that Fianna Fáil had many years in which to fix it but chose not to. For many years, Fianna Fáil-led Governments had a Minister for Health who came from a party that officially had no policy on health reform because its members stated the health system was too complicated and simply could not be fixed. I believe it can be fixed and I am not asking people to look at some pie-in-the-sky fantasy. I ask them to look at health systems that actually exist in countries that are similar to Ireland demographically, and on where they fit in terms of OECD wealth scales, etc. I acknowledge no system is without criticism but in such health systems, the torrent of criticism ours faces and which is largely deserved simply is not heard because there is a higher level of satisfaction with the systems. I do not wish this debate to turn into another in which Fianna Fáil criticises Fine Gael and vice versa and where the latter's principal defence in response to these charges is that Fianna Fáil could have fixed it. That is my job. I am not a member of either group and have been equally critical of both. The one Minister for Health up to now who I thought made a huge difference in fixing something was Deputy Michael Noonan. He is the one who deserves most of the credit for improvements that occurred in cancer care in Ireland. That is another day's work and I will not go into it today.

We have had the great experiment and the two great hypotheses have been subjected to experimental trial. The first hypothesis was that what was needed to fix the health system was not to change the way in which it was funded but to change the way the administrators were organised. Since I came back, we have had a Department of Health, an Eastern Health Board, an Eastern Regional Health Authority, regional health authorities, ultimately a Health Service Executive and now hospital groups. I believe that none of these will make any difference because they do not deal with the core problem, which is the disconnect between reimbursement and efficient activity. This is what must be done if we are to get rid of the waiting list problem.

Without going into all the details, the waiting list problem is not comparable with any other country in the western world but is absolutely at the bottom of the scale. We have an unbelievable waiting list and once again I must tell the Minister, on the basis of evidence that has been presented to me and which I have discussed in this House with the Minister's predecessor, the waiting lists may actually be worse than we know because there is a great degree of artifice in the manner in which the HSE and hospital outpatient clinics are now structuring who precisely is considered to be on a waiting list and at what time does a person actually become somebody who is subject to a waiting list. While it is not necessary to go into it all, there is something wrong with a system in which people are waiting two years for paediatric cardiology consultations or in which deaf children are waiting for a year and must strain to hear at the front of a class before they can get their hearing tested. There is something wrong where cataracts or orthopaedic surgery, which may not turn up very much in life expectancy tables but which have huge effects on quality of life, take so long and where people wait five or six days or a week in a hospital bed for a magnetic resonance imaging, MRI, scan because it suits the hospital to have them wait. This is because if one uses the single scanner more efficiently, thereby getting people to go through more quickly and if one has people working at night time, it will cost more money. The bed will be emptied faster but will not be emptied as it will be replaced by the next person who comes in off the list.

This is what happens when one has a disconnect between reimbursement and activity. If one looks at a league table based not on fluffy stuff like whether the hospital system has an ombudsman but on the core value of access to care, in all the scores that look at the various OECD countries, the countries that feature at the top of the list with boring regularity are those that follow the Bismarckian model of health care where there is a connect between activity and reimbursement. Those which are based on the Beveridge model of global budgeting and on that money being given in January with people being told to make it last until midnight on New Year's Eve are the ones with the waiting lists. They are cheaper systems but one other piece of advice for the Minister is not to fall into the trap of thinking that spending money on health care is bad for the economy. He should think of the United States and Japan in the 1990s, when former President Clinton campaigned on trying to make America more competitive with Japan because Japan's health care costs were so much lower. He failed and health care reform did not work at the time in the United States, although there has been a degree of health reform subsequently. Nevertheless, America's economy went through the roof throughout the eight years of President Clinton's rule while the Japanese economy tanked.

The Minister should consider the countries that spend more than Ireland on health care. Are they failed states with failing economies? I am referring to Canada, Germany and Israel, which faces an entirely different set of challenges that gobble up its GDP. There are examples of countries which have been shown to make it work, such as Switzerland. We can and need to do this.

As for the second major experiment we did, the Minister has been first in terms of peer reviewers who have looked at the experimental details and he has come to the correct conclusion. It was that there was something fundamentally wrong with the position regarding consultant contracts which were causing problems in the health service; therefore, we changed them.

We appointed a whole group of younger consultants to, more or less, full-time public jobs with no distracting private commitment. The waiting lists, however, did not go down by one second. What is more, we found it harder to fix the jobs, a problem which the Minister is now addressing.

The problems are manifold and the challenges are great but the Minister is up to them. This is his chance to really put a stamp on the service, to be the Noël Browne of our era. He may not particularly like that accolade ideologically but I mean it in terms of somebody who left a big positive mark on the health system in his brief period as Minister. No one has been given a better opportunity to do this than the Minister. The tide is rising boats economically and, as the Minister said, the era of cuts is over.

I find myself in the strange position of agreeing with the Sinn Féin amendment to this motion because it correctly points out that the problems in the health service come from both sides of the House. There was a commitment made to reform the health services. Fiddling around the edges and introducing new bureaucracies will not fix this. We have to fundamentally reform and fix the system. I hope and believe the Minister is the man for the job.

I welcome the Minister. I have to admit I was somewhat perturbed by the opening remarks of Senator Thomas Byrne. It was an unnecessary attack on the Minister, demanding answers and solutions while accusing him of having no health policy. He said it is the Minister's job to keep people well. Senator Thomas Byrne is not in the Chamber now but I do not believe it is the Minister's job to keep the people well or his responsibility to look after their health. Neither do I believe it is the doctors’, the nurses’ or the Government’s. Responsibility for looking after one's health remains with oneself.

I notice the same health service issues are to the fore now that were there when I returned from the United States in the early 1990s. Personally, I cannot understand why. Senator John Crown referred to structures which seem to be the nucleus of the problem. There have been ten different health Ministers since the early 1990s but we are continually experiencing the same problems. The Minister inherited a poisoned chalice, a point made in the media when he took over the role. I certainly know he is not God. I do not even know if God can put this right. At this particular stage, after many years of trying, we need a miracle to get it in the right direction.

There has been a complete mismanagement of the health service, a feature of the last Government which held office for 14 years. What did it do about it? Absolutely nothing. It led the economy from bust to boom and bust again. Unfortunately, the health service remained in a bust situation through that time.

Sarah Burke, in her 2009 article “Boom to Bust: Its Impact on Irish Health Policy and Health Services” in the Irish Journal of Public Policy, cited several reasons for the difficulties experienced, particularly the population experiencing a baby boom and people living longer. From news reports yesterday, we see we will be facing into serious consequences in this regard for several years when the baby boomers pass their mid-60s. Sarah Burke stated, “Medical inflation has continued to rise alongside increased expectations and demands on health services.” She also stated the greatest failure of the last Government was that during the boom time in health, the budgetary allocation multiplied. However, lots of time and money was wasted on reform yet things got worse. Why? The answer is structures. She stated, "Between 2001 and 2010 there has been much time, effort and money spent on reforming the Irish health services, most evident in the establishment of the Health Service Executive, HSE, in 2005." The HSE was in total disarray right from the beginning when it took many months even to appoint a chief executive. Many of the problems we are currently dealing with originate from this particular period. For instance, instead of prioritising increased front-line staff, medical care staff, nurses, doctors and consultants, 11 different health boards, over 50 hospitals and multiple other health and social care agencies were merged into one centralised unit but not one person lost his or her job. There were no changes to work practices. Roles were duplicated and, in the end, there was absolutely no difference in how the health care system was delivered. Sarah Burke said this was all done under the name of reform. What reform has taken place?

The last Government was accused of wrecking the economy. It also wrecked the health services. The Government is trying to fix the health services, just like it helped fix the economy and put it back on track. In December, the Minister convened a task force to find a long-term solution to overcrowding in accident and emergency departments, a welcome move. While attendances at accident and emergency departments increased by 3.1% for December, we cannot blame the Minister or the Government for overcrowding. What has the Minister done since? Up to 750 transitional care beds were funded by the Department. In addition, across the country hundreds of short-stay beds have been made available while arrangements are in place in the HSE to recruit front-line staff in Beaumont, Limerick, Drogheda and Naas hospitals. A communications campaign has been put in place to encourage more people to use minor injury and local injury units. This should help to relieve pressure on the emergency departments and allow patients to get treated more quickly.

Spending on health services runs into the billions of euro. Many years from now, this will come to trillions. This is money spent on sick people. We need to look at how we can nip this in the bud. Prevention is better than the cure. Today’s young children and adults must be educated from a young age to look after their health and well-being. In the long run, this will mean fewer people attending hospitals in the future.

I welcome the Minister. Depending on who is doing the number-crunching, approximately 1 million people go through accident and emergency departments every year. There are several main issues with accident and emergency departments from ambulances, patient processing, staffing and step-down beds. From my experience of dealing with the ambulance service, I know the situation nationwide is dire when response times for 500 emergency calls are longer than the times recommended by the HSE. This has consequences. People are dying in County Kerry because of their geographical position. More important, they are dying because of cuts to ambulance services. Before, two emergency ambulances were based in Killarney, one in Kenmare and one in Millstreet, which covered the east Kerry area. Now, there are just two ambulances covering the same area. That in turn means ambulances are pulled in from Dingle, Caherciveen, Tralee and Listowel to cover the gaps in the service in Kerry. It is death by geography.

The lack of emergency ambulance cover means when paramedics do arrive to a patient, the patient has already deteriorated to such a degree that he or she will spend longer in an intensive care unit, hospital and the step-down care facility. In some cases, they may never leave hospital.

As the Minister knows, when a patient is suffering a heart attack, the longer it takes to put in the stent, the greater the likelihood the person will have an irreversible heart attack, will spend his days not being a productive member of society, or will die. We had such a case in Kerry where the Caherciveen ambulance was not available and nor was the Killarney ambulance. It was out on call with the result that the Kenmare ambulance had to travel one hour and 40 minutes to see this man in south Kerry. When he was seen, they called the coastguard helicopter. He stepped into the helicopter and said that it was not good. The paramedic agreed with him and he died on the operating table in Cork. If he had been seen earlier and if the ambulance had been available, the outcome could have been different. As we do not have enough emergency ambulances, we have people dying or having irreversible effects on the health, including heart attacks and strokes. There is an ongoing review and I take on board the point that the previous Government was in charge. A system where an ambulance is sitting outside an accident and emergency room with the patient inside on a trolley waiting for two hours for someone to say they will take him in is beyond belief. It means, for example, that the ambulance is not available in its home county to bring stroke and heart attack victims to Cork, leaving the service devoid of cover in Kerry. The same situation applies around the country.

The Minister has an action plan for stepdown beds. With regard to the 700 beds occupied in hospitals and having them taken by people who should be in longstay care, there is an obvious loss of process. From the issue of the ambulance not being there to bring the critically ill patient to the hospital in order that they can get the treatment they need and do not have to go into long-term care to the fact that ambulances arrive and are not immediately released, the process is not as it should be. This has been the situation for decades. Paramedics tell me they wait for hours for the patient to be taken into accident and emergency units. That is a lot of equipment sitting there idle. It is not about money but about process and it can be fixed without throwing more money at the system.

Stepdown beds are about money. There are 20 beds in the Kenmare hospital available but we do not have the staff to take them from Cork University Hospital. Staff will be employed in the acute care hospital but not in community hospitals. Nursing homes are at full capacity. There are issues that can be solved by money but other issues must be solved by the processes currently in place, which are not working effectively. Tonight, 100 emergency ambulances are available around the country. If all 100 are out on call, no one wants to be the 101st victim of a car accident, a stroke or a heart attack because the ambulance will not be there when it is needed.

I welcome the Minister for a debate that is of the utmost importance. It is to the forefront of everyone's mind. Like my colleagues, I deal with dozens of families and individuals weekly on a variety of topics but I mostly deal with housing and health care. I dealt with a number of people on a variety of issues ranging from surgery, waiting lists, hospital overcrowding and the filling of vacant consultant positions. I do not want to get into the political space, with one side blaming the other, but I agree with Senator John Gilroy when he said it was ironic that Fianna Fáil is bringing forward the motion when much of the problem was inherited by this Government from the previous one.

That is lazy analysis.

I refer specifically to County Louth, where a Fianna Fáil Minister said the hospital would not close on his watch. The hospital closed, or the service was greatly reduced, and everything moved to the so-called centre of excellence in Drogheda. We are now suffering from it, yet Fianna Fáil is acting high and mighty over it. We are not here to discuss that but to find some way to rectify the position, get over it and work together to see what can be done. People are suffering and dying because of the way it is structured. The INMO Trolley Watch data estimate 275 patients on trolleys in our emergency units, with 104 patients on trolleys, chairs, beds and beds in wards. This amounts to 429 people nationwide today.

The Trolley Watch figure in the emergency unit and the wards in Our Lady of Lourdes Hospital is 40, one of the highest in the country. I wish I could say this was the highest figure at the hospital this year but, unfortunately, it is not even the highest figure in the past week. On Monday last week, the INMO Trolley Watch calculated the number on trolleys at 50. This figure has not once dipped below 25 patients in the past week. As a result of the high number of patients on trolleys early last week, the INMO requested that the HSE take the hospital off-call for emergency ambulance calls. I make no apology for making it a local issue. I appreciate the recognition that there is a problem, particularly at Our Lady of Lourdes Hospital and I welcome the agreement to recruit an extra 88 nurses to help deal with the crisis but I wonder whether it will be enough to improve the situation for patients. This is a dangerous situation and it cannot continue for the people living in County Louth and the surrounding area who rely on the hospital to provide safe and compliant care, like the hospital in Dundalk. Day case procedures were cancelled because nurses had to be moved to Drogheda.

One of the first things I did when I became a Member of this House was to call for a paediatric orthopaedic surgeon in Our Lady of Lourdes Hospital. This was not in place almost four years ago. I went through hell and back trying to get an orthopaedic paediatric surgeon, yet we do not have one. I keep hearing that applications have been advertised. Sitting in the orthopaedic clinic any day of the week one can see the numbers waiting for treatment from counties Louth, Meath and Monaghan. I have spoken to orthopaedic surgeons and other hospitals who report that babies that need hip operations must wait over one year before getting into the hospitals in Dublin. The surgery required is then greater.

I am not attacking the Minister, who has probably the most difficult job in the Oireachtas. We must see how we can remedy this dysfunction. How can we make sure we provide safe working conditions for medical staff and patients? We cannot expect patients, some of whom are extremely ill, to focus on recovery or treatment while lying on a hospital trolley or in a hallway. We certainly cannot expect our medical staff to work in such a dangerous work environment as has developed in Drogheda. I regret saying that and it is through no fault of the excellent front-line staff in Our Lady of Lourdes Hospital. I commend them for their dedication to their patients and their work, which astounds me.

In addition to the 88 additional nursing posts to be recruited for Our Lady of Lourdes Hospital, a number of measures have been introduced to deal with immediate problems nationwide, including delayed discharges. These include the introduction of 900 transitional care beds in private nursing homes; the provision of 300 overflow beds in acute hospitals; the number of nurses employed by the public health service to increase by at least 500; and additional funding of €3 million in December and €25 million in 2015.

As evidenced by this, we have experienced progress in increasing resources and seeking solutions to the matters outlined in the motion, but will it be enough? We need not only to address overcrowding in hospitals, waiting times and staffing but also the supports available when patients leave hospital, that is, the community supports that allow them to receive treatment or recover at home or in another facility. We need to examine this issue. We cannot address the issues in hospitals without addressing and properly resourcing supports in the community. We cannot only address the immediate and obvious issue at hand in Our Lady of Lourdes Hospital, as we also need to consider the other supports to create a long-term solution. We all have anecdotes and could all contribute for hours outlining a broken system, but there are areas that need particular attention such as waiting lists. It is unacceptable that people must wait more than 18 months for a cardiac or neurology appointment.

I welcome the Minister. The Government, as I do, fully acknowledges the difficulties with overcrowding in accident and emergency departments and the problem this causes for patients and families and staff who are doing their utmost to provide safe, quality care in extremely challenging circumstances. It is my understanding optimum patient care and patient safety at all times remains a priority of the Minister and the Government. A wide ranging set of actions has been put in place by the HSE to achieve improvements which it is important to highlight. They include specific measures which have been put in place to address hospital waiting lists more efficiently and effectively through initiatives covering colonoscopies, special funding for scoliosis and ophthalmology services, additional consultations and the extension of ultrasound access to additional primary care sites.

Actions taken to date to address overcrowding in accident and emergency department include the opening of additional overflow areas; providing for additional diagnoses and strengthening discharge planning with a range of measures, including 900 transitional care beds funded in private nursing homes to assist the discharge of patients from acute hospitals; the opening of 173 short stay public beds across the country for three months; agreement on additional nursing posts; the opening up of 300 overflow beds in acute hospitals; and the introduction of additional community interventions introduced in Naas and Drogheda, with 11 such teams now in operation. This year the number of nurses directly employed in the public service will increase by at least 500, which was a welcome announcement recently made by the Minister.

The Minister convened an emergency task force last year to find long-term solutions to overcrowding by providing for an additional focus on dealing with the challenges presented by trolley waits. The HSE is finalising an action plan under the auspices of the task force to be implemented immediately to specifically address emergency department-related issues across hospitals, social care and broader community services with a view to achieving a significant reduction in trolley waits this year. I hope this will prove successful.

Actions being taken by the HSE to address waiting lists include observations on the national waiting list protocol, prioritising day of surgery admission where clinically appropriate, provision of new patient care pathways such as medical assessment, minor and local injury units and urgent care centres and provision of care in non-hospital settings to support the efficient use of hospital resources. Waiting list targets have been changed and the HSE is finalising an action plan for waiting lists with a focus on long waiters such that by mid-year nobody will wait longer than 18 months for inpatient and day case treatment or an outpatient appointment, with a further reduction to 12 months by the end of the year. The HSE has committed in its national service plan for 2015 to the publication of waiting lists online at consultant and specialty level and aims to reduce waiting lists by way of process redesign, consolidating further the work of the special delivery unit to date.

The Government has made provision for a welcome increase in the total financial resources available to the HSE this year, the first such increase in seven years. The HSE knows that there is an urgent service requirement to recruit the necessary staff, including additional nurses, doctors and therapists. The Government provided additional funding of €3 million last December and €25 million in 2015 to address delayed discharges and this funding is targeted at hospital and community services which can enable initiatives to address specific needs of delayed discharge patients positively and, thereby, aims to improve timelines for admission from emergency departments and reduce waiting lists.

The review of the nursing home support scheme which is under way and due to be completed shortly will consider the future funding and sustainability of the scheme, as well as how community and residential services are balanced. We all remain hopeful the measures that have been implemented in the recent past will have the effect of improving health services and reducing waiting lists.

I would like to highlight the hypocrisy of Fianna Fáil, given its failure to make proposals on health in its alternative budget for 2015 and not least that it created the HSE which, as previous speakers said, is a basket case. The structural problems in the organisation are difficult for any Minister, but despite serious work on the part of Ministers, one wonders whether those working in the HSE are motivated to improve the system at all, given the internal politics. Contrary to comments made by the Opposition, I have every confidence that the Minister is committed to and passionate about the health service. His only motivation is to make a genuine effort to improve health services. I have every confidence that he will be successful in both the short and long term.

I support the Government amendment and oppose the motion. Senators Thomas Bryne and Marc MacSharry asked about the actions that had been taken. It is possible to explain what is going on, analyse it and act at the same time. Fianna Fáil Members may, however, find it impossible to explain, analyse and act at the same time, but there are those of us on this side of the House who do not think it is difficult to do and that they are not mutually exclusive.

With regard to actions, 900 transitional care beds are being funded in private nursing homes, 500 in January and a further 400 in February, to assist patients waiting on the fair deal scheme to be discharged from hospital and put in transitional care; 173 short stay public beds are being opened across the country for a three month period - they should all be opened by the end of the month; there has been agreement on additional nursing posts, with at least 500 additional nurses directly employed in the public health service this year - in addition, there will also be mental health posts; I am double counting in this regard; up to 300 overflow beds have been opened in acute hospitals; and additional community intervention teams have been introduced in Naas and Drogheda. I also convened the emergency department task force and the HSE is finalising an action plan.

We are going through a difficult period in the health service. There were four years of cutbacks under Fianna Fáil and three years of budget freezes under the Government as a consequence of the recession that those proposing the motion helped to cause. That has left its mark and done enormous damage to the health service.

In 2015, for the first time in seven years, there has been a modest budget increase, of approximately €150 million. However, we still spend approximately €1.5 billion less than we did seven years ago and we have approximately 15,000 fewer staff. Even with considerable improvements in efficiencies during the past seven years, rising demand has created enormous problems for us. Those problems are reflected in emergency department overcrowding in some hospitals and excessive waiting times for many patients.

It is important to recall some of the good things that are happening in health. Sometimes, in these debates one can become despondent and begin to believe nothing ever changes or improves. One of the many things I did today was to visit the National Maternity Hospital, Holles Street where I had the pleasure of opening the new neonatal intensive care unit, NICU, which is a major improvement on the one I remember from when I worked there seven or eight years ago. It was great to see it. Maybe 36 years ago, when I was born, 90% of the children in that NICU would have died, whereas now 80% or 90% survive. Let us allow ourselves, now and again, to recall some of the good things in health.

We have a very good capital programme under way. At long last, planning permission for the children's hospital will be lodged within months, before the summer recess. I hope, with the agreement of An Bord Pleanála, we can start work on it before the country goes to the polls. Work will begin on the new forensic mental health campus in Portrane, allowing us to close the Central Mental Hospital in Dundrum. We have been promising it forever, and now it will happen. We are providing one primary care centre per month and the National Maternity Hospital will move to St. Vincent's University Hospital. The planning application will be submitted this year.

We are succeeding in our efforts to make health insurance more affordable. The numbers of people who have insurance increased in the last two quarters of last year. I expect a big increase in the first quarter of this year and a further increase next month with long-term community rating. The first step in my objective of making health insurance universal is to make it affordable. We must always have regard to this.

Senator Mark Daly mentioned ambulance services. Only last week I announced that we would hire 50 additional paramedics in the west to improve services there. Not long ago, an ambulance was just a vehicle that took a person to hospital. It is no longer like that. Ambulances are staffed by emergency medical technicians, EMTs, paramedics and advanced paramedics. If an ambulance does not reach a person, the rapid response vehicle does and care begins immediately, long before one reaches hospital. We also have the air ambulance, which did not operate before the Government. We have 100 community first responders, and we need many more of them. DELTA and ECHO times are improving, despite how busy it has been during the past few months. We are very close to meeting the DELTA targets, although we are not quite there for ECHO yet. Despite the fact that December was the busiest month ever for ambulances, turnaround times at hospitals improved. This is a tribute to ambulance service and staff. The budget is not being cut this year but increased by €5 million. It is important that people understand that our ambulances work on the basis of dynamic deployment. We no longer have the idea that an ambulance is just for a particular area, just as taxis no longer operate from taxi ranks, as they used to, but use systems such as Hailo and Uber. Dynamic deployment is the best way to manage a fleet. I already mentioned recruitment, the 500 additional nurses and the 30 consultant posts just advertised.

Emergency department overcrowding is not a new problem and is not unique to Ireland. Many of the protocols we use come from Australia and America where it is also a problem. It is also a problem in Northern Ireland. It is a chronic problem which turns into a crisis whenever there is a surge of patients or significant delays in discharges at the other end. The Government acknowledges that the problem of overcrowding is serious, real and cannot continue. While surges will occur from time to time, the difficulty in Ireland is that it is a year-round phenomenon and extensive time spent waiting for admission on a trolley is a patient safety issue. Some people were shocked by my admission today that delayed treatment can result in increased morbidity and mortality. To me, it was a statement of the obvious. Since everybody knows it is a fact, why deny it? Aside from the discomfort and loss of privacy and dignity, it is a patient safety risk, particularly for the elderly. Senator Moran received the INMO figures, which are done at 8 a.m. The more up-to-date figures show that as of 2 p.m. today there were 279 patients on trolleys in emergency departments and on wards, of whom 198 had been on trolleys for more than nine hours. The figure will continue to fall throughout the day but will increase overnight.

What about Our Lady of Lourdes Hospital?

There is great variation among the hospitals. There are four hospitals in which nobody is waiting for more than nine hours on a trolley. They are St. James’s, Kerry, Navan and Cavan hospitals. There are others hospitals in which there is very severe overcrowding, such as Beaumont Hospital where more than 24 patients have been on trolleys for more than nine hours and there is a similar situation in Our Lady of Lourdes Hospital. I hope the provision of 24 additional beds this summer through the modular development will help matters in Our Lady of Lourdes Hospital. However, as Senator John Gilroy accurately pointed out, providing more beds does not necessarily reduce the number of trolleys.

The INMO is stating the situation tonight is unprecedented in Our Lady of Lourdes Hospital.

It requires much more than that. The reasons for overcrowding vary. Some hospitals put it down to problems with delayed discharges, others to a difficulty recruiting and retaining senior medical staff or a lack of acute beds. Experience has taught us that it is not just a matter of delayed discharges, staffing or skill levels, hospital avoidance, patient flow, overall management or advanced planning. It is about all of these factors and more. An integrated approach implementing changes in how we deliver health care is required and simple actions such as ensuring discharges take place at weekends and working with primary community care providers to deploy home care resources are essential if we are to get patients who need care into hospital beds and get those who have completed their treatment out safely. Since the current period of sustained pressure began, we have approached the issue with a hallmark of transparency and honesty. The Minister of State, Deputy Kathleen Lynch, and I have spoken regularly and at length about the numbers affected and we have not shied away from admitting this cannot be fixed instantly. How could it be? The infrastructural and resource constraints have built up over a number of years of austerity, and repairing the system will take time too. While sticking plasters are all right for minor grazes, deep wounds inflicted by previous Administrations require extensive reconstruction if we are to build a system that can respond to future need.

In the meantime, it is important to reassure people that all hospitals can and do manage patient flow and safety in a way that supports and ensures the delivery of optimum patient care. They are supported in this by the HSE, which plans appropriate ongoing actions by teleconference seven days a week. As has been outlined, an additional €3 million has been provided in the Supplementary Estimates of 2014 and €25 million this year to address delayed discharges. I have already pointed out how it has been deployed. In the past couple of hours, I received figures that show that the number of delayed discharges is down to 705 from a peak of 850 a few months ago. At least it is going in the right direction, albeit there is a long way to go.

The HSE has put in place arrangements to recruit front-line staff where it has been established that there is an urgent service requirement. This has led the HSE to enhance the use of smaller hospitals such as Louth County, Nenagh, Ennis and Bantry hospitals for patients who require non-complex care after they have been medically stabilised. The extension of the community intervention teams, comprising nurses who go into homes and nursing homes to provide intravenous therapy, IVs, and other treatments, has been introduced in Naas and Drogheda and it has allowed 2,500 people to avoid hospital admission. I want this to be expanded further. All these additional actions underline the fact that the solution does not lie solely in the realm of acute hospitals, rather, a multidisciplinary approach is essential to care for patients appropriately.

We need to do much more. The Minister of State, Deputy Kathleen Lynch, and I have expressed time and again our view that social supports such as the fair deal, home help and home care packages should be demand-led, which is a fancy way of saying it should be a right or an entitlement in the same way as a pension, welfare benefit or school place. If a person qualifies for the support, it should be provided, not rationed. Matters such as this require the approval of the Government as a whole and I am exploring ways we can achieve it, whether by reprioritising in my budget or bringing forward spending planned for later in the year. We cannot ignore it.

Inevitably, the cancellation of elective surgery to help manage the need for immediate emergency or trauma care will affect waiting times where it is necessary to prioritise cancer or other urgent cases. The HSE assures me this is being done. The challenge is to minimise the need for cancellation at short notice and to manage the impact of such cancellations effectively.

Realistically, I do not envisage significant improvements in elective waiting times in the early part of this year. However, based on the high priority attached to this area in the HSE service plan, the provision for an additional 20,000 day cases this year and the first overall increase in the HSE budget in seven years, I expect we will turn the corner on that later in 2015.

The movement of care and treatment from inpatient to day case and from day case to outpatient departments is very important. There is a commitment in the national service plan to pilot the provision of additional minor surgery services in primary care centres to allow GPs to do more minor surgery, I hope reducing some of the waiting lists. My Department is also working with the HSE to develop a plan to address waiting lists with a focus on very long waiters such that by mid-year the maximum waiting time will be no longer than 18 months for inpatient services, day case treatment or outpatient appointments. A further reduction will bring the maximum waiting time to no greater than 15 months by year end. This will involve both productivity improvement and rigorous waiting list management. This does not mean the existing targets have been changed. The 20 months target for children, the eight month target and the 12 month target remain and will continue to be reported on in the HSE PAR on a monthly basis. We are setting maximum waiting times which is different.

Can children be subjected to the maximum waiting time? Are they part of that or is the 20-week target completely separate?

The target remains but I need to be very frank about this. There are a few sub-specialties where it is going to be very difficult. It is not just a matter of money in those cases, but one of specialists and theatre time.

In other words, the 20-week target is not completely separate from the 18-month maximum.

The 20-week target remains. Hospitals must adhere to chronological scheduling and observation of guidelines drawn up by the national clinical programmes as well as improving efficiency in the management of referrals and reducing the number of unnecessary return appointments. Rather than the current situation whereby a consultant or his or her staff sees one new patient for every 2.6 repeat appointments, the HSE has set a target to achieve a ratio of one new appointment for every two reviews. That will free up thousands of appointment times for new patients without any additional resources being required. Similarly, with the assistance and guidance of the STU and the NTPF, poorly maintained waiting lists are gradually becoming a thing of the past. I refer to the old-fashioned waiting lists in boxes; that is charts in boxes rather than registers. Multiple referrals of individual patients by GPs are being tackled.

I expect all hospitals and clinicians to do everything they can to reduce waiting times within their own hospitals and specialties and not to allow overall patient waiting times to build up in order that patients become urgent cases where this can be avoided. A new referral system which can speed up and streamline the referral cycle is being piloted and specifications for e-referral systems incorporating protocols and standards from the STU and clinical programmes are in development. This will allow the quality of referrals to improve. These are short-term targets which do not detract from the achievement in the medium term and, where it is possible this year, the retention of the Government's original waiting targets. Consultants are also being provided with quality audited data to allow them to benchmark themselves against best practice standards nationally and internationally. In turn, this will promote further efficiencies in the provision of care.

The NTPF and HSE will continue to publish monthly waiting list figures and ensure that we can all monitor the benefit of those efficiencies through the gradual reduction of waiting lists and waiting times. The HSE has also made provision where possible to address services where there are particular challenges. For example, funding has been allocated in the HSE service plan for 2015 for the appointment of an orthopaedic surgeon, an anaesthetist and support staff at Crumlin in recognition of the pressures relating to surgery for scoliosis. This will maximise the use of the available theatre sessions in the hospital. The provision of funding for additional funding and support staff is expected to allow an additional 25 cases to take place in 2015. That is roughly an increase of 50% on the number of cases that took place last year. That is part of a total of €5 million made available for the overall development of the orthopaedic service infrastructure nationally. A sum of €1 million has also been provided for a paediatric ophthalmic waiting list initiative and a colonoscopy initiative is under way to reduce waiting lists in that regard.

Picking up on the remarks of Senator Colm Burke on GP access to diagnostics, which is an enormous problem, I note that it is one of the most prevalent criticisms heard in the past few years. This year, the HSE is implementing a pilot project which will provide GPs with direct access to ultrasound at approximately eight primary care centres across the south and west with the aim of addressing existing GP referrals to ultrasound in those areas. It will mean that GPs can refer patients electronically to the preferred provider who will see urgent patients within five working days and non-urgent patients within ten working days, thus negating the need for referral to outpatient departments or hospitals in the first place.

As Senator Eamonn Coghlan eloquently pointed out, the long-term solutions must involve public health and a shift from the worsening ill health of our population to greater wellbeing through societal change supported by the Healthy Ireland initiatives on obesity, smoking, alcohol and greater physical activity. Among the things we will see happen this year is the publication of the first Healthy Ireland survey. This will be the first snapshot of our nation's health since 2007. The survey will be repeated on an annual basis. I have sought and received approval from the Government to introduce new legislation on alcohol. The Minister for Children and Youth Affairs, Deputy James Reilly, is pressing ahead with legislation on tobacco plain packaging and I will also be bringing forward specific legislation on obesity, specifically calorie posting and workplace plans.

The motion is a Fianna Fáil one. I point out once again that Fianna Fáil remains a party with no policy on health whatsoever. I can only echo the comments of Deputies Éamon Ó Cuív and Michael McGrath who pointed out that Fianna Fáil should concentrate more on its policy development. I agree. In the alternative budget put forward by Fianna Fáil only a few months ago, there was less money provided for health than was provided by the Government.

That included last year's bailout.

However, now Fianna Fáil says it is underfunded. It certainly did not think so last year. It shows how much things can change dynamically. I accept that Deputy Micheál Martin did some very good work with the smoking ban as Minister for Health, but it is difficult to take some of the shrill criticisms he makes sometimes given that he should know how difficult health is. Of course, he is the former Minister who promised to abolish waiting lists within two years but failed miserably. He is also the former Minister who established the HSE in a disastrous, ham-fisted manner, establishing a new bureaucracy on top of bureaucracies that still exist even now. Even now, there are still nine payroll systems in the HSE. That was the worst reform in the books when it comes to health. When he was Minister, they did not count the trolleys at all. However, newspaper reports at the time show that children waited six years for appointments and in some cases patients were treated in ambulances and car parks one winter. He needs to bear that in mind a little better.

While Sinn Féin makes promises to hire additional nurses and health care staff in its policy documents here, in Northern Ireland, where it is actually in coalition, it has signed up to reducing the number of public servants by 20,000, which would be the equivalent of 60,000 in this jurisdiction. It has also signed up to a spending freeze in health and denied health staff in the North their promised pay rises. In addition, it is closing minor injury units across the province. A little bit of realism would be helpful there too.

We have learned our economics from Fine Gael and the Conservative Party.

Since December, we have done everything possible to alleviate the current problems in health. More than 1,000 beds have been reopened or freed up but the demand for health care created by our rising and aging population means that the service is still struggling to meet that demand. While the actions we have taken may have alleviated the pressure temporarily, they are not a sustainable or appropriately planned approach and further demands will arise in 2015, including over the coming winter. That is why we must return to planned service levels as soon as we can, but only when the safety of patients is no longer at risk of being compromised.

I am absolutely determined that there should be a continuing focus on emergency department overcrowding and a renewed focus on making sure that the longest waiters get their appointments, scans and operations. It will be necessary for clinicians and administrative management to work hard together to implement changes in processes as well as in respect of day-to-day service delivery to solve this problem. None of these things can be done quickly and none can be done without additional cost, at least initially. However, it can be done and I will do my best to drive it forward. Ireland should be a country in which one can grow old with dignity. The long trolley waits which have dogged previous Governments as well as our own should be consigned to history. I commend the amendment and reject the motion.

I thank the Minister for his patience and for staying here. It is appreciated as I would have understood if he had to put his Minister of State in for a while as Our Lady of Lourdes in Drogheda is facing an unprecedented crisis.

Is the Senator saying he should go up there himself now?

I am not saying that and I am not saying he should leave. I am saying I would have understood. I do not want the Minister in a hospital. The last thing hospitals need is to have politicians floating around. The reality is that there are 30 admitted patients there according to the INMO.

There should be 14 nurses working tonight, but I understand from the INMO that only nine are rostered and the agencies cannot provide extra staff. The Minister stated there was no one waiting excessively in Our Lady's Hospital in Navan. I attended its accident and emergency department a year and a half ago and was waiting for half an hour.

In some areas, the problem is that people do not know what different hospitals do. If someone from Louth or Meath lives close to Drogheda, there is an inclination to assume that the hospital there will handle something. Many people do not know what Our Lady's Hospital in Navan, which effectively has a full accident and emergency unit except for some patients, or the hospital in Dundalk do. For example, people from north County Meath live closer to Dundalk than they do to Navan. It is a serious problem, but not enough is being done to address it. Tell people what services are available in each hospital and where they should go. The same applies in the case of Blanchardstown. Should people attend it or Navan if they live in the Dunshaughlin-Dunboyne area? My local area has been at the centre of health politics for a long time.

We must follow up on the solution with the current Minister, as the former Minister, Deputy James Reilly, provided no news. Before the last election, Fine Gael made a specific promise to have the hospital built before the next election. The Minister can read all about it because I raised the matter with his predecessor a number of times, but he denied all knowledge of it. The Fine Gael Party made a political promise, signed by its five candidates in the general election, to build a hospital within five years. Not only that, but Fine Gael had already started the negotiations with a private sector developer which would undertake the project on a public-private partnership basis. It was madness. It was main news in the newspaper at the time, but nothing has happened. People voted for this Government because of political promises like that one that were made during a crisis that is still ongoing.

It is okay for Senator Mary Moran because the public blamed Fianna Fáil at the last election for the problems. There is no doubt about that. However, it is being claimed that those problems are connected to the four-year delay since-----

Of course, they are.

-----in respect of the lack of orthopaedic and paediatric services after that man retired.

There were 250,000 more people unemployed.

The Government can sit back and relax because it is all Fianna Fáil's fault. That election was over four years ago.

No, that is not what I said. I said-----

Senator Thomas Byrne to continue, without interruption.

It is an easy way of abdicating responsibility and asking what the Government can do because its hands are tied.

We are just pointing out-----

It is a statement of fact.

Today, the former Minister for Justice and Equality, Deputy Alan Shatter, complained that the Minister for Health was pretending about something. On the questions of targets and maximum waiting times, there are strong hints of pretence. What is a target? What is a maximum waiting time? How do they relate? There is no clarity. In fact, after parsing the Minister's speech and the motion, there is currently no maximum waiting time or target. The Minister stated the target for a maximum waiting time of 18 months, which is outrageous and goes far beyond what was committed to after the Government entered into power, did not apply. According to the Government's motion, it will be introduced in the middle of this year. That target has been extended. People are getting sorer, suffering and paying more for medication while they wait.

When the Senator's Government had money-----

Of course, it is all someone else's fault from four years ago. The Government entered into office with specific commitments on universal health insurance, which was dropped by the current Minister last summer but has been resurrected in the light of the upcoming general election. The former Minister, Deputy James Reilly, stated we would need two terms to do it but little has been done.

He said that before the general election. He acknowledged that it would take two terms.

Senator Thomas Byrne to continue, without interruption.

The Senator has mentioned parsing statements. He is parsing the facts.

The establishment of the HSE did not even take that length of time. The period of two terms was just an excuse for the Government to do very little. It is the Minister's Government that has no health policy. That is frightening. The Minister is crisis managing day in, day out, analysing and stating the obvious. There is no problem in that regard, as he is a good man at stating the obvious. It is necessary. Where is the vision? Where is this health service going? When will the child who needs grommets, whose mother contacted me and who has been waiting since last April with a 20-week target, be given an appointment? When will that mother have to stop buying medication and be relieved of that financial pressure? Her family and many others around the country are under financial pressure and individuals are in serious pain. It is about time that we had a vision. It is about time that we told the people where we are going.

Amendment put:
The Seanad divided: Tá, 24; Níl, 17.

  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Conway, Martin.
  • Cummins, Maurice.
  • D'Arcy, Jim.
  • D'Arcy, Michael.
  • Gilroy, John.
  • Hayden, Aideen.
  • Higgins, Lorraine.
  • Keane, Cáit.
  • Moloney, Marie.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Naughton, Hildegarde.
  • Noone, Catherine.
  • O'Keeffe, Susan.
  • O'Neill, Pat.
  • Sheahan, Tom.
  • van Turnhout, Jillian.


  • Barrett, Sean D.
  • Byrne, Thomas.
  • Crown, John.
  • Cullinane, David.
  • Daly, Mark.
  • Healy Eames, Fidelma.
  • Heffernan, James.
  • Leyden, Terry.
  • MacSharry, Marc.
  • Mooney, Paschal.
  • Ó Clochartaigh, Trevor.
  • Ó Domhnaill, Brian.
  • O'Sullivan, Ned.
  • Power, Averil.
  • Reilly, Kathryn.
  • White, Mary M.
  • Wilson, Diarmuid.
Tellers: Tá, Senators Paul Coghlan and Aideen Hayden; Níl, Senators Ned O'Sullivan and Diarmuid Wilson.
Amendment declared carried.
Amendment No. 1 not moved.
Question put: "That the motion, as amended, be agreed to."
The Seanad divided: Tá, 24; Níl, 17.

  • Bacik, Ivana.
  • Brennan, Terry.
  • Burke, Colm.
  • Coghlan, Eamonn.
  • Coghlan, Paul.
  • Comiskey, Michael.
  • Conway, Martin.
  • Cummins, Maurice.
  • D'Arcy, Jim.
  • D'Arcy, Michael.
  • Gilroy, John.
  • Hayden, Aideen.
  • Higgins, Lorraine.
  • Keane, Cáit.
  • Moloney, Marie.
  • Moran, Mary.
  • Mulcahy, Tony.
  • Mullins, Michael.
  • Naughton, Hildegarde.
  • Noone, Catherine.
  • O'Keeffe, Susan.
  • O'Neill, Pat.
  • Sheahan, Tom.
  • van Turnhout, Jillian.


  • Barrett, Sean D.
  • Byrne, Thomas.
  • Crown, John.
  • Cullinane, David.
  • Daly, Mark.
  • Healy Eames, Fidelma.
  • Heffernan, James.
  • Leyden, Terry.
  • MacSharry, Marc.
  • Mooney, Paschal.
  • Ó Clochartaigh, Trevor.
  • Ó Domhnaill, Brian.
  • O'Sullivan, Ned.
  • Power, Averil.
  • Reilly, Kathryn.
  • White, Mary M.
  • Wilson, Diarmuid.
Tellers: Tá, Senators Paul Coghlan and Aideen Hayden; Níl, Senators Ned O'Sullivan and Diarmuid Wilson.
Question declared carried.

When is it proposed to sit again?

Ar 10.30 maidin amárach.

The Seanad adjourned at 7.10 p.m. until 10.30 a.m. on Thursday, 26 February 2015.