Commencement Matters

National Lottery Funding Disbursement

I welcome the Minister of State, Deputy Simon Harris.

I am pleased that my matter has been accepted and I am grateful to the Minister of State for attending to answer it. I am here to make an appeal on behalf of natural environment organisations that they would finally receive their fair share of lottery funding for the fantastic work they do the length and breadth of the country on a variety of community, conservation, habitat protection and wildlife protection projects. It is a very broad spectrum. Wisely, back in 2013, when the Government introduced the new National Lottery Bill, it agreed to an amendment to incorporate the natural environment as one of the six qualifying categories that could apply for lottery funding, along with other sporting and community categories. However, none of the bodies or organisations represented by the umbrella group the Irish Environmental Network, which is made up of over 30 different NGOs, has been able to secure lottery funding since. I know this funding is disbursed through up to eight different Departments, but it seems bizarre, to say the least, that while they have been able to put forward many projects of merit, deserving of national lottery funding and while this has been included as a qualifying sector, it has not been able to draw down any national lottery funding to date.

I hope that can be put to rights in the next round of funding.

We have a difficulty in this country with what has been referred to as implementation deficit disorder. This can result from local resistance and suspicion, which is well founded in some cases, such as those in which State agencies try to impose structures and projects on the community. That is why I believe organic projects that are built by communities from the ground up, with local ownership and community buy-in, work very well. I am in favour of direct community input from the ground, in collaboration with State agencies, when work is being done in areas such as conservation, habitat protection, biodiversity education, eco-tourism, adding value to the landscape and protecting wild flora and fauna. It is estimated that this range of activity is worth up to €2 billion per annum to our economy. As I have said, it is spearheaded by bodies such as the Irish Environmental Network and Irish Rural Link. However, it has certainly been the poor relation in terms of lottery funding to date. I have seen successful projects on the ground in my own community organised by groups such as the Abbeyleix Bog Project, the Portarlington Community Development Association and the Mountmellick justice and environment group, which is inspired and led by the local Presentation sisters. These organisations have done great work to restore areas such as river walks and to reclaim bogs to make them available to communities to enjoy. Their work has climate change benefits and all sorts of ecological and environmental dividends. Communities are proud of these groups, which are spread across the country, and feel they have ownership of them. I would also like to mention the work that has been done at Fenor Bog in County Waterford, the Wexford Slobs and Wildlife Reserve, Clara Bog in County Offaly, the Ballybay wetlands in County Monaghan, the Cabragh wetlands in County Tipperary and the Ballyhoura Mountains in County Limerick.

If the Government takes the great opportunity it has to support such projects throughout the country, it will get a really good bang for its buck. Those who support this kind of community organisation really get good value. The dividend in terms of community buy-in, public participation and tourism, and the economic and environmental benefits, cannot be exaggerated. There is an opportunity to get good value for money. I think that was the purpose - the pure and real intention - of those who first founded the national lottery and provided for the allocation of this funding in 1986. I do not want to pick on anyone when I say that in my view, national lottery funding was never supposed to replace core Government funding for services. It was supposed to be an additional benefit for communities. I know the Cathaoirleach is an avid and enthusiastic golfer, but I do not think national lottery funding was ever intended for the construction of new golf clubs. I do not think that was the purpose or intention of this structure when it was designed. It was supposed to provide additional resources to voluntary and community organisations, which were supposed to be the main beneficiaries. I would like to see us revisit the matter to ensure that the allocation of the next round of national lottery funding is grounded in such a principle. I am particularly keen for us to make up for lost ground in terms of projects that pertain to the natural environment.

I thank the Senator for raising this matter and giving me an opportunity to respond on behalf of my colleague, the Minister for Public Expenditure and Reform, Deputy Brendan Howlin, who is unable to attend. I will begin by giving the background to the sale of the national lottery licence. In view of the prevailing economic challenges, the Government decided to explore the opportunities presented by the expiry of the national lottery licence, and agreed in April 2012 that there would be a competitive process for the award of the next licence. The key drivers were to yield up-front revenues for the State to fund projects such as the Wild Atlantic Way, the 1916 commemorations, the National Sports Campus and the new national children's hospital and to strengthen annual revenues for good causes, which will benefit worthwhile projects throughout the country for the next 20 years.

The National Lottery Act 2013, to which the Senator referred, provided for the holding of a national lottery on behalf of the Minister for Public Expenditure and Reform, the establishment of the Office of the Regulator of the National Lottery and the definition of the functions of the regulator. The overarching function of the regulator is to ensure the national lottery is run with all due propriety, the interests of participants in the national lottery are protected and the long-term sustainability of the national lottery is safeguarded. Subject to this, an important additional function is to maximise revenue for good causes. The national lottery provides funds for good causes in accordance with the National Lottery Act 2013. The areas to be funded are set out under section 41(1) of the 2013 Act, which states:

Moneys paid into the Central Fund pursuant to section 44 shall be applied for the purposes of such one or more of the following, and in such amounts, as the Government may determine from time to time:

(a) sport and recreation;

(b) national culture and heritage (including the Irish language);

(c) the arts (within the meaning of the Arts Act 2003);

(d) health of the community;

(e) youth, welfare and amenities;

(f) natural environment;

(g) such other objectives (if any) as the Government may determine from time to time.

The reference to "natural environment" was added in the 2013 Act.

Funding is provided by the Oireachtas, in accordance with the Act, through expenditure subheads which form part of departmental programmes. For over a decade, the total allocation for these subheads has exceeded the amount available from the national lottery. These subheads are described as being part-funded by the national lottery. The balance of the expenditure allocation for the subheads comes from normal Exchequer sources such as tax revenue or borrowing. Senators may wish to note that a breakdown by Department of all the expenditure areas supported by the proceeds of the national lottery is set out in Appendix 1 of the annual Revised Estimates for Public Services 2015, which is available on the website of the Department of Public Expenditure and Reform.

During the debate on the National Lottery Bill in 2013, the Minister for Public Expenditure and Reform accepted an amendment proposed by Deputy Maureen O'Sullivan and supported by others to include the "natural environment" as a category that could benefit from lottery funding for good causes. As Senator Whelan has said, lottery money has not been applied to this area to date. The Government's response to proposals submitted in the future for lottery funding for the natural environment will take account of the level of funds available for good causes in the relevant year and the impact it would have on other areas already in receipt of lottery funds. It is important to note that if national lottery funding is provided for the natural environment, corresponding reductions will be required in other areas which are currently in receipt of such funding. Accordingly, the reallocation of funding to support the natural environment at the expense of one or more of these other sectors can only be undertaken following careful reflection. The Minister for Environment, Community and Local Government is aware of the position and we are keeping the matter under review.

I would like to draw the Senator's attention to the fact that since 2011 some €259 million has been disbursed to the environment sector from the environment fund. A further €146 million, which has been provided to the environment sector by the Department of Environment, Community and Local Government through Exchequer-voted expenditure, can be added to this. In light of the challenging budgetary context in which the Government is operating, the Minister for the Environment, Community and Local Government considers that the allocation of such a considerable amount of funding to environmental initiatives represents a commitment to the environment sector. Senators will be aware that funds for good causes have been in decline in recent years. It is hoped that this trend will be reversed and there will be a growth in lottery sales in future years, as this would provide more revenue for good causes. The question of applying funding in the area of the natural environment could be reviewed again at that stage.

I thank the Minister of State for his comprehensive reply. I accept that the Government provides valuable support to many community projects in this category and this sector by means of a range of other funding tranches managed by the Department of Environment, Community and Local Government. I suppose there would have been very little point in the addition by the Government of "natural environment" as a qualifying category under the 2013 Act, which is what happened when it accepted an amendment in good faith as outlined by the Minister of State, if the Government did not intend to follow through on it. I do not think it is a question of other worthy causes being displaced. Of course there are challenges associated with competition for limited resources. I think the merits of any of the projects across the country that I have mentioned would stand up to scrutiny in terms of giving good value for money to the Government and to communities for generations to come. That is really what we have to look at. We have to ensure the inclusion of "natural environment" was not merely a cosmetic exercise. The best way to do that is to follow through on it with funding.

The Senator can take it that the Minister, Deputy Brendan Howlin, accepted Deputy Maureen O'Sullivan's amendment in the Dáil because he wanted the Government of the day to have the flexibility to provide some of this funding to areas related to the natural environment, as long as that is possible when the Government is looking at the pot of money that is available. I have had an engagement on this matter with some of the non-governmental organisations in the environment sector. The Minister for the Environment, Community and Local Government and the Minister for Public Expenditure and Reform are aware of this issue, which will be kept under review. We hope the new operation of the national lottery leads to an increase in lotto sales, as this will ensure a greater pool of money is available to be disbursed to good causes. This is something that will be kept under review. I will certainly relay the Senator's strong feelings to the Minister for Public Expenditure and Reform.

Hospital Procedures

I welcome the Minister of State, Deputy Kathleen Lynch.

Cuirim fáilte roimh an Aire Stáit.

I wish to use these few minutes to bring to the Minister of State's attention a very frustrating problem which has arisen in the health service. It relates to a very promising, relatively new but well established technique called transcatheter aortic valve implantation, or TAVI. To put the Minister in the picture, aortic stenosis is a condition in which the aortic valve, which is one of the four major valves of the heart and the last place through which blood goes as it leaves the heart and goes out to the rest of the body, becomes narrowed. In sad bygone days we used to see this very frequently in times of social deprivation as a consequence of things like rheumatic fever. It is now mainly a disease that occurs in older people as a result of degeneration of the valve with age. This degeneration occurs in approximately 2% of older people and has a 50% mortality rate over two years. If it is severe and causing the patient to have symptoms, the mortality in one year is 50%. The symptoms tend to be shortness of breath, blackouts, chest pains, etc. Basically, the blood cannot get out of the heart and into the rest of the body.

I am old enough to remember that when I was an intern in the national cardiac centre at the Mater hospital, we had to go around getting consent forms from patients who were to have the very significant and intrusive operation of aortic valve replacement. Their chests would be opened, they would be put on the bypass machine and their hearts would be opened. There was an appreciable chance of dying on the operating table, despite the great skills of surgeons such as the late, great Maurice Neligan and others who brought this procedure to Ireland. Through one of the great miracles of innovation, there is now a way of doing this in a minimally invasive fashion by threading a catheter through the blood vessels to the heart and, by way of wonderful skill and technology, implanting a valve without having to open the patient's body or heart. This is obviously a vastly better way to proceed because, in the past, many patients who needed this procedure could not have it done as they were too sick for the operation. It was a vicious circle. They had a serious diagnosis and needed the operation but they could not have it. They needed a general anaesthetic and intensive care. In our system, of course, there is a desperate shortage of intensive care beds. One can understand, as such, how difficult this problem became.

The new technology is wonderful. People are in hospital for as little as two nights and they do not have to go into intensive care. Some of them avoid a general anaesthetic altogether and the operation is done under a deep level of sedation without the input of an anaesthesiologist or anaesthetist to put them to sleep. This is a win-win. The actual piece of hardware that is put in - the valve - is more expensive than the valve that is put in through the traditional big, onerous and dangerous operation. It costs approximately €16,000 to €17,000, as opposed to €5,000 to €7,000. The Minister of State has been in the health service for a few years now and will understand the potential for colossal cost savings if people do not need to go into intensive care, do not need all the tests carried out and are not subject to the complications of major surgery. Instead of being in hospital blocking up beds that could be used for other people, people would have access to a simpler and safer procedure with good outcomes and with less time in hospital. The problem at the moment is that it is done in an unco-ordinated fashion. We have three centres, at the Mater hospital, St. James's Hospital and University College Hospital Galway, staffed by extraordinarily skilled and dedicated people who are doing the best job they can. However, t is not a national service.

The case that precipitated this particular discussion arose in St. Vincent's University Hospital, where this procedure was recommended to a patient by skilled cardiologists. They correctly arranged for the patient to go to the Mater hospital, which is our designated centre, but the Mater hospital has imposed a limit because it is not a national centre. That limit is 17 procedures per annum. The 17th procedure will take place in August, which means that the Mater hospital cannot do any procedures after that. The Mater hospital is asking hospitals that are referring patients for a procedure which by definition can only be done in a small number of hospitals to bring their own funding. This is a colossal problem and, unsurprisingly, the number of TAVI procedures carried out here is only one third of the number carried out in the United Kingdom.

In truth, the United Kingdom is pretty poor on most metrics. It has a mediocre health service by the standards of the better social democracy medical systems in Europe, such as those of Germany, the Nordic countries and France. If one looks at the European league table, Ireland is at the very bottom. We are the lowest in terms of TAVI procedures.

We have a real problem here. It is a classic example of a problem which is purely administrative. If there were a recognition that this was a national need and not a matter of a number of isolated islands of excellence that, understandably, are giving priority to patients within their own catchments, we would not have developed a sort of geographical or postcode apartheid for the procedure. I happen to know that my good friends and colleagues in the Mater hospital, who have been doing a phenomenal job - for which I thank them on behalf of patients from their hospital, St. Vincent's University Hospital and all other hospitals that are sending them patients - have been beating the bushes to try to get this problem rectified. One of them told me that clinicians are attempting to bring this to wider attention, but their concerns are falling on deaf ears. This could be a win-win. The procedure is good for patients, waiting lists and economics and it is something we should do very quickly. The problem is that we are too used to the abnormalities of our health system, whereby people can be on waiting lists for six months or two years. One cannot be on a waiting list for two years for this procedure, as one will disappear from the waiting list on average after one year. These people are no longer a vocal group pushing for reform, because they have died. It is a matter to which the Minister of State should give urgent attention.

I could start by reading out the first two pages of my speech, which tells me exactly what the Senator has told me, if not in the same language. I thank him for sparing me the medical terms, which I am not very good at. There are some things we should point to. I thank the Senator for raising this matter, because when he raises issues here, it is usually in order to find a solution rather than to pour scorn. Very shortly, we will enter a process on the Estimates and the budget for October. One of the things that was raised around two years ago - I saw a documentary about this on Monday night on RTE - was cochlear implants. It was something that affected a considerable number of people. We were doing some of it but not enough of it. That programme has now come on stream because of the type of focus and attention that was given to it. This is another area to which we will need to give particular attention, but there are competing issues within the health service, as the Senator knows better than most, as he works within it every day of the week. Sometimes, I highlight one among those competing programmes. We have a clinical programme and are making advances. As Senator Crown pointed out, a number of hospitals are carrying out the procedure, including St. James's, University College Hospital Galway and Mercy Hospital in Cork. However, until there is a co-ordinated approach in a national clinical programme, the benefits of which we have seen in other areas, the numbers will not be coming through and we will not be able to retain the necessary skills. We all know where that leads us.

I thank the Senator for raising the issue. It is an issue about which we should all be concerned. If we are lucky enough to get to later life, it is a procedure we may need ourselves. It would be nice to know it was available. Among those who have received the treatment, some have been hospitalised for only 36 hours before returning home to a new life, able to do far more physical activity. I will ensure that this is brought to the attention of officials as they prepare the health Estimates. I am not promising the Senator anything, but when we shine a light on certain areas, we have a degree of success. I hope that by raising the matter today and getting this attention, the Senator will see that something is done about it.

I am very grateful for that. My cardiology colleagues and I will eagerly follow the debate as it evolves. For clarity, I am not advocating more centres or any attenuation or dilution of the numbers coming through.

I understand that perfectly.

We have about the right number of centres now. With Cork semi-officially open, that makes four, which is probably enough, as it has to be linked to places where cardiac surgery is done. The problem is that it is being done in an uncoordinated fashion and without a designated budget. When someone comes from another hospital that does not have a budget for cardiac surgery, he or she has less chance of getting the procedure than someone in a hospital where it is designated. The people in the latter hospital are limited also, because it is not seen as the national service.

I am more aware than most of competing demands. In fact, I gave a lengthy interview in a newspaper today about immoral and predatory pricing by drug companies with respect to new cancer drugs.

This will save money. The problem is that it might not save it this year; that is the catch. We have to have Japanese style forward thinking in terms of health economics which, with great respect, the officials are very bad at, as are politicians, who tend to see things in terms of the next budgetary and electoral cycle. There is a need to understand that if we do this right now, we will save money.

I agree with the Senator. We have enough centres. It is not something that needs to be available to every hospital. We will probably have enough with the four, although if one were sensible about it, one might add one more in terms of the west, but hospital groups will help regarding the development, delivery and co-ordinating of that. I would like to think we are getting a little better at advance planning. It is not always about what we can do within the coming week. We have to plan for the future, as one usually plans for one's own.

I would make the point that the Mater hospital and St. Vincent's University Hospital are already in the same hospital group.

Ambulance Service Provision

I thank the Minister of State for coming to the House to respond to this issue regarding the national ambulance service, which is an issue in County Kerry but also nationwide. It is about joined-up thinking with regard to our national ambulance service and how the lack of that has affected Kerry, Cork and many other rural areas.

The epitome of the position was highlighted by a response from officials within the national ambulance service when they were withdrawing ambulances from west Cork. They told a local action group concerned about the effect of that in terms of life and death situations that was what they got for living in a rural area. County Kerry was at the tail end of this process of reconfiguration or, as they like to call it, dynamic deployment, which is guessing where the next heart attack will take place - it is like Russian roulette when it comes to an ambulance service. In Kerry, fewer than 60% of the ambulances arrive within the 19 minute response time set by the Health Information and Quality Authority, HIQA, for emergency cases such as heart attacks, strokes and car crashes. The only way they will meet those response times is if they expand the length of time.

We are in a very rural area and we have seen ambulances being withdrawn. The Millstreet ambulance was withdrawn almost two years ago. That also covered a large part of east Kerry. Subsequently, one of the two emergency ambulances in Killarney was withdrawn and the strain on the system is evidenced by the fact that every month or so, there is a headline in The Kerryman or Kerry's Eye about how it took 50 minutes for an ambulance to get to Kenmare, Caherciveen or Dingle. That is complicated by the fact that when the ambulance arrives, and it is an excellent service because the paramedics are highly trained, it then goes to Cork where there could be a three hour wait just to have the patient admitted to Cork University Hospital because of a systems failure that has been ongoing in that hospital for years, which is amazing. That has been acknowledged by the Health Service Executive, HSE, and yet it continues.

This situation is costing the HSE more money because as the Minister of State will be aware, if stroke or heart attack victims do not get help immediately, their chances of recovery are greatly lessened. If they do not die their recovery takes longer, which means they tie up those beds in Cork University Hospital and throughout our national hospital network. There are also physiotherapy, speech therapy and other ancillary costs because the ambulance did not get to those patients in time.

There was a tragic case in south Kerry, which resulted in a fatality. The ambulance in Caherciveen was not available and there was not one available in Killarney. The ambulance had to come from Kenmare, which is nearly 50 minutes away. By the time it arrived, it was decided that the victim, who was suffering a heart attack, should go to Cork University Hospital. The helicopter was called from Shannon. It was now two hours after the initial call. When that patient stepped onto the helicopter he said, "I am in trouble, aren't I?", and he ended up dying on the operating table because the ambulance in Caherciveen had been pulled, as had the ambulances in Killarney and Millstreet. Tragedies are occurring as a result of these ambulances being withdrawn.

Next weekend Cork will play Kerry and we will have 40,000 people in Killarney, but there will be only one ambulance in the town. Killarney is unique because its population can double on any given weekend and yet it has only one ambulance. Very few towns can say their population will double on any given weekend and to have just one emergency ambulance in that situation is far from ideal.

I ask the Minister of State to look into that because not having ambulances available, and the cost of rehabilitation for those who do not get an ambulance in time, is costing the taxpayer a fortune.

I thank the Senator for raising the issue. I am pleased to be able to outline to him the current developments in pre-hospital services, both nationally and in the Kerry area, in particular.

The national ambulance service, NAS, has undergone a huge programme of reform and modernisation in recent years, and it is important to acknowledge that progress is being made. The Minister, Deputy Leo Varadkar, recently officially opened the new national emergency operations centre in Tallaght, which allows the NAS to operate on a national rather than a regional basis. All calls for ambulance services for the Kerry region are now taken in Tallaght, and resources are dispatched from that centre.

Additional funding of €5.4 million has been provided this year to improve technology and clinical audit, and address gaps in service. Improved technology is facilitating better co-ordination of the national fleet, and that is improving control and dispatch performance.

It is important to note that the NAS is not a static service, but rather deploys its resources in a dynamic manner. This ensures that the nearest available and appropriate resource is sent to an incident. The NAS continuously evaluates its services in tandem with available resources and activity levels.

Kerry has 14 emergency ambulances and one rapid response vehicle. Seven crews operate on a 24 hours a day, seven days a week basis. The service operates from six ambulance stations in Tralee, Killarney, Listowel, Dingle, Kenmare and Caherciveen. Paramedics and advanced paramedics are deployed across the county, which ensures that practitioners with the appropriate skill level are located strategically to provide the best possible cover.

We are continuing to develop the intermediate care service, ICS, which transports patients between facilities, allowing emergency vehicles to focus on emergency calls. The ICS now carries three quarters of the non-emergency workload. In the Kerry area, two intermediate care vehicles operate from Monday to Friday, 8 a.m. to 8 p.m, and one operates on Saturday and Sunday from 10 a.m. to 7 p.m.

We are expanding the number of community first responders, CFRs, particularly in more rural and sparsely populated areas. These are volunteer groups in the community who are registered and trained to a certified standard. We now have over 120 teams operating around the country. Four of these teams are operating in the Kerry region and are linked to the national control centre. On receipt of an emergency call in a geographic area served by a team, the NAS computer aided dispatch system will send out a text alert to the group and simultaneously deploy a NAS resource. CFR teams are dispatched to persons with cardiac and respiratory difficulties. The responder may get to the scene before the arrival of the ambulance crew and will apply their training, thus increasing the person's chance of survival. It is a great community initiative, which I fully endorse, and is a real case of helping thy neighbour. I have seen it in operation, and it is impressive.

We have also seen the establishment of the emergency aeromedical service, EAS, operated from Athlone by the Air Corps and staffed by NAS advanced paramedics. The EAS provides swift transfers of seriously ill or injured patients to appropriate hospitals. Over 1,050 missions have been completed since June 2012.

These are all significant achievements. However, the House can be assured that the Government intends to drive further improvements in our pre-hospital emergency care services, which will benefit the people of Kerry and those in the rest of the country.

I thank the Minister of State for her outline of the services. The main issue is the paramedics in County Kerry will tell one there are simply not enough ambulances. It is not the case that they were not there before; they were and they were withdrawn. The emergency ambulance in Millstreet was taken away. The second ambulance in Killarney was taken away. Will the Minister of State ask for a report on how much it costs us to have fewer ambulances? If one tracks the patients going through the system, one sees the extra stay as a result of the ambulance not arriving in time costs money. Unfortunately, in some cases, it costs lives. It is a simple fact that if the ambulance does not arrive in time for a heart attack or stroke patient, or at a car accident, the outcome will be fatal in some cases and tragic for the family in the long run in other cases. The reply does not state we have fewer ambulances. We have dynamic deployment but the paramedics tell me they cannot be everywhere. If they are in Cork University Hospital when a call comes in, and the next nearest ambulance is in Caherciveen, which is 40 minutes away, this will lead to tragic outcomes. I ask the Minister of State for an evaluation and impact assessment on how much it costs over a one-year period. As one can see from the reports, ambulances in Kerry do not arrive within HIQA's guidelines and, therefore, the outcomes are tragic.

I know Kerry fairly well, as does everyone in Cork, not just from the clashes in Killarney but from holidaying there. Ambulances are based in Tralee, Killarney, Listowel, Dingle, Kenmare and Caherciveen. I know getting from Caherciveen along the coast road can be quite difficult at times and it is not a short journey. On paper, it looks to me as though there is extensive coverage, but I promise the Senator I will inquire as to whether there are particular difficulties. On paper, it looks as though there is extensive coverage.

I thank the Minister of State.

Sitting suspended at 11.15 a.m. and resumed at 11.30 a.m.